Record number of inmates died in North Carolina jails. Supervision failures persist.

Kyle Kepley of Reidsville had been hearing voices and experiencing panic attacks, his mother said. He knew he needed help, but feared telling others he was mentally ill. At one point, his girlfriend drove him to a mental health facility in nearby Greensboro, but he was too afraid to seek admission.

Not long after that, the couple was involved in a minor car accident. Police arrested Kepley after seeing he had a warrant for failing to return to court on a traffic violation, his mother said. A magistrate set his bond at $25,000 cash, an amount the part-time electrician who struggled with bipolar disorder and drug addiction couldn’t meet.

So Kepley, 35, was brought to Rockingham County jail, where four inmates had died the previous year — three of them after jailers failed to check on them at least twice an hour as state regulations require. Two died by suicide.

That pattern repeated itself just two days after Kepley was locked up, state Department of Health and Human Services officials found. Detention officers failed to check on him for stretches as long as three hours prior to the early hours of May 3, 2022, when Kepley used a bed sheet to hang himself.

“It’s sickening,” said his mother, Melissa Efird.

Kepley and two other inmates who died inside the Rockingham jail last year are among 77 inmates in North Carolina jails who died in 2022, the sixth consecutive year of record-high deaths in this state’s county detention centers.

“It’s terrible, it’s skyrocketing and it’s shocking,” said Susan Pollitt, a supervising attorney with Disability Rights North Carolina, a nonprofit advocacy group.

A News & Observer review of jail deaths in 2022 showed several grim trends:

• Deaths among inmates locked in county jails more than doubled when compared to 2017, when 36 inmates died. Deaths inside jails have accelerated since 2020 while the average number of people locked inside jails dipped due to the pandemic, state records reviewed by Disability Rights NC show.

• More than half of the deaths occurred at jails where inspectors found staff failed to comply with state rules for supervising inmates, state records show. In previous years, DHHS investigators found supervision violations in roughly a third of the deaths.

• Suicide accounted for more than a quarter of all deaths, with supervision lapses documented in state investigations of 14 of those 23 deaths. In McDowell County, video footage did not back a claim that an inmate who died of suicide had been checked on.

• The opioid abuse epidemic played a lethal role. Eighteen deaths were tied to overdoses or complications from opioid withdrawal, autopsies show. In some cases, inmates accessed the drugs inside jails.

• For the fourth time in four years, an inmate killed another inmate, one autopsy reported. No one has been charged in that death.

The overall death toll is likely higher. Jails reported 13 additional inmate deaths but told DHHS officials those happened out of custody in hospitals or at state-owned Central Prison. Autopsies show some of those inmates who died in the hospital had become infirm in jails.

But since judges released the inmates from custody, their deaths were not investigated, a loophole The N&O exposed in the 2017 series Jailed to Death. After the investigation was published, lawmakers required sheriffs to report inmates who died at hospitals while still in their custody, but not inmates released from custody.

Two jails failed to notify DHHS of deaths in 2022 within five days, as regulations require. The Hoke County jail took several weeks to notify DHHS of two deaths.

In the Triangle area, DHHS cited Durham, Harnett and Wake county jails for missed checks after an inmate death. Staff at all three told DHHS that they were taking steps to make sure detention officers made checks in a timely manner.

Advocates, sheriff see different causes

The dramatic rise in the number of deaths and the violations show a broken detention system that needs reform, say those monitoring the loss of life. In death after death, DHHS investigators found repeated violations of supervision regulations, but the result is almost always the same: Jail officials say they are taking corrective actions and DHHS accepts the promises.

“It just shows the consequences of a lack of a regulatory system that works and can enforce the jail rules,” said Luke Woollard, a staff attorney with Disability Rights NC.

State jail regulations require detention officers to check inmates in person at least twice an hour. It’s a standard meant to protect inmates and staff. If inmates become ill or infirm, jailers have a better chance at rescuing them. It also helps reduce the risk that inmates will try to harm others.

Detention staff can be charged with misdemeanor criminal negligence under state law, but DHHS officials have said they lack the authority to use it. The State Bureau of Investigation often investigates jail deaths at the request of sheriffs, but their findings are not made public and rarely lead to criminal charges against jail staff.

DHHS has the authority to close a dangerous jail, a last-step option. The department needs other mechanisms, such as fines, to force jails to take the actions necessary to be in compliance, powers the department has when adult homes and psychiatric facilities fail to meet state requirements, Woollard said.

Sheriffs, however, point to traits among people brought to their jails and to challenges in finding enough staff to supervise them.

In email responses to questions, Orange County Sheriff Charles Blackwood, president of the North Carolina Sheriffs’ Association, said a growing number of people with drug addictions and mental illness behind bars contributes to the rise in death toll. This is happening while jails are struggling to find enough detention officers to do the required inmate checks.

One death in the Rutherford County detention center shows how that can be a deadly combination. The day before inmate Andrew Hodge, 34, died from a fentanyl overdose, jail staff intervened in four other inmates overdosing. DHHS found 10 missed checks of Hodge over the 20 hours leading up to his death on Jan. 12, 2022.

