On a Saturday afternoon nearly three months ago, a Wake sheriff's deputy arrested 19-year-old Ralph Madison Stockton IV in Southeast Raleigh for misdemeanor marijuana possession. He was booked into the downtown county jail without incident.
Sixteen hours later, Stockton was found unresponsive on his mat in a common area that doubles as a sleeping quarters because of persistent overcrowding. Stockton was pronounced dead an hour later.
It was a surprising end for a young man who had served as a state Senate page, graduated from the prestigious Ravenscroft private school and was the grandson and namesake of the co-founder of one of the state's more prominent law firms.
Reports released this week indicate the younger Stockton died of a drug overdose - and that jail officials did not follow proper procedures designed to prevent such deaths. The reports add more fuel to concerns about the jail's administration that began 10 months ago when an inmate left the facility with a debilitating head injury after an altercation with a detention officer.
A state medical examiner's autopsy shows that Stockton had a lethal combination of methadone and other depressants in his system.
A state Department of Health and Human Services report found that detention officers did not properly monitor Stockton. State regulations require that inmates be observed twice every hour to make sure they are not in physical distress. In reporting Stockton's death, jail officials said he was last seen an hour and two minutes before he was found unresponsive.
"There are things in the report they have got to correct," said Steven Lewis, who oversees the department's Jails and Detention Section.
Jail officials dispute the findings, according to a spokeswoman, Phyllis Stephens.
She said video shows that detention officers were in the common area in which he slept at least four times during that 62-minute period in the mid-morning, but she did not say whether those officers actually observed Stockton during all of those times.
The sheriff's department would not release the video. It's not a public record, Stephens said.
Stephens also declined to say whether jail staff had received information indicating that Stockton should have been monitored more closely. State regulations require jail staff to check inmates who are suspected of being on drugs or alcohol at least four times an hour.
Lewis said in an interview that jail officials had given him no information showing that Stockton needed more intensive supervision. Public records of Stockton's arrest and processing into the jail showed no indication he would be a high-risk inmate.
But the autopsy said when he was brought to the jail about 3 p.m. that day, Stockton's pupils were noted to be dilated, a sign of drug use. Other inmates told investigators that Stockton acted "disoriented and intoxicated" before bedtime and said he mentioned the drugs Valium and Ecstasy.
Stockton's family declined to be interviewed, but his mother, Tanya, said in a statement: "We are concerned that this agency found that the Wake County jail did not follow regulations in its care for Ralph. Our family grieves for Ralph and we will continue to look into the circumstances surrounding this tragedy."
There were signs that Stockton had made a recent turn toward drugs and alcohol.
Stockton had twice been cited for marijuana possession and once for underage drinking last year, charges now dismissed because of his death. One of those charges stemmed from the day his best friend, Sam Biedermann, 19, was found dead in the North Raleigh residence they shared, also from an overdose.
Stockton's dream as a high school student was to enter UNC-Chapel Hill, state Sen. Richard Stevens of Cary said. Stockton had served as a page for Stevens during the 2010 session. He came back after his page duty to spend another week answering phones and greeting constituents.
"He was a very nice young man," Stevens said. "He was very interested in civics and public affairs."
Stevens said Stockton knew he did not have the grades to get into UNC-CH, one of the nation's top public universities, so he enrolled at Western Carolina University with plans to transfer later to UNC-CH. But he soon left school to return to Raleigh.
It's unclear when the drug use began. On his online obituary page, family and friends spoke of Stockton as caring, funny and athletic.
His parents had separated years earlier, and his father, Matt, died five years ago. His grandfather, Ralph Madison Stockton Jr. of Winston-Salem, who died in 2004, was a distinguished trial lawyer who led his firm in a merger that created the Kilpatrick Stockton law firm in 1997. The firm is now known as Kilpatrick Townsend & Stockton.
Busy with breakfast?
An inspector for Lewis, the state health and human services official, said in his report that the Wake jail has 14 days to respond with a plan of corrective action. A jail official, Maj. Cleveland Sanders, told the jail inspector that detention officers may have been busy with breakfast duty at the time Stockton was found unresponsive.
"The Major reported that there may be some times when the rounds are not being made as required such (as) feeding time, clothing exchange and other events that may go on in the facility," inspector Chris Wood wrote.
He said in the letter he told Sanders it is "imperative that inmates be observed twice per hour on an irregular basis. Additionally, officers can not be assigned other duties that interfere with the continuous supervision of inmates."
The standard has been in place in its current form since 1993. Lewis said it exists because jail inmates often enter the facilities under extraordinary circumstances. Also, the charges that led to their arrests have typically not yet been heard in court.
Lewis said detention officers need to make sure the inmate is acting normally. If it is nighttime, they are supposed to verify that an inmate is breathing by seeing his chest move or hearing him exhale.
Violations of the observation standard are rare, Lewis said, even though the state has limited means to enforce the regulation. The only penalty is to shut the jail down, which would bring major complications.
The day Stockton entered the jail, there were 555 inmates there with him. The jail has 480 beds, which means jail officials had to find alternative sleeping arrangements for 76 inmates. Typically, those inmates are put on mats in the common areas of the jail floors.
Other jail problems
The state report is another indicator that jail staff may be putting inmates at risk by not following proper procedure.
Early this year, the county paid a homeless man, Lynwood Artis, and his attorneys $20,000 to settle the jail's part of a lawsuit in which the man alleged jail officials ignored his cries for medical attention after a Raleigh police officer broke his leg during an arrest. The county did not admit wrongdoing.
Another lawsuit alleges the jail's administration tolerated an abusive detention officer who has injured at least three inmates within a year. One of those inmates, Joshua Martin Wrenn, ended up in a coma after being punched once in the head by detention officer Michael Hayes. Wrenn has regained consciousness, but is disabled and requires round-the-clock care at a Johnston County nursing facility.
In the cases involving Wrenn and Stockton, jail officials did not notify the public of a death or serious injury.
Phyllis Stephens, the sheriff's spokeswoman, said the reason for no notification of Stockton's death is simple: There's no requirement to do so.
News researchers David Raynor, Brooke Cain, Teresa Leonard and Peggy Neal contributed to this report.