Content warning: This story discusses suicide. Call the 988 Suicide and Crisis Lifeline if you or a loved one needs help.

The deputy warden was at home on his acreage south of the Tecumseh state prison when his phone lit up with a text.

Inmates had set fires in their cells.

After his calls went unanswered, Scott Busboom got into his white Ford pickup and drove to the prison where he’d spent most of his 35-year career with Nebraska’s Department of Correctional Services. 

Smoke had been filtering from around Jesse Spencer’s cell door — cell B6 — into the hallway for more than 15 minutes before Busboom arrived. 

Already, prison guards had made a cascading series of mistakes, including briefly cutting off power to the housing unit before abandoning it. More missteps would follow over the next three hours as corrections officers waited to enter Spencer’s smoky cell.

Spencer wouldn’t survive the night. Busboom wouldn’t survive its aftermath.

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. The records 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.

A spokesperson rejected multiple interview requests with corrections department leadership. 

But behind the scenes, corrections leaders directed at least some blame at Busboom, scheduling a pre-disciplinary hearing five months after the incident.

Busboom, 63, was found dead in his truck 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.”

Igniting a tinderbox

About an hour before smoke and embers started floating into the hallway from Spencer’s door, an inmate started yelling to other inmates in the library. When staff moved to restrain him, the inmate tried to elbow a corporal in the head, according to the internal review. Staff strapped him to a gurney and wheeled him back to his cell.  

It was the spark that ignited a night of mayhem — 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, and set fires. Two died, apparently killed by other inmates; staff wounded two more. A review found conditions were ripe for rebellion. 

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.

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

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

Within an hour after the altercation in the library, Spencer 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 the spread of pepper spray. It also allowed smoke to accumulate in Spencer’s cell. 

The same corporal 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 ordered staff to evacuate.

That wasn’t a risk, reviewers later determined. 

Busboom arrived at the prison and the shift supervisor briefed him on events. The Corrections Emergency Response Team — specially trained for incidents like this — was assembling, the supervisor told Busboom. It would take well over an hour for them to gather 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. 

“I see references to corporals and sergeants and lieutenants, and I'm wondering: ‘Who's really in charge here as this all evolves?’” Lux said.

‘Kill the f***ers’

As CERT team members trickled into a visiting room, Busboom warned them: Any inmates who didn’t cooperate 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. 

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 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 “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.

As 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.

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, a review noted. The defibrillator droned “push harder” — likely because Spencer wasn’t on a backboard and his hands remained cuffed beneath him. 

“His pupils are fixed; he’s gone,” a nurse said. 

Officers backed away, and the defibrillator delivered a shock. It 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.

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

The 16-member panel agreed. 

But the jurors raised questions over how long it took prison staff to pull Spencer from his cell — a delay that corrections experts 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.”

Jurors 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 member of the internal review team, 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. 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.

Settles and the review team issued at least 35 recommendations, some of which called for further staff training on existing policies and procedures.

The review recommended prison leaders create a new procedure requiring air handlers 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.

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.”

‘It crushed his very soul’

The night before Busboom took his own life, 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.

“And he said, ‘Yeah, OK.’ That's the thing I heard last from him,” Tiedeman recalled. “And then the next day, the sheriff was out here at my door.”

A friend found Busboom dead on his acreage 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 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, 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. … It humiliated him,” Tiedeman said. 

In their review, 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. The prison’s warden was reassigned.

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?”

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