In “Case in Point,” The Marshall Project examines a single case or character that sheds light on the criminal justice system. An audio version of Case in Point is broadcast with The Takeaway , a public radio show from WNYC, Public Radio International, The New York Times and WGBH-Boston Public Radio.

The final six days in the life of 37-year-old Army veteran Elliott Earl Williams read like a table of contents in some ghoulish law enforcement manual about how not to treat a mentally ill person in jail. Or maybe a horror movie would be a better metaphor, since his final hours inside the David L. Moss Detention Center in Tulsa, Oklahoma, were recorded on surveillance tape, portions of which will be shown next month to jurors in a federal courtroom there.

The panel of citizens will decide in a civil rights trial beginning Feb. 21 whether Tulsa County Sheriff’s Office executives strayed from their constitutional obligations to Williams in October 2011 and how much, if anything, the county should pay for those fatal transgressions. More than that, the panel will hear about Williams’ avoidable death within the context of a seemingly ceaseless stream of similar stories about abuse and neglect inside the Tulsa County jail. At least 20 people have died inside that facility since 2010, many in grim circumstances.

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There also are stories of extraordinary carelessness within the facility that did not result in death. In April, for example, another federal jury will hear a case about a special needs jail inmate, Aleshia Henderson, who in September 2011 was raped by a fellow inmate when the two were left briefly alone by guards in the medical unit of the jail. Another lawsuit, filed last year, alleges that an inmate was deprived of the medicine she needed once she arrived at the jail, began having seizures, and suffered cardiac arrest after a breathing tube was negligently inserted into her throat.

The allegations in all of these cases — more than a dozen lawsuits have been filed, and some already have resulted in jury verdicts — may differ in their particulars but they share three themes. First, inmates in that jail were often in mortal danger because of poor training, flawed policies, and a lack of adequate funding for staff and services. Second, the grave problems that emerged over the years were either discounted or covered-up by administrators. Finally, even now, amid heightened public awareness of the problems, officials have been slow to make the jail safer.

Williams' story, both in the days that led up to his death and the years that followed it, tracks a broader story of the treatment of the mentally ill in the nation's jails. First came the failure to train first responders. Next came inept screening by medical staff. Then came the mistreatment by jailers, untrained and unsupervised in the handling of vulnerable inmates.Finally came the cycle of madness and discipline: the more Williams’ guards lashed out at him, the sicker he got, which only made his jailers more frustrated and angry.

And what happened after Williams’ death is also familiar: foot-dragging, cover-up, and nobody held accountable except, perhaps, the taxpayers, when courts award damages.

Six Days

According to court records and coverage by The Frontier, a Tulsa-based news organization that has doggedly covered the unfolding jail scandal, Williams’ relatives took him on October 21, 2011 to a hotel in Owasso, a northern suburb of Tulsa, because he “was having psychological issues” following a break-up with his wife. Williams wasn’t sleeping. He was said to be suffering from a bipolar disorder. He quickly made trouble in the lobby of that hotel and the local police were called to the scene. They saw him eat dirt and ramble on about God. He refused their commands to sit down, and acted strangely, so the cops pepper-sprayed Williams and took him from that hotel to the city jail.

There, Williams began barking like a dog, taking off his clothes, and trying to hide. The police moved him to the Tulsa County jail. There he was roughed up and locked in a cell. Even though he had told the police that he wanted to die he was not placed on a suicide watch. Within an hour, he had rammed his head so hard into the steel door of his cell that he fell to the floor. He told his jailers, including medical personnel at the jail, that he couldn’t move because he had broken his neck. They didn’t believe him.

So they left him for 10 hours in that holding cell without any medical help. The next morning, when he still couldn’t move, jail staff belatedly declared a “medical emergency” but all that meant was that a nurse yelled at him to get his “nasty ass” into the shower and to “quit fucking faking.” To get him into the shower, two guards put Williams onto a gurney and then dumped WIlliams off the gurney into the shower, where the prisoner again hit his head. He was left in that shower for three hours. He continued to complain that he was paralyzed. His jailers continued to refuse to believe him.

For the next three days Williams languished in a holding cell, untreated. Instead, he was told to adopt “coping skills.” It took three days for a psychiatrist affiliated with the jail — a doctor paid for by a private prison health care company — to evaluate Williams, but the doctor did little more than order the prisoner put into a so-called medical cell. No neurological test was administered to confirm (or rule out) Williams’ claim that he was paralyzed.

For two more days Williams told his jailers that he could not move, that he was thirsty and hungry, and for two more days the staff inside the jail failed to adequately feed him, care for him, or provide him with water. Staff tossed food trays into his cell, considering him a safety risk, but Williams could not reach them. Nor could he reach cups of water placed there for him to drink. Jail supervisors laughed at him and made jokes about sodomy. Take a look at the video and judge for yourself:

Around noon on October 27th, less than six days after he was first arrested, Williams was found dead on the floor of his cell. The video from that morning shows that his guards were more concerned with cleaning his cell of the food trays they had left for him than they were with getting him any medical help. Even in those final few hours he could have been saved, Daniel Smolen, the lead attorney in the civil rights litigation, told me last week. But he wasn’t. An autopsy confirmed that he had died from complications of a broken neck and dehydration.

