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when he provided the night meal. He was not informed that Vaughn had requested a transfer from the K Module to the SHM. Eve Kendall, the DOC's Intelligence and Investigation Manager, interviewed Turpin, who said Vaughn was resting on his bed during the majority of his shift that day. Turpin said that at about 6:20 p.

Turpin responded he would look for out and he would likewise talk to a manager to authorize a telephone call for Vaughn. At roughly 7:04 p. m., Rhone found Vaughn hanging from a bed sheet that was secured to the air intake grate in his cell. Vaughn was dead.

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Rhone and Turpin were disciplined for missing their set up observations and for falsifying log entries. Gillespie had been the DOC's director considering that August 2000. The DOC had a zero tolerance for inmate suicides. When she started her tenure, she analyzed the suicide prevention policies at the jail and instituted a number of changes.

Thomas White, a consultant in suicide prevention in January 2001, who made sure recommendations for the prison's suicide avoidance policy. Modifications consisted of altering suicide watch checks from every 15 minutes to every 4 minutes, identifying and evaluating risk consider inmates, producing the close observation status, and looking at the different approaches by which inmates can dedicate suicide.

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The DOC had inmate suicides in 2001, 2002, and after that Vaughn in 2003. The inmate suicide in 2001 likewise used the air vent to assist in the suicide. Prior to Vaughn's suicide, Gillespie had chosen that the higher priority for suicide prevention was correct screening and supervision of prisoners instead of physical changes to the facility.

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Vaughn's mother, Sharon, testified she knew Vaughn was self-destructive. He had actually discussed taking his life in front of her and had made such remarks within a year prior to his death. Dr.  Source  suggested that Vaughn displayed common self-destructive propensities consisting of being violent, intoxication, and irrational habits. He said Vaughn's behavior of not bailing himself out with the cash in his pocket was quite illogical.