Victor Garcia in a photo from his Facebook page | Photo courtesy the Garcia family

Months after a suicide attempt at Columbia Correctional Institution, an online court database indicates that Victor Garcia, 34, died on April 5. 

His sister, Susan Garcia, said her brother was removed from a ventilator and died from complications from his attempt to hang himself on July 19 in a Columbia Correctional Institution shower. At the time, Garcia was on clinical observation because he said he was feeling suicidal.

Garcia gave the Examiner access to records her family received from the Wisconsin Department of Corrections, including incident reports that provide accounts from the day of Garcia’s suicide attempt. 

Questions remain about the purpose and origin of the tether Garcia used in the suicide attempt, as well as why an officer waited for a supervisor and did not immediately remove the tether when Garcia was found. 

The Wisconsin Department of Corrections has received notice of an anticipated lawsuit being filed against the department on behalf of Victor Garcia, DOC communications director Beth Hardtke said in an email in response to questions from the Examiner. DOC practice is not to comment on matters relating to pending or ongoing litigation, Hardtke said. 

Attorney Lonnie Story said he plans to file a lawsuit involving Victor Garcia’s attempted suicide at the facility. He said he needs to obtain more information before filing a suit. 

Garcia’s prison sentence and mental health strugles

In March 2008, when he was 16, Victor Garcia was found guilty of criminal trespassing in a dwelling, battery, disorderly conduct and a domestic abuse incident. He was sentenced to two years of probation. Garcia’s probation was revoked in July 2008, and in August he was sentenced to nine months in jail. 

When he was 18, Garcia was found guilty of being party to a crime for burglary and being armed with a dangerous weapon, causing substantial bodily harm and two counts of armed robbery with use of force. He was sentenced to over 20 years in prison. 

Garcia was placed in clinical observation on July 8. According to records provided by Susan Garcia, Victor Garcia was placed there because he told security staff and psychological services that he was feeling suicidal. 

An incident report said that Garcia stated he was using psychological services to remove himself from general population status “due to fears that he was being targeted as an informant.” Susan Garcia said her brother had suicidal thoughts and had been threatened by another incarcerated person. 

In the two days prior to his suicide attempt, Garcia did not engage with staff during multiple attempts to evaluate him. According to a review on July 16, Garcia said he felt depressed and felt like dying every day. 

The report said it appeared other members of the psychological services team had recommended exploring a stabilization referral for Garcia to the Wisconsin Resource Center (WRC). WRC provides treatment for severe impairments in daily living caused by mental health challenges. Susan Garcia believes her brother should have been sent to WRC earlier in his time in prison. 

According to a mental health report dated July 19, Victor Garcia was to be monitored every 15 minutes. 

Under the DOC’s clinical observation policy, the frequency with which a patient is monitored can vary. Depending on the level of risk, a patient might be observed at 15, 10 or 5-minute intervals, or constantly. 

According to an incident report by Psych Associate Chastity Drake, Drake thought she heard someone from the clinical observation area “yell they were ‘going to hang’ themselves.” She was unsure who it was. Her report was dated July 19, with an incident time of 2:30 p.m. 

Drake asked who had yelled, and the clinical observation checker told her who it was. The name is redacted in the incident report. Drake stopped at a door to check with that person about whether he was the person who had yelled about hanging himself, and he denied it. 

In front of the shower, Drake reported she “heard a man yelling and it sounded like the voice heard earlier. Due to PIOC going into shower, this writer determined she would touch base with him after the shower.” 

Garcia had access to a ‘tether’ 

At 2:30-3 p.m., Drake followed the observation checker to check in with Garcia, who was seated on the floor with his back against the door, according to her incident report. Drake could see a “tether” around his neck. She began to bang loudly on the door, yelling “Garcia.” He did not respond. 

Both ends of the tether were secured to the shower door near the shower drain.

Another incident report was completed by correctional officer Anthony Rego, who drove to the hospital where Garcia was treated. He wrote in the report that he’d learned Garcia had been in the shower for approximately 40 minutes, and at some point had the tether around his neck. 

It is unclear if the tether was meant to be attached to the shower door. One incident report said Garcia had used “the tether that was attached to the shower door.” An incident report by correctional officer Tyler Peterson also mentions a tether.

In his report, also dated July 19, Peterson wrote that he was assisting with removing and escorting Victor Garcia from a cell to the observation shower. Once he was in the shower and the door was shut, another correctional officer “removed the tether and wrist restraints,” he wrote. 

Family member questions why Garcia was left tethered while unresponsive 

An incident report by Courtney Schmidt, a licensed psychologist, states she was in RH1 at approximately 2:30 p.m. Schmidt’s report states that she and Drake were waiting to check in with Garcia to assess him for risk and that at the time, he was naked in the shower.

