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Wadoc Incident Review Report Micc Suicide 2008

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Date & Time: 9/18/0_L
Loca.!'i0I!=-J~nitQdl El..12,.Iy1LG.c;:
Brief Description of Incident: At approximately 1129 staffIn Unit F B 012 made a radio call announcing
that there was a medical emergency in Segregation Cell FEI2, Shortly thereafter it was announced that CPR
had been initiated, Responding staff found Offender Toney hanging with a sheet wrapped around his neck,
hanging from the t.v, stand. There was a Quick Response Strike Team Response on site with medical staff.
Offender Toney was airlifted to St. Joseph Hospital once he was stabilized. He remains at St. Joseph
Hospital as of this date.
- Name;'T'I,~i·~&'f<\~J;ss of'Wwj1m--:--~-eslnvolved:-ilk: f_-.'·_~'s~~'t;t:'z~-;;t&;j:<f5: ~:~ ~~.,
Lleutenaq¢\!:~,Jm W!b~l§hIft Ll~'\ltenan

~~g ~~~~~n~~:~'l~er i;~! 'r':'.1',

C/O Dibf,~~petto, HearfJr ES_,,;,

(First Res~1hder)~~~:

~ .-~~ ~. I.-.'!.~()El!.d.,lita..:~~'
L~.Cl~a_t!~ ~.!?_l!.sc~!R.tion 1~9pertY\(!?~~.maged;}




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Chronological Summary of Facts/Events: Mr. Toney was placed in segregation for an incident that
occurred on 9/18/08. At approximately 0018 on 9/18/08 Offender Luis Perez #763928 was found with a cell
phone in his possession. Subsequent search of his cell revealed that there was also a bottle of tattoo ink in his
(Perez) cell. Search of the cell phone produced pictures ofMr. Toney (to include naked pictures) stored in
the cell phone, Consequently a cell search of Mr. Toney's cell was done. A cell phone charger that matched
the confiscated cell phone was found in his cell. Additionally, personal writings from his cell indicated that
he too had used the phone for unauthorized access to people in the community, Mr. Toney was then placed
in segregation at approximately 0530 hours, He communicated with the unit nursing staff at approximately
1015 on 9/18/08 during her rounds that he had been having difficulty sleeping for several days and asked to
speak with a mental health provider. He was specifically asked by the nurse ifit was emergent or ifhe felt
like hanning himself. To both questions he answered "no", Approximately one hour later, at 1130 during the
distribution of lunch, Officers Leal and Mildon found Mr. Toney hanging from a noose looped over his
television shelf. An immediate medical emergency response was initiated to include life-saving techniques
and helicopter evacuatiol1_fi_rO!.n_M_ct!~i!U~I_~I1~to St~lo_se1'h's_H_o_sp_it_aL." ....
Summary of Witness Statements (Include Name of Each Witness):
, CIO Leal: It was a routine shift with nothing out of the ordinary. He served breakfast to Mr. Toney and
,)bserved nothing unusual. When they were delivering lunch he looked into the ceIl and saw him hanging
[_frolll_~I1().os(l()yer lf~s_t,~-,,<:t.ill1~,-I}~_irnm.ediat.(lI)'~l1il~~tl1e__e]:l1e~g~ncy radi.<J...aI1I1()1111c.emcntt<J..s.~1.TI1Inons .__
... .•







DOC 18-022 (Rev 03/06/07)


