Brandon Greene was acting out of sorts on July 13. The sixteen-year-old resident of the Mountain View Youth Development Center in Jefferson County reportedly gave away his belongings and seemed to observers to be "at peace or resolved." Hours later, he was discovered in his room, hanging by a T-shirt he'd fashioned into a crude loop.
Two weeks later, eighteen-year-old Frank Cass was found dead by the same method.
Greene and Cass' suicides were the first in twenty years at Mountain View. They triggered a state investigation carried out by the Tennessee Commission on Children and Youth, at the request of Department of Children's Services head Jim Henry.
The investigation report, released on Wednesday, highlighted possible deficiencies in how Tennessee's juvenile detention system cares for and monitors inmates at risk for suicide. The three panelists who reviewed video footage, interviewed those who knew Greene and Cass, and retraced the events that led to the youths' deaths concluded that more could be done to prevent repeat incidents.
Personnel at Mountain View reacted as quickly as they could to the suicides once they occurred, the report stated. But certain steps, including more careful monitoring and additional guards on duty, could have prevented Cass and Greene's deaths. Among other recommendations, the panel suggested annual reviews of safety protocols at all Tennessee juvenile detention centers, better training on how to manage juveniles who have complex mental health issues, and collaborative efforts that will help detention center staff recognize and react to students who are at risk for suicide.
Greene in particular was a high risk for suicide, according to the investigation. He attempted to kill himself more than once, and was placed on suicide watch at least three times during his stay at Mountain View.
The report recommended improved monitoring of medications administered to students. Both Cass and Greene were on a prescription antidepressant whose label includes a warning about possible suicidal thoughts. In both cases, the report said, "The unit staff at [Mountain View] is not aware of the types of medications being prescribed and their potential side effects."
57 percent of the 115 students at Mountain View are on some kind of psychotropic medication, according to the report.
Department of Children's Services commissioner Jim Henry said Wednesday his office is reviewing the report's conclusions.