Ten men and one woman hung themselves in San Diego County jails during the last six years. They used socks or sheets, stringing handmade nooses from sinks, doors and bunks.

One inmate flung himself headfirst over the second tier of his unit. Two men intentionally overdosed on prescription medication. One drowned himself in a toilet. Another purposefully ingested a large amount of water so quickly that he died from acute water intoxication.

All counted, the San Diego County Sheriff's Department recorded 16 inmate suicides between 2007 and 2012. Among California counties, only Los Angeles, whose jail system is roughly four times the size of San Diego's, recorded more suicides—24—during that period.

"The sad reality is that a person who is determined to commit suicide will commit suicide, and by using the everyday objects within their reach," Sheriff's Department spokesperson Jan Caldwell writes in an email. "We train our deputies to look for signs of distress. However, drinking water would not be a recognizable signal for anyone."

But for correctional health experts, the county's high suicide and mortality rates signal something could be wrong in San Diego's five jails.

As we reported in the first part of our investigative series "60 Dead Inmates," between 2007 and 2012, San Diego County had the highest mortality rate among California's 10 largest jail systems. Using the statistical method adopted by the U.S. Bureau of Justice Statistics (BJS) and the National Institute of Corrections—the number of deaths divided by each jail system's average daily population—CityBeat also found that San Diego had the second-highest suicide rate among the state's large jail systems: 54 suicides per 100,000 inmates, more than 60 percent higher than the average.

Caldwell described the BJS methodology as "mathematically exaggerated" and argued that it's more appropriate to compare the number of suicides with the total number of inmates who pass through the jail system annually. Using that method results in a rate of 2.8 suicides per 100,000 inmates.

"If San Diego County wants to calculate their suicide rate based upon yearly admissions, they're perfectly free to do so," says Lindsey Hayes, a suicide-prevention expert with the National Center on Institutions and Alternatives. "But then they cannot compare themselves to others because no one else calculates the rate like that. Clearly, the average daily population rate has its drawbacks, but it's the purest rate."

CityBeat obtained and analyzed medical-examiner reports, oversight-body findings and jail policies and interviewed family members to put together a picture of how suicides happen in jail.

"When I investigate a jail system that's had [16] suicides in a six-year period, I tend to find that there were either bad practices or preventable deaths in many of the cases," Hayes says. "You normally come to the conclusion that not all of those 16 deaths were preventable, but many of them were."

Hayes says he looks for problems with training, intake screening, inadequate medical and mental-health staffing and whether there are enough officers to do rounds at regular intervals.

"There are usually multiple reasons why these problems exist," he says. "You don't have to average two or three suicides a year in your jail system."

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Blame is a hard thing to place when an inmate commits suicide. In a broad context, jail suicides can be viewed as a product of history, with the de-institutionalization of the mentally ill in the 1960s and '70s.

"A lot of people have made the observation or argument that with that change in our mental-healthcare system, a lot of the chronically mentally ill who previously resided in state hospitals are now circulating between the streets and correctional settings," says Dr. Hal Wortzel, a University of Colorado professor who's examined suicidal behavior among inmates and recently released inmates. "That may, in part, explain why we see so many suicides in correctional settings."

Caldwell describes the department's medical screening and care as "excellent."

She acknowledges the Sheriff's Department's role as one of the county's largest mental-health service providers—roughly a quarter to one-third of inmates are on psychiatric medication, she points out.

For the parents of inmates, blame often turns inward. Shane Hipfel had always been bipolar, but at the end of the summer of 2011, the 39-year-old tutor was off his medication and experiencing violent, paranoid-schizophrenic episodes. In October, he was arrested after attacking a gardener who was mowing the lawn near his window.

Shane's parents, Wayne Hipfel and Peggy Leder, had been flying back and forth from Michigan, where they lived, staying for weeks at a time to check on their son. They're haunted by their decision not to bail Shane out of jail.

"I wish to heck I had," Wayne says. "I thought about it, but I wasn't really ready to do it, either, because I didn't know what we were going to do when we got him out."

In jail, they thought he'd be protected from himself and receive treatment. Shane was a "green-banded" inmate, which meant he wore a fluorescent-green wristband to indicate he was highly assaultive. When his parents visited him, he was covered in bruises and abrasions and expressed fear that someone was going to kill him.

"He would never say who," Wayne says. "We didn't know if schizophrenia was going on with him or if somebody was threatening him in jail."

Shane was sentenced to a three-year term at Patton State Hospital in San Bernardino County, but the transfer was weeks away, if not months. The paperwork allowing psychiatric treatment to begin at the jail also was delayed by a backlog at the court.

New Year's Day 2012 brought good news: Shane finally had been transferred to the jail's psychiatric security unit, where he could be medicated.

"Boy, that was the best call we got," Wayne says. "We were so happy about that."

The next day, another call came. Shane was on life support after attempting to drown himself in his toilet. He died five days later.

Wayne and Peggy have yet to find closure; there's just not enough certainty. They remember Shane's fear, his injuries and how an independent pathologist said his autopsy pointed to homicide. But the pathologist never saw the video that reportedly captured Shane's death.

A San Diego attorney watched a portion of the video on behalf of the family's lawyer and said it was clearly suicide, but Wayne wants to see it himself, even if it means going to court.

