Jesse Spencer’s death on Oct. 5, 2023, sparked an internal review that questioned prison staff’s understanding of emergency response policies at Tecumseh — the site of numerous previous violent outbreaks — and made dozens of recommendations. It triggered a Nebraska State Patrol investigation and grand jury proceedings, with jurors concluding that prison staff weren’t criminally at fault for Spencer’s death. 

The Flatwater Free Press and Lincoln Journal Star spent days combing through transcripts and hundreds of pages of documents from the grand jury proceedings — records accessible to the public only at the courthouse in Tecumseh. This reporting is based on these records, which offer a window into a night plagued by confusion and chaos.

“There’s a lot of explaining to do,” said Marshall Lux, who served as Nebraska ombudsman, the state’s top government watchdog, for nearly four decades before retiring in 2018.

A prison system spokesperson rejected multiple interview requests with department leadership. 

But behind the scenes, corrections leaders directed at least some blame at Busboom, though he wasn’t among the staff members singled out in the internal review. Five months after the incident, leaders scheduled a pre-disciplinary hearing.

Busboom, 63, was found dead in his truck, wearing his work uniform, less than a week later. 

“He’s always discussed that he would — that his job would kill him,” said Julie Tiedeman, Busboom’s widow. “We just figured it’d be a different way than what they did to him.”

‘A terribly tragic outcome’

Smoke and embers started floating into the hallway from Spencer’s door just before 5:50 p.m. 

An inmate since 2014, Spencer was housed in Tecumseh’s restrictive housing unit, where inmates are typically locked inside their cells 23 hours a day.

On the day of the fires, he had spent 2,598 days, more than a quarter of his life, in restrictive housing. He was 27 years old.

Another inmate who started a fire around the same time had, like Spencer, spent about seven years in restrictive housing.

“They’re allowed to deteriorate in these environments,” said Craig Haney, a professor at the University of California, Santa Cruz, who has studied the psychological effects of prison conditions since 1971. “Eventually, they act out. The prison system responds to the acting out in the only way it knows, which is the application of force. And in this case, it’s a terribly tragic outcome.”

Spencer’s siblings said the prison system changed him.

Ashley Sharp, Spencer’s brother, remembers him as a curious problem-solver with a big imagination.

“When we’d play a video game and the video game would say, ‘Go straight to the next level’ — he’d try to go right, he’d try to go left, he’d try to go under,” Sharp said.

Spencer started making trouble young and was institutionalized early. At 17 years old, he stole a car, signed a plea agreement and then violated the terms of his probation. A judge sent him to prison, where he was in and out of restrictive housing from the start.

He amassed 287 misconduct reports and three convictions for crimes like assault and terroristic threats, extending his stay. 

“When we talked on the phone, he was still my little brother,” Sharp said, “but I heard sometimes when he would argue with a guard, and he would sound real tough. 

“That wasn’t, you know, the guy that I knew before.”

Igniting a tinderbox

About an hour before the smoke started seeping from Spencer’s cell, an inmate started yelling to other inmates in the library. When staff tried to restrain him, the inmate tried to elbow a corporal in the head, according to the internal review. Staff took him to the ground, strapped him to a gurney and wheeled him back to his cell in the restrictive housing unit.  

It was the spark that ignited a night of mayhem — then the latest at a prison that had long been a tinderbox.

In 2015, inmates took control of much of the prison, assaulted and trapped staff, set fires and caused other damage. Two died, apparently killed by other inmates; staff wounded two more. A commissioned review found conditions were ripe for rebellion. Among recommendations, it said Tecumseh should consider holding lower-custody inmates, since its far-flung location lends itself to a less experienced staff.

In 2017, the prison put two inmates in one restrictive housing cell due to overcrowding. One killed the other. The same year, an inmate lit a fire in a restrictive housing unit. The state’s prison watchdog found inmates in restrictive housing felt staff were dismissing their concerns. 

In reviewing a 2021 incident in which staff shot 200 projectiles at an inmate with “serious mental illness,” the inspector general found “a lack of clear leadership and directions, in addition to a chaotic and confusing scene …” 

It’s a characterization that echoes through investigators’ reports analyzing the night Spencer died, just five months after that report was published.

Within an hour after the altercation in the library, evidence in Spencer’s cell suggests he shoved metal and tightly rolled paper or a cotton swab into an outlet.

‘Who’s in charge?’

Spencer and at least one other inmate in his hallway lit fires. Staff, moving fast, sprayed fire extinguishers into the cells. 

