Anatomy of an End – Episode 1, Part 1: Susan – The Scene

Welcome to the first episode of Anatomy of an End.

Our mission is simple, though the subject matter is not: to examine deaths by suicide through the lens of psychological autopsy and use what we learn to advance prevention. By revisiting these stories with compassion, honesty, and evidence, we hope to challenge the stigma, misconceptions, and cultural myths that often prevent meaningful conversations about suicide and mental health.

In Part One of our inaugural case, we begin with the death of Susan. We examine the scene, the known facts, the emergency response, and the evidence that would become the foundation for years of debate and speculation. Before we can understand the person, or the circumstances that led to her death, we must first understand what happened.

This is not an exercise in sensationalism. Behind every investigation is a human being, a family, and a community left searching for answers. Our goal is not simply to retell these stories, but to learn from them.

This episode contains discussion of suicide, self-harm, mental illness, and death.

If you or someone you know is struggling, call or text 988 in the United States or contact your local crisis service. Help is available.

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Transcript

SPEAKER_01 0:03

Welcome to Anatomy of an End, a podcast where we retrace the final days of those lost to suicide through the lens of forensic psychological autopsy. Each episode, we take a step back through time to understand what was happening beneath the surface and what might have brought someone to the edge. Our goal is not to cast dispersions or assign blame, rather, we want to understand. We hope to shine a light on warning signs, missed opportunities, and the delicate complexity behind these all-too common tragedies. This series contains discussion of suicide, drug use, and mental illness. Listener discretion is advised.

SPEAKER_02 0:52

Hey Davis, how are you doing today?

SPEAKER_01 0:53

I'm good, I'm good. How are you doing? Beautiful weather today.

SPEAKER_02 0:56

Very nice, very nice. Lots of rain. I guess we need it. But uh hey, I want to tell you, just call me Dana. D. Edward Tatum is uh yes, my professional name, but uh it's a little stuffy, I think. So uh we can go with the familiar, Dana.

SPEAKER_01 1:09

Sure, that sounds good to me. Well, Dana, before we get started, do you mind giving us just a brief explanation of what it is you do as a forensic psychological consultant?

SPEAKER_02 1:18

Sure. I mean, over the last 35 plus years, I have been a licensed psychotherapist, but I've also, through my training, have been fortunate enough to be sponsored by law enforcement into trainings from huge law enforcement agencies such as the FBI and GBI and other agencies across the United States in behavior analysis, hostage negotiations, de-escalation processes. And that along with my clinical training, I have been called upon and utilized to de-escalate situations between law enforcement and uh the mentally ill in crisis. I add forensic consultation on both open and cold cases, in particular in psychosexual cases, as well as uh adding consultation to the Metro Atlanta FBI and GBI's uh threat assessment and threat management team, which takes a look at potential school shooters, potential mass shooters. I give my two cents on those um subjects as well. And I and I also educate people, educate school systems, law enforcement throughout the United States in the um the importance of destigmatizing mental illness and lowering the uh recidivism of the mentally ill.

SPEAKER_01 2:29

Excellent. Outstanding. Well, I'm glad you uh glad you mentioned education because we're we're gonna do some education here today. Great. We're gonna provide some education, I should say rather. And on our last episode, we spoke at some depth about some of the myths and stigma surrounding suicide and got into why people don't want to talk about it, how those myths and stigma drive individuals to avoid frank and open discussion pertaining to suicide, and how we as a community can act in furtherance of prevention. We we also covered some suicide statistics in the United States and abroad, but we're gonna stay away from some of those big nebulous statistics today, and today we're gonna zoom in quite a bit. We're diving into our first real case. We're gonna be talking about an individual named Susan R., who unfortunately is no longer with us. And Dana, like all our future episodes, this episode will feature a real life psychological autopsy that you actually conducted in the course of your career. Is that right?

SPEAKER_02 3:21

That's correct. I've um conducted, unfortunately, over 300. And I don't know a lot of people that have been in it this long and done that many. And we're going to take one at a time and thoroughly take a look at all the dynamics involved in leading a person up to that tragic decision and event. And hopefully along the way, we can dispel stigma and help people understand that these myths are costing us lives of loved ones, and um we can prevent quite a bit of this.

SPEAKER_01 3:52

I agree. And it's not a comfortable thing to talk about for a lot of people, but not at all. It's not about being comfortable, it's about it's about trying to save lives.

SPEAKER_02 3:59

Well, certainly. And and I think you know, that's part of the stigma. Uh, this business of walking on eggshells and using different words uh instead of the words we really fear.

