His dad warned me. He said it’d be difficult to read. I printed the eight-page document anyway and left it on the outskirts of my desk for a few days. Boldface words on the cover sheet would creep into my peripheral vision, though, and after taking a few deep breaths, I picked up the paperwork. No one, I thought, should have to read the autopsy report of a friend.

Using the emotionless prose of a pathologist who sees dead bodies every day, the coroner described Brian Heath Roundtree’s six-foot, 165-pound frame, brown hair, graying beard, and blue eyes. She noted that he looked roughly his age, which was 43.

They were prosaic details, things even an acquaintance would’ve observed. But I’d known Brian for a little more than 13 years as a co-worker and a friend, so when the coroner indicated a small scar on his lower back, recounted his pierced left ear, and chronicled several tattoos I knew the stories behind—the names and birthdates of his first two children on his right forearm, his wedding date on his stomach (“Til the wheels come off 5-14-05”), crude lettering of his nickname “Tree” on his left ankle—a smile tugged at my lips.

In life, Brian always had a story to tell. He was one of those people who seemed to have squeezed two lifetimes into the space typically reserved for one. After a beer or two, he would unfurl outlandish anecdotes from a troubled early adulthood—the time he spent on the streets, the drugs he did, the women he slept with, the serious legal trouble he got into—in a way that made you feel as though he had never left out a single detail, no matter how damning or disheartening. His candor was charming. His self-deprecation, irresistible. To know Brian was to know him fully. He had nothing to hide.

Except that wasn’t really true. The remaining notations in the autopsy report reminded me that, like anyone else, Brian had kept some things mostly for himself. Three names I’d never heard him mention were inked into his skin. Several other words had been purposefully made illegible. Scripted on the inside of his left wrist was “Be the water,” and scrawled on his shoulder was a quote from Henry David Thoreau.

Apparently, Brian still had tales to share, but it would be his body that would reveal the details of his life’s closing chapter, a story he wouldn’t be able to narrate himself. Even with his preternatural ability to turn a lesson learned the hard way into amusing happy hour chatter, Brian would’ve struggled to explain his final weeks, days, and hours. The fog of major depression—something else he had hidden from most of us—can engulf the mind and make even the most irrational decisions seem rational. That may have been why, in part, on January 19, 2018, Brian lay prostrate on a stainless steel table wearing an orange shirt and pants stamped with “Arapahoe County” and why the coroner concluded that there were fractures of the laryngeal cartilage consistent with suicide by hanging. It was the fourth time the Arapahoe County coroner had seen such a death in the county jail in as many years.

County jail is where many people land when life takes an unexpected, dramatic, and potentially criminal wrong turn. Perennially underfunded, inundated by the ebb and flow of arrestees and detainees, run by elected sheriffs who can come and go every four years, and subject to zero statewide standards in Colorado, county jails vary wildly in quality.

Recently, critics and activists have directed their ire at the gross deficiencies of jailhouse health care. Inmates, they say, are not receiving necessary medications, being seen by appropriate providers, or having their health concerns taken seriously—all of which has led to negative outcomes and bad press, particularly for the large, for-profit health care companies that are increasingly contracting with county jails.

The free public rarely dispenses much compassion for the woes of the incarcerated community. But, according to everyone from county sheriffs to the American Civil Liberties Union (ACLU), it should. “It’s really a ‘there but for the grace of God go I’ situation,” says Denise Maes, public policy director for the ACLU of Colorado. In other words, one extra cocktail, one bar fight, one unpaid fine, one lapse of character, or one moment of desperation might be all that stands between you and some unplanned time spent in the custody of the sheriff. On any given day in the United States, roughly 746,000 people are held in jail, where their lives are no longer their own and where their abilities to go to their medicine cabinets for their hypertension or antidepressant medications or call their doctors for a prescription antibiotic or ring their therapists for a mental reset can disappear for a couple of days or much, much longer.

The troubling reality is that approximately 74 percent of people who are handcuffed, read their rights, and held for varying lengths of time in jail are never convicted of a crime. In fact, the majority of people locked up in this country’s 3,134 local jails are pretrial detainees—in other words, they are presumed innocent until proven guilty. Many of them have mental health conditions that contribute to their inabilities to bond out, and many others simply cannot afford to post bail. “There are a lot of people in jail who are clearly a risk to society, and they should be here,” says Jefferson County Sheriff Jeff Shrader. “But most of us also know someone who’s had a bump in the road, made a mistake, and ended up in jail. We all have a vested interest in making sure jail is safe and provides the services it should for everyone.”

