Early this year, detention officers evacuated inmates from an older section of the Watauga County jail as sewage backed up into the hallway.
But inmate Lincoln Horner was later returned there from a medical check, by staff who didn't know about the evacuation. He was left alone for 45 minutes. A short-staffed detention crew thought the section no longer had any inmates and had stopped checking.
That gave Horner, 40, plenty of time to use a blanket to hang himself. He's now among more than 70 inmates who have died after supervision lapses in North Carolina jails since 2012.
It's a problem the News & Observer exposed in a recent five-part series, Jailed to Death. Some state officials — including Senate leader Phil Berger — found the number of supervision failures troubling. But lawmakers on a legislative oversight committee that looked into jail deaths didn't address the issue.
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Proposed legislation offered by the health and human services oversight committee attempts to deal with two other concerns associated with jail deaths — a reporting loophole and issues with providing prescription medications.
Advocates for the care of inmates say lawmakers need to address the supervision issues when they return for the short session that begins May 16.
"What is happening now is not working," said Susanna Birdsong, senior policy counsel for the ACLU of North Carolina.
The News & Observer found that in the past six years, supervision failures were involved in more than a third of 190 inmate deaths. In many cases, jailers weren't making the required number of checks, or allowed inmates to slip out of view behind towels and blankets.
In some cases, equipment breakdowns have contributed to supervision issues. Last October, inmate Anthony Jones suffered a heart attack in a pod in the Nash County jail where the intercom wasn't working. Video cameras also weren't trained on the pod, a state investigation found. Other inmates yelled and banged on windows to get the jailer's attention.
Nash County Sheriff Keith Stone said a jailer specifically assigned to the area responded quickly. Jones, 42, died about an hour later at a local hospital. The intercom has been repaired, Stone said, and he is seeking to upgrade the video camera surveillance system.
For more than a decade the jails have become a holding facility of last resort for those with mental illness, and in recent years they have been hit with a wave of opioid addicts. Both populations are higher risks for suicide and infirm health. They are one reason why jail deaths in the state have trended upward the past several years, making inmate supervision and tracking of inmate deaths even more important.
The state Department of Health and Human Services' Construction Section often inspects jails when inmates die. But the N&O found it wasn't being alerted to all deaths. In some cases, sheriffs didn't notify the state when an inmate later died at the hospital after a suicide or other life-threatening event happened in the jail. State law only requires the reporting of deaths in the jail.
The proposed legislation seeks to close that loophole by requiring all "in custody" inmate deaths be reported. But that change still wouldn't catch all deaths. Some of the deaths the N&O reviewed showed that inmates had been released from the sheriff's custody while in the hospital.
"All deaths due to serious injury and illness, whether people die in the jail or at the hospital, must be reported so we understand the scope of the problems and can address them," said Vicki Smith, executive director of Disability Rights NC, an advocacy group.
She said the DHHS needs more staff, and inmate supervision requirements are "minimal."
"Stiffer sanctions are needed," she said.
Eddie Caldwell, the executive vice president and general counsel for the N.C. Sheriffs' Association, said the organization supports changing the reporting requirement to include deaths in custody. He said the association hasn't taken a position on whether lawmakers should introduce legislation to address inmate supervision.
"We haven't requested them to look into it, we haven't requested them to not look into it," Caldwell said. "If there is proposed legislation we will look into it and evaluate it thoroughly and then the membership will decide if they will take a position or not."
Some inmates have died after being denied prescribed medications, family members say, resulting in lawsuits and out-of-court settlements. The draft legislation proposes the DHHS perform a study.
Rep. Donny Lambeth, a Winston-Salem Republican and co-chair of the oversight committee, said the proposed legislation should be revisited to make sure all inmate deaths are reported.
"We should figure it out and get the lawyers to put language in there to make sure that that's not a loophole," said Lambeth, a former hospital administrator. "There could be circumstances when they were in the custody of the county that could have contributed to that death."
He said he was unaware of the high percentage of supervision failures tied to inmate deaths. There was little more than an acknowledging of the problem in the oversight committee meetings. He said he wanted to learn more.
"Sounds like we didn't ask the right questions," he said.
Officials at Watauga, where Horner hanged himself, admitted their supervision failure in correspondence with the state DHHS investigator. Sheriff Len Hagaman said jailers would now walk through all sections of the jail where inmates are housed, even if a section was believed to be vacant. The jail would also "reassess" the location of video cameras in the facility.
State officials also say they are looking to find ways to steer those with mental illness or drug addictions into treatment instead of incarceration. It's a mission with big upfront treatment costs, but potential public safety and health care savings over the long run.
One county, Alamance, recently announced an effort to create a diversion and restoration center for mentally ill people who might otherwise wind up in jail. It's received $1.2 million in start-up money from Cardinal Innovations Healthcare.
Jails are largely funded by counties that may be hard pressed to keep facilities up to date and wages competitive. Sheriff Stone of Nash County said he would like to increase his detention staff and pay them more to reduce turnover, and replace a nearly 40-year-old jail that's been added on to over the years.
"Obviously it's costs and funds and things of that nature, but it has been something on my mind that we need to do," he said.