Inmate’s death in Malheur County Jail followed lapses in security checks

The bedding and slippers as Oregon State Police troopers found them last November as they investigated the death of an inmate at the Malheur County Jail in Vale. (Oregon State Police photo)

VALE – The disturbing end to a troubled man’s life in a Malheur County jail cell last fall drew scant public attention.

Yet interviews and government records obtained by the Malheur Enterprise reveal that Zelon O’Neal’s suicide occurred after jailers left him unmonitored for hours despite a history of instability and troublesome episodes at the jail.

He died Nov. 17 – just hours before his attorney was to appear before a judge to ask that O’Neal be committed to the Oregon State Hospital for treatment.

It was the first suicide in the Vale jail since it opened in 1996.

At the time, authorities told the public little about his death.

The Oregon State Police investigated, and Malheur County Sheriff Brian Wolfe then directed an internal investigation. In a recent interview Wolfe said he disciplined three deputies who were on duty the night O’Neal died.

Wolfe also said there was no way to determine whether O’Neal’s suicide would have been prevented if jail procedures had been followed.

In response to public records requests, the State Police and Wolfe released police reports, interview transcripts, photographs and jail records that documented O’Neal’s time in the jail and the events the night he died.

Little is known about when or why O’Neal arrived in Ontario. He was born in Texas, lived for a time in Utah and had recently been in Colorado. Records in Colorado show he had a lawn maintenance business.

His brother, Jessie O’Neal, said O’Neal had been married at least once and had a daughter.

He said O’Neal struggled with mental health issues for years, attempting suicide when he was a teenager. He said his brother was stable when on prescription medications.

Jail records show he was issued only an allergy medication.

“He should never have been kept in a single cell by himself,” said the brother, who lives in Hawaii.

O’Neal, then 49, was jailed last summer.

Ontario police encountered him early on Aug. 30, 2019, when they responded to a call of damaged glass door at the Malheur County Council on Aging on Southeast First Avenue. O’Neal ran, chased by officers in their cars. One deployed a Taser to stop him.

“Zelon O’Neal stated he was schizophrenic,” said one officer’s report. “He would alternate between being calm and having fits of mania,” ripping out one of the Taser probes, the report continued.

He was booked into the Malheur County Jail on six charges, ranging from felony first-degree criminal mischief to a misdemeanor resisting arrest. In the ensuing weeks, he proved to be a troublesome inmate, according to the sheriff.

In September, his attorney requested a hearing to determine if O’Neal was mentally fit to stand trial. The attorney, Renee Denison of Ontario, didn’t respond to emails or telephone messages about the case.

A medical doctor on Oct. 15 tried to evaluate O’Neal at the jail but he was “very confrontational during exam” and “exam was stopped due to the patient becoming aggressive,” according to the doctor’s notes.

By October, O’Neal had been placed in a segregation cell at the end of a short hallway accessing four separate cells used to isolate inmates who pose a risk.

“That’s where they go for disciplinary action,” Wolfe said.

Malheur County Sheriff Brian Wolfe. (Rachel Parsons/The Enterprise)

The cell has concrete block walls, a bed, a sink and a toilet. O’Neal’s only view was through a tall skinny window in the door.

On Nov. 7, a psychologist tried to assess O’Neal’s mental condition.

“He refused to participate in the evaluation,” according to Dave Goldthorpe, Malheur County district attorney. “It was left to the court to decide the aid and assist issue without the help of a full evaluation.”

Three days after that visit, O’Neal disrupted the jail. For nearly five hours, he wouldn’t return to his cell after using the shower in his cell block.

While he was in segregation, deputies were supposed to check on him every 30 minutes, night and day.

Wolfe said those checks are meant to safeguard inmates.

“If you’re housed by yourself, there is nobody else to report if you’re having a problem,” Wolfe said.

Corrections deputies are required to follow detailed orders, Wolfe said.

General Order J.213 – “Inmate headcounts and security checks” – directs that “Inmates will be personally observed by employees not less than once each hour.” Checks on inmates in segregation – where O’Neal was housed – “will be conducted not less than twice per hour.”

That rule stands day and night.

“When headcounts, formal headcounts and/or security checks are conducted on sleeping inmates, corrections deputies shall determine that the inmates are present and breathing,” according to the orders. “A portion of the inmates’ body shall be seen by the corrections deputy and visual signs of respiration must be detected.”

The order directs corrections deputies to “enter the cell” if they can’t confirm an inmate’s welfare by outside observation.

The order explains that failing to follow the orders carries risk for the county.

