Politics & Government

Could her death have been prevented? NC jails on track for deadliest year.

On April Cumbo’s 42nd birthday, her husband and two young sons, ages 3 and 6, planned to visit her in the Wake County jail, where she was being held on driving-while-impaired charges.

But as her husband waited for the school bus to drop their eldest son home from school, sheriff’s deputies pulled up with devastating news.

Cumbo was in the hospital on life support. She had hanged herself in the jail that afternoon. She died a day later, on April 10, one of 33 inmates in the first eight months of this year who died in North Carolina jails or in hospitals while in custody.

Suddenly, Donald Weaver became a single dad, raising two children while juggling his work as a building contractor.

“He thinks momma is still at work,” Weaver said of his youngest son. “The older one, he really took it hard for the first couple months. He’s better now, but he still cries himself to sleep at least once a week wanting his mom.”

Her death and the 32 others potentially put North Carolina on pace to easily exceed the highest annual death toll for inmates in county jails. That was in 2015 when 40 inmates died, part of an upward trend in recent years that includes 39 inmates’ deaths last year. The state began tracking deaths in 1997.

Cumbo is also among 16 of those deaths investigated by state authorities in the first eight months of this year to see whether supervision requirements were met. In her case and six others, authorities found inmates weren’t properly watched. Department of Health and Human Services investigators found no evidence Cumbo was checked during one hour-long shift, and the jail’s electronic logs lacked evidence she had been checked at least twice an hour on two other shifts.

Cumbo may have needed closer observation. She had a history of depression and post traumatic stress disorder, her husband said. The state requires checks at least four times an hour for inmates who are a risk for suicide.

Jailed to death

Last year, The News & Observer reported in a five-part series, Jailed to Death, the high percentage of supervision failures connected to inmate deaths. More than a third of the deaths over a five-year period showed problems such as inadequate checks or items left in cells that made it easier for inmates to kill themselves.

The series prompted some state lawmakers to call for reforms, but the short legislative session that ended in June didn’t address the repeated problems with inmate supervision.

“It’s time for people to start taking this seriously,” said Susan Pollitt, a senior attorney for Disability Rights North Carolina, a nonprofit that advocates for those with physical and mental disabilities. “These are people’s parents and children and aunts and uncles who are dying in the jails.”

Lawmakers passed legislation that seeks to end a loophole that allowed jails to not report deaths if inmates had become injured or infirm in jail, but didn’t die until they reached the hospital. The law now requires all “in-custody” deaths be reported. That change, however, won’t capture cases in which a dying inmate was released from custody while in a hospital, unless the jail volunteers to report it. State records show two of the 33 deaths reported by jails were out of custody.

Lawmakers also required a study into how prescription medications are handled in the jails. The N&O and other news organizations had reported several deaths in which autopsies and other records pointed to discontinued or inappropriately administered medications.

Some of the DHHS investigations for this year found lengthy lapses in supervision. The regulations require all inmates be checked at least twice an hour. Those considered a threat to themselves, with a record of mental illness, suspected to be drug or alcohol impaired, or acting strangely or wildly, are supposed to be checked at least four times an hour.

In Swain County, the investigation showed Kendall Ryan Creasman, 27, had been checked only twice in five hours. He died June 1 of a drug overdose.

In Burke County, Paul Hyler, 56, should have been checked four times an hour, an investigation determined. In one hour-long shift there were no checks documented, and in five others the records showed he’d been checked only once. He died on March 31 in a local hospital of natural causes.

In Richmond County, Adrien Campbell, 30, died on June 14 of causes yet to be determined. He was in an overcrowded jail in an area where a video camera wasn’t working, the DHHS investigation found. There were no checks documented for three hour-long shifts, and only one check for each of 15 other shifts.

Burke County’s jail administrator, Billy Boughman, said Hyler didn’t need to be on a heightened watch. Boughman declined to comment on the lack of checks for some shifts, but the jail’s response to DHHS shows a jailer was fired and another was “counseled” on his responsibilities. Swain County Sheriff Curtis Cochran declined to comment as the SBI had yet to report its findings in the death, and Richmond officials could not be reached.

The DHHS handles each inmate death the same way. DHHS staff point out the flaws in supervision and require the jail to come up with a plan of correction, which the DHHS typically accepts. There are no fines or suspensions, even if a jail has repeated instances of supervision violations. The most the DHHS’s Construction Section officials say they can do is recommend to the DHHS secretary to close a jail, which has never happened.

State law allows for those negligent in supervising inmates to be charged with a misdemeanor, but that’s also never happened. DHHS officials last year said they were not aware of the law, and were not in a position to use it since they are not law enforcement officials.

