For years, the general public had no approach to know simply how many individuals died in Missouri’s prisons, a Marshall Mission investigation discovered, as a result of the state Division of Corrections wasn’t counting.
As a substitute of annual totals, the division traditionally responded to public information requests with partial counts, cobbled collectively from a number of sources. Information retailers and researchers unknowingly reported the inaccurate numbers to the general public: Did 125 incarcerated folks die in 2023? Or 134? Possibly 137?
“Deaths are reported as they happen,” DOC Communications Director Karen Pojmann wrote in an e-mail to The Marshall Mission – St. Louis in October. “At no level through the yr is the division required to current a complete/complete tally to any exterior company or different group.”
The division is required to report every loss of life to the federal authorities, however these information are additionally flawed and lacking a number of Missouri deaths, a Marshall Mission investigation discovered. Missouri’s Division of Public Security collects loss of life information from the jail system, however a DPS spokesman stated these are closed to the general public. Based on its web site, DPS “doesn’t evaluation, compile, consider or analyze the submitted studies.”
Some states, like Illinois, share annual studies on jail deaths brazenly. However in Missouri, the jail system isn’t required to report year-end totals to anybody.
The quite a few discrepancies underscore how simply folks in jail can disappear from the report — and the way little residents, researchers and policymakers truly learn about who dies in jail and the way. Consultants say withholding particulars and mixture knowledge from the general public makes it tougher to determine developments, and simpler for the system to evade accountability for deaths that would have been prevented.
The shortage of year-end loss of life knowledge is “extraordinarily regarding,” stated Dr. Roger Mitchell Jr., co-author of the e book “Demise in Custody” and president of the Nationwide Medical Affiliation. “There must be mortality opinions in order that we evaluation these instances, not simply to carry folks accountable for issues that weren’t accomplished appropriately, however in order that if issues can enhance — we enhance these issues.”
In early 2024, the DOC up to date its knowledge assortment methodology, routinely pulling every loss of life from its “offender administration system” right into a single doc and updating it weekly. However the brand new course of wasn’t utilized retroactively, that means loss of life information previous to 2024 have been incomplete.
Nonetheless, in response to repeated questions from The Marshall Mission – St. Louis about discrepancies in beforehand offered loss of life information, the division’s analysis workforce generated a brand new report. This report consists of each loss of life recorded by the DOC from 2018 to 2024, and marks the primary time complete jail loss of life totals have been made publicly obtainable.
A complete of 844 folks died over the seven-year interval, in accordance with the brand new report, greater than has beforehand been reported. The division’s sample of inconsistent record-keeping — which mirrors nationwide developments — highlights the necessity for skepticism towards any loss of life in custody knowledge, specialists say.
Even the latest knowledge launched by the state supplies an incomplete image of deaths in jail. It doesn’t embody age, race, gender or the trigger and circumstances of a loss of life. The lacking particulars make it unimaginable to identify patterns or use the info to higher perceive why persons are dying.
Typically, coroner information can fill within the gaps. In April, The Marshall Mission – St. Louis obtained entry to seven years of loss of life investigations at South Central Correctional Heart, a jail in Licking, Missouri. The archival information from the county coroner cowl deaths from 2018 to 2024 and provide a vital window into the power’s wrestle to adequately deal with drug use and persistent well being circumstances behind bars.
Based on its new record-keeping system, and confirmed by coroner information, the division recorded 18 deaths at South Central in 2024 — the second-highest rely of any Missouri facility. South Central additionally had the second–highest charge of deaths per 100 folks incarcerated within the state’s services final yr, in accordance with knowledge from the jail.
“Folks [in prison] are calling South Central ‘loss of life row,’” stated Déna Notz, a former corrections officer on the jail who left after a yr and have become a jail reform advocate. “Due to how many individuals find yourself dying there, and the way many individuals find yourself attending to the purpose the place they may have died.”
