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Editor’s note: This story contains descriptions of suicide and may not be suitable for all readers. If you or someone you know is contemplating suicide, call for help now. The National Suicide Prevention Hotline is a free service answered by trained staff 24 hours per day, every day. The number is 1-800-273-8255. Or text 273TALK to 839863.

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After 40 days in the Josephine County Jail, Janelle Marie Butterfield looped a white sheet around her neck and tied the other end to the metal bunk bed in cell 408.

Deputies found her during their hourly rounds, around 8:45 in the morning. She was slouched in the corner of her cell, wearing her jail blues. Her long, dark hair covered the sheet around her neck.

“All staff respond to 408, possible suicide,” a jail deputy radioed.

More staff arrived. They tried CPR. Her lips were purple, her eyes wide open. Butterfield died behind bars at the age of 34.

“The antiquated mindset that ‘inmate suicides cannot be prevented should forever be put to rest,’” the U.S. Department of Justice said in a 2010 report.

But the issue hasn’t been put to rest. Despite decades of concerns about jail suicides and some progress being made, jail leaders and elected officials have failed to take all the necessary steps to curb the problem and protect inmates, an investigation by OPB, KUOW and the Northwest News Network has found.

Over the past decade, at least 122 people have died by suicide in county jails across Oregon and Washington. Suicide, specifically hanging, is by far the leading single cause of deaths in the region’s jails. It accounts for nearly half of all cases with a known cause of death.

The suicide rate in Oregon and Washington jails also exceeds the national average.

In 2014, the national rate had reached its highest point since 2000 and was 50 suicides per 100,000 inmates. Over a 10-year span, the average rate in Oregon was 55; in Washington, it was 71.

Cause Of Death In Northwest County Jails

Over the past decade, suicides were the single most common cause of death in county jails. The vast majority of those were hangings. Click for details.

Tony Schick, OPB. Source: Staff reporting by OPB, KUOW and the Northwest News Network.

“Especially when we know that half of the folks are dying by suicide, something’s wrong,” said Oregon House Majority Leader Jennifer Williamson, D-Portland. “It shows me we have people who are very sick and the mentally ill in our facilities, and we don’t know how to deal with them. And because we don’t know how to deal with them, they’re dying.”

Years before she died, Butterfield was diagnosed with schizophrenia. She fell through gap after gap in the health care system before landing in a county jail that, records show, failed to keep her safe from herself.

“I do not believe they had no clue that she was ill. That’s a bunch of bull,” said Connie Dence, Butterfield's mother. “And why the hell would they put her with a bunk bed? That’s just — that’s messed up.”

A Turning Point

Butterfield grew up in Candor, New York, a tight-knit town north of the Pennsylvania border.

She moved to Anchorage, Alaska, at the age of 20 to live with her aunt and look for jobs. She met Dan Ryan at a party there, and he hired her to help him paint the outside of his family’s historic hotel in Seward.

“When she and Dan came back at the end of the summer, I saw them holding hands, and I thought, ‘Oh, there’s something going on here,’” said her aunt Rhonda Butterfield.

Janelle Butterfield, right, had been diagnosed with schizophrenia years before she died in the Josephine County Jail. Butterfield's mother, Connie Dence, left, says she doesn't believe the jail didn't know her daughter was ill. Courtesy of Connie Dence

Less than two years later, Ryan and Janelle Butterfield married.

“She was kind of a tomboy. We had great chemistry,” Ryan said. “I was super happy with her, and I knew I wanted to be with her forever.”

In September 2007, the couple left for their honeymoon near Puerto Vallarta, Mexico.

“Around our third day there, we were at one of the bars by the pool just kind of having some drinks and kind of getting drunk and partying a little bit with some people there,” Ryan said. “Janelle had a drink. She didn’t think it tasted good. She’s like, ‘Something’s wrong with this drink. It tastes weird. I don’t want it.’ So she gave it to me and I drank her drink.”

Ryan blacked out. He said he remembers waking up in the dark room of a clinic with an IV in his arm and a deep cut on his hand that was wrapped in a dressing.

The couple was drugged and thought they had been attacked by the bartender and another hotel employee. Ryan said when he woke up, he was in the haze of what felt like a nightmare. He wasn’t allowed to see Butterfield for days. When they were finally reunited, Ryan said he noticed she was bruised. She told him she’d been fighting with two men who were attempting to rape her.

