Todd Lamont Caveness had a long history of bipolar disorder, anxiety attacks and paranoid thoughts when he was booked into the Wilson County jail early last year.
His mental illness quickly took control. Caveness stopped eating, believing his food was poisoned. In the space of three weeks, he lost 30 pounds.
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By the time he was sent to the hospital on Feb. 3, he suffered from severe malnutrition and dehydration, and his kidneys labored to filter impurities from his blood. Hospital staff persuaded him to eat again, but he died two days later from a blood clot in the lungs caused by dehydration and malnutrition.
It was the kind of death that the state Department of Health and Human Services might investigate to see if the jail followed state regulations for supervising inmates. Jails are supposed to notify the state agency of inmate deaths, but that didn’t happen in Caveness’ case.
That’s because long-standing state law only requires notification when the inmate actually dies in the jail. Caveness, 40, died in the Wilson Medical Center.
“It’s like they don’t want to have the responsibility to explain how this inmate ended up in the hospital,” said Shanna Marie Worley, Caveness’ girlfriend. “It’s less headache for them. They won’t be in trouble if there’s wrongdoing.”
A News & Observer investigation identified more than 25 deaths of jail inmates in the last decade where neither state officials nor county sheriffs could produce a report showing DHHS was notified. In many of those cases, jail officials cited the outside-the-jail exception in not filing the reports to DHHS.
Those deaths include inmates who hanged themselves, who died from assaults by officers or other inmates, or whose families said the inmates died after receiving negligent health care.
In at least four of the deaths that went unreported, families received out-of-court settlements from counties.
The largest known settlement for such a death is $150,000 to the family of Shon McClain,
who died of head and neck injuries in 2013 after a Wake County detention officer twice slammed him into a concrete floor. That officer, Markeith Council, received 90 days in jail and three years probation after a jury convicted him of felony involuntary manslaughter.
McClain’s death was one of three that Wake officials didn’t report to DHHS. The others were a 39-year-old man in poor health who died after a fall at the jail in 2009 and a 20-year-old man who hanged himself in 2011. DHHS didn’t investigate any of them.
“As I have indicated, if persons do not die ‘in the jail’ they are normally NOT reported to DHHS,” Lt. Col. John Maxfield, an attorney who works for the sheriff’s office, said in an email to The News & Observer.
During the past 11 years, 18 inmates died in the Wake jail or in a hospital after an episode in the jail. The other 15 were reported to DHHS.
Advocates for inmate safety say the limit on reporting is a loophole that keeps the public from knowing the circumstances surrounding an inmate’s death.
DHHS’ investigations, done by its construction section, are public record, even if they aren’t widely known. The other state agency that often investigates jail deaths is the State Bureau of Investigation, but its findings typically do not become public unless criminal charges are filed. Internal reviews done by jails are often kept private, with officials citing a state law that allows them to keep many employee matters secret.
Vicki Smith, executive director of Disability Rights North Carolina, which advocates for people with mental illness, said the “died-in-the-jail” loophole needs to be closed.
“This type of bending of the intention of a rule would require better rule-making in the first place and some guidance,” Smith said, “because if we’re splitting hairs, if someone has an incident in a jail but isn’t pronounced dead until they go someplace else, then we don’t really know what’s going on in jails.”
Lindsay Hayes, project director for the National Center on Institutions and Alternatives, is an expert on suicide prevention in jails and prisons. He said sheriffs have often sought to deflect attention on inmate deaths by pointing out they didn’t die in the jail.
“They might walk away from the responsibility of reporting it, but they won’t walk away from liability,” he said. “Plenty of jails have been sued for care resulting from a suicide, and it doesn’t matter where the inmate ultimately died. It matters how long they were in the jail and the facts concerning their care that led to them to attempt suicide.”
No report required
North Carolina is one of roughly 30 states that have some sort of state regulations for county jails, experts say. It’s also among a subgroup of those states that has a state agency overseeing those regulations.
Long-standing North Carolina law requires jails to provide a written report within five days of an inmate death. But the law speaks to deaths in the jail, and the reporting form notes it has to be filed for “the death of an inmate in a local confinement facility.”
Steven Lewis, the head of the DHHS unit that investigates conditions in jails, said the sheriffs who don’t report when an inmate dies after leaving the jail are correct on the law. He wouldn’t say whether he agreed with the “in-the-jail” limitation on filing a death report.
DHHS correspondence shows that in some deaths, investigators told jails they wouldn’t investigate because the deaths didn’t occur in the jail.
Two years ago, detention officers in the Duplin County jail found Nicholas Gaverlos, 51, unresponsive in his cell. He was a turkey factory worker being held for failing to make child-support payments.
A day earlier, he had been moved to a solitary cell after urinating on himself. He wasn’t eating and said he wasn’t feeling well, but didn’t request medical attention. In the hours leading up to his death, cameras showed him “constantly” switching between pacing in his cell and lying down, records show.
Emergency workers rushed him to Vidant Duplin Hospital, where he died an hour later, on May 4, 2015.
“The Captain indicated that the inmate was alive when he left the (jail) and the death was not related to a suicide,” wrote state jail investigator Chris Wood, who works at DHHS. “This matter was discussed with supervisor Carey (Gurlitz) and No Report of Inmate Death required.”
Some sheriffs report
In Caveness’ case in Wilson County, DHHS found out about the death through news reports, and Wood inquired two weeks later. That’s when the jail lieutenant told Wood that Caveness didn’t die in the jail. Wood requested an inmate death report anyway, telling the lieutenant he could note on the report that Caveness hadn’t died in custody.
Wood then investigated. He found the jail had not been checking on Caveness in accordance with state regulations. The evidence showed Caveness should have been watched four times an hour because he was mentally ill, but in the final week of his life, detention officers failed to do that 50 times.