SPEAKER_01 4:10

Totally agree with that too. So let's let's just give our listeners some frame of reference to the scope of an investigation like this. Now, I received from you a 42-page document um when we began pre-production on this episode, and I I mean 42 8.5 by 11 inch pages, which very much triggered my ADHD. But I bring that up because it's important to note that even that does not begin to scratch the surface of the data that you typically will collect in the course of one of these investigations, right?

SPEAKER_02 4:38

That's right. And I want to clarify it was actually 56 pages, but you changed the font so an old guy like me couldn't really read it.

SPEAKER_01 4:45

I was trying to make it seem to myself like it wasn't so many pages.

SPEAKER_02 4:50

Yes, it it it is a lot. It is a lot to look at. There, you know, we're talking about a human being. Uh human beings are complex. Uh we have a lot going on as a human being. Up a human being in crisis or perceived crisis has a lot more going on. Suicides in general are not uh simple events. They are they are quite complex if you really take a look. We like to make them simple. Uh we like to think, well, a sad person doesn't want to live, so they take their life. And my goodness, that doesn't even scratch the surface of a true suicidal event. And jails and prisons have a requirement for a psychological autopsy to take place. The public sector does not have that requirement. Uh not too many people reach out for one because they want to put this event behind them quickly and they they want to guess at what really happened in a way that makes them feel better. But for our purposes, um, we have quite a few of these to take a look at from within jails and prisons over the last 30 years.

SPEAKER_01 5:52

Well, outstanding. I'm very excited to hear everything you have to say about this case. And Susan R is who we're talking about today, but that's not her name. Would would you mind explaining to our listeners what the importance of anonymity is in a case like this?

SPEAKER_02 6:05

Sure. I mean, we we have ethical concerns. We have to respect her and her family, though this was 30 years, more than 30 years ago. And we we have to respect that privacy. I mean, the location, the names uh have all been changed because it's not up to us to decide whether it's uh whether it's uh okay to expose the folks. I mean, some of these that we'll do in the future will will be with the full cooperation of the loved ones, friends, or family, and some will not. This is one of them that will not. It's not my call to decide if the public should have access to these folks' personal information, whether it be directly or passively. Besides that, you know, it's the elements, names, places, they're they're not as important as the factors that we want to take a look at. You know, our purpose is to expose and combat stigma and myths regarding suicide in our culture and our society. And we want to make sure we do that in a way that folks can take what we're talking about and translate that into their life and into with their loved one.

SPEAKER_01 7:08

That is exactly what we're gonna do. Our goal today is to get to know Susan and see how we can, like you said, translate her tragedy into others' survival. And before we step back in time, if you or somebody you know is in a dark place right now, please reach out to the 988 Suicide and Crisis Lifeline. It's available 24-7. All right, Dana. I want you to let's get in the time machine. I want you to take us back to August of 1997.

SPEAKER_02 7:32

Sure. At that time I was a um mental health director within a large uh metropolitan jail here in the South, a very large place, uh, average day population around 2500, 2600 folks. And um, this facility uh was what we call a direct supervision model facility. What does that mean? Uh that means that the officers are in and amongst the population. They're not in a tower looking in, they're not outside a glass wall looking in at the population. Their workspace is within the unit and not protected by any any kind of barrier. There's a philosophy to direct supervision, whereby the officer in that unit becomes the leader of that unit. They control everything that happens in that unit. They control the movement, they control when meals are served, they control who comes in and out of the unit, they set up the visitation schedules and so on. Typically in direct supervision model jails, everything takes place within the unit. There's not a cafeteria that they take people to to eat. There's not the big rec yard like in the movies. All that is built into each individual unit. So they're like jails within jails. And this particular facility is quite spread out. It's quite large and requires hundreds of uh people to make it operate.

SPEAKER_01 8:53

So anything anything unique from a psychology standpoint for this particular facility?

SPEAKER_02 8:58

I would say so. I mean, what may be unique is that it is a jail within a jail. So their environment, the things they see, the stimulus they have are contained at all times within that one and that one unit. Uh we'll call it a unit, or sometimes it's called a pod, meaning they have their wreck within the pod. They have their food is brought into the pod. Their visitation takes place through special booths that they remain in the pod and meet people, lawyers, probation officers, through the glass within the same pod. They never leave the pod except for certain medical conditions, going to the hospital, going to the infirmary. So psychologically, if you're in there quite a while, you're not seeing anything but that pod, that unit. You're not seeing the outside. You're not going to see other people. It becomes a community in some respects. Now, a lot of people are in and out all the time. People come to jail, they're there three days. Some people wait five years for trial. They may be in these units quite a while. So that that that has a bearing on uh the mentality, then the potential for lack of stimulus, lack of positive stimulus. Also has potential for a structured community of folks that may not have each person's uh best interest in mind. And the officer is tasked with trying to control all of that. Aaron Ross Powell, Jr.