“I don’t really know,” Ryan said about the alleged assault. “She told me they didn’t [rape her].”

They bought plane tickets home and spent the night in the airport.

Dence, Butterfield’s mother, said she remembered seeing stab wounds on her daughter's arms.

“I would not be surprised if she was raped,” Dence said.

Dence believes whatever happened in Mexico brought about a turning point, a fundamental shift in her daughter’s mental health.

“I think that was a catalyst of bringing her into the paranoia, the schizophrenia,” Dence said.

Jail Suicides: Preventable Or A Certainty?

Many jail commanders say the top thing they worry about is suicide.

They have a good reason. The suicide rate in local jails is higher than in the outside world — and even in prison. The shame of arrest, guilt, isolation from family, fear of the unknown, the pain of detoxing from drugs or alcohol, and an approaching court date can elevate the risk, according to county jail commanders and mental health advocates. So can mental illness.

“Suicide is the highest risk and the one we have the most control over,” said Capt. Lee Eby, commander of the Clackamas County Jail.

“Your hope is that you can drive that number down,” he said. “You can do the best job you can and things still do happen.”

A Clackamas County sheriff's deputy stands in the hall of the Clackamas County Jail on Tuesday, Jan. 22, 2019, in Oregon City, Ore. “Suicide is the highest risk and the one we have the most control over,” said Capt. Lee Eby, commander of the Clackamas County Jail. Conrad Wilson / OPB

John Bishop, executive director of the Oregon State Sheriffs' Association and former sheriff in Curry County, Oregon, said suicides in jail are a certainty.

“If somebody’s going to kill themselves, they’re going to do it,” Bishop said. “I think, in theory, maybe you can say it could be preventable but not practically.”

Mental health advocates disagree. They say suicides are preventable, especially in a controlled setting like a jail. Each year, the number of suicide attempts in jails significantly outpaces actual suicides. In 2017, there were 239 suicide attempts in Oregon jails, according to data from the Oregon State Sheriffs' Association. But there were four suicides in Oregon jails, our investigation found. Last year, there were 225 suicide attempts in Oregon jails, according to OSSA. But our investigation found five suicides. The Washington Association of Sheriffs and Police Chiefs doesn't track suicide attempts.

“There are lots of steps that can be taken in order to keep people safe,” said Sarah Radcliffe, managing attorney for Disability Rights Oregon, who has met with inmates and jail administrators around the state. “We know a lot about suicide risk in terms of what are those risk factors — even for an individual that doesn't come out and say, ‘I’m feeling suicidal.’ So, I don’t think that we should accept this rate of suicidality in jails as inevitable.”

Nationally, the U.S. Department of Justice found in 2010 that the rate of suicides in jail had dropped significantly in the previous 20 years. In 1986, the rate of suicide in jails was 107 deaths per 100,000 inmates, according to the DOJ report. By 2006, the rate fell by two-thirds, to 36 deaths per 100,000 inmates.

That’s still much higher than the rate outside of jails. Jail administrators point to rising suicide rates outside of jail as one reason the problem has persisted.

“Is it my fault if somebody comes in the jail and within five seconds they take a piece of clothing and hang themselves?” said Capt. Michael Shults, who runs the Deschutes County Jail in Bend, Oregon. “Suicide and death happens every day on the outside. So it’s going to happen inside custody.”

Alone In A Cell

Of the inmates who died by suicide in Oregon and Washington jails, more than 50 percent of those deaths occurred within two weeks of an inmate's incarceration, the investigation by OPB, KUOW and Northwest News Network found.

Mental health advocates say that finding and others underscore a fundamental problem with how some jails approach suicide prevention.

“What this data shows is that those security-focused tools that jails have at their disposal are not effective in mitigating the risk of suicide,” Radcliffe said.

Clark County Jail Commander Paul Dougher shows a suicide smock at the Clark County Main Jail in Vancouver, Wash., on March 14, 2019. The jail has invested $1.3 million in suicide mitigation in its physical space, like doing away with bedsheets and traditional doorknobs. Bryan M. Vance / OPB

In some jails, inmates Radcliffe spoke with told her that suicide watch feels more like a punishment. Rather than tailoring solutions to the risk of an individual, she said, the standard jail approach is to put a person in a suicide smock, deprive them of their personal belongings and have them on lockdown in their cell.

“Human contact is known to ameliorate the risk of suicide, whereas being locked in a cell all by yourself is bound to make a person feel worse,” Radcliffe said.