Checks lacking in Wake jail

In Cumbo’s death, Wake jail director Dail Butler, in a written response to the DHHS, confirmed no checks were done for the first shift, but jailers performed the required checks for the other two. Problems with the system that records checks electronically caused those shifts to not be logged.

He told the DHHS the jailer on duty for the shift in which no checks were done had been disciplined, but didn’t explain what the discipline entailed. The jailer was not fired, demoted, suspended or given a pay cut — personnel actions that are required to be made public under state law. When asked by the N&O, Wake officials chose not to use what is known as the “integrity exemption” in state personnel law that allows more information to be released to provide the public with more confidence in government operations.

State officials had found no supervision issues regarding the death of another Wake inmate this year. Carl Cotton, 65, died from natural causes on April 22.

Cumbo’s death also prompted Wake jail officials to institute a new policy to keep 24 hours of video evidence at the time an inmate dies or is seriously injured. The jail had been erasing all recorded video after 30 days, so it had no visual evidence of how well Cumbo had been monitored. There is no state requirement to preserve video when an inmate dies.

Paul Gessner, an attorney for the sheriff, said the lack of checks for one hour “occurred at a remote point in time and had no bearing on the death of Ms. Cumbo.”

But there was another aspect to Cumbo’s death that doesn’t show up in the DHHS investigation. Cumbo had a history of depression and PTSD, her husband said. Evidence of her mental struggles exists within Wake’s incident reports, as well as a prior driving-while-impaired arrest in Pitt County.

On March 29, 2017, a little more than a year before her death, Cumbo set fire to a walking-talking Elmo doll in the fireplace of the family home, said Weaver, her husband. She then fled the house when a cable company representative showed up for an appointment, leaving their two young children, then ages 2 and 5, at the home as the plastic toy smoldered and smoked up the house.

Unbeknownst to Weaver, his wife had gone three months without her medications, which she began taking after their third child was stillborn in 2015. She thought Elmo was out to kill her children, and the cable representative was another threat.

“She just went further and further away,” he said.

Weaver said his wife was later found parked on NC 98 just west of Wake Forest, backing up traffic as she sang gospel songs. She was taken to WakeMed, he said, and placed in a psychiatric hospital for several weeks.

Weaver said representatives with Wake County Child Protective Services told him he needed to take out an order keeping her from the home or they would have to remove the children. Dara Demi, a county spokeswoman, said she could not confirm or deny his account because state law keeps child protective services cases confidential.

Cumbo was allowed back into the home several months later, after being put back on antidepressants. Things seemed to return to normal, Weaver said, but she had secretly begun drinking.

In response to a records request, Gessner provided an incident report that shows a detective investigated “a family offense” at the home at the time Weaver mentioned, with the victims listed as two children. The report said the case was closed with prosecution declined. He said the sheriff’s office had “no record” of whether that report was shared with jail staff.

The investigation into her first driving-while-impaired charge on June 10, 2017, nearly three months later, showed that she told an officer she had been recently discharged from a hospital after a “nervous breakdown.” She was ordered to take a blood test for drugs that may have impaired her driving. The test only found methadone, a painkiller also used to treat drug addiction (her husband said it was used to treat pain from a nervous system disorder); venlafaxine and o-desmethylvenlafaxine, two anti-depressants; and zolpidem, a sleep aid.

Shortly after Cumbo was arrested for the second DWI charge, Weaver said he brought her medication to the front desk of the Wake jail on Hammond Road. He said he told staff she had been previously institutionalized.

“I said, ‘Look, I got her medicine. If she doesn’t get her medicine, she’s going to lose her mind,’” Weaver said he told a staffer. “He told me that he couldn’t take her medicine, they will evaluate her there.”

Weaver said his wife told him in three phone calls from the jail that she hadn’t gotten her medicine. Gessner said federal privacy laws prevent him from speaking about an inmate’s specific medical information, but all inmates go through a screening in which they can report mental health and medical issues.

The DHHS investigation indicated Cumbo was not on a heightened, four-times-an-hour watch at the time she hanged herself. Weaver said he doesn’t understand why.

“Something went wrong in that jail cell is the reason she’s not here today,” he said.

It’s been hard explaining to their children what happened a year ago, and the loss of their mom today.

At one point, Weaver and Cumbo’s older son asked: “Why is mommy trying to burn me?”

“It was a bug in her head,’” he said he told his son. “She wasn’t trying to hurt you. That’s the way I tried to explain this. The bug came back and took her over. That’s why she passed away.”

Families not notified

Weaver was not aware that state DHHS investigators had found problems with her supervision. State law does not require families to be notified.

