Guy Duffy predicted that he was going to die in the Essex County jail. Barely two weeks into a 30-day sentence for animal cruelty -- Duffy’s first time behind bars -- the retired sign maker tearfully told his wife that he couldn’t eat or stop shaking. He was losing weight, he said, and losing hope.

“I’m gonna die here,’’ he told Laurie Duffy in a recorded call in July 2015. “I’m breaking down.’’

Corrections officers twice sent Duffy to the infirmary, where staff dressed him in a paper anti-suicide gown and kept him behind a glass door for constant monitoring. But Duffy hated it, believing the staff was laughing at him. Eventually, they moved the anxious inmate to “protective custody” in a single cell, records show, because he was afraid to be with other prisoners.

There, alone with his demons, Duffy hours later made a make-shift noose out of stripped bed sheets and hanged himself on a laundry hook. He died just 10 days before he could have returned a free man to his North Andover home.

The suicide of former New England Patriots star Aaron Hernandez at the Souza-Baranowski Correctional Center in Shirley last month has put a harsh spotlight on the suicide risk for inmates in state prison. But Guy Duffy is part of a much bigger -- and largely unnoticed -- group who’ve taken their lives while behind bars in this state’s county jails, where inmates serve shorter sentences or await trial.

At least 42 men and women have died by suicide in Massachusetts’ county jails since 2012, more than twice the number of suicides in the state prison system over the period even though both house roughly the same number of inmates. And while state prison suicides have declined in recent years, the rate of suicides in the state’s 13 county jails has doubled, according to an investigation by The Eye, the online news site of the New England Center for Investigative Reporting.

But almost no one is focusing on the county jail death toll. No state office collects or examines death data in county jails. No regulator requires county sheriffs to report the results of internal mortality reviews. And jails rarely release information about deaths to the public in purported deference to confidentiality rules and privacy concerns, but also making it difficult for outside advocates to monitor suicides.


To obtain information on jail suicides statewide, reporters had to request death data from each of the 13 sheriff’s departments that house inmates. But several counties, including five of the six largest, declined to release names, requiring reporters to identify suicide victims one by one.

The review found that the number of jail suicides rose from an average of four annually between 2006 and 2011 to eight a year from 2012 to 2016.

Among them were suicides that followed explicit warnings that the inmate was bent on harming himself. In Bristol County, which accounted for nearly a quarter of all jail suicides from 2006 to 2016 even though it houses just 13 percent of inmates, court officials recently warned the sheriff’s office on two separate occasions that inmates were likely suicidal, records and interviews show. But both men were left alone in their cells and killed themselves within days.

The state’s scrutiny and response to suicides in prisons has no parallel in the jails, a striking fact given that county inmates are generally more psychologically vulnerable than their state counterparts. Most state inmates have already done time in jail awaiting trial before starting a prison sentence -- Hernandez, for example, had been incarcerated since his arrest in 2013 for the murder of Odin Lloyd and was serving a life sentence at the time of his death. As a result, they’ve had time to acclimate to incarceration. By contrast, the majority of jail inmates who die by suicide had not even been convicted of a crime yet. And county jail inmates are rarely sentenced to more than two and a half years of jail for lower-level crimes including drug charges, breaking and entering and assault and battery.

Most new jail inmates come straight off the streets, often struggling with drug withdrawals, mental illness and other health problems that make them especially vulnerable to what experts call “the shock of confinement.” Duffy, for example, suffered from depression, anxiety and high blood pressure, and he complained that the medications he received in the jail infirmary made him dizzy.

“I said you sent a sick man to jail and you just gave him a death sentence,’’ his wife Laurie said she told the prosecutor. “I just knew this was going to be the worst possible thing for him.”

Essex County officials released a mortality review of Duffy’s death which concluded that staff “responded appropriately” in his case. But questions remain about why he was sent to segregation after exhibiting “mental health issues,” according to the review carried out by jail officials.

Guard at Worcester Jail with "cut down" tool in hand.