SPEAKER_01 10:19

And in a lot of these cases, the a lot of the corrections officers end up having to wear all these multiple hats, like having to serve the role of a psychologist or or deal with these individuals in a capacity that they weren't necessarily meant to in some situations. And it's unique that you were at this facility at the time, right?

SPEAKER_02 10:35

Aaron Powell Yes, it is. And you know, you really nailed something there. These these these officers come to work, they want to be public servants, civil servants. Uh they have the idea of going into law enforcement, and then they find themselves because of our society, because of the closing of all our mental hospitals and so on, suddenly they find themselves as frontline mental health workers. I mean, the jail is the place, as it's been said before, they can't say no. So, I mean, in this particular facility that we're talking about right now, we fast forward to today. That facility has 760 people that are severely mentally ill in that facility. There's not more than a hundred people that are severely mentally ill in our very largest mental hospitals in the state. And those are hospitals set up for one purpose, treatment.

SPEAKER_01 11:23

Yeah, people might be surprised to know that typically in any given state, the largest mental health facility is probably the jails.

SPEAKER_02 11:30

Every across the nation, there's no exception to that. In any county in this nation, the largest accumulation of severely mentally ill will be in the jail. And that's due to stigma and a whole lot of things we won't get into today. But so this particular facility was no different. And uh so that that kind of sets a stage for um these kind of uh events to take place sometimes, not all the time, because these officers are dedicated and they receive a lot of training from folks like me on signs, symptoms, and uh de-escalation techniques. But even so, this is back in the 90s, so we didn't have as much training as we have now in regard to officers because that transition 97 was around the same year that the largest hospital in Georgia closed at that time. It was uh Georgia Mental Health Institute, GMHI, which is located in the city of Atlanta. When those hospitals started closing, the migration to the jails began.

SPEAKER_01 12:27

And at this particular facility, on the morning of August 30th, 1997, something pretty notable occurred, correct?

SPEAKER_02 12:34

Absolutely. Um, you know, it it's interesting that this happened uh with me actually in the building over all these years, uh being called around the country to conduct these psychological autopsies. I normally and they're after the fact. And here's a case where I'm actually there. It was that morning in August of 97, uh, about 0700 hours. An alarm went off, a call went over the radios, a a special code, and it sounds uh something like this a a 53 zebra one.

SPEAKER_00 13:05

Code 53 zebra one, code 53 zebra one cease all movement standby for emergency traffic.

SPEAKER_02 13:13

Which is um an alarm and a code to everyone in the building that a suicide attempt is taking place or has taken place, uh, or someone has been discovered already having completed one or and and so on. So what that ha what happens then is uh everyone not attached to a direct job, meaning they're not in the middle of moving a uh a detainee or in the middle of treating someone. They stop what they're doing and they start running. They start moving quickly down these very long hallways. And I'm in my office that on that day. Uh it's early in the morning. I just got there, and I turned on my radio and I hear the the code. And uh honestly, you know, this is uh I was kind of new into this back in those days a couple of years in, and I hear the you know, all the folks running past my office, running down this this main hallway. So I jump in and I'm on my way to this unit. I get there, and obviously, you know, the officer who called it was the officer in the unit, had discovered Susan. I get there and per protocol, I'm gonna wait and let the first responders, the medical responders, the other officers go in ahead of me. I don't want to get in the way, and I'm helping hold the door open as they move into the Sally port, and then from there, a second door into the actual unit. So, of course, in an emergency like this, both doors are open. Uh they've been popped open by Central Control, who controls all the doors and everything else. And everybody's moving in, and uh, and of course, not being a person who's going to perform CPR or or what have you, I make sure I'm the last in. This unit is a very large unit, typically holds about 150 persons. But this unit has a unit within it. It's on the second floor. There's a unit in the back, and it's used for disciplinary purposes. It's used for, in this case, females who uh you know don't play well with others. You know, they're they've been they've they're in trouble possibly for acting out, uh assault, assaulting a fellow detainee or assaulting an officer or refusal to take direction or what have you, and they're putting a timeout, they're putting a cell up in the second floor of this main unit, they're away from the general population. And that's where Susan was located. So we have about a dozen people going up the stairs, and you can hear them, those iron stairs pounding as all these folks are rushing up there. Medical responders are rushing up there, and I'm coming up behind them. And as we turn into that part of the unit, it's visible that the officer who called the code is there and working very hard to save this life, uh, working CPR on on her knees, performing CPR. And um, you know, that that's the initial scene. It's uh, you know, you have concrete floors, the hallways are stark white, so you have this sterile environment, the sterile-looking environment. This place is not like a lot of jails that you may imagine in movies. This is uh a place where the walls are painted white, the floors are shiny, it's a quiet place.

