One year later, inmate's death looms over state prison mental health debate
Posted March 12, 2015
It’s hard to say when Michael Anthony Kerr stopped taking his meds.
Before he began refusing treatment, the right of any prisoner within the North Carolina corrections system, the drugs had for months calmed his delusions and kept the symptoms of schizoaffective disorder in check. He stayed out of trouble, kept a job in the kitchen.
That refusal is the sort of thing the prison system is supposed to track. But in this case, the dates conflict a bit.
The timing is important, since medical experts say inmates who stop using psychotropic medication to treat mental illness start acting out around three months later.
But for all the uncertainty in this man’s timeline, a few dates stand out with absolute clarity.
On Feb. 5, 2014, the 53-year-old Army veteran entered solitary confinement.
Thirty-five days later, Kerr would be dead.
• • •
Kerr’s death by dehydration one year ago ignited a barrage of activity in the state’s corrections system and raised questions about inmate treatment that will reach the chambers of the General Assembly in the coming months.
At Alexander Correctional Institution, the maximum-security facility on the outskirts of Taylorsville in rural western North Carolina where Kerr was kept handcuffed for five days before he died, 25 people lost their jobs or were disciplined in some way. Kerr’s death prompted reorganization at the 10-year-old facility that ended in the transfer of its mentally ill inmates in an attempt to combat persistent staffing shortfalls.
And as lawmakers decide how to respond to the governor’s request for an additional $49.8 million over the next two years to tackle longstanding problems with the entire prison system, they’ll do so under the specter of state and federal criminal investigations and possible civil lawsuits.
Prison officials say Kerr’s death is the result of cascading failure by individuals in the custody, medical and mental health staffs at Alexander to properly care for an inmate serving more than 30 years as a habitual felon. Citing personnel, privacy and public safety exemptions, the state has declined to release much more of an explanation than that.
Hundreds of pages of documents presented in open court paint a clearer picture.
They show mental health and nursing staff dismissed Kerr’s slow deterioration as “faking” or “malingering,” ignoring the concerns of their colleagues and delaying proper treatment for days. They reveal growing uncertainty on how to deal with an inmate who by some accounts was too sick to follow orders as well as a siloed approach to prisoner treatment that prevented informed decisions.
Mixed with persistent staff shortages that forced long hours and frequent overtime, fired employees say cases like Kerr’s were primed to fall through the cracks.
And without significant changes, mental health advocates say it’s only a matter of time before it happens again.
• • •
At Alexander, much like other prisons across the country, segregation is the place you go when you break the rules – the jail within the jail.
If it’s disciplinary segregation, you land there for infractions like disobeying orders or assaulting prison staff.
Michael Kerr did neither.
Prison officials moved him in early February for mental health evaluation under “administrative segregation,” a transitional designation that may lead to more permanent solitary confinement. Court testimony attributed the move from general population to a need for observation after Kerr began throwing water in his cell and chanting.
Daily reports from the wing where Kerr was confined – called the Red Unit – don’t really mention him.
But on the morning of Feb. 18, 2014, he became disruptive, earning infractions for disobeying orders and banging on his cell door. Those offenses meant a greater level of confinement.
'I just felt that there was no longer a point to keeping him in restraints as he was just sitting in the floor in his own urine refusing to move or do anything.'
Alexander Capt. Lane Huneycutt
Correctional officers bound Kerr’s ankles and wrists with grip restraints, made from a seatbelt-like material designed to prevent injury.
For two days, Kerr racked up additional infractions for kicking the door and refusing to return food trays. Corrections officers noted he would sit on the floor of his cell and pour cups of water, talking to himself.
“Come on in, the water is fine,” he would repeat.
For attempting to flood his cell, guards cut off the water to his combined sink and toilet on Feb. 19.
At a certain point, Alexander Capt. Lane Huneycutt saw no need for the restraints anymore. He removed everything but the handcuffs, then was able to get Kerr to stick his hands through the port in the cell door to get those removed too.
“I just felt that there was no longer a point to keeping him in restraints as he was just sitting in the floor in his own urine refusing to move or do anything,” Huneycutt wrote to the prison’s top nursing, medical and custody staff at 1 a.m. on Feb 21. “Medical was also worried that he was dehydrated. Over a period of time staff was able to get him to drink some water and he appears to be doing some better.”
