It couldn’t have been any clearer to Wilkes County jail staff that Emily Jean Call intended to kill herself.
She had been arrested on April 16, 2012, for missing a court date. Call had told detention officers then that she was high on crystal methamphetamine and wanted to kill herself. She had cut her wrist two weeks earlier, requiring a trip to the emergency room, state records show.
After two days in jail, she told medical staff she was sick, fatigued and depressed, feeling like she was going to have a nervous breakdown. The county’s mental health provider was no longer offering services at the jail, which meant no one was available to treat her mounting depression, the records show.
She should have been watched closely – at least four times an hour, according to state regulations. But Call, 32, a mother of two struggling with drug addiction, went unwatched for more than an hour. She slipped away to a bathroom in a common area, slung a bed sheet over a water pipe, tied it around her neck, stood on a toilet and stepped off.
“I said: ‘Please, I beg you, watch her,’ ” her mother, Anna Call, recalled telling a jail employee she knew. It was among many phone calls she said she made to jailers to keep an eye on her daughter.
She said her daughter was being treated for a suicide attempt when she was arrested for missing a court date.
Emily Call was one of 51 inmates who died in North Carolina’s county jails in the past five years after being left unsupervised for longer than state regulations allow, a News & Observer investigation shows. Jailers failed to make timely checks, left in place sheets or towels that prevented them from seeing suicide attempts, or didn’t fix broken cameras or intercoms that helped them keep in touch with inmates.
The deaths of unsupervised inmates came in 38 different jails, in rural and urban areas. Twelve of the jails, including Durham, have been cited for violation of regulations in more than one death.
In Carteret County, Patrick O’Malley, 32, died of a heart attack in 2015 after being left in a restraining chair for more nine hours. Amy Blankenship, 35, was left unobserved for 51 minutes in her Davidson County cell in 2013 before she was found hanging; a video camera used to observe inmates was not running during part of that time.
In Durham, Terry Demetrius Lee hanged himself in 2013 on dangerous window bars; the 21-year-old had been left alone for nearly six hours in his cell. In Dare County in 2012, Matthew Clayton Reynolds, 29, went nearly seven hours between checks, plenty of time to hang himself.
“There were no rounds made the entire day,” a state report said of Reynolds’ death. “...It is clear that there was a gross failure to properly supervise inmates.”
Numbers are ‘appalling’
At any given time, up to 24,000 inmates are held in North Carolina’s 113 jails. They include inmates awaiting trial, some convicted of misdemeanors and a few federal prisoners. The jails are supervised by elected sheriffs.
Often, the inmates who died had not been convicted of the charges that landed them in jail. Many were for lesser offenses such as illegal panhandling, drug possession and larceny, though some had been charged with more serious offenses, such as murder.
The deaths account for slightly more than half of those investigated from 2012-2016 by the Department of Health and Human Services’ Construction Section, which is better known for inspecting medical facilities. A lack of supervision was blamed for one out of every three of the 151 deaths in county jails in that time period.
The deaths also expose the rising number of inmates who suffer from mental illness, drug addictions or both – and underline the importance for jailers to check on them frequently.
Since 2012, DHHS has been routinely sending an investigator to review inmate deaths to see if jails are following regulations for safety and security that have been on the books for two decades. The regulations require detention officers to check on jail inmates at least twice an hour – and a minimum of four times an hour if inmates show signs they are mentally ill or suicidal, appear to be on drugs or alcohol, or are acting wildly or aggressively.
Detention officers are supposed to directly observe inmates and document those checks. Cells for inmates considered a suicide risk should be free of items that could help them kill themselves.
Experts in jail security and the care of inmates said the number of supervision failures point to broader problems that need quick attention.
“What it tells you is these county jails are maybe 50 percent of the time not doing the supervision they are supposed to do,” said Jeffrey Schwartz, a nationally-known expert on jail and prison security who has been a court-appointed monitor of troubled detention facilities. “And by doing that they are putting inmates at risk, and it’s a life or death matter.”
State Rep. Marcia Morey, a former chief district judge in Durham, said she was shocked at the number of deaths linked to supervision failures.
