Cause of death: passive hanging

David Gueits Jr.’s family wants Pennsylvania officials to explain exactly how he died in custody.

Cause of death: passive hanging

David Gueits Jr.’s family wants Pennsylvania officials to explain exactly how he died in custody.

Elid David Gueits, Jr., known as David, posted on Instagram for the first time in March 2018: a grainy selfie video from a cellphone camera, with him in the drivers’ seat of a car and police lights flashing in the night behind him. He looks exasperated, maybe a little amused, his Philadelphia Eagles hat lopsided on his head. The incident doesn���t seem to be referenced in his court records, so who knows why the police stopped him that particular night. If you were a kid like David, you got pulled over a lot.

David grew up in Lancaster, Pennsylvania, nestled in Amish country about 80 miles west of Philadelphia, where the poverty rate is consistently double the state average. David and his half-brother Jonathan Quinones — both of Puerto Rican heritage, like about a third of Lancaster’s population — spent their childhoods in the city’s majority-Latino southeastern neighborhoods. David and Jonathan were adventurous kids: always outside, known to neighbors as big-hearted but a little reckless, willing to get rough. The police started paying attention when they were teenagers, often ordering them inside well before the city’s 10:00 p.m. curfew. “It was kind of difficult,” Jonathan, now 27, told me when I visited him in Lancaster in September. “But for us it was just everyday life.”

David lived every moment of his adult life under some form of correctional control. A marijuana arrest as a teenager put him on juvenile probation, and as an adult he was sent to Lancaster County Prison at least four times between 2013 and 2018. When he wasn’t locked up, he was always on parole.

David Gueits at SCI-Camp Hill in December 2018.

David Gueits at SCI-Camp Hill in December 2018.

“I knew what I was getting into when I met him,” Nelly Colón, David’s longtime partner, told me. Jonathan introduced Nelly and David in the summer of 2014 when David was fresh out of his first stint in county lock-up. David already had a daughter from a previous relationship, and soon he and Nelly had another. The pregnancy was a surprise: Nelly told me she remembers a powerful craving for passionfruit, David running to the pharmacy at midnight for a pregnancy test, the two of them waiting together in a bathroom for the results to appear. Two months later, in October 2015, they were engaged to be married. Their daughter was born in July 2016.

The young family spent a lot of time apart. “He was locked up basically our entire relationship,” Nelly said. As an adult, between 2013 and his last arrest in 2018, David was convicted of six misdemeanors — drug possession, theft, vandalism — and one felony count of aggravated assault stemming from a confrontation with a parole officer in 2016.

Sometimes Nelly brought their daughter to visit David at the Lancaster County Prison, where they could only speak to him through a heavy pane of glass. The baby’s attention wandered. Nelly didn’t like exposing her to the prison’s loud and crowded visitation room. Still, the couple made their relationship work, organizing the rhythm of their lives together around David’s release dates.

David’s final arrest came just a few weeks after Nelly gave birth to their second daughter. On April 16, 2018, he found himself mistakenly locked out of his grandmother’s house in Lancaster. He often slept there when he needed an escape; since his release from Lancaster County Prison about a year prior, he had shared a crowded and sometimes tense home with Nelly and their young family. But that night the cops spotted him asleep in his car parked on the street. Once they got him awake their work was easy: He had marijuana and 32 grams of cocaine in the car.

After David was arrested the district attorney stuck him with serious charges: multiple charges of drug possession with intent to deliver, plus a paraphernalia charge for two smoking pieces that were also in the car. As a repeat felon, David was facing serious time, five to 10 years. He called Nelly from lock-up to tell her she could go her own way in life — she didn’t have to wait for him to be released — but she wouldn’t hear of it. In the end, David cut a deal: he pled guilty for a sentence of 15 months to four years.

That September, he was transferred from Lancaster County Prison to the State Correctional Institution at Camp Hill, a facility run by the Pennsylvania Department of Corrections outside Harrisburg. He could have been eligible for early release and parole in March. “We always talked about 2019 being our year, because that was when he’d get free,” Nelly said.

Instead, David died in his cell on January 1, 2019, less than two weeks after his 24th birthday.

