Reading University Legal Services‘ latest report on conditions at St. Elizabeths, one story popped out as particularly horrifying. It’s worth repeating here. The story involves a man the lawyers refer to as Mr. Jones (his name has not been made public due to confidentiality requirements).

Mr. Jones had been hospitalized multiple times over the years after several failed suicide attempts. He has struggled with schizophrenia and depression; according to the report, he informed St. E’s staff that he had attempted suicide between 12 and 15 times. In 2009, he entered St. E’s for an evaluation after picking up a criminal charge.

So what did St. E’s do to help him?

Mr. Jones highlighted his suicide attempts and made them aware of his psychiatric history. Court documents stated in bold: “[d]ue to Mr. Jones’s current mental condition, immediate hospitalization in an inpatient treatment facility setting is necessary in order to provide treatment. Furthermore, Mr. Jones is an imminent danger to self. While in the D.C. Superior Court cellblock awaiting transfer to the hospital and during transport to the hospital, he should be closely monitored for suicidal behavior.”

Early on, St. E’s staff ordered that Mr. Jones had to be “watched at all times,” according to hospital records. And that he was a “very high risk for suicide.” Mr. Jones continued to talk about suicide as the months passed. The only thing that changed was how the hospital monitored him. Eventually,  Mr. Jones was no longer was “watched at all times.”

Then St. E’s staff decided they didn’t need to monitor him at all. They had transferred Mr. Jones to the D.C. Jail. Soon, D.C. Superior Court ordered Mr. Jones returned to the mental hospital with a message (again) in bold: “Mr. Jones has suicidal ideations and plans to harm himself.”

When Mr. Jones returned to St. E’s, he managed to find a razor blade. He then started cutting himself at 8 p.m. and didn’t call for help until midnight. For those four hours, no one was watching him.

According to the ULS report, one staff member reported what they found: “Mr. Jones was sitting on his bed: both his arms were dangling at his sides and both wrists were bleeding heavily. There was a large amount of blood on the floor. He was holding a razor in his hand…I also got some sheets so we could cover the floor and get to him.”

The staffer went on to report:

“As we entered the room, he took the razor, looked at us and in ‘one clean swipe’ he made cuts up both arms. He then squeezed his arms to force the blood out. I can still see the look on his face…”

Mr. Jones lived.