This is the first part in a five-part series investigating jail deaths and other issues in Kentucky's correctional system. Check back throughout the week for parts two through five.
HAZARD, Ky. — Larry Trent was just one of the 154 or more inmates who died in a Kentucky jail during the past 6½ years.
Arrested on July 5, 2013, in his car outside a Hazard doughnut shop, the 54-year-old Trent told police he drank “about four beers and mouthwash” before driving to the store with his 10-year-old grandson.
Booked into the Kentucky River Regional Jail, Trent couldn't post bond, so he remained in custody. Four days later, he was dead, allegedly the victim of a fatal beating by two jail deputies.
Within 48 hours of Trent’s death, jail Administrator Tim Kilburn completed a required report for the state Department of Corrections and classified Trent’s death as a homicide. And a few weeks later, the two deputies were charged with manslaughter, accused of killing Trent by “striking, kicking and restraining” him.
The case is still pending, and a federal civil-rights investigation is ongoing. But Trent's estate already has received a $2.375 million legal settlement -- one of the largest in the state during the past 15 years.
The Department of Corrections doesn’t investigate jail deaths. “That would fall to law enforcement,” said department spokeswoman Lisa Lamb.
The department’s responsibilities do, however, include ensuring the safety of inmates and staff, as well as enforcing jail standards, such as those related to training. But DOC documents provided recently to the Kentucky Center for Investigative Reporting give no indication that the department found anything related to Trent’s death that merited its attention.
For example, the documents list Trent’s cause of death simply as an “altercation” in the jail. An internal DOC memo written after Kilburn’s report says little except that Trent “became combative” and that “use of force was necessary” to subdue him. And although the accused killers served as the jail staff trainers, department records don’t indicate a need for more or better training.
Trent's is by no means the only in-custody death involving a jail inmate that raises questions about the aggressiveness and thoroughness of Department of Corrections’ oversight.
A months-long investigation by KyCIR found that at least several inmate deaths for which the cause is listed in DOC records as “natural, “unknown” or “autopsy pending” appear to have involved jail staff lapses, misconduct or indifference.
And the Department of Corrections’ own findings and follow-up in those cases were sketchy or nonexistent, despite evidence that the deaths were preventable.
Over the next five days, the “Trouble Behind Bars” series will show numerous Kentucky jail inmates have died or been injured because officials at all levels of government failed to ensure their health and safety.
The causes of more than 40 percent of all Kentucky jail deaths in the past 6½ years are listed ambiguously in department records, with the cause of death variously given as “unknown,” “natural” or “autopsy pending” -- even though many of those deaths occurred years ago.
When KyCIR recently asked the department for more current, specific information about the unclear, years-old causes of death, DOC responded that it had none.
The department refused to say whether it followed up on jail deaths, and if not, why not.
“The Department of Corrections has been responding to your questions regarding county jails to the best of our ability for the past 10 months,” a DOC statement read. “We do not have anything further to add on this topic.”
Search Kentucky's Jail Deaths
(Click on the map to search DOC data on deaths. This is an incomplete list. Know of a deat that's not included or have info that will help KyCIR update the database? Contact KyCIR here.)
In another case, the DOC list of deaths shows that Valerie Jones, a disabled veteran, died of “heart disease” after being jailed in LaRue County in September 2009. But a lawsuit filed by Jones’ family alleged that she was not properly treated for severe pain, and that she was left in her cell when she desperately needed medical attention.
More than five years later, DOC records still list the autopsy in her case as “pending.” The lawsuit was settled in 2011 for $92,859.
The death of Danny Burden isn’t listed at all in the department’s compilation of jail deaths. Burden was discovered unconscious in the Grant County jail in March 2013 and later died at an area hospital. A civil suit filed by his family and alleging neglect is pending. A state police inquiry found that Burden, a diabetic, badly needed insulin but did not receive it.
The Department of Corrections, however, found nothing to warrant concern -- or action. The department would not comment on the omission of Burden’s death from their list of jail deaths.
A KyCIR examination of the Grant County jail, one of the state's most troubled and the focus of a U.S. Justice Department investigation for more than a decade, shows lax government oversight and little action following Burden’s death and at least two others that seemingly could have been prevented by jail staff.
