Inside The Missteps At Louisville’s Jail: A Missed Transfer, An Ignored Inmate And A Late Investigation

[Editor’s note: This story was published as the second in a series about what LEO Weekly has learned about the deaths of Louisville jail inmates. To read Part I, an in-depth look at the circumstances surrounding the suicide of an inmate who was locked in an “attorney booth” and not checked on, please click here.]

The suicide of Louisville Metro Department of Corrections inmate Stephanie Dunbar in a cramped “attorney booth” that lacked a bed, running water or a toilet was not the only death at Louisville’s troubled jail where missteps were made.

Just days before an officer returning from a smoke break found Dunbar’s body hanging, another LMDC inmate had died after he was meant to be transferred to a hospital but kept in jail due to a “miscommunication,” records show.

And a third inmate’s death was not subjected to an internal breach of policy investigation for nearly four months — and that investigation was only initiated as the result of a journalist’s prodding.

Despite pledges from city leadership to find out what was behind the surge in fatalities at a facility that the mayor said previously averaged about three deaths a year for the past decade and a half, little remains known about most of the deaths.

LEO Weekly has obtained files related to the investigations of three of the ten jail deaths that have occurred in Louisville since May 16, 2021, a span of just over 14 months. In all three cases reviewed by LEO, there were significant missteps. LEO’s attempts to get files on other jail death investigations have failed, with the city repeatedly denying open records requests. 

Incarceration experts LEO spoke to were disturbed by both the number of deaths at Louisville’s jail as well as conditions in the jail.

“There’s the good, the bad and the ugly,” said Aaron Kinzel, a criminologist with the University of Michigan-Dearborn who previously spent a decade behind bars. “This really sounds like the ugly if there’s this many deaths that have occurred in such a short period of time.”

‘The Toughest Type Of Harsh Environment’

Experts who spoke to LEO Weekly said they had never heard of a jail using an attorney booth — a small room where inmates meet with legal counsel through a window — as housing before.

“I have not heard of a scenario before where someone was placed in an attorney visiting area as a housing alternative. That is just crazy to me,” said Michele Deitch, director of the University of Texas at Austin’s Prison and Jail Innovation Lab. “Not to mention illegal to put them somewhere that doesn’t have a bed, doesn’t have a toilet. I’ve never heard of something like that before.”

Dunbar, the inmate who hanged herself on Dec. 4, had been kept in an attorney booth that lacked a bed, running water or a toilet for the last 18 hours of her life. She was put in the booth after a fight in general population because no single cells were available. Despite policy requiring that detox inmates like her be checked on every 20 minutes, an internal breach of policy investigation provided to LEO by an attorney for Dunbar’s family found that officers did not regularly check on her and that her death might have been prevented if policy had been adhered to.

Kinzel, the formerly incarcerated University of Michigan-Dearborn professor, said being kept in solitary confinement without running water was “the toughest type of harsh environment” a person can face in jail or prison. 

“Think about it: You don’t have running water. You’re pissing or shitting on yourself. You can’t clean up yourself,” he said.

Kinzel said when he was in his early 20s, he spent three days in a prison cell with no water after corrections officers turned off the water as punishment after a neighbor had flooded his cell. He said he was so dehydrated he started hallucinating.

“Of course that’s going to cause them to go into a state of psychosis or suicidal ideation. Because they’re so desperate,” he said.

Inmates locked in attorney booths like Dunbar have to request that guards let them out to go to the bathroom or get something to drink. While Dunbar was meant to be checked on every 20 minutes, an LMDC investigation of her death determined the only time guards checked on her was when they “happened to walk by while conducting other business.”

Responding to a question from LEO at a July 15 press conference,  jail director Jerry Collins said attorney booths like the one Stephanie Dunbar died in could still “possibly be used” when single cells were full, but said, as a result of a policy change, they could not be used for longer than an hour and that the inmate had to be observed while they remained in an attorney booth. Asked if the policy change was a result of Dunbar’s death, Collins, who was not with LMDC when Dunbar died, said he was not sure when the change occurred.

Christine Tartoro, a professor of criminal justice at New Jersey’s Stockton University who studies suicide in correctional facilities, said jails and prisons are obligated to provide inmates with access to basic needs.

“When the government restricts somebody’s freedom, the government then becomes obligated to provide people with some basic needs, including water, sanitation and other basic necessities. Because we are restricting someone’s ability to go get those things themselves,” she said.