David’s body was sent to the Dauphin County Forensic Center in Harrisburg, right across the Susquehanna River from Camp Hill. After an examination by Dr. Wayne Ross, a forensic pathologist who conducts autopsies for the coroners of Cumberland, Dauphin, Lancaster, and other Pennsylvania counties, Cumberland County Coroner Charles Hall ruled David’s death a suicide by “passive hanging.”

David’s family had never heard of the term prior to seeing it on David’s coroner’s report. And they weren’t alone.

According to Eric Bieber, chief deputy coroner of Lancaster County, the term “passive hanging” is used to refer to hanging deaths in which the body does not hang freely — instead, the person must lean against a ligature, often from a kneeling or slouching position, to put pressure on the carotid artery, resulting in asphyxiation. It’s not a term unique to prison deaths; in fact, Bieber told me, the majority of ligature hanging deaths he sees can be accurately described as passive hangings.

The use of “passive hanging” as a cause of death designation appears to be rather isolated. “It’s specific, I believe, to legal medicine, or to legal medical death investigations,” Bieber said. But the term doesn’t seem to come from the scientific literature on forensic pathology, having never appeared in the American Journal of Forensic Medicine and Pathology nor Forensic Science, Medicine & Pathology, two of the field’s leading academic journals. Dominick Adamo, the coroner of nearby Union County, told me he has never encountered it, despite years of experience investigating suicides at jails and prisons.

Dr. Kevin Whaley, a board-certified forensic pathologist with 15 years’ experience performing autopsies for the coroners of 14 Pennsylvania counties, told me he’s never heard the term either. “But, you know, sometimes people get creative,” he said, explaining that every pathologist will have their own naming practices. Whaley said he has seen cases in which prisoners died by hanging in confined quarters, but the cause-of-death designation he used in those cases was “asphyxia by hanging,” a more common term. “Unless you’re trying to separate out active hanging, and I don’t know what an active hanging is,” he said.

David’s family is tormented by the authorities’ confused account of his final moments and frustrated by their inability to hold the Department of Corrections accountable.

Still, since 2008, “passive hanging” has been cited as the cause of death for at least four deaths at SCI Camp Hill, at least five deaths at Lancaster County Prison, at least two deaths at Dauphin County Prison, and at least one death at Cumberland County Prison. (Neither Hall or Ross responded to requests for comment, nor did Dauphin County Coroner Graham Hetrick.)

“I’ve been in practice for 15 years, and I’ve used the term for that whole period. Our forensic pathologist [Wayne Ross] has been using ‘passive hanging’ for 30 years,” Bieber said.

After his autopsy, David was released to a funeral home in Lancaster. His family sold T-shirts with his likeness to raise money for the service. For months after the funeral, David’s mother, Stacy Lovill, used her grief to fuel hours of research. She heard stories about the Camp Hill prison even before David was sent there. As she searched the internet for old news articles, Stacy understood why. She found reports of sub-standard conditions, scandalous allegations about a “code of silence” enforced by powerful guards, and deaths. Too many deaths.

Pennsylvania state correctional institutions don’t issue press releases for deaths deemed natural, and while standard operating procedure is to notify the press of all non-natural deaths, they are not legally obligated to do so. Still, officials at Camp Hill issued six press releases reporting non-natural prisoner deaths between 2014 and 2018 (David’s death, which took place around noon on January 1, was the first of 2019). At least three of those press releases described circumstances similar to David’s case — men who hanged themselves in their cramped cells, discovered too late to be revived. In two other cases, local news media reported that the coroner later attributed the deaths to “passive hanging.” Stunned, Stacy started a Facebook page called “Make Camp Hill accountable for David’s death,” hoping to stir up some information.

But answers have been hard to get. David’s family is tormented by the authorities’ confused account of his final moments and frustrated by their inability to hold the Department of Corrections accountable. “There’s a lot of people dying in prison,” David’s aunt, Tammy Wilson, told me. “It’s like you can’t do anything about it. You don’t have money for lawyers, and they know that. It��s like you’re never gonna know what happened.”

David’s death was a dark start to 2019, a year the York Daily Record called “the worst in a generation” for non-natural prison deaths in the state. Suicide was already a growing problem for Pennsylvania prisoners prior to last year. In 2017 and 2018, there were 30 suicides in facilities run by the state Department of Corrections — the highest rate in 20 years, as the Philadelphia Inquirer reported in 2018.