SPEAKER_01 16:30

It it looks like how most people would envision a mental hospital. It does.

SPEAKER_02 16:34

It does. And and and it's it's that way on purpose because it's part of direct supervision, the cleanliness, the quiet, and and and so forth. So when you have a crowd of people plowing through uh in an emergent situation, it's quite disruptive and loud compared to what we normally hear. And I remember it was a very um overcast day. And the windows there are translucent. I mean, they allow some light in, but you can't see out and you can't see back in uh for security purposes. And I remember up in the second level, what you know, that that level is um designated as a discipline level. Um it was a little more dim back there. And I couldn't help take in that here is this officer working away, and then the other group comes in, and at per protocol, the medical personnel now take over for the officer. And they jump right in seamlessly. I was very so impressed. They jump right in seamlessly and keep the CPR going. At the same time, the EMS, the local EMS fire department, has been called already. That's part of the initial call. That code that went out that caused all of us to take off to the unit, there's a second code that's sent through the central control unit of the entire facility that goes to the local fire department EMS. So they're on their way. They're on they're in route as we are in route. Obviously, we get there first. Uh the medical personnel working feverishly to save this life. As I stood there and looked over their shoulders as all of them on their knees and and in a coordinated effort there, um I recognized who it was. It was someone I had actually recently met. Someone I had known about for several months, but I actually had spoken with this uh young lady on a couple of occasions just uh a week or so before this event. So there she was. Um and it was obvious to all immediately that she she was she was dead. Her her eyes were open, pupils were fixed. But that doesn't stop the effort. That's not their call to make. She's brought out from the cell, laid down by the officer, and CPR begins immediately. That's the protocol. It doesn't no one stops and makes a judgment. Oh, uh, we don't need to even try, she's gone. That's not what that never happens.

SPEAKER_01 19:02

Never.

SPEAKER_02 19:03

That's not what they do. And thankfully, the medical team is working very hard. They're putting the AED machine on her, and it's it it's advising no shock, meaning it's not picking up the signal. It needs to advise a shock level to try to uh save this life. But nonetheless, they keep going with their efforts. About five minutes later, really, we're there uh I mean the call went out around seven, I believe. And then we were there by three minutes after, because this is a very long way to run. And then uh the EMS was there probably by ten after, I uh if I recall. And then the protocol is they take over from the nurses. But the nurses stay in in uh and give give assistance.

SPEAKER_01 19:46

And all this takes a f a psychological toll on the staff, correct? It certainly does. It certainly does. And you're involved in in that part of the process.

SPEAKER_02 19:54

And um, that's one reason that uh persons like me also run. We're not gonna do CPR unless we were the only ones there, obviously, but we're not there for that. We're there for everything else that goes along with this, which is quite a bit. As I stood there watching them work frantically, you know, you're looking at people on their knees working, people who are being who are relieving each other from the work, and and the person being relieved is out of breath and they're falling back on their hands or on their rear end and moving away. There's gauze and and wraps and wires and and things strown about. There's folks on the phone with other docks. There's so much happening at once that if you didn't know what you were looking at, you you you'd think that there they even had a shot. But the truth is, even when I came in and the initial officer who found her was working on her, it was clear right then. Her um sh her lips were blue. Uh there was some white substance about her chin and lips and neck. Um, and I'll we'll talk more about that later. That's significant. It becomes significant later. The blue is uh a signal of asphyxiation, lack of oxygen, and you know, her facial colorings and and all were were a bit blue too as well. And so as soon as the call is made that this is not going further, a hush comes about. You know, there's this frantic, not chaotic, but intense situation with all these people working so hard, and then suddenly it's over. And there's no sigh of relief, there's no sigh of of of um, you know, that hey, you know, we we did the best we could, so there's no high fives, okay? It's just a very heavy moment. It's a heavy, heavy moment. We're in this dark place, the light's barely trickling in through these translucent barred windows. There lies Susan on a concrete floor, her young life gone. There's people Mneeling around, sitting down. Others have sat down, taken a knee. The the remnants of intense life-saving attempts all around, like I said, wires and gauze, and people are slowly putting the AD back together and in its box. There's other folks consoling each other. There's tears from uh, yes, officers. There's tears from nurses, and there's solemnness from the EMTs who probably see this more than anybody. You know, there's a solemnness, an unspoken communication. I'm witness between all of them that, hey, are you okay? Without words, they just look at each other and nod, are you okay? We did this, we did the best we could. Uh even a nonverbal reassurance to each other, trying to hold each other together because here is a young person who is gone. And let me say this: we expect death. We're wired for mortality from an early age. We talked about this in our last episode. We are not wired for suicide. As I said before, try to fall forward and see if your hands don't come out in front of you.

