Bensalem resident Charles Freitag had a documented medical history of suicidal behavior and severe depression. But Bucks County prison did not consider the 57-year-old first-time offender a suicide risk on the day last year when he took his own life in his jail cell.

When Charles Freitag took his own life last year while incarcerated at Bucks County prison, it was not his first suicide attempt. Or his second.

Twice before in 2017 he tried to end his life, according to family and medical records. His first attempt was on his 57th birthday. His second attempt two weeks later was after he slammed his pickup truck into his former wife’s house, which led to the criminal charges that landed him in the jail.

After that second suicide attempt and subsequent arrest on Sept. 13, 2017, the Bensalem postal worker was diagnosed with major depressive disorder. Months before that diagnosis, Freitag was treated at two psychiatric hospital units where he was taken for suicidal thoughts, according to copies of medical records his family provided.

Nearly two months after he entered prison last June, his attorney emailed the corrections center requesting a well-being check. His family feared that Freitag, a first-time offender, was showing signs of mental deterioration in phone calls and visits with him.

Three weeks before he died, Freitag began mental health counseling, his family said. Corrections officers were required to check on him every half-hour the day he died, according to the prison.

But Freitag was not considered a suicide risk when he fatally cut his forearms, an executive with the county's private medical contractor confirmed.

The failure to recognize Freitag as a danger to himself is not unusual, according to behavior and correctional health experts and studies.

“A substantial number of inmates who do commit suicide were not identified to be at-risk,” said Christine Tartaro, a professor of criminal justice at Stockton University in southern New Jersey and an expert on suicide in correctional settings.

The last two Bucks County inmates who died by suicide, in 2006 and 2010, were not considered suicide risks, though one previously had attempted suicide at some point, according to published reports. In Montgomery County jail, none of the six inmates whose deaths were ruled as suicides in the last five years were on a suicide watch, a status that triggers safety measures, according to prison officials.

While national research has found jail inmates on suicide watch protocol rarely take their own life, experts say that suicide prevention programing in local county correctional centers is often superficial, if it exists at all. This is despite federal data that shows suicide rates in jails are consistently higher than in state prisons.

In Pennsylvania, suicide surpassed natural causes as the leading cause of death among county prisoners for the first time in 2016, according to state Department of Corrections data, which is self-reported by county jails. Reported suicide attempts in jails increased slightly from 159 to 165 between 2012 and 2017. Montgomery County had the highest number of attempted suicides in county jails reported to the state in 2017, accounting for 27 percent of the 165 incidents reported to the state.

Bucks County prison averaged 68 inmates on suicide watch per month, roughly 7 percent of its 960 inmate average daily population between July and September last year, according to PrimeCare Medical, the contractors that provides health care services for Bucks and Montgomery County prisons. At Montgomery County prison, the average is 113 inmates, roughly 6 percent of its average daily population of 1,877 inmates.

It is unknown if Freitag was placed on suicide watch protocols at any point during the 72 days he was incarcerated or if he had additional suicide risk screenings. A PrimeCare Medical executive said that he was unable to answer some questions about Freitag, citing privacy concerns and pending legal action.

On the day he died, Freitag was under “psychiatric observation status,” according to Todd Haskins, vice president of operations for PrimeCare Medical. The enhanced monitoring is for inmates whose behavior warrants closer observation, but it is not used for suicide prevention, he said. Haskins did not say what behavior led to placing Freitag on the protocol.

On Aug. 25, 2018, Freitag spent his last hour alive alone in his cell, monitored periodically by a correction officer, according to a county-led death investigation. His cellmate had left to play basketball shortly after 9 a.m.

The day before, Freitag had been sentenced to serve six to 12 years in state prison for aggravated assault, criminal mischief and reckless endangerment. His bail was revoked, but the judge agreed to delay his transfer to state prison for a week so he could get his affairs in order.

At 9:12 a.m., Freitag was given undisclosed medications, according to Bucks County Coroner Dr. Joseph Campbell. Four minutes later, a corrections officer checked on him. Two more checks followed at 10:04 a.m. and 10:21 a.m., Campbell said.

