When detention officers at the Wilson County, N.C., jail found Reggie Monroe, he was already cold to the touch.
He had gone unchecked for at least two hours and died from a fentanyl overdose, according to a state investigative report obtained by The News & Observer and The Charlotte Observer. All told, detention officers failed to make timely checks on the 28-year-old father of one through much of the night and into the morning.
Jails are responsible for the safety of their inmates. State regulations require detention officers to check on jail inmates at least twice an hour, and double that if an inmate is considered infirm or unstable. But that didn’t happen with Monroe, jail officials admitted in their response to investigators with the state Department of Health and Human Services.
“My son could have been saved,” said his father, Reginald Monroe, who his son is named after.
Jail deaths in North Carolina dropped significantly last year, the first reduction in seven years. But investigations of the deaths — whether they are deemed suicides, overdoses or deaths from natural causes — continue to reveal supervision failures. As in past years, investigators found them in more than a third of all deaths.
The N.C. Department of Health and Human Services reported 46 “in custody” inmate deaths in the jails for 2023, based on reports submitted by county sheriffs as required by law. But another 17 inmates died “out of custody,” and autopsy reports for several show they had become infirm behind bars before dying in local hospitals. Three of them overdosed in jail, records show.
Still, the 63 deceased inmates last year were well below the 90 reported for 2022, by far the highest death toll since DHHS started tracking. Seventy-seven of the 90 deaths that year were inmates still in custody.
Sheriffs, DHHS officials and those who advocate for inmate health and safety welcomed the decrease in deaths. But the toll remains well above what the state was seeing a decade ago when the annual number of deaths was roughly 30.
“We are glad the numbers are down and we’ll investigate them,” said Susan Pollitt, a supervising attorney with Disability Rights North Carolina, a nonprofit that keeps a close eye on jail conditions. “But 63 is a lot.”
Reasons For the Decline
DHHS spokeswoman Summer Tonizzo said the department was “pleased” to note the reduction in deaths, but referred all questions to the sheriffs who run the roughly 110 jails across the state.
Orange County Sheriff Charles Blackwood, who served as president of the N.C. Sheriffs’ Association last year, couldn’t say for certain what may have caused the deaths to drop. But he cited several recent changes that may have contributed.
Several counties, including Orange, have opened new facilities that are better designed for inmate observation, he said. The sheriffs’ association also included training on jail death prevention at a recent annual conference.
More jails are providing inmates with medications to combat opioid addiction, and paying more attention to inmates with mental illness, Blackwood said.
“We have put a great deal of emphasis on spreading the word about the success of these programs and the fact they are helping to reduce jail deaths,” Blackwood said in email messages. “Having our medical providers help us increase the assistance to those with mental health concerns has also been very helpful.”
He also credited Todd Ishee, the N.C. Department of Adult Correction secretary, with reducing the backlog of jailed inmates awaiting transfer to state prisons, since that helps keep jail populations more manageable.
“When he came into office he made this a priority and he has done an awesome job at getting it down and keeping it down,” Blackwood said.
Officers Fail to Check on Inmates for Hours
Autopsies have yet to be completed for some of the 63 inmate deaths, and DHHS investigations also haven’t been completed in some of the in-custody deaths. But the investigation reports filed so far and obtained through public records requests show continued problems with inmate supervision, as well as a continuing battle with two drivers of inmate deaths — drug abuse and mental illness.
DHHS found at least 19 of the 46 in-custody deaths involved supervision failures, many of them missed checks by detention officers. That’s 41 percent, and reflects a long-standing systemic problem. Just as in past years, the percentage of deaths tied to supervision failures is in the range of a third to half of all deaths.
In some of the 19 cases, inmates went unchecked for hours. Ray Charles Hill, 67, died of heart disease at the Duplin County jail on Jan. 8, 2023. The DHHS investigation found gaps in his supervision as long as three hours. Duplin County Sheriff Stratton Stokes did not respond to an email seeking an interview on Monday.