Overcrowded And Understaffed; A Perfect Storm

Dunbar died in a jail that was overcrowded and understaffed — a recipe, experts say, for dangerous inmate conditions.

Video footage showed that the night before Dunbar was placed into an attorney booth, she was attacked by several inmates in a dorm after she tried to reclaim a bunk inmates that had thrown her mattress off of. At the time, the dorm was so crowded that at least five inmates were already sleeping on the floor. Then, Dunbar was placed into an attorney booth because all 19 of the women’s section’s single cells were already full.

“Overcrowding places a stress on every aspect of life in the facility,” said Deitch, the University of Texas at Austin’s Prison and Jail Innovation Lab director. “It strains the delivery of services. It strains the delivery of programs. It strains relationships between incarcerated people and between incarcerated people and staff. It leads to increased levels of violence. You name it, whatever aspect of life you’re talking about in prison or jail is implicated by overcrowding, and it’s made much worse for it.”

Understaffing, Deitch added, leads to a lot of “cutting of corners” which can see inmates who need to be checked on, like Dunbar, go unwatched.

During the investigation of Dunbar’s death, two officers were found to have forged observation sheets, declaring that parts of the jail were “all secure” at times when they were actually in a different area of the facility.

When confronted by an investigator about the discrepancy, the guards pointed to a lack of staffing. One officer said they were alone by themselves on the women’s floor of the jail for a time and were working on forced overtime.

“It winds up being a situation where you don’t have enough staff members there and the staff members who are there are exhausted and just have extremely low morale,” said Tartoro, the jail suicide expert. “So it winds up being a perfect storm in terms of not being able to properly supervise people and just not doing the job according to the standards that are set.”

In the internal investigation into Dunbar’s death, a total of eight LMDC officers were found to have violated the jail’s policy on monitoring detox inmates. Of the eight, two were also found to have forged observation sheets and another was found to have given Dunbar the middle finger as she was locked in the attorney booth. According to LMDC spokesperson Maj. Darrell Goodlett, “several” officers were disciplined and received suspensions of between two and 15 days.

“We have to start thinking about the types of individuals we hire to oversee people. Corrections officers and their actions in this case were sickening,” said Kungu Njuguna, a policy strategist with the ACLU of Kentucky. “They have complete control over peoples’ lives and the complete lack of care and understanding that they showed with Miss Dunbar — I don’t even have the words for it.”

Jail Missteps Not Isolated

The jail’s missteps were not a one-off surrounding Dunbar’s death.

In late November, Kenneth Hall’s health was declining. The 58-year-old inmate, who had been booked in Louisville’s jail weeks earlier on a charge of failure to comply with the sex offender registry, was refusing to keep his colostomy bag on, increasing health risks. One officer described Hall’s cell as having an “infection” smell. In poor health and either unwilling or unable to take care of himself, Hall was meant to be transferred to the University of Louisville Hospital on Nov. 24, according to a Louisville Metro Police Department investigation obtained by LEO Weekly under Kentucky’s open records law. 

However, that transfer never occurred.

“I was advised by LMDC PSU Lieutenant Redmon the victim was never sent to University fo Louisville Hospital as requested by medical staff,” wrote Sgt. Scott Beatty with LMPD’s Public Integrity Unit in a Jan. 24 report. He added that a supervisor with Wellpath, the company contracted to provide healthcare in the jail, “stated a miscommunication occurred between shifts, and it was believed the victim went to the University of Louisville Hospital and returned the same day.”

That supervisor, Beatty wrote, “stated in her tenure with Wellpath an instance of a medical inmate not being transferred to the University of Louisville Hospital had never occurred, and a new protocol was in place to assure it never happened again.”

Days later, Hall was dead. An inmate work aide responsible for checking on other inmates who require additional monitoring told investigators that the night before Hall died, he was “laying on the floor of his cell knocking on the door. The inmate was laying in urine and feces and was asking to be helped back up on his bed, but no one helped him.”

The report did not say what policy had been changed as a result of Hall’s death. 

In a written response to LEO, Goodlett, the Metro Corrections spokesperson, said: “The process that was referred to is a formal way of reporting in writing to all shift commanders the need for an inmate to be transported to the hospital at a later time. Because of ongoing litigation, I am unable to talk specifically about the miscommunication you refer to.”

Wellpath did not respond to requests for comment.

