North Carolina regulators have the authority to inspect local jails at any time when the care of inmates is in question. State law includes a provision to recommend charges against those who fail to provide proper supervision of inmates.
But for many years, the unit within the state Department of Health and Human Services tasked with making sure jails are safe rarely investigated when an inmate died. And state officials say they aren’t aware of any criminal charges being filed against a jail employee as a result of a DHHS investigation.
DHHS’ construction section only routinely began inspecting deaths in 2012, after a change of leadership – and the death of the 19-year-old grandson of a prominent Winston-Salem lawyer who went to sleep on a mat on the floor of an overcrowded Wake County jail and never awoke.
Ralph Madison Stockton IV’s death from a drug overdose resulted in a $250,000 settlement to his estate. He hadn’t been checked in more than an hour when he was found dead, DHHS determined.
Steven Lewis, who heads the DHHS construction section, took responsibility for the jail inspection unit in 2010. Lewis said by the time Stockton died, he had seen several inmate death reports from jails that suggested the supervision requirements hadn’t been followed. Stockton’s was another. He decided his staff should begin investigating deaths that showed the potential for violations.
“I’m as human as I hope most people are, and hearing an 18- or 19-year-old died is a bad thing, regardless of how it happened and what happened,” Lewis said.
Since then, more than one of every two death investigations has turned up non-compliance in the supervision of inmates, DHHS records show: 51 deaths in the past five years in which jailers failed to properly monitor inmates. That’s one-third of the 151 inmates who died in North Carolina jails during that time.
But inmate death reports from 2006 through 2011 – before DHHS was investigating – indicate there may have been many other such cases, an N&O review shows. The reports identify at least 12 deaths from that period in which detention officers didn’t monitor inmates for periods of more than an hour.
7 hours, no monitoring
In Mecklenburg County, for example, records show that Allison Carpenter, 44, of Cornelius, hadn’t been monitored through the night – from 11:30 p.m. until 6:35 a.m. the next day – when jailers found her unresponsive.
She died on July 16, 2007 from a thyroid gland that was feeding her body too much hormone, an autopsy found. Cocaine use contributed to her death. The sheriff and jail staff declined to be interviewed about inmate deaths, according to Anjanette Grube, a sheriff’s spokeswoman.
Mecklenburg County agreed to pay Carpenter’s estate $10,000. Prison Health Services, a subcontractor providing health care to inmates in the jail, agreed to pay the estate $2,500.
In 13 other inmate deaths from 2006 to 2011, the final supervision checks were spaced so far apart – 45 minutes to just under an hour – that an investigation would have been warranted, inmate death reports show.
Autopsies also point to questions about supervision.
On Nov. 26, 2007, detention officers found Timothy Allen Maynard hanging in a cell at the High Point Detention Facility in Guilford County.
Maynard had a history of depression, and his death was ruled a suicide. But the autopsy and the medical examiner’s report noted something that didn’t turn up in any other jail suicide reviewed by The N&O: Maynard’s hands were tied behind his back.
“It seems someone else helped him, but he could do it himself,” the medical examiner’s report said. “His suicide note clearly expressed desire to die.”
Guilford sheriff’s officials said they are convinced Maynard killed himself, and had time to do it since he was being checked twice an hour. Sheriff’s officials didn’t view his mental illness as reason for increased monitoring. He had been in the jail for five months awaiting the outcome of child sex abuse charges before he hanged himself.
Lewis, of DHHS, said he couldn’t say whether the number of supervision failures related to inmate deaths were an indicator of a widespread problem, given that there are 113 jails in the state with beds for a combined 24,000 inmates at a time.
“My feeling is one death is more than there should be,” said Lewis, who is an engineer by training. “Everything above that, as far as I’m concerned, is not a good thing.”
The former DHHS supervisor over jail safety for the previous five years, John Harkins, could not be reached. He left DHHS in 2011 and worked at the Department of Public Safety until leaving at the end of 2013, state personnel records show.
