Several errors may have contributed to the apparent jailhouse suicide of suspected serial child rapist Matthew Coniglio, eliminating the best chance that investigators had for identifying victims across the Southeast.
Police arrested the 46-year-old Coniglio on April 10 in Pooler, Georgia. Ten days later, he apparently hanged himself with a cord inside his cell at the Chatham County jail in Savannah, Georgia.
Here are key findings from an internal investigation into the death obtained by The Associated Press.
MEDICAL CARE: A staffer for the medical contractor at the jail, Corizon, prescribed Valium to help Coniglio cope with panic attacks and symptoms of alcohol withdrawal, according to a report by Sheriff's Office Cpl. Allen O'Berry. He determined Coniglio never received the sedative. Medical staffers also didn't do follow-up evaluations with Coniglio. O'Berry described the lapses as "poor practices" in his report. Corizon spokeswoman Rebecca Warren wouldn't comment on Coniglio's care, citing patient confidentiality rules.
SUPERVISION: Investigators believe Coniglio killed himself while alone, and he may have plotted the attempt for several days. His cellmate, Donald Graham, told investigators Coniglio had asked about a week earlier for an hour of privacy in their cell in the evening, right after prison guards usually finished a round of checks. O'Berry wrote in his report that video from the jail shows a guard did not make those cell checks on Easter night, when Coniglio died, then falsely claimed he did in official paperwork. That guard, Ashton Tatum, resigned May 7 rather than get fired, records show. Tatum told the AP that he was not properly trained.
IS THE DEATH INVESTIGATION FINISHED? No, not yet. O'Berry found no signs of foul play and concluded that Coniglio killed himself. The Georgia Bureau of Investigation has not yet completed its inquiry.
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