After Multiple Suicide Attempts, Jail Staff Left Man to Kill Himself, Lawsuit Says

This piece contains descriptions of self-harm and suicide.

In one of his last calls from a rural New Mexico Jail, Jacob Gutierrez told his sister she would never see him alive again. 

“He said, ‘I’m dying in here,’” Gutierrez’s sister, Andriana Furne, told The Appeal. “Before the call ended, he tells me he won’t come home alive.” 

It would be the last time they spoke. Less than a week later, on June 18, 2023, Furne would travel to the hospital to find Gutierrez, a 26-year-old father, brain dead, with one arm “shackled” to his hospital bed. 

Over the course of nine days at New Mexico’s Otero County Detention Center last June, Gutierrez repeatedly engaged in self-harm and survived multiple suicide attempts, according to a wrongful death lawsuit filed by his mother earlier this month. 

Despite those incidents, correctional officers and medical staff failed to keep Gutierrez safe, ultimately placing him in a room with access to a corded telephone, which he used to take his own life.

Gutierrez’s mother, who is represented by the New Mexico Prison and Jail Project, a nonprofit advocacy organization, brought the lawsuit against the Otero County Board of County Commissioners and the jail’s private healthcare provider, VitalCore Health Strategies, as well as several staff members. The suit seeks both compensatory and punitive damages. VitalCore has been accused of providing incarcerated patients with inadequate care in jails and prisons throughout the country. 

Gutierrez was one of four people to die at the Otero County Detention Facility last year—two by hanging, one from an overdose, and one from a “medical condition,” according to county records. So far this year, one detainee has died, also by hanging. There were zero deaths at the jail from 2019 to 2022.

The four deaths last year are “a shocking number for a relatively small-population county jail,” said Mallory Gagan, a staff attorney with the New Mexico Prison and Jail Project, in an email to The Appeal. As of June 17, the jail housed 180 people, according to the County. The deaths suggest “an ongoing culture of indifference to inmate life and safety, from jail detention and medical staff,” added Gagan, calling it “a deadly combination.”

The jail’s director told The Appeal in an email that they do not comment on pending litigation. VitalCore and the county commissioners did not respond to requests for comment.

When Gutierrez arrived at the Otero County Detention Facility on June 9, 2023, he reported to the nurse that he had struggled with alcoholism and had a history of seizures and methamphetamine abuse, according to the complaint. His sister, Furne, told The Appeal that Gutierrez had experienced seizures after suffering a head injury at age 16. 

Gutierrez was placed in an observation cell in the jail’s medical unit. The next day, at 7:45 p.m., he told an officer he had ingested a large quantity of fentanyl pills. He collapsed. Staff administered Narcan, the opioid overdose reversal drug, but Gutierrez still appeared to be having a seizure and was taken to the hospital, according to the complaint. In the early morning hours of June 11, Gutierrez returned to the jail and was placed in a suicide smock—a sleeveless garment made of a heavy material designed to prevent self-harm. According to Furne, Gutierrez had never attempted suicide or harmed himself before his stint at the jail.

Two days later, on June 13, Gutierrez spoke with Furne for the last time. He told her he was cold, naked, and hungry and didn’t have a blanket. After the call, Furne said she contacted the jail and begged them to watch her brother. 

“They told me he had to request medical attention,” she said. “They could keep an eye on him, but he had to request medical.”

That same day, Gutierrez was moved into general population, where other detainees stole his mattress, blanket, uniform, and other items, according to the complaint. 

“I can’t be in here. I need to get out,” Gutierrez told an officer over the intercom system, according to jail records.

As officers escorted him out of general population—where he had been for less than two hours—he collapsed and began having a seizure. Doctors at a nearby hospital determined he had overdosed a second time, according to the complaint. He was transported by helicopter to a hospital in El Paso, Texas, for intensive care.

The jail did not call Gutierrez’s family to tell them about either overdose incident, Furne told The Appeal. They learned of the second hospitalization from a relative who also happened to be detained at the jail. After hearing this, Furne went to the local hospital and was told her brother had been air-lifted to another hospital, though no one would say which. 

After staying up all night with her aunt and calling every hospital, they “finally found him in the ICU in El Paso,” Furne said.

