When Alan Lancaster died in January 2023 at South Central Correctional Heart in Licking, Missouri, his household went on the lookout for solutions.
The Missouri Division of Corrections recorded his loss of life as an accident and supplied few extra particulars. His household requested information from the jail’s investigation into his loss of life, paperwork similar to the interior investigative report which may paint a fuller image of Lancaster’s final moments. However their requests for extra info have been “largely ignored,” based on their lawyer, Joe Allen.
It wasn’t till they reached out to the county coroner who dealt with Lancaster’s physique that his household realized the 39-year-old had been in a restrictive housing unit for over two weeks when he died from a fentanyl overdose.
In March, Lancaster’s mom, Mary Harris, filed a wrongful loss of life go well with in opposition to the jail system. The coroner’s information, together with a loss of life certificates ruling Lancaster’s loss of life a murder, offered the idea for Harris’ lawsuit alleging that jail officers did not correctly look after her son.
“Alan was in solitary confinement and by some means dies of a fentanyl overdose,” Allen stated. “How do you get fentanyl whilst you’re in solitary confinement?”
When somebody dies in a Missouri jail, the jail system is required to offer sure info to households in regards to the loss of life. Workers ought to notify emergency contacts of the loss of life and clarify how one can entry the deceased’s medical information, based on the Missouri DOC’s communications director. For extra info, households or their attorneys can submit information requests. State regulation dictates that even when sure information are usually closed, the DOC ought to present households entry to these paperwork “for functions of investigation.”
However households of people that died in jail and their attorneys advised The Marshall Venture – St. Louis that the DOC doesn’t at all times observe its personal insurance policies. Left with unanswered questions on how their family members died, some have as an alternative turned to the coroner. Whereas coroners are elected officers typically answerable for investigating violent or surprising deaths of their county, Missouri’s statute requires coroners to “totally examine the important info” surrounding each loss of life in custody, no matter the way it occurred. The data from their investigations may also help households discover a sense of closure — and when deaths are suspected to be the results of abuse or neglect, a coroner’s investigation may play a job in holding the jail system accountable.
In contrast to states similar to New York which have medical boards to overview deaths behind bars and mandate coverage adjustments, coroners present the one assure of outdoor scrutiny when somebody dies in a Missouri jail. And though individuals who die in custody annually are notably weak to disappearing from public document, the statutes governing precisely how coroners conduct their investigations include nearly no record-keeping necessities.
Traditionally, these insurance policies have granted coroners broad discretion in how completely to analyze, leading to an uneven normal of jail loss of life investigations throughout the state.
Now, in Missouri and throughout the nation, a coalition of forensic scientists, public well being researchers and authorized consultants is pushing for extra sturdy coverage and oversight to carry each jail loss of life investigator to the identical excessive bar.
“The coroner actually is, in lots of locations, the one alternative for out of doors overview or oversight,” stated Dr. Roger Mitchell, president of the Nationwide Medical Affiliation and co-author of the e-book “Dying in Custody.” “So states have to take management over their loss of life investigation equipment, making certain that there is uniformity.”
When Tanekka Visitor’s husband, Christopher, died at South Central jail in October 2023, she struggled to study the reality about his loss of life from jail officers. All of the warden advised her when he broke the information was that her husband died in his sleep, Visitor stated.
“I used to be like, ‘How? What occurred?’” she recalled. “The warden simply stated, ‘I’ll let you understand extra info after we get it.’”
Visitor stated she referred to as the jail almost every single day for a month to talk to the warden, however he was by no means out there. Finally, she spoke to an investigator, who advised her she would obtain a flash drive with the contents of her husband’s pill. Neither the flash drive nor the data she was promised ever got here, she stated.
“They stated they might let me know once they had the reason for loss of life — they by no means did that, by no means advised me any info,” she added. “It was only one pushback after one other.”
Particulars about her husband’s reason behind loss of life finally got here from the county coroner, who referred to as Visitor to elucidate what occurred: After a interval of suicidal ideation, her husband overdosed on fentanyl and died. Visitor stated the largest distinction between her communication with the coroner and the jail was the follow-up. For weeks, Visitor stated she referred to as the jail and by no means obtained any particulars. However each time she referred to as the coroner, she received a solution. If she left a voicemail, it was promptly returned.
