There also have been three such deaths in the St. Louis County Justice Center this year. Multiple investigations are underway. Across the nation, deaths per capita in local jails have been on the rise every year between 2011 and 2014, the last year that full data are available, according to the Bureau of Justice Statistics.

Ames’ death stands out because of the way it happened, strapped to a chair in a holding cell directly in front of the booking desk.

“It blows my mind that they use that chair the way they do,” says Farmington attorney Vonne Karraker, who filed the wrongful death lawsuit on behalf of Ames’ father, William Ames Jr., and mother, Laurie Braun. “If they just read the instruction manual, Billy would be alive.”

The first words of those instructions? “WARNING: Use of the SureGuard Correctional Chair without first reading and thoroughly understanding the instructions could cause injury or death.”

Detainees “must be monitored regularly,” the instructions say, and provided “medical treatment.” Instructions suggest a two-hour time limit to be held in the chair. If monitored by a doctor, an inmate could be held in the chair for up to 10 hours, the instructions say.