NC officials stumble in prison death review

Inmate Michael Anthony Kerr’s death came as the last link in a chain of administrative error and neglect. It also should have become the first link in a new chain of corrections and reforms leading to better treatment of the state’s growing population of mentally ill inmates.

Now it seems the response was as bungled as the conditions leading to Kerr’s death were negligent. Kerr, 53, died after lying handcuffed in his cell for five days at Alexander Correctional Institution in Taylorsville. Prison officers found him unresponsive, wheeled him into a van and drove him 2 1/2 hours to a hospital at Raleigh’s Central Prison. He was dead on arrival on March 12, 2014. He died of dehydration. Water to his cell was cut off because he had flooded it.

Secretary of Public Safety Frank Perry said the case set off alarm bells about the need to provide better care for inmates with psychiatric conditions who behave erratically and need close supervision. He said he conducted a “righteous” investigation that led to the firing of nine individuals.

“I am satisfied with every decision made here,” Perry said. “Everybody here wanted to be fair, firm and forthright.”

Firings reversed

But righteous isn’t necessarily right. On appeal, five of the nine employees have gotten their firings rescinded. One of those fired and reinstated was Michael Youron, a psychologist. He was fired for failing to treat Kerr, but Kerr wasn’t his patient, and Youron was on leave when the inmate was left manacled in his cell, lying in his own urine and feces for days.

The flawed investigation was conducted by Phyllis Vandiford, a retired administrative service manager. She was assigned the role by the public safety department despite having no experience in psychology and only a year and half of experience as a correctional officer. In summarizing Vandiford’s credentials, The News & Observer’s Joseph Neff reported on Monday:

“Vandiford had no medical or mental health background. She did not know that Youron, as a psychologist, could not prescribe medicine. Vandiford testified she did not know the mental health staff was overworked and understaffed, despite statements in her file to the contrary. She never interviewed Youron’s superiors and she never reviewed minutes of the weekly staff meetings at which the mental health staff discussed Kerr and his care.”

Three other employees who were fired were reinstated with back pay. A fourth had her dismissal rescinded and characterized as a resignation.

The only effective part of this investigation is how reviews by the Office of Administrative Hearings found fault in several of the firings. Those results show the value of the appeals process, a process that Gov. Pat McCrory has proposed eliminating when it comes to state employee firings.

Responsible for care

It’s not the fault of the state’s prisons that a failing system of caring for the mentally ill means more of the mentally ill are ending up in prison cells. But once people are incarcerated, it is the responsibility of the prison system to see that these challenging inmates are not abused or abusive to themselves.

The system did not meet that responsibility in the case of Michael Anthony Kerr, and it’s likely that many more mentally ill inmates have suffered unacceptable neglect. The Kerr case challenged the system’s capacity to correct and improve its procedures.

The slipshod investigation and the reversal of firings suggest that the Department of Public Safety is more committed to bold pronouncements and surface discipline than effective and lasting reform. If that’s the mindset, then another Kerr case is inevitable.

This story was originally published July 6, 2015 at 6:11 PM with the headline "NC officials stumble in prison death review."