DOC 400,110

Jtaff and nursi~g were both-ve;:Yg~;dabout lett{;;:gth~m know aboutoffu~ders ~ilO l~eede~Ctobe se~;-fOr-­
emergent care.
Jim McGinnis: Conectional Mental Health Program Manager - Mr. McGinnis made rounds on every
Friday during the month of August when Mr. Toney was in segregation. Mr. McGinnis spoke with him on a
number of occasions and he was fine. He made no requests for services or talked about any problems. Mr.
McGinnis did state that since Dr. Richardson was not on the unit the morning of the incident there would
have been someone on call if there had been a request for services by the staff, and they know how to request
Lt. Kim White: She was briefed about Mr. Toney and Mr. Perez's segregation placement by the oft:going
shift. Nothing unusual relating to this occurred until she heard the medical emergency being called at 1130.
She initiated the emergency response to include the request for the helicopter. She received a call from Mrs.
Renee Toney while Mr. Toney was still on the helipad. Mrs. Toney asked ifhe had a heart attack and
thought he had been taken out by ambulance. No facility staff had notified Mrs. Toney ofthe medical
Dr. Frank Longano - Medical Director: Responded to the incident with the other medical staff when he
heard about it. He observed and oversaw the medical response and was satisfied with the care given. He felt
that staff had done everything they could for this offender and observed no difficulties with the care.
Captain Bratten: Captain Bratten was on duty when the emergency occuned. He responded to the site and
ob~erve~1~:fitst1F~~~,on?erS"a~f~0:ns~!l\1~~ve:saw the ac~~t~ties 0 f the"e~tr~li!t))')~~;1 ~;il}.'H)ir(;')!ff§'iJ'!;i';'1
Mike Hi1J,~~, CUS~~"qlt: He~its on t\1~.;\lmt at the tlm" the emergell.~q' and reslio~ded tottliJ.e mCloent
e medical rr~ponders. After Mr.~9ney had been
site. He cf~trolledaCb~~~,to th~~pcidentf~~~eand obse
removed.~~m the ~ite ~~~'\Uad1;~vre th~fljWellness ,11 offende~~?n theiod occune11i~{\lso, during
the remm~~y.g ~ortlOn 1&\lpe da:~Jkfenders on B p~~ wel)_;\ersonallylt~~~ed by ment~'pealth staff
for stres8~~bn~fing. H~t~otes ~~~hl , . '. ut of the US']~tig1f,~ .-: s for tM,wo:mn&. The staff (-f,\P actively
5 oil¢:nders
and no on
orted afiYthmg
unusual or pro):ilematlc to
engaged lll'gettmg
him. He ,~t aware t~~~!Mr. Ti~y had'1)~~e in se~e~atio~ in
gus: a14~thus knew who .he ~~s. At that
tlme th_e~1iJ!,tt~.i2iOO~ea a fami~'!iR?ne ca~~~e.f9#n£tlficatlOn'i.-_it.\dm$~20a,!.hs m hiS faml!Y'fi~i;;~, __
Matt C~'sse'He:::CUS B Untt"'Hewas awaJ!e6f'K'ff:Toney, h1'weve} B:eWasa low key offeffdefwho he did
not know a lot about. He was familiar with his request for extended family visits with his wife and that it had
been turned down, however, he had no other relevant information about Mr. Toney.
Angie Hilton - Assigned Counselor from B Unit: She had been his assigned counselor since last Spring. He
was easy to work with and caused no problems. She saw him when he had business that she could help him
with. He was polite, respectful and a very good workers. She helped him with his job situation after he lost
the work crew assignment due to his segregation placement in August. She also helped process a couple of
administrative requests that he made concerning visits and transfer of funds. She was also aware of the
situation regarding deaths in his fmnily in August and had had numerous contacts with various family
members. She said she last spoke to him in passing in the courtyard the day before he harmed himself. They
talked about his job situation and he seemed like his usual self, happy and upbeat. She noted nothing
Rita Reynoldsen - Fonner Work Program Supervisor: She supervised Mr. Toney for some time. She
described him as a good offender with a strong personality who could get along with anybody. He was very
likeable and tried to mentor others about how to get out ofthe gangs. He showed no signs of weakness and
didn't let things get him down for vcry long. He seemed adjusted to confinement and made the best of it. He
liked to work and was good at it. He talked a lot about his family and seemed to genuinely care about the
children. He was always well dressed, well kept and took a lot of pride in his jewelry. He always put his gold
nug<Jet wedding ring on his necklace when
he wasn't wearing it.
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DOC 18-022 (Rev 03/06107)

OOC 400.110

Jssistance and entered the cell with C/O Mildon as soon as the door was opened. He and C/O Mildon entered
the cell, wrapped their arms around his waist, removed the noose from the t.v. and lowered him to the floor.
They then engaged in first responder actions.
C/O Mildoll: He was with C/O Leal as they delivered the lunch tray to Mr. Toney's cell front. He was on
and off the tier all morning getting the offenders ready for transport that was leaving. Additionally, he had
delivered the morning tray and made medication rounds with the nurse. He noticed nothing unusual all
moming. C/O Mildon observed Mr. Toney hanging from a noose over the t.v. stand. He assisted in removing
him hom the hanging position and provided First Responder care to Mr. Toney.
C/O Norberg: He was the assigned booth officer for the shift. He was operating the control booth except for
a half hour meal period around 8:30am. He had control of the pod entry door and all cells on F Unit B Pod.
During this time he allowed no one to enter Mr. Toney's cell until he opened it for C/O Leal and Mildon to
respond to the emergency at approximately 1130. He saw only authorized staff on the unit and neither saw or
heard anything unusual.
C/O Dibenedetto: He is a hearing escort officer who was preparing to enter the F Unit, B pod when the
emergency occurred. He saw the officers look into the cell and heard the emergency announcement. He
entered the pod with Sgt. Anderson, as soon as the door was opened. He proceeded to the cell where he
assisted in moving Mr. Toney and then performed First Responder actions.
Sgt. Anderson: He was taking his meal break when he heard C/O Leal make the emergency notification
over t1re~~fg>i;I{~~~ediatel~f;~\).i1tt~~\Podand entere,~"the pod with;~~O?lD:ib:~li).~de~~H:~~~tete~i~he cell


