This story discusses suicide. If you or someone you know is having suicidal thoughts, you can call or text the Suicide Prevention Lifeline at 988.

Dave Johnson has a simple life. He goes to work, comes home and turns on the TV. When the weekend rolls around, he might have a couple of beers at the bar. He leaves the dartboard alone — it’s not his thing. And you’ll never catch him joining a bowling league. 

Nearly every day, though, for the past eight years, he’s thought about his son, Hunter.

He’ll remember Hunter’s big smile or his alternating haircuts — long or shaved, depending on the weather or the mood. Whether his son might have made a living welding. Maybe Hunter would have gone back to college or worked at a hamburger place, instead. Neither would have surprised Dave. Driving through Cheyenne, he will sometimes be struck by a memory, like Hunter walking away, saying goodbye over his shoulder. He was close with his teenage son and knew him well. But he wishes he understood Hunter a bit better and the troubles that took his life. 

Mostly, he wishes things could’ve been different. That’s because on Dec. 26, 2015, Hunter, at age 19, died following a suicide attempt in the Laramie County Detention Center. 

Hunter, like many of the people who die by suicide in Wyoming’s jails, did not have a significant criminal record at the time of his death — he’d never been to jail before. But he did have mental health challenges, and his dad said Hunter had multiple concussions in his childhood. During his teenage years, he experienced depression and started drinking. In the months before his death, Hunter had twice been involuntarily hospitalized in connection with suicidal ideation, according to court records. He was set to enter an outpatient treatment program for his alcohol use, but by the time treatment was supposed to start, he had been arrested.

The arrest happened on Dec. 19. Hunter was drunk in a Cheyenne Walmart. He got into an argument with a cashier, and the store manager called the police. When officers arrived, Hunter resisted arrest. Officers knew about Hunter’s mental health struggles: Dave told officers that Hunter had issues with alcohol and depression. Hunter told police he was suicidal and demanded to be taken to the hospital, according to court documents authored by a federal judge in connection with a later civil lawsuit. Strapped to a gurney, Hunter rode to jail in the back of an ambulance.

Because he said he was suicidal, deputies booking Hunter in put him on suicide watch, which required that he be checked every 15 minutes. Two days later, staff removed him from suicide watch but kept him on a medical watch to monitor for alcohol withdrawal.

Following his initial court appearance, Hunter walked toward the courthouse door leading outside and away from custody. A deputy intercepted him. Back in jail, staff responded by putting Hunter into disciplinary isolation, which meant he was housed entirely alone and away from other inmates. At the time, he told deputies that he was not suicidal. But within an hour of being booked into the new cell, Hunter undertook the fatal suicide attempt, court documents show.

On Dec. 26, 2015, Hunter Johnson died at age 19 following a suicide attempt in the Laramie County Detention Center. Johnson is one of six people to die by suicide at the facility in the last 10 years. (Maggie Mullen/WyoFile)

Hunter is one of 22 people who died by suicide in Wyoming’s county jails over the course of a decade beginning in 2012. That makes suicide — by far — the leading cause of death in Wyoming’s jails. Although jailers have immense control over the inmates in their care, and although experts say that suicide can be prevented, the problem remains unsolved.

Among the deadliest

The scourge of jail suicides is not contained to Wyoming. According to a Department of Justice report, suicide is the leading cause of death in jails nationwide. But Wyoming’s facilities are among the deadliest. The suicide rate in jails here is the fourth-highest in the country. In the Mountain West, it is second only to Montana. Although even among the general public, Wyoming has a notoriously high suicide rate, that number triples for people incarcerated in county jails.

To investigate this story, WyoFile submitted requests under public records law to the sheriffs of each of Wyoming’s counties. In those requests, WyoFile asked sheriffs for details on deaths in their jails: who had died, when they had died, the cause of the death, and whether the sheriff had requested an external investigation from the Wyoming Division of Criminal Investigation. By statute, DCI — part of the Attorney General’s Office — may investigate at the request of a county law enforcement official. Otherwise, it would only be authorized to investigate jail deaths at the governor’s direction or if a death occurred under certain circumstances, such as in connection to intra-county organized crime. 

Sheriffs for all 23 counties replied to WyoFile’s records request. Eight of them reported no in-custody death over the preceding decade. The remaining counties reported 34 deaths in total. Two-thirds of those were suicides. 

Over the time period examined by WyoFile, six people died by suicide in the Laramie County Detention Center, the facility in which Hunter died. Publicly available details, though, are sparse. 