But it did prompt questions between a few of them who sought to correct an assertion that Kerr needed a transfer to Raleigh’s Central Prison, a facility with better mental health treatment options. Those familiar with Kerr weren’t inclined to move him, interpreting his behavior as intentional rather than a mental health issue.
The way Kerr’s psychologist explained it to Dr. Karis Fitch, Alexander’s psychological program manager, “he was not going to be referred to CP because this is an attempt to get to CP to be near a specific family member,” Fitch wrote to a case manager on Feb. 24. “That assessment suggested malingering over actual psychosis, which we would manage here.”
It wouldn’t be the last time Kerr’s caretakers would accuse him of faking.
• • •
Without a doubt, the North Carolina prison system has a mental health problem – and it starts as soon as inmates walk through the prison doors.
Nationally, the average percentage of inmates suffering some form of mental illness hovers around 17 percent.
In North Carolina, only 12 percent of inmates are receiving some form of mental health treatment, according to a consultant the Department of Public Safety hired to examine mental health services at Alexander in October 2014. That study by Dr. Jeffrey Metzner came nearly two years after a similar report he completed for the overall mental health system in prisons amid concerns by advocacy groups such as Disability Rights NC over inmate treatment.
'Mental illness is so broadly misunderstood. That's where the malingering comes into play.'
Vicki Smith, Disability Rights NC executive director
In that earlier assessment, Metzner found the prison system’s definition of mental disorder “vague,” and he said although it was not necessarily too narrow by policy, “by practice it may turn out to be.”
Vicki Smith, executive director of Disability Rights NC, says the result, either by practice or policy, is that the prison system simply underdiagnoses mental illness.
"There could be many causes,” Smith said. “It could be that they don't have the staff, but also, prisoners and people with disabilities have certain rights that a regular prisoner wouldn't have. So sometimes underidentifying could be to their advantage."
Even those with a diagnosis or history of mental illness, though, could be accused of trying to fool staff with exaggerated physical or psychological symptoms to get something they want. It’s called “malingering” – and it is not a mental illness.
"Mental illness is so broadly misunderstood," Smith said. "That's where the malingering comes into play."
When these under- and misdiagnoses combine, advocates and experts say the symptoms of real mental illness can land prisoners in the jail within the jail – whether it’s their fault or not.
That’s a problem, says Dr. Joel Dvoskin, a national expert in forensic and clinical psychology based in Arizona. He said prisoners in a psychotic or suicidal state shouldn’t enter solitary confinement except in the most extreme circumstances, and even then, it’s important for therapeutic services to come to them.
“I don't believe it's right to punish somebody for a symptom of their mental illness,” Dvoskin said. “If someone has an epileptic seizure and they hit someone in their head, they shouldn't get accused of assault.”
While he said there’s no doubt a mental health diagnosis is complicated by a prison environment, Dvoskin said he advises those who suspect malingering to think critically about the underlying motivation – and consider the consequences of getting it wrong.
“Some people are just so concerned about not getting fooled that they're too skeptical,” he said. “I ask them, ‘What are they malingering for?’”
• • •
For everything we don’t know about the final days of Michael Kerr, one thing is clear: Those responsible for his supervision and care didn’t believe him.
In the weeks after Huneycutt’s email mentioning concerns over dehydration, prison officials shut Kerr’s water off to keep him from flooding his cell. They offered to turn it back on for good behavior, in the meantime offering water almost every hour.
He racked up enough infractions by throwing water, hitting the door and his bunk – and eventually, on Feb. 24, putting feces in the cell door pass box – that he was put on a meal of milk and “nutraloaf,” a much reviled yet nutritionally sound mash used as punishment.
But to Dr. Christine Butler, Kerr’s prison psychologist, the inmate’s actions were attributable to malingering.
"The belief at that time from Dr. Butler, the treating psychologist, was that Kerr was trying to manipulate a transfer to Central Prison," Michael Youron, a psychological manager fired after Kerr’s death, testified Tuesday at a hearing contesting his dismissal.
Butler, who resigned following Kerr’s death, could not be reached for comment.
'I wanted inmate Kerr to have every opportunity to come out of the restraints. I didn't want them on any longer than they needed to be.'
former Alexander Capt. Shawn Blackburn
These repeated violations also landed Kerr in disciplinary segregation in the long-term isolation unit, often called Big Seg, on the afternoon of Feb. 26. Later that night, he asked a sergeant on the block to speak to a psychologist, a request the officer passed along to Fitch, Youron’s boss.
