In some custody deaths, surveillance video casts doubt on the actions of officers. In others, such as the 2008 death of Vanessa Morales (shown), it shows how difficult it can be to adequately monitor prisoners. Credit: Greenfield Police Department

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Myron Weston told a health care provider at the Milwaukee Secure Detention Facility he had tried to kill himself six times, all of them by drinking cleaning fluid and taking pills.

But that didn't stop officials from letting him work as a janitor.

Six months after revealing his previous suicide attempts, Weston made another one, drinking window cleaner. No one noticed — even though he was housed on a unit for mentally ill and infirm prisoners and was supposed to be closely monitored.

Despite the information in his prison medical record, neither guards nor medical staffers put the pieces together when Weston got sick. They allowed his condition to deteriorate for three days before taking him to the hospital.

By then, it was too late.

Of the 18 deaths in law enforcement custody from 2008 through 2012 in Milwaukee County, 12 — including Weston's — were classified as suicide or natural. Officials at every level have used those rulings to absolve themselves of responsibility for prisoners' deaths, a Milwaukee Journal Sentinel investigation found. In many cases, officials did not evaluate all of the circumstances surrounding the fatalities.

A 13th death, that of Derek Williams in the custody of Milwaukee police, originally was ruled natural but was changed to homicide after the Journal Sentinel reviewed the case more than a year later.

A state law specifically designed to hold law enforcement accountable when prisoners die was passed 30 years ago. But no one — in Milwaukee County or anywhere else in the state — has been charged with violating it for more than 20 years, according to a Journal Sentinel review of online court records, which date back to 1992. In Milwaukee County, Deputy District Attorney Kent Lovern said he could not recall the charge being issued in the 10 years before that, either.

Jailers who neglect sick prisoners are rarely disciplined. When they are, the punishments are often overturned.

Meanwhile, investigations of jail and prison medical staffers are kept secret, making it virtually impossible for the public to know if health care workers did the right thing, and whether they faced consequences if they did not.

Focusing on the manner of death is missing the point, said Fred Cohen, a retired law professor who has served as an independent monitor in several federal cases involving prisoners' civil rights. Instead, officials should be asking: Was this death preventable?

Weston's death, Cohen said, clearly was.

"That is as bad as anything I've ever heard," he said of the decision to let Weston work with cleaning products. "Not only did they know he was suicidal, they know how he did it, and they gave him the very agent that he's used to try to commit suicide. That sounds criminal."

Patient privacy cited

Weston, 41, suffered from schizoaffective disorder, a serious mental illness characterized by delusions, hallucinations, mania and depression, according to the medical examiner's report.

After serving prison time for second-degree sexual assault of a child, Weston was re-arrested and taken to the secure detention facility, a holding site for people who have violated probation or parole. It is run by the Wisconsin Department of Corrections.

Weston told a health care worker about his history of drinking cleaning fluid during a medical screening when he arrived at the facility in January 2009, records show.

Asked why he would be allowed to work as a janitor after that, Department of Corrections spokeswoman Joy Staab blamed the federal Health Insurance Portability and Accountability Act, a federal law designed to protect patient privacy.

"HIPAA prevents many DOC employees from knowing an inmate's medical history," she said in a statement.

Generally, inmates are assigned to jobs by security personnel, not medical staff, she said. Prisoners also can volunteer for open positions.

Records do not indicate which path Weston took to get onto the janitorial crew, Staab said.

Weston drank the cleaning fluid in late July 2009, about six months after his initial medical evaluation, according to an interview his cellmate did with a Milwaukee police detective.

On the first day Weston showed symptoms, a Thursday, he couldn't get out of bed. By Friday, he had moved his mattress to the floor in front of a fan and lay there all day, sweating profusely. When he tried to drink water from a jar, he spilled it. On Saturday night, Weston vomited in his bed. Corrections officers cleaned up and gave him a new mattress. On Sunday morning, he tried to stand and fell facedown on the floor. That's when officers called an ambulance.

After Weston died, an internal investigator at the Department of Corrections found no problems and made no recommendations for preventing similar deaths in the future.

"The death of Inmate Weston was a tragic event," the investigator wrote.

The only reason for Weston's suicide, the investigator concluded, was a recent breakup with his girlfriend.

Cohen said the breakup didn't absolve officials of responsibility.