“The duties of the jail to properly manage, supervise, care for these inmates is paramount,” said Morey, a Democrat. “And the number of cases that you’re telling me about when the regulations are not being followed is appalling.”
“...No one should die in a jail.”
Shrouding the details
Many family members weren’t aware about the details of the deaths of their loved ones, and they didn’t know about the DHHS investigations. No one told them.
Nearly four years ago, Lovina Coffin refused to believe her daughter would have hanged herself in a Davidson County jail cell. She asked a lawyer to look into her daughter’s death. Amy Blankenship of Thomasville had a history of drug abuse that helped land her in jail, but she also had four young children.
The lawyer confirmed what the sheriff had reported: It was a suicide. Coffin had to accept it.
What she didn’t know was that Blankenship was left unobserved for 51 minutes in her cell before she was found hanging. A video camera in the cell block set up to keep inmates under observation also wasn’t running for much of that period.
DHHS investigators cited the Davidson jail for violating the supervision standards, but that wasn’t conveyed to Coffin. She cried when a News & Observer reporter recently showed her the report.
“Why didn’t somebody tell me?” Coffin asked. “This shouldn’t have happened to her.”
Blankenship’s death ended a troubled life. She dropped out of high school and never held a job, suffering from what her mother called a nervous disorder.
She had drug arrests and four children she couldn’t care for because of her drug habit, her mother said. Lovina Coffin said the drug use, mostly methamphetamine, began about three years before Blankenship’s death.
Lovina Coffin said she had to kick her daughter out of her house.
A police officer arrested Blankenship after she drove to Coffin’s home in violation of a protective order. When the officer arrived, Coffin said she and her husband had changed their minds about pressing charges and wanted to take Blankenship to a treatment facility, but the officer arrested her. She had also violated probation on a drug-related conviction.
Initially, jail staff put Blankenship on a suicide watch, but that ended after four days. She hanged herself three days later. The DHHS investigation found the jail hadn’t met the minimum twice-an-hour check required for all inmates.
“We thought her going to jail, it would help her,” Coffin said. “People kept saying if she went to jail maybe she’d get off of that stuff.”
A year before Blankenship’s death, DHHS officials found the Davidson jail had failed to properly check another inmate, Raymond Miller, 51, of Archdale, who died of complications from diabetes. He was supposed to be checked four times an hour, but the logs showed that didn’t happen. A video camera had been set up for observation of his cell, but it was motion sensitive. If an inmate didn’t move, the camera didn’t record, and it didn’t pick up Miller’s distress.
Davidson County officials declined to talk about inmate deaths in the jail.
9 hours in restraint
Patrick O’Malley’s family described him as a hard worker who hoped to be a chef. The father of two had worked as a grill cook for a Cracker Barrel and as an assistant manager at a fast-food restaurant and a convenience store.
But he developed an addiction to inhaling chemicals in spray cans used to clean off computers and other electronics, and had spent time in a rehab facility to try to stop it, said his stepfather, John Parker.
O’Malley couldn’t stay off of the inhalants. On Dec. 7, 2015, he had been caught stealing the spray cans from a store in Carteret County, arrest records show.
After seven days in the Carteret jail, O’Malley became agitated and attacked a detention officer. He was shot with pepper spray and strapped into a restraint chair, state records show.
He would stay there for more than nine hours, at times hallucinating, before he had a seizure that shut down his heart. Jail policy limits use of a restraint chair to two hours in most cases, and no more than six without the approval of a doctor, detention captain, chief deputy or sheriff. No one had approved the lengthy use of the chair.
Daniel King, a jail captain, told a DHHS official in a letter four months later that all restraint chairs had been removed after O’Malley’s death until all staff had been trained. They were also to undergo training to recognize and properly respond to inmates acting abnormally because of drug withdrawal or mental health issues.
Parker didn’t learn of these issues until contacted by an N&O reporter. He said he received a call from Sheriff Asa Buck the day his stepson died, but there was no mention of anything improper.
“He was never a violent person,” Parker said of his stepson, who stood 5-5 and weighed 155 pounds. “... He was so small you could pick him up, put him on your shoulders and take off running with him.”