The next few days were more of the same. More kicking the door. More cell flooding. Another order of nutraloaf. On March 3, prison officials turned Kerr’s water off again around 5 a.m.
On March 6, 2014, though, Butler began to doubt her diagnosis.
She told Youron, her supervisor, that Kerr’s condition was deteriorating and that he had missed several scheduled videoconference psychiatry appointments – attempts to get him back on his meds. Youron told her Kerr needed a transfer to Central, and she replied that she had contacted the Raleigh facility and that it had no mental health beds available.
A subsequent investigation by the state found no evidence of any calls from Alexander to Central on March 6 or 7. And in fact, records showed Central had 20 open beds at the time.
By then, prison logs indicate, Kerr’s disruptions had begun to slow.
Checks by corrections officers that first week of March noted that he rarely responded or moved in his cell.
On March 8, 2014, just after sunrise, prison staff called a code blue to cell B-1: Kerr was unresponsive on his bed.
As officers and nurses entered the cell, they bound Kerr’s wrists and ankles according to policy to protect the medical staff as they evaluated him. Records conflict on the nature of that evaluation, but they indicate the first nurse on the scene, Brenda Sigman, said he was OK and that his blood pressure was normal.
Custody officers reported in a shift narrative that he was “acting as if he was incoherent,” and referred to the mess he made in his cell as a “malicious” act.
“He was also coherent and mischievous enough to clog his sink and toilet with milk cartons,” the segregation unit shift narrative noted after the code blue.
Capt. Shawn Blackburn, the officer in charge of the facility at the time, cleaned out those cartons himself after sweeping up bits of nutraloaf and other garbage from the cell floor.
As they exited the cell, officers removed Kerr’s leg restraints and backed out, leaving the handcuffs on per policy. Blackburn told the inmate he’d have to come to the door and place his hands through the port to get them off.
Kerr didn’t move.
Blackburn ordered his officers to check on the inmate every 15 minutes.
“I wanted inmate Kerr to have every opportunity to come out of the restraints,” Blackburn testified in his own personnel hearing. He also asked another psychologist to try to convince Kerr to come to the door. “I didn't want them on any longer than they needed to be.”
On the outside of the cell, someone scrawled another order on the chalkboard paint meant for notes about the inmate inside.
"Do not give him milk, per Capt. Blackburn," it read, according to hearing testimony.
'I asked Mr. Kerr to sit up so that I could get his vitals. He just looked at me and smiled.'
Michael Archer, correctional health assistant
DPS said it did determine Kerr had access to water from the sink in his cell and that it had not been turned off in the days immediately preceding his death. But officials aren’t sure when exactly it was turned back on.
That night around 7 p.m., after scores of repeat entries noting Kerr remained on his bunk, a custody officer noted that the inmate was standing.
It was the last time records indicate he was upright his own.
At least one staffer did voice her concerns that day.
Amber Triplett, a correctional health assistant, told her lead nurse that Kerr needed a transfer to Central, much like his psychologist had two days before.
The nurse, Lisa Kemp, later told investigators she passed the information along to the on-call psychologist. But Triplett tells it differently.
"She stated to me, no, she wasn't going to do anything," Triplett wrote in a statement to investigators. “She said he is faking, that if he could urinate on the floor and tear up a milk carton and put it in his commode, then there was nothing wrong with him."
Triplett raised her concerns again to Blackburn the next day, and together with another corrections officer later, the on-call psychologist.
“He needs to ship,” a corrections sergeant named William Johnson heard them say.
Yet in his cell, handcuffed and nearly motionless, Kerr remained, either refusing or unable to come to the door.
A day before his death, on March 11, 2014, Butler instructed a health assistant named Michael Archer to take Kerr’s vital signs – a requirement before they could ship him out. According to Archer's statement to investigators, Butler told him the inmate had “faked his way” into a psychotic state, which had earned him a trip to Central Prison, Archer told investigators.
Although he was warned ahead of time, Archer noted the smell in the cell was bad.
“I asked Mr. Kerr to sit up so that I could get his vitals,” Archer wrote in a statement. “He just looked at me and smiled.”
After asking again, Archer interpreted the grin as refusal to comply.