Thirty-four minutes later, another inmate found Freitag slumped over his bed, Campbell said. He used a piece of broken plastic cup to inflict fatal wounds, according to the autopsy.

His memorial service took place five days later, the day before his 58th birthday.

'Shell of a person'

Months later, frustrated family members have many questions about the death.

The biggest is why someone with a documented mental health history was not placed on suicide watch protocols, which would have required correctional officers observe him at intervals no longer than every 15 minutes. The prison was sent Freitag's medical records, including his mental health diagnosis and history of treatment and past suicide attempts, the family said.

“This was the first time he had ever been in jail so he was very scared and confused,” his brother, Bob Freitag, said. "As far as we can tell, my brother was not given the care and compassion that we requested and that he so desperately needed."

Bob Freitag recalled a July 31 phone conversation with his brother, during which Charles told him that he no longer wanted to get out of bed. The conversation prompted Bob Freitag to contact his brother's attorney to see if the prison could put Charles on a suicide watch.



The family doesn’t know the outcome of the request. But after his attorney asked for a well-being check, Freitag started receiving mental health counseling three times a week, according to Bob Freitag. Haskins declined to confirm the counseling.

“I remember (Charles) saying that the therapists would tell him that he needed to forgive himself for what he had done,” Freitag added. “But when he tried forgiving himself, he was told by authority figures that he was not taking responsibility for what he had done and was using his mental illness as an excuse.”

Family members describe Freitag as a loyal, kind and generous man who loved fishing. He earned an American Red Cross pin for donating 15 gallons of blood in his lifetime and he was an organ donor.

But Freitag grew increasingly despondent starting in February 2017, after the deaths of two brothers and a close friend, and a divorce that followed a two-year separation, family members said.

His family believes Freitag intended to die the night he drove his pickup truck into ex-wife's house, the act that led to his arrest. It took at least 60 stitches to close a wound he inflicted with a box cutter just after the crash, said Sherrie Crane, who had known him since she was a teenager and considered him a father figure.

When Crane visited him in the hospital after the accident, Freitag told her he wanted his ex-wife to find him dead, she said.

“He didn’t want to live without her,” Crane said. “He was scared and remorseful.”

Freitag told the same thing to licensed therapist Mary Edwards, who treated him after he was arrested, according to a copy of a letter the Freitag family provided this news organization.

While free on bail, Freitag entered intensive outpatient treatment for his depression and continued therapy for the eight months before his June trial, according to his family and medical records. He returned to work and his mood started improving, his family said.

“He was so full of life,” Crane said. “I thank God for the last eight months.”

But over his two-day trial, his mood deteriorated, family members said.

“You could see the life sucked out of him,” another brother, Joe Freitag, said. “He was a shell of a person.”

Edwards said she wrote a letter to the prison two days after he was convicted and bail revoked strongly recommending he be put on a suicide watch.

A second psychotherapist who treated Freitag also wrote a letter to the prison warning it was imperative that Freitag be placed on a suicide watch. The family provided copies of the letters to this news organization.

“Due do to the outcome of his trial and the pending sentencing, it is my clinical belief and concern that he may have some thoughts of harming himself,” therapist Erica Shmilovich wrote.

Balancing act

First-time offenders are more likely to experience the so-called “shock of confinement,” described as heightened feelings of hopelessness, loss of normalcy and fear of an unknown future, which can trigger suicidal thoughts, said Tartaro, the Stockton University professor. Individuals with histories of mental health and substance abuse issues are also at a higher risk for suicidal thoughts.

Individuals with recent suicide attempts, like Freitag, are especially vulnerable, she added.

But identifying inmates who pose a suicide risk can be a challenge for jails, which generally house defendants awaiting case outcomes or those convicted of minor offenses. Jail turnover rates are far higher, but staffing, funding and resources are more limited than state prison systems, studies and correctional behavior experts said.