O’Malley’s death was the second in eight days in which Carteret jail staff failed to supervise an inmate properly, a DHHS investigator said. Amanda Hogan, 28, should have been identified as a suicide risk and checked more frequently, DHHS investigator Chris Wood said in a report to the jail. She wasn’t, and she hanged herself.
Jail officials disputed that they had enough information to view her as suicidal, but agreed to be more thorough in screening inmates during booking. The jail began contracting with a psychologist, and Buck expanded medical staff hours.
‘We’re not insensitive’
Sheriffs and jail administrators who spoke with The News & Observer say they place a high priority on keeping inmates safe.
“We’re not insensitive people,” said Durham County Sheriff Mike Andrews. “We all have families and we all have loved ones and have had those we know that have been incarcerated. So I don’t want anything to happen to anybody, and neither do the men and women who work here in this facility.”
'He said during the past five years his staff has taken several measures to make the jail safer. One was removing window bars that inmates had used to hang themselves. That’s how Terry Lee killed himself in a Durham cell in 2013.
The DHHS investigation found Lee had a known history of mental illness and should have been observed four times an hour. The electronic record of detention officers’ rounds showed Lee went unobserved for nearly six hours the day he hanged himself, and had put a towel over his cell door window so no one could see what he was doing.
The Durham detention officer who was supposed to be checking on Lee was fired, said Maj. Julian Couch.
DHHS investigators cited Durham again three years later, when Matthew Lamont McCain, 29, died from a seizure disorder. A review of the electronic sensors again showed a lack of required supervision, though this time detention officers’ rounds were more frequent. A detention officer was disciplined.
In June, DHHS cited the Durham jail a third time, as an investigation into a teen’s suicide found a lack of supervision and a failure to take seriously a tip that the inmate was planning to harm herself. Uniece Fennell, 17, had not been checked at least twice an hour through much of the day leading up to her suicide, and was not put on suicide watch when the tip came roughly two hours before her death in the early morning of March 23.
The jail has added new policies to make sure checks are done and requiring that any information suggesting inmates are threats to themselves be brought to the attention of supervisors and mental health staff.
Hiring enough officers?
The state has not set staffing standards for county jails, state officials say. Sheriffs determine proper staffing depending on the number of inmates, level of supervision required and the physical layout of the jail.
But the state expects staffing to allow proper checks on inmates. DHHS investigative records show that in some cases jails were understaffed or overcrowded, or where detention officers had been given tasks that kept them from supervising inmates.
Some sheriffs have gone to their county commissioners for more money for additional officers and more money to boost their pay. Sheriffs have also asked for new jails that are better designed for inmate supervision and free of items inmates can use to kill themselves.
But in other cases, jail officials admitted their detention staffs didn’t do their jobs.
In Matthew Reynolds’ death in Dare County, two detention officers claimed they were making repeated checks.
A DHHS investigator reviewed the video. It showed no checks being made from 9:39 a.m. to 4:34 p.m., on June 23, 2012, when another inmate found Reynolds hanging in his cell. He had used a bed sheet tied around three clothes hooks that were supposed to collapse, but didn’t.
“It’s my understanding they were just standing behind the desk and not going out to actually walk around and do the rounds,” Capt. Allen Moran, the jail administrator hired after Reynolds’ death, said in an interview.
Reynolds lived with his wife in Manteo and took care of stray cats and dogs for the Outer Banks SPCA. But he also had a history of opioid abuse, and had completed a detoxification regimen at Central Prison before being sent back to the Dare jail to await the outcome of domestic violence charges.
Kyle Kerrigan, a friend who also had worked at the shelter, said he never knew Reynolds to be violent. He loved animals, and his wife had four dogs, two of them rescues.
Reynolds sought to curb his addiction, driving regularly to Virginia Beach, Kerrigan said, to obtain methadone to control his heroin cravings. Kerrigan said his friend needed drug treatment, and likely struggled with confinement.
“What he needed to do is to go to a psych ward where he would be evaluated,” Kerrigan said. “But I don’t know who made the decision that he should be locked up, like a criminal, and that’s what did him in.”
A day before Reynolds hanged himself, he complained of severe back pain. He couldn’t receive pain medication because of his drug addiction.