SPEAKER_01 23:07

It's so counter to the very existence of humanity in general. It's it's the opposite of what your brain and your body wants you to do.

SPEAKER_02 23:16

That's absolutely right. We're wired. We've heard of fight or flight, we're wired to survive. When someone can bypass that wiring, that innate wiring, and take their life, there's a a lack of words for that amongst especially the first responders who even see death all the time. When this group of people kind of let out that last breath of we've done all I can do, it's not the same as if a person just died of a heart attack or an accident. They're looking at something very different, and therefore the psychology of what they've witnessed and what they've taken part in is very different. And that's why I'm there. I'm there to debrief with them to make sure they're okay. I mean, there there's no therapy going on, but there is just an awareness and a being present with them in that moment. That's a very difficult thing, and it's a very strong feeling that everyone there gets. And I think that's a scene that very few people will ever see. We're in a closed environment, we're not out in the street next to a car accident. We're up in this unit. We're up in a unit within a unit, in the bag, a dozen people who have responded, and it's suddenly quiet. And yes, this was a quote unquote inmate. This is a quote unquote detainee, but it was a young life.

SPEAKER_01 24:39

Yeah, it was a young life. And to carry around this notion that, oh, someone in jail committed suicide probably happens every day, right? Well, that's just as unfair and and misguided as assuming that just because these these EMS workers and first responders witness death and injury every day, they must be somehow unaffected by scenes like this, because that that's certainly not true.

SPEAKER_02 25:01

Not not at all. And the impact of it being a suicide, the impact of it being a young person, the impact of the the visual appearance of a person who has hanged themselves, it is a tough thing to see. And when I look at this, I look at this person lying there that I had met a couple of times, and what I see as what I always see when I find a come upon this situation with a young person, I'm looking at this young lady and I'm thinking, I'm seeing this little girl who was excited for her first day of school, kindergarten. I'm seeing a little girl who was had excitement, wondering who's coming to her birthday party when she was eight years old. I'm seeing this little girl who who had trials and tribulations in life, like all young children, and and and and I'm thinking about all of her benchmarks in life, her first steps, her first words, her maybe her graduations uh and and so on. That's what I'm seeing. I'm looking at this person. And um at that moment is when I click in and know uh I have to begin a psychological autopsy. That's when you gotta go to work. Right then. Right. So everything I saw in that life-saving effort and everything I'm looking at at this young person laying on this concrete floor in this dim, dark area, is irrelevant to the point that we can no longer ask how could this happen? We have to ask why did it happen.

SPEAKER_01 26:39

Because as soon as you go into the mode where you begin your psychological autopsy in earnest, how it seems no longer matters.

SPEAKER_02 26:47

No longer matters. As I said, I look at this young person laying there and I'm thinking, was that her life? But obviously, laying there in that place, there's a strong possibility that that was not her life. It's what I hoped her life was, but my experience tells me it probably will not be. As I begin this process, I'll probably learn quite a bit. Because in that moment I have to walk in her shoes, and I have to learn about her dealings in this world, how she mitigated her issues within this world, what were her connections, what were her disconnections? Was this, as we do with all psycho psycho autopsies, was this a determined act? Was this an accident? Was this a murder? Was this influenced by anybody? Was anyone complicit? We don't know anything. All we know right now is that she's gone and apparently she put something around her neck and it killed her. But there's so much more to it than that.

SPEAKER_01 27:46

Well, let's talk about that because the EMS and first responders have cleared out at this point. The initial chaos of the discovery has passed. Now the room is quiet and you're left alone to begin your investigation. As you shift into that objective clinical headspace, what's the very first thing that really draws your attention? Like what what is it about this scene that strikes you as exceptional?