Jim Walsh, executive director of the Massachusetts Sheriffs’ Association, defended the county jails, saying sheriffs struggle with limited resources to deal with a troubled daily jail population that averages just over 10,000 inmates. He said they train staff to watch for warning signs and closely watch suicidal inmates. When inmates do attempt suicide by hanging -- the most common suicide method nationwide – jails are equipped with blades to cut them down quickly. As a result, county officials prevent many deaths, Walsh said, but their system is not perfect and inmate behavior can be impulsive and unpredictable.

“You can’t always know what is going on in the mind of an inmate,” he said.

However, he said the sheriffs group has yet to take a systemwide look at the problem.

Lindsay Hayes, a national expert on suicide prevention, said county sheriffs should do more for their troubled prisoners, including demanding more state funding for staff training and expanded mental health services. He said they should also be forthright in disclosing when deaths occur, and under what circumstances, to make it easier to discern how future deaths can be prevented.

Catalogue model wearing a "suicide smock," clothing sometimes worn by inmates considered at risk of killing themselves.

County jails need to develop standard procedures to prevent suicides, he said. Currently, he said there is no standardized medical or mental health care in county jails and no statewide protocol for how to screen or protect at-risk inmates. As a result, each jail’s commitment and approach to suicide prevention varies, as does funding for mental health services. For example, Hampden County has 10 full time mental health clinicians for an average of 1433 inmates, while Bristol County has three for some 1350 daily inmates, according to the Massachusetts Sheriffs’ Association.

“Sheriffs need to stop complaining about being the largest mental health provider and start acting like it, by getting the resources they need and knocking on doors and publicizing it,’’ said Hayes. “There are a lot of preventable, foreseeable suicides.’’

Indeed, the suicide rate in Massachusetts’ county jails is higher than the national rate. In 2014, the latest year of comparable data, inmates in Massachusetts’ jails died at a rate of about 78 per 100,000 people -- significantly higher than the rate of 50 per 100,000 inmates in county jails across the US. In contrast, the rate of suicide among the general US population is about 13 deaths per 100,000.

In the state prison system, the Department of Correction began a concerted effort to reduce suicides and improve mental health in 2006, a year in which records show eight state prison inmates killed themselves. A 2007 Globe Spotlight series focusing on prison suicides provided added pressure for the state to act. With the help of Hayes, the state implemented a series of steps to prevent suicides, including creating longer-term units for the mentally ill and adding “suicide-resistant” cells, removing clothing hooks and bed rails that facilitate hangings.

The measures appear to have had an impact: From 2012 through 2016, a total of 16 state inmates committed suicide for an average of slightly more than three per year out of a prison population of about 10,000.

Leslie Walker, executive director of the Boston-based Prisoners’ Legal Services that advocates for inmates, said state prevention efforts only started after media scrutiny about the high number of suicides, but the results have been encouraging. She hopes a sharp look at county jail deaths will prompt similar action.

“Humane treatment and oversight is required,’’ she said, “or more preventable deaths will occur.”

The most jail suicides
Brandon St. Pierre of Fall River made it clear in May 2015 that he wanted to end his life if he was sent back to the Bristol County Jail and House of Correction run by Massachusetts’ longest-serving sheriff, Thomas Hodgson.

The 32-year-old St. Pierre, charged in a “road rage” incident, told a court psychologist about his intentions, records show. His attorney begged an Attleboro District Court judge to move St. Pierre to a state prison or Bridgewater State Hospital where more mental health services would have been available. St. Pierre had previously served time in state prison for another offense and told family he was desperate to transfer to a system where he felt more comfortable.

Judge Daniel O’ Shea declined the request, determining that St. Pierre was competent to stand trial. He did, however, require that jail officials were informed of the suicide threats, “to make sure that Mr. St. Pierre is observed and doesn’t have an opportunity to carry out the expressed intent to hurt himself,” O’ Shea said in court.

The court designated St. Pierre a “Q5,” a classification indicating a suicidal history, written on a court order alerting jailors to be sure to keep him safe.

No such precautions were taken, said Barbara Kice, St. Pierre’s mother. Instead of protecting her son by putting him on suicide watch, she said officers put him in the general jail population where he got into a fight and was transported to segregation as punishment. The next day he was found alone hanging in his cell

“From the court house to being alone, they left him everything to hang himself,’’ said Kice. “What a horrible mistake they made.”