A corporal was ordered to turn off the housing unit’s air handlers, reflecting a widespread belief it would prevent pepper spray from spreading throughout the prison. It also allowed smoke to accumulate in Spencer’s cell. 

The same corporal — who had no training on the system — was ordered to turn off power to the cells in that hallway. Instead, he briefly cut power to the unit’s control center, leaving staff there “freaking out” and screaming, corporals told reviewers.

Fearing that the power loss could unlock the doors, the shift supervisor — a lieutenant who had been in his position for three months — ordered staff to evacuate. It’s not clear whether the fires had been extinguished.

“So we were told to get off the gallery due to the fact that all of us believed those doors would open, and you have 22 of the most aggressive inmates in Nebraska coming at you with weapons,” one corporal later testified. 

That wasn’t a risk, reviewers later determined. Cutting power doesn’t unlock the prison’s cells.

Busboom arrived at the prison and went to central control, where the shift supervisor briefed him on events, in part telling Busboom that the Corrections Emergency Response Team, or CERT — specially trained for incidents like this — was assembling. It would take well over an hour for them to gather in rural Tecumseh and enter the smoky gallery.

The shift supervisor finished his briefing and thought Busboom had assumed command of the incident. But Busboom later said he never took over.

The confusion was evident that night. The internal probe later concluded that staff couldn’t identify who was in charge. It’s one of the most troubling missteps in a response littered with them, experts said. 

“You need to have that kind of clarity in these situations and we don’t know if that happened,” Lux said. “I see references to corporals and sergeants and lieutenants, and I’m wondering: ‘Who’s really in charge here as this all evolves?’”

A half hour after Busboom’s arrival, the hallway was filling with smoke. Two sergeants had assembled about 20 staff clad in protective gear just outside. 

They planned to put out the fires, turn off power to cells, clear the smoke and evacuate the inmates. They had pepper balls and other chemicals for those who refused. They requested permission to take back the smoke-filled gallery, but the shift supervisor ordered them to stand down and wait for CERT.

Prison staff didn’t enter the gallery for nearly another hour.

‘Kill the f***ers’

As CERT team members trickled into a visiting room, Busboom warned them: Any inmates who didn’t cooperate, he said, likely planned to assault them.

The men incarcerated in the Tecumseh prison’s restrictive housing unit — including Spencer — had done this before, Busboom told CERT members. The 27-year-old had attacked staff members at least three times while incarcerated at the prison and had lit a fire in his cell at least once before, according to grand jury testimony.

Busboom later said he also instructed the responders to ensure “no inmate was in distress, ensure all fires are out, and to systematically move all involved inmates” to another area. He suggested they start with Spencer and the other inmate who had set the initial fires.

Some CERT members later said they never received those instructions — the directive was to deal with fires, reviewers found. 

They concluded that “the well-being of inmates was not” the team’s “top priority.”

By the time they entered the gallery — almost an hour and a half after staff had evacuated — Spencer’s 8-by-10 cell was so smoky they couldn’t see more than a couple of inches past the door.

The CERT leader that night wondered why Tecumseh’s fire department wasn’t on scene.

In fact, a local volunteer crew had arrived but were denied access to the gallery, then sent home after an assessment by the prison’s safety officer, who didn’t enter the unit to make that assessment, according to the internal review. The safety officer later attributed the decision to Busboom.

Smoke hung in the air and water seeped into the hallway from under Spencer’s cell door as CERT members — at least 14 of them — gathered outside it nearly two hours after the first sign of smoke.

The team pounded on the door of cell B6, demanding that its occupant come to his door to be restrained.

Spencer didn’t. Staff shot pepper balls and Mace-like chemical spray through his cell door’s hatch.

Some staff reported hearing other inmates encouraging Spencer to hold out, to not give up, to “kill the f***ers.” Multiple CERT members later said they only heard coughs coming from behind the wall of smoke.

‘He’s totally unresponsive’

For over 70 minutes, CERT members shouted orders and fired pepper balls and chemical spray into the smoke. Eventually, they used a small office fan to clear the air through Spencer’s door hatch.

They saw the 27-year-old’s foot sticking out from under his bed and fired pepper balls at his ankle through the hatch. He didn’t move.

At 8:58 p.m., CERT members entered cell B6. Smoke poured out of the open door. They put restraints on Spencer’s body, dragged him into the hall and put him on a gurney as paper smoldered in his soot-covered cell.

“He’s totally unresponsive,” one voice can be heard saying on footage captured by a handheld video camera.

“Everyone” thought Spencer was faking until a nurse could not find a pulse, a captain later reported.