E~'~.Y.i;.~., M~.1.*.',~

~;.\M.·r Toney'an?.{~.glf,

t~.·\~nng hl.m;on~o

'.~ wher~

. C/O
.n d
.•;.. n Wltl;i.
. ,.f.cted them •.
the tle.".. . •
would be~Wf~e room t~b%? C~~~s the ci~ers had l~d\~a'W~, there was ~p'u1se. ~e o~e.rsa"':~~,f first'
respondet;i;~~tlOnsas rrle@lpallrltllrventIs;t\1§'were appheff toJMI'. Toney. . . ng the mommg, It!j¥ld been a
routine nt~ing and h~~d nO~~~~~~lYd\anything ul};fsuaq~~\
LPN Fis~tJflhilemak~~~ire ,;•• WG¥h~SS checks 0t~~!t;,~~~~&;gtrs on th,.hnit, sh~ spok~ witl'£i~r. Toney at
approxlma,;rly 1030 0~1~/18/0
e sa~9J;~e was ~a~ng a pr(jTjJc~f sl~epi~~ ~d was so tIred. ~~ also Said
that he c~~~n't stop"tl%Pkmg
ut thmg~,\He sard;he was nOl\li!(l-.pam aQ!ijhls sleeplessness ~~.~ not due to
being plf,\~~~~J:1.,§e~!i'~£tion. N .' Fish a~geB ifl~Ineeded to l1:~~ffn ril~,n,ow or if it cotild~,a,it. She said
that he~1filirwritfen a reques' 0 se~'menta1'keilirii'ffi'li'i'he gav~'rteft(f(tC1i~er to mental h~1TItti·staff. She
asked ifhe thought he had plans to hann himself and he said "no". She told him she would pass the message
on to the mental health staff and would check back with him when she made noon medication rounds. After
finishing her wellness checks she stated that she placed Mr. Toney's written request in Dr. Richardson's
distribution. She responded to the medical assistance and oversaw, with other medical staff, the first
responder care to Mr. Toney.
C/O Randy Sears: CIO Sears was working overtime the rnoming of9/18/08 on first shift. He is normally a
transport officer on 2 nd shift. He was involved in placing Mr. Perez in segregation. He also escorted Mr.
Toney to segregation after the cell phone charger was found in his cell. He stated that Mr. Toney was doing
janitorial work on the unit. The sergeant informed him that he would be going to segregation. When he
escorted him to segregation he said that Mr. Toney did not ask the reasons or make any protest. He was
totally compliant and cooperative. They escorted him to segregation and the F Unit officers took over
supervision of him at the entrance to the unit.
Dr. Richardson: She was off of the unit most of the morning performing other duties. She became aware of
the emergency on the unit, however, was not present during the emergency response as she had no reason to
be present. She did participate in stress debriefings with other offenders during the day. She did not observe
the request for mental health services in her distribution box on Thursday but did find it when she returned to
work on Monday, after being off on Friday. She said it is general practice on the unit for her, or another
_J)rg\li~er,J:<l.,'!eeoffender.s. wl1.o..re9.uesLlll.ental hc;alth seryice.s.Jl§....8.Q()11.,[\.s.po,~sibl(),§'ec;ti()n.'l1.

DOC 18-022 (Rev 03/06/07)

..•.,....., .,

DOC 400.110

.yan Denzer - CC2 F Unit: He was familiar with Mr. Toney because he delivered the news to him about
the deaths in his family last August. After telling him about the deaths and ananging a telephone call to his
family he asked Mr. Toney ifhe wished to talk to mental health or a Chaplain. Mr. Toney declined and said
he was okay. Othelwise, Mr. Denzer stated that he had no contact with him.
C/O Becerra - B Unit 3rd Shift: She is assigned to his unit but had no relevant information as she only knew
who he was.
C/O McNally - B Unit 3 rd Shift: Was familiar with his facility reputation and conduct. He said that he
generally was a bright personality but since the loss of visiting with his family over the infraction last month
he had seemed a little down. He said he did not talk with him as he didn't feel he wanted to discuss it. He
was a good worker and was helping with the ACA inspection preparations with regards to cleanliness and
physical plant preparation.
C/O Crossen - B Unit 3rd Shift: C/O Crossen felt like he was a loner who would keep to himself a lot of the
time. He didn't view him as problematic as he knew how to do his time and kept to himself.
C/O Perry - B Unit 3"d Shift: He said he was always smiling. He seemed to have a lot ofmovment within
his assigned duties. He was always respectful and never angry. He had a lot of property and stores in his cell.
C/O Ray Harring - B Unit 3''(\ Shift: C/O Haning said that he was never any trouble and was always in the
back ground doing his own thing. He had been working night clean up and had mentioned he was tired
because he hadn't been sleeping. Mr. Toney never let on that he was having any problems or issues. He


genera%~ ~Jitttt1~W.r~e1.~ ~il:··.~,qm~~., evenin~s ~,.~ ,

SC5m~.,."~.,~.: tiXli.t~(.g~ wa.,.~.l·qb:~'d~.a

.• . .:•.,. .,•.,.
. •.•c..,:.:..:•.e. •. supervIseun.1
. . : •. •. h.e not~Qrthy
. :. :c.•
.. \tllnd.
:.• . •. • .s• . •. :•.pJtt\S'.¥ame.
- B~B.\1.ltin3 .Sf'.i(ft: Ea~Ni?
lil hJs
C/O ~cq:P!~lum
C/O FmdJl)Y - B Um nd Shl .:';iRe was2P~.nsClOUS ofhl''\!pjJearance an~;:1J.1ways took care oJX.1,llmse1f well.
~e spok~lot and. hig ofhi~~~bildr5~J~dprogram,~ed'[lr took pri~¥J~n his 'York. He sa,figo change in
hIS basehRf~behavlOr .",:.¥h Wi\¥,,~~~~yo~slstent. He ~jtd a g~ad attltudet~.l!s~ays pohte, rl~:l?ectfu1 and
dId what ~¢ls asked of,;" H~Id ~~ unu~ua1.tfll,Jl1Jf~1ll~ey told ~\Ir a feV:! weeks befq,t~the mCldent
that the Pl"r,~on who w~~ttespOlI~p1e fOH&1'llm bemg \Bcarceratc~E\1adbee4i~lled recently. Mr.~9ney told C/O
Findley ti~ he hadt%lg~his pailors "h~¥i::if0Uoug~t to let that~~9' I hav~~~ C/O Findley did *9ct, think
anythir;g:~~R:l-H)t,1tt.[th.e.' time, h~~4Ww wJfj,~$,J;~gji~ll~s some sl:~tJ,Lcan..i~{»~estated that he. ~~~9ciated with
other ofterraershe thought ife11c'STG associll''fes.''''''
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Perez, Luis 763928 - Interviewed by I & I investigator G. Gilbert. Mr. Perez stated that the cell phone
belonged to him and no one else.
Dr. Tom Foley - Staff Counselor: Responsible for the staff critical incident debriefing. It was held the week
following the incident and the staff seemed to appreciate the opportunity to debrief the incident.
George Gilbert - I & I Investigator: Was interviewed various times by the Critical Incident Review Team.