Hodgson, who prides himself on tough policies such as offering up his inmates to help build President Donald J. Trump’s border wall, has seen more suicides than any other sheriff. Advocates at Prisoners’ Legal Services said the data reflects their concerns -- that the jail segregates too many mentally ill inmates rather than providing needed services. More people die in segregated cells than when housed with other inmates, national studies show.

“The reflexive response is, ‘Let’s just put him in the hole. Put him in segregation. Get rid of him,’’’ said James Pingeon, litigation director at Prisoners’ Legal Services. “That can be hard for anybody, but it’s particularly hard for people who have mental illness.”

Hodgson said he wasn’t aware that Bristol’s suicide numbers surpassed other counties and declined to discuss individual cases. He attributed high numbers of deaths partly to his troubled region which suffers from a high level of drug addiction and mental illness. He agreed that housing inmates with others can prevent suicides, but said he leaves treatment decisions to the jail’s mental health team. He is not aware of any specific changes the jail has made following the recent deaths. Like other jails, the facility relies on suicide-resistant cells, putting at-risk inmates on mental health watch and providing tear-resistant clothing to suicidal inmates.

“There’s a point where, no matter how protective you are, that people who are often successful committing suicide never give you the indicators, never let you know, exactly what’s going to happen,” he said.

Colleen Lewis of Dighton said her 48-year-old brother Kevin Leonardo might still be alive if Bristol County jail officials had only listened to what he was telling them.

Lewis said her older brother, who struggled with depression and drug addiction, threatened to kill himself after being arrested in 2016 on charges of statutory rape.

During an arraignment in Taunton District Court, a prosecutor said that the father of three told police, “As soon as I have a chance, I’m going to do it.”

The judge, in turn, filed a “suicide notification form” warning jail officials that Leonardo should “be monitored closely,” records show. Lewis said Leonardo’s attorney assured her he would be on suicide watch. But four days later, she was told he hanged himself in segregation. Now, she said, their family is bereft.

Lewis is struggling to get more information about her brother’s death – trying to understand why he was put in a single cell or even whether he left a suicide note. She joins other families who have lost loved ones in county jails who complain they can’t get basic information about what occurred.

Deborah Taylor of New Bedford filed a wrongful death suit last year in Bristol County Superior Court partly to get more information about her 31-year-old son Aaron Brito, a heroin addict who died by suicide in 2013.


Taylor claims county officials should have known Brito was at risk because he was an addict suffering from drug withdrawal. Records show he was supposed to be in a medical unit, but never was moved there. Taylor is still haunted by the way she learned about her son’s death – a phone call from a woman at the jail who wouldn’t identify herself.

“They said, ‘your son died today, if you want more information today call St. Luke’s hospital,’” she said. “These are words no person would forget.”

Hodgson acknowledged that he does not personally call families of inmates who commit suicide, and that the department is limited about what information it can give families because of legal and confidentiality issues, a claim echoed by officials at other large jails.

“We feel badly for the families, we always do,’’ Hodgson said. “We go as far as we can to give them what we can to give them closure.”

One jail’s reforms
Some county sheriffs say they have, in recent years, responded to the mounting death toll with new suicide prevention measures. Worcester County is one that has tried, but officials there say they ran into a familiar problem: not enough money. In 2013, four inmates committed suicide in the Worcester County Jail and House of Correction, prompting the family of one victim, 24-year-old Michael Reilly, to file a lawsuit.


Darlene Reilly, claims that the jail did not adequately assess or protect her son, who was addicted to heroin. She says Reilly was put on a “mental health watch” for 15 minutes and then inexplicably transferred to a single cell where hours later he hanged himself.

“My son died on their watch,’’ she said.

Since then, the jail has improved its intake process to allow new inmates more privacy to discuss mental health concerns and created a “new man unit” where recent arrivals are housed separate from other inmates, said David Tuttle, the jail superintendent since 2011.

In addition, Tuttle armed his corrections officers with cut-down tools to quickly release a prisoner from hanging -- something other jails have been reluctant to adopt out of fear they could fall into the hands of inmates.