A Spiral, A Song, A Diagnosis

In early June 2011, Butterfield began a five-month spiral that resulted in her being admitted to a hospital — twice — for psychological evaluation.

She thought a radio in her home was letting the government spy on her and Ryan.

A few times, she returned to her Athens, Pennsylvania, home scratched and cut. She told Ryan she got the wounds while running away from people who were attacking her.

“The first time she came home scratched up, I thought maybe people had actually been throwing rocks at her,” Ryan said. “I didn’t realize she was probably just hallucinating.”

Janelle Butterfield is pictured in an undated photo. In June 2011, Butterfield's condition deteriorated as she had flashes of delusion and paranoia. Courtesy of Connie Dence

She started expressing strange religious ideas. "She thought she was Eve," Ryan said, referring to the Bible's Old Testament. "And I was the devil."

A few months later Butterfield disappeared for a few days. She was ultimately committed to a nearby hospital.

Butterfield would have flashes of paranoia and delusion, Ryan said, and then level out. She didn’t take her prescribed medication, because she thought nothing was wrong with her, and that the medication was part of a conspiracy against her, he said.

Then, Butterfield left Ryan and headed west to stay with a friend in California. She’d call her husband from time to time, always from a different number.

Ryan remembers one call in summer 2012. Butterfield said she was alone, having a party in her car. The song on the radio was about suicide.

“She thought the song was to her,” Ryan said. “Like the singer of the song was sending a message to her.”

Hours later she was booked into a jail in Reno, Nevada, where a psychiatric nurse officially diagnosed her with paranoid schizophrenia.

After being released, Butterfield made her way to her sister’s house in Grants Pass, Oregon.

“She was homeless for the last, probably six years,” Dence, Butterfield’s mother, said through tears. “She just lost it.”

Bedsheets And Self-Harm

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Research shows that suicide is among the leading causes of early death for people with schizophrenia. One study from 2011 found patients with schizophrenia have 8.5 times the risk of suicide.

Suicides like Butterfield’s — where inmates use bedding and a bed frame to hang themselves — have been a well-documented concern for decades.

A February 1988 report by the U.S. Department of Justice’s National Institute of Corrections found nearly half of all people who died by suicide in jail used their bedding. An updated report in 2010 found that rate climbed to two-thirds. The report does not distinguish between bedsheets and other types of bedding, such as blankets. In Oregon and Washington, bedsheets were commonly used by inmates to hurt themselves, according to documents reviewed by the news organizations.

Yet, national standards developed by the American Correctional Association recommend jails give inmates bed sheets. ACA did not return multiple requests for comment on why the standard is in place.

“We still issue bedsheets,” said Marin Fox, the Cowlitz County Jail director in southwest Washington. “We’ve talked about it, going away from it. I know some jails have, but we’ve not made the decision to at this point.”

Fox said she believes whether it’s sheets or blankets that can be more difficult to tie, the risk is similar. She said inmates could just rip blankets and use them in the same way as a sheet.

A ball-bearing hook system in a Clark County Jail cell in Vancouver, Washington, on March 14, 2019. The bearings allow inmates to hang light personal items but does not allow a cord or rope to be affixed to the bearings. Bryan M. Vance / OPB

In April 2017, in neighboring Clark County, Washington, the entire main jail did away with bedsheets, despite ACA’s standards and complaints from some inmates and community members.

“As an industry, it’s something we’re going to have to move away from,” said Ric Bishop, the chief corrections deputy for the jail. “It’s a changing population: more mentally ill, more vulnerable. We have to move away from linen bed sheets.”

Bishop, who travels and consults with local jails around the country, said the risk for suicide is too great. Instead of sheets, the jail now gives inmates suicide resistant blankets. Bishop likens it to a sleeping bag that is thicker and difficult to tie onto objects. “The bedsheets had to go because of the potential for self-harm,” he said.

And he’s speaking from experience.

In 2012, there were four suicides in the Clark County Main Jail in Vancouver.

“Those deaths in a short amount of time brought a spotlight onto the Clark County Main Jail and the issue of in-custody death,” Bishop said.

Another five people died by hangings at the jail between 2014 and 2016.

In addition to doing away with bed sheets, the jail responded by increasing training. More than 70 percent of corrections deputies in Clark County have undergone crisis intervention training — a specialized training to help corrections deputies assist people in a mental health crisis. It’s still relatively new in jail settings. The jail also has a phone number on its website that’s answered day and night, so family and friends outside the jail can relay concerns they may have about those locked up inside the facility.