Reynolds’ death prompted jail officials to add an electronic system that confirms rounds have taken place. Detention staff also must write comments after rounds to show they are doing them. Supervisors and the chief jailer are also required to make rounds.
The county paid his estate a $25,000 settlement.
A mother’s pain
Emily Call’s death led to a $105,000 settlement from Wilkes County, but the money hasn’t erased the pain her mother feels. Her most devastating thought is how long her daughter hung from the water pipe above the toilet before she was taken down.
Call struggled with arthritis and fibromyalgia, a disorder that causes widespread muscular pain, Anna Call said. Her daughter gave up work as a certified nursing assistant and had gone on disability. The father of Emily Call’s daughter had died unexpectedly several years ago. That’s when her mother believes she started abusing drugs.
She had a record in North Carolina of misdemeanor larceny and operating a vehicle without insurance, court records show. Two weeks before her arrest, she begged on her Facebook page for people to pray for her.
“Only God can save me,” she wrote. “I am so broken down in so many ways. Where do I go for peace?”
Wood, the DHHS investigator, wrote about multiple mistakes of jail staff: “...Several failures occurred that could have possibly prevented this suicide,” he wrote. “...While there is no way to be sure that this suicide could have been prevented, the facility failed to follow several requirements.”
Wilkes County Sheriff Chris Shew did not respond to requests to discuss Call’s death.
Like several family members of inmates who died in North Carolina jails, Anna Call shared her daughter’s story for a simple reason: She doesn’t want anyone to die the way her daughter did.
“If it can save one person that they do not have to go through this, that it can change one situation, it’s worth it,” she said.
Next: Why some deaths don’t count.
90 minutes or more
Inmate: Jerry Dewayne Stanley
Cause of death: Stanley, 52, was high on cocaine, oxycodone and fentanyl in March 2015 when he entered the jail to serve a weekend stint for an impaired driving conviction. An officer said he thought Stanley was asleep when he looked in on him before going to lunch, but he didn’t check further to make sure he was OK. When the officer returned an hour later, he found Stanley dead from an overdose.
Time between observations: Two hours, 40 minutes
Inmate: William Joseph Gares Jr.
Cause of death: Gares, 37, was awaiting extradition to Pennsylvania on a parole violation when he put a sheet over the bars and door of his cell in November 2014. Detention officers left it there as they walked by. Two hours and ten minutes later, another inmate looked behind the sheet. Gare’s lifeless body was hanging in what was later ruled a suicide.
Time between observations: Two hours, 31 minutes
Inmate: Archie Kelly McNeilly Jr.
Cause of death: McNeilly, 40, complained of feeling weak when he was booked into the jail in May 2015 on charges of felony breaking and entering, larceny and possession of stolen goods. He couldn’t control his bowel movements. He went unobserved in his cell for more than two hours before detention officers found him dead of renal failure.
Time between observations: Two hours, 35 minutes
Inmate: John Trenton Smith
Cause of death: Smith, 39, suffered from depression, seizures and alcohol abuse and was in jail awaiting transfer to state prison after pleading guilty to assaulting an officer with a deadly weapon. He had appeared to be sitting on the floor next to his bunk in March 2015, but an inmate later noticed he was partially suspended by a sheet wrapped around his neck and tied to the top of the bunk. A state investigation found detention officers were performing other tasks that kept them from their required rounds.
Time between observations: One hour, 30 minutes
Source: Sheriff’s reports, State Department of Health and Human Services
Today: Left alone to die
Monday: No report necessary
Tuesday: Who gets punished?
Wednesday: Housing the mentally ill
Thursday: Some courts keep secrets
About the series
For this series, The News & Observer began filing public records requests two years ago to obtain reports of inmate deaths. The initial requests were to the state Office of the Chief Medical Examiner, and then to the state Department of Health and Human Services’ Construction Section and sheriff’s departments from across the state. The N&O also identified some inmate deaths through news reports in other in-state media.
Under former Gov. Pat McCrory’s administration, DHHS charged the N&O $255.60 for producing records. The N&O paid under protest. The state’s public records law says records must be provided “free or at minimal cost unless otherwise specifically provided by law.” McCrory’s successor, Gov. Roy Cooper, waived fees for substantial requests The N&O made after he took office.