Internal affairs investigators concluded that St. Louis County jail staff repeatedly didn’t listen to inmates who said they were sick and could have done more to treat the men before they died while in custody last year.
The investigators criticized the jail staff’s actions in the days and hours before the inmates died, according to reports that were released by the county this week.
The internal affairs investigators wrote that the jail’s nurses and correctional officers responded to one inmate’s health crisis “without a sense of urgency” and violated another inmate’s “right to health care” by not responding to his medical needs.
In a report about the death of an inmate in June, an unnamed internal affairs manager said one correctional officer, whose name was redacted in the report, “was not receptive to the inmate’s concerns and failed to take necessary action as required to maintain a safe, secure and humane environment.”
Tashonda Troupe, whose son Lamar Catchings died in the jail last year, said the newly-released reports broke her heart. They contained information she had never seen.
“This report confirmed what I always felt, and that is that my son’s death could have been prevented. And he should be here alive with me,” said Troupe, who’s suing the county.
Troupe said the report makes it clear her son was sick for weeks before he died.
“I guess I wanted to believe that the county helped him a little bit more, but reading the report, I know that they didn’t,” she said.
Looking for transparency
The county released the internal investigative reports Wednesday after records requests from the St. Louis Post-Dispatch. The county’s justice services advisory board also complained last month that the jail wasn’t being transparent about the inmate deaths.
Board members contacted Thursday and Friday declined to comment on the newly released reports because they hadn’t received copies yet, but they expect a meeting to be held next week focusing on the information.
For most of the last year, the county has been refusing to release details about the deaths of five inmates in 2019, but the jail and county came under new leadership in the spring. County Executive Sam Page’s administration said it wants to be more open about the inmates’ deaths.
“We want to learn from these experiences and make improvement when necessary,” said Page, who is also a medical doctor, in a written statement.
Several jail staff members have been disciplined or fired over the past year as a result of the reporting about the inmates’ deaths, said Doug Moore, Page’s spokesman.
The county has also tried to train its staff to handle serious medical issues, which are becoming more frequent in the jail, according to the Page administration. Emergency transfers from the jail to the hospital doubled in 2019 when compared to the previous three years, according to the county.
Three inmates in the St. Louis County jail died in their cells within the first three months of 2019, raising questions about whether the medical care was adequate. Larry Reavis was found dead in his cell Jan. 18, John Shy on Feb. 23 and Catchings on March 1.
After the first three deaths, former county executive Steve Stenger temporarily replaced Julia Childrey as head of the jail in April with Lt. Col. Troy Doyle, from the police department. Doyle was then replaced with a permanent jail director, Raul Benasco, late last year.
Benasco could not be reached for comment Friday afternoon.
The changes in leadership didn’t prevent further deaths of inmates, but the two most recent ones occurred after the men had been moved out of the facility. Daniel Stout died a few hours after being moved out of the jail to the Missouri prison system on June 11. Jo’von Mitchell died on Dec. 27 after being sent from the jail to the hospital.
The newly released reports on inmate deaths include redactions of information. The names of correctional officers, nurses and inmates interviewed are typically blacked out. Some of the specifics about the medical care and what existing illnesses or complaints the inmates had are also redacted. In one case, the investigator’s recommendation for a reprimand of a specific staff member was hidden.
The reports were prepared by internal affairs managers who are part of the justice services staff. The investigations are not related to others done by the police or prosecuting attorney, according to county officials.
Deaths came under similar circumstances
The reports show there were similarities concerning the five inmates’ deaths. Jail staff members recalled all of them all acting strangely shortly before they died. In most cases, they asked for medical assistance that they didn’t receive.
Reavis was shaking so significantly that he couldn’t hold a cup of milk in the hours before he died, according to the report. He said he thought he was having a seizure, and it was later determined his death was related to alcohol abuse, according to the report.
Shy had been taken to the hospital twice for stomach pain over the course of a few hours and eventually returned to the jail. Then, he started screaming for help from his cell about seven hours before he died, according to a report.
About a week before he died, Catchings was so weak he wasn’t able to walk out of court by himself. He had to use a wheelchair. He also stopped eating meals about two weeks before he died and complained of hearing loss. At one point, the jail staff transferred Catchings to a cell on a lower floor because they were afraid he could fall down the stairs, according to the report on his death.
Stout repeatedly asked to see a nurse in the few hours before he was transported to the Missouri prison system where he died, according to the report. He vomited a few times shortly before being put on a van to go to the prison.
Mitchell felt too ill to visit with his brother and nephew on Christmas Eve. When he went to the infirmary on Christmas Day, he was having trouble walking and stumbled out of his cell, according to testimony from a witness. He died two days later.