Hunter’s death wasn’t investigated by DCI. In fact, no death in the Laramie County Detention Center has been investigated by the outside agency since a suicide in 2012, according to DCI.

The details of Hunter’s death were only made public because his family sued the county. 

Sheriff Brian Kozak, who was sworn into office in January, said he would only request an investigation from an outside agency like DCI when deaths are tied to jail staff use of force or misconduct.

Suing for change 

Wyoming doesn’t have a regulatory mechanism providing independent oversight of county jails. Instead, each county sheriff is responsible for his or her own compliance with legal limits on jailers’ conduct. If a sheriff’s jail doesn’t comply with the law, it’s typically up to individual inmates or their families to seek their own remedy by way of a lawsuit.

The Johnson family did just that. After Hunter’s death, the family sued county officials and employees. Even though the lawsuit sought money, that wasn’t really the point, Dave Johnson said. He’d wanted to inspire change in a jail that had a rash of suicides. “People do not listen, and changes do not get made in this country,” Dave said. “Unless it hurts their back pocket.”

(Eda Uzunlar/WyoFile)

Court records show that after years of litigation, a federal judge dismissed some of the causes of action via qualified immunity, a judicially created doctrine that protects government employees from financial liability under certain circumstances. The court did not rule on another set of claims arising under state law. The family indicated it would appeal the decision on the federal claims and — while that process was underway — settled with the defendants.

Dave declined to talk about the details of the legal process, referring WyoFile to John Robinson, partner in the Jackson law firm Robinson Bramlet LLC, which represented the Johnson family in the litigation. The attorney said the Johnson family received “a monetary settlement that was a compromise between the positions of the parties.” He declined to otherwise detail the terms of the settlement, citing confidentiality concerns.

Talking generally about the litigation process, Robinson said that litigation cannot serve to replace the regulation of jails. Lawyers serve their clients, and the client’s interest won’t always match what a regulator would do or what’s in the best interest of other inmates. But because county governments and their insurance pools pay the costs of jail litigation, suing county officials can induce change. “When things like this happen — and it costs the county money — most governmental agencies will look at that,” Robinson said. 

Not all lawsuits, though, seek to recover money damages. Robinson and the ACLU had previously represented a Wyoming woman seeking to enter a local boot camp program in lieu of a prison sentence. Although young men in Wyoming had access to such a program, women did not. And, as a result, the woman was shipped off to a boot camp in Florida. The 10th Circuit U.S. Court of Appeals — which hears cases from Wyoming and other states — ruled that when Taylor Blanchard successfully completed the program, her case became moot. Although Blanchard lost in court, the Legislature passed a law to create a women’s boot camp in Wyoming.

When dealing with county jails, though, litigation tends to be more piecemeal. Because sheriffs are elected county-by-county, they have broad autonomy in performing their jobs. Conditions can thus vary significantly from county to county. A plaintiff is less likely to identify a uniform problem across jails. And lawsuits thus tend to be brought against one county at a time. Although litigation can help to change conditions in a given jail, Robinson said, uniform change in Wyoming’s county jails won’t likely come from a lawsuit. Systemic change would likely require statehouse intervention.

Kozak would welcome more guidance and oversight from the state because, he said, when he assumed office as Laramie County’s sheriff eight months ago he was frustrated by how out of date the agency’s policies were. 

“They’re not best practices,” Kozak said. “And so I would welcome some sort of oversight so that sheriff’s offices across the state are following best practices.”

Kozak said he signed a $20,000 contract with the National Institute for Jail Operations to help the detention center update its policies as soon as possible. 

The institute helps make “facilities safer and more secure, helping you proactively defend against frivolous litigation to protect against adverse publicity and liability,” according to the website. 

In plain sight

In addition to providing accountability and spurring change, lawsuits can reveal information that might otherwise go unknown. At the time of Hunter’s death, Laramie County Detention Center had video cameras in each cell. But deputies didn’t watch them live, according to court documents authored by a federal judge. The video footage was only reviewed after the fact. When the footage was reviewed, it showed Hunter spending about 15 minutes preparing for suicide. For 10 minutes he constructed a noose from bags, measured it against his neck, and tried to attach it to a ceiling vent. A deputy saw him putting something in the vent, confiscated the bags and threw them out, court documents state. The documents do not indicate whether the deputy knew that the trash was a noose. The deputy moved on and, over the course of five minutes, Hunter took off the shirt of his jail uniform and tried placing it over fixtures in the cell with the other end over his head, apparently testing whether he could hang himself. But, because the jail staff did not watch the video live, deputies did not know that Hunter was actively suicidal in the hour before his fatal suicide attempt. 