• • •
David Guice is a stout, plain-spoken man with a reputation.
In the corridors of downtown Raleigh’s legislative office building, he can’t go far without handshakes from friends in the state senate and house.
A lawman turned lawmaker, his past career in the General Assembly and community corrections, which supervises offenders once they’re out of jail, has earned him a great deal of respect as the Department of Adult Corrections’ director. Far away from legislative committee rooms, mental health advocates speak highly of him, noting his background and their hope that he can affect long-needed change.
"They need a strong champion internally,” said Deby Dihoff, the executive director of the National Alliance on Mental Illness North Carolina who retired last year after years at the helm of the nonprofit advocacy group. “Possibly Commissioner Guice could be that guy.”
Guice has offered frequent and frank assessment of the prison system and the need for significant changes – including an infusion of cash from the General Assembly for mental health.
“My commitment is to talk about these issues and try to help educate people to the point where we can address these issues,” Guice said. “This, to me, is not a game. This is serious business. We’ve got to change some things.”
Although he said the corrections system had been moving toward those changes, Kerr’s death underscored the need to do more.
Just last week, lawmakers got a look at what those additional efforts will cost.
Gov. Pat McCrory’s budget calls for an additional $49.8 million over the next two years for prisons. That includes $20.8 million for correctional officer raises, as well as $17.8 million for a total of 271 additional mental health positions.
'This, to me, is not a game. This is serious business. We’ve got to change some things.'
David Guice, commissioner of adult correction
Other changes include a new training center for corrections officers and a new electronic health record system for inmates.
Guice already made the pitch for money and staff once to lawmakers late last year, where he noted continued problems with recruiting qualified custody officers, nurses and mental health professionals.
He said one obvious sign corrections is “working our people to death” across the board is the growth in spending on overtime pay. Years ago, Guice said, corrections might spend $12 million on overtime annually.
“This past year, we spent about $16 million,” Guice said in an interview in December. “We’re on track to spend over $21 million this year.”
Those worker shortages played out at Alexander to significant effect.
According to staffing records of the facility provided by DPS, the vacancy rate for nurses the month of Kerr’s death was about 18 percent. Department spokesperson Pam Walker said that was “considered to be average” for the state.
Nevertheless, staff at Alexander repeatedly asked for more resources as they struggled with high caseloads.
Nurse Supervisor Jacqueline Clark, who just last week won a reversal of her dismissal after Kerr’s death, said she reported to her supervisors that she “felt like I was an island alone.”
It was a problem the judge in Clark’s case noted should have been fixed by corrections management. Yet from fall 2013, those same supervisors neglected to even visit Alexander for more than six months.
That surprised Director of Nursing Faye Duffin, who testified in Clark’s hearing that it was “a failure for them not to visit every month.”
Since last March however, the vacancy rate at Alexander has skyrocketed – 38 percent as of mid-February.
To compensate, the facility has leaned more heavily on temporary “travel” or contract nurses. What was once a travel nurse headcount of five last March has ballooned to 20.
That concerns advocates like Vicki Smith at Disability Rights NC.
"You can have positions filled, but if you constantly have travelers coming in and out, you're not going to have the same quality of care because of turnover," she said.
DPS says it’s tough hiring correctional medical staff everywhere, but Alexander’s newfound notoriety has made it even more challenging there.
• • •
Hours before dawn on March 12, 2014, Sgt. William Johnson got word from his captain: Kerr was finally shipping to Central, and it was Johnson’s job to prep him.
Johnson asked Kerr if he wanted to ship.
“He moved his head up and down, but refused all orders to sit up and get dressed,” Johnson wrote in a statement to DPS investigators.
To protect themselves from allegations of sexual assault, the officers used a video camera as they dressed Kerr in clean underwear and pants. That video, according to a judge who viewed it, depicted a “lethargic and unresponsive” man who was unable to rise even as officers slapped him on the shoulder to rouse him.
But the handcuffs were a problem.
Over the last five days, they had become embedded in Kerr’s wrists and were so caked with fecal matter that Johnson couldn’t unshackle Kerr to dress him in a clean T-shirt. Officers left them on, and after getting a shirtless Kerr into a wheelchair, they draped a sheet around him “so he would not look to be nude,” Johnson wrote.