Summary of Facts:
1) Three different fixed cameras were continually recording in the F Unit, B Pod that had an unimpeded
view of the door to his cell.
2) There is no disruption ofthe camera coverage on these three cameras. It is continuous.
3) The three cameras show the entire time from when Mr. Toney entered the unit through the entrance
gate and arrived on the unit. He can be seen being escorted into the unit and placed into the cell. No
one was observed entering his cell until the C/O's initiated an emergency response.
4) The three video records have been reviewed independently by two different staff These staff are
MICC I & I investigator George Gilbert and CIR Team member Dr. Mike Robbins. They both
conclude that no other person entered Mr. Toney's cell during his confinement there.
5) Staff interviewed by the CIR, who were on the unit that day did not observe anything unusual or
_ ... __ ~.1l.spici<J.1:I~J:11~~VlSl1l1~.s.llJlllSlrt.JI1('JJ()s~.\Ji1ity...CJLsorl1.e_one
__~l_s(),,'.t!l..t.oMI:.Toll()Y_iJl._!" U11it... _

DOC 18-022 (Rev 03/06/07)

DOC 400.110

6) No one is observed, either on recording or by eyewitness infonnation, entering Mr. Toney's cell after
his placement in FB 012.
7) The booth officer, C/O Norberg, who was in the booth from 6 am to 12 pm (except for meal period at
approximately 0830) did not observe any person enter Mr. Toney's cell (FB 012). He also states that
it would be impossible for anyone to get into the cell without him allowing access. He did not.
8) There was no staff on the unit or near Mr. Toney's door who was not supposed to be on the unit
during the course of their business. Before regularly assigned and authorized staff can even enter the
pod, the pod control booth officer must receive permission from either the Sgt. or CDS. No such
entry was attempted or authorized.
9) No specific individual has been identified as the person who wanted to harm Mr. Toney. In fact, this
review did not surface anyone, either staff or offender, who threatened to hann Mr. Toney.
10) Mr. Ron Van Boening, Superintendent, stated that after this incident he directed Mr. Shawn Murphy,
Associate Superintendent, to inspect the cell for possible intrusion. He stated that Mr. Shawn Murphy
thoroughly inspected the cell and found no evidence .of alteration to the cell.
11) There is no evidence of physical injuries to Mr. Toney. Staff who observed Mr. Toney saw no signs
of injury. This included the custody staff, medical staff and attending physician at St. Joseph's
Hospital. The only injury observed by these staff was relative to the abrasions on his neck caused by
the bed sheet noose.


pli¥~tfalinl~1~s or ~NuPt!on to ~i~bc~ftj\ The cell col~nts w~re e&tirely ~l;:~sistent with

eifJrnce of
n~~;~la.1 usage,


~~W;.clU~~&&IS w~i:2jng nng bel1j"f 101~ttd

,.i ,.l ~. \., mve~.,~.,"j\t~ ~.·


on the






13) !'1T.;c.1.•. Gllbert ( I &.' :.•
f t.Feported that..•• .,.fi.•. . '•. Jo.•. .n. had
from ano.!f.,..•. offender
tlt!:,there was rn~Jiltal slIli~ss b~p~een Mr. TotJ!1¥,.I.1H9'!JM~, Wife. A~rF~edly ~lS Wife had~eatened to
b~~!'f offtheir.t~lation ,., if~~}oney diqi\iot'eI1d·li~~~~elation~jp(s) with other woiflRn. Many staff
~Q1bers spoJ(e.:ofhow ch irff~R~ance~. Toney P~~~~d on hf~4family relationshil1i~:J.1articularly
tli!~,thpdrlin:i\fldition,,~ehad1~j*j!!:1tiP:ti;.\v,rith his W~{%if~nni!l~b.ecause oftheJB)!~~,f~on in the
"v1sitirig room in 8/2
. 'is estabTlsTigf15oss1ble str~'S'ln1V:ir~w'f~ney's life.
..... ,,_.
14) Mr. Gilbert also reported another piece ofinfonnation that indicated an offender's wife had stated
words to the effect: "if Toney comes out of this, you all are in a lot oftrouble". The meaning is
unknown at this time, however it is suspected that Mr. Toney had complex "prison business" interests
and gang affiliations that may have contributed stress to his life.
15) The phone which was confiscated was connected to Mr. Toney. Tied with infonnation found in his
cell, it appears that he was an active participant with various individuals on the street. The
infonnation in his cell and on the cell phone indicated internet nicknames with sexual overtones for a
number of women; a credit card number and expiration date; a connection to his female crime partner
and posting on "My Space". The full extent of his connections and what he was involved in is not
known at this time. Again, this establishes stress in Mr. Toney's life.
16) Mr. Toney indicated that he was having difficulty sleeping (had been up for 3 days straight) and
asked to talk with a mental health person. He did state it was not emergent.
17) During the approximately II years ofMr. Toney's incarceration he sporadically accessed mental
health services 9 times with complaints of sleep disturbance and depressed mood for which he
received psychotropic medications.