Schmidt wrote that as they walked back to the clinical observation shower, she saw Garcia hanging from the tether. He was unresponsive and she could see that the tether “was wrapped tightly around his neck.” 

Drake began to pound on the shower cell door, and the officer accompanying them called for a “supervisor/help over his radio.” Drake left to go and wait for help in the front, while Schmidt stayed with Garcia. She wrote that she saw his belly slightly moving. 

Schmidt asked the officer if he could take the tether off, “but he stated ‘I am not taking it off until a supervisor comes.’” He then called again over his radio, and Schmidt waited until help arrived. 

In an interview with the Examiner, Susan Garcia questioned the decision to wait for another person to arrive. She thinks the door should have been  opened, and staff should not have waited to assist her brother, “if you obviously see something’s wrong.”

Drake wrote that she heard the officer call for help and went to the clinical observation table to wait for help to arrive. She wrote that “the response appeared delayed due to other high priority events happening at the same time.”

“This writer went to find help and ran into Dr. Stange and Sgt. Ferstl,” Drake wrote. “Sgt. Ferstl and moments later Lt. Laturi and support staff rushed to the clinical observation shower. I observed as the PIOC was removed from cell and began to receive medical treatment.”

In his incident report, supervising officer Steven Laturi wrote that he was working as a shift supervisor. At about 2:40 p.m., he was responding to another emergency in Restrictive Housing Unit 1 (RH1) when he heard a radio call for a supervisor to report to the observation area. 

Laturi wrote that he was unable to respond immediately because he and a team were responding to someone else, whose name was redacted in the report. This person was in a restraint chair in a program cell, and he had tipped his restraint chair back and removed his legs from it. 

According to Ferstl’s incident report, he was assisting Laturi and completing inventory when Drake came out from the RH1 observation area and told staff that Garcia was unresponsive. He reported that at around that time, the observation check officer made a radio call, asking for a supervisor to come to the observation area for an inmate who was harming himself. 

Ferstl wrote that he arrived in the RH1 observation area and saw Garcia sitting upright at the shower door. He tried to get Garcia’s attention, but Garcia was unresponsive. Ferstl made a radio call for a supervisor to report to the observation area. 

Ferstl then “unsecured one end of the door tether which removed the tether’s tension,” he wrote, allowing Garcia to rest in a lying position near the cell door. Ferstl made another radio call, asking the health services unit to report to RH1 immediately. 

How Garcia described himself

Garcia has a profile on penacon.com, a website for finding an incarcerated pen pal. Susan Garcia said her brother set up the profile, which includes photos of artwork. 

Garcia described himself as “an avid reader that enjoys educating, empowering & entertaining myself mentally in a place designed to break the mind, body & spirit.” 

He wrote that being incarcerated at 17 “forced me to mature fast.” “When I’m out,” he wrote, on his bucket list was traveling the Atlantic, Gulf and Pacific coasts, experiencing the life of different cultures through food. 

“He would call my kids almost every day,” Susan Garcia said. “Weekly, definitely weekly. He would send them gifts. He loved kids… My brother would give the clothes off his back for you. He was emotional, but hid it. He hid it very well.” 

Further information not yet available 

According to the DOC’s mental health training policy, the department’s division of adult institutions (DAI) is supposed to provide annual update training in suicide prevention to all DAI staff who have contact with incarcerated people. DAI facilities are also supposed to conduct drills simulating a suicide attempt by an incarcerated person and staff response.

On April 17, the Columbia County Sheriff’s Office said it could not release any information pertaining to the investigation at this point. The investigation was being reviewed by the Columbia County District Attorney’s Office, and additional investigation may need to occur. On May 23, the sheriff’s office said there had been no change in the status of the case. 

On May 21, the Examiner submitted a public records request to the Wisconsin Department of Corrections, asking for any records produced by any DOC investigation of Garcia’s death.

The DOC denied Susan Garcia access to body camera and security camera footage of Victor Garcia’s suicide attempt, citing security concerns and the public interest in protecting the safety of incarcerated people and staff. 

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Waupun Correctional Institution, photographed in 2017 (Wisconsin Department of Corrections photo)

A federal civil rights lawsuit was filed Thursday over the death of Joshua Botwinski, 43, at Waupun Correctional Institution (WCI). The lawsuit named Randall Hepp and Yana Pusich as defendants, the then-warden and then-security director of the prison. 

According to the lawsuit, Botwinski suffered from a severe drug addiction and from mental illness at all times while serving his prison sentence at WCI. It says he died of a fentanyl overdose.

The lawsuit alleges prison staff known to be smuggling drugs were assigned in proximity to Botwinski. It also alleges a failure to order Botwinski into close observation until drug smuggling could be controlled. 