Two hours after his death, prosecutors (who may or may not have been aware he was dead) finally charged Williams with a crime; a misdemeanor charge of obstructing the police because he refused to sit down on a curb. It was a crime that would not necessarily have resulted in any prison time had Williams been tried and convicted for it. Williams’ family members, who were not allowed to visit him during those six days, told reporters recently after watching what amounts to a snuff video: “At the end you can tell he knows nobody’s going to help him and he has given up and he’s thinking; ‘Lord forgive them, for they know not what they do.’”

Unheeded warnings

But they did know. In the six years since Williams died the men and women directly responsible for his care, and their supervisors, have offered up a series of legal defenses designed to shield them from liability for what happened to Williams and to the other Oklahoma residents who entered the jail healthy and left it dead or injured. The main defense is that they are or should be protected by what’s called “qualified immunity”; a standard that requires any plaintiff seeking damages to show that jailers were “deliberately indifferent” to a “substantial risk of harm” that existed at the time of the accident or injury.

It’s a high legal standard designed by the courts and legislators to protect police and prison guards from liability for borderline cases of neglect or abuse. But the federal judge presiding over the Williams case concluded last July that this was no borderline case; that Williams’ basic medical and nutritional “needs were obvious to any layperson” and that he was deprived of necessary care and treatment because of “the medical unit-wide attitude of inhumanity and indifference shown” to him.

It wasn’t just how Williams was treated that convinced U.S. District Judge John Dowdell that this might be a “deliberate indifference” case worthy of getting to a jury. It also was the fact that those same jail officials were told six times in independent audits between 2007 and 2011 that there were systemic problems with the way inmates received (or, more precisely, did not receive) medical care inside the jail. Williams’ jailers were warned, over and over again, that there were systemic deficiencies in the delivery of medical care to inmates. One medical auditor, for the Department of Homeland Security, even noted a “prevailing attitude of indifference” shortly before Williams’ death in 2011.

It would be inaccurate to say that jail officials did nothing when confronted with these critical evaluations. Newly-disclosed records show that the sheriff at the time, Stanley Glanz1, reacted to the consistently poor audits of his detention facility by ordering his subordinates to hide inmate files that might generate additional concerns from investigators. Another official, an employee of the private prison health care company, even ordered her staff to gin up what the court called “dummy charts” for the auditors to chew on.

1 Glanz made national headlines two years ago when one of his friends, Robert Bates, acting as some sort of "reserve" deputy, fatally shot a man during an undercover drug buy. Glanz was forced to resigned after he was caught covering up an earlier investigation into Bates' work.

The problems at the jail were not secrets kept hidden by bureaucrats. In 2010, according to records obtained by The Frontier, Tulsa County prosecutor Andrea Wyrick warned then-Sheriff Glanz and company that there were serious problems with the jail’s health-care system. Wyrick knew, she said, because Oklahoma County had sued the company that provided that care, Correctional Healthcare Companies, Inc., for falsifying records to cover up understaffing. Glanz did not fix these problems. Nor did prosecutors. No charges ever were filed against any of the men and women who let Williams die on the floor of his cell. The private provider, meanwhile, settled with the Williams’ estate several years ago.

Only one of the medical professionals involved in the treatment, or mistreatment, of Williams was disciplined for misconduct. One jailer was fired after the incident, The Frontier reports, but she says she was dismissed because she tried to help Williams and was precluded from doing so. She has now filed a discrimination lawsuit against her former employers. The Oklahoma State Bureau of Investigation, which at the time had ties to Sheriff Glanz, looked into the case, and issued a report, but the agent who headed the probe evidently did not even watch videotape showing Williams’ final days and death.

In 2013, in response to a wave of lawsuits generated by the deaths and injuries incurred inside the jail, Tulsa County Sheriff officials hired a new internal “watchdog” to review the procedures of the private medical provider at the jail. The watchdog, a nurse with considerably less experience than initially required for the position, had worked for medical care provider before, was married to a shift captain at the jail in charge of jail investigations, and failed to produce a single report2 about the death of the seven inmates who have perished there within the past two years.

2 The lone report she did produce, in 2015, was sharply critical of the performance of the private medical provider that succeeded the company that had been working at the jail at the time of Williams’ death.

Little wonder. In another document obtained by The Frontier, a former nursing executive swore in an affidavit that some jail staff members pretended to resuscitate dead inmates “so that the jail would not become a ‘crime scene.’” An internal review later determined that as many as six of the inmates who died in 2009 and 2010 might have lived if they had been given even adequate medical care. All of this was known to jail officials when, in 2014, they claimed through a spokesman that their record of care at the facility was “impressive” given “the clientele that we have to deal with.” Calls to the jail last week went unanswered.

Meanwhile, there’s a new sheriff in town. Vic Regalado has taken over for Glanz, who was forced to resign in disgrace after a national scandal involving the shooting death of a civilian by one of Glanz’s friends. Like his predecessor, Regalado has told reporters that he hasn’t spent time reading the details of the allegations contained in the lawsuits now pending against him. Like his predecessor, he’s in court fighting to keep secret more written records and surveillance video that could shed light into other deadly episodes at the jail. Last summer, in a written statement, his office offered this: “Sheriff Regalado is committed to administering the Tulsa County Sheriff’s Office with positive leadership, accountability and compassion.”

An earlier version of this story incorrectly said that Williams was arrested in 2001. It was 2011. In addition, Stanley Glanz's name was spelled incorrectly in one instance.