Correctional officers, including Capt. Shawn Blackburn, say there wasn’t anything unusual about moving Kerr in a wheelchair. They say it was easier and faster to wheel Kerr’s 6-foot-tall, 243-pound frame to inmate receiving, where he would have to be searched and wait for transfer.
'The inmate turned his head toward me and looked at me but never said a word, just as he hadn’t the entire time since arrival that morning.'
Alexander Correctional Officer Jason Johnson
When the guards arrived there with Kerr, they had to use bolt cutters to remove the cuffs, which revealed bright red wounds on his forearms.
Concerned about those injuries, officers called the main medical station for help, reporting to nurse Wanda St. Clair that Kerr had “superficial lacerations” on his arms.
St. Clair was busy dealing with another inmate with a medical emergency, according to the officer who met her at main medical. She gave the officer bandages and told investigators she never heard anything more.
There’s no evidence she was ever told Kerr was unresponsive or unable to rise from his bunk.
Just 15 feet away from her down the hallway, at least seven nurses, including senior staff, were conducting their monthly meeting discussing, among other things, how to hold staff accountable without "pointing fingers."
DPS fired St. Clair less than a month later.
Returning to Kerr with the bandages, Officer Jason Johnson found the inmate on the floor, lying on his side. The officer asked if Kerr was all right.
“The inmate turned his head toward me and looked at me but never said a word, just as he hadn’t the entire time since arrival that morning,” Jason Johnson wrote in a statement to investigators.
A member of the medical team never evaluated Kerr before he left the facility in the back of a transport van around 8:15 a.m.
At some point during the two-and-a-half-hour trip to Raleigh, as he sat bound and secured in his wheelchair suffering from the symptoms of severe dehydration, Kerr slipped into unconsciousness and died. Harold Shytle, a 75-year-old serving a 23-year sentence for sexually assaulting a child, was transferred alongside Kerr – likely the last person to see him alive.
DPS refused to allow Shytle to be interviewed.
The corrections officers who interacted with Kerr that morning described his responses to their presence in different ways. Most say he looked at them or acknowledged them in some way. One notes he made only “growling noises.”
But before officers loaded Kerr into the van, he did speak to Sgt. William Johnson.
“The inmate only said one word,” William Johnson wrote. “‘Please.’”
• • •
One year later, no criminal charges have been filed in Kerr’s death. With investigations on the state and federal level ongoing, that could change at any time.
Within weeks of his death, 10 officers, nurses and mental health staff were fired or resigned on their own and more than a dozen others received demotions and disciplinary warnings.
'I believe DPS pretty much just looked for scapegoats. They just wanted to find someone to blame.'
Michael Youron, former Alexander psychological services coordinator
In a handful of the disciplinary cases, the state has changed course or had its decisions overturned, although in the case of Capt. Shawn Blackburn, it took an administrative law judge just 24 hours to decide to uphold his firing. He is appealing.
Youron, the psychological manager now fighting to get his job back, told a judge this week that the department did not do enough to address the underlying lack of resources that he says contributed to Kerr’s death.
“I believe DPS pretty much just looked for scapegoats,” Youron said in a hearing Tuesday. “They just wanted to find someone to blame.”
Yet the state has made changes. Mentally ill inmates were moved from Alexander's residential treatment wing as the state works to consolidate mental health treatment at a handful of facilities across the state. A new management team is also in place there, and regular team meetings now bring together medical, mental and custody staffs to discuss issues.
But as the General Assembly grapples this summer with the funding proposals contained within the governor’s $21.5 billion state budget, they’ll be asking themselves the same questions as many other states struggling to fund their prison populations.
"Americans want to lock up more people than we're willing to pay for,” Dvoskin, the national psychology expert, said. “That's a dilemma that almost every correctional administration in America faces.”
The question now is whether the changes will help.
After reviewing the governor’s budget this week, Smith, of Disability Rights NC, called McCrory’s proposals a “forceful step toward improving mental health services.”
But what those proposals need now, she said, is action.
Otherwise, the approximately 4,500 inmates currently receiving mental health treatment – and the nearly 2,000 more whom statistics indicate likely need it – remain just as vulnerable as Michael Anthony Kerr.
"If this situation and the recommendation of experts like Dr. Metzner are not implemented, it will not just be on the shoulders of the Department of Public Safety,” Smith said. “There are other people – the governor and the General Assembly – that will have some culpability.”