"If they do show me the video of him, I don't cherish seeing that, but at least I'll know."

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In 2007, the Sheriff's Department—at the recommendation of the county's Citizens Law Enforcement Review Board (CLERB), the oversight body that reviews jail deaths and officer-related misconduct—implemented a new suicide-prevention training program to help staff better identify suicidal inmates. An April 2008 letter from CLERB's then-chair Robert Winston acknowledged the progress but demanded more after 21-year-old Adrian Correa, a schizophrenic who'd threatened suicide in the past, fashioned a noose out of a blanket and hung himself from the top corner of his bunk.

CLERB's investigation identified significant gaps in how information regarding at-risk inmates is communicated between guards and support staff. The board advised the Sheriff's Department to include briefings during shift changes and implement a checklist system so deputies could better keep track of suicidal inmates.

"There is no written guidance on the type of information passed from deputy to supervisor, or from supervisor to supervisor," Winston wrote.

It took the Sheriff's Department nearly two years to respond to Winston's letter.

In his response, Earl Goldstein, the jail system's medical director, downplayed the problem of suicide in county jails, saying that during a two-year period—July 1, 2007, through June 30, 2009—only four inmates had killed themselves.

His count, however, was off by two. Six inmates killed themselves during that period; a seventh committed suicide on July 3, 2009. In 2010, five people killed themselves in county jails—the most during the six-year period CityBeat reviewed.

The jail system's written suicide-prevention policies are brief. They state that, during intake, every inmate's to be asked whether they've considered suicide, attempted suicide or been hospitalized for suicidal thoughts. Inmates who answer "Yes" to "Are you feeling suicidal?" are either placed in a safety cell or refused entry to the jail and transported to the county's psychiatric hospital. After intake, "[a]ll reports of suicidal behavior shall be considered serious," the policy says.

"Once they're on suicide watch, rarely does an inmate commit suicide," Hayes says. "Suicides occur when they're not identified properly and they slip through the cracks or they're prematurely released from suicide watch and put back into the population, and then hours, days, weeks later, they commit suicide."

Sean Wallace is one such example. The 38-year-old had been moved back and forth from a safety cell to the general population several times, a medical examiner's report notes. He was bipolar and schizophrenic, had repeatedly said he planned to kill himself and had reportedly tried to slice his wrists with a butter knife. On April 23, 2011, 48 minutes after he'd been moved back to the general population, he was found hanging from his bunk by a bed sheet torn into strips.

Hayes says the standard of care is to closely monitor suicidal inmates—every 15 minutes for inmates at moderate risk—keeping in mind how quickly someone can kill himself.

"Someone who is either threatening suicide and seemingly very serious about it, someone who has already attempted suicide—those are folks that almost everyone agrees are at high risk and you can't afford to put them on a 15-minute level of observation because it only takes three to five minutes to successfully commit suicide."

For some inmates, the warning signs aren't as clear. They won't admit suicidal thoughts to jail staff because they don't want to be placed in a safety cell, or there will be a triggering event—a bad day in court, an upsetting visit with family—that might push an inmate over the edge. Hayes says he'll do a "psychological autopsy"—go over an inmate's medical and psychiatric records, talk to jail staff and family members, basically do everything possible to try to get inside a person's head.

Connie Jones is trying to do that. She doesn't want to think her son, Christopher Blenderman, killed himself. The medical examiner categorized Blenderman's death as an accident, not a suicide, concluding that the 40-year-old overdosed on drugs, but not intentionally.

This doesn't jibe for Jones. Her son always stuck to his drugs of choice, cocaine and alcohol, but it was the odd combination of meth and heroin that were found in his system. And though he was a longtime addict, "Chris never drugged when he was in jail," Jones says. "He always went to the top of the class, and I would say, Why can't you live like this on the outside?'"

Blenderman's criminal history was tied to his addiction— he'd steal, often from family and friends—to buy drugs.

At the time of his death, he'd been in jail for a year and was facing another year, his mother says. The last time she talked to him, he "sounded forlorn." She wrote him a letter via the jail's email system, but it didn't arrive until the day he died.

Prior to his last jail stint, Blenderman, who was bipolar, had been in Tri-City hospital's psychiatric ward at least twice, Jones says. The medical examiner's report says he'd tried to commit suicide in the past; another part of the report says he admitted to jail staff that he'd thought about killing himself. Early on Sept. 7, 2012, he was found dead from a lethal combination of meth, heroin and antidepressants and anti-anxiety medication, some of which had been prescribed to him, some of which hadn't. His cellmate told a deputy that Blenderman had been "hoarding" medication.

In its September 2009 review of the death of James Phillips, a sex offender who took a lethal dose of the anti-depressant Doxepin, CLERB noted that other inmates had helped Phillips hoard the medication "in defiance of the jail's watch take' program, in which medical staff members watch inmates take their prescribed medication." The review board didn't, however, offer any policy recommendations.

Jones wants to find her son's cellmate, to see what exactly he knew. Like other parents CityBeat's talked to for this series, Jones has had trouble getting basic information from the Sheriff's Department.

She says her son "should have been on watch. They knew he'd been in the psych ward. He was on psych meds. So, if he stopped taking those meds on their watch, and if he used something on their watch, then that is their responsibility."

Kelly Davis

Suicide in the cell