_.__ .~


__._ _ _

DOC 18·022 (Rev 03/06/07)



.._ _

.. _""~'--""






-B~~ed on the factual findings listed above, this criti~al incident-t~-;;-m det;;;'nin~dthat M~. To~~y;s il~urie~'-]
were self int1icted by Mr. Toney.

- -...-

- - _...







~lST,gFAPP!__E_6Bl:ERC\y'.S \yAC'~_gOCPOLI~IEp &PRogEDtJllES __" __ _"~__. _.. ~ __
DOC 630.550 Suicide Prevention
DOC 630.510 Mental Health Services
DOC 320.255 1MU/ITU/Segregation/Mental Health Segregation Operations
DOC 30.200 Administrative Segregation

While the AED was not appropriate for use on Mr. Toney and was available to the medical staff, the facility
may want to consider location and number of AED's across the facility. Dr. Longano indicated that they are
doing this at this time.
Tier checks as, recorded in the u~it log book are not visiblp on the fixedcal1l~rarec9rdin1{ofF-~~od.
The Hea "aril;!Yta!'1l\ger it~sI~61l$ifin .a more definitiy~\time for tJ1e~ii1i:tian:e-view dt'blf~~~~fsbgi!1g

~;. reg_ati~.·_i ~ .:~
.:.: ~, ~-n.,~: .~j.•i[.•(.[.·:.·_

p,.l_aced .in••:.•. . . .__. :.. ._. .'
__ .'.",.• ," •.',' _

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-tf::9i~~i"'1'1~,C"lfw;,,~j,' ···Icr-·--~··l~ti: .~------

There wa¥i\VJ extra9..rginary fasji.rrsponsei9xfirst J;~ponders a4~-\?-ealth~~Xe staff to begin 1ife;.~fving
measure&f6hMrj;·~il~y. Thed!1~dical dir~¢'fbD.w;~l.lfl site and:tiJ1ttlsfie.d4Wth.the response.•.bl.~~ridicates that it
was excellent. Staff should be commended.
After the incident staff immediately began wellness check of other offender on the pod and each offender
had a one on one interview with a mental health provider to provide emotional debriefing and support.
Additionally, each offender on A Pod was seen at cell front and offered mental health support.
The administrative segregation paperwork was properly completed and served to Mr. Toney.
The first shift staff and supervisors were alert and observant when they observed Mr. Perez with the cell
phone. They used good investigative techniques to further identify Mr. Toney as connected to the cell phone.
The CISM Debrief that was conducted by Dr. Foley for the staff was useful to them and helped reduce stress
related to the incident.
The staff engaged in an emotional, energetic and robust effort to save Mr. Toney's life.
Training Records for staff indicate that First Aid/CPR and Suicide Prevention have been conducted as

DOC 18-022 (Rev 03106/07)

DOC 400.110

Signature (Team Lead)


Signature (Deputy Secretary/Designee)


The contents ofthis document may be eligible for public disclosure. Social Security Numbers
are. considered confidential information and will be redacted in the event of such a request. This
form is governed by Executive Order 00-03, REW 42.56, and RCW 40.14.
Distribution: ORIGINAL-Risk Management Department COPY-Appointing Authority, Deputy

OOC 18-022 (Rev 03/06/07)

DOC 400.110





Attempted Suicide

Detective Juli A. Gundermann




Toney, Leon Glennquaree

Case Summary

On September 18,2008, at approximately 11:29 a.m., Offender Leon G. Toney was found by
McNeil Island Department of Corrections (DOC) Officers Leal and Mildon in his segregation cell
hanging from a large steel shelf. They requested "Control" to open the door of Toney's cell and
called for medical assistance. When the cell door opened, Leal and MUdon entered the cell releasing
Toney from the noose which was made from his bed sheet. They placed Toney onto the floor
outside the cell and started CPR. Airlift was summonsed while CPR continued. Airlift arrived and
transported Toney to St. Joseph Hospital. Toney is currently in a coma and resides in a nursing
The initial investigative' report was written by DOC Chief Investigator George Gilbert who
forwarded all supporting documents to the Pierce County Sheriff's Department for review. On
October 6, 2008, an incident review report (Critical Incident Review # l30-08-P) was completed by
C. Grandmontagne, Team Leader with DOC. On October 10, 2008, DOC Secretary Eldon Vail
requested assistance from tile Washington State Patrol (WSP) as the Toney family alleged the
incident' was a result of an attempted homicide. Secretary Vail asked tile WSP to conduct an
independent investigationof the circumstances surrounding Toney's
Toney, Leon G.
McNeil Island Correction Facility
DOB: 9-6-77
WA: WA17695855
DOC: 745863
Injuries: Toney sustained a brain injury
from the hanging and is currently in a coma.


WSP-1SB-2iJ8 8fll5


Toney, Leon G.