Angus Love, former executive director of the Pennsylvania Institutional Law Project, told me there’s no doubt the Department of Corrections has failed in its duty to diligently safeguard the lives of those in its custody. As suicide rates continue to climb in disadvantaged communities in general, he told me, that trend is mirrored inside the prison system.

The stress of incarceration heightens the risk of suicide, and in some cases it can be lethal. The Pennsylvania Capital Star reported this year that prisoners in the state die by suicide at double the rate of the general population.

“Prisons are atrocious, violent places. Being locked in a cage is deeply violent,” said Judah Schept, associate professor of justice studies at Eastern Kentucky University. “Add to that the daily humiliations, the lack of physical and mental health care, the degradation, the separation from your loved ones, to say nothing of interpersonal violence, whether from guards or other prisoners. It’s a recipe for crisis.”

There are almost 17,000 people employed as county jailers or state prison guards in Pennsylvania, and the Pennsylvania State Corrections Officers Association is a powerful lobby in Harrisburg.

It isn’t just the rising suicide rate that evinces that crisis in Pennsylvania. In November 2019, the Pennsylvania Department of Corrections suspended 13 medical and security employees at the State Correctional Institution at Mahanoy, a little over an hour’s drive from Camp Hill, after 29-year-old prisoner Tyrone Briggs died under suspicious circumstances. Briggs, who had been incarcerated since the age of 15, died of traumatic injuries while awaiting transfer to an administrative housing unit inside the prison. Alongside lawyers from the Abolitionist Law Center in Pittsburgh, Briggs’s family has publicly demanded accountability from the DOC, alleging that Briggs died after guards used force against him.

At the same time, two bills making their way through the state legislature threaten to greatly enhance the power of corrections officers in the state. The bipartisan bills, HB 256 and 257, would expand the definition of felony assault in cases of prisoner-on-guard contact and establish mandatory minimum sentences (to be served consecutively) for such assaults. There are almost 17,000 people employed as county jailers or state prison guards in Pennsylvania, and the Pennsylvania State Corrections Officers Association is a powerful lobby in Harrisburg.

If current trends continue, things could get even more dangerous for incarcerated people. Around the country, county jails (often called county prisons in Pennsylvania) have grown for a variety of reasons, including to compensate for reductions in state prison budgets, Lydia Pelot-Hobbs of the New York University Prison Education Program told me. County jails are even more dangerous than state correctional institutions (SCIs). A recent investigation by WHYY in Philadelphia revealed that from 2015 to 2018, 81 prisoners died by suicide in Pennsylvania county prisons — more than double the number who died in state correctional institutions during this time, even though the average daily population in county prisons (about 35,000) is only about two thirds the size of the state prison population (44,967 as of December 31, 2019). Including one military-style boot camp facility, there are currently 25 state prisons in Pennsylvania, all under the control of the state DOC, and 62 county prison facilities, each of which is maintained and administered by a county sheriff.

“The realignment of states’ carceral geographies is the major trend we’re seeing in states across the country,” Pelot-Hobbs said. Since Louisiana first innovated the practice of housing state prisoners in county jails in the 1970s, Pelot-Hobbs told me, many other states have followed suit. Carceral capacity at the county level has expanded across the country even as prison reform laws have accomplished laudable reductions in state prison populations.

Despite some state corrections departments’ attempts to reduce the number of people held in their prison facilities, rates of new jail admission remain high. As a result, the burden of mass incarceration is delegated from centralized state systems to diffuse county ones, posing new challenges for reformers and fresh dangers for inmates. A recent report from the Vera Institute of Justice shows that, nationwide, county jail populations rose by 4.3 percent between 2015 and 2019 — an increase of about 31,000 prisoners.

This national story resonates with Pennsylvania’s local history. Sentencing reforms — including commutations for life-without-parole prisoners — have produced some promising results. Pennsylvania accomplished a 2.2 percent reduction in its SCI population in 2018, which, while still lagging behind neighboring states like New York and West Virginia, nevertheless represented a decrease of more than 1,000 prisoners.

