Stephen Leonardo is no mental-health expert; he's just an inmate who was assigned to janitorial duty on the unit of Graterford prison where the psychiatric observation cells were located. Still, even he could tell that Christopher Gilchrist — a 28-year-old inmate with diagnosed serious mental illness — was on the precipice.
It wasn't hard, he said: Gilchrist, already on suicide watch, was standing right in front of him with a homemade rope around his neck.
"I talked the rope off his neck three or four times on [Feb.] 13th," said Leonardo, adding that a corrections officer was present but did not intervene or remove the rope, made from a sheet and towel, items typically not allowed for those on suicide watch. "On the 14th is when he actually died. He actually finished committing suicide on the 14th. On the 13th is when they should have done something, and they didn't." A state police report would later confirm that the guards had seen the hanging sheet at least an hour before his suicide and failed to act.
Gilchrist — locked up for aggravated assault in Chester County — would become the fourth of 13 people to commit suicide in Pennsylvania state prisons so far this year. Last year's total was 14 suicides, the worst toll in more than two decades.
In addition, the number of serious suicide attempts reported by the Department of Corrections has tripled in just four years, from 181 in 2014 to 551 in 2017.
This year, 29 prisoners on average have tried and failed to kill themselves each month; one or two have succeeded.
It's difficult to identify the driver of this grim trend, though theories abound. DOC spokeswoman Amy Worden offered this explanation: "The DOC's increases align with those experienced in the community."
It's true that the suicide rate in Pennsylvania has increased, by 22 percent from 2008 to 2017. But over that same decade, the suicide rate in Pennsylvania prisons grew by 103 percent.
To put it another way: 10 years ago you were 20 percent more likely to kill yourself in prison than out in the community; now you're twice as likely to do so.
Seena Fazel, a forensic psychiatrist and University of Oxford professor who has studied prison suicide, said any single explanation for trends in suicide in confinement has so far eluded experts.
There are, however, numerous factors known to drive suicide risk in prison. Those include individual factors — such as mental-health problems, substance-use disorders, or, most dangerously, a combination of both — and environmental ones, such as a lack of social support or connections.
It's also known that prisoners are at high risk for suicide toward the beginning of a prison stay.
That was true for Brendan Allen Weaver, 28 — whose criminal misadventures went unfortunately viral in January after he ransacked the Ephrata Review newspaper offices, accidentally dialed 911, and was found naked and high in a hallway. He took his own life on July 11, less than two months into his sentence of 1½ to four years. At Muncy state prison, Jamie Ridge, a 35-year-old Allegheny County woman, was also just a couple of months into a one- to four-year term for theft when she hanged herself on June 3.
People serving life sentences, too, are thought to be at particular risk. In the last two years alone, six lifers have committed suicide in Pennsylvania.
The oldest, James Michael Bailey, was 70 when he jumped from a second-floor cell block, 28 years after he was sentenced in the 1989 murder of a former girlfriend near Harrisburg. The youngest was Alec Kreider, 25, who killed three people in Manheim Township, Lancaster County, in 2007 when he was just 16.
One emerging theory that explains the increases in incidents of self-harm — as well as the increase in assaults in prison — is the widespread use of synthetic cannabinoids, Fazel said. The Department of Corrections reported a 4 percent year-over-year increase in assaults for the first half of 2018, and attributed the rise to inmate drug use.
"That at least needs to be examined," Fazel said, "because what happens is, when people come off these drugs, a lot of people have idiosyncratic or bad reactions."
But that effect doesn't necessarily extend to the rise in completed suicides, which are in most cases accomplished by hanging.
This isn't the first time that the DOC has struggled to prevent suicides.
In the 1980s, before a comprehensive suicide-prevention policy was in place, the rate was even higher, but it plummeted after the DOC instituted staff training and new unit-management protocols.
When it spiked again in the mid-1990s, officials chalked it up to the new legislative and political realities that inmates were facing that year: a drastic reduction in the number of people granted parole, the effective elimination of commutation, and the first executions in more than three decades. In response, the DOC introduced measures such as risk-assessment checklists, special anti-suicide smocks for those on strict observation, and yet more staff training.
This time around, Corrections Secretary John Wetzel declared a suicide cluster after five inmates at Graterford committed suicide in the span of three months in the run-up to the closure of that institution; since then, one more took his own life at Phoenix, Graterford's replacement. In response, the state Department of Corrections hired Lindsey Hayes, an authority on prison suicide, to review its policies and practices. (Hayes did not respond to an interview request, nor did the DOC make any member of its psychiatric team available for an interview.)
To inmates, though, the DOC is not doing enough.
One, Aaron Fox, wrote a letter regarding a lifer named Roland Alston, who had sought psychiatric help at Graterford in March.
"He expressed feelings of hopelessness and despair. … He went to a [corrections officer] and expressed his despondency, and broke down in tears. He had him sent to the psych," Fox wrote. Alston was interviewed, then returned to the general population, according to Fox. The next morning, March 28, he was found hanging in his cell.
Then there's Gilchrist, who, nearly a year before his death, filed a handwritten federal lawsuit alleging outright torment by corrections officers.
The complaint, filed together with another inmate, Corey Bracey, in August 2017, alleged that guards had first harassed Bracey for subscribing to a newsletter for LGBTQ inmates called Black & Pink and then, as Bracey descended into suicidal thoughts, told him, "go ahead and kill yourself." He later "had to actually be cut down off a noose," according to the lawsuit.
The same staffers allegedly then threatened to retaliate against Gilchrist for submitting a statement as a witness in support of Bracey's grievance. It claims that later the officers handcuffed Gilchrist — choking, punching and dragging him, and leaving him with injuries including a dislocated shoulder.
"[Gilchrist] began to fear of his food being poisoned," the complaint states, "… and became overtly suicidal."
Nancy Winkler, a lawyer with Eisenberg, Rothweiler, Winkler, Eisenberg & Jeck representing Gilchrist's family, provided a copy of a state police report on his death that chronicles what she calls "outrageous conduct" by the guards. In a police interview, Officer Robert Caban confirmed Gilchrist was on "one-on-one" suicide watch when he died, and that officers had seen the sheet hanging from a vent at least an hour before his death, but had not removed it.
"He didn't have to die," she said. "They could have prevented it, but they chose not to do anything."