Detective JnIi A. Gundermann


Rene Matthews (Toney) DOB: 5-12-1977, Toney's girlfriend.
Twila Robinson DOB: 5-16-1974, Toney's ex-girlfriend.
On September 18,2008, at approximately 12: 18 a.m., Officer Humphrey was conducting a routine
tier check when he heard a female voice coming from Offender Luis Perez's prison cell. Humphrey
investigated and recovered a cell phone from Perez. Examination ofthe cell phone reveled several
nude photos of Offender Leon Toney in a prison cell and unknown females.
Perez searched Toney's prison cell and located a cell phone charger. Toney was placed into
segregation pending the iovestigation ofpossession of a cellular phone charger (contraband).
Later that morning at approximately 5:31 a.m., Toney was placed into segregation. Nurse Fish talked
to Toney at approximately 10:30 a.m. when he gave her a DOC Health Services Kite stating "I've
been up for three days straight I can't sleep, I need help, for real! Please help." A "late" is a written
document requesting to speak to DOC persoual. Toney stated he was haviog problems sleeping, was
tired, and could not stopthinldng about things. He stated he was not in .any pain and his
sleeplessness was not due to being placed into segregation. Nurse Fish asked Toney ifhe had plans
to harm himself and he stated no. She told Toney she would give the lcite to Mental Health and she
would check on him during her noon medication rounds.
At approximately 11 :40 a.m., Officers Leal and Mildon were serving lunch. When the officers
approached Toney's cell one officer looked into the cell and the other officer pushed the lunch cart
back to the left. The cell door opened and Leal and Mildon entered the cell. Within one mioute,
additional staffresponded and Toney was brought out of the cell and into the open area where they
started CPR. At 12:01 p.m., (within 20 minutes) a stretcher was brought into segregation and CPR
continued. Airlift then transported Toney to S1. Joseph Hospital.
On October 15, 2008, WSP Detective Gundermann was assigned to the investigation. On October
16, 2008, Detective Gundermann contacted Earl Wright with DOC and was given two CD's with the
footage from Toney being brought to segregation and the cameras in segregation. Wright also
provided Detective Gundermaml with a packet ioc1uding all the reports regarding the attempted
suicide. In the packet were also reports of an incident that occurred on July 18,2008, between
Toney and Rene Matthews, Toney's alleged wife. During this incident they were caught engaging in
sexual acts in the visiting room. Wright provided copies of the paperwork found in both offender
Toney's home prison cell and segregation cell, photos ofthe segregation cell, and copies ofoffender
Toney's My Space account photos.
. -2-

Toney, Leon G.

Detective Juli A. Gundermann


On October 23,2008, Detective Gundel1nann met with DOC ChiefInvestigator George Gilbert.
Gilbert briefed her on the incident and the allegations that have resulted. Investigator Gilbert
notified Detective Gundermann his investigation reveled Officer Natasha Davson may be bringing
cell phones into offenders for $500.00 per phone and allowing congenital visits between the offender
and their visitor for $150.00. Investigator Gilbert interviewed Offender Ronnie Hamilton and he
stated the July 18 th incident, where Toney and Rene were caught engaging in a sexual act, was a
result ofRene not paying Officer Davson for her congenital visit with Toney. (See WSP Case #09006934.)
On October 28, 2008, Detective Gundermann met with Investigator Gilbert and FBI Special Agent
Blauser. Agent Blauser stated he wanted to see the video to ensure Toney's civil rights had not been
violated. Investigator Gilbert gave Detective Gundennann several CD's of phone calls from
offenders at McNeil Island that were discussing the incident. Investigator Gilbert indicated offender
Toney was involved with the "Bloods" gang.
On October 28, 2008, Detective Gundermann met with Investigator Gilbert and Wright at the DOC
headquarters in Olympia to review the video tapes.
The following is a time line of events on the video's.
05:02 a.m. Toney being escorted into segregation.
05:31 a.m. Toney escorted into a cell and the door closes.
05:52 a.m. Officer at Toney's cell door.
06:56 a.m. Officer's walking from cell to cell, looking into the cells.
07:02 a.m. Officer's delivering breakfast.
07:07 a.m. Officer at Toney's cell door.
08:06 a.m. Officer picking up breakfast.
09:56 a.m. Nurse looked in cell.
10:26 a.m. Nurse at Toney's cell.
10:28 a.m. Nurse leaves Toney's cell.
11 :41 a.m. Officer's deliver lunch to Toney and door opens.
11 :42 a.m. Additional staff arrives.
11:43 a.111. Toney brought out of cell in open area.
The tapes of segregation showed the door to Toncy's cell was never opened between the hours of
5:31 a.m. and 11:41 a.m., when he was found hanging from the steel shelf.


Toney, Leon G.

Detective Juli A. Gundermaun


On November 5, 2008, Detective Gundermann and Agent Blauser met Gilbert
at McNeil Island. Detective Gundennann broke the evidence tape and
went into the prison cell where Toney was found. She took
measurements and photos of the cell. The segregation cells are
designed for one occupant and the door slides right or left, to
open. Located inside the cell Toney was in, is a sink and toilet
combination that is made from galvanized steel. Above the sink
is a metal mirror, to the right is an intercom system, and directly
above is a large steel shelf (TV stand). Located in the left comer
is a twin size metal and concrete platform with a mattress. In the
right far comer are a metal desk and a slender window.
Detective Gundermann checked the intercom and it was in
working order. Detective Gnndennann took another bed sheet,
wrapped it tight, and hung it over the steel shelf. It was obvious
to her that it was possible to hang yourself with these materials.




A friend of Toney's, Offender Ronney Hamilton, was For illustration purpose only
interviewed and stated he did not believe there was "foul play"
with Toney's hanging. He believed Toney hung himself out ofloyalty to his "brothers," meaning
gang members. Hamilton stated Toney knew the possession ofthe cell phone charger was going to
be investigated and he would prefer to kill himselfthan give up his "brothers." He believed offender
Toney was also under a lot of pressure from Rene. (See attached witness statement)
After interviewing several offenders, they believed it was the pressures ofloosing his visitation with
Rene, the possession ofcell phones investigation, and the possibility ofimplicating other offenders
that caused Toney to attempt suicide. (See attached witness statements) Valery Brenda Toney
(Leon's mother) stated she Imew DOC was not involved in the hanging and she believed it was
because he was under stress. Brenda also told Detective Gundermann that Rene Matthews had hired
a civil attomey by the name ofNathan P. Roberts.
Detective Gtmdermann attempted on numerous occasions to obtain the medical records regarding
Toney's i~ uries he sustaioed during the hanging. All requests for the records to Toney's family have
been denied and they have been advised by an attorney not to provide them to law enforcement.