"That's just a trigger, but it's a trigger on a gun you shouldn't have put in his hands," said Cohen, author of "Practical Guide to Correctional Mental Health and the Law."

The Department of Corrections' internal report does not say anything about Weston's history of drinking cleaning fluid or his work as a janitor. It also does not describe Weston's symptoms in the days after he drank the cleaning fluid.

The warden of the Secure Detention Facility, Floyd Mitchell, declined to be interviewed.

The Department of Corrections initially refused to release any records of internal investigations. After more than four months, the department turned over Unit Supervisor Rose Larson's investigative reports, which were heavily redacted and addressed only the actions of officers — not health care workers.

Department of Corrections staffers are trained annually in suicide prevention, according to Staab. Since 2012, more than 700 employees around the state have received more specialized training to help them better understand mental illness and potentially prevent suicide.

The years 2012 and 2013 saw just one suicide each throughout the entire Department of Corrections, which houses about 22,000 inmates, she said. The national average for that size prison population is about three or four per year, she pointed out.

Weston's suicide, which occurred in 2009, was one of four within the state's correctional facilities that year, Staab said.

The actions of medical providers are always reviewed when an inmate dies, according to Staab. She would not share the results of that review in Weston's case.

According to Larson's report, Milwaukee police were called to the scene of Weston's death.

But officials at the Police Department said they had no record of it.

Asked to check again, the department released a series of memos written by Milwaukee police officers to their supervisors.

The officers did not file official police reports, as they routinely do when they open a formal investigation.

The Police Department's involvement ended when the medical examiner's office ruled Weston's death a suicide.

The district attorney, too, closed the book on the case.

Looking at homicide

John Chisholm, who took over as Milwaukee County's top prosecutor in 2007, has never criminally charged an officer in connection with a death in custody.

Chisholm declined to be interviewed for this story, despite the fact that a reporter informed Lovern, his chief deputy, of the Journal Sentinel's findings and presented a detailed list of questions several months before publication.

Instead, Lovern submitted a four-paragraph statement on his boss' behalf that said, in part:

"The primary concern with an in-custody death investigation is threefold: first, was a prisoner exposed to excessive and unjustified force by law enforcement, second was there abuse by fellow prisoners and finally did the conditions of confinement contribute to the death in an unlawful manner. In our experience, the vast majority of in-custody deaths relate to pre-existing medical conditions, ingestion of dangerous substances, suicide and natural cause. Because there is rarely evidence of physical trauma that is identified as the primary cause of death, we rely heavily on the determination of death by the medical examiner."

Lovern made the same point last year, during an inquest into Williams' death.

Williams died after gasping for breath in the back of a Milwaukee police car as officers disregarded his pleas for help.

During the inquest, Lovern testified that when it comes to custody deaths, prosecutors are chiefly concerned with "whether in particular a homicide occurred at the hands of a law enforcement officer."

Every time someone dies in police custody — whether or not foul play is suspected — representatives from the district attorney's office respond and question officers.

In Williams' case, Lovern went to the scene. There, he viewed the squad video, which shows Williams struggling to breathe for nearly eight minutes.

The prosecutor's primary concern "was whether any officers had put their hands on him, frankly," Lovern testified. He wasn't looking for neglect. Rather, he was looking for obvious signs of injury.

The inquest into Williams' death is the only one Chisholm has ever asked for. It was convened only after a Journal Sentinel investigation found police had used force in arresting Williams, which prompted the medical examiner's office to change its ruling from natural to homicide.

Often, when Chisholm reviews a possible criminal case against an officer but does not issue charges, he writes a letter to the department's top administrator explaining the decision.

He followed that practice in the Williams case.

The prosecutor did not write letters after the deaths of Weston and the 11 other prisoners whose deaths were not considered suspicious by the medical examiner, according to Deputy District Attorney James J. Martin.

The reason?

"Because the individuals died of natural causes or suicide, and there was no reason to believe law enforcement officers contributed to the deaths," according to Martin.

Homicide, however, is not the only criminal charge that may be issued when someone dies in police custody.

Lacy law never used

In 1981, Milwaukee police arrested Ernest Lacy after a woman reported being raped by a black man.

Officers were escorting Lacy — who did not commit the rape — to a squad car when he tried to run away. Police admitted there was a struggle, but denied striking Lacy. He lost consciousness in the back of a police wagon and was pronounced dead about an hour later.