Joyce Holloman, whose son hanged himself in the Watauga County jail on Jan. 12 and died two days later, said she also received no notification. Holloman wasn’t told that Lincoln Horner, 40, had been left alone for 45 minutes in a section of the jail that had been evacuated due to a sewage backup. The DHHS cited the jail for supervision failures.

Lincoln Horner

She said she learned about the failures in an N&O report published May 10.

“I had no idea that my son was treated that way,” she said in a telephone interview, her voice breaking. “And they did nothing but lie.”

Horner was a single father who left behind a 14-year-old son and a 10-year-old daughter. Holloman said she is taking care of them on a limited income.

“I’m doing everything I can do to take care of his kids,” she said. “I’m just in this myself.”

It’s an open question whether lawmakers will want to take on jail supervision in next year’s long legislative session, which runs for several months every other year.

State Rep. Allen McNeil, an Asheboro Republican and former chief deputy for the Randolph County Sheriff’s Office, said in an emailed statement that jail deaths “continue to be a problem that needs attention.”

“I cannot specifically speak about why the issue was not addressed in the short session except to say the short session was truly short and we handled very little besides the budget,” he said. “I will look into this.”

Senate leader Phil Berger said a year ago after The N&O’s series that reforms were needed to help reduce jail deaths. He couldn’t be reached for this story, but his spokesman, Bill D’Elia, said the number of deaths so far this year are “extremely disconcerting.” D’Elia said that in addition to the reforms, lawmakers provided $10 million for community-based substance abuse treatment, which could help some people with addictions clean up before ending up in the jails, where they are high-risk inmates.

He also noted DHHS is in the process of adopting new rules that would make the four- and twice-an hour checks more effective, along with emphasizing that no other duties are to be performed while inmates are being checked. Advocates for inmate safety say those changes don’t go far enough.

D’Elia didn’t rule out lawmakers revisiting jail regulations when they return in January for the long session.

“This is something that the legislature will continue to keep an eye on and make sure that counties are living up to their responsibility to safely house inmates,” D’Elia said.

A passing report from the DHHS after an inmate death does not necessarily mean there were no other problems. In Durham, for example, no deficiencies were found in the supervision of Dashawn Evans, 23, who died on May 27 of a drug overdose. An autopsy found a toxic combination of fentanyl and heroin in his system.

Evans had been in the jail for seven months.

Carteret jail lawsuits

In the space of 18 months three inmates died in the Carteret County jail. The state found supervision problems in all three deaths.

Since then, the families of Amanda Hogan, 28, Patrick O’Malley, 32, and Justin Everett, 28, have all filed lawsuits, and four months ago O’Malley’s family settled with the county for an undisclosed amount.

O’Malley died of a heart attack on Dec. 15, 2015, after being left in a restraint chair for more than nine hours — beyond what the sheriff’s policies allowed.

U.S. District Judge Terrence Boyle signed the settlement.

Hogan and Everett hanged themselves in the jail. State investigations found the jail hadn’t checked them as closely as regulations required. Hogan died Dec. 7, 2015, and her family early this year filed a lawsuit against the county, jail officials and Southern Health Partners, a company that provides health care in jails.

In July, the family of Everett, who died June 2, 2017, filed a lawsuit against Carteret County Sheriff Asa Buck and several unidentified jailers.

In all three cases, the families of the inmates learned of the supervision issues from News & Observer reports.

National reporting on jail deaths

While North Carolina’s death toll in jails has been trending upward the past few years, federal authorities have fallen behind in reporting jail deaths nationally.

The latest full report on jail deaths from the U.S. Bureau of Justice Statistics covers 2014, and includes preliminary information on 2015. It came out in December 2016.

Tannyr Watkins, a spokeswoman for the bureau, said staffing shortages and backlogs of death reports contributed to the delay.

“There are just all types of different reasons why the data is not published as soon as we’d like it to be,” she said.

The bureau plans to publish full reports for 2015 and 2016 later this year, she said.

Deaths in Mecklenburg

Mecklenburg County has seen four jail deaths in a two-month period this year. State Department of Health and Human Services officials say there were no supervision problems with two of those deaths, while the other two remain under investigation.

The four deaths, and a fifth officials announced Wednesday, are the most the county’s jails have seen in a year since 2007, when seven inmates died, state records show.

The state found proper supervision of Kenneth Bigham, 39, who hanged himself from a sheet and died May 13, and Jamarcus McIlwaine, 34, who died June 28 from a cause yet to be determined.

The deaths still under investigation are Lavarchio Allen, 35, who died July 5 from a cause yet to be determined, and Jerome Thompson, 52, who died July 12 after jumping from the second floor of a general housing pod.

The sheriff’s office reported Karla Griffin, 33, died just after midnight Wednesday of an apparent suicide in a Jail North general housing pod. That death will likely also be investigated by the state DHHS.