Safety—from a variety of would-be threats—is a tricky thing to guarantee in a correctional facility. Yet those who are incarcerated are theoretically protected from abuse and torture and promised reasonable medical care services under the cruel and unusual punishment clause of the Eighth Amendment and the due process clause of the 14th Amendment. Based on rulings from the Supreme Court of the United States and other lower courts, these amendments assert, among other things, that confinement is the punishment for a crime; compounding imprisonment with barbaric corrective tactics or deprivation of appropriate health care violates inmates’ constitutional rights. “Essentially, the courts have said even if you’re a serial killer, we must provide humane treatment,” says Ed Budge, a Seattle-based civil rights attorney who has worked on more than a dozen wrongful death cases in correctional facilities across the country, including in Colorado. “This is not execution by denial of medical care.” That medical care is supposed to include proper psychiatric care. It often does not, and that can have fatal consequences.

Standing onstage, the house lights bathing him in their warm glow, Brian had never looked so alive. It was April 2011, and the 36-year-old was playing to the small crowd at Herman’s Hideaway, a divey music venue along South Broadway in Denver. As the frontman for Fujita Scale, a glorified four-piece garage band that had somehow persuaded the bar into letting it be an opening act, Brian had appropriated the fashion stylings of a young Axl Rose—bandana, stringy hair, sleeveless shirt, and ripped blue jeans. As a performer, he shined. As a vocalist, he really didn’t.

That wasn’t important. At least 25 of his friends, co-workers, and family members, including his wife of six years, Nikki, and their five-year-old daughter, were happy to forgive his pitchiness. A lasting career as a lead singer wasn’t likely, but this musical interlude wasn’t about a pipe dream. Life was pretty good for Brian. He had a steady job as the production manager at this magazine, his second marriage was solid, and his kids—four of his own and two stepchildren—were doing well. For everyone in the audience, this was simply a chance to applaud a guy whose life could’ve gone in a very different direction. For Brian, it was an opportunity to make up for lost time. Most people go through their garage band phases in their teens and early 20s. Instead, Brian had spent those typically carefree years as a resident of several county and state correctional facilities.

Brian always said he had a thief’s mentality, ever since he was a child. As a teenager, he once ran off with a car—a joyride at the expense of someone who’d left keys in their vehicle. He even figured out while working at Keystone Resort that if he stole a ski instructor’s jacket, riding the chairlift would always be free.

His capers were mostly small-time, punk-kid stuff fueled by booze, weed, and teenage bravado—that is, until an ill-advised bet on the 1994 Super Bowl left him unable to pay rent on his condo in Keystone. At 19 years old and on a bad path, he’d clashed with his dad enough that he couldn’t stay at his house in Aurora. Brian ended up homeless on the snowy streets of Denver, where cold, hunger, and desperation helped birth the idea of robbing a pizzeria he’d once worked for.

On March 28, he borrowed a loaded .22 from an acquaintance, stole a red pickup truck, and surprised his former employer, who didn’t think Brian was serious until he unloaded a round into the floor. The pizzeria owner gave Brian the only cash he had: $3. High on adrenaline, Brian then held up a gas station, where the register yielded $97. For $100, he bought himself what would end up being close to five years with the Colorado Department of Corrections.

By the time I met him, in November 2004, Brian had gotten out on good behavior at 24 years old, married a woman named Trish, had two children, gotten divorced, and spent time working for the Denver Post. As a colleague, he was easygoing, worked hard, and didn’t complain. He called everyone “brotha” or “lady,” terms of endearment that were far more endearing coming out of his mouth than they look on paper. Except for a diet that often consisted of gas station fare and Mountain Dew, a wardrobe that relied too heavily on Nuggets and Broncos jerseys, and a colorful vocabulary tinged with profanity and prison vernacular, he was just like the rest of us. That is, he was just like the rest of us, save for what his dad calls the “grenades.”

Brian’s friends never had a name for it; we just knew that good decision-making was not always his strongest attribute. We joked about it—with him and sometimes without him. We chided him about having unprotected sex with an old girlfriend, which led to an unplanned pregnancy. We rolled our eyes when he proposed to Nikki only three weeks after meeting her in a bar. We shook our heads when he left a can of gasoline where his kids could mess with it, resulting in a small house fire. These things happen to people, of course, but they always happened to Brian.

He did manage to stay clean when it came to the law, never violating his parole, but his dad says that whenever life was going well for Brian, his son would inevitably make a bad decision that would “toss a grenade” into his life and blow things up. Such was the case, his dad says, when Brian quit his job at 5280 in 2013 to become a motivational speaker for teens and prisoners, a gig that floundered and left Brian barely cobbling together a living. “It was as if he never felt like he deserved it when things were good,” Dennis Roundtree says. “That was the pattern of his life. I’m convinced it was a symptom of his mental illness.”