The medical examiner documented more than 30 cuts and bruises on his body.

After Lacy's death, the state Legislature made it a misdemeanor for a police officer to fail to render aid to a prisoner.

At the time of Williams' death 30 years later, the law had never been used.

As a result, special prosecutor John Franke had to write his own jury instructions for the Williams inquest.

Franke's interpretation: The law requires that an officer "knew that first aid was necessary and knew that bodily harm would result and either had the purpose of causing bodily harm or was aware that his conduct was practically certain to cause bodily harm."

Attorney Jonathan Safran, who represents Williams' family, disagrees. Safran believes the only intent required by the law is that the officer "intentionally failed" to render aid. Not calling paramedics for someone who needed medical assistance would qualify even if the officer did not intend to harm anyone, in his opinion.

Even using Franke's stricter standard, the inquest jury found probable cause to charge three Milwaukee police officers with failing to render aid to Williams. Franke, though, declined to issue the charges, saying he didn't think he could prove the case.

Two other state laws could be used to hold officers accountable for in-custody deaths, but in Milwaukee County they never have.

One is a felony: abusing or neglecting a prisoner in a penal facility. That charge has been issued just twice in the county since 1992 — only once under Chisholm, according to online court records. Both times, corrections officers were charged for non-fatal beatings. Charges were dropped against one officer after a jury couldn't reach a unanimous verdict. The other officer reached a plea agreement and was convicted of two misdemeanors.

The final charging option for prosecutors faced with a death in custody is misconduct in public office, which may be filed as either a misdemeanor or a felony. Prosecutors in Milwaukee County have secured misconduct convictions against dozens of police officers in connection with a range of behaviors, such as beating suspects, conducting illegal strip searches and taking bribes.

Discipline usually avoided

Not only do officers avoid criminal charges when prisoners die, they rarely face discipline of any kind — even when investigations cast doubt on their actions.

The 18 prisoners identified by the Journal Sentinel died in the custody of four different agencies: the state Department of Corrections, the Milwaukee Police Department, the Greenfield Police Department and the Milwaukee County sheriff's office.

Not all of the deaths were preventable, and many resulted in policy changes designed to better protect prisoners in the future. Other deaths involved lapses in judgment or failure to follow rules by jailers.

The Department of Corrections did not discipline any officers in connection with Weston's death or the other two fatalities at the Secure Detention Facility over the five-year period reviewed by the Journal Sentinel. One of the inmates was supposed to be monitored for substance abuse withdrawal, but no one checked on him when he reportedly had a seizure in the middle of the night.

The medical examiner determined that the other inmate, Peter Fengier, died of "early lobular pneumonia." Fengier, 40, had asthma and bipolar disorder but seemed healthy in the days before his death on July 29, 2012, nurses at the secure detention facility told police.

Symptoms of pneumonia include cough, fever, chills and trouble breathing, according to the American Lung Association.

Lewis Nelson, a physician and professor of emergency medicine at New York University, said that while anything is possible, dying of pneumonia without showing symptoms beforehand is "pretty unlikely."

At the Police Department, three people in addition to Williams have died in custody since Edward Flynn took over as chief in 2008. Neither Flynn nor the civilian Fire and Police Commission disciplined officers in connection with any of those deaths, despite potential rule violations.

A statement issued by Lt. Mark Stanmeyer said since Flynn became chief, the department has changed several procedures in an effort to better protect prisoners.

"Each in-custody death is a tragedy," the statement said, "and the Critical Incident Review Board examines each in-custody death and makes recommendations for policy change when appropriate. Several policy changes have been made as a result of those reviews."

The review board was formed in September 2012, after a Journal Sentinel investigation into the death of Williams. It consists solely of Police Department employees and is answerable only to the police chief.

In Greenfield, several policies were changed as a result of the death of Vanessa Morales in April 2008, according to Chief Brad Wentlandt.

Morales died of a drug overdose after being arrested for selling cocaine to an undercover officer. Video of her alone in the holding cell at the city lockup shows her quickly putting her hand to her mouth. Officers believe Morales, 20, may have swallowed cocaine she had hidden in her shoe or in the cuff of her pants.

In the past, officers would search shoes and return them to detainees immediately. Now, prisoners don't get their shoes back until they are released, Wentlandt said.

