MINDEN - Three jail suicides over the past year were the result of a chronic staff shortage, the Douglas County grand jury concluded.
The grand jury listed concerns about the number of jailers and their training, as well as leadership in the jail. After one jail inspection, the jury told jail administrators they needed to immediately train jail deputies on how to use a self-contained breathing apparatus in case of a fire.
Jurors also heard testimony about staffing levels and learned that additional jail deputies were requested, but money was not provided. That might have been a factor in three inmate deaths that occurred at the jail in a 12-month period, the report said.
"Administrators characterized the three suicides as unfortunate, but not surprising given the critical shortage of personnel available to run the jail," according to the report.
Sheriff Ron Pierini could not be reached for comment late Friday.
One inmate was highly intoxicated when he was brought to the jail and was found dead of an overdose.
Thomas Robert Soria Sr. committed suicide just after his murder trial began in January, and Joseph E. Manoukian hung himself in March.
The report says efforts by the sheriff's office to keep Soria Sr. content may have contributed to his ability to hoard heart medication, causing an overdose. Soria Sr. was being held pending trial for his role in the murder of 9-year-old Krystal Steadman.
"Handling of inmate Soria Sr. was one of 'hands off' as directed by supervisors. Deputies were instructed to leave the inmate alone and not annoy him for fear of receiving complaints from his attorneys. They were told to keep him 'happy,'" the report says. "It is understandable, then, that the report by Washoe County investigators revealed that deputies never conducted searches of Soria Sr.'s cell... the overriding feeling among jail deputies was that short of any security breach, Soria Sr. was not to be upset or disturbed."
The report goes on to say deputies granted a request by Soria shortly before his death to dim the lights in his cell because he was having trouble sleeping, and tape a sheet of sheet of paper over his cell window because people were staring at him.
Jurors made several recommendations, such as keeping a sergeant on duty to oversee the jail at all times; making the sergeant responsible for approving all bookings instead of leaving it to deputies and increasing the number of deputies who staff the jail.
Another recommendation was revision of the jail's policy for giving medication to inmates, including training so jailers can recognize inmates who might hoard their medications.
In other public safety findings, the jury reviewed the East Fork Fire and Paramedic District and the county's communications division.
The report says the county needs to look at expanding fire and paramedic services in Carson Valley, perhaps using the new Station 7 in the Gardnerville Ranchos - which combines paid paramedics and volunteer firefighters - as a model.
The jury's investigation also showed inconsistent personnel practices at the volunteer stations that provide most of the county's fire protection. The report makes several recommendations about updating policies and suggests that an elected fire commission be considered in the future.
Also, the grand jury made several recommendations regarding the operation of the county's 911/communications department.
In response to a complaint, the grand jury wanted to know if the communication department head was away from his job too often.
Jurors discovered he was "indeed absent from his responsibilities a greater amount than other department heads." However, the absences were related to the duties of the department head.
However, the absences "were not routinely reviewed by (County Manager Dan Holler) for cost/benefit on the department."
Regarding the communications department, other discoveries were made including the lack of a backup plan in the event of a 911-system failure.
Also, the grand jury learned several dispatchers either had not received training or had not had their training recorded on official records in a timely manner.
As a result, dispatchers were locked out of the computer system as part of built-in security. They were then allowed to use other employee log-on codes to override security in order to begin dispatching.
Jurors recommended this practice "stop immediately."
Douglas County's 911/Communications Department has one of the county's highest rates of employee turnover and expends a large amount of overtime to fill positions. The grand jury said the department head has not received approval for additional positions despite repeated requests. The grand jury recommended funding for a new full-time dispatcher.
Establishment of a backup system was recommended.
Also, the grand jury recommended improvements in the quality of communication transmission and equipment. Weekly status reports made by the communications department head should be made each week to the county manager, according to the grand jury.
The 2000-2001 Douglas County Grand Jury report is on the Web:
cltr.co.douglas.nv.us