The changes appears to have helped: since 2013, only two inmates in Worcester have committed suicide. Tuttle says officers stop about two or three suicide attempts a month, including hangings and other incidents like cuttings and head bashing.

But Tuttle said the jail is still overwhelmed by the troubled inmate population and lacks resources to hire more mental health counselors and expand substance abuse treatment. The jail’s entire $45 million budget, he says, is woefully inadequate to pay for basic services, much less for enhanced services for mentally ill and drug addicted inmates.

Tuttle released a letter sent from Worcester County Sheriff Lewis Evangelidis to lawmakers complaining about what he described as inequality in funding of county jails. Each county submits its own budget proposal to the state and there are no standards about how much money should go to mental health or inmate services.

“We have the desire to help these guys out. Nobody wants to step up and help us do it,’’ Tuttle said. “We don’t want people to die here.”

“This poor man”
Whatever the state may do to address jail suicides, it will come to late to help Guy Duffy, one of five men to commit suicide at the Essex County jail in Middleton in a 12-month period.

Michael Marks, the jail superintendent, said Duffy exemplifies the type of inmate who likely should never have been incarcerated at all.

“He had a cat that was old and he didn’t bring it to the vet and it died,’’ Marks said. “I don’t get it.”

Duffy was a 54-year-old retiree when he was charged with animal cruelty after bringing Jesse, the family tabby cat, to the Massachusetts Society for the Prevention of Cruelty to Animals in Methuen to be euthanized.

MSPCA staff claimed the cat was in terrible condition, with a maggot infestation in her eye and appeared to be neglected, records show. Duffy maintained he loved the sick feline and wanted her to die at home.

After his sentencing in July 2015, Laurie said she didn’t hear from her husband for six days. When she finally did hear from him, he was slurring his words, nearly incoherent. He was admitted directly to the jail infirmary with a low body temperature, records show.

Duffy was moved nine times during his 20-day stay, according to jail records, moving back and forth from the infirmary.

In phone calls to Laurie, Duffy described how he had no appetite for food, lost 17 pounds and feared for his life. He described sweating and shaking in the summer heat, so intense and unrelenting that corrections officers providing ice to inmates for respite.

About two weeks into his sentence, Duffy told Laurie he was losing hope; he wept and apologized to her. He described being put on a mental health watch, placed in a small cell with a glass door visible to infirmary staff. “I’m knocking on the window of the door, and the cops just look at you ... make fun of you,’’ he said.

Advocates worry that suicide watch, often including dressing prisoners in a so-called “suicide smock,” can be such a harsh alternative that many inmates conceal their distress so as not to be assigned to it.

“It’s preventing a suicide, but it’s not improving the prisoner at all,’’ said Walker of Prisoners’ Legal Services.

But Duffy also was unhappy housed with others, worried to the point of paranoia about his safety. So the jail decided to place him in protective custody, meant for inmates who need to be alone because they are dangerous to others or need protecting.

He didn’t want to go there, either. He resisted and was taken to the ground and shackled before being escorted to the infirmary, records show, and put back on mental health watch.

Hours later, Duffy was sent back to segregation. Later that same day, he hanged himself.

Essex County officials said Duffy had been cleared by mental health to be transferred to segregation. Marks declined to discuss details about Duffy’s death but said the jail has strived over the last several years to improve mental health services and reduce deaths. The county is one of the few large jails that release information to the public when someone dies in custody. There have been no suicides since 2015.

“Inmate deaths, staff injuries or death, or escape, those are the things that keep everyone in this room awake at night,” said Marks.

On the day of her husband’s death, Laurie said a dark SUV drove up to her house and three men knocked on her door. Among them was former Sheriff Frank Cousins. She knew immediately why they’d come. The love of her life was gone. “They broke him down,” she said. “It was just awful what they did to this poor man.”

Chris Burrell, Miranda Suarez, Debora Almeida, and Kaylie Piecuch contributed to this report, in partnership with The Boston Globe and WGBH News. Timeline created by Shaz Sajadi. Jenifer McKim can be reached at