Female civilian employees, who sometimes search women in custody when female officers are not available, began receiving periodic refresher training on search procedures, he said.

The department instituted medical and psychological screenings for everyone who enters the lockup. This is a step beyond state rules, which require screening only for those who must stay in jail, not those who are booked and released, Wentlandt said.

The department also improved video monitoring of holding cells to allow for real-time monitoring if necessary.

An internal investigation did not show any rule violations by officers, Wentlandt said.

Police cannot legally strip search everyone who comes into the station because many have not been convicted of crimes, he said.

"As such, it is possible to conceal contraband in certain areas of one's person where even a same-sex search may not locate it," he said.

House of Correction death

Just two of the 18 in-custody deaths during the five-year period — both under the jurisdiction of the sheriff's office — resulted in discipline.

But more than half the punishments were reduced or overturned by the county's civilian Personnel Review Board.

Virgilio Jimenez, 30, had not been seen alive for at least six hours when his body, cold and stiff, was discovered around 10:25 a.m. March 3, 2009.

Jailers at the House of Correction, where Jimenez was being held on several misdemeanors and an immigration violation, are required to check on inmates every 30 minutes. But no one checked on Jimenez, who died of heart disease, when he missed breakfast or when he did not get out of bed during a search of the locker in his cell earlier that morning.

Sheriff David A. Clarke Jr., who oversaw operations at the facility at the time, recommended demotions of two sergeants and suspensions for three corrections officers for failing to make timely and thorough checks.

The Review Board overturned the sergeants' demotions, instead imposing five-day suspensions.

As for the three corrections officers, one negotiated for a shortened suspension. The review board upheld the other two suspensions.

"The Jimenez case highlighted many of the policy and practice problems of the (House of Correction), most notably related to the proper practices of housing unit inspections," Sheriff's spokeswoman Fran McLaughlin said in a statement. "The Milwaukee County Sheriff's Office corrected these practices and instituted new policies related to inmate management and oversight."

Man found hanging in cell

Two years later, Paul Heytens, his body rigid and his skin mottled purple, was found hanging in his cell at the county jail. His jaw was so stiff first responders couldn't get his mouth open to perform CPR.

An internal Sheriff's Department investigation determined that Heytens had not been seen alive for almost 11 hours. What's more, Heytens, who was being held on charges of felony drunken driving and hit-and-run, should have been monitored even more closely for symptoms of alcohol withdrawal.

Three days before he hanged himself by wrapping a sheet around a sprinkler head, Heytens told two nurses he was being treated for an anxiety disorder.

His doctor had prescribed two medications before his arrest, but once in custody, he never got them, records show.

The night before he died, Heytens filled out a form that said he urgently needed the pills, Pristiq — often specifically prescribed to prevent suicidal thoughts — and trazodone, which relieves depression and anxiety.

The form was found in his cell with his body.

Clarke recommended that four corrections officers be fired for failing to monitor Heytens properly. The Review Board exonerated one officer and reduced the punishment for another to a reprimand. The Board upheld the other two firings.

Clarke has routinely criticized the review board's decisions to overturn discipline. Often, the sheriff writes letters to the board expressing his displeasure with their actions.

"High standards start by my sending a clear and convincing message about appropriate behavior for our personnel. It is critical that we mean what we say. To say it but not show it sends a conflicting message," he wrote in one of the letters. "The needs of the public should not take a back seat to the interests of the employee when it comes to issues of integrity and credibility."

Standards for jail health workers

National standards dictate that jail health care workers, with the inmate's permission, contact outside doctors or pharmacists to verify medications or other necessary mental health treatment, according to Mary Perrien, an Idaho psychologist who served as an expert witness in a federal lawsuit regarding inmate suicides in California.

Because people booked into jails usually don't stay long, some workers feel it's not worth the effort and don't bother, she said.

"They have a constitutional obligation to provide treatment for any serious and chronic mental health diagnosis and anything like suicidality," she said. "They have to screen inmates as they come in and identify whether they have a mental illness and if they're suicidal, then they have to provide treatment if the person does have those kinds of symptoms.

The Sheriff's Department follows those standards, McLaughlin said.

"Of course, not all pharmacies are open 24 hours to confirm medications," she added.