SPEAKER_02 28:06

Well, in this case, I'm there, so I'm not looking at photos as many times I have to. I'm not looking at a file or autopsy photos. So this is an opportunity for me to pull in my own feelings and reactions and become objective and clinical. My first thing, I'm looking at her, I'm looking at her neck. Um, I'm wondering, I'm trying to see if I see any scratch marks around her neck. Why would I do that? And well, that's because I want to see if maybe she put something around her neck, but then she changed her mind and clawed at the ligature, trying to remove it, trying to get it off, and maybe couldn't. A struggle with her own behavior, trying to pull that ligature off that she had made. I want to see what was the ligature made of? What was at her disposal in that event to create a ligature? I looked in the room. I'm looking for a suicide note, number one. I'm looking for how she attached the ligature. How did she create it? What did she use? And how is it attached in such a way that it performed as it did? I'm uh looking for, is the room disheveled? Is the room organized? Uh was her hygiene intact. And why are these things relevant? Because it it it it speaks to her psychological presentation leading into the moments that she put this thing around her neck. So her room in this case was highly organized. Her room was not disheveled. Her hygiene was intact. She was obviously taking care of what we call her ADLs, her activities of daily living. And now we're not even speaking of personality right now, and we're not there yet. We're looking at just, like you said, manifest physical observations of the environment in which she died. Her bed was made as though she had never slept on it. It was made military style. It was very neat. Her toiletries were lined up by height along the back edge of the sink. And these this type of cell, there's an iron bunk that is welded to brackets in the cinder block wall. There's a toilet and sink apparatus that's stainless steel, that's a one-piece apparatus that comes out of the wall as well. It's not separate. And there's a metal desk, as we'll call it a desk. It's about you know 16 by 16 piece of metal that comes out of the wall. And there's a small bench type seat that comes out of the wall. Next to that, where one sits if they want to write or something. So on the left, facing this particular cell is this bed, this bunk. On the right front corner is the toilet sink apparatus. And then next to that is the desk apparatus, small desk and chair apparatus. The bed made, the toiletries lined up perfectly. The towels are kept. There's a little hook, but it's not actually a hook, it's more of a clip that doesn't allow anyone to hang from, where her towels were placed neatly, her washcloth and her larger towel for her hygiene. Her toothbrush was in a styrofoam cup on the sink as well. I looked to see what the ligatures made of it because she was fully clothed until they pulled her one piece cover all uniform apart so that they could um place the ADs and and work on her. But it was her uh issued undershirt. It's kind of like a tank top type of undershirt they're they're issued, and she had used that, uh, evidently. She had meticulously torn it and woven it to make it long a little longer than it would have been. Uh that was noticeable. Uh obviously it was in two pieces because the officer, upon finding her, cut it. And no light. The level of light in there was, like I said, very dim. So there's there is some light deprivation that could have played into any decisions made. I have to take note of all this type of thing. But I did notice also that her trays, her star foam trays for food were stacked up. I opened several, and then she had not been eating for several for at least I counted seven trays, so that's a at least a couple of days where she was not eating.

SPEAKER_01 32:13

But there's there's some very deliberate staging in this room from from your initial observation.

SPEAKER_02 32:18

It was meticulous. As I learned more in the process, in the room made sense. She had compulsivities that came to light in the process. I'll get into that later. But it made sense in retrospect, but in the moment standing there, it it was almost impressive to see a cell that neat and and orderly, and it was orderly in a in a determined way, you know, like I said, lined up by height, the various items. On the desk, I saw writing material, a pen and um and paper, and there was a uh a letter written actually to um a friend of hers, and we'll go into that later as well. It was not a suicide note, it was not a there was no indication in this note about her frame of mind, which is what I was looking for. Also, there was an unfinished letter that had not been complete. I could tell by the phrasing that she had more to talk about in that letter, and it was not prepared for for posting at at all. There was no suicide note. There was no mention of her plan in any of her writings at at any time. Now that's the initial physical view of what I'm looking at. There's so much more to go, but that's where I start. Where I start where it ended.

SPEAKER_01 33:36

Okay. So that's just your initial your base observations.

SPEAKER_02 33:40

Right. Now it becomes important that I stop that because at present there's people that need help. They are reeling from what just happened.

SPEAKER_01 33:49

The corrections officer who made the discovery is in particular. In particular, yes.

SPEAKER_02 33:54

This is a new person, not a lot of experience, but I'll say that she did an outstanding job in her life-saving efforts. But you know, who's prepared for this? Who's prepared when you come to work that I'm going to have to try to save someone's life who try to take their own life? Also, per protocol, we have to begin the process of debriefing and checking on not just the first responders there, but anyone who uh was living in that unit for uh several reasons. One, they live together, right? They're not just in a jail. These people live in a unit as I described. Therefore, they live together. And someone they know a few feet away just killed themselves, you know, at least it appears. So there is a a loss that they suffer because there's one, everything is not in their control, right? They can't go talk to their best friend, they can't go sit in the living room and with loved ones on the couch and cry. They're in jail. So we have to debrief one by one throughout the entire unit to make sure everybody's okay, to make sure we're keeping an eye on them. And there's another phenomenon that happens in jails. There's copycat factors. There's a this happens, there's a huge commotion. People are upset, they have no outlet, and sometimes there will be a copycat behavior. Someone will, whether it be a parasuicidal gesture or an actual full-fledged attempt, it's very common that that can happen in the same unit that a suicide was completed.

SPEAKER_01 35:26

What is parasuicidal behavior?

