By Amy Silverman
By Olivia LaVecchia
By Monica Alonzo and Stephen Lemons
By Chris Parker
By Michael Lacey
By Weston Phippen
At 2:30 p.m. on May 14, 2002, Maricopa County jail psychiatrist Joe Franzetti scribbled a note into the medical chart of his patient, inmate Steve Cervantes. He wrote that Cervantes was "stable, compliant, and with a brighter mood. No homicidality. No suicidality. No delusions. Insight and judgment improved. Socializes appropriately, and should do well in general population. . . . Social worker will follow up in five to seven days. Inmate out to court."
Exactly half an hour before Dr. Franzetti made that upbeat notation, sheriff's deputies across the street at the Superior Court complex in downtown Phoenix discovered the body of an inmate in a holding cell.
Though the inmate had been handcuffed and shackled while awaiting his court date, he'd fashioned a makeshift noose out of his two pink jail-issue socks and tied it to the bars of the cell door.
Steve Cervantes then hanged himself.
Neither deputies nor firefighters who'd rushed to the grisly scene could revive him. Cervantes was 39.
Detectives found a scrawled handwritten note in a shirt pocket of his jail-issue black-and-whites.
"Why must I die to save my family from harm?" Cervantes had written. "Now I say to those who lie . . . it's time to die."
Detectives soon told his girlfriend, Shannon Sintic, the terrible news. She'd been awaiting his arrival for the hearing in an eighth-floor courtroom. Sintic had left her four children, including three-week-old Angelina -- one of her two kids with Cervantes -- at home with a sitter.
"I really thought Steve would be safe from himself in jail," says Sintic, now 29. "They told me he was on suicide watch, and I thought they meant something. Something like this just couldn't happen."
But such things do happen, and with tragic frequency in Maricopa County.
Cervantes was one of six prisoners who committed suicide in the county in 2002, according to statistics provided by the County Attorney's Office. Seventeen jail inmates have killed themselves in custody since then.
Cervantes' suicide, however, was the first ever at the courthouse. The nature and unprecedented location of his death sent shock waves through the Maricopa County Sheriff's Office and Correctional Health Services -- the county agency that provides medical care to inmates.
Attorneys in a lawsuit filed on behalf of Shannon Sintic and her two young children with Cervantes still are sorting out what led to the suicide, and whether it could have been prevented.
And though it's impossible for jail officials anywhere to stop every self-inflicted death on their watch, the evidence that's emerged in the Cervantes case is damning.
It was bad enough that Dr. Franzetti had released a dead man back to the general jail population with his 2:30 p.m. notation in Cervantes' medical chart. What Franzetti was trying to cover up with his tardy notation makes this a story worth telling.
Truth is, Franzetti spent almost no time with Steve Cervantes -- just minutes at the start of the inmate's 10 days in the jail. He barely evaluated Cervantes and provided no treatment save prescribing antidepressants and sedatives.
But Joe Franzetti claimed in his medical chart notation and, much later, in deposition testimony that he'd examined Cervantes on the morning of the suicide.
All indications, however, are that Franzetti never saw Cervantes on the fateful day. That's because Cervantes left his cell for court long before the doctor ever got to work.
Sheriff's detention officers have testified that they routinely would have taken Cervantes and other inmates from jail to the courthouse at 6:30 a.m. By all accounts, including his own, Franzetti rarely, if ever, got to work at the Madison Street Jail before 8 a.m.
Usually, his colleagues have said, he arrived after 9.
Franzetti himself testified that he probably examined Cervantes after 9 a.m. on May 14, well after sheriff's deputies would have taken him to the courthouse holding cell.
Because he hadn't seen his patient, Franzetti had no independent basis to take Cervantes off suicide watch -- which Cervantes had been on since his incarceration -- or to send him into the general population of inmates.
Steve Cervantes then sat for hours in a tiny cell, alone and overwhelmed by his own twisted thoughts. On top of that, the deputies guarding him at the courthouse admittedly were woefully untrained in the sheriff's office's own suicide prevention policies.
Claudio Fausto, one of the deputies who found Cervantes' body, said in deposition last year, "If he was suicidal, then he would not have been transported to court, period. I mean, he would have been on a [suicide] watch or something."
Fausto added that he was unaware that Cervantes needed special attention, or that he had a recent history of aggressive suicidal attempts.
All Fausto said he knew was that an inmate had come to court from the jail's psych unit, so he separated the man from other prisoners awaiting court hearings for everyone's protection.
Fausto described how he'd checked on Cervantes in the little cell only once over a period of about four hours, even though he and others heard the inmate screaming for much of that time.
By way of explanation, the deputy said he and his peers had never received special training for dealing with suicidal inmates, and knew little about the importance of frequently checking on them.