This story misstated the number of prison employees fired afterward. the Department of Public Safety fired nine employees and demoted two. Two employees resigned.
Michael Anthony Kerr spent the last five days of his life handcuffed in a prison cell, unresponsive, off his mental health medicine, and lying in his feces and urine. An hour or two before the former Army sergeant died, officials at Alexander Correctional Institution put him into a wheelchair and drove him 2-1/2 hours east to a prison hospital in Raleigh.
When Kerr, 53, arrived at Central Prison, his body was cold.
Somewhere between Taylorsville and Raleigh, as the prison vehicle passed emergency rooms at eight hospitals, Kerr died of dehydration.
“They treated him like a dog,” said Brenda Liles, his sister.
The state Department of Public Safety has released almost no information to the public on Kerr’s March 12 death. Secretary of Public Safety Frank Perry declined to discuss the facts of the case but said he called in the State Bureau of Investigation to look into the death.
Perry said his staff conducted a thorough and transparent investigation and had disciplined 40 employees, including nine who were fired and two who were demoted. Two employees resigned.
“We have been righteous with our investigation and dismissals,” Perry said.
Other state agencies have faced obstacles investigating the case. An agent for the State Bureau of Investigation had to get a court order to obtain Kerr’s records.
As the Office of the Chief Medical Examiner conducted an autopsy, prison officials’ help was so minimal that the pathologist could not determine the manner of death: accident, suicide or homicide.
Days after the autopsy was released and the lack of cooperation became public, the U.S. attorney in Raleigh opened a grand jury investigation of the death.
There was a remarkably similar death by neglect at Central Prison in 1996: A Vietnam veteran died of dehydration after eight days in the prison’s mental and medical hospitals. At that point, prison officials opened the dead inmate’s medical and security records and allowed a reporter to interview dozens of the responsible officials, from psychiatrists to doctors to correctional officers.
“We are very concerned about the case of Mr. Kerr,” said Vicki Smith, executive director of Disability Rights North Carolina, which provides advocacy and legal services for the disabled. Smith pointed out that Kerr had spent the last 35 days of his life in solitary confinement, which causes mental health to deteriorate.
“There is a common trajectory of people who see the symptoms of their mental illness criminalized,” Smith said. “The root of this is untreated mental illness.”
Death of two sons
Kerr was born in Sampson County, in southeastern North Carolina, in 1960 to a family of six boys and six girls. He joined the Army in 1979, serving in an artillery unit. After an honorable discharge in 1991 from Fort Sill, he sold real estate in Lawton, Okla., and was pastor of the Faith Temple church.
While an intensely religious man, he began getting in trouble with the law in 1995, with a string of larceny convictions, and served 10 months in prison.
Liles, his sister, said Kerr began falling apart after two of his sons were murdered in Sampson County: Anthony Kerr in Harrells in May 2007, and Gabriel Kerr in a Garland juke joint in June 2008.
“That’s when he began to have those nervous breakdowns,” Liles said. “He had two or three.”
In October 2008, Kerr fired nine shots into a house in Garland. After his conviction, Kerr’s prior felonies earned him a conviction as a habitual felon and a roughly 31-year sentence. The men convicted of killing his sons were sentenced to 16 months and about 25 years, respectively.
In prison, Kerr was diagnosed with schizoaffective disorder, a condition in which the person experiences schizophrenia symptoms, such as delusions or hallucinations, as well as mood disorders such as mania or depression.
Prison officials put Kerr into solitary confinement in February. For several weeks, guards observed him standing, sitting or sleeping, according to a prison log.
Sometimes he lay on the floor singing; at other times he kicked, banged or pecked on his cell door. On four occasions, he plugged up his sink to flood the cell, and guards periodically cut the water off. He was held in full restraints or handcuffs for days at a time.
On Feb. 21, Capt. Lane Huneycutt wrote in an email that he took off all Kerr’s restraints.
“I just felt that there was no longer a point to keeping him in restraints as he was just sitting in the floor in his own urine refusing to move or do anything,” Huneycutt wrote. “Medical was also worried that he was dehydrated. Over a period of time staff was able to get him to drink some water and he appears to be doing some better, although we continued his water shut off due to after he drank a few cups of water he began pouring it in the floor stating ‘come on in the water is fine’ as he was doing before.”
In early March, Liles received a call that her brother was being treated poorly at the prison in Alexander County. She does not want to identify the caller. Kerr had been kept in solitary confinement since early February and was not receiving any treatment for his schizoaffective disorder.
Liles said that on March 3, she called a prison administrator, who was dismissive. She said she then called and spoke with George Solomon, the state’s director of prisons.
On March 4, she said she was called by her brother’s caseworker and then by his psychologist. Liles said she begged them to help her brother, and that both promised to try to send him to Central Prison, where there is a medical and a mental hospital.
But according to a detailed account by an inmate held next to her brother, Kerr got no help.
Handcuffed in a cell
David Chambers, a 32-year-old from Charlotte, is serving a 17-year sentence for kidnapping, robbery and assault. He’s accumulated 113 infractions in prison and is held in disciplinary segregation, one of several categories of solitary confinement.
Prison officials declined to let The News & Observer interview Chambers. He wrote in a letter that he kept notes and wrote down the dates of the events he witnessed and overheard from March 6 to March 12. The letter, with sometimes-sloppy grammar and spelling, describes a suffering man left alone in his cell, handcuffed.
