Confusion reigned inside the isolation-segregation unit at Smith State Prison when inmate Richard Tavera hanged himself in his cell, and it didn't end when guards finally summoned paramedics.
For more than a minute, a prison official -- a woman who didn't identify herself by name -- struggled to tell the Tattnall County dispatcher why EMS was needed at the Glennville facility, according to the recording of the 911 call.
The official said Tavera had attempted suicide, prompting the dispatcher to ask exactly what the inmate had done.
“Attempted suicide. He tried to hang himself,” the official replied.
“There you go,” the dispatcher said. “OK, that’s what I mean.”
The dispatcher then asked, “Is he conscious?”
The official told the dispatcher to “hold on for a second” so she could find out.
No, the official said, after making contact with someone elsewhere in the prison via radio.
“Is he breathing?” the dispatcher asked.
"He’s not conscious,” the official replied.
“That don’t mean he’s not breathing," the dispatcher said. "Is he breathing? I’m sorry. I have to (garbled). They got to know where to take him there.”
So the official went back to her radio, twice asking the question before learning that, indeed, Tavera wasn’t breathing.
OK, the dispatcher said, paramedics were on the way.
The 74-second call is just one piece in a chain of events that suggest dysfunction in the face of emergency on that Sunday night in December 2014.
As reported by The Atlanta Journal-Constitution, the prison's incident report shows that guards didn't enter Tavera's cell even when they saw him tying one end of a bedsheet noose around a sprinkler on the ceiling and the other end around his neck. Ten minutes went by before a lieutenant showed up at the cell and ordered the door opened.
Paramedics arrived at the prison 25 minutes later, according to the incident report. But there was nothing they could do to save the 24-year-old inmate, who was pronounced dead before he could be transported to a hospital.
Tavera's mother, Maria Arenas, has filed federal lawsuits in Georgia and Texas accusing the Georgia Department of Corrections and the employees involved of violating her son's civil rights.
“No reasonable correctional officers would have chosen to stand by and let a man die while it was obvious he was attempting to take his own life,” the suits state.
The GDC declined to respond to questions from the AJC regarding the incident, but the state’s lawyers wrote in court filings that the officers did nothing wrong and were only following protocol designed to protect prison staff from inmates who fake illness for nefarious purposes.
The department's standard operating procedures call for at least two officers to be present when a cell door is opened in isolation-segregation. The policy is the industry standard, experts in correctional administration told the AJC. However, officers would be expected to respond to an emergency with far greater urgency -- preferably within four minutes or less -- the experts said.
Tavera had a history of mental problems, including bipolar disorder, and had been moved to the isolation-segregation unit the day before his suicide after behaving erratically in the prison infirmary.
The Austin, Texas, native was serving a three-year sentence after he and three other men from that city were convicted of robbing three employees of a Roswell Publix. The men, all of whom had come to Atlanta to work temporarily in construction, pleaded guilty to aggravated assault and robbery by intimidation after using an “offensive weapon” -- a beer bottle -- to take the employees’ cash and cell phones as the employees were leaving the store.