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when he delivered the evening meal. He was not notified that Vaughn had requested a transfer from the K Module to the SHM. Eve Kendall, the DOC's Intelligence and Examination Manager, talked to Turpin, who said Vaughn was resting on his bed throughout many of his shift that day. Turpin said that at about 6:20 p.

Turpin responded he would attempt to discover out and he would also inspect with a manager to approve a call for Vaughn. At roughly 7:04 p. m., Rhone found Vaughn hanging from a bed sheet that was attached 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 actually been the DOC's director given that August 2000. The DOC had an absolutely no tolerance for prisoner suicides. When she began her period, she examined the suicide prevention policies at the prison and set up a number of modifications.

Thomas White, an expert in suicide avoidance in January 2001, who made certain recommendations for the prison's suicide avoidance policy. Changes included changing suicide watch checks from every 15 minutes to every 4 minutes, identifying and screening threat elements in prisoners, producing the close observation status, and taking a look at the different techniques by which prisoners can commit suicide.

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The DOC had inmate suicides in 2001, 2002, and after that Vaughn in 2003.  Full Article  in 2001 likewise utilized the air vent to help in the suicide. Prior to Vaughn's suicide, Gillespie had actually decided that the greater concern for suicide avoidance 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 suicidal. He had spoken about taking his life in front of her and had made such remarks within a year prior to his death. Dr. Victor Lofgreen believed that Vaughn exhibited typical self-destructive tendencies consisting of being abusive, intoxication, and irrational habits. He stated Vaughn's habits of not bailing himself out with the cash in his pocket was quite illogical.