Drug overdose was the highest explanation for loss of life at South Central from 2018 to 2024, the coroner information present, revealing the size of the drug drawback contained in the jail. The overdoses, most frequently from fentanyl, symbolize roughly a 3rd of deaths in 2024. Problems from persistent well being circumstances equivalent to coronary heart illness or diabetes made up one other third of the deaths that yr. Exterior jail partitions, these circumstances could be extra readily monitored and handled.
The information additionally reveal discrepancies within the method of loss of life: the broad classes used on loss of life certificates to explain how somebody died. In two instances, deaths with causes that have been listed as “unknown” within the DOC’s information have been dominated by the coroner to be homicides.
Pojmann, the DOC’s communications director, stated the in-custody loss of life charge for Missouri is “common amongst corrections programs” within the U.S. and decrease than that of six of the 9 bordering states. The loss of life charge additionally continues to say no, she stated.
Whereas the division has pointed to an growing older inhabitants as one of many major causes for jail deaths, greater than half of the individuals who died at South Central have been 55 years outdated or youthful.
The life expectancy for males in Missouri is ranked fortieth within the nation, at barely over 71 years. At South Central final yr, males died on common simply shy of 53 years outdated.
A coroner’s loss of life investigation can embody all the things from the post-mortem and toxicology studies to medical information and the jail’s personal notes a couple of loss of life. These studies generally reveal the circumstances surrounding an individual’s loss of life, equivalent to after they have been discovered, who notified jail officers and whether or not the individual was alone.
Within the absence of particulars from the jail, coroner information could be illuminating. Every so often, coroner investigations can make clear, or complicate, the usually sparse narratives provided by the jail. For instance, the DOC reported {that a} man died in January 2020 from an accident at South Central, with few different particulars talked about within the loss of life log apart from his title. Coroner information reveal that the person was discovered of his cell, useless in a janitor’s closet from a drug overdose and soaked in an unknown liquid. (The coroner’s report reads: “urine?”)
Later that yr, a 46-year-old Haitian man suffered a sudden coronary heart assault on the jail throughout breakfast, and was pronounced useless that afternoon. The jail’s investigation reported “no main well being historical past,” in accordance with the post-mortem report, regardless of a well-documented historical past in his medical information of coronary heart illness and excessive ldl cholesterol, and a earlier coronary heart assault on the jail in 2011.
The DOC reported {that a} man died of pure causes at South Central in December 2022. His post-mortem report, included in coroner information, recognized an untreated tooth an infection because the contributing think about his loss of life.
And in September 2023, the DOC reported {that a} man died by suicide, once more with little info apart from his title. The coroner’s investigation discovered that the person had a recognized historical past of psychological well being challenges, and hung himself in his cell two months after the jail system stopped offering correct treatment for his melancholy.
Consultants say stopping future deaths throughout the jail system hinges on recording details about deaths of their totality, quite than one after the other.
“You want the [total] quantity, and never simply the quantity,” stated Mitchell. “It is the trigger, it is the circumstances, it is the extent of therapy. It is full opinions of these deaths.”
Nationally, researchers have known as for an overhaul of record-keeping for deaths in custody. Some states have medical evaluation boards that examine deaths behind bars and suggest adjustments correctional and medical workers should make to forestall related deaths sooner or later.
However recognizing developments isn’t potential with out strong historic loss of life knowledge. And insufficient record-keeping presents a problem not just for policymakers, but additionally for grieving households who should struggle for solutions about how their family members died. For some elected officers in Missouri, the dearth of reporting necessities and exterior oversight is an indication that the DOC is overdue for reform.
“There must be some stage of documentation and there must be some form of scrutiny,” stated state Rep. Gregg Bush, a Jefferson Metropolis Democrat who’s a nurse by coaching.
“It’s simply so unconscionable to me,” Bush stated, that households of the deceased are “having to piece these items collectively, contextualizing the loss of life of any individual who’s in our custody, who we’re accountable for their wellbeing.”