SPEAKER_02 35:28

Parasuicidal behavior is behavior that can appear as an attempt to die, or even maybe just an uh if taken further, could have been lethal, but was not the intent. The problem with that is there's a myth attached to parasuicidal behavior, and that is, oh, they just want attention, or they're cutters. So if you're a cutter, that means you just want attention. People who want to die, they'll kill themselves. They don't just cut. So we don't have to worry about these people. And that's not true. A estimates from five to nine percent of persons who begin parasuical behaviors end up dying by suicide or at least making a lethal attempt at suicide within five years of beginning that type of behavior.

SPEAKER_01 36:13

Man, that that five to nine percent statistic is just staggering. And I think that's why it's so vital that we stopped and defined what parasuicidal behavior actually is. Because most people know the term superficial attempt, but they've never heard it put this way. And I think it's just really critical to explain why that's important.

SPEAKER_02 36:29

Aaron Powell Well, it's it's important because in the public sector, we hear of people cutting, and we hear, or she's a cutter, or he's a cutter, and they're automatically placed in this bowl of cutters and not potentially suicidal people, as though those were two different bowls.

SPEAKER_01 36:46

Right. It should always be taken just as seriously. Absolutely. That's the that's the spirit of the Certainly.

SPEAKER_02 36:51

It it really should. And that's one of the myths, that's one of the stigmas that cost us lives.

SPEAKER_01 36:57

Aaron Powell So going back to the scene, you've you've debriefed with some of the staff who are involved directly and indirectly. You you've had you've made an initial observation of the scene in which Susan was found. You noticed ligature abrasion patterns and no scratch marks. What else did you notice when you were able to get back to to that room and continue your investigation?

SPEAKER_02 37:16

As you know, as meticulously as that room was kept, I did notice uh a large amount of hair. And I'll come back to that. Also, on second view of her, yeah, I noticed that she didn't have fingernails to make scratches. And it was clear that she bit her fingernails quite a bit. In fact, they were red, the cuticles were red and swollen. Uh she had uh bitten her nails so so far down that there's really no way she could have made scratches about her neck had she tried. Now, at that moment, do I know if she tried to loosen the ligature? I do not know at that moment, but I have to make note of that. As I'm debriefing with everyone, I find out from an officer that they went ahead and made the notification to the next of kin. In her case, it was her mother. And something very interesting happened in that moment. When her mother was called and told that this happened, the first words, and I have them quoted here, and it struck me then and still strikes me now. The first words from her mother's mouth was, Y'all murdered her. There's no way she would have done this to me. And I thought that was an interesting phrase. That's very interesting. That her daughter's death was something that she framed in her first words upon learning of it. The very first thought process was that something happened to her, not her daughter. Her thought process was one, her daughter was murdered, but the reason she knows it's a murder was because her daughter would not do this to her, not to herself, but to her. And then the second part of this, which was very interesting, was you know, the medical examiner had not shown up yet. I found out that he was out at another call uh of a death, a suspicious death in a home in the public sector, was going to be a little while in showing up. So therefore they went ahead and notified the mother. Before the medical examiner came, before Susan's body was put on a gurney and taken away, her mother had already come to the jail and demanded all the any monies, all the money off of her inmate account. And for those who don't know what that is, uh all the persons in a jail or prison, they have a type of banking account where persons on the outside can put money on that account with which the detainee or inmate is able to buy snacks and store call and cigarettes and whatever the case may be from what they call the canteen or store call. It's something that's ordered through a sheet and then brought to the unit twice a week, and you get your store call. It's like what kind of like now where we have people shop online and they and they bring the food to their home. It's kind of like that. It's always been in case. Her mother, it couldn't have been more than 30, 40 bucks in that account. It was odd in the moment, but it becomes incredibly significant later and congruent to her initial statement about this death being something that's been done to her, not to her daughter.

SPEAKER_01 40:21

That is very strange. I mean, that would have I think that would have set off alarm bells to people who aren't in the mental health field as well.

SPEAKER_02 40:27

Oh, I agree. It was it was very odd. And going forward in my career, I've never seen it again.

SPEAKER_01 40:33

So you hear this strange interaction that her mother had with uh the folks that work at the facility, and around this time the medical examiner shows up, correct?

SPEAKER_02 40:41

Yes. I I'm still up in the unit. Now remember, she's up in the disciplinary area. That's why she was alone. That's why there was no cellmate. And that's significant as well, which we'll talk about later. But the word had come up from some folks that her mother was just in the lobby demanding her m uh money from her books. Now, her mother was there within 15-20 minutes. The medical examiner had not shown up yet. I guess about 30 minutes after that, the medical medical examiner shows up and they walk him in, they walk him to that side of the facility, and it's about a quarter mile from the front to that part. They bring him in and he makes his examination. And I'm standing and watching his examination, and he makes the call. Um, he looks at everything. And, you know, from the outside looking in, what do you see? You see a young lady with who had a ligature around her neck who's now gone. It's a jail. So he wasn't there very long, obviously. But I want to see, because he turned her over. Now, she was not turned over while I joined the life-saving efforts. And I want to see if there are any if there's any markings on her back or what have you. And I could see that some of the ligature had been twisted and her hair had been twisted within the ligature. You know, I'm trying to find the words to describe that, but it looked like some of her hair got caught and was woven within the twist. It was like tangled in the twist. Tangled in the twist.