“Speaking to her was so comforting as a result of she saved it 100% trustworthy,” Visitor stated. “She stated all the pieces she might to place your coronary heart and thoughts relaxed.”
Karen Pojmann, the DOC’s communications director, stated the jail system “doesn’t withhold loss of life info from households.” Post-mortem stories, performed by the health worker, can be found to anybody who requests them, she stated. Experiences from the division’s inside loss of life investigations are technically open to the general public, however Pojmann stated they are often closed or closely redacted “for quite a lot of causes, together with … delicate info that might compromise the safety of the power.”
Though no company or division retains an official rely, there are quite a few reported cases of households submitting lawsuits in latest years in opposition to the Missouri Division of Corrections to attempt to get info in regards to the deceased’s ultimate moments in jail. Households in Missouri describe being repeatedly stonewalled by jail officers.
In a single occasion, an appeals courtroom ordered the DOC to pay a mom over $60,000 in penalties and courtroom charges for failing to offer video footage and the jail’s inside investigation of her son’s suicide in 2021. In one other case, a courtroom ordered the DOC to pay $5,000 after ruling that officers “knowingly and purposefully violated” public information regulation by refusing to offer video and different investigative information to a different lady whose son was crushed to loss of life in jail that very same yr.
“They don’t hear again from the Division of Corrections, or they’ll deny plenty of information requests,” stated Lori Curry, government director of the advocacy group Missouri Jail Reform, of households’ experiences with the jail system. “It might probably actually break your spirit to attempt to discover out the reality about one thing and regularly run into brick partitions.”
The coroner’s independence from the jail system can imply they’re emboldened to be direct and trustworthy with households about how somebody died, loss of life in custody researchers famous. Coroners have the power to freely hand over info like post-mortem stories and loss of life certificates. In contrast, restricted oversight and the chance of being held legally accountable for a loss of life behind bars creates an incentive for jail officers to both cowl up or misattribute causes of loss of life.
After Christopher Scroggins died at South Central in June 2022 on the age of 23, the Division of Corrections listed his method of loss of life as “unknown.” However when an legal professional representing the household requested the coroner’s information, he realized that Scroggins’ loss of life was truly because of a fentanyl overdose.
The legal professional, Geoff Meyercord, stated he wasn’t afraid to sue the DOC for extra particulars if essential, regardless of dealing with what he described as appreciable pushback and roadblocks. However protracted litigation, and having to relive the loss of life time and again, is usually a important emotional burden for households, he stated. Notably for households who’re simply trying to reply fundamental questions on their cherished one’s loss of life, it’s usually simply simpler to ask the coroner.
“We at all times need to take the trail of least resistance if we will,” he stated.
When households do select to file a lawsuit in opposition to the jail for a wrongful or preventable loss of life, consultants say coroner information will be crucial to constructing a case. In Lancaster’s case, the household’s repeated makes an attempt to get information from jail officers or from the DOC went unanswered. “All of the companies have collectively failed and refused to adjust to the regulation and produce the requested paperwork, conspiring to and interesting in a cover-up,” the criticism states, inflicting the household “excessive psychological and emotional ache, struggling and anguish.”
In contrast, the coroner’s report was offered with out protest and supplied essential particulars, together with {that a} corrections officer was reportedly “fired over the episode” two days after Lancaster died.
“Lancaster was murdered whereas within the custody and care of MDOC,” the criticism alleges. “The Division of Corrections … abjectly failed of their obligation of care to Lancaster, leading to his preventable murder.”
The lawyer for Lancaster’s household famous he “ wouldn’t have made that particular assertion with out some supporting info.”
Bettering record-keeping is very invaluable for deaths in custody, stated Marie Lasater, the previous Texas County coroner who investigated the deaths of each Lancaster and Visitor. When a loss of life happens behind jail partitions, households not often see and even communicate with their cherished one of their final moments, and don’t have speedy entry to the essential info they in any other case would about how the particular person died. If a loss of life was preventable, prisons could make it troublesome for households to ever discover out, Lasater famous. Because of this, she added, incarcerated folks want extra of an investigation than a loss of life within the free world.