Reggie Monroe was found “unresponsive, apneic and pulseless” on the floor of a Wilson County jail cell on July 29. An autopsy found that he overdosed on fentanyl, an addictive narcotic that can kill in small amounts.
Reggie Monroe had a 3-year-old son and a passion for computers, his father said. The elder Monroe recalled watching his son build one of those computers.
He’s had a number of questions, but few answers. Prior to an Observer reporter calling him, he had seen no DHHS reports, no autopsy, no medical examiner’s records. He plans to sue over his son’s death, but has had trouble finding a lawyer, he said.
“They’re going to pay for my son’s death,” he said.
The Wilson jail had 19 of its 51 detention positions vacant at the time of Monroe’s death, the DHHS investigation found. The sheriff’s office declined to comment, and said there was a pending investigation by the North Carolina State Bureau of Investigation.
A plan of correction submitted by the sheriff’s office said officers involved were disciplined, and that a “corrective action” was put in place.
Drugs, Contraband and Suicides
Monroe was among at least 11 inmates who died of drug overdoses in county jails last year. Jail records show Monroe and several others, including Da’Marious McClain, 19, who died in a Wake County jail on July 24, had been behind bars for two weeks or more before they overdosed.
The Wake County Sheriff’s Office said it requested an investigation by the SBI after McClain’s death. In a statement to the Observer, sheriff’s office spokesperson Rosalia Fodera wrote that the sheriff’s office has taken on “various initiatives” to keep contraband out of jail facilities:
- A scanning service that delivers mail “such as letters, pictures, and drawings” electronically, which inmates then read on tablets.
- Full-body scanners to find “any hidden contraband on or within inmates’ persons” are being added.
- To further reduce contraband, “private visitations are conducted via monitors.”
DHHS investigators found supervision failures in 10 of the 13 inmate suicides they looked into last year. In one case, video captured a detention officer at the Davidson County jail walking near Curtis Watts’ cell to do an inmate check.
The officer logged in at a nearby electronic checkpoint without looking in on Watts, who was in the midst of hanging himself with a bedsheet. Watts, 39, had a history of suicidal behavior and substance abuse. Davidson County Sheriff Richie Simmons did not respond to an email request for an interview sent Tuesday.
One of the State’s Deadliest Jails
In the past three years, the Rockingham County jail has become one of the state’s deadliest. Ten inmates have died in the jail in that period, and DHHS investigators have found supervision failures in seven, with two others from last year still being reviewed.
Longtime Rockingham County Sheriff Sam Page, who was an unsuccessful candidate for lieutenant governor in this year’s primary election, said he wouldn’t discuss specific deaths.
But his jail has faced familiar issues, he said. Namely: staffing and an inmate population that’s struggling with mental illness and substance abuse.
As for the missed rounds?
“If you miss your check by one minute, you’re deficient,” he said. “There’s not a lot of leeway in those checks… We do try to meet those needs, but I do know we’re deficient. We’re trying to improve on that area.”
Fights, inmates’ needs and other factors tie up staff sometimes, he said.
Page said he’s put several measures in place to make the jail safer. Among them, he said: For about six months now, deputies have been filling out observation sheets that answer questions about an arrestee’s physical and mental health before they’re booked.
“It’s very important because everybody in our jail is somebody’s family,” he said of the measures he’s put in place.
Staff Vacancies Among Factors Blamed
The Rockingham County jail is in the district represented by one of the state’s most powerful politicians, Senate leader Phil Berger. Near the hometown of his House counterpart, Speaker Tim Moore, the Cleveland County jail has also had problems with supervision connected to jail deaths.
The Cleveland County jail was cited for repeatedly failing to check on Carla Shull, 29, at least four times an hour. Shull had tested positive for marijuana, methamphetamine and benzodiazepines and hit herself about her face and head as she was brought to the jail, a medical examiner’s report said.
Jailers isolated her in a cell after several altercations with other inmates, which prompted the more intensive supervision. But the DHHS investigation found improper gaps between checks as long as 35 minutes. Shull hanged herself with a payphone cord on May 25, the medical examiner’s report said.