The county has also invested $1.3 million for suicide mitigation in the physical space.

The entrance to the Clark County Main Jail is pictured in Vancouver, Wash., on March 14, 2019. The jail has taken several suicide mitigation steps in the past few years, investing in staff training and modifications to its physical space. Bryan M. Vance / OPB

In addition to removing bedsheets, bunk beds in higher security areas of the jail are smooth, molded from plastic and are difficult to tie anything on. The jail has also done away with traditional door knobs and shower hooks in parts of the jail.

The jail has not had a suicide since July 2016.

“Changing just one thing — bedsheets — isn’t going to just eliminate a jail in-custody death problem,” Bishop said. “It has to be that holistic approach.”

'We Are The Family Of Janelle Butterfield'

Staff at the Josephine County Jail knew Butterfield. For around two years, she was in and out of their custody for misdemeanors such as theft and disorderly conduct. At times she didn’t comply with directions from corrections deputies. Things became physical. She was disciplined.

After one altercation, Butterfield tried to drink cleaner off a cleaning cart in the jail. The jail responded by placing “mental alerts” on Butterfield.

In May 2018, Butterfield was arrested again, this time outside her sister’s house in Grants Pass. She was in the street swinging a shovel, striking vehicles and herself. Officers tased her several times.

Butterfield’s sister told police her sister was in a “psychosis.”

“Butterfield was saying a lot of things that made no sense, she was throwing items, yelling and making a lot of noise,” a police report noted.

Butterfield told officers she had used a small amount of methamphetamine, according to the police report.

She was taken to the hospital for medical care and then to jail. Butterfield was charged with resisting arrest, interfering with a police officer and criminal mischief — all misdemeanors.

Suicide Rates In Local Jails Exceed National Rates, Prisons

Annual suicide rates in local jails are much higher than prisons and suicide rates for those not incarcerated. The suicide rate calculated for Oregon and Washington between 2009 and 2018 is higher still.

Tony Schick, OPB. Sources: U.S. Center for Disease Control, U.S. Bureau of Justice Statistics, staff reporting by OPB, KUOW and Northwest News Network. Note: National jail and prison suicide numbers are not yet available past 2014.

On May 11, Susan Tubbs — Butterfield’s aunt — wrote an email to the Josephine County Sheriff’s Office.

“We are the family of Janelle Butterfield,” it said. “If our Janelle were just another drug user, it would be hard enough to accept. But compound that with the horrible disease of PARANOID SCHIZOPHRENIA, and you can begin to imagine what our hearts deal with on a daily basis.

“We want to thank you for realizing that Janelle has people who love her dearly,” Tubbs wrote. “We appreciate anyone who keeps our Janelle safe.”

The jail never got back to Tubbs. But records show Butterfield was in the jail at the time the email was sent.

After several days in the Josephine County Jail, Butterfield was released around May 15, 2018, with an order to show up for court. When she failed to appear, a warrant was issued. On July 27, she was arrested again. It would be the last time.

At the jail, Butterfield didn’t want to get out of the squad car. “She appeared to be under the influence of an amphetamine or had a mental disorder, and had insurmountable strength,” a deputy wrote in a jail incident report. “We secured her in the restraining chair with difficulty.”

Deputies wrote that they started checks on her every 15 minutes and made a “mental health request.”

The jail’s medical and suicide questionnaire notes that Butterfield was not under the influence of alcohol or drugs. It also notes she had “unusual speech or behavior” and a “history of mental or emotional disturbance.”

Jail staff housed her alone in the 400 cellblock, a higher-security wing in the Josephine County Jail where Butterfield’s contact with other people was limited. Because of her behavior during booking, two corrections deputies escorted her around the jail when she was allowed out of her cellblock.

“400 is a female lockdown unit,” Josephine County Corrections Deputy Robert Selby told Oregon State Police when they investigated Butterfield’s death. “So there’s only going to be one person out at a time.”

‘Oh, There Were Signs’

As summer turned to fall, Butterfield’s mood changed, documents show. She stopped eating. She hid in the corners of her cell, refusing to leave during the daily hour inmates in the 400 cellblock are allowed out of their cells.

After Butterfield died in September, the jail asked Oregon State Police to conduct an investigation. The one inmate Butterfield confided in, Elizabeth Hudson, told investigators that jail was hard for Butterfield.