“There’s much more chance for a jail loss of life to be reported [as] one thing apart from what it was,” she stated.
After Howard County Coroner Trisha Clark moved again to Missouri from Florida simply earlier than the pandemic, she stated she was shocked by a few of her friends’ practices. Quite than coroners, Florida’s system for loss of life investigations depends on health workers, who’re required by statute to maintain duplicate copies of information, together with post-mortem stories and lab investigations. Florida additionally has a information to record-keeping, and a fee whose job it’s to guarantee “uniform requirements of excellence.” In Missouri, no such guardrails exist.
Clark additionally works as a forensic investigator for Boone County, house to the minimal safety Fulton Reception and Diagnostic Heart, the place 5 folks died final yr. She stated a lot of Missouri’s newer coroners perceive the significance of investigating jail deaths completely and independently, quite than merely rubber-stamping the jail’s model of occasions. Nonetheless, it’s a problem to get coroners in each county on board with out some minimal normal of record-keeping.
“You may have coroners that actually have a pocket pocket book the place they’re writing a reputation and a date of beginning,” she stated. “These households should not getting a full, thorough investigation as a result of [the coroner] is rather like, ‘Oh nicely, no matter.’”
Nationally, authorized and medical researchers, in addition to forensic scientists, are pushing to reform the investigative system for deaths in custody. The purpose, they are saying, is to enhance public understanding of how deaths occur and cut back the variety of preventable deaths. In a latest report, the Nationwide Academies of Science, Engineering and Drugs advisable that states require licensing for anybody performing jail loss of life investigations, in addition to an annual peer overview for all coroner and health worker’s places of work of not less than 10% of their circumstances. The report additionally advisable the federal authorities replace its loss of life certificates template to incorporate a checkbox for deaths in custody.
Specialists say there are a number of easy measures Missouri might take to enhance the investigative course of for individuals who die in jail, beginning with clarifying expectations. State coverage instructs coroners to analyze, however doesn’t say a lot about what that investigation ought to appear to be. Coroners can select to speak to witnesses, or not, and there’s no requirement for digitization of information.
Making certain transparency round jail deaths would require the state to create new requirements, famous Aaron Littman, co-lead of UCLA Regulation’s Behind Bars Knowledge Venture. These requirements would possibly stipulate how shortly jail loss of life investigations have to be accomplished, what information have to be collected from the jail, and the way a lot of it have to be public or made out there to households.
State legislators might standardize record-keeping by mandating all coroners and health workers use the identical software program and reporting methods, consultants added. (The previous head of Missouri’s Coroners and Medical Examiners Affiliation advised The Marshall Venture – St. Louis he’s within the early phases of proposing a invoice to just do that.) Policymakers might additionally require the general public well being system to replace the state’s loss of life certificates type with a transparent designation for in-custody deaths, researchers famous, so the general public isn’t reliant totally on the felony justice system to trace and report deaths. Missouri’s Division of Psychological Well being has a fatality overview panel tasked with assessing “all suspicious deaths” of adults within the division’s custody; researchers identified that the state might create an identical panel for jail deaths.
To grieving households, a coroner’s skill to be a useful resource within the face of an opaque jail system can imply not solely accountability for his or her cherished one’s loss of life, but additionally closure. Coroners famous that bettering the usual of reporting would provide all households an equal probability to know what occurred, eliminating the hypothesis and uncertainty that may exacerbate their grief and struggling.
For weeks after her husband’s loss of life, Tanekka Visitor clung to a fading hope that jail officers would offer any details about Christopher’s ultimate moments. She stated the one element the warden shared — that Christopher died in his sleep — left her with extra doubt and questions: Was he alone? What might have killed him so abruptly? When she heard a rumor from one other incarcerated particular person about foul play in her husband’s loss of life, she stated it almost broke her.
After going weeks with out solutions, Visitor stated the coroner gave her the data she wanted to correctly grieve. Eventually, she stated, she might relaxation.
“I couldn’t consider it at first,” Visitor stated. “However that’s how I used to be lastly in a position to get nearer to him: realizing what occurred.”