Dennis Roundtree holds a photo of his son, Brian, who died by suicide while in the custody of the Arapahoe County Detention Facility in January 2018. Photo by Matt Nager

People die in jail, but things get complicated when those jailhouse deaths are deemed avoidable. Those situations can morph from complicated to litigious when it appears as though a preventable death was an acceptable casualty in an effort to maximize someone’s bottom line.

The most recent data available from the Bureau of Justice Statistics show that the single leading cause of death in local jails in 2016 was suicide, accounting for 31 percent of in-custody fatalities. Along with substance abuse deaths (10.4 percent), homicides (2.9 percent), and accidental deaths (1.7 percent), suicides are generally designated by advocacy groups as preventable, as are any deaths from illnesses that could be treated or cured with reasonable medical intervention.

It’s who’s responsible for the intervention—be it for medical or psychiatric reasons—that has caught the attention of news organizations in recent years. In lengthy investigative pieces, the New Yorker, the Atlantic, and CNN have homed in on not only the questionable medical tactics of several of the country’s largest, for-profit correctional health care companies but also on their recent consolidations that, to some, look like a conspicuous yet unchecked monopolization of the correctional health care industry. The reports suggest that cost motivation—that is, for-profit firms’ focus on their net revenues—becomes a very real factor when it comes to their abilities to provide the care guaranteed by the U.S. Constitution.

Hundreds upon hundreds of federal lawsuits and an untold number of state court cases claim that companies with names such as Wellpath, Armor Correctional Health Services, Corizon Health, NaphCare, and others have shirked their responsibilities to furnish reasonable care in favor of padding the bottom line. In so doing, the articles and lawsuits say, these businesses have displayed negligence, if not deliberate indifference, to inmates’ health care needs, a dereliction of duty that has too often resulted in permanent disability or death.

The grim narratives, some of which take place in Colorado and the details of which make it seem like landing in jail with so much as an infected hangnail could be dangerous, focus primarily on the withholding of physical health care. Forty-four-year-old Kenneth McGill, for example, was booked into the Jefferson County jail after violating probation on a DUI conviction in July 2012. Two months later, McGill begged for medical care when his face drooped, he felt weak on one side, and his speech slurred. He and other inmates repeatedly reported to several medical staffers with Correctional Healthcare Companies—now part of Wellpath—that McGill was experiencing classic symptoms of a stroke. According to the lawsuit, it took the company 16 hours to send him to the hospital, where doctors diagnosed him with a stroke. The injury was severe, however, and left McGill with permanent disabilities. The parties settled out of court for an undisclosed sum.

A lawsuit filed on behalf of Coloradan Jeffrey Lillis, a 37-year-old pretrial detainee being held on drug charges at the Arapahoe County Detention Facility, alleged that medical staff from Correct Care Solutions and Correctional Healthcare Companies—both now part of Wellpath—failed to treat his severe bacterial pneumonia and sepsis, conditions that likely could have been managed with antibiotics. Lillis was sick and in pain for days in December 2014; he died on the floor of his cell in a pool of his own blood and vomit. The lawsuit was settled for $2.45 million in 2019.

These stories of poor physical health care delivered by for-profit health care businesses, however, may obfuscate what is arguably a larger issue: The same companies’ substandard mental health care services have failed to stop suicide from being the number one killer of jail inmates. “It’s not abnormal to have suicidal thoughts after being caught for a serious crime,” says Jennifer Longtin, a Denver attorney who specializes in serving those with mental illness who are involved in the criminal justice system. “Jails are aware this is a known risk, yet their protocols are often lacking.”

In Colorado, the inmate suicide numbers could be even worse than the national average. Statewide statistics reported by the Denver Post in January 2017 suggest Colorado’s inmate suicide rate—meaning the percentage of total deaths as a result of suicide—could be as high as 41 percent, 10 percentage points higher than national statistics. 5280’s open records request of the 10 most populous Front Range counties showed a jail suicide rate of 37 percent between 2010 and 2019.

But numbers are just numbers until you attach names to them. Names like Jesse Binam, Holly Peck, Mark Witkowski, Jillian White, Michael Roach, Benjamin Fueston, Dillon Blodgett, Jerome Bornn, Robert Petersen, Clinton Mitchell, Kenneth Conti, and Michael Stutsman remind us that the problem is personal. The list of Coloradans who have died by suicide in county jails goes on and on, and in far too many of these cases, risk factors for suicide were evident. In far too many of these cases—but not all—those risk factors were seemingly overlooked by mental health professionals employed by for-profit companies operating in county jails. In all of the cases, someone died alone.

