Susan Garcia knew it was time to turn off her brother’s life support.
It was April 5 — her brother’s 34th birthday — and the gentle whoosh and melodic beep of Victor Garcia’s ventilator and heart monitor sounded in the background.
Garcia had been on life support since July 19, 2024, after hanging himself in the shower at Columbia Correctional Institution. It took prison staff at least 10 minutes to cut him down.
Prior to his fatal attempt, Victor Garcia had roughly 20 incidents of self-harm or suicidal ideation, according to his prison records.
He had previously tried to hang himself, swallowed nail clippers, cut his wrists with a piece of plastic from a broken surveillance camera in his cell, and ingested 30 500-mg Ibuprofen pills at once.
It’s impossible to know how common this kind of situation is in Wisconsin’s prisons, because the department does not comprehensively track self-harm incidents.
DOC compiled and shared with the Milwaukee Journal Sentinel a list of self-harm incidents rated as “high seriousness.” The list includes only incidents where a prisoner was placed on clinical observation afterward. Prisoners who were transferred to a hospital or another care facility for treatment are not included on the “high seriousness” list — even if their attempt proved fatal, as it did for Garcia earlier this year.
A Journal Sentinel review found the list does not include other serious incidents, including a suicide attempt that left a man in a wheelchair and another that resulted in a substantial settlement paid out by the state.
Beth Williams Hardtke, a DOC spokesperson, said the department shared the data “in the interest of transparency.”
“The data is not an exhaustive or comprehensive list of any and all self-harm incidents,” she said.
Hardtke said there is not any comprehensive list of all self-harm incidents. Asked about how DOC tracks and monitors self-harm incidents to look for trends or assess risks in its facilities, Hardtke said psychiatric staff use prisoners’ individual medical records.
Experts and advocates for prison reform say a lack of self-harm data obscures the true scale of mental health crises behind bars, both for the public and those who work in the system. Operating without a full picture of prisoners’ needs strains staffing and resources, and may put prisoners at risk and prevent families and the public from holding the system accountable.
“It gives a false sense of security that things are really not a problem, when — if these things are being ignored and left out of the data — they are, in fact, a problem,” said Christine Tartaro, a criminal justice professor at Stockton University who studies suicide and self-harm in state and federal prisons.
For Susan Garcia, the fact that so many of her brother’s incidents are missing in the data set is “disturbing.”
“They’re not taking any of this seriously,” she said. “None of it.”
Self-harm incidents remain dangerously high, but underreported
Victor Garcia had roughly 20 incidents of self-harm or suicidal ideation, according to his prison psychiatric records.
Psychiatric staff are supposed to assess such incidents and gauge whether intervention is needed. If placed on clinical observation, prisoners’ incidents are rated as low, medium or high risk.
High-risk incidents include those that require emergency medical care, could cause serious injury, or “appear to have been carried out with an intent to die.” Low-risk incidents are those that require no medical intervention or are less likely to be fatal. The mediums are “in-between,” according to a DOC spokesperson.
Less than half of Garcia’s incidents were evaluated by psychiatric staff for risk. Just one of those was marked as high-risk.
DOC’s issues with tracking such incidents go back more than a decade.
From 2012 to 2018, staff had to use a cumbersome, time-intensive system to enter information about clinical observation cases, Hardtke said. There was no way to ensure data was entered for every case.
DOC says the data from that period is not “reliable.”
In 2019, DOC shifted to a new electronic data entry method for medical records, and made entering information mandatory.
The number of “high seriousness” self-harm incidents is consistently higher beginning in the 2019 data.
The data still includes only cases where a prisoner was placed on clinical observation. The data does not include prisoners’ names, but notes the date an incident occurred, which prison the incident took place in and the type of self-harm behavior.
Though incomplete, the data offers a small window into the self-harm crisis across the state’s prison system.
Between Jan. 1, 2012, and June 2, 2025, there was an overall upward trend in “high seriousness” self-harm incidents across the state’s adult facilities, with a spike of roughly 200 cases in 2023.
Other years it fluctuated between 60 and 163 incidents.
The most common “high seriousness” self-harm behaviors were cutting, overdosing on medication and ingesting objects, with the highest number of cases reported at Columbia Correctional Institution, the Milwaukee Secure Detention Facility and Waupun Correctional Institution.
Garcia’s first attempted hanging at Fox Lake Correctional Institution in 2023 was rated as “high,” records show, and appears to be reflected in the “high seriousness” data set.
When he ingested nail clippers it was not classified in his records as “high seriousness.” Swallowing approximately 15,000 milligrams of Ibuprofen — five times the recommended daily dosage — also didn’t rise to that level.
Both incidents were classified as “medium seriousness,” according to Garcia’s clinical observation records.
When Garcia cut himself with a shard of plastic from a camera inside his cell, he was already on clinical observation. Records show psychiatric staff do not appear to have rated the incident on the seriousness scale.
Garcia isn’t the only prisoner whose self-harm incidents do not appear in the DOC data set.
