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."
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.
An indifferent effort to treat Steve Cervantes by a jail psychiatrist, the ineffectual presence of sheriff's deputies and an inmate haunted by his own dark thoughts became the ingredients of a tragedy that could have been averted.
"Dr. Franzetti knew very well that Steve Cervantes was a danger to himself, but he did nothing at all to prevent Steve from hurting himself," says Phoenix attorney David Don, who with Joel Robbins is representing Shannon Sintic in the federal lawsuit against Maricopa County.
The pending suit also accuses Sheriff Joe Arpaio of nurturing the atmosphere that led to the deaths of Cervantes and others inside his jails.
"The spate of lawsuits and claims about inadequate medical care gave Arpaio actual notice of unconstitutional conditions," Don wrote in court papers filed last month. "Despite this, Arpaio did nothing to improve the medical care in the jails. In fact, he ratified it."
Lawyers for the county have accused the plaintiffs of using "impassioned buzzwords" to try to bolster an otherwise weak case.
Dr. Franzetti did not respond to New Times' request for an interview. His side of the story comes from a remarkable deposition he gave to Don in May 2004.
The journey that led Steve Cervantes to that tiny courthouse cell was perilous, but not without love.
"Steve had some great sides to him, and I was crazy in love with him," Shannon Sintic says. "He loved our kids, really did, and that never stopped. Even though we had fights, usually about his taking drugs, I didn't leave him. We considered ourselves husband and wife."
Born in Chicago, Cervantes often found himself in legal trouble during his adult life. Police arrested him on theft charges shortly after his 18th birthday, the first in a series of sporadic run-ins with the law that culminated in his May 2002 bust on a charge of aggravated assault.
Cervantes also was prolific in another area; he fathered seven children by four different women, including his final two with Sintic.
Sintic met Cervantes in 1994 while working across the street from him in a Chicago suburb. She was 13 years younger than Cervantes but already was pregnant with her second child when they met.
The two later connected, and Sintic moved in with Cervantes, young children in tow, in the spring of 1996. She says he told her up front about his addiction to cocaine.
"It was a long battle with him and drugs," Sintic says. "He never could stay away from them, no matter what."
Though he was a master auto mechanic, Cervantes often had trouble keeping a job. Sintic says he suffered from depression for years, and spoke more than once of committing suicide.
According to court records, a judge sentenced him to a stint in the Cook County, Illinois, jail in the late 1990s for driving with a suspended license. During that incarceration, he tried to hang himself, a documented attempt that he revealed to Dr. Franzetti during his jail intake interview in May 2002.
Illinois authorities placed Cervantes in a facility for the mentally ill, before they allowed him to go home.
Looking for a fresh start, Cervantes moved in November 1998 to Phoenix, where his parents were retiring. Sintic joined him here in early 1999 with her three children, including Nicholas, her first child with Cervantes.
But trouble followed Cervantes to the desert.
Phoenix police arrested him months after he relocated on a charge of buying what he thought was crack cocaine from an undercover officer.
Because it was Cervantes' first felony conviction, a judge allowed him to enter a jail-diversion program. But he failed to show up for his substance-abuse treatment sessions or pay his court-ordered fine.
Prosecutors reinstated the drug case against him, but Cervantes won yet another chance to stay out of jail. He started his own auto repair business in west Phoenix in 2001, and apparently attracted a fair share of customers.
Sintic says she visited Cervantes during his short stay behind bars, and was stunned at the depth of his depression.
"He told me that when he was there by himself he would start thinking all kinds of things," she recalls, "and he couldn't control how his mind was, and that he would feel like swinging from the nearest pole."
Sintic took Cervantes' words seriously, knowing of his suicidal tendencies, and of his family's history of suicide (a grandfather had killed himself).
But, she says, neither she nor Cervantes had health insurance, and he didn't seek mental-health help after authorities released him.
The last months of Cervantes' life were notable for two events: the birth in late April 2002 of Angelina Cervantes, his and Shannon Sintic's second child together, and his arrest for assault.
Angelina's birth provided a joyous moment, Sintic says, but the elation proved only temporary.
Cervantes' arrest that May 4 came after a clash with a neighbor. The neighbor claimed Cervantes bashed him in the head with a wrench, causing an injury that required stitches. Cervantes said he'd thrown the tool at the other man in self-defense.