They turned Spencer onto his back, his handcuffed wrists between his body and the gurney. They called for medical staff. Someone grabbed a defibrillator. A nurse started chest compressions, then stopped.  

Compressions were interrupted several more times as staff wheeled Spencer to the prison’s emergency room and continued care, a review noted. The defibrillator consistently droned “push harder” — likely because Spencer wasn’t on a backboard and his hands remained cuffed beneath him, the review found. 

A nurse checked Spencer’s eyes: “His pupils are fixed; he’s gone,” she said. 

Then, at the direction of the defibrillator, officers backed away. It delivered a shock. The electrical impulse may not have reached Spencer’s heart, the review found, because his body was touching the metal restraints and wasn’t on a hard surface.

The prison nurse left the room to call a doctor off-site. When she returned, she said the doctor had advised they stop CPR. 

The doctor declared Spencer dead at 9:15 p.m. He later said that with more accurate information, he would have continued treatment and had Spencer transported to a hospital.

A corporal who called 911 wrote in a report that an ambulance arrived at the prison at 9:15, the same time Spencer was declared dead.

The nurse resigned less than two months after Spencer’s death.

During the autopsy, a pepper ball rolled out of the 27-year-old’s clothing. State Patrol investigators later determined staff had fired a total of 25 of them, along with six bursts of Mace-like spray, into his cell that night.

‘Staff should have gone in there’

The conclusion was clear. 

The “confusion,” “chaos” and miscommunication the night the fires burned “inevitably ended up contributing to the situation in which Jesse Spencer died,” Amy Thompson, an investigator with the State Patrol, told a grand jury nearly a year after Spencer’s death.

But, Thompson added, there “was no criminal intent, no malice.”

“I found that his death was accidental,” she told the grand jury during a secret court proceeding at Johnson County’s courthouse.

The 16-member panel — tasked with determining whether anyone should be criminally charged for Spencer’s death — agreed. 

But the jurors raised questions over how long it took prison staff to pull Spencer from his cell — a delay that corrections experts, including the prison’s former warden, said lasted too long.

“There’s just — there’s a body in there,” one juror said. “I know the guy has caused a bunch of problems, but we got 15 people guarded up there. Go in and pull the dude out.”

The CERT leader that night told the grand jury about other simultaneous crises — an inmate flooding his cell, another breaking things, more fires. And she said the lack of visibility into Spencer’s cell slowed them down.  

“With Mr. Spencer’s past history, he does have a history of ambushing or assaulting staff when they come into his cell,” she said. “That’s why we didn’t want to rush in.”

Fear likely prevented staff from entering the smoky cell, said Brian Gage, a former Tecumseh warden. But, he asked: “What if it was your son or daughter in that cell?”

“Staff should have gone in there, because they have all the protective equipment available,” said Gage, who now teaches criminal justice at Southeast Community College. “Somebody may get injured, yeah. But what’s the other outcome? Well, the outcome is somebody gets killed.”

Jurors and former officials weren’t the only ones to criticize the response. 

The Department of Correctional Services launched an internal investigation. Shaun Settles, then a warden at an Omaha prison, and a team of corrections leaders scoured staff reports and inmate case files, reviewed 40 hours of video and listened to every radio call made that night, he later told grand jurors. They interviewed more than 50 staffers.

Settles ultimately told jurors that Spencer was responsible for his own death. But the review scrutinized the staff and their decisions that night and questioned their lack of understanding of “major facility systems” and emergency response procedures. 

It criticized the medical response. It called staff’s failure to remove things blocking cell windows and the “fishing poles” that inmates use to pass contraband “a serious sign of staff complacency and lack of good day-to-day security.”

It noted staff failed to film portions of the response — a violation of department policy. Those issued body cameras didn’t turn them on and admitted they rarely follow that procedure. In at least one instance, video of staff shooting pepper balls at a restrained inmate didn’t match written reports by prison staff, which were often brief or inaccurate.

The grand jury offered four recommendations to prevent a similar incident in the future. 

Settles and the review team issued at least 35 recommendations, some of which called for further staff training on policies and procedures that were already in place.

The review recommended prison leaders create a new procedure requiring air handlers — like the one wrongly shut off during the fire — to remain on in case of fires or when prison staff use chemical agents. 

Whenever possible, the prison system should rely on emergency responders like the trained firefighters sent home that night. 

And the review called for department leadership to develop “alternate tactics” for staff to enter hazardous areas. Fourteen staffers stationed “within a few feet of Spencer’s door” solely relied on chemical agents to try to force him out.

A “corrective action plan” says that many recommendations were addressed.