In 2018, Matthew Harris, 46, almost cut his entire ear off and cut his arm and wrists with razor blades he found in his cell while on clinical observation in Waupun Correctional Institution’s restrictive housing unit.
He had warned guards he was going to cut himself and the guards did nothing except taunt him, according to a lawsuit filed by Harris. His case, which was later handled by attorneys Kim Motley and Nate Cade, resulted in an undisclosed settlement.
His self-harm incident is not included in DOC’s “high seriousness” self-harm data set.
Neither is Casey Schueneman’s.
With a history of suicide attempts and after warning staff, Schueneman, 44, jumped off the third story of his unit at Waupun in April and was later hospitalized, medical records show.
According to Schueneman, he is now in a wheelchair and learning to walk again, after being transferred to the Wisconsin Resource Center, the state’s specialized mental health prison. He and his former cellmate told the Journal Sentinel that staff did not appear to intervene as Schueneman was about to jump.
“I was crying for help,” he said. “They failed to keep me safe.”
It’s unknown how many other incidents might be missing from the data.
More than 76% of those incarcerated in the state’s prison system have a mental health or serious mental health illness, according to the DOC. The agency has routinely mentioned the toll of increased rates of mental and behavioral health among prisoners and the limited resources for in-custody treatment, treatment alternatives and diversion programs. The Wisconsin Resource Center is also consistently at-capacity.
As a result, staff can become strained. And, for Tartaro, staff can also become skeptical of and mistrust prisoners’ warnings that they are suicidal or considering self-harming. In some cases, prisons mislabel self-harm or suicide attempts as a misadventure or a disciplinary infraction, resulting in conduct violations, she added.
“(Staff) just start to look at situations and define them as, unfortunately, conduct violations, when it really is a sign that the person is in need of mental health assistance,” she said.
The first time Victor Garcia attempted to hang himself in Fox Lake’s restrictive housing unit, staff wrote him up with a conduct violation, placed him in restraints and on clinical observation.
Victor Garcia loved his family, but struggled with the law
Everyone remembered Garcia for his wide, easy smile and unmistakable laugh — loud, a little giggly and almost boyish.
“He was funny, always played jokes on people, outgoing,” his sister Susan Garcia said. “He would take care of you before he took care of himself. Always.”
His family said his life changed when he was 13 and robbed a local gas station for candy. According to his sister and brother, he was sent to a boys’ boot camp, then later to Lincoln Hills, the state’s long-troubled youth prison.
There, he began expressing anger through self-harm, including banging his head and biting his arm, according to mental health records.
When he returned home in his late teens, Garcia went by “Loco” and became involved in gangs. His sister believed he needed extensive therapy.
Incarceration at a young age can alter the brain’s “wiring,” exacerbating mental health issues or leading to the onset of new conditions, according to Elizabeth S. Barnert, an associate professor of pediatrics at the University of California, Los Angeles, who has studied the health outcomes of incarcerated youth.
It can also push youth deeper into the criminal justice system, she said.
By 19, Garcia was sentenced to over 20 years in prison for a violent armed burglary committed with his older brother, Fernando Garcia. He became a father around the same time.
A few years into their sentences, the brothers reunited at Waupun Correctional Institution.
“I loved seeing him,” Fernando Garcia said. “But it was different. We were men then.”
Fernando Garcia served eight years, was released in 2018, and went on to raise a family and rebuild his life.
Victor stayed behind, missing his daughter’s childhood.
He ignored almost all of his brother’s calls and letters about life outside the prison.
“I wish, instead of cutting me out, he would’ve let me in,” Fernando Garcia said.
‘I see no way out’: Garcia’s escalating threats of self-harm
Inside prison, Garcia had started to feel neglected and isolated from his family, according to one of his cellmates.
“He fought religiously to get out on appeal,” the cellmate, Johnny Mojica, said. “He never stopped, even when they closed the doors.”
For most of his 14 years in custody, Garcia had little interaction with psychological services.
But in early March 2023, the situation quickly began to change. Garcia reported experiencing anxiety, thoughts of self-harm and trauma, according to mental health records.
On March 11, 2023, Garcia told staff he had ingested more than 30 500mg tablets of Ibuprofen, but does not appear in DOC’s “high seriousness” self-harm data despite other similar cases being reported there.
Incident reports state Garcia had told his mother over the phone that he was trying to end his life.
Garcia refused medical treatment and was placed on observation, where he declined meals and was later sent to the hospital after he banged his head on his cell door.
In mid-April 2024, while in the restrictive housing unit at Fox Lake Correctional, Garcia attempted to hang himself with a sheet in the recreation pen in front of multiple correctional staff.
This is the one self-harm attempt that appears to be reflected in DOC’s “high seriousness” self-harm data. But rather than being categorized as “hanging” or “noose,” which the DOC used for other self-harm incidents, Garcia’s attempt is listed as “stood at height.”
Staff kept him on clinical observation and, at the time, he was on psychotropic medication, according to records.
“I see no way out,” Garcia told staff the day after his attempt.
In the months following, Garcia’s reports of suicidal ideation continued to land him on clinical observation. He repeatedly spoke of and acted on thoughts of self-harm.