But the limited reduction in Pennsylvania state prison population has not been accompanied by a similar roll-back of many legal mechanisms that drive mass incarceration in the state — notably the length and severity of Pennsylvania’s parole and probation practices. Pennsylvania has the second-highest parole/probation rate in the country (second only to Georgia): 2,220 per 100,000 people.

A 2012 study from Penn State University’s Center for Criminal Justice showed the capacity of Pennsylvania’s county prisons growing rapidly between 2004 and 2011, far outpacing any increased demand from new arrests. Of the 44 county prisons included in the study, 19 of them untook a major expansion project during the study period; taken together, these expansions represented “a potential source of bed space for the state prison system,” which was then overcrowded. While county prisons offer significantly fewer rehabilitative services than SCIs, their daily per-prisoner costs (as low as $40 in some cases) tend to be more efficient than the DOC’s $90 daily per-prisoner price-tag, the report pointed out. The county prison network “appears poised to act as an available relief valve to other jurisdictions’ crowding issues,” it concluded.

The trend towards expanded carceral capacity at the county level has continued apace since that particular study ended in 2012. Since the beginning of 2013, no fewer than 12 county jails in Pennsylvania have reported significant renovations resulting in capacity expansion, according to data collected by the state Department of Corrections.

“Lancaster County has positioned itself as a leader in ending mass incarceration,” Jasmine Heiss of the Vera Institute told me, citing the implementation of new re-entry programs for prisoners released from the county prison there. But, she said, the reality is more complicated. For example, the Lancaster County Prison has seen a 75 percent uptick in admissions due to parole revocations since 2013.

Any sustainable solution to Pennsylvania’s over-incarceration crisis, Heiss told me, would require substantially reducing new county jail admissions. For this to happen, law enforcement priorities will have to change dramatically: judges, prosecutors, parole officers, and police will all have to exercise a much greater level of restraint, particularly when deciding whether to place someone under arrest or revoke someone’s parole.

When he was arrested on April 16, 2018, David became one of about 23 people to be booked into a county prison in Pennsylvania every hour, according to data from the Vera Institute. In September, because of the length of his sentence, David was transferred to the State Correctional Institution at Camp Hill, where he stayed until his death on January 1.

Stacy Lovill learned her son had died five hours after his body was found. Stacy passed the news on to Nelly, who broke down and was taken to the hospital in anguish.

First thing the next morning, Stacy drove to Camp Hill with other family members, where they met with the superintendent’s assistant Deb Alvord. They learned that they could order a copy of the coroner’s report from the county clerk, but if they wanted anything from the prison, like security camera footage from David’s cell block, they’d need a subpoena. The family left Camp Hill feeling stunned. (Alvord, who is the prison’s public relations officer, declined to comment and deferred my requests to Secretary of Corrections John Wetzel. Through an associate, Wetzel repeatedly canceled our interview appointments. He did not respond to a list of written questions.)

According to the coroner’s report, Deputy Coroners Christopher Yohn and Jeff Miller got to K Block a little after 1:00 p.m. and were promptly escorted to cell A1-31, where David was lying on the floor. His ankles were bound with restraints. There were defibrillator pads and EKG nodes attached to his chest.

Trooper Wells, the state police investigator assigned to the case, was already present (on the Pennsylvania state police website, officers are only identified by their last names; a spokesperson would not release Wells’s first name or make him available for comment). A corrections officer reported that, while doing his noon rounds, he saw David lying on the floor of his cell, a bedsheet around his neck. But this description of events is contradicted elsewhere in the report, which also says guards found David hanging from the bars of the cell’s bunk bed and cut him down prior to notifying EMS at 12:14 p.m. (Yohn and Miller did not respond to requests for comment.)

For Stacy, the coroner’s report — and especially the designation suicide by “passive hanging” — presented more questions than it answered.

By the time EMS arrived, it was far too late to revive David. Stacy has doubts about the prison staff’s emergency medical efforts — the postmortem report mentions no broken ribs or other physical signs of vigorous CPR, and the T-shirt David was wearing was returned to Stacy uncut, making her doubt the speedy placement of defibrillator pads on her son’s chest.

