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Pennsylvania prison suicides are at an all-time high. Families blame ‘reprehensible’ mental-health care.

The families of at least five suicide victims who died at Graterford state prison in 2017 and 2018 have filed lawsuits alleging that the deaths represent systemic failures.

One of the exercise yards at Graterford prison in Montgomery County is seen in a file photograph. The prison closed in 2018.
One of the exercise yards at Graterford prison in Montgomery County is seen in a file photograph. The prison closed in 2018.Read more

Roland Alston was despondent.

The Graterford Prison lifer, who had been diagnosed with depression and paranoid personality disorder, had thrown out all his photos and legal materials. According to a legal filing, he told mental-health staff in March 2018 that he wanted “to give up,” and emphasized that in the event he took his life, his family members should not blame themselves.

Then, the staff allowed him to return to his cell in the general population with no special monitoring, precautions, or psychiatric treatment. Two days later, he was dead.

Alston was one of 15 people in state prison to die by suicide that year — a figure that climbed to 19 in 2019, the most in at least 25 years and likely the highest figure in Pennsylvania’s history. That put the state prison suicide rate at 42 deaths per 100,000 people, a figure that’s double the national average, according to the most recent data available from the Bureau of Justice Statistics.

The families of at least five of those suicide victims, who died in the now-shuttered state prison in Montgomery County in 2017 and 2018, have filed lawsuits in recent months alleging that the deaths represent systemic failures by the state Department of Corrections and contractors including MHM, a mental-health provider, and Correct Care Solutions, a medical provider that according to a 2019 CNN investigation has been sued over more than 70 deaths in the last five years.

The most recent lawsuit, filed Feb. 13, details the events leading to the death of Christopher Gilchrist, a prisoner with diagnosed depression and a long history of suicide attempts who was on constant, one-on-one monitoring in a psychiatric observation cell when he died.

According to the suit, prison staff failed to act on suicidal actions and statements by Gilchrist, who was serving a sentence for aggravated assault and warned staff that they should “take everything away” that could be used for self-harm. An MHM psychiatrist, despite noting Gilchrist’s suicidal ideation, recommended on the day of his death that he be sent back to the general population, according to the lawsuit. And corrections officers, the lawsuit alleges, observed a makeshift noose in his cell more than an hour before his death but did not attempt to remove it.

“This guy was failed by so many people on so many levels. It’s not just one doctor committing malpractice and dropping the ball. It was a systemic failure that went on for days, weeks, months, that led to this ultimate tragedy,” said Todd Schoenhaus, who filed the lawsuit in Montgomery County Court along with Nancy Winkler of the firm Eisenberg, Rothweiler, Winkler, Eisenberg & Jeck.

Winkler said the “reprehensible” level of care began weeks before Gilchrist’s death, when he was allowed to harm himself repeatedly, and continued to the end with insufficient efforts to revive him.

David Thompson, vice president of prison operations at Wellpath, formerly Correct Care, declined comment except to say that the provider is not responsible for mental-health or psychiatric services in Pennsylvania prisons. In court documents responding to two of the lawsuits, Correct Care denied any recklessness or negligence and said its staff at all times gave proper care. An MHM representative did not respond to phone and email messages.

Chris Oppman, a deputy secretary at the Department of Corrections who oversees health care, said he could not comment on individual cases but attributed the rise in suicides to the reality that state prisons “have become the de facto mental-health service institution for the Commonwealth of Pennsylvania.” He said the department has responded by holding a clinical review after each death, conducting more frequent suicide risk assessments, and introducing more specialized units.

Suicide is very preventable in prison and jail systems,” said Christine Tartaro, a professor of criminal justice at Stockton University. Increases in institutional suicides are often tied to insufficient psychiatric screening and inadequate mental-health staffing levels, she said.

Lawsuits by Alston’s family and relatives of three other men who died at Graterford, filed in federal court in Philadelphia, describe a pattern of failures that left the men, who all had histories of mental illness, susceptible to self-harm.

“Two weren’t given proper medications," said Bill Davis, a Philadelphia lawyer who filed the suits on behalf of Alston and three others. "None were really provided with any emergent psychiatric care and, most important, none were supervised in any way, be it one-on-one constant supervision or even 15-minute checks. The things that could harm them were not removed from their cells, bed sheets and things like that.”

Tartaro said such claims are cause for concern: “If those allegations are true that would be very problematic. Once officers and other staff members at the facility know that somebody is suicidal, that requires an extra duty of care.”

One-third of those incarcerated in Pennsylvania require some mental-health care, according to the department. About 8%, or 3,579 people, have serious mental illness. In response to its expanding mental-health roster and related challenges — including 1,774 serious suicide attempts over the last five years — the Department of Corrections has installed a mental-health advocate, deputized prisoners as peer-support specialists, trained staff in mental-health first-aid, and placed a psychiatric nurse at each prison.

After a cluster of suicides at Graterford in 2018, the department reviewed its practices and, according to Oppman, instituted changes including ensuring those in psychiatric observation cells can meet with treatment providers in a confidential setting and can safely have additional personal items with them in their cells.

In 2015, the department also agreed to stop holding prisoners with serious mental illness in solitary confinement in order to settle a lawsuit filed by the nonprofit Disability Rights Network.

Yet, according to a lawsuit

filed in November 2019, Patrick Henry took his own life after 30 days in a solitary-confinement housing block at Graterford known as the Restrictive Housing Unit. Henry, who had major depressive disorder, was incarcerated in 2009 for an arson conviction after he attempted suicide by self-immolation and caused a gas explosion that destroyed seven homes.

Davis also sued on behalf of Isaac DeJesus, who had schizophrenia and depression and a history of suicide attempts, and Arthur Phillips, who had major depressive disorder and was in a psychiatric hospital at the time of his arrest. Both were serving sentences for sexual assaults.

Neither received their previously prescribed psychiatric medications while at Graterford, according to filings; both died while in general population, without any special monitoring in place.