The DOC’s online offender locator dates Botwinski’s death on January 19, 2023. Botwinski is at least the eighth incarcerated person to die at the prison since 2023. The death of Damien Evans, 23, was at least the seventh death at the Waupun prison since 2023, according to reporting from the Milwaukee Journal Sentinel earlier this year. 

Another man incarcerated at Waupun, Tyshun Lemons, died on Oct. 2, 2023 when he overdosed on a substance containing fentanyl, the Examiner reported. 

The estate of Joshua Botwinski is the plaintiff for the lawsuit, by special administrator Linda Botwinski. The lawsuit alleges Hepp and Pusich were deliberately indifferent to a serious medical need, knowingly created a danger for Botwinski and knowingly failed to protect him from danger. It argues that their alleged deliberate indifference caused Botwinski’s death. 

In January, the Milwaukee Journal Sentinel reported that nearly a dozen prison employees had resigned or been fired since the U.S. Department of Justice’s launch of a probe into a suspected smuggling ring within the prison.  

In September, William Homan, a former facilities repair worker at WCI, pleaded guilty to smuggling contraband in exchange for bribes. A sentencing memorandum by prosecutors said the presence of contraband in WCI contributed to a “lack of institutional control.” 

In late April, Hepp was convicted of a misdemeanor and fined $500 in the death of Donald Maier, who was incarcerated at WCI. 

A sentencing memorandum by a lawyer for Hepp said that in March 2023, “conditions and actions of the inmate population created an environment that posed an immediate threat to the safety of the staff and inmates while also threatening the security of the institution.” 

The memo said Hepp put the prison in modified movement, “at times referred to as a ‘lockdown.’” 

“This led to an investigation of the conditions and a search of the institution,” the memo said. “Information and physical evidence that was developed revealed a level of corrupt behavior taking place that was historical in scope involving trafficking of illegal drugs, cellular telephones, finances, and other contraband.”

The sentencing memo from Homan’s case said the lockdown involved incarcerated people “being confined to their cells twenty-four hours a day except for medical or other emergencies.”

“As part of its efforts to reestablish control, a facilitywide search was conducted, resulting in the recovery of numerous cellular phones, controlled substances, and other contraband,” the memo said. “WCI provided information obtained from its investigation to the Federal Bureau of Investigation (FBI), which included information that WCI staff were receiving bribes in exchange for smuggling in contraband.”

The lawsuit alleges that before Jan. 19, 2023 — and therefore before the lockdown and investigation — “via the reports they received from staff, both Pusich and Hepp knew that illegal drug use was rampant at WCI, and they knew that prison staff was smuggling drugs into WCI.”

Lawsuit includes alleged timeline leading to overdose

The lawsuit alleges that on August 15, 2022, WCI officials found out that Botwinski was under the influence of drugs. Botwinski tested positive for opiates and stimulants. 

Incidents of prisoners being under the influence of drugs “is automatically reported to Pusich as security director,” and Pusich would report incidents of prisoners using illegal drugs to Hepp, the lawsuit alleges. 

Before Jan. 19, the day of Botwinski’s death, Pusich and Hepp knew illegal drug use was “rampant” at the prison, the lawsuit alleges. 

“From the reports of drug use and overdoses, they knew that inmates had an almost unfettered access to drugs in prison,” the lawsuit alleges. “Botwinski’s access to drugs in WCI was greater than his access to drugs outside of WCI.”

The lawsuit alleges that Hepp and/or Pusich assigned prison staff known to be smuggling drugs into the prison in proximity to Botwinski. It alleges that they knew placing staff who smuggled drugs into the prison in Botwinski’s proximity would lead to overdose. 

According to the lawsuit, staff observed Botlinski in his cell at about 5:10 p.m. 

“At about 6:45 p.m., Botwinski was discovered in his cell: he had been the victim of a drug (fentanyl) overdose, from which he died,” the lawsuit says. 

The Wisconsin Department of Corrections did not immediately respond to a request for comment from the Examiner. 

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The Waupun prison sits in the middle of a residential neighborhood (Photo | Wisconsin Examiner)

Former Waupun Correctional Institution (WCI) warden Randall Hepp was convicted of a misdemeanor Monday in the death of Donald Maier and fined $500 and court costs. Hepp pleaded no contest.

In June, Hepp was charged in Maier’s death. Maier’s mother sued Wisconsin Department of Corrections Secretary Jared Hoy, Hepp and others Monday, seeking compensatory and punitive damages. 

The lawsuit alleges that the defendants’ “lack of accommodation, deliberate indifference, and negligence in ignoring his rapidly and obviously deteriorating physical and mental health while he was in their care” caused Maier’s death. 