Caveness had a lengthy criminal record. He was in the jail at the time on charges of attempted murder.
Wilson sheriff’s officials declined requests for interviews about the case.
Wood’s finding placed Caveness among 51 inmates who died after lapses in supervision in the past five years, or one out of three inmate deaths during that time. DHHS had rarely investigated inmate deaths prior to 2012.
Some sheriffs require staff to fill out the reports regardless of whether the death happened inside the jail or at a hospital.
“From this administration, that notification will be made. That’s not even a question,” said Durham County Sheriff Mike Andrews. “I have been just as transparent as I can.”
Other sheriff’s departments simply point to the fact the death wasn’t in the jail. Cumberland County, for example, had filed no inmate death reports with DHHS in recent years. Autopsy reports, however, show that since 2012, two inmates became unresponsive in the jail and died after being rushed to a hospital.
The lack of reporting points to a broader problem with jail deaths. No state or federal agency has a firm grip on how many inmates die each year in North Carolina’s 113 jails, the N&O’s review shows. Experts say this is a problem across the country, and tied to the fact that jails are run by sheriffs, who are elected local officials distanced from state and federal government.
“Generally, in terms of professionalism, education of staff, how they are run, there are some pretty bad jails around the country ... snake pits small, medium and large,” said Jeffrey Schwartz, a California-based expert on correctional facilities.
Missing some deaths
The N&O identified 309 inmate deaths during the past 11 years by reviewing death files from the state Office of the Chief Medical Examiner, DHHS and the U.S. Bureau of Justice Statistics as well as surveying the state’s 100 sheriffs and searching online for news reports. So far this year there have been 19 inmate deaths, including one each in Wake, Durham and Johnston counties.
The N&O’s investigation exposed deaths that had gone unreported to some agencies. The U.S. bureau wants jails to report inmates who become infirm in the jail but die in the hospital, but it is not catching all the deaths for North Carolina. It’s hard to know which deaths the bureau is missing. It doesn’t publish the names of those who died.
Mecklenburg County acknowledged that it failed to report two 2009 deaths to the federal justice statistics bureau. County officials said the omission was unintentional.
“We acknowledge this oversight and accept responsibility,” Anjanette Grube, a spokeswoman for the Mecklenburg sheriff, said in an email response. The sheriff and jail officials have declined to be interviewed about inmate deaths.
Guilford County didn’t notify DHHS, the Bureau of Justice Statistics or the state medical examiner when Ellin Beth Schott, 57, a homeless panhandler, died after becoming ill in the jail in 2015. The medical examiner only became aware of her death when her family’s rabbi contacted Greensboro police. By then, her body had been buried. No autopsy was performed.
She is one of two Guilford inmates over the past decade whose deaths weren’t reported to DHHS after they were rushed from the jail to a hospital. In both cases, Jim Secor, the sheriff’s attorney, said a prosecutor dropped the charges, releasing the inmates from custody before they died. As a result, Secor said the jail wasn’t required to report them.
It can also be difficult to track deaths even when state officials have the records.
The state Office of the Chief Medical Examiner has files on most inmate deaths. But it doesn’t file them in a way for officials there, or anyone else, to easily track the deaths.
Dr. Lou Turner, a DHHS official who helps administer the medical examiner’s office, said the office has an outdated electronic filing system and has received nearly $2.2 million from state lawmakers for an upgrade.
“We’ll have a more robust electronic system where we can pull data, write reports, do queries, all of that,” Turner said. “We just don’t have the capability now. The system is not able.”
As for the N&O’s query to sheriffs, roughly a third of them didn’t respond, or didn’t provide information after saying they would. Of the two-thirds who did provide information, many did not have the death reports on hand, and contacted DHHS to obtain copies.
Mecklenburg and Davie each reported a death to federal officials and to the N&O that they hadn’t reported to DHHS. Mecklenburg’s happened in 2012 when an inmate collapsed in the jail and couldn’t be resuscitated; Davie’s was last year. Both said those lack of disclosures were inadvertent and would be reported to DHHS.
‘She’s not trash’
In Davie’s case, DHHS investigated upon receiving the report. It cited the jail for a lack of proper supervision of Victoria Christine Short, 28, who hanged herself.
“The young lady was alive when she left our facility and actually passed in Forsyth County at the hospital several days later,” Davie Sheriff J.D. Hartman said in an email. “The DHHS report simply fell through the cracks. This is the only death we have ever had related to our detention facility.”
Short was a heroin addict who had tried to kill herself two months earlier, said her husband, Charles Short. Davie County deputies had responded to that attempt. She was in the jail for misdemeanor assault and possession of drug paraphernalia.
Her husband said she should have been kept on a suicide watch, but jail officials say she was taken off close monitoring after several hours. She hanged herself with a bed sheet.
“I know she was on drugs, but she’s not trash,” Charles Short said tearfully. “They just treated her like she was trash.”
Next: State investigators move cautiously.
Database editor David Raynor contributed to this report.
In our previous story on deaths in North Carolina jails, we revealed that 51 inmates had died during the past five years in cases that showed lax supervision.
Sunday: Left alone to die
Today: No report necessary
Tuesday: Who gets punished?
Wednesday: Housing the mentally ill
Thursday: Some courts keep secrets
Three years only
The N&O asked sheriffs to provide information on deaths in their jails during the past decade. One county declined to go back that far, citing a state rule.
Transylvania County said it only had to provide information regarding inmate deaths for the past three years. Jail administrator Capt. Eddie Lance cited state records retention rules that allow sheriffs to destroy inmate death reports after three years.
DHHS records and news reports show Transylvania had four inmate deaths during the past decade, including a 28-year-old woman who hanged herself in December.