“A failure on the part of the corrections deputies to make timely headcount and security checks can result in liability in the event that harm to inmates occurs,” the order said.

Records from the county and Oregon State Police document show “timely” checks on O’Neal were missed.

In the overnight hours of Nov. 17, three deputies were on duty. Logan Butler was tasked with running the control center. Teresa Alexander was the senior deputy on duty. She had 18 years’ experience at the sheriff’s office. She was teamed up with Tyler Osborn, a relatively recent hire at the sheriff’s office who was still on probation.

According to the jail log for that night, Osborn did hourly checks on inmates throughout the jail at 1:03 a.m., 2:05 a.m., 3:03 a.m., and 4:04 a.m. The log indicated he did the half hour checks, which should have included O’Neal’s cell, at 12:40 a.m., 1:40 a.m., 2:24 a.m., 3:28 a.m., and 5:02 a.m. Alexander is recorded as helping with checks at 1:40 a.m.

The jail log showed her down for the half hour check at 4:32 a.m., which should have included O’Neal and one other inmate then in that cell block, according to Wolfe.

But Alexander later told state police investigators she didn’t go into the cell block housing O’Neal that night.

“I didn’t see him at all on my shift” until she went to serve his breakfast in the morning, she said.

Alexander retired from the sheriff’s department in February, lives in Idaho, and couldn’t be reached for comment.

Toilet paper covers the only window in the cell at the Malheur County Jail that housed Zelon O’Neal, who died there in November 2019. Under jail procedures, such coverings are supposed to be taken down. (Oregon State Police photo)

Osborn, her partner in cell checks that night, wasn’t clear about his actions when questioned by investigators.

According to the interview transcript, Osborn said that he was “pretty good about doing all our checks.” He told investigators “I believe” he did his checks and “I don’t” remember how many times he checked on O’Neal.

Osborn then said he thought his last cell check was at 2 a.m. or 3 a.m. and that O’Neal was “just shuffling in his bed, like tossing.”

But he couldn’t see O’Neal because the inmate had papered over the window in the cell door with strips of toilet paper.

Wolfe said corrections deputies are supposed to direct inmates to remove such coverings or act to get them removed.

Osborn said nothing in his police interview about doing so. He didn’t respond to a request for an interview made through the jail commander.

From 2 a.m. until the time breakfast was delivered outside O’Neal’s cell nearly four hours later, the jail log showed six cell checks that should have included O’Neal.

Instead, O’Neal was left alone for up to 3 ½ hours, according to records.

In that time, O’Neal took the sheet from his bedding and worked it through the tight weave of a vent in the wall just below the ceiling and above his sink. Wolfe acknowledged that it would have taken time to work the sheeting through the grill.

Photos taken later by investigators showed the sheet knotted in at least four places after it was looped through the grill.

At 5:44 a.m., Alexander took a sack breakfast to O’Neal’s cell.

“I went over and opened the tray slot and I said, ‘O’Neal, I got your meal.’ He didn’t say anything and I looked in there,” Alexander said, according to a transcript of her police interview.

She looked in and saw him, kneeling over the sink in his cell.

“He’s not responding,” Alexander said.

When deputies got the cell door opened, they found O’Neal was dead, the sheet cinched around his neck.

“He was really cold to the touch,” Alexander told police.

Supervisors and Wolfe were notified, the cell was sealed with evidence tape, and the state police were called in to investigate.

Over the next few hours, the state investigators questioned all three deputies, concluding that O’Neal died by suicide.

“Deputies had not checked on O’Neal’s cell for some time,” their report said.

An internal investigation ensued. Wolfe wouldn’t release the results but said Alexander, Osburn and Butler were disciplined for not obeying orders on cell checks. He declined to elaborate.

O’Neal’s brother learned of the death and contacted one of the state police investigators.

“He asked me why a person with mental problems would be inside a single cell,” the detective said.

Jessie O’Neal remains angry about his brother’s fate.

“His death could have been prevented,” he said.

Wolfe said the internal investigation identified two concerns – the lack of checks and allowing the window to be covered.

He said he met with his department’s command staff subsequently to make clear procedures were to be followed.

Wolfe said he wanted the community to know that people are cared for while in jail.

“We do have a responsibility to make sure that they’re safe while they’re here,” Wolfe said. “We take that responsibility seriously.”

Zelon O’Neal was held in the last cell in this short hallway at the Malheur County Jail. Jail policy required he be checked on every 30 minutes, but he was left untended for up to three and a half hours. (Oregon State Police photo)

Contact editor Les Zaitz by email at [email protected].


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