For weeks, law enforcement officers in Arapahoe County had been quietly working a string of amateurish yet mostly successful armed robberies. Wearing a fake beard and fabricated muscles, the suspect had been knocking over liquor stores, gas stations, check-cashing services, dry cleaners, restaurants, and even doughnut shops since sometime before Christmas 2017. No one had been physically injured, but the thief had brandished a firearm, traumatized dozens of people, and made off with more than $10,000 after 19 jobs.

It was the aftermath of the 20th hit, however, that found Arapahoe County Sheriff’s Deputy Benjamin Sears cataloging the contents of the suspect’s Jeep Liberty at the Farm Crest gas station on East Dry Creek Road in Littleton around 6:30 p.m. on January 17, 2018. As the officer peered through the SUV’s windows, he could see a costume beard and mustache tucked along the passenger side floorboard, a box of blue nitrile disposable gloves in the cargo area, a Broncos shirt in the back seat, and a bottle of Mountain Dew in the center console.

Officers from the Littleton Police Department had spotted Brian Roundtree’s Jeep just minutes after he’d stolen $310 from a Safe Ship store less than two miles from the gas station. Low on fuel and itching to buy a few lottery tickets, Brian had pulled over. Twenty-three years after he entered the Arapahoe County Detention Facility in handcuffs for the first time, Brian would be returning in similar fashion.

In an interview room at Arapahoe County headquarters, Brian waived his Miranda rights before doing what he’d always done: He confessed, seemingly leaving out not a single detail, no matter how damning or disheartening. Arapahoe County Sheriff’s Office Investigator Stevie True and Littleton Police Department’s Detective Christina Goodman asked him questions, but Brian unburdened himself without much prodding.

The responsibilities of life had stacked up over time, he said. He had just gotten a good job making $70,000 a year, but he also had a new, more expensive place to live; he’d gotten a DUI after trying to drink away marriage problems in the fall (after 12 years of being married to Nikki, the divorce had been finalized in early December); he had a gambling addiction; and he had four kids for whom he’d wanted to buy nice Christmas presents. Being able to deliver gifts on Christmas Eve was the impetus for the first robbery, on December 16.

The investigators asked Brian about the weapon he’d been using. For the majority of the crimes, he said, he’d been using an unloaded BB gun. In the week leading up to his arrest, however, he’d switched to a small, silver .38-caliber pistol he’d found in an unlocked SUV from which he was stealing plates. He said he couldn’t even figure out how to take the safety off the gun. “I want to make it clear right now,” he said, “that I had zero intentions to hurt anybody.”

He knew he’d inflicted wounds, though. He told the officers he thought about how all those people now knew what it was like to have a gun pointed at them. The “poor old lady” at the Circle K. The man at East Quincy Liquor who “was really mad.” A guy at Cherry Knolls Liquor Store who appeared to know Brian’s weapon was nothing but a cheap Daisy BB gun. A pair of women and a little girl at OK Tailor and Shoe Repair. A girl “probably in high school” at Paradise Cleaners, who was so polite she actually called him “sir.” And “the foreign guy” Brian felt bad for because he was probably “here just trying to live the American dream and some asshole goes in with a BB gun and takes their shit.”

Partway through answering questions about each crime, the tears came. They’d stop and then start again, usually when he was apologizing for what he’d done—or when he’d mention his children, who he thought were going to hate him and whom he said he’d let down forever. “My kids are the biggest victims of this whole thing,” he said, “because I was really a good dad.”

Throughout the interrogation, True and Goodman had picked up on Brian’s despondency. “This might be my last good conversation,” he told the officers. He said he’d stopped taking his antidepressant medication and hadn’t seen his “shrink” in weeks. What concerned the officers most, however, was that Brian had decided that had he been caught with a gun, his “plan was to go out like a soldier”—in other words, suicide by cop. Brian would’ve checked nearly every box on any psychiatrist’s suicide risk assessment test. True and Goodman made sure that when Brian was booked into the Arapahoe County Detention Facility at 12:15 a.m., he was immediately placed on suicide watch.

Jail Division Chief Chris Laws can’t remember exactly when the idea for building a dedicated mental health unit at the Adams County Detention Facility was born. His best guess is 2008, but it felt like it had been even further back that he and his colleagues at the jail began noticing an uptick in arrestees suffering from significant psychiatric issues. “We had such an influx of people who really would’ve benefitted more from inpatient mental health care,” he says, “than from being in jail. Many of them really didn’t belong in jail. We had nowhere to put them and no real resources to help them get better.”

