Highlights of prison system findings on death row suicide

Highlights of findings by the Department of Rehabilitation and Correction into the May 7 suicide of death row inmate Martin Koliser:

- There was no evidence a nurse assigned to death row had completed CPR training in 2003, nor did she receive training in 2004 or become recertified this year until 10 days after Koliser's death.

- An officer unnecessarily delayed an ambulance's arrival at the prison in response to Koliser's suicide by searching the vehicle. That violated department policy which says emergency vehicles should be stopped only long enough to verify the employment of emergency workers.

- Institutional logbooks were lacking proper documentation of shift activities.

- The cells of Koliser and other inmates were so filthy that the view into them was blocked, indicating that officers are not requiring inmates to keep their living areas clean. Staff failed to follow up on a memo dated May 4 regarding cell cleanliness.

- Metal loops extended from the top and bottom bunks of the beds in Koliser's cell, and Koliser used the top loop to hang himself. The report recommended the loops be removed from death row beds.

- No supervisor visited Koliser's unit the night of May 6, a violation of department policy.

- Guards apparently didn't know how to work night lights in the cells that are operated from a central control area.

- Seals were broken on first aid kits and supplies were missing from the kits.

(source: Department of Rehabilitation and Correction)

(source for both: Associated Press)