The following information was obtained from Leon Toney's file at McNeil Island;
Leon G. Toney was sentenced to prison on September 28, 1997, for 336 months (28 years). Toney's
scheduled release date was in 2024.

Toney, Leon G.

Detective Juli A. Gundermann


On April 15, 1998, Toney asked for individual counseling due to his poor sleeping, emotional
struggles, and a childhood incident. Medical reports state Toney was soft spoken and appeared
frightened, withdrawn, cowered, and anxious.
On April 25, 1998, Toney went to Psychiatrist John P. Moulton, Ph.D. for a new patient evaluation.
Toney told Dr. Moulton he had been receiving mental health services since 1989. Toney stated in
the past he was prescribed Doxepin, as well as some other psychotropic medication. Toney recalled
Doxepin helped him to sleep at night and to stay calmer during the day. He expressed he would like
to be placed back on Doxepin. Toney disclosed he has had chronic depression and it had been worse
during his incarceration, but he has not had suicidal thoughts.
May 6, 1998, Toney's medical reports indicate he was depressed.
On October 22, 1998, Toney saw Psychologist Gene Stroobants. Stroobants indicated in the therapy
notes, "Toney was palpably depressed and asked for medications to help with his depression and
poor sleeping behavior."
On January 3, 2000, Toney's medical reports indicated he had "suicidal ideations".
On January 4, 2000, Toney had an appointment regarding Doxepin to help him sleep.
On January 7,2000, Toney asked to be placed back on Doxepin to help him sleep.
On March 10, 2000, Toney was seen by Dr. Jon Berner. Dr. Berner stated Toney was on Doxepin
for insomnia and depression. Dr. Berner said he is not socializing and suspects other inmates are
watching him because he is from California. Toney believed they might harm him if he is not
constantly vigilant. Notes indicate they will try Neurontin for his headache, flight of ideas, and
On March 22, 2000, Toney complained offatigue, nausea, and fever. In the notes, it states Toney
had suicidal ideations.
On October 26,2000, Toney reported erratic sleep, was hTitable, and not eating regularly. His chart
notes indicate Toney has paranoia and isolates himself in his cell.
On October 25,2001, Toney complained ofhaving difficultly adjusting to prison in Washington. He
stated he does not relate to other offenders and is having problems withdrawing from gang
affiliation, as other members are trying oflure him back.


"Toney, Leon G.

Detective Juli A. GlIndermann


On July 18,2008, Toney and Rene were caught inappropriately touching each other in a conference
room with her children present. DOC personal suspended Rene's visitation privileges for 90 days
for the incident. Officer McNally later noted since the loss of his visitation rights, Toney has
seemed a little down.
Officer Harring noted Toney had mentioned he was tired because he had not been sleeping before
the hanging.
On August 4, 2008, Toney attempted to call Rene thirteen times. Call records show the carrier
blocked all the calls.
On September 17,2008, Toney attempted to call Rene two different times and both calls were not
accepted. (Detective Gundermal1l1 asked Twila Robinson,Leon Toney's ex-girlfriend, what was
going on during the two months before Toney attempted suicide. Robinson stated Toney wanted to
"get rid" of a false marriage certificate between Rene .and Toney. See WSP Case #09-005494.)
On September 18, 2008, at 10:15 a.m., nurse Fish made an entry in Toney's medical file. She stated
she did a wellness check and Toney stated he had not slept in two to three days. Toney told her he
had "thoughts running through his mind" and they were keeping him awake. She asked ifit was due
to him being placed in segregation and he stated no. Nurse Fish asked him if he had thoughts of
harming himself and he stated he did not. Toney gave Nurse Fish a DOC Health Services Kite
asldng to see a Mental Health Professional. Nurse Fish asked if he needed to see Mental Health
innnediately and he stated he did not.
On September 18,2008, Leon G. Toney attempted suicide at McNeil Island. DOC persol1l1el found
Toney hanging fi'om a bed sheet in his segregation cell and innnediately started CPR. Except for the
initial allegation made by the Toney family, there is no evidence to implicate DOC personnel in the
hanging and all evidence points to an attempted suicide. The video surveillance of his segregation
cell clearly shows no one entered or exited the cell between 5:31 a.m. and 11 :41 a.m., when he was
found hanging. There was also documented evidence to show Toney had suicidal thoughts in the
past and suffered from depression.


vVashington State Department of Corrections
Investigative Report

Case Number:

Date Opened:
Date Closed:



Staff Involved:


Offendel's Involved:
DOC Number:

Toney, Leon G.