“She hasn’t really been herself lately,” Hudson told an Oregon State Police detective. “The deputies said she’s perfectly normal, but the last — I’d say five days — she’s hasn’t been wanting to talk to me. … She wouldn’t even touch her food and sometimes she would refuse it.”

The times Butterfield reached out to her family, they got the sense that something was wrong.

“She actually called me and talked for a long time. She was very confused,” Tubbs said. “Half the time, I didn’t know what she was saying. But I was thrilled that she called me.”

The Josephine County Jail in Grants Pass, Ore., is pictured in an undated photo. Dave Blanchard / OPB

Jail deputies told Oregon State Police detectives there was nothing they were aware of that indicated Butterfield was a threat to herself.

Deputy Selby told OSP that, as far as he knew, Butterfield hadn’t been on suicide watch.

“I never would’ve suspected Butterfield to do this,” Selby told OSP the day of her suicide. “She was always a little strange, a little bit different. But she never seemed like that type.”

Another deputy backed up Selby’s account, saying he didn’t see any signs that Butterfield might be suicidal.

Just before she died, deputies at the Josephine County Jail did notice one thing had changed: Butterfield appeared happy and smiling. One deputy recalled her “happy and dancing around” the day before she died, according to the investigation by OSP.

Dr. Michelle Guyton, a Portland-based forensic psychologist who frequently evaluates inmates in jails, reviewed the Oregon State Police investigation into Butterfield’s death at OPB’s request.

“It’s clear that Ms. Butterfield was exhibiting some behavioral changes that we know are associated with potential for suicide and that she had clear means,” Guyton said. “Looking back we can say, ‘Oh, there were signs.’”

Guyton said deputies and nurses in the jail should have noticed those signs.

The Josephine County Sheriff’s Office won’t talk about Butterfield’s death, citing “potential pending litigation.” They also refused to discuss their suicide prevention efforts.

Looking For Answers

Answers also have been hard to come by for the family. Last month they hired an attorney.

“My investigation will attempt to determine whether the Josephine County Jail complied with national health care standards for jails and whether her death was preventable,” said attorney John Devlin, who has won cases against other jails he sued in Oregon over deaths in custody.

After Butterfield died, her mother traveled to southern Oregon. She saw her daughter's body. She kissed her and said goodbye. Butterfield was cremated. Dence flew the ashes back to New York for the funeral.

Butterfield’s photos are all over Dence’s house in Candor. She’s said she’s seeing a counselor. It’s clear her grief is still raw.

“There’s a lot of people out there that have mental issues. They’re not just homeless because they’re lazy. They’ve got issues that they’re dealing with. And to treat them like they’re humans — a lot of them are born that way and they should be treated differently,” Dence said. “Shame on the jail, shame on the jail for not recognizing.”

During the course of the next year, OPB, KUOW and the Northwest News Network are teaming up to report on the epidemic of deaths at Northwest jails in our ongoing series "Booked and Buried." If you have a tip or a story idea, email us cwilson@opb.org, aschick@opb.org, austin@nwnewsnetwork.org or sydney@kuow.org.

A man walks into a Multnomah County Jail cell after being arrested on Friday, Sept. 21, 2018 in Portland, Ore. Jonathan Levinson / OPB

Booked And Buried: More In This Series

Northwest Jails' Mounting Death Toll | Dead But Not Convicted | Suicide Is The Leading Cause Of Death In NW Jails

About The Data

This analysis relied on death-in-custody reports filed with the federal government, requested from county jails in Oregon and Washington. This analysis excludes municipal and tribal jail facilities. Some counties provided full records, some provided redacted copies and some provided only basic information such as the number of deaths in a given year. Where possible, missing data was filled in using information from news reports, court filings, interviews and correspondence with law enforcement.

This dataset includes people who died behind bars and those who died after being taken from jail to health care facilities. It consists of both official “in-custody” death records and inmate deaths that did not meet that specific definition. The number of inmate deaths in this data is likely an undercount.

Each county was given a list of jail deaths compiled for years 2008-2018 to review for accuracy. All but two counties responded.

This data collection represents an ongoing effort and will be updated. A fuller explanation of data collection and methodology is available. If you have additional information about jail deaths in Oregon or Washington, or if you wish to obtain a copy of the data, contact Tony Schick at aschick@opb.org.