In June, the Examiner reported that Hepp and eight members of his staff had been charged with crimes related to the treatment of people incarcerated in the prison. Six staff members were charged along with Hepp in the death of Maier, who authorities said died due to dehydration and malnutrition, the Examiner reported in June. Seven incarcerated people have died at WCI since 2023, the Associated Press reported. 

A statement in a criminal complaint said Hepp didn’t oversee his staff to make sure they followed all policies/procedures. 

“Randall Hepp did not follow through the requirements of his position required by law as the staff at WCI are poorly trained on many policies and procedures regarding missed meal(s), water restrictions, medication refusals, round checks, and more,” the complaint stated. 

DA, Maier lawsuit tell different stories about Hepp

Earlier in the case, Hepp was charged with felony misconduct in public office. Penalties for a Class I felony are a fine up to $10,000 or up to three and a half years’ imprisonment, or both.

Hepp was convicted of violating law governing state or county institutions. The Class C misdemeanor comes with a fine up to $500 and up to 30 days imprisonment, or both. Hepp was not sentenced to imprisonment.

The Associated Press reported that Dodge County Circuit Court Judge Martin De Vries cited Hepp’s service record, lack of a criminal record and “‘subpar employees’” who failed to follow policy. 

Dodge County District Attorney Andrea Will lowered the charge to a misdemeanor in exchange for a no contest plea, the AP reported. Will told De Vries that she lowered the charge because Hepp was well respected within the Wisconsin Department of Corrections and didn’t know guards weren’t following policy, according to the AP. 

De Vries said the criminal charge against Hepp was “‘to some extent…symbolic,” the Post-Crescent reported. 

According to the Associated Press, Maier’s mother, Jeannette Maier, called Hepp’s sentence a “‘slap on the wrist.’” She said her son had been treated worse than a caged animal.  

“Nothing can bring my son back but I like to think we as a society would at least learn something from this tragedy so it never happens to someone else’s son,” she said in a statement, according to the AP.  

The lawsuit from Jeannette Maier alleges Hepp was aware of a “systemic lapse in enforcement” of the hunger strike and water shut-off protocols. It alleges that Hepp did not take action to attempt to make sure that the protocols were followed. 

The lawsuit also says Hepp was deliberately indifferent to a substantial risk regarding the most at-risk incarcerated people in the restricted housing unit. 

The risk, as described by the lawsuit, was that they were not receiving the level of care and supervision needed in order to afford them adequate medical and mental health evaluation and treatment and did not have humane conditions of confinement.  

This risk was created by understaffing, low morale and lack of adequate training, the lawsuit alleges. 

Sheriff supports conviction

Dodge County Sheriff Dale Schmidt released a statement on Facebook in support of the settlement and conviction. 

“I can understand why some may feel additional sanctions are warranted, but our court system must be blind to ‘feelings’ and ‘agendas’ and decisions made solely on the facts of the case,” Schmidt said. 

Schmidt said that “investigating and arresting Randall Hepp was one of the most difficult cases I have been part of, leading to some of the most difficult decisions I have had to make during my time as sheriff.” He said Gov. Tony Evers and then-Department of Corrections Secretary Kevin Carr put Hepp in a very difficult position. 

“Don’t get me wrong, he was the warden and was by law administratively responsible for Waupun Correctional Institution, and as a result, two deaths that occurred,” Schmidt said. “While we explored it, no Wisconsin or federal law directly tied back to his bosses, who failed to provide adequate resources or leadership.”

A sentencing memorandum by an attorney for Hepp said the former warden “was chosen to run Waupun because of his history of building great work environments and teams, creating positive institution culture and improving operations.” 

According to the memorandum, “Waupun Correctional was known to be the most challenging institution for correctional officers to work.”

“This institution was in complete [dysfunction], there was an extreme understaffing of uniformed positions and no goal to improve the staffing,” the memorandum stated. “There was a historically high vacancy rate that existed over a lengthy period of time that required officers to work an extremely unheard-of number of forced shifts further aggravating an already difficult situation and burning out among staff members. This situation contributed to the staff’s concerning level of apathy, distraction and a desire to transfer to other institutions.”

The memorandum said Hepp “became the primary and recurring voice” for the need to improve staffing at Waupun.

“Unfortunately, his voice was not heard,” the memorandum stated. 

“Many pieces to this puzzle” have not yet gone through the criminal justice system, Schmidt said, since cases are still being processed through the courts. 

One former Waupun employee pleaded no contest in September and was fined $250. Charges were dismissed against another, and other cases are pending, the Associated Press reported.

The Wisconsin Department of Corrections did not immediately respond to an email seeking comment on Hepp’s conviction on Tuesday afternoon.

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