Cervantes' biggest problem was that he'd allegedly committed that felony while on probation for the drug charge. That potentially meant a longer prison sentence if convicted, and gave prosecutors more leverage when tendering a plea bargain offer.
A Phoenix police officer took Cervantes to the Madison Street Jail for booking. The cop later noted in his report that Cervantes had tried to hang himself in the back seat of the police car during the trip.
"SUICIDE WATCH," the officer noted on a form that he turned over to sheriff's deputies at the jail.
Jailers put the distraught inmate in a restraint chair for several hours. Later, they took him to the sixth floor of the recently closed jail, to the psychiatric unit.
This is what Dr. Pam Drapeau, who has toiled as a county jailhouse shrink since 1997, said in a deposition last year about working at Madison Street:
"It's jail. It's a horrific environment. . . . We run largely a crisis center. It's a MASH unit a lot of the time. Somebody comes up in the [restraint] chair psychotic, screaming, yelling, flailing."
A few months ago, sheriff's deputies moved the 70 or so men from the sixth-floor psych unit to the new county jail on Lower Buckeye Road.
It remains to be seen if employees at the new facility will overcome the chronic lack of staffing, overcrowding, and assorted other problems outlined in a 1997 report to the U.S. Department of Justice.
Despite those long-standing problems, most jailhouse staffers are said by many (including some inmates) to be devoted, competent and kind toward patients.
"The folks who work at the jails aren't there to get rich and famous, believe me," says Dr. Patricia Crellin, who recently resigned as medical director of Correctional Health Services. "If you're not going to help someone on the job, then why take it? It's not an easy place to be. But so many people go above and beyond with the inmates."
But Steve Cervantes would have the misfortune of having Dr. Joe Franzetti as his treating psychiatrist at the jail.
Perhaps Franzetti was overworked at the time, or maybe he was distracted by his other mental-health jobs outside the jail.
Whatever the reason, the psychiatrist clearly would fail his troubled patient.
And that allowed Steve Cervantes to fatally harm himself inside that little cell at the courthouse.
In May 2002, Joe Franzetti was an independent contractor for CHS, assigned to the psych ward at the downtown Phoenix jail.
He said later he also was moonlighting at a therapeutic group home for adolescents in Phoenix, was seeing patients in Guadalupe and was performing competency examinations in criminal cases.
The pay for his jail gig translated to about $130,000 annually based on his hourly wage of $75.
The doctor had taken quite a route to government shrink work.
In his May 2004 deposition, Franzetti described how he'd worked as a professional drummer after earning his undergraduate degree. Later, he went to a medical school in Guadalajara, Mexico, graduating in 1989.
Franzetti eventually turned to psychiatry, and completed a residency at the county hospital in the late 1990s before taking the job at the Madison Street Jail.
"It is very akin to working in an emergency room," Franzetti has said of his work there. "The cases are very acute. The pathology changes on a daily basis, and the men and women that I work with, counselors and nurses alike, are well-trained and they're very good-natured, and it's almost like a family there."
He said a definite advantage for the inmates locked up on the psych unit was that "they are seen more frequently by the [mental-health] providers."
That statement now seems cruelly ironic.
Franzetti was the on-call doctor at the jail on Sunday morning, May 5, 2002.
Cervantes' medical chart shows that Franzetti conducted the intake interview with his new patient in the most restrictive pod of the psych unit's four levels.
There, suicidal inmates are routinely placed in four-point leather restraints or in restraint chairs for everyone's well-being.
Mental-health professionals consider interviews such as the one Franzetti did with Cervantes as crucial to predicting and maybe preventing jail suicides.
An inmate's self-report of substance abuse, suicidal thoughts, or history of suicide attempts often puts psychiatrists and staff on special alert, which has proved to be a lifesaver in many instances.
Franzetti's notes say Cervantes mentioned he'd just tried hanging himself in the police car, and had attempted suicide at the Cook County Jail three years earlier.
The doctor also wrote that Cervantes "is able to tell me he has a family to live for, wants treatment."
Franzetti's initial assessment after the short session was that Cervantes was suffering from major depression -- but not necessarily a psychotic disorder.
Later, the doctor would concede that his diagnosis had been incomplete. He'd never asked Cervantes if he was hearing voices -- a possible sign of a psychotic break, extreme depression or another serious mental illness.
Franzetti continued his new patient on suicide watch, which was supposed to mean extra monitoring by medical staff and detention officers. He also ordered staffers to start Cervantes on antidepressants and anti-anxiety medications.