In those three sentences, Laws sums up one of the United States’ most complex social justice issues: Over the past several decades, correctional facilities have become the largest providers of mental health care services in the nation, in part because America inadvertently criminalized mental health conditions. The abridged history lesson is this: There has never been an all-encompassing national system for mental health care in the United States, but state-run psychiatric hospitals began caring for those with severe mental illness early in the country’s history. By the first half of the 20th century, though, America’s asylums were overcrowded, hitting their peak in the 1950s. During the decades that followed, several things led to a decrease in the use of inpatient beds, particularly the Community Mental Health Act of 1963, which encouraged a shift from mental health care services being delivered in state facilities to being meted out in what, in theory, would’ve been community-based settings. By the late 1990s, most psychiatric hospitals had closed; however, the federal government had not allotted appropriate funding for community-based mental health care services to meet the needs of those who still required care. A vacuum had been created, and it was filled by the criminal justice system.

Today, when someone with psychiatric illness displays behaviors that had once been managed by being admitted (sometimes involuntarily) to a mental health hospital, he is instead often met by police officers, who in turn may arrest him—often for violating what are known as nuisance laws, crimes such as loitering, trespassing, or disorderly conduct. In Colorado, it has been unlawful since 2017 to house in jail people experiencing a mental health crisis who may be a danger to themselves or others but who have not committed a crime. However, if inpatient beds at hospitals or other psychiatric care facilities are full—and they often are—jail may be the only alternative. “In this country, we’re trained to dial 911 when someone needs help,” says Shannon Scully, senior manager of criminal justice policy for the National Alliance on Mental Illness. “But that doesn’t necessarily mean a medical response; it often means law enforcement shows up. Even if officers don’t want to take someone to jail, they often have nowhere else to take them. Which is a contributing factor to Bureau of Justice Statistics numbers that say 44 percent of people in jail have a mental health condition.”

The problem, as Laws points out, is that jails are not equipped to deal with severe mental illness. Detention centers, many of them built long before the steep rise in inmates with mental health conditions, often do not have the brick-and-mortar facilities or staff necessary to appropriately screen people for acute or chronic psychiatric conditions nor to monitor them once they are identified. At the Adams County Detention Facility, inmates struggling with mental illness had been sent to the on-site medical unit, but the isolation of that area wasn’t ideal. A spate of suicides—10 of the jail’s 13 deaths between 2011 and 2016 were from asphyxia—emboldened officials at the jail to finally make the idea of a dedicated mental health unit a reality.

After a $3.2 million renovation of what had been a dorm-style pod, the mental health unit, which is currently staffed by Wellpath, opened in March 2018. The area has a variety of cells to accommodate different circumstances, a reintegration or “step-down” area for inmates coming off suicide watch who aren’t yet ready to join the general population, and a daytime communal space. Since its opening, the facility hadn’t experienced a suicide—until late spring this year. “We feel like we have a better overall grasp of those who need mental health services now,” Laws says, adding that communities and the state should help fund similar efforts in other counties. “Honestly, every jail needs an area like this.”

Inmates in the United States are the only Americans with an actual legal right to health care, but the law doesn’t offer much guidance on exactly how to provide it. Without mandatory national standards and no state regulations or inspection programs in Colorado, county sheriffs must determine for themselves how best to deliver Constitution-worthy care—lest they open themselves up to litigation.

Depending on available resources, sheriffs often choose between three potential setups: a public option, in which a county employs its own health care workers to run an in-house jail medical unit; a contract with a local hospital network or other local providers; or a contract with a private, for-profit correctional health care firm. An open records request of the Front Range’s 10 most populous counties found the vast majority of the jails employ a for-profit firm for part or all of their health care services. Because of jail sizes, varying demographics, and hybrid delivery methods, there’s no easy way to quantifiably determine which route serves inmates best; however, civil rights attorneys, ​physical and mental health experts, and even some sheriffs argue that having a for-profit company in the equation complicates matters.

In 2018, the Adams County Detention Facility opened its behavioral health unit, which officials say helps them better treat inmates with mental health conditions. Photo courtesy of the Adams County Sheriff’s Office

Perhaps not surprisingly, detractors of for-profit health care companies operating inside jails make the most noise about cost motivation. Once a county has selected a profit-oriented firm through a government bidding process, that firm—frequently the lowest bidder—knows generally what its gross revenue will be over the term of the contract. “They’re in it for the money,” says El Paso County Sheriff Bill Elder. “They will do necessary operations, but if they can increase their net, they’ll do it…. What happens if a nursing job comes open and they don’t fill it immediately, or ever? Those dollars go directly to the bottom line.”