“His name is Mr. Kerr and he died from all of this and some of the thing they did to him just wasn’t right,” Chambers wrote. “He wasn’t eating and he was using the bathroom on himself laying in feces.”
March 6: “He used the bathroom on his self.” A guard and a sergeant said “his pants is halfway down, his butt is out, look at his crusty feet.”
March 7: “Ate nothing and they called a code blue because he was unresponse.” A guard went into the cell and handcuffed Kerr. A nurse went into the cell.
“I don’t no what they did but when they came out of his cell they were like, Mr. Kerr come to the door so we can take the cuffs off,” Chambers wrote.
Kerr did not respond and was left in handcuffs. The prison log of observations made by guards who routinely checked on him shows he wasn’t seen standing, sitting or moving after the night of March 7. Over the next 99 hours, they noted “Appears Asleep” 91 times and “Awake On Bunk” 26 times.
March 8: A guard told Kerr to let them know when he wanted the handcuffs removed. Kerr did not respond.
March 9: Again, Kerr did not respond or eat anything. “Still using the bathroom on his self feces smell all in his cell and the block and was still left in handcuffs and this was the third straight day in handcuffs pants still half way off and urine feces all over his cell.”
March 10: Kerr ate nothing and did not respond to anyone. After lights out, a guard and nurse went in to check on Kerr but did not remove the handcuffs.
March 11: Kerr ate nothing and did not respond to anyone. “Sgt told him let us no when you want out of those handcuffs but never responded. Later a nurse came don’t know what time heard them talking with Mr. Kerr. They ask did he want his vitals takeing he didn’t respond so they said are you refuseing to have your vitals taken he didn’t say anything so they say okay you refuseing and left.”
On March 12, Kerr again ate and drank nothing. A guard and a sergeant went in the cell and cut off the handcuffs so they could dress Kerr. The two pushed him out of the cell in a wheelchair.
“His face had a blank far off stare and and his eyes wide open but seeing nothing and he had something white coming out of his mouth.”
The prison van that took Kerr that day to the hospital at Central Prison drove past emergency rooms from Statesville to Chapel Hill. “When bus arrived at receiving area he was DOA and cold,” according to the autopsy report.
State law requires an autopsy for anyone who dies in state custody. Pathologists routinely use medical records, eyewitness reports and other records to help determine the cause and manner of death.
The cause of death was clear: High levels of sodium, chloride and nitrogen showed that Kerr died of dehydration.
But the pathologist, Dr. Susan Venuti, was stymied when it came to determining whether the death was a suicide, homicide or an accident.
Gwen Norville, the deputy director of prisons, allowed Venuti to look at a “Sentinel Event Review” conducted by the department, but did not permit the medical examiner to keep a copy, and the department did not provide any other reports.
“The nature of his dehydration, whether as a result of fluids being withheld, or the decedent’s refusal of fluids, or other factors, is unclear,” Venuti wrote. “Since the circumstances surrounding the development of dehydration leading to death in this incarcerated adult are uncertain, the manner of death is best classified as Undetermined.”
The medical examiner’s office has the power to subpoena records but did not in this case. The Department of Health and Human Services said Venuti would not comment for this report.
“I have been a criminal defense lawyer for 20 years, and I’ve never seen a situation where a state agency does not fully cooperate with the medical examiner in a death investigation,” said Bradley Bannon, president of N.C. Prisoner Legal Services. “Especially when the death is by dehydration.”
Perry, the director of public safety, said if information was withheld, it was for “a righteous reason like privacy or respect for HIPAA,” the federal law covering the privacy of individual medical records.
“I don’t think anyone intentionally withheld anything,” Perry said.
Less than a week after the release of the autopsy report, a federal grand jury in Raleigh opened a criminal investigation into Kerr’s death and filed subpoenas demanding hundreds of records relating to Kerr and his care in prison. The subpoenas seek information about Kerr’s death and the state’s handling of the case.
Since Kerr’s death, the Department of Public Safety has fired five people and demoted two at Alexander Correctional Institution, while two others resigned. Several are challenging their dismissals, saying they were working under impossible conditions, particularly high turnover and an inordinate number of vacancies.
An Oct. 17 review of the prison by a prominent expert on inmate mental health echoed some of those arguments. Dr. Jeffrey Metzner, a psychiatrist at the University of Colorado, noted a 17 percent vacancy rate among mental health workers.
“Problems continue with regards to the bureaucratic hiring process, which has significantly hampered recruitment,” Metzner wrote.
But the psychiatrist found a bigger and more fundamental problem in the prison system’s work with inmates who have mental health issues.
Only 12 percent of state inmates are classified with mental illness; that concerned Metzner because other prison systems report that the mentally ill make up 12 to 22 percent of their population. The state is likely not identifying some mentally ill inmates, he said.
Metzner was particularly concerned with how the Alexander prison practiced solitary confinement. Mentally ill patients such as Kerr received no therapeutic activity outside their cells. In addition, mentally ill inmates spent very little time out of their cells, less than 5 hours a week either getting a shower or in isolated recreation cages with high concrete walls.
Those practices, Metzner wrote, are harmful to those in need of mental health treatment.