The investigators are critical of the jail staff, particularly in the reports of the two most recent deaths. Both corrections officers and nurses involved in the Stout case are chastised for a “dereliction of duties” in the investigator’s report.
“[CORRECTIONAL OFFICER NAME REDACTED] failed to be mindful of the responsibility in her to respect human dignity, perform her duties in an empathetic manner and to exemplify the quality of compassion, which according to the Corrections Code of Ethics, is to be practiced by all Justice Services employees,” reads one passage of the Stout report.
A correctional officer is also criticized for taking a few minutes to complete the rest of his rounds after finding Mitchell unresponsive in his cell. The investigator wrote the correctional officer “falsified his report” to make it look as if the correctional officer responded immediately to Mitchell’s health problem, but video recordings reviewed by the investigator suggest the officer didn’t act with urgency.
All of the reports show a general lack of trust between the inmates and staff.
When a correctional officer asked another jail staff member about Catchings’ illness, the staff member said: “There’s nothing wrong, he’s (expletive) faking,” according to the report. Catchings ended up dying of untreated leukemia three days later.
For Troupe, reading the faking comment about her son was hard.
“He said my son was (expletive) faking, but he’s dead. So you tell me, was he faking? The report made it a little bit more vivid,” she said.
Pleas for help ignored
After Shy had already been taken to the hospital twice and was screaming for help, one staff member reported that another worker said she was “not going to inmate Shy’s cell until he calms down.” Both staffers’ names were redacted.
A correctional officer, whose name was redacted, also told another staff member, "If inmate Shy don’t be quiet, he’s putting him in the restraint chair," according to the report.
One correctional officer, whose name was redacted, said that they muted the call button Shy was using to ask for help because Shy was not hanging up the call button properly. The correctional officer said if one call button was muted, that meant they were muted for all of the cells, meaning no inmate could use the call button.
The correctional officer compensated for the muting by checking the call button board frequently to make sure no one was asking for help. But the muted call button worried at least one other jail staff member, who mentioned it to the investigator.
The report also details that Shy was found groaning on the floor of his cell shortly before he died and that his cell had to be “cleaned.” The Post-Dispatch has reported that Shy was found in a pool of his own blood, but most of the explanation for why Shy’s cell had to be cleaned has been redacted from the report released this week.
St. Louis County Prosecutor Wesley Bell had considered whether charges should be filed against nurses who were responsible for treating Shy, but decided against doing so in May.
County officials said they are working on the culture of the jail. They said sick-call procedures have been updated, and correctional officers have been instructed to initiate sick calls if they see someone who is ill. The jail staff is also now telling inmates “verbally and in writing” that they have a right to medical care, officials said.
But the internal investigations also document trouble with communication between nurses and correctional officers.
Members of the nursing staff said they weren’t made aware that Reavis was shaking uncontrollably until after he was found to be unresponsive in his cell. “Medical staff trust the Corrections Officers are the eyes and ears to let them know if an inmate is in distressed [sic],” according to the report.
Some of the nursing staff also said they weren’t given all the information about Stout’s illness before he was transferred to the prison where he died. One said if she had been on duty and known more about the situation, the nurse would have treated him immediately and blocked the transfer. “Nurse [NAME REDACTED] stated that what occurred was a result of neglect,” the report reads.
County jail and health officials said they have made significant progress in improving communication between the nursing staff and correctional officers.
“New communication practices from a patient safety perspective are being implemented and joint trainings are happening on a regular basis. In order to change a culture, it is necessary to work on both large and small issues and lines of communication,” wrote Moore on behalf of jail and health officials in the county.
“All staff understand the consequences of significant breakdowns in communication not only for the outcomes for our patients, but also that all such breakdowns can result in disciplinary action,” he said.
The jail’s shortage of nurses is also mentioned in a couple of instances in the internal reviews. Only one nurse was on duty in the infirmary when Reavis became ill, according to the report. A nurse on duty when Stout was sick reported she was having trouble retaining information because she had been in training all night.
The county health department is trying to boost its numbers of nurses, in part by working with nursing schools to provide a staffing pipeline for the jail, officials said Friday.
The investigators noted that in some cases staff refused to meet with them for interviews and occasionally refused to even submit written statements about the deaths.
The scope of the internal reports differ over time. The first three reports rely exclusively on interviews with staff members and reviews of logs made by staff. In the last two reports — done after the jail had changed leadership — inmates’ testimony is included. The most recent report, on Mitchell’s death, also includes information from his final phone calls made to family outside the jail and a review of video footage from inside the jail.
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