He also experienced insomnia, hearing voices, severe pain in his leg, depression, anxiety, exhaustion from years of incarceration, and frustration at the inability to develop a relationship with his teenage daughter, according to his prison psychiatric records.
“He was so monotone, and that’s when I knew something was wrong,” Susan Garcia said, recalling her brother’s voice on the phone.
During this time his sister had questioned why psychiatric staff did not re-evaluate his mental health status.
His sister said she filed a complaint against Garcia’s psychiatric doctor at the prison, but nothing changed. Garcia’s family long suspected the escalating attempts — about 20 are listed in his file — would end up being fatal.
“It’s written all over his file,” Susan Garcia said of her brother’s struggles with his mental health. “I thought my brother was safe in there. He wasn’t.”
By late January 2024, Garcia had been transferred to maximum-security prison Columbia Correctional Institution, despite his wishes to remain at Fox Lake Correctional or be transferred to the Wisconsin Resource Center, records show.
Once there, Garcia grew increasingly concerned about suicide and death, often crying during psychological staff visits, according to his mental health assessments. While on observation he refused to eat or drink.
During one of his final assessments on suicide watch on July 15, 2024, Garcia told staff:
“I feel like dying every day. Every day I wake up here I feel like dying.”
The cost of delays
Incident reports and a psychiatric evaluation are the only record of Garcia’s final hours in the prison.
The morning of July 19, 2024, Garcia would not engage with psychiatric staff. They observed that Garcia was still at high risk of harming himself and recommended he continue to be closely monitored under clinical observation.
By the afternoon, Garcia was escorted to the shower block in the prison’s restrictive housing unit by prison staff.
Shortly after, an on-site psychological associate stationed in the unit heard someone yell — the person was threatening to hang themselves. While she couldn’t identify the voice, it appeared to echo from the showers.
At 2:30 p.m., as part of a scheduled suicide risk check, the associate and a licensed psychologist approached Garcia, who had been in the shower block for roughly 40 minutes.
They found Garcia was unresponsive, slumped on the shower floor with a tether wrapped around his neck.
The associate began pounding on the shower door, shouting Garcia’s name. There was no response.
Correctional staff were hesitant to enter. One correctional officer refused to cut the tether until a supervisor was present.
Per DOC policy, all correctional staff are given suicide prevention training and informed where rescue tools, including a 911 knife, are located in inmate living areas. Responding staff must notify security or other nearby staff. Trained staff must follow security procedures to stabilize the inmate and the scene, and begin first aid when deemed safe. But prison guidelines offer no clear directive on when immediate intervention is required.
At the time, other staff on the unit were busy with another prisoner who had overturned his restraint chair and freed his leg.
Between 2:40 and 2:45 p.m., 10 to 15 minutes after Garcia was found unresponsive, staff called for help.
“Ten minutes is a very long time,” said Tartaro, the expert who studies in-custody suicides. “It could be the difference between life and death in this situation.”
After staff finally cut Garcia down, he was later transported to a UW-System hospital, where he was intubated.
The DOC did not respond to questions on the specifics of Garcia’s case.
‘This broke me as a person’
Susan Garcia learned of her brother’s suicide attempt three days after he was transferred from prison to UW-System hospital.
Hospital staff told her that he had experienced severe brain damage and had been placed in their intensive care unit. By late March, he was transferred to Milwaukee’s Aurora St. Luke’s.
With little hope Garcia would ever regain consciousness, his family decided they had no choice but to end all life-sustaining treatment.
Susan Garcia is pushing for accountability and retained an attorney, planning to explore legal options. The Columbia County Sheriff’s Office has finished its investigation into her brother’s death and sent the reports to the local district attorney for review. The district attorney’s office did not respond to questions from the Journal Sentinel.
“I’d have to say this broke me as a person,” Susan Garcia said of her brother’s death. “(Prisoners) are still human. They’re still somebody’s brother. They’re still somebody’s dad. They’re still somebody’s uncle.”
Inside his hospital room, family and friends shared smiles and tears surrounded by blue and purple star-shaped balloons as they celebrated Garcia’s birthday and readied their final goodbyes.
For Allen Strzyzykowski, his close friend, the day was bittersweet. It was one of the few times he had seen Garcia since he went to prison.
“We all grew up. We all changed. We became positive members in our community,” he said in an interview, reflecting on that day.
Garcia deserved that chance, too, his friend said.
“His time was coming,” he said. “He was coming home.”
Susan Garcia kissed her brother’s brow, signaling to staff it was time to remove his life support.
She said she’ll never forget the rattling sound as he drew his last breath.
Vanessa Swales covers Wisconsin’s prison system and Milwaukee politics for the Milwaukee Journal Sentinel. You can contact her at 414-308-5881 or vswales@gannett.com.
This article originally appeared on Milwaukee Journal Sentinel: He died by suicide after repeated self-harm inside Wisconsin prisons. How many others are like him?
Reporting by Vanessa Swales, Milwaukee Journal Sentinel / Milwaukee Journal Sentinel
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