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The wife of a prisoner who hanged himself last year while awaiting trial at the Oahu Community Correctional Center is suing the state, alleging staff at the jail were warned at least twice the inmate was suicidal before he died.

Jimuel Gatioan, 49, was found hanging in his cell at OCCC on March 28, 2023, adding to an alarming rise in jail suicides. He was taken to a local hospital where he was declared brain dead, and died six days later, according to court records.

Honolulu lawyer Jonathan Burge, who represented Gatioan, said in an interview last year jail staff were warned by both Burge and Honolulu Deputy Prosecutor Benjamin Rose that Gatioan threatened to kill himself. But Burge said 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 at the time. “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.”

The lawsuit filed on behalf of Gatioan’s wife Judith alleges “the jail failed to provide Jimuel with necessary and appropriate mental health care, failed to keep Jimuel under constant supervision on suicide watch, and then failed to exercise reasonable and appropriate care to protect Jimuel from harming himself.”

It also alleges a “a pattern and practice” in Hawaii’s correctional facilities of “breaching the standard of care with respect to the custodial treatment of inmates and the protection of inmates from self-harm, and this pattern and practice has resulted in numerous instances of self-harm by inmates, including, but not limited to, Jimuel’s suicide.”

Data compiled by Civil Beat shows the Hawaii correctional system had at least 12 known or suspected suicides from 2020 to 2024. That compares with only six suicides in Hawaii prisons and jails from 2015 to 2019, according to Bureau of Justice Statistics.

Myles Breiner, who filed the lawsuit last week on behalf of Judith Gatioan and Jimuel Gatioan’s estate, said “normally you don’t have both the prosecution and the defense on the same page saying ‘Hey, this person is in need, he needs assistance.’ “

“So, it’s really rare to have everyone who has had contact with him noting that he’s at risk. That’s really shocking,” Breiner said. “In this case, everyone was well informed in advance of the suicide that he was at risk.”

Breiner said there is a long-standing protocol in place in the correctional system that requires people at risk for suicide to be kept under intensive supervision, “and they didn’t do it.”

Spokespersons for state Attorney General Anne Lopez and the Department of Corrections and Rehabilitation said in written statements Friday they had not yet been served with the complaint, and do not generally comment on pending litigation.

Lawsuits over jail and prison suicides have proved to be quite expensive for the state.

A judge awarded the family of Joseph O’Malley $1.375 million in 2022 in connection with his suicide at Halawa Correctional Facility, and lawmakers agreed that same year to pay $550,000 to settle a lawsuit over the death of Daisy Katsitati.

Katsitati, 26, hanged herself at the Maui jail on Oct. 12, 2017. According to written testimony submitted to lawmakers by the state Attorney General’s office, Katsitati suggested to a jail guard that she be placed on suicide watch, but “no action was taken to get her medical help or to put her on suicide watch.”

Another lawsuit over a suicide at OCCC was filed earlier this year over the death of Diamond Simeona-Agoo, 21, who hanged herself at that jail in 2022.

At the Federal Detention Center on Oahu, convicted crime boss Mike Miske Jr., 50, was found dead in his cell on Sunday, an apparent suicide. That death is still under investigation and an autopsy pending.