LMPD investigations to determine if criminal charges are warranted are standard practice after a jail death. The LMPD investigation obtained by LEO Weekly only included investigator summaries of witness interviews instead of verbatim transcripts. 

An open records request made by LEO in June for the jail’s internal breach of policy investigation into Hall’s death received no response, despite Kentucky’s open records law only allowing five business days for an agency to respond to such requests.

In his statement to LEO, Goodlett said no staff were disciplined as a result of the jail’s breach of policy investigation.

‘I Wouldn’t Call It A Problem’

David Dahms, 37, died on May 16 of last year after being found unresponsive in his cell. But an investigation into his death would not be initiated until Sept. 9, nearly four months after Dahms’ death and just hours after a Courier Journal reporter asked about the lack of an investigation.

“Per our conversation an internal investigation will take place for the death of David Dahms,” wrote Lt. Mike Redmon of LMDC’s Professional Standards Unit in a Sept. 9, 2021 email to then-jail director Dwayne Clark one hour and 41 minutes after a Courier Journal reporter emailed a series of questions about the lack of an investigation to former mayoral communications director Jean Porter and jail spokesperson Steve Durham. The newspaper had learned there was no breach of policy investigation through a response to an open records request.

“Proceed with an investigation,” responded Clark to Redmon’s email about an hour and a half later.

Additional emails from that day showed confusion among city officials as to whether or not an investigation had occurred as they discussed how to respond to the journalist.

The emails were provided to LEO Weekly by Dahms family attorney Trenton Burns, who obtained them in discovery in part of an ongoing lawsuit.

The delay of the investigation was first reported by WAVE 3 News in March.

In a deposition with Burns in February, Clark was asked if it was a problem that the investigation didn’t start until four months after the death.

“I think it’s concerning. I wouldn’t call it a problem,” he said. 

When the investigation was ultimately completed, it found no breaches of policy by LMDC staff. The death was deemed an overdose. 

In his statement to LEO Weekly, Goodlett, the LMDC spokesperson, said current LMDC Director Jerry Collins, who took over in April, was committed to conducting investigations promptly and said he was unaware of any other delays in investigations.

Calls For Change Continue

LMDC says it is working to improve inmate safety. 

The jail has appointed a full-time psychologist to oversee mental health treatment. The jail also says it has taken measures to try to stop drugs from entering the facility, including the use of a new body scanner they say has intercepted narcotics on at least 45 occasions since April. LMDC now has a program to hire back retired officers and a lateral transfer program that would make it easier for correctional officers to transfer to LMDC has been approved, both measures that Collins believes will “greatly increase” staff numbers in the coming months. And the jail hopes to add suicide-resistant cells as well as cameras that will help monitor inmates held in single cells. 

Since Collins took over as LMDC’s director on April 1, there has been only one inmate death, a July 8 incident jail authorities have portrayed as drug-related. After that death, Collins said investigations were launched “immediately.” 

Some advocates of jail reform have been cautiously optimistic about Collins taking over, saying the shift in leadership could result in some changes. 

But they also say that more needs to be done and that the still-emerging picture of recent jail deaths points to systemic failure.

Among them is Shameka Parrish-Wright, the runner-up in May’s Democratic party mayoral primary and the director of the newly-formed organization VOCAL-KY, which focuses on mass incarceration, homelessness and other issues weighing on Kentucky.

“It is our responsibility, when we incarcerate someone, to make sure their human rights are honored, that they have dignity, that they have respect. No matter what they are charged with or how long they have been sitting in there. This is a complete failure,” she said.

Parrish-Wright added that she does not think that real changes will happen until the jail population is “severely reduced.” She also fears that jail conditions will be used by some to push for a new jail in Louisville, leading to more incarceration without the jail dealing with its internal problems.

Njuguna, the ACLU of Kentucky strategist, is critical of the lack of information about jail deaths many months after they occurred.

“I think there’s a complete lack of transparency,” he said. “I think as soon as these investigations were over, the city should have come forward and said we are done with the investigation, here it is and here are the findings. If we are ever to have any trust in government, they need to be open and transparent and held accountable for their failings.”

To Parrish-Wright, the lack of information about jail deaths means the lives of inmates remain in danger.

“It’s the police policing themselves. It’s the jail policing themselves. And they’re not going to be transparent enough for us to have the clarity we need to prevent these jail deaths,” she said. “Every jail death is preventable.” •

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