A state investigation has found that Wake detention officers didn’t keep a proper eye on an 18-year-old man who hanged himself in the county jail five months ago while awaiting a psychiatric evaluation.
Jose Humberto Lara-Pineda is among six inmates in North Carolina county jails this year who didn’t get proper supervision in the hours before they died, state Department of Health and Human Services investigators say. Three of those deaths were in the Triangle, including a 17-year-old girl who hanged herself in the Durham jail and a 61-year-old man who died of natural causes in the Johnston County jail.
Paul Gessner, a Wake sheriff’s attorney, said in a short emailed statement that jail officials “disagree with some of the findings, conclusions and regulatory interpretations,” but wouldn’t provide details until the jail responds in writing to DHHS investigators. DHHS gave the jail a Sept. 6 deadline.
The news of the recent supervision lapses follows The News & Observer’s series, “Jailed to Death,” which revealed state investigators had cited jails across the state for poor oversight in the cases of 51 inmates who died in county jails in the past five years.
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The stories also showed why some jail deaths are not reported, how some jails struggle to care for mentally-ill and drug-addicted inmates, and that some judges have allowed legal settlements to be kept secret.
The state supervision regulations require that inmates be checked at least twice an hour, and at minimum four times an hour if the inmate is believed to be suicidal, mentally ill, on drugs or alcohol, or behaving erratically.
The DHHS investigation said that Lara-Pineda was on a special psychiatric watch and should have been checked four times an hour. Logs of inmate checks showed they didn’t happen at that frequency until 87 minutes had gone by.
The logs also showed a later shift had three checks instead of four, and no checks during the hour in which he was found hanging.
The state requires jails to send in a one-page report when an inmate dies. Wake’s report said 71 minutes had passed between checks when Lara-Pineda was last seen alive and then found in distress. But the report included a note saying he had been observed standing in the doorway 35 minutes before he was found hanging.
A small corner cell
Earlier this month, The News & Observer toured the Wake jail and saw the small corner cell Lara-Pineda had been placed in within the jail’s booking area after being charged with murder.
The cell has a large window taking up nearly the top half of the cell door, but detention officers working at a command desk in the booking area could not see the entire cell. A ceiling camera connected to a computer screen at the command desk offered a more expansive view.
It wasn’t enough to stop Lara-Pineda from hanging himself. Using a string from his jumpsuit, he fashioned a ligature that he tied around the nozzle of a waist-high drinking fountain and around his neck, jail officials said. When he sat, the string tightened and asphyxiated him.
Thomas Matthews, the assistant jail director, said during the tour that the mandated checks did not apply in the booking area, since inmates were still being processed.
Wake Sheriff Donnie Harrison fired two detention officers shortly after Lara-Pineda was found, but he said in an interview last month that supervision wasn’t the problem. He cited other policy violations that he didn’t specify.
“We may not have picked it up if we had not done the internal investigation, but all this happened prior to the suicide,” Harrison said.
One of the officers dismissed had regularly racked up overtime. In several years, records show, she roughly doubled her salary. But jail officials said the long hours weren’t a factor in Lara-Pineda’s death.
24 deaths this year
This is the second time a Wake jail inmate’s death prompted a report of deficient supervision from the state. In 2012, the state cited Wake for failing to properly check Ralph Madison Stockton IV, who overdosed in the jail. Wake paid his estate a $250,000 settlement, but did not admit responsibility.
That death prompted state officials to regularly investigate jails for compliance with supervision regulations when an inmate dies.
The N&O previously reported that DHHS found deficiencies in the Durham jail after the death of Uniece Fennell, 17, on March 23. DHHS investigations the N&O obtained earlier this month show the Johnston County jail was cited in the death of Edward Charles Cowdrey Jr., 61.
The report said in the hours leading up to Cowdrey’s death no checks were made during one hour, and only one check was made in a subsequent hour. Cowdrey died from natural causes in the jail on March 23, the sheriff’s inmate death report said.
Johnston Sheriff Steve Bizzell said in a response to the state that electronic logs and video cameras show detention officers were making timely checks of at least twice an hour as required, but the electronic logs were an hour off because the system failed to reset from daylight saving time.
The jail uses an electronic log system in which hand-held probes must be pressed against buttons next to cells to record an inmate check.
Cowdrey’s death marks the first time the jail has been cited for not meeting supervision regulations after an inmate death.
Jails have reported 24 deaths reported so far this year to DHHS, which would put the state on track to reach 40 deaths for the full year. That would tie the number of inmate deaths the N&O found for 2015, which DHHS officials say is the highest since 1997.
In six of those deaths, including one in a Mecklenburg County jail in June, DHHS found no deficiencies after investigating.