Despite Dr. Franzetti's testimony, the evidence proves he never saw Cervantes again before the May 14 suicide.
But other sixth-floor staffers did visit Cervantes over the next nine days, including jail nurse Rand Antokal.
Fewer than three days before he killed himself, Cervantes told Antokal he was having trouble coping. Antokal noted on Cervantes' chart that he was "holding it together, voices telling him to hurt self, stated he needed to talk."
Antokal had given Cervantes paper and a pencil, and suggested he write to Shannon Sintic.
"After writing letter, inmate feels more calm, decreased anxiety," the nurse's note concluded.
The next day, May 13, jail counselor Marlena Lopez noted that Cervantes "wants to keep a positive attitude throughout, even though he's in jail. States he has been writing to his wife. Looks less depressed, socializes appropriately and contracts for safety. There is no danger-to-self behavior."
Lopez later testified that she'd drawn those conclusions from a short interaction at Cervantes' cell.
Shannon Sintic says she visited her boyfriend five times during the 10 days he was in the psych unit.
He tried to keep a stiff upper lip on the night before he killed himself, she says, asking after the children and about the day-to-day aspects of her life.
But Sintic also was worried about the underlying sadness that permeated their last conversation.
"He never mentioned suicide to me," she says, "but he said he just couldn't see himself spending a lot of time in prison because he hated it so much. I told him I'd see him in court the next day, that me and the kids loved him."
After he died, jail officials found a letter that Cervantes had scribbled to Sintic, probably the night before he died.
"I just got done scrubbing the flore in my cell with a toothbrush," Cervantes wrote. "They turned the lights in hear, so can't realy see what I'm doing. I want so bad to end the Hell. I think soon I will . . . I know this is not what you want to hear, but as long as you know, yes, I realy missed you and my babys. If this is what it takes to prove my love to and for you well then, so be it . . . There are just so many ways I can do this."
In a deposition last year, Sheriff's Lieutenant Scott Frye described how deputies would take inmates to court hearings.
Frye said detention officers routinely picked up prisoners about 6:30 a.m. and took them to the Main Jail, adjacent to the courthouse complex.
Steve Cervantes had a hearing in his assault case scheduled for 8:30 a.m. that May 14, on the seventh floor of the central court building.
But the hearing was way behind schedule. Handcuffed and shackled, Cervantes sat alone in the cramped space as the hours passed.
Later that morning, his public defender came by the cell: The prosecutor in the assault case had delivered his plea-bargain offer, and it was a tough one -- 10 years at the Arizona Department of Corrections. Probation wasn't an option.
What followed was exactly what the National Commission on Correctional Health Care warns jail authorities to look out for with suicidal inmates:
"While inmates may become suicidal at any point during their stay," the commission wrote a few years ago, "high-risk periods include: after adjudication, when the inmate is returned to a facility from court; [and] following the receipt of bad news regarding self or family."
Cervantes already had baggage -- previous suicide attempts, drug abuse, deep depression. Now he was staring at a long prison sentence and a painful separation from his family.
The commission also has warned that "a suicidal inmate should not be housed or left alone. An appropriate level of observation must be maintained. . . . The inmate should not be isolated."
But Maricopa County authorities did just that with Steve Cervantes.
They isolated Cervantes and ignored him when he started screaming for help before he killed himself.
"A person on suicide watch requires constant supervision," sheriff's lieutenant Frye admitted in his deposition. "They are required to be watched at least every 15 minutes. With the way our courts are set up, we have a number of inmates who will go to the same court. We wouldn't have the ability to have constant observation of that person."
The policy of the sheriff's office is actually: "DO NOT LEAVE ALONE" any inmate on suicide watch.
And department policy also requires officers to observe even inmates who aren't on suicide watch at least once every half an hour.
But Dr. Franzetti had failed to alert the courthouse jailers about the inmate's suicidal tendencies -- even if he hadn't said he wanted to harm himself over the previous day or two.
In fact, the shrink testified in his deposition that he hadn't even known Cervantes had gone to court that day. That flies in the face of Franzetti's final notation in his patient's chart: "Inmate out to court."
Deputy Fausto said in his deposition that he'd returned to the seventh floor after locking Cervantes in the cell one floor above him.
Soon after that, the deputy testified, he'd heard Cervantes screaming and whistling from his courthouse cell.
By now, it was late morning.
