Only 20 percent of U.S. jails reported a death in 2013, according to the Bureau of Justice Statistics. The Durham County Detention Center was one of them.

On March 14, 2013, Terry Demetrius Lee, a twenty-nine-year-old arrested for firing a gun in a hotel room, tied a bed sheet to the bars on his cell window and hanged himself.

Jail reports obtained by the INDY indicate that his suicide was likely preventable.

In 2011, a jail inspector the N.C. Department of Health and Human Services performed a semiannual visit to the jail. Her report noted: “Area behind bars in cell windows identified as potential hanging hazard. Highly recommend administration research options to make these areas safer and less accessible.”

And yet, two years later, Lee was able to kill himself in the exact fashion the DHHS inspector had warned about.

As the INDY has reported, the Durham County jail has been a tumultuous place over the past year. Two detention officers were fired and charged with assaulting inmates. Inmates have reported being served maggot-infested food. And in January, detainee Matthew McCain was found dead in his cell. His family says the jail staff wasn’t providing him with his diabetes medication.

The jailwhich largely houses individuals awaiting trial, who have not yet been convictedis such an inhumane place, former and current detainees say, that people take plea bargains just so they can escape to the state penitentiary. Suicide attempts are common, they say. The jail reported twelve attempts in 2015. None were successful.

Deaths at North Carolina jails prompt a mandatory investigation by DHHS. The investigation into Lee’s death identified several areas of concern. By rule, for example, jail officers are required to observe inmates in person at least twice per hour. On the day of Lee’s suicide, however, as many as six hours passed between supervisory rounds.

The DHHS investigation also found that Lee was improperly housed. Lee’s medical-screening process, taken upon admission to the jail, had determined that he could be placed in a regular housing unit, not one designed to house inmates with mental health issues. But Lee had a well-documented history of such problems, and this history was known to jail officials. He had been incarcerated at the jail six times previously. In 2007 and 2008, he was transferred from the jail to John Umstead Hospital for mental health reasons. In 2009, he came to the jail from Central Regional Hospital, where he had been “housed to restore his competency.”

“The member of the medical staff who conducted the initial health screening should have access to the medical records of this inmate and should have access to prior history of mental health issues,” the DHHS investigation report states. “This inmate could have been placed on a four times per hour check and placed in an area that affords better supervision of this type of inmate.”

Instead, Lee was treated like an inmate with no mental health risk. He committed suicide the very next day.

The DHHS investigator also observed the same suicide risk the 2011 inspector had: “The design of the bar that is mounted over most windows in the facility does not prevent an inmate from using this design to facilitate suicide.”

In response to the DHHS report, Durham County Sheriff Mike Andrews in 2013 assured the DHHS that changes had been made at the jail. He wrote in a letter that security-tour logs were now being audited daily, and that a jail mental health diversion program had been established to review new inmates “on a daily basis to ensure that past, current, or future mental-health clients are identified as quickly as possible.”

The officer who failed to conduct timely rounds was terminated following Lee’s death.

Tamara Gibbs, spokeswoman for the sheriff’s office, says that, prior to Lee’s death, the sheriff’s office had begun the process of making cells more suicide-proof. “There was a reasonable effort to make necessary changes,” she says. At the time of Lee’s death, she adds, pods on the third floor were used for suicide observation. But, Gibbs says, “The medical staff did not classify Mr. Lee as suicidal, and he was not placed on the third floor where additional safety measures were in place.”

The bars in the cells of certain jail pods have since been modified and are considered hazard-proof. Gibbs also says the sheriff’s office is trying to establish a designated mental health pod.

“The proposed mental health pod is a priority and will require additional personnel,” she says, “but recruitment and retention of detention officers has been a significant challenge. As soon as the agency is able to hire and train detention officers, the mental health pod will be operational.”

This article appeared in print with the headline “Suicidal Tendencies”