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July 2, 1998



Before Schwelb and Farrell, Associate Judges, and Mack, Senior Judge.

The opinion of the court was delivered by: Schwelb, Associate Judge:

The court-appointed Special Administrator of the estate of a prisoner who hanged himself at the District of Columbia Jail brought this wrongful death and survival action against the District of Columbia, alleging that the decedent's death was proximately caused by negligence on the part of the District's agents and employees. The case was tried in the Superior Court before a judge and jury. At the conclusion of the plaintiff's case-in-chief, the trial judge granted the District's motion for a directed verdict, holding that the plaintiff had failed to establish a national standard of care or a violation thereof. The plaintiff appeals; we reverse the judgment.



A. The decedent's arrest and suicide.

On or about October 7, 1994, the decedent, Bentley G. Ross, then thirty-two years old, was behaving erratically on the premises of a [714 A2d Page 770]

Crestar Bank in northwest Washington, D.C. Police officers were called to the scene. When officers questioned Ross as to whether he was in possession of a weapon, he disclosed that he had a handgun in his bag. Ross was then placed under arrest.

On the following day, Ross was arraigned in the Superior Court and charged with carrying a pistol without a license. The presiding judge ordered that Ross be detained pending a forensic examination, and Ross was transferred to the District of Columbia Jail pursuant to a commitment order on which the following handwritten notation appeared:



The "FORENSIC" designation was a potentially significant one for officials at the jail. Approximately sixteen months before Ross' arrival at that facility, the Department of Corrections (DOC) had issued a departmental directive "establish[ing] uniform guidelines and procedures for mental health service delivery to residents housed in the Detention Facility." See DOP 6014.1a (May 13, 1993). This directive provided, inter alia, as follows:

Residents ordered by the Court to be housed on the Mental Health Units to undergo Competency or Criminal Responsibility Examinations shall be transferred to the Mental Health Unit. . . .

The plaintiff introduced testimony showing that jail officials understood this directive to require them to place in the Mental Health Unit any prisoner with the word "FORENSIC" noted on his commitment form. Nevertheless, Ross was not placed in the Mental Health Unit, but was housed instead in the open population.

In the early morning of October 10, 1994, Ross, who was apparently being harassed by other prisoners, expressed fear for his safety. He asked to be placed in protective custody. Jail officials moved Ross to "Northeast One," an "intake cellblock" consisting of eighty cells. The correctional officers in charge of the cellblock were not advised that Ross had a mental problem of any kind.

Ross never left the intake cellblock alive. A prisoner in a nearby cell testified that, on the morning of his death, Ross became agitated. According to this inmate, Ross was begging to be released from his cell, even if only to sweep the floor. The jail staff did not respond to this request, however, and at 10:26 a.m., a second inmate advised an officer that there might be a problem in Ross' cell. The officers entered the cell and found Ross "in a sitting-like position between the toilet and the foot of the bunk," with a sheet tied around his neck. The other end of the sheet was tied to the top bunk. Shortly thereafter, a physician determined that Ross was dead. Ross had hanged himself with a bedsheet.

Ross' suicidal activities had escaped the notice of the staff of the jail. There was testimony that jail officials maintained a log book which contained contemporaneous written entries reflecting relevant activity in the unit. The log book did not contain a single entry for the period from 8:40 a.m. to 10:00 a.m. *fn1

B. The trial court proceedings.

On February 14, 1995, Jewel Phillips, Ross' aunt, was duly appointed by a court in the State of Kansas to serve as the administrator of Ross' estate. On May 23, 1995, Ms. Phillips filed suit against the District under the Wrongful Death Act, D.C.Code § 16-2701 (1997), and the Survival Act, D.C.Code § 12-101 (1995). Ms. Phillips claimed, inter alia that notwithstanding the "FORENSIC" notation on Ross' commitment order, jail officials had negligently failed to place Ross in the Mental Health Unit. Ms. Phillips also alleged that the officers at the intake cellblock failed to take measures to maintain continuous observation of Ross. Ms. Phillips claimed that these and other acts of negligence proximately caused Ross to suffer emotional distress and led to his subsequent death. Ms. Phillips asked the court to award [714 A2d Page 771]

substantial compensatory and punitive damages.

The case was tried before the trial judge and a jury on November 18 and 19, 1996. The plaintiff introduced testimony relating the events which we have described above, and which culminated in Bentley Ross' suicide. The plaintiff also called Joseph Rowan, an experienced correctional administrator, as an expert witness on proper prison administration and related issues. Rowan testified extensively regarding the standard of care applicable to the treatment of jail inmates with mental health problems, as well as the standard relating to the treatment of prisoners generally. This appeal turns largely on the question whether Rowan's testimony was sufficient to establish a national standard of care and its breach by officials or employees of the District of Columbia Jail.

With respect to the handling of prisoners with mental health problems, Rowan testified that the applicable standard of care was set forth in Standard No. 110 of the American Medical Association's "Standards for Health Services ...

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