The deputy coroner’s report says David’s “ankles were secured with flex cuffs” — a term generally used to describe single-use plastic handcuffs. Pennsylvania state correctional institutions use leg restraints for transporting prisoners, and soft leather straps may be used for prisoners on suicide watch (which David was not). Nowhere does the deputy coroners’ statement explain if the restraints were put in place after David’s body was discovered, as prison staff attempted to revive him, or whether he was already restrained alone in his cell when he died.

The state police investigation into David’s death didn’t take long. For Stacy, the coroner’s report — and especially the designation suicide by “passive hanging” — presented more questions than it answered. But Wells quickly concluded that David had committed suicide and, following the coroner’s investigation, closed the case. Unlike Stacy, Wells never doubted that David’s death was a suicide.

To Stacy, it didn’t seem like he had done much investigating at all. Her only conversation with him was by telephone a few days after David’s death, before the coroner’s report was completed. Wells had not yet interviewed David’s cellmate, but he had listened to some of David’s recent phone calls from the prison. (Most telephone calls placed from Pennsylvania SCIs are recorded and archived by the DOC.)

Based on his listening, Wells attributed David’s suicide to a series of tense conversations with Nelly, which he said took place only days before David’s death. (When we spoke, Nelly acknowledged some phone calls similar to those Wells described, but said that the conflict was resolved by New Year’s Day.) Wells described David fighting bitterly with Nelly, whom the state trooper called “a miserable person” and “a real hardcore bitch,” Stacy told me. But Wells never contacted or attempted to interview Nelly. Nor did Wells contact or attempt to interview Jonathan, who was also in contact with his brother and might have offered insight into David’s mental state.

Nelly maintained daily contact with David while he was at Camp Hill; she spoke with him by telephone twice on the morning he died. But because Wells never contacted Nelly, he likely never saw David’s final written communication, sent through the Interactive Inmate Kiosk, an electronic messaging service available to Camp Hill prisoners. In the note, sent to Nelly at 9:06 a.m, David looks forward to his future with Nelly, saying “it will take time” and “I want you as my wife.” David was dead in his cell three hours later.

“We all get in depressions and whatnot,” David’s aunt Tammy told me. “We weren’t there, so we don’t really know what happened. But we really don’t think...” Her voice trailed off. “He only had a couple months left, and he had three daughters. He was a kindhearted person.”

“He was always saying, ‘I’ll be here for my kids,’” Nelly said. “I was really looking forward to spending my life with him.” Like Stacy and the rest of David’s family, Nelly holds the DOC accountable. “Why can’t we see the video?” she said of the security footage denied to Stacy. “ At least then I’d have a story to tell my daughters when they ask what happened to their dad.”

I first reached out to Stacy after coming across her Facebook group — Make Camp Hill accountable for David’s death — in March 2019. “I would like to get ahold of other mothers, families, people that the same thing happened to,” she told me. Stacy imagined a coalition of grieving relatives, their outrage aimed at the Pennsylvania Department of Corrections, and at the Camp Hill prison in particular.

In June, a 41-year-old man named Carlton Madden died like David did, asphyxiated by a sheet in his cell at Camp Hill. It was less than a week before a preliminary hearing on the DUI charge that had gotten him sent to the prison as a parole violator. Cumberland County Coroner Charles Hall designated the death a suicide by passive hanging.

On December 4, guards at Camp Hill reported that they found 24-year-old Dominic Ingle unresponsive in his cell. Ingle, who was serving a three to six year sentence stemming from a 2015 incident in Lancaster County, had been at the prison only a month and a half, since October 22. Local news reports suggest the state police are now investigating his death as a suicide.

In the year since David’s death, Stacy tells me, she’s made some connections with others in the state whose loved ones have become ensnared in the Pennsylvania justice system. “It’s ridiculous that they’re not being held accountable,” she said of the Pennsylvania Department of Corrections. “They don’t realize, these inmates have families.”

Already, this year’s rate of suicide in Pennsylvania SCIs is on pace to meet or exceed last year’s. So far, the Pennsylvania Department of Corrections has reported four non-natural prison deaths in 2020, all of them apparent suicides. One of those deaths took place at Camp Hill, where 39-year-old Robert Sheetz was found dead in his cell on January 4, hanging from an air vent.

Jonah Walters is a freelance writer from central Pennsylvania and a PhD candidate in geography at Rutgers, The State University of New Jersey.