In a statement, a spokeswoman for the Department of Correctional Services said the prison system “completes a thorough after-action review following any significant incident.”

“This review is a stand-alone process designed to take a critical, structured look at how NDCS responded to the incident to identify problems and implement changes to enhance safety and security,” Dayne Urbanovsky said. “Following the after-action review in this matter, independent investigations were conducted, staff members were held accountable as necessary, and NDCS adjusted policies, procedures and protocols. All recommendations from the after-action review have been completed.”

Lux, the former state government watchdog, called the department’s review a plus, not a minus. It is “key to have people in charge who are willing to acknowledge weaknesses in the system and respond to it.”

But Gage, the former warden, was struck by the volume of recommended changes, many of which double down on old policies.

“Why did you have to change policy if it was good policy?” he asked.

“If something would happen today … Would the same thing happen?”

‘It crushed his very soul’

The night before Busboom took his own life on a Wednesday morning in Johnson County, his widow had sent him a text. She was at home, hours away in the Colorado mountain town she moved to in 2020 amid the strain she said Busboom’s job had placed on their marriage. 

A snowstorm was rolling across the Rockies and threatening to disrupt their normal Wednesday night phone call.

“I texted him and said, ‘We might be having storms up here if we don’t connect.’ He usually figured that out,” Tiedeman said. “And he said, ‘Yeah, OK.’ That’s the thing I heard last from him. And then the next day, the sheriff was out here at my door.”

A friend found Busboom dead on his acreage south of Tecumseh that morning. He was taking antidepressants, had been dealing with pain from a recent knee surgery and “was going to be getting in trouble at work,” an autopsy report noted.

Busboom, who worked at Tecumseh “since almost day one of when it opened” in 2001, harbored decades of trauma and physical pain, Tiedeman said. He’d become increasingly tethered to the prison after the deadly 2015 riot.

“These riots happened on his watch, type thing,” Tiedeman said. “It’s almost like it was his responsibility, and only his responsibility, to make sure that he’s there taking care of both employees and inmates. It’s almost like he felt like he just had to be there.”

His devotion to the prison had created a rift in his marriage with Tiedeman, she said. He would hurry the couple home from vacations or grocery runs to get back to it, she said. But he wouldn’t talk about his job with his wife.

Tiedeman knew nothing of what happened the night Spencer died until after her husband died. She said she visited the home they once shared in Johnson County and found a copy of the internal disciplinary charges the department filed against Busboom on the table where he would stash Tiedeman’s mail.

“If he didn’t want me to know about his statement of charges, he would have thrown them away,” she said. “He wouldn’t have put it on my table. And that, to me, was him telling me, ‘This is what they did to me.’”

“He knew I would go after them,” she said. “He knew I wasn’t just gonna lay down and accept what took place.”

Busboom was not among the staffers Settles and a team of corrections leaders recommended for review after Spencer’s death. 

In a section titled “Things done well,” they noted Busboom’s decision to voluntarily respond to the prison. Upon his arrival, the review said, he “gave clear directives and assignments to responders” and staff.

But in the charges Tiedeman found a month after Busboom’s death, higher-ups accused him of violating fire safety, ethics, use-of-force and emergency preparedness policies. 

They accused Busboom of never formally taking command of the incident that night but later giving orders to responding staff members. They accused him of giving those orders without permission from the initial incident commander, according to the charges.

They had scheduled a pre-disciplinary hearing for March 8, 2024, at the department’s central office in Lincoln. 

Five days later, he put on his work clothes, tossed his work phone into a pan of water, drove in his truck down the road on his property and shot himself, Tiedeman said. He did not leave a note.

His widow calls it “murder by suicide.”

“It crushed his very soul that they would do that to him. That’s what I think,” Tiedeman said. “It humiliated him.”

In their review of what went wrong on Oct. 5, 2023, corrections officials did not assign blame. They scrutinized at least seven staff members, though it’s unclear how many faced discipline. At least two no longer work for the state.

In the months since, they reassigned the prison’s warden and replaced him with Settles.

A year after her husband’s death, Tiedeman took out an ad in the newspaper, accusing the prison system of using her husband as a “scapegoat” for what happened that night.

“The Department needed someone to blame,” the ad read.

They chose Busboom, his widow wrote.

She is still grappling with whether the deputy warden blamed himself.

“And that’s what I don’t understand, either, because we’ve always discussed that,” she said. “How can you feel guilty if you know you did the right thing?”

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This story is a joint investigation by the Flatwater Free Press and Lincoln Journal Star.

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