Feb. 13 - State juvenile corrections officials are drafting a plan they hope will avert a federal lawsuit over conditions at Arizona's three juvenile lockups, where investigators documented dangerous practices they say led to three teen suicides at Adobe Mountain School in one year.

In the meantime, attorneys, judges and others involved with the juvenile justice system are thinking twice before sending youths to the juvenile prisons.

The governor and the state Department of Juvenile Corrections must address the alleged civil rights violations to the satisfaction of federal officials or risk a lawsuit. Key state lawmakers are waiting for the state agency's plan, which federal officials want by March 12, before deciding whether legislative action is necessary.

In a blistering 38-page letter to Gov. Janet Napolitano dated Jan. 23, assistant U.S. attorney general R. Alexander Acosta detailed a wide array of problems at the facilities outside Phoenix and Tucson that he said put hundreds of youths at risk. The report describes incidents where teens were beaten, sexually abused, isolated for weeks at a time, left unsupervised and denied mental health and medical care, among other things.

Conditions are worst at the largest facility, the 434-bed Adobe Mountain in Phoenix, where East Valley boys are sent.

"Our investigation revealed that the Adobe suicides are emblematic of the inadequate suicide prevention measures throughout the facilities," Acosta's letter said.

David Horvath of Mesa was still in Adobe's intake unit when he hanged himself with a bed sheet July 11, 2002. David's death came three months after another teen at the facility committed suicide the same way.

Maricopa County Juvenile Court Judge Emmet Ronan had sent David to Adobe for at least six months after he violated probation by punching a wall and breaking a telephone. He was first arrested three years earlier for chasing his sister with a knife.

The staff knew the 14-year-old was suicidal as soon as he arrived June 25, but he never was seen by a psychiatrist. In a visit with his mother, David said his medication had been changed and it was making him feel sleepy, then agitated and irritated.

"I told David, 'You need to let them know.' And he's like, 'Well Ma, nobody's listening to me,' " Barbara Horvath said. "The week after is when he hung himself."

David's case gets particular attention in the report as an example of poor communication, inadequate supervision and monitoring, and shoddy training and intervention for suicidal youths.

Although he had attempted suicide in detention, and his file included information about previous suicide threats and attempts, none of that was reviewed by Adobe's front-line staff, according to the report.

David was locked alone in a room following an argument with his roommate and was to be checked on every 10 minutes. The teen was still alive when he was discovered, but it took 15 minutes for emergency help to arrive and staff members had trouble removing the noose from around his neck, both the report and Barbara Horvath said. Once medical staff did arrive, they discovered the oxygen tank they brought was empty and the nurse forgot to bring a mouth shield to do CPR, Horvath said.

"I'm telling you, they let him die," she said. Horvath sued the state and settled in December for an undisclosed sum.

Stepped up training

Nearly two-thirds of the staff at Adobe Mountain had no suicide prevention training, a standard for any youth or adult correctional facility.

State officials anticipated many of the criticisms in the report and have been working to fix them since federal investigators last visited a year ago, said Patti Cordova, spokeswoman for the state Department of Juvenile Corrections.

As of last week, Cordova said, 876 staff members, including all of those in direct contact with youth, had received eight hours of suicide prevention training. The training also will be required of all new hires, she said.

Front-line staff also are now required to carry a "911 fanny pack," which includes a knife capable of cutting a noose, rubber mask, gloves and CPR face shield.

By June 30, 12 of the facilities' 44 housing units will have been renovated to eliminate any "anchor points," such as vents, exposed bolts, hinges and other hardware that would enable youths to hang themselves. All of the units for the highest-risk juveniles, including the intake, mental health and separation units, have been renovated, Cordova said.

"We hope we're moving in the right direction, but we feel we have a long way to go," she said.

The letter listed 16 remedial measures the state should implement "to rectify the identified deficiencies and protect the constitutional and statutory rights of the youth." Cordova said it was too soon to estimate how much the state's action plan would cost.

Senate Judiciary Committee Chairman Steve Tully, R-Phoenix, said he met with department officials about the report and has asked them to present their plans for fixing the problems during a public hearing next month.

"Our position is we'll wait for the agency to make its recommendations and then we'll review them," Tully said. Attorneys who represent juveniles are citing the report in court to keep their clients out of the troubled facilities.

"We're concerned about sending children there knowing that all of (the problems) could not have been addressed," said Helene Abrams, chief of the county's juvenile public defenders office.

Ronan, who took over last month as Maricopa County's presiding juvenile court judge, has similar worries.

"I do have a concern about sending children into that kind of environment for the purpose of treatment and rehabilitation," he said. "The conditions reflected in the report certainly would not seem to be very therapeutic."

Lack of supervision

The report paints a disturbing picture of housing units run amok because of staff shortages, with one person supervising as many as 48 youths overnight. Standard practice is one staff for every eight juveniles during the day, and one staff per 16 youth at night. None of the three facilities met the state's own ratios, according to the report.

"Adobe staff reported that fights are commonplace in the youth rooms at night and often go unreported," the letter said. "A review of internal affairs investigations of youth-on-youth sexual assaults demonstrated that these victimizations occur regularly."

Staff members also have sexually abused young inmates, the report said, and complaints routinely have been ignored.

"Our investigation revealed that sexual abuse of youth by staff and other juveniles occurs with incredibly disturbing frequency at Adobe, and that ADJC management does not effectively address this serious problem," the letter said.

Boys at Adobe told investigators they were threatened by other youths to perform sex acts or risk being raped or beaten. There were similar incident reports from girls at the Black Canyon facility north of Phoenix, which currently houses 93 females.

Juveniles also are confined alone, or entire housing units are put on lockdown, for seemingly no reason, the letter said. Over the objections of mental health staff, one youth was confined for 33 days. A girl upset about the death of her mother was locked in a separation unit for three days, with no explanation. The investigation also found inadequate health care.

Ronan, who scheduled a meeting with agency officials next week, said he is particularly troubled in light of the department's history. Arizona settled a 1987 federal lawsuit over strikingly similar issues. In a 1993 consent decree, the state agreed to provide individual treatment plans for each youth. Under the agreement, which was dismissed in 1998, no youth could be isolated for more than 24 hours without outside approval. The department also was required to hire more staff to reach a staff-child ratio of 1 to 8.