DHHS produced one letter regarding a jail death during Harkins’ tenure. He questioned Harnett County detention officers’ handling of Brandon Bethea, 24, who died after an officer shot him three times with a Taser in a padded cell on March 15, 2011. But Harkins did not cite the jail for supervision violations in the letter he sent four months later.
Bethea’s death was featured in an N&O series last year about aggressive tactics by members of the Harnett County Sheriff’s Department.
Lewis, the DHHS official, said there is no law that requires his unit to investigate deaths to make sure that inmates were properly supervised. The regulations only stipulate that his section inspect jails twice a year for compliance with the supervision and safety requirements.
The unit has three investigators who perform the inspections, looking at sanitation, fire safety, security and the supervision and treatment of inmates. They also look into inmate complaints about quality-of-life issues. The investigators are stationed in Goldsboro, Charlotte and Montgomery County.
Lewis has put in place a standard reporting system for deficiencies so that staffers follow up to make sure jails are following regulations. But he said he doesn’t have the staff or resources to analyze broader trends in inmate deaths.
Lewis said there’s little he can do to force a jail to follow the supervision requirements. He can’t fine the jails or order people fired. The one weapon he said he has is to tell the DHHS secretary he has found the jail unsafe. The secretary could then order the jail closed. Lewis hasn’t seen reason to make such a report to the secretary.
State law provides another option. It says a misdemeanor criminal charge can be filed against jail staffers if they fail to supervise inmates “closely enough to maintain safe custody and control.” Lewis said he wasn’t aware of that provision. The regulations make no mention of it.
In the past five years, DHHS has cited 12 jails more than once for supervision failures following inmate deaths. But investigators handled the subsequent deaths much like the first – issuing letters explaining the violations and requiring a written response from the jail as to how they would be corrected.
A broken intercom
In Rutherford County, Jeffrey Neal Watkins had stopped eating the day before he died in his jail cell. Watkins, 47, had a history of alcohol abuse. It led to gout, a painful arthritic condition. He had been arrested for a drug-related offense and was supposed to be sent to drug and alcohol treatment.
An hour before his death on April 20, 2012, he had been seen standing naked in his cell, but told a detention officer he was OK, according to a medical examiner’s report. It turned out Watkins, 47, of Spindale, was overdosing on tramadol, a powerful opioid painkiller.
His mattress was soaked with urine, and three food trays sat untouched. His lack of appetite should have signaled to detention officers that Watkins needed to be seen by medical staff, the DHHS investigation found, but it didn’t happen.
The death revealed another problem. In prior, twice-a-year jail inspections, DHHS had pointed out a broken intercom system that needed to be fixed. It wasn’t, which meant Watkins, or neighboring inmates, had no way to call for help.
DHHS “instructed your facility to utilize direct supervision some time ago or repair the two-way communication system,” investigator Chris Wood wrote. “The facility has failed to do either.”
In response, jail administrator Lt. R. Allan Young wrote that the jail would make sure detention officers notify medical staff if an inmate wasn’t eating. He said the jail would deploy direct supervision of inmates until the intercom system was repaired.
Two years later, William Anthony Miller, 41, of Rutherfordton hanged himself in a cell at the jail. He was considered suicidal, and should have been monitored four times an hour. Seventy-one minutes had gone by before he was found dead. Wood investigated again. The intercoms still weren’t working, and the video showed no detention officer stationed in the housing unit, records show.
Another inmate had died, and jail officials had not followed the commitments they made two years earlier. There would be no DHHS recommendation to the secretary that Rutherford close its jail. But DHHS officials did more than write the standard deficiency letter.
This time, Wood’s supervisor, Carey Gurlitz, wrote a letter citing the long-standing deficiencies. And she put them in bold type.
Rutherford County Sheriff Chris Francis declined to be interviewed about the inmate deaths. His office did report that Miller’s family received a $9,000 settlement.
Next: 5 years, 151 deaths.
In our previous stories on deaths in North Carolina jails, we found that some deaths go unreported because the inmate who was hurt or sick in jail actually died outside the facility.
Sunday: Left alone to die
Monday: No report necessary
Today: Who gets punished?
Wednesday: Housing the mentally ill
Thursday: Some courts keep secrets