(Eda Uzunlar/WyoFile)

In some ways, Hunter’s death was not unique. A WyoFile review of 16 DCI investigations demonstrated a common set of circumstances in the suicide deaths of jail inmates. At least four of the deceased had a history of threatening or attempting suicide, including in custody. More inmates had histories of mental illness and drug addiction. Frequently, the DCI investigations show, inmates have completed suicide by hanging or strangulation, with nooses fashioned from bedding or clothes. To prevent a person seeing them, suicidal inmates block their cells’ windows with trash bags or laundry. Because it is also common for inmates to cover windows while using the restroom, guards don’t see the preparation as out of the ordinary. But in some instances, a cell window will have been covered for an hour before a person is found deceased. 

Risk factors

One of the big differences between suicides completed inside incarceration facilities and those completed in the free world is the method used, said Carolyn Pepper, a psychology professor at the University of Wyoming whose research focuses on self-injury and suicide in the Mountain West. In Wyoming, firearms are the most common way to die by suicide. But that’s not generally an option in jail. People who die by suicide in jail tend to do so by hanging, according to Pepper. And that holds in Wyoming’s jails. According to records provided to WyoFile by the Wyoming Division of Criminal Investigation, 12 of 16 suicides investigated by the agency between 2013 and 2022 were by hanging. 

“Each suicide represents an individual story,” Pepper said. But certain factors make a person more likely to die by suicide. Demographically, suicides tend to occur among older white and Native American men. People who have mental illness — including depression, like Hunter — and substance dependence also tend to be at higher risk of suicide. And stressful life events can correlate with suicide: in an interview, Pepper gave examples ranging from loss of a job, interpersonal loss and incarceration. 

All of these factors tend to make jails a perfect storm of sorts. Most people incarcerated are men. And, in Wyoming, most of those men are white. Mental illness and substance dependence also occur more frequently among people jailed than in the general public. Even without those factors, an arrest and jailing tends to be a stressful life event on its own. Incarceration often precipitates job loss, relationship dissolution or even the loss of a place to live. “That initial shock of being in the system,” Pepper said by phone in September, “is such a profoundly upsetting event that it seems to lead to suicide.”

A different model

Although Wyoming relies on lawsuits to provide jail oversight, that’s not the case everywhere. Some states have different mechanisms. In such states, an agency such as the state corrections department might be responsible for regulating the conditions of confinement and ensuring that jail staff is complying with the rules. But, until the Wyoming Legislature passes a law authorizing regulation, the state will go without such a tool.  

Michele Deitch, a distinguished senior lecturer at the University of Texas’s LBJ School of Public Affairs, has helped jail systems throughout the country develop operating standards that include a target of reduced suicides. Deitch told WyoFile that regulation of jail administration “can be very effective.” About half of states have some form of statewide oversight of county jails, according to Deitch’s academic publications authored in 2010 and 2020. 

U.S. Department of Justice research found that increased awareness of jail suicide, improved suicide prevention training, better intake processes and the coercive pressure created by litigation may reduce jail suicides. (Illustration by Eda Uzunlar/WyoFile)

Although people being booked into jails tend to be at higher risk of suicide than the general population, jail suicides can be reduced. A study conducted by the Department of Justice found a threefold decrease in the rate of jail suicides between 1986 and 2006. The study’s authors suggested that the decrease might be attributable to increased awareness of jail suicide, improved suicide prevention training, better intake processes and the coercive pressure created by litigation. 

Pepper, the Wyoming professor, said that one of the best ways to prevent suicide is to remove the method that people use to attempt suicide. Researchers in the field concern themselves with “anchors,” which are outcroppings to which a person might connect a makeshift noose. Removing anchors from jail spaces — and especially from a space an inmate might occupy privately, like a restroom — can greatly reduce the risk of suicide in custody. 

And because suicides are often impulsive acts, Pepper said, it’s best to avoid housing people in single cells. Another person in the room can serve as a deterrent effect. And having another person to talk to can also serve as a distraction from suicidal ideation. 

Training staff to assess people being booked into jail and to watch for indications of suicidality can also greatly reduce the risk of suicide. Suicidal people will often say that they are considering suicide, which can then put staff on notice and allow them to watch for suicide attempts, Pepper said.

