State jails on track for dead­li­est year for in­mates

The Charlotte Observer (Sunday) - - Insight - BY DAN KANE [email protected]­sob­

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 hos- pital 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.


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 fiveyear pe­riod showed prob­lems such as in­ad­e­quate checks or items left in cells that made it eas­ier for in­mates to kill them- selves.

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 in-

ju­red or in­firm in jail, but didn’t die un­til they reached the hos­pi­tal. The law now re­quires all “in­cus­tody” 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.

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.


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 in-

‘‘ THESE ARE PEO­PLE’S PAR­ENTS AND CHIL­DREN AND AUNTS AND UN­CLES WHO ARE DY­ING IN THE JAILS. Su­san Pol­litt, a se­nior at­tor­ney for Dis­abil­ity Rights North Carolina, a non­profit that ad­vo­cates for those with phys­i­cal and men­tal dis­abil­i­ties

mate 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-whileim­paired 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 an­tide­pres­sants; 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, four­times-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.”


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.

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.”

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.

April Cumbo

Lin­coln Horner

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