The state has agreed to pay $800,000 to settle a lawsuit over the death of a pre-trial jail inmate who repeatedly threatened to kill himself, and then managed to hang himself with a rope even after two lawyers involved in his case warned he was suicidal.

Jimuel Gatioan, 49, died on April 4, 2023 after he hanged himself at the Oʻahu Community Correctional Center, where he was being held while awaiting trial in connection with a domestic violence case.

Sean Fitzsimmons, a lawyer who represented Gatioan’s widow Judith in the lawsuit, said jail staff failed to follow OCCC protocols in the case, and allowed a graduate student who was studying to be a psychologist assess Gatioan’s mental state.

“It’s clear from the discovery and the depositions that the facility is responsible for a cascade of failures,” Fitzsimmons said. “Ignored warnings. Failure to initiate suicide watch. Improper mental health evaluations. Lack of supervision. Lack of safety rounds. Inadequate staffing. Inadequate training. All of this was a perfect storm in this case.”

Gatioan’s case is the latest in a long string of lawsuits and settlements in connection with suicides in Hawaiʻi’s prisons and jails. The Legislature still needs to approve the settlement for Gatioan’s case.

The Department of Corrections and Rehabilitation last year allowed national experts to inspect Hawaiʻi correctional facilities to assess the mental health services being provided to inmates. Those experts issued a report last summer that describes “atrocious” conditions for mentally ill inmates who receive inadequate treatment in understaffed facilities.

This year DCR Director Tommy Johnson is asking lawmakers for more than $2.6 million to hire nearly three dozen new health care workers including psychiatrists and nurses to improve mental health services and medical care in general.

Multiple Warnings

Before he died, Gatioan “expressed suicidal ideation to several family members over multiple phone calls,” according to written testimony to lawmakers submitted by staff with the state Attorney General’s Office.

“Mrs. Gatioan notified both the prosecutor and Mr. Gatioan’s defense attorney who both made phone calls to the facility warning it that Mr. Gatioan was a suicide risk,” the statement said.

According to the statement, Gatioan “was evaluated for his suicidal risk after these phone calls and was determined to not be at risk of suicide.” He was therefore not placed on suicide watch, where he would have been closely supervised.

But Fitzsimmons added important details to that terse account. The person tasked with doing the risk assessment was a student “intern” studying to be a psychologist, Fitzsimmons said, and the cursory mental health assessment of Gatioan was conducted through a slot in a locked cell door.

Jail protocols require that a licensed mental health practitioner do that assessment, he said.

Another problem was two other men in the cell with Gatioan, Fitzsimmons said, and the assessment should have been done in a confidential setting where Gatioan could speak freely about his mental condition.

Another mystery is the rope, said Myles Breiner, a lawyer who is also representing the Gatioan family.

“How did he get a rope in there?” Breiner asked. “It’s not like shoelaces, which you’re not supposed to have anyway. It raises all kinds of questions.”

When Gatioan’s cellmates began pounding on the door to call for help, one of the two corrections officers who was assigned to the jail module was absent for some reason, Fitzsimmons said.

That caused a delay in getting aid to Gatioan because the second officer in the module had to remain in the control booth, and another officer had to be summoned from another module to assist Gatioan.

The lawsuit alleged negligent training and negligent supervision of the jail staff, among other claims.

Fitzsimmons said the corrections officers involved told him during depositions that “if protocols were followed, there’s a very strong chance that Jimuel would be alive.”

Toni Schwartz, public information officer for the Attorney General’s Office, said the office had no comment about the case beyond the testimony submitted to lawmakers. She added that “settlement agreements do not constitute an admission of liability or wrongdoing on anybody’s part.”