ROOT CAUSE ANALYSIS – 2
Kent Kroehler, one of the four members of the “Root Cause Analysis” team looking into the suicide of John Kruger in March of this year followed James Laughman (see “ELIMINATION OF SECOND TIER PLACEMENT” below) and added four additional recommendations:
1. “The problem was defined carefully. The event was a successful suicide. We got beat by an inmate. ….We were outsmarted. It can’t happen again.”
2. “The new operational goal is to have zero suicides. …This is the most controlled environment in the county. It is unacceptable to have a suicide.”
3. There should have been and should be a root cause analysis done after every suicide.
4. The prison needs to speed up a retro fit of the railing – even if it’s temporary.
Several additional notes:
Judge Dennis Reinaker, a member of the Prison Board, said immediately following James Laughman’s presentation, “This is the first report of this nature that I remember seeing.” The Judge indicated he was pleased.
Kent Kroehler is also a member of the “Have A Heart” group which submitted an excellent white paper to the Board Members. Click here for their site and click on the link for “White Papers and other Resources” to read it. There will be more on this at a later date.
Many of the details of presentations made at the almost three hour Thursday Board Meeting are available online at the prison website. Click here for the 133 page report from this meeting. There is a tremendous amount of information within this document. You can thank Commissioner Craig Lehman for this as during the April Board Meeting he stated that the Warden’s report and all information provided during these meetings should be posted online and readily available to the public.
Yesterday, I noted that District Attorney Craig Stedman was texting during the first hour of the meeting. Commissioner Scott Martin also told everyone Stedman had to leave the meeting at about 11:00 am to meet with the coroner. There may have been a very good reason for all that texting and the meeting with the coroner as an arrest was made yesterday afternoon in the murder of Allison Walsh and her unborn child. That, of course, is today’s big story and really gruesome and lurid details are coming out about these tragic murders. Her boyfriend, Matthew Becker. has been charged with first degree murder. It is likely the DA will ask for the death penalty.
Please check back tomorrow.