Oahu Inmate Kills Himself After Jail Staff Fails To Put Him On Suicide Watch
Jimuel Gatioan hung himself at OCCC despite warnings by a prosecutor and a defense lawyer that he was suicidal, court records show.
Staff members at the Oahu Community Correctional Center were warned at least twice that a prisoner there was suicidal, but the inmate managed to kill himself anyway in a case that raises questions about suicide prevention procedures at the state’s largest jail.
Lawyer Jonathan Burge, who represented prisoner Jimuel Gatioan, said jail staff were warned by both Burge and Honolulu Deputy Prosecutor Benjamin Rose that Gatioan had threatened to kill himself, but the jail failed to keep Gatioan under constant supervision on suicide watch.
“(Rose) did what he could, and I did what I could, and it’s just ridiculous they didn’t put him on suicide watch,” Burge said of the lawyers’ efforts to intervene. “I hope things change there, because when both the state and his lawyer notify the jail, and they don’t do anything, it’s a tragedy that could have been avoided.”
Staff at the jail who spoke on condition that they not be identified said Gatioan was sharing a cell with two other inmates in Module 11 of OCCC when he hanged himself on March 28. One of his cellmates woke up and found him hanging, staff said.
Staff said the jail was notified by Gatioan’s wife a week before he died that he was suicidal, and that warning was recorded in a log book in Module 11. Mental health staff spoke to Gatioan briefly after that report but did not move him to suicide watch, staff said.
The Department of Public Safety said in a written statement that an inmate between the ages of 40 and 50 was found “unconscious and unresponsive in his cell” at 1:20 p.m. on March 28. Staff provided aid to the inmate and called for medical assistance, and the prisoner was transferred to a local hospital. He died a week later.
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According to a Circuit Court filing by Burge, Gatioan was later deemed to be “brain dead” and in critical condition at the The Queen’s Medical Center.
Gatioan had been jailed for his wife of nearly 30 years with a screwdriver, and jail officials told the family she could not visit him at the hospital because she was the victim in the case.
Burge then filed a request with the court asking that Gatioan be “released” so his wife could visit him in the hospital to say goodbye. Judge Ronald Johnson granted that request, and the Department of Public Safety said he was officially released on April 3.
“She did get to say goodbye” before Gatioan died on April 4, Burge said of Gatioan’s wife.
The Department of Public Safety declined to answer questions about the case, including why Gatioan was not on suicide watch.
“As is normal procedure, an internal investigation is pending. The Department of Public Safety won’t be commenting further, at this time, in order to allow the on-going investigation to take its course,” DPS said in the statement.
Burge had planned to ask the court to move Gatioan to Hawaii State Hospital for an mental health evaluation by a panel of experts because “there were mental health issues that caused all this in the first place,” he said.
He visited Gatioan on March 24, and “he didn’t look good emotionally, but he was still alive, so I figured they were doing whatever they were doing and keeping him that way,” he said.
“He obviously was emotionally distraught when I met him, but this is just dropping the ball at OCCC, I can’t believe it still,” Burge said.
Burge said he told Gatioan to “just hang in there,” and that he was making efforts to get Gatioan moved but it wouldn’t be immediately. He recalled telling the inmate “‘You have to wait a week.’ And he couldn’t wait a week.”
Michael O’Malley, a Honolulu lawyer whose son Joey killed himself at Halawa Correctional Facility in 2017, said the Gatioan case “is a giant exclamation point” that underscores the need for dramatic improvement in mental health services in state correctional facilities.
O’Malley and other local attorneys are working with Pablo Stewart — an expert on adult and juvenile prison mental health systems — to seek reforms in the system, particularly in the area of mental health.
“For us, it’s a rallying cry, that we’re on the right track and this is something we can’t turn away from,” O’Malley said.