Right now, there’s no regulatory oversight to guarantee suicide prevention is happening in all of Wyoming’s 23 county jails. 

Suicides are not inevitable

Despite the high risk of suicide among inmates, Deitch said, the highly controlled environment should more than counteract that risk. Jail officials’ ability to limit access to weapons or other methods of suicide means that in-custody suicides are “not inevitable at all,” Deitch said. “You shouldn’t have the opportunity in jail.”

Although regulation can be effective, Deitch acknowledged that a human component is required for any regulation to be effective. The standard is only a baseline for operations. Training can help staff to understand how to behave. “You can’t regulate how people talk to each other and how people care about each other,” she said. 

Deitch pointed to the Scandinavian model as a possible alternative. There, prisoners live in single cells and have private bathrooms. But despite the additional privacy, there is a relatively lower incidence of suicide. Deitch attributes that to the concept of “dynamic security,” in which the safety of the institution arises from relationships between staff and residents. The more rehabilitative model can help to create a sense of community and reduce risk of suicide. 

The four-volume “Rights of Prisoners” sits behind Lt. Steve Dunning’s desk in the Sublette County Detention Center. (Tennessee Watson/WyoFile)

Allen Thompson, a former Sheridan County sheriff who now serves as executive director of Wyoming Association of Sheriffs and Chiefs of Police, agreed to speak to WyoFile as a former sheriff rather than in his WASCOP role. Before his current position, Thompson worked in law enforcement for 25 years, the final five of which were as Sheridan County sheriff, a position from which he stepped down in 2022. During his five years as sheriff, two people died in Thompson’s jail; one of those deaths authorities ruled a suicide. 

“Any one suicide in a jail is something that we should always be working to avoid,” Thompson said. He acknowledged that the level of control and supervision in a jail is significant: “Sounds easy, right?” But Thompson said that suicide prevention is not as simple as it might seem. A determined inmate might spend their days watching for patterns in deputies’ behavior, waiting for the ideal moment to attempt suicide.

The needs of inmates might vary from jail to jail, depending on the population of people being booked in, the communities in which the facilities are located and the sizes of the jails. But based on his experience overseeing the Sheridan County jail, Thompson said that there are measures that work, beginning with facility design: ensuring walls are smooth and no pipes are sticking out that could serve as an anchor for a noose; installing bunk beds that can’t serve as anchors either. Deputies should be trained properly, get to know the people in the facility and learn to spot when inmates are acting out of the ordinary.

Thompson pointed to the Sublette County Detention Center’s approach as one worth emulating. The county reported zero in-custody deaths over the past decade. 

Lt. Steve Dunning, who helps run the jail, said that deputies in the Sublette County Detention Center try to provide a standard of care higher than that required by law. Mutual respect, and a philosophy that incarcerated people are humans who deserve to be treated with dignity, is an important part of the equation.

“It’s definitely a cultural thing,” Dunning told WyoFile. “Those individuals who come [to work] here that don’t agree with the culture usually move on.”

Thompson noted that the general public in Wyoming has historically had among the highest suicide rates in the country. That Wyoming’s suicide rate in jails from 2000-2019 was fourth in the country, rather than first, Thompson argued, is a testament to effective suicide prevention by the state’s sheriffs. 

(Eda Uzunlar/WyoFile)

“There’s a lot of work being done on suicide prevention in the state and has been for the past several years,” Thompson said. “Continuing down that path and including any in-custody suicides as part of that discussion” is an important part, Thompson said, of a difficult process. But, he said, zero suicides in Wyoming’s jails is an achievable goal.

A goal that would be easier to reach if the state expanded access to in-patient psychiatric care, Kozak from Laramie County said. 

“We have people in jail, that shouldn’t be,” Kozak said. “They should be at the Wyoming State Hospital.” 

There are currently ten people held at the Laramie County Detention Center with severe mental illness waiting for evaluations from the state’s psychiatric facility, which is backed up due to staff shortage, Kozak said. He hears similar stories from sheriffs across the state.

When people don’t get the mental health care they need they commit crimes and end up in jail, Kozak said. Of the 250 inmates currently held in the Laramie County Detention Center, 40% have been diagnosed with a mental illness by the jail’s medical staff, according to Kozak. 

To better serve those with mental illness and suicidal ideation, the sheriff’s office set aside $750,000 to create a mental health pod, Kozak said. Because inmates in crisis need 24/7 monitoring, they are currently held in booking, where it’s loud and the lights are on all of the time. The mental health pod, set to open in March 2024, will be a less chaotic alternative, Kozak said. 