In a phone interview with the Observer, Cleveland County Sheriff Alan Norman acknowledged that his staff missed rounds, but said that they saw Shull just 13 minutes before they found her unconscious. They had made that round two minutes early, he said.
When they found her hanging, they took her down and she was given first aid until medics arrived, he said.
“There were rounds missed by staff, and that’s due to two things: a staffing shortage and other issues within the detention center,” he said.
Today, the jail has 53 employees and 11 vacancies, he said.
Shull was one of three Cleveland County inmates who died last year. The other two had been released from custody before they died. One of them, Whitney Renee Brooks, 34, was a woman who said she was homeless and who spent two weeks in the jail before deputies took her to the local hospital.
A medical examiner’s report said that upon admission she said that she suffered from generalized body aches, headache, vomiting, diarrhea, chest pain and shortness of breath while she was in the jail. She died of sepsis and heart disease a day after being admitted to the hospital.
“Your best goal is: You don’t want to see anyone die either in custody or out of custody,” he said. “Unfortunately, it’s going to happen.”
Cleveland County’s recent history with jail deaths includes a $347,500 legal settlement, paid to the estate of a man beaten and asphyxiated to death in 2019. Jeffery Todd Dunn, 37, was in a holding cell that detention officers couldn’t see into because the window was badly scratched.
‘Glaring Loophole’
The state can do little when jails fail to provide proper inmate supervision. State investigators can seek the DHHS secretary’s approval to close down a problem jail, but that’s a last-ditch option rarely considered given the impact on the justice system. Typically, investigators accept the jail’s correction plan.
Jail officials told DHHS investigators in some cases that detention officers were disciplined but did not specify punishments. They also said jail supervisors would provide more daily oversight, or they would upgrade the tracking systems used to make sure detention officers are checking inmates.
DHHS investigators do not look into most out-of-custody deaths. The exceptions, Tonizzo said, are jail suicides.
But some others are the result of incidents within the jail, including overdoses. Since the inmates had been released from custody while in the hospital, those deaths can escape DHHS investigation. That’s a loophole that lawmakers only partially closed in 2018.
Before then, even in-custody deaths weren’t required to be reported if the inmate had left the jail and died elsewhere, The N&O reported in a series on jail deaths in 2017. But lawmakers have not acted on calls requiring DHHS to investigate all deaths in which an inmate became infirm in the jail.
“That is the worst behavior, when somebody is ill or near death and the jail goes to the effort to perhaps involve a judge or the district attorney to change the conditions of the bond to avoid the responsibility for the death,” Pollitt said. “That’s a glaring loophole in our system.”
Will Jail Deaths Keep Dropping?
There is hope that jail deaths continue to decrease. Last year, state lawmakers and Gov. Roy Cooper approved Medicaid expansion, which is expected to make health insurance coverage available to roughly 600,000 more people. Improved health care may divert those with mental illness, drug and alcohol addictions or other serious maladies away from jails.
“If those folks get the help they need to never come to our detention centers, then we see the benefits,” said Blackwood, the Orange County sheriff.
In addition to that, state lawmakers directed $99 million of a federal Medicaid expansion signing bonus to provide services to people in the justice system who suffer from mental illness, substance abuse, intellectual or developmental disabilities, or people with traumatic brain injuries.
“This one-time tranche of funds (to be spent over a two-year period) will help to ensure we are providing treatment and support when and where it is needed — ideally, before the involvement of law enforcement, or while they are incarcerated,” Tonizzo said in an emailed response.
But Pollitt noted the money won’t last, while two key underlying causes of jail deaths will continue.
“$99 million should make a difference,” she said. “But in many of those areas they mentioned, it needs to be recurring funding, not one-time funding.”
The state budget also includes money for two additional inspectors that Cooper and state Rep. Carla Cunningham, a Charlotte Democrat, had requested to look into deaths and jail conditions. Tonizzo said the DHHS expects to post those positions for hire soon.
If you know someone who is thinking about suicide, help is available at 988, the Suicide and Crisis Lifeline.
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