The same goes for not providing prescription medications to inmates in a timely fashion, not calling in a physician to see a very sick patient, or not dialing 911 for an ambulance to bring an inmate to the emergency room. Other common complaints include poorly trained staff, high staff turnover, nurses making medical decisions doctors should make, employees buying into the widespread idea that inmates are often faking their illnesses, lax screening practices, and unsound policies surrounding suicide watch procedures.

For civil rights attorneys who field calls from both inmates’ families and former inmates themselves, the grievances are familiar: Someone had been mentally ill or physically sick, had suffered, or, in some cases, had died, all because they didn’t have a free person’s access to health care. When a private correctional health care firm is involved, though, mounting a case to show that its employees acted with “deliberate indifference” toward an inmate’s health care needs—the high bar set by the U.S. Supreme Court—can be an exercise in futility.

“There’s a real transparency barrier,” says civil rights attorney Ed Budge. “If a jail is run by the county, at least I can get records through open records requests. If it’s a private company, it is not subject to those requests. I can’t get the information I need to get to know what happened. And I can’t file a lawsuit without knowing what happened.” It’s a Catch-22 that means many cases—whether they’re filed against the county or the private firm or both—that may have merit never get filed, much less see the inside of a courtroom.

For those who have lost loved ones inside a county jail, the legal smokescreen produced by a private firm for a county can appear intentional. In 2019, Wellpath’s chief strategy officer told the New Yorker that the company routinely indemnifies local governments from legal costs of suits alleging medical mistakes. “Using a private firm can be a key part of the decision for some counties who want to wash their hands of this,” Budge says. “This isn’t always true and doesn’t always work, but plausible deniability can come into play.”

If for-profit health care companies are challenging to manage, appear to put the bottom line above inmates’ health, and only offer some measure of legal protection, the logical question is: Why do jails partner with them so willingly? The short answer is money. After disappointing experiences with Correct Care Solutions (now Wellpath) and Armor, El Paso County Sheriff Elder decided in 2019 that he’d had enough of for-profit companies operating in his jail. He and his team went about trying to set up a community-based model, working with local hospitals and health care professionals, for 2020. Although Elder believes there is a way to make the switch and that it’s the right thing to do for the incarcerated community, he wasn’t able to find a way to get it done. “The challenge is just a complete lack of funding,” he says. “The private company says it can get the mental health part of the contract done for $1,250,000. It was going to cost $3 million to $4 million for us to do just that part in the community.”

Knowing it had to find some way to provide health care until the sheriff could get the pieces in place for a community model, El Paso County sent out a request for proposals, hoping it might find another, less frustrating firm with which to work. The county received three bids, but only one that met the county’s needs—from Wellpath. “There just aren’t a lot of options,” Elder says. “We had to hire Wellpath, even though they’re now the same people we had to get rid of two years ago.”

In prisoner parlance, “turtle suit,” “Bam Bam suit,” and “pickle suit” all refer to the same thing: a safety smock. Made from heavily quilted fabric, the bulky, collarless, sleeveless gown can’t be tightly rolled or easily torn and typically has Velcro fasteners to keep it in place around the otherwise naked body of an inmate who has been placed on suicide watch. It is well-known among anyone who has ever been in jail or worked in a jail that people despise wearing the smock and that they will do or say nearly anything to avoid it as well as the other indignities of being constantly observed. I have no doubt Brian hated it, too.

Between the hours of 12:15 a.m. and shortly after 9 a.m. on January 18, 2018, Arapahoe County jail security staff monitored Brian roughly every 15 minutes. The observation log notes his movements—“sitting on bunk” at 12:34 a.m., “on [right side] breathing” at 2:57 a.m., “on stomach” sleeping at 5:11 a.m., sleeping and breathing at 8:42 a.m. Approximately 23 minutes later, at 9:05 a.m., the final entry reads “cleared.”

The initials next to the last memo signify that Brian was evaluated using a Suicide Watch Initial Assessment form and then taken off suicide watch by a Correct Care Solutions mental health professional, presumably to allow Brian to attend his 9:30 a.m. advisement hearing in court without being on suicide watch, according to a lawsuit filed on Brian’s behalf in January 2019. Although the Arapahoe County Detention Facility says it has never had a policy that inmates must be released from suicide watch to attend court hearings, Wellpath declined to comment for this story and would not answer questions about its current policies or practices or those of Correct Care Solutions, which became Wellpath during a merger in 2018.

