A prison doctor has been fired and two staffers are in the midst of being dismissed after an inmate at the Kentucky State Penitentiary starved himself to death ina case that has exposed lapses in medical treatment and in how hunger strikes are handled at the facility. Prison officials have asked prosecutors to investigate after the Associated Press began asking questions about the inmate's death.



James Kenneth Embry, 57 and with just three years left on a nine-year sentence for drug offenses, began to spiral out of control in the spring of 2013, after he stopped taking anti-anxiety medication. Seven months later, in December, after weeks of erratic behavior – from telling prison staff he felt anxious and paranoid to banging his head on his cell door – Embry refused most of his meals. By the time of his death in January 2014, he had shed more than 30lb on his 6ft frame and died weighing just 138lb, according to documents reviewed by the AP.

An internal investigation determined that medical personnel failed to provide anti-anxiety medication that may have kept his suicidal thoughts at bay and didn't take steps to check on him as his condition worsened. The internal review of Embry's death also exposed broader problems involving the treatment of inmates – including a failure to regularly check inmates on medical rounds and communication lapses among medical staff.

The AP, tipped off to Embry's death, obtained scores of documents under Kentucky's Open Records Act, including a report detailing the investigation into Embry's death, an autopsy report and personnel files. Along with interviews with corrections officials and correspondence with inmates, the documents describe Embry's increasingly paranoid behavior until his death and the numerous opportunities for various prison staff to have intervened.

"It's just very, very, very disturbing," said Greg Belzley, a Louisville, Kentucky attorney who specialises in inmate rights litigation and reviewed some of the documents obtained by the AP. "How do you just watch a man starve to death?"

According to the report of the internal investigation, Embry stopped taking medications for anxiety in May 2013. Seven months later, he told the lead prison psychologist, Jean Hinkebein, on 3 December that he felt anxious and paranoid and wanted to restart those medications. But the psychologist concluded Embry didn't have any significant mental health issues, even though Embry repeatedly talked about wanting to hurt himself. Hinkebein and an associate considered his comments vague, and his request for medication was denied.

Seven days later, Embry began banging his head on his cell door and was moved to an observation cell where he refused meals and told the prison psychologist: "I don't have any hope."

He soon began refusing most food, though he drank tea on occasion while continuing to make threats to hurt himself in the ensuing weeks.

A nurse checked on Embry on 4 January, finding him weak and shaky, and advised him to resume eating. Embry responded that it had been too long for him to start taking food again. Nine days later, on the day he died, an advanced practice registered nurse named Bob Wilkinson refused a request from other medical staffers to move Embry to the infirmary at 11.51am and said the inmate should be taken off a hunger strike watch, according to the internal investigative report. Guards found Embry unresponsive in his cell hours later, his head slumped to the side. He was pronounced dead at 5.29pm.

Lyon County coroner Ronnie Patton classified Embry's death as a suicide and listed dehydration as the primary cause of death, with starvation and several other medical ailments as secondary causes.

The documents obtained by the AP show a prison system with a dated protocol for handling hunger strikes, staff who weren't familiar with its provisions, and others who said they were told not to follow them. In Embry's case, those in charge of his well-being were simply counting on him to cave in and start eating again on his own, the records show.

On 16 January, three days after Embry's death, Steve Hiland, the lead physician at the maximum-security prison, signed off on a nurse's note about Embry consistently refusing food and being taken off of the hunger-strike watch because he drank tea. During the internal investigation, Hiland said he believed a hunger strike consisted of missing "six or eight meals" and ended when the inmate ate or drank anything at all.

In a revealing exchange, investigators asked Hiland how he thought inmates were supposed to be removed from a hunger strike. Hiland told them that prison staff "usually don't have to worry about it because they [the inmates] eventually give up."

James Kenneth Embry died on 13 January. Photograph: uncredited/AP Photograph: uncredited/AP

When Embry stopped eating regularly, the Corrections Department's existing guidelines recommended multiple checks of the inmate's vital signs three times a week, repeated visits with a physician and ongoing evaluations by a psychologist.

Medical staff would later tell internal investigators they were either unfamiliar with the protocols for handling a hunger strike or that Hiland and Wilkinson forbade those procedures from being used. There is no mention of whether anyone considered force-feeding the inmate.

Corrections investigators determined Embry continued to refuse most food, though he drank tea on occasion while continuing to make threats to hurt himself in the ensuing weeks. Investigators concluded that Embry refused 35 of 36 meals before his death.

The state has placed Hinkebein, who is also in private practice in Central City, Kentucky, on administrative leave, and said it is in the process of firing her and her associate. Hinkebein declined to comment, saying she was still a state employee.

The internal investigation found that Hiland and Wilkinson didn't check on inmates as they should have during routine visits. The report also documented multiple communication problems among medical staff and allegations that other nurses were intimidated by Wilkinson, a contract staffer who works for Nashville, Tennessee-based Correct Care Solutions.

Phone and email messages left with the company seeking comment from managers there and from Wilkinson were not returned.

Embry, a heating and air conditioning repairman by trade, had no family or friends visit him at the prison, and no one claimed his remains. He is buried in a potter's field near the penitentiary.