On June 16, a day after returning to the Otero County Detention Center, Gutierrez told an officer he wanted to kill himself, according to the jail’s reports. He was placed in a holding cell, outfitted with a suicide smock, and put on suicide watch. The room, however, was not a “special observation cell” and differed in some critical ways, according to the complaint. It did not have oversized windows “which would facilitate easier viewing and constant monitoring,” the suit states. The room also had a pay phone mounted to the wall, which the complaint alleges “was an obvious tool … for purposes of self-harm.” 

Although staffers were supposed to check on Gutierrez every 15 minutes, jail records show they did not do so consistently. 

At about 8:30 p.m. that night, an officer found Gutierrez seizing and called for medical help. When the nurse, who is named as a defendant in the lawsuit, arrived, Gutierrez asked to be put in a medical cell. The nurse told him this “was not possible at the moment,” according to his report.

Staff checked on Gutierrez again at 9:00 p.m., according to jail records. Although he was supposed to be checked on every 15 minutes, the next entry in the welfare check log is at 9:37 p.m., when he told an officer he felt “a possible needle in his arm.” 

The nurse returned to the cell to find Gutierrez pushing “a small metal object”—an IV needle—out of his arm, according to jail records. After the nurse removed the needle from Gutierrez’s arm, Gutierrez told him there was another needle still in his arm. According to the officer’s report, the nurse suggested Gutierrez try to remove it himself and said he’d come by later with tweezers. 

(The nurse’s report says he told Gutierrez he would return with a “tweezers/suture removal kit” but does not mention asking Gutierrez if he could remove it himself.)

At about 10:00 p.m., the officer on duty heard Gutierrez “grunting and groaning,” went to the cell, and saw that he was harming himself, according to jail records. She called for assistance. One of the officers who arrived at the scene wrote that Gutierrez was “covered” with “self-inflicted cuts.” Staff cleaned his wounds and told him they would inform mental health staff. 

Despite his repeated acts of self-harm, staff then extended the time between welfare checks from 15 to 30 minutes, according to the jail’s welfare check log.

At about 5:45 p.m. the next day, an officer found Gutierrez unresponsive in the cell after another suicide attempt using the cord of the payphone, according to the incident report. Gutierrez was taken to the hospital and never regained consciousness.  

Gutierrez’s family didn’t learn that he had been hospitalized until a day later, said Furne. When they went to see him, he was unresponsive. One hand was shackled to the bed. His wrists were bruised, and his body was covered in cuts. He looked nothing like the person who had loved to admire himself in the mirror, said Furne. With two older sisters, Gutierrez was the “baby” of the family, she said. 

“He was loving,” Furne said. “He was affectionate. If I walked in the room, he would tell me, ‘Sister, you’re so beautiful.’”

Since Gutierrez’s death, no one from the jail has offered their condolences, said Furne. When she went to pick up his belongings, she said they gave her a pair of boots, an earring, hospital gowns, and $40 from his spending account. She had put $120 in his account and asked about the missing $80. Staff told her the jail had charged her brother a booking fee each time he returned to the facility from the hospital—the $10 fee applies to all bookings, including “transports back from prison or other institutions,” according to the jail’s handbook.

The jail’s director would not answer The Appeal’s questions about the jail’s suicide prevention protocols or policies concerning booking fees or notifying families of hospitalizations. The jail’s suicide policy prevention policy, which The Appeal obtained through a public records request, states that while a person is on suicide watch, staff should remove all “potentially harmful items such as belts, shoelaces, pens, pencils, mirrors, glasses, and any sharp items” from the detainee “and the cell in which he or she is placed.” It also states that “Often our best tools in deterring suicide attempts is a caring, thoughtful word, positive reinforcement, listening to reports from fellow inmates or officers, and observed behavior.”

Furne says she hopes the lawsuit will hold the jail accountable and help ensure the next person gets the care they need. One of the jail’s primary responsibilities is to protect people in their custody, including from themselves, she said. 

“They treated my brother like he was nothing, like he wasn’t human,” Furne said. “How many more times did he have to cry out for help for them to take him serious?”

If you or someone you know is struggling with suicidal thoughts, help is available. The 988 Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States.