Dressed in an orange jumpsuit, Brian appeared in front of Judge Eric White looking tired and lost. He barely moved as the prosecutor explained the circumstances surrounding Brian’s arrest, informed the judge that Brian had essentially told investigators he was suicidal, detailed that the mandatory minimum sentence he could seek for each robbery would be 10 to 32 years, and asked the court to increase the bond from $250,000 to $1 million, an unusually high number that elicited outbursts from other detainees awaiting their hearings. The public defender objected to the proposed bond increase; however, White disagreed, saying that although it “…certainly sounds counterintuitive every time I say it from here to keep someone in jail, the jail is the best place for me to ensure this defendant doesn’t harm himself.”

As an Arapahoe County Sheriff’s Office deputy escorted him out of the courtroom, Brian looked at the gallery. His one-time girlfriend, Sarah, with whom he shared a daughter, and his sister, Becky, were at the hearing. Becky said “I love you” loud enough for him to hear—and he said it back to her as he walked away.

Upon his return to the Arapahoe County Detention Facility, a different Correct Care Solutions employee spoke with Brian and administered a Receiving Screening. The nurse’s documentation demonstrates that he was aware Brian had “major depressive disorder, recurrent”; that he had been receiving mental health treatment for depression and had been prescribed the antidepressant citalopram; and that Brian’s DUI back in the fall had actually been a suicide attempt. Yet on the Suicide Potential Screening portion of the form, the nurse incorrectly marked that the arresting officers hadn’t believed Brian to be a suicide risk. He also marked “no” to the question about whether Brian had expressed thoughts about killing himself. According to the form itself, if the nurse had checked “yes” to either question, Brian would have been immediately referred for a mental health evaluation.

Instead, after having just learned his bond had been raised to $1 million and that he was looking at a lengthy prison sentence for his crimes, he was not given any medication for depression. No consultation with a psychiatrist was ordered; he would be checked on by a counselor in seven days. His module card—an inmate classification tool—should have been highlighted to alert corrections staff that Brian recently had been on suicide watch and should be monitored more diligently, but it was not. Brian was discharged to general population, where he had unfettered access to the jailhouse equivalent of a suicide toolkit: an unmonitored cell, no cellmate, a triple bunk, and bedsheets. He was dead less than 10 hours later.

Twenty-one days after Brian took his own life, his father met with Arapahoe County detention services bureau chief Vince Line and two other jail officials. In that February meeting, Dennis says Line appeared to answer his questions as transparently as he could, which Dennis says might have been satisfactory if Line hadn’t volunteered what amounted to a professional philosophy regarding the inmates in his care. “He said to me, ‘You need to know, Mr. Roundtree,’” Dennis recalls, “‘that if they really want to commit suicide, they’ll find a way to do it.’”

It wasn’t the first time Line (who declined to speak with 5280) had been quoted saying as much. Roughly four months before sitting down with Dennis, Line told the Denver Post that “inmates are creative, and if they’re intent on self-harm, they will find a method to accomplish that.” Line’s actions at the jail—specifically, a roughly $200,000 suicide mitigation effort in late 2017 that focused on decreasing tie-off points, including those on bunk beds—seem at odds with his words. However, the fact remains that although its rates are slightly below the national average, the Arapahoe County jail still has a 25 percent suicide rate over the past 10 years. The fact also remains that even though many of the jail’s cells had undergone that mitigation process by January 2018, Brian was not placed in one of them.

“After 40 years of studies about suicides in correctional facilities,” says Lindsay Hayes, former director of jail suicide prevention and liability reduction for the National Center on Institutions and Alternatives (NCIA), “no one should have the attitude that inmate suicides cannot be prevented.” Hayes points out that in 1986, the NCIA reported that the suicide rate in county jails—107 deaths per 100,000 inmates—was approximately nine times greater than that of the unincarcerated population. Having that data, Hayes says, helped the Justice Department and the NCIA convince jail administrators across the country that a reduction was necessary—and possible. After much work, which included spreading awareness of risk factors (history of mental illness and suicidal behavior) and high-risk periods (like the first 24 hours after booking and the hours immediately after receiving bad news in court or taking a distressing phone call), better training of employees, and revising screening methods, there was a noticeable shift in philosophy in the jail community. There was also a shift in the numbers. In 2010, the NCIA released a second study that showed inmate suicides at county jails had dropped to 38 deaths per 100,000 inmates, a threefold decrease.