The medical staff may lack immediate access to detailed behavioral health histories for incoming inmates and corrections staff may not be trained to recognize inmates in distress, Tartaro said. Most jail suicide watch programs focus exclusively on inmates identified at imminent risk of harming themselves, but ignore ones with risk factors who are not actively suicidal, she added.

“So many inmates are experiencing some level of mental stress,” Tartaro said. “The challenge is identifying who might be suicidal, and human behavior is very hard to predict.”

A 2013 study by Lindsay Hayes, a nationally recognized expert in suicide prevention in correctional settings, found only 20 percent of county jails had comprehensive suicide prevention programs in place that included regular staff training and retraining on identifying and reporting suspicious behavior and provided ongoing mental health screenings during incarceration.

The Hayes study also found few jails had suicide-resistant bedding and clothing. Bucks and Montgomery county prisons use suicide-resistant smocks, and Montgomery County uses tear-resistant bedding.



A national survey of jail suicide conducted in 2005 and 2006 by the National Institute of Corrections found 63 percent of jails did not conduct a death review after a jail suicide, according to a 2016 report by the Vera Institute of Justice, a national correctional research and policy organization. The report also found no comparable research exists on the prevalence of reviews for incidents involving self-harm or injury in jails.

Research shows the initial suicide screenings given inmates entering jail are important, but that it should not be a “one-and-done” event, Tartaro said. The American Correctional Association, American Psychiatric Association, and the National Commission on Correctional Healthcare all recommend repeat suicide risk screenings during incarceration at significant junctures such as after a court appearance or sentencing, she said.

The suicide prevention protocol that PrimeCare uses is reviewed annually with a national expert in the field and employs several tools to potentially identify suicide risk levels, such as whether an inmate is experiencing drug or alcohol withdrawal, according to Haskins, the company executive.

When they enter prison, inmates are asked if they want to see a mental health professional or if they have thoughts of harming themselves, Haskins said.

Suicide risk assessments are done when an inmate is placed on suicide watch and if that status is changed, said Haskins. Risk assessments are done if a referral is received suggesting an inmate may be suicidal, but it is unknown if any referral was made with Freitag after his sentencing.

Inmates considered at an extreme risk for suicide are placed on a 24-hour watch protocol with a corrections officer stationed outside the cell. Inmates who have indicated they plan to commit suicide, attempted suicide in the past 30 days, engage in self-injurious behavior, or have a history of self-destructive behavior are put on watch protocols where they are observed at five-minute and 15-minute intervals, Haskins said.

Inmates identified as having serious mental illness are seen by PrimeCare medical staff a minimum of every 30 days during incarceration, Haskins said. An inmate previously placed on suicide watch is seen a minimum of every 90 days, even if they are not receiving mental health services, Haskins added.

Bucks County prison also has a separate suicide prevention policy for corrections staff, according to Director of Corrections Chris Pirolli. Under the policy, if a staff member identifies someone as potentially suicidal, the inmate is placed on suicide precautions and referred immediately to mental health staff, Pirolli said.

A shift commander, mental health or medical provider may initiate a suicide watch, but a licensed mental health professional designates the suicide watch level and supervision needed, he added.

Under the PrimeCare procedures, inmates typically are not on suicide watch for long periods, Haskins said.

“The goal is to downgrade watch levels as quickly as clinically indicated for the inmate’s safety while keeping them in the least restrictive level of observation,” he said.

No answers

The family has hired an attorney to find out more about the care Freitag received while he was jailed and the circumstances surrounding his death. They also started an online petition calling for Bucks County to create a trial diversion program for people with mental illness; so far, it has collected more than 1,500 electronic signatures. Nineteen other Pennsylvania counties, including Montgomery County, have such programs in place.

"We have not received any information regarding his death. We still can't believe it happened. We don't even know how something like that could happen," Bob Freitag said. "If a sentence like that is handed down there should be an automatic psychiatric evaluation. He just had his life pulled out from underneath him.

"Obviously we can’t bring my brother back, but we can try to make sure this don’t happen to somebody else.”

Added Crane, "No family should ever have to live this nightmare."