Type of Investigation:

Atteropted Suicide

Origin of Complaint:

Eroergency Call via Radio

Locations of Occurrences:

FE Pod (Segregation)

Dates of Occurrences:

September 18,2008
i" ---

Iny estigated By:

George Gilbert~"

Case Humber: 09-D41-D8-IOLi
Washington State Department of Corrections
Intelligence and Investigations Unit (1IU)
Report Submitted by: Chief Investigator G, Gilbert

'.." 000001

On Sep1.ember18, 2008 at approxlIIlately 0018brs, Correctional Officer l\1:ichael
Humpbrey was conducting a routine tier check when he (C/O HUll1.1Jbrey) observed what
appeaTed to be offender Luis Perez #763928 talking to himself facing away from the cell
door. IVbile standing at the cell door, Offlcer Humpbrey reported bearing a i'emale voice
over a speake], OfflCer.Humphrey stated ·offender Perez answered back to the female
voice whicb Officer Humphrey then cOl1frrmed a conversation was going on between
oHender Perez and a female Dna cellular phonE.
Officer Humpbrey notITled the Shift Lt. (A Daniels) and informed him oi'the situation.
Additional staff responded to upper B-Unit and once at cell (\lBA 19) staff could still
hear offender Perez talldng to a female from outside the ce]] door. The cell door was
opened and offender Perez handed the cellular phone over to Officer Humphrey. A searcb
of offender Perez cell revealed bottle of tattoo ink. No additional cellularpbone
components were discovered in offender Luis Perez's cell. The items conflscated were
taken to Lt. A. Daniels, which he inspected the cellular phone and discovered photos of
oHender Leon Tone)' #745863 in his cell naked. Additional nndi'l)' photos of females
were. also discovered. N.onE of the photos .appeared to be photos of any .staffmembers at
McN eillsland Corrections Center.
Offender Toney's cell (B325) wasseijI'ched and a cellular phone charger was discovered
plugged into an outlet inside offender Toney's cell. Offender Toney was placed in
segregation on Administrative Segregation status (AD-Seg) pending an investigation by
the facilities lnvestigatlOns Unit; for allegation ofpossessing a cellular phone charger
which matChed the celllilar puone coniiscated from offender LuisPerezwitbiI' the
At approx 5:31am on September 18,2008, oHender Toney was placed in cell FB-12 in
segregation. At approx. 11 ADam staff entered FB-Pod to .start serving"lunch and at
approx.ll :41 am staff discovered offender Toney with a bed sheet around his neck
hanging from the TV st.a:nd III th<~ cell.

After reviewing the canlera footage from F ~Unit there is no evidence of any staff
misconduct. Staff escorted offender Toney to segregation without any problems.
Offender Toney was processed into segregation then escorted to cell FB-12. At no time
did 1 see any misconduct on involving staff nOT did 1 see offender Toney ref-using to
follow staff directions.
Pierce County SheriffDepartment was informed of the attempted suicide involving offender
Leon Toney.·A copy a'rtbe reports and all supporting documents will be forward to Pierce
County Sheriff Department for review.

Case I~umber: 09-04 '1-08-104
WashIngton State Department of Corrections
Intelligence and Investigations Unii (1IU)
RepoI1 Submitted by: Chief rnvestigator G. Gilbert


Timeline ofmovemerii in FE-Pod Jrom 5:02am tD 12:01pm
Copy of vieleo surveillance cameras in FE-Pod (3 cameras)
Copy of vIdeo sLJrveillance camera of offender LeaD Toney entering segr:egation
(3 cameras)
8 Photos of FB-12

,Vhile conducting a routine tier check in E-Unit, Correctional Officer M, Humphrey
heard a female's voice ,coming from offender Luis Perez cell, Officer M, Humphrey then
heard offender Luis Perez responding to the voice, Offender Perez was facing away from
the cell .door and did not see Officer M. Humphrey,
OffIcer Humphrey reported his frnding to the Shift Lt. additional staff responding to BUnit and confronted offender Perez at his cell, which hew was still sp::aking to the
female's voice, Once the officer confronted offender,Perez he hung up the cellular phone
and handed over the officer. Offender Perez cell was searched and no other cellular
phone components were discovered, However, a bottle oftattoo i.nJi: found during the
The cellular phone was talcen to the Shift Lt. which he inspected the cellular phone and
.discovered photos of offendeI Leon Toney in his cell naked, Offender Toney's cell was
searched and the charger to the cellular pholJ,e was discovered plugged into the wall.
Offender Toney was placed in segregation pending an investigation by the Investigations
Unit for allegation of possessing a cellular phone charger which matched the cellular
phone confiscated from offender Luis Perez within the facility,
Offender Toney was escorted to F-Unit (segregation) at approx,5 :02am and was
discovered by custody staff passing out lunch tray at approx, 11:4] am with a bed sheet
arolmd his neck hanging from the TV stand in FB-l2.,

Case Number: 09-041-08-104
Washington State Department of Corrections
Intelligence and Investigations Unit (1IU)
IZeport Submitted by: Chief Inv.estigator G, Gilbert






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If you feel you have an actual medical emergency, alert the staff and do not use this form.
TYPE OF REQUEST (check only one box per form)

o MEDICATION REFILL (list medicationls or place sticker below)






REASON FOR REQUEST (list problem or medications needing refill)

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RESPONDER signature and stamp (all copies)




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Distribution: WHITElYELLOW - Responder, PINK - Offender keeps
Distribution upon completion: WHITE - Health Record, YELLOW - Return to Offender with Response
State law (RCW 70.02; RCW 70.24.105; RCW 71.05.390) and/or federal reg!tl{J(ions (42 CFR Parr 2; 45 CFR Part 164) prohibit
disclosure of this information 'without the specific written consent of the pel:wll to whom it pertains, or as otherwise permiued by law.
DOC 13-423 (07/27/2007) MED

File in appropriate section