But death by suicide still accounts for roughly a third of county jail fatalities in this country. This is an unfortunate fact that Hayes, who has worked in this arena since 1978, understands maybe better than anyone—and he believes there are myriad ways to continue shrinking that percentage. That is, if sheriffs and their staffs fully commit to that goal.

Suicide watch procedures, for example, would need to be more nuanced, ideally avoiding the tradition of taking away all comforts and privileges (so inmates will admit to suicidal thoughts) and including at least two observation levels and some kind of step-down practice. Privacy measures would have to be greatly expanded so inmates would feel comfortable being honest with medical staff, especially during mental health screenings during booking procedures. Jail administrators would need to vigorously monitor their for-profit contractors to make sure mental health professionals are well trained and that positions do not go unfilled, leaving remaining mental health employees overworked and potentially prone to mistakes.

Sheriffs—and county commissioners who execute multimillion-dollar deals with for-profit correctional health care companies—also would need to learn to ask about and spot unsound or outdated health care policies and procedures and amend contracts that are often lacking in specifics. According to Hayes, best practices, like allowing an inmate to go to court while remaining on suicide watch in case they receive bad news or checking in on an inmate who has recently been discharged from suicide watch more quickly than seven days, may not be part of these firms’ repertoires.

Civil rights attorney Ed Budge says it really should be incumbent upon counties to force these companies to be more forthright about what they’re delivering in exchange for none too few taxpayer dollars. “The public knows how much a county spends and the basic terms of a generic contract,” Budge says, “but these firms don’t have to explain their policies on nursing qualifications or procedures for helping patients with drug addiction or pregnancy or depression.” That’s, of course, because those things fall under the umbrella of proprietary information, or information that a private company wants to—and can—keep secret.

Almost two years after Brian’s death, I met his dad and stepmom at a Starbucks off East Arapahoe Road. I hadn’t seen them since the memorial service, where more than 300 people showed up, inundating a chapel that had been set up for 140. Over lattes, we took turns telling—and chuckling at—old stories about Brian, but it was the newer stories I hadn’t heard that stuck with me. Brian’s October 2017 DUI, which had really been a suicide attempt, wasn’t the first time he’d tried to end his life. In fact, Brian had attempted suicide twice during the summer of 2017. All three times, a loved one had saved him in one way or another. That was the difference with the fourth attempt, Dennis said: “There was no one in that jail who gave a damn.”

Dennis is haunted by the fact that he’ll never know what might’ve happened if Brian had been put back on suicide watch after returning from his advisement hearing. “If they could’ve kept him alive for 48 or 72 hours, gotten him some mental health treatment and antidepressants,” he said, “and let him see or talk to his kids…maybe things would’ve been different.”

Having said that, Dennis shook his head as if to rid it of those painful hypotheticals and then explained why he’d decided to file a civil suit in January 2019 against the Arapahoe County Sheriff, the Arapahoe County Board of County Commissioners, Correct Care Solutions (now Wellpath), and two Correct Care Solutions employees. “During my meeting with Vince Line, I asked a very simple question,” Dennis said. “I asked, ‘What have you learned from Brian’s death?’ and it was as if he didn’t understand the question.” Dennis says Line’s palpable indifference led him to believe everything he then read about county jails contracting with for-profit health care firms was probably true: Suicide watch was an inconvenience they’d scuttle given the slightest defensible opportunity; mental health treatment from a psychiatrist was too expensive for the bottom line; and they’d wait as long as possible before dispensing costly prescription medications. “If we can get reforms made, I want to do that,” said Dennis, who hired Denver-based civil rights firm Holland, Holland Edwards & Grossman. “And I want a settlement for Brian’s kids.”

In April 2020, the Estate of Brian Heath Roundtree settled with the Arapahoe County Sheriff and the Board of County Commissioners of Arapahoe County for $85,000, part of which went to attorneys’ fees. Arapahoe County made only one concession: to let Dennis and Brian’s son see the cell where Brian died.

The civil lawsuit against Correct Care Solutions, now part of Wellpath, and one of its employees (the other employee was dropped from the suit) is scheduled to go to trial this month—however, the COVID-19 pandemic almost certainly will stall dockets. Dennis says he will wait it out. He isn’t afraid to talk about his son’s demons in court because he believes he knows what happened; because he believes county governments need to stop abdicating their responsibilities by turning over humanitarian functions to businesses; and because he believes no matter what Brian had done, he didn’t deserve to leave this life in a jail cell, an environment Brian once described as the loneliest place in the world to die.

Getting Help

If you or a loved one is experiencing an acute mental health crisis, Colorado Crisis Services offers a hotline where trained professionals can talk you through an emergency. Call 1-844-493-8255 or text TALK to 38255.