Nearby at the jail, the Madison psychiatric team was meeting in its daily briefing. Drs. Joe Franzetti and Pam Drapeau attended the session, as did nurses and counselors.
According to Cervantes' medical chart and depositions, jail counselor Marlena Lopez recommended that the inmate be kept on suicide watch in the psychiatric unit, but in a less-restrictive pod.
But Dr. Franzetti overruled her.
"I remember Dr. Franzetti saying that [Cervantes was] stable, the depression had decreased," Lopez testified. "If the psychiatrist says general population, the consensus is general population."
Despite Franzetti's orders, a staffing note written in Cervantes' chart shortly after that May 14 meeting said the inmate should stay in the psychiatric unit, on suicide watch.
"There was obviously a communication breakdown with whoever wrote that particular staffing note and what I wanted to have occur," Franzetti testified.
About 12:40 p.m., Deputy Fausto and another deputy briefly checked on Cervantes, who had continued screaming from his cell. They said they'd told him the judge would be back on the bench at 1:30, and to try to take it easy until then.
A few minutes after that, a court bailiff on the eighth floor heard Cervantes pleading loudly for someone to get him a doctor.
Franzetti conceded in his deposition, "If I heard a patient screaming for an hour, I wouldn't consider that vague. That's a cry for help."
But the sheriff's deputies ignored the wails.
Deputy Fausto said about 1:10 p.m., he realized that Cervantes finally had quieted down.
At 2 p.m., he and a colleague went to the eighth floor to fetch the inmate for court.
Steve Cervantes was dead by then.
The courthouse suicide was the talk of downtown Phoenix, especially among county employees who work for the sheriff's office and for Correctional Health Services.
But Dr. Joe Franzetti has testified that, somehow, he didn't learn about Cervantes' death until much later.
"I think it was possibly weeks after the occasion," Franzetti said. "I don't remember. I was not told directly of his passing. . . . I believe there was a meeting, a general meeting, and that was brought to my attention."
"And after you heard that one of your patients died in the courthouse, did you ask any questions?" plaintiff's attorney David Don asked the doctor.
"I wasn't sure if it was somebody I knew at the time," he responded. "The name didn't ring a bell. [But] it didn't take long to figure out [he] was mine. I was the treating doctor."
Jail counselor Marlena Lopez spoke in her deposition of when she'd learned of his death:
"I think it was the same day. I remember very well that day. My supervisor called me at home and let me know what happened in the court. As a counselor, you start reviewing what you did, what did I do wrong, what I missed."
In the aftermath of Steve Cervantes' death, it would have seemed natural for jail authorities to assess what went wrong and to try to determine how to prevent it from happening in the future.
But no one in authority ever officially asked Dr. Franzetti about his treatment of Cervantes, or about his curious posthumous note stating that he'd just seen the patient and everything was fine.
In July 2003, CHS hired the doctor as a full-time county employee, ending his contract as an independent contractor.
That November, County Recorder's Office records show that Franzetti and his wife took out a $557,000 loan to buy a north Scottsdale home that sold for $1.25 million.
But last August, then-CHS medical director Patricia Crellin submitted a scathing annual evaluation of the doctor.
Dr. Crellin could have been writing about Franzetti's work with Cervantes when she wrote that he "completes adequate initial evaluation, but could improve the follow-up care. [He] needs to work on time management to improve the follow-up frequency for [patients]."
Crellin concluded that Franzetti needed "to work on keeping to schedules, attending key treatment meetings and departmental meetings. [He] needs to be more available to staff and clients."
Without specifying why, county officials fired Dr. Franzetti last February 16, according to his personnel file.
Currently, he is a central figure in three lawsuits. Two of them stem from the suicides of psych unit inmates Cervantes and Michael Thompson. The third concerns the self-maiming of former inmate Miguel Zaragoza, who blinded himself last year with a golf pencil while under Franzetti's care.
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Despite his legal problems, Dr. Franzetti landed on his feet after the county fired him. He's working as an outpatient shrink for ValueOptions, a behavioral-health company that serves thousands in Maricopa County.
Now back in Illinois, Shannon Sintic found a job as a trainer for a telemarketing firm near Chicago. She and her children live near Steve Cervantes' final resting place, a cemetery near Blue Island, Illinois.
"I don't think that anyone in the jail actually planned for Steve to kill himself," Sintic says, "though it's hard to understand what happened there. What I do know is that doctor [Franzetti] sure didn't do his job to protect my guy."