Jail failed to produce required reviews of inmate deaths
Cuyahoga County Jail officials failed for more than a year to follow county protocol and produce reports that analyze inmate deaths, records show.
The county required the reviews of all jail deaths in 2019, in part to identify how future deaths could be prevented. The new protocol came after nine inmates died during an 11-month span in 2018 and 2019. A U.S. Marshals Service inspection found, among other things, that jail officials conducted lackluster death investigations.
More than one year ago, cleveland.com and The Plain Dealer requested reports about three deaths that happened in 2020. They included an inmate who died of a fentanyl overdose, an inmate who died from heart disease and an inmate who died after authorities said a cellmate attacked him.
Cuyahoga County spokeswoman Mary Louise Madigan said last week she was unsure if Jail Administrator Ronda Gibson, who enacted the policy, conducted reviews on any of the deaths. The county does not have any jail death reports to release, Madigan said.
“I’d have to review that and get more information and talk with Ronda to get her take on this and pull the policy and find out what’s going on,” Cuyahoga County Council Safety Committee Chair Michael Gallagher said. “I’m interested to find out where the ball got dropped, if indeed it got dropped, and find out what we can do to make things better.”
Two other inmates died in 2021 — one from cancer and another from COVID-19. And last Saturday, a 30-year-old man died after he was “down for hours” in his cell before someone found him, according to Cuyahoga County Medical Examiner records.
The 2018 deaths sparked a series of investigations by the state department of corrections, the attorney general’s office and the FBI. Several jail officials and officers were convicted of crimes, including the former jail director, whom a jury found guilty of making negligent decisions that cut costs at the expense of inmate safety.
Since that time, 30 lawsuits have been filed against the county over the treatment of inmates. The county has settled nine of those