During the past 6½ years, a Kentucky jail inmate has died an average of about once every 15 days. But in-jail deaths generally are not of interest or concern to the public at large, said Louisville attorney Greg Belzley, who has filed several dozen lawsuits over the past 15 years alleging wrongdoing in connection with inmate deaths.
No lawsuit often means no accountability, Belzley said. When a jail inmate dies, “People may look it and say ‘s---, another one gone, thinning the herd,’” Belzley said. “There is no question that some deaths that aren’t litigated involve wrongdoing that never gets exposed.”
About three-fourths of the state’s jails have incurred at least one inmate death since 2009. Oldham County Jailer Mike Simpson said no one had died in his jail since the 1990s. And while he didn’t think that fatality could have been prevented, he said, “when something like that happens, we all have a little bit of ownership.”
Incomplete Accounting of Deaths
In Kentucky, the DOC’s incomplete death data show that at least 33 of the 154 deaths have been suicides. Suicide is the single-most frequent cause of deaths in jails across the country, and it has been for at least the past 15 years.
That’s at least partly because large numbers of people housed in jails have significant emotional problems, because jail staff often aren’t trained to deal with them, and because jail conditions can exacerbate or trigger those mental-health issues, said Preston Elrod, a professor in the School of Justice Studies at Eastern Kentucky University.
Among the deaths reviewed by KyCIR were two suicides that occurred in 2010 at Grant County’s jail. The Justice Department has asserted in a document obtained by KyCIR that the two suicides there resulted from “serious breakdowns in jail medical care.”
Carl Lewis hanged himself in the jail on April 11, 2010. He had been placed in a cell by himself with a bed sheet, despite the fact that he was deemed a suicide risk and had what the Justice Department later called a “history of suicidal ideation.”
Justice Department documents show Lewis was given antidepressant medication in a quantity “that was likely too low to be effective.” He received no other mental-health treatment in jail, DOJ found.
The jail’s own inquiry into Lewis’ death, by contrast, concluded that “all operational procedures, medical procedures … were followed professionally and correct.” Nor did the state police or the Department of Corrections find any fault with the jail in connection with Lewis’ death, or that of the other Grant County jail suicide in 2010, involving Derrick Rose.
“Any time you have a fatality in a jail, there should be a very careful investigation and assessment of what went wrong, what happened,” said Elrod, the EKU professor. “Unfortunately, in so many instances, the only way you’re probably going to get closer to an understanding of what happened is if there’s a lawsuit where the parties become compelled to produce evidence.”
Judge Raises Questions
That’s what appeared to have happened in the case of Shannon Finn: minimal if any probing by the Department of Corrections, yet significant revelations come out in court.
On March 17, 2009, Finn was arrested and booked into the Warren County Regional Jail for a probation violation. The following day, he began to shake, sweat and act erratically. He was put on a “detox protocol” and given medication for alcohol and drug withdrawal.
Three days later, a deputy found the 34-year-old Finn lying in a puddle of blood and yellow liquid in his isolation cell. Soon after, he was pronounced dead.
The family filed a civil suit, and a jury exonerated jail staffers at trial. However, U.S. District Judge Joseph McKinley concluded in a pretrial opinion that there was ample evidence of questionable conduct.
Among other things, McKinley noted that a jail deputy did not intervene after discovering Finn on his knees, shaking and mumbling. And a nurse neither contacted the jail’s medical director nor sent Finn to the emergency room, McKinley wrote.
Despite jail policy that characterized alcohol withdrawal as a medical emergency, deputies had received no training regarding its symptoms and dangers, according to the judge.
The department's listing of jail deaths says only this about Finn: "Found unresponsive--KSP (Kentucky State Police) investigating."
This story was produced by the Kentucky Center for Investigative Reporting, a nonprofit news organization. Reach R.G. Dunlop at email@example.com or (502) 814-6533.
This article was produced by the Kentucky Center for Investigative Reporting, a nonprofit newsroom from Louisville Public Media. You can read more at KyCIR.org.