SPEAKER_01 41:56

It's like someone twisting a rag, but like someone's hair got caught in that. Like when it's okay.

SPEAKER_02 42:01

Um I found that interesting because they cut the ligature, but there were still pieces of the ligature in her hair. She had kind of uh long, long hair, very thick hair. Again, no marks on her back there. When he got up, uh a nurse, and I I thought this was very moving. I noticed a nurse come over and put her top back on or zip up and and close up her top of her coverall that was stretched open, wide open, and her her exposed torso was there for medically for people to try to save her life. But I noticed the nurse came back over and closed that up, gave her some dignity, you know, and I and I and I I was moved by that because there's a person that realizes that that's still a person, even though she's passed away, she's a person. A lot of people wonder why I do a psychautopsy? I mean, this is a jail inmate, who cares, some criminal or what have you. But and I hear that all the time. One, it's required, it's a standard that's required nationwide. But two, we have to learn from it. We have to learn, did the security side do something wrong that could cause more deaths later? Did was there something done that was missed in the screenings or the examinations of certain people? Was there uh something wrong with the physical situation of the cell that lended the cell or the person's um personal items uh lend uh them more latitude in and coming up with ways to harm themselves and so on. Um when a person is in disciplinary, they have to be checked on in regimen at times, you know, with every 30 minutes. If they're not on suicide watch, if they're on suicide watch, they're checked on randomly in 15 minute intervals, or unless they're within the direct line of sight. All the checks were made on this individual properly. But going back to the nurse putting her clothes back on her, it made me, you know, more intrigued by who is this person. I had met her twice in session. And now that the medical medical examiner's gone and they put her on the gurney. And they zip up the bag, there's a transition that happens. She's in a black bag now and she's on a gurney going away and you're left with just the scene and the memory of what you have uh encountered. Then uh you're able to be more clinical. I'll I'll admit that. You're able to be more objective at that moment. While she's lying there, I'm guilty. Many are guilty. Maybe it's harder to be objective. You're thinking about what life did she have, what life could she have had in her younger days, and you're also understanding that probably none of that was her life, and as I said earlier, but when they take her away, it's time to to start this process in a very vigorous way. I've already done the preliminary examination of the room while waiting for the medical examiner. I heard some tales about her mother already, and I'm thinking back to my encounters with her. By all accounts, she she was not a pleasant person, not at all, in my encounters with her. And what we know about her at that point while I'm standing there is that she had been in that facility alone 11 times. Now we're looking at a 22, 23-year-old who had been getting locked up in that facility that many times between the ages of 18 and 22, 23, 11 entries. She was on probation many times, which she didn't follow the rules, which is why she was back in so often. I find out through my investigation, she had been in juvenile detention. My last count, I believe, was 12 times prior to going to grown-up jail. So here we have a very complicated person. What is going on? Just by those stats alone, we know that what I hope for all young ladies or young people when looking at them, what I hope that their background and developmental life look like, I know for a fact now that was not her life. So I need to understand that, to understand what led her to this place on this day at that time that she's now gone.

SPEAKER_01 46:09

When you packed up your briefcase that day and you went home, what was in your head?

SPEAKER_02 46:15

Well I'll say that I just wanted to hold my two little boys close. I just wanted to hold them close.

SPEAKER_01 46:28

That's a powerful reflection. And moments like that are an important reminder that these cases aren't just records or timelines, they involve real people and they leave a lasting emotional impact on those who encounter them directly. Well, today we focused on the initial scene, the urgency of the response, the environment, and the structured condition of Susan's room where she was found. In the next episode, we'll shift our focus away from the scene itself and begin a deeper, respectful examination of Susan as an individual, looking more closely at her psychology, her behavioral patterns, and the intrapersonal dynamics that shaped her experience leading up to her death. As always, this series is presented in the interest of understanding and ultimately prevention. If you're in the U.S. and you're thinking about suicide or you're in crisis, call or text 988. If you're in immediate danger, call 911. If you're outside the U.S., look up your local crisis line. There are equivalents in many countries. And if you know someone you're worried about, remember, engage with them. It can only ever do good. Thanks so much for joining us. We'll see you next time.

SPEAKER_02 47:28

Thank you.