A collaborative approach

A spokesman for Gov. Mark Gordon told WyoFile that his schedule did not allow time to be interviewed for this story, but he did provide a written statement.

“Addressing the state’s mental health crisis and reducing Wyoming’s suicide rate continue to be priorities for Governor Gordon. This requires a collaborative approach to improving mental health services for this at-risk population,” the statement said.

The governor noted a recent pilot diversion program in Campbell County as one approach “that will help keep individuals with mental health conditions out of jail, instead directing them to available mental health services.”

“In addition, behavioral health reform remains an ongoing effort that dates back many years,” the statement said. “Challenges remain, but the governor is optimistic that the situation will continue to improve.”

The Campbell County program is yet to be implemented but is scheduled to begin operation in early 2024. It will allow for some people accused of non-violent crimes to have the criminal proceedings against them suspended while they undergo mental health treatment. If they successfully complete the treatment program, the charges will be dropped. 

But if they fail to complete the program, the local prosecutor will be able to go ahead with the original charges. The Legislature indicated that it will follow the program in Campbell County and determine whether to expand the program elsewhere in the state. Whether or when that reaches Laramie County remains to be seen. 

‘This is serious’

In the meantime, Dave Johnson will keep missing his son. When he grabs his steering wheel, he’ll see a tattoo of Hunter’s name on his left forearm. Occasionally, he’ll get an update from the person to whom Hunter donated his pancreas. And he’ll keep looking for a solution to Wyoming’s suicide crisis, especially in county jails. 

Dave doesn’t think he’ll go back to being the easygoing person he once was. He’ll watch TV after work. On Friday, he might drink a couple of beers. And when he talks to a friend whose kid is having a hard time, he’ll tell them: This stuff is serious; act like it. Talk to a doctor. There’s help available. Get it.

He knows that guards are busy. They don’t want deaths on their watch. He still wonders if something could have been different. Maybe more suicide awareness in schools and training for deputies in the jail. Maybe Hunter could have been taken to the hospital again, instead of the jail. But still, he thinks: “Is there any other place in the world where you’re more guarded than in a jail setting?”

If you or someone you know is having suicidal thoughts, you can call or text the Suicide Prevention Lifeline at 988.

Reporting contributed by Tennessee Watson. 

This is part two, of an ongoing investigative series, examining why people die in jail, why the public knows so little about these deaths and how they might be avoided in the future. 

This reporting was supported by the Fund for Investigative Journalism.

Shane Sanderson is a recent graduate of Georgetown University Law Center. Previously, he covered cops and courts for the Casper Star-Tribune.

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  1. So much I’d like to address concerning this article. But one point in particular stands out and that is the staff shortage at the Wyoming State Hospital. I’m a retired LCSW and I worked less than 9 months at the state hospital. At the time I worked there, they had the largest amount of staff assaults by patient’s since they kept record. Most of my training there was how to protect myself. You can’t work at your best capacity as a clinician when you are consistently worried about being assaulted. I was no stranger to being assaulted on the job but at the state hospital it was more severe. Staff that had been assaulted were hospitalized, required surgery or were forced to retire due to injuries. We were a staff of traumatized clinicians seeing our coworkers assaulted and injured. We were always short on staff. I hated working there and quit. The state must address the suicides in jails and the conditions at the state hospital in tandem. It’s a multi prong approach. The state hospital is also not for everyone who suffers from chronic mental illness. We need more local community mental health services that address those needs as well and try to combat the stigma attached to treatment.
    Trauma informed care is a must in our jails. When you have people who have been traumatized with addictions and then placed in jails, it can be deadly. This can be addressed differently with trauma informed care training for staff that is ongoing.

  2. “deadliest in the nation” headline gets reader advertising clicks but rates per 100,000 residents is not an indication of systemic problems. All low population states will have high “rates” of incidents even though the actual number of events is very small. Wy (pop. 5K)& Montana with several hundred deaths per year but very low populations will always have the “highest rates” in the country. States like CA (39 million), TX, & NY with thousands of deaths will always be the lowests rates because of high populations. Don’t let the use of rates determine the scope of the problem. Remember, provocative headlings sell advertising but don’t tell the whole story.

  3. Do you think that people who live in the Mountain West have acclimated to the space & outdoors? Incarceration could be more oppressive for them.