Nurses visit the jail's housing units at least twice per shift, according to McLaughlin. In the past, inmates would submit routine written requests for medication to a guard, who then passed it on to a nurse on one of those rounds. Due to privacy concerns, inmates are now instructed to place their requests in locked boxes, which the nurses pick up.

For urgent issues, "correctional staff summons a medical professional to the housing unit immediately," McLaughlin said.

Because Heytens' daughter has taken the first step toward filing a civil suit, McLaughlin declined to answer specific questions about his case.

When a suicide occurs, a comprehensive review of all employees' actions should be done to determine whether it was preventable, Perrien said.

Officials at the Sheriff's Department do not evaluate medical decision-making as part of their death investigations, according to McLaughlin.

"That review is between the medical professionals (at the facility) and the medical professionals of the medical examiner's office," she said.

Last year, the County Board removed the House of Correction from Clarke's supervision. He continues to run the jail.

Health care worker accountability

State and federal laws make it difficult for the public to know if health care workers are held accountable when prisoners die.

Laws in Wisconsin and other states maintain the confidentiality of mortality reviews, the process by which medical professionals evaluate their colleagues' performance when patients die. Secrecy is necessary, proponents say, for doctors and nurses to honestly examine their shortcomings and come up with improvements. Fear of lawsuits or other public exposure would lead to less candor, they say.

On the federal side, the Health Insurance Portability and Accountability Act makes it illegal to disclose private health care information, even if the care is provided in a taxpayer-funded institution such as a jail or prison. The prohibition continues for 50 years after death to protect the family's privacy, according to the statute.

In response to an open records request, the Sheriff's Department released hundreds of pages of records detailing the investigation into the guards' interactions with Heytens. The department also turned over 28 pages of medical records, which listed the names of doctors and nurses who treated him, detailed the medications he received and described the efforts of first responders after he was found hanging in his cell.

But not a single document turned over to the news organization mentions why Heytens was not given his prescriptions for depression. Not a single page addresses the quality of the medical care he received in jail or the actions of doctors and nurses.

The state Department of Corrections disclosed even less information about Weston's case.

In the documents released to the Journal Sentinel, the department blacked out basic facts, including that corrections workers performed first aid and called paramedics. The department also redacted the cause and manner of death, which are routinely released by the medical examiner. Names of doctors and nurses responsible for Weston's care also were withheld, making it impossible to check their credentials or disciplinary histories.

The only way to be sure prisoners are receiving adequate health care is to file a civil lawsuit, said Ronald Shansky, a physician who has served as an independent monitor in several prisoners' civil rights suits, including one against Milwaukee County.

"There isn't a program in this country where a politician has bragged about the quality of services provided to inmates. It doesn't happen," Shansky said. "If there's no political clout behind providing good quality services, where is the pressure coming from? The answer is nowhere except litigation."

Family members have hired lawyers or filed notices of their intent to sue in connection with at least six of the 18 custody deaths examined by the Journal Sentinel.

Lawsuits can take years to wind their way through the courts. The last major settlement in a Milwaukee County custody death case — $1.2 million — came in 2003 as a result of the death of Paul Schilling, 51.

Schilling, an attorney and former president of the University of Wisconsin Board of Regents, died in the Milwaukee County jail in 1999. A diabetic who battled alcoholism late in his life, Schilling was arrested in Madison on a drunken driving warrant. While in the Dane County jail, he was treated for high blood sugar. When he was later transferred to Milwaukee, neither his medical records nor his prescription medication went with him.

A nurse at the Milwaukee County Jail, who did not have the results of a Dane County blood-alcohol test to the contrary, believed Schilling was drunk. She failed to diagnose ketoacidosis, a dangerous buildup of acid in the blood. Schilling collapsed in a cell and asphyxiated.

At the time, there was no law requiring jailers to share medical information about prisoners. As a result of legislation passed after Schilling's death, the Department of Corrections developed a standardized form for inmate medical information, which is now shared among jails and prisons.

But if that information is not passed on to individual workers responsible for an inmate's safety, it's of little use, Shansky said.

Weston should have been identified as a suicide risk after he revealed past ingestion of cleaning products — and not allowed to work as a janitor, Shansky said.

"When you've got that kind of detail, that would be a red flag and you would attempt to make sure that person didn't have that kind of assignment," he said. "That clearly is a breakdown."

Ellen Gabler of the Journal Sentinel staff contributed to this report.