Rutherford’s sheriff’s office told DHHS that the 208-bed jail was 12 detention officers short and had increased pay by 10% to try to fill positions. Sheriff Aaron Ellenburg, who was elected in November, did not respond to requests for comment. Foothills Catalyst, an online news site, previously reported the supervision issues.

“We know that the best way to reduce jail suicide is to have an adequate number of staff to care for the facilities population,” said Blackwood, the sheriff association president. “We also know that factors which lead to suicide across our nation include but are not limited to; mental health issues, alcoholism, depression, anxiety, drug misuse, isolation, a feeling of loneliness, and most importantly folks simply looking for an escape from the situations they find themselves faced with. Do you think any of those factors might exist within our detention facility?”

“Considering all this I’m left to wonder why the numbers are not higher than they are,” said Blackwood.

Suicides and overdoses

DHHS cited Mecklenburg County for missed checks in four of five inmate deaths in one of its jails last year, the most of any county in the state. One was a suicide, two involved inmates with chronic health issues and what caused deaths in the other two cases has yet to be determined.

Mecklenburg Sheriff Garry McFadden said the hidden story amid the rising death toll is the number of inmates who county jail staff save from suicides and overdoses.

McFadden said in an interview that his staff performs roughly 2,200 checks in the jails per day. At times, jailers are dealing with a medical emergency or a fight and that can cause them to fall behind.

Fentanyl, a powerful opioid that can kill in very small amounts, has infiltrated jails, he said. In recent weeks, detention officers prevented two inmates from overdosing on it, he said.

“How do we stop fentanyl from coming in?” he said. “Nobody knows. Nobody can answer that.”

State officials could help by providing funding to help jails instead of adding punishments, McFadden said.

“If the state sees a problem why don’t we fund a remedy to solve these problems?” he asked.

Infrastructure investment?

This year, state lawmakers may be ready to spend more on county jails.

Republican state Sens. Danny Britt of Robeson County, Jim Burgin of Harnett County and Democratic state Sen. Julie Mayfield of Buncombe County have filed Senate Bill 451. It would create a $10 million fund intended to help sheriffs comply with the state health and safety standards.

The money, which counties would have to match, must cover “repairs and improvements” to bring jails into compliance. A Disability Rights NC investigation into jail inspections prompted the legislation, Mayfield said.

The money could be spent on infrastructure such as electronic systems that document inmate checks, but not personnel, she said.

“I don’t disagree that many of the deaths — perhaps most or all — are due to insufficient staffing, but we don’t have objective standards about staffing in the way we do about the condition of jails,” she said in an email.

The House budget would expand drug treatment in jails under a $2 million competitive grant program to include addiction inhibitors such as methadone and buprenorphine. Many jails are not deploying them, DHHS records show.

And after balking for a decade, lawmakers in the Republican-led General Assembly approved a Medicaid expansion plan this session. The expansion, which the sheriffs’ association supported, could provide health care to drug addicts and the mentally ill, potentially preventing downward spirals that often land people behind bars.

Budget proposals from Cooper and the House also include money to add two more DHHS jail investigators to the three on staff charged with keeping up with twice-yearly inspections at more than 100 jails and the growing number of death investigations.

Disability Rights NC supports all the proposed measures, Pollitt said. But their passage is not guaranteed.

One family’s investigation

No lawmaker has proposed legislation that would penalize jails for serious violations. The harshest penalty county detention facilities face now is when surviving family members file lawsuits.

That may be the next step for Kyle Kepley’s family. They have hired an attorney, David Ventura of the CR Legal Team in Greensboro, who is investigating his death.

The Rockingham jail’s track record over the past two years is a target for scrutiny, Ventura said. The DHHS found that the two inmates who died in the jail after Kepley in 2022 also lacked required supervision. An autopsy found one overdosed on fentanyl nine months after being admitted to the jail; the other inmate’s cause of death hasn’t been released.

All told, DHHS has flagged supervision failures in its investigations of six of the seven deaths in the Rockingham jail in 2021 and 2022.

Rockingham County Sheriff Sam Page declined to talk about the 2022 deaths. In an interview last year about deaths of inmates, he acknowledged staffing issues. His jail had added electronic reminders to detention officers and supervisors so that checks aren’t overlooked and two clinicians and a nurse, he said then.

In correspondence with the DHHS after Kepley’s death, a Rockingham sheriff’s captain said the jail was adding alerts to the devices detention officers carry to document the checks they make.

When a second inmate died after Kepler’s suicide, a captain told DHHS the jail began sending an email report documenting checks to supervising sergeants. After a third inmate’s death, a captain wrote: “We have met with each shift and stressed the importance of making rounds. Each shift was told that rounds are their number one job and everything else comes second and can wait.”

Kepley’s mother said the repeated supervision failures inside the jail that once confined her son show a dangerous situation that must be corrected. It would dishonor her son’s memory to do nothing, she said.

“I know there are hardened criminals that need to be put somewhere,” Efird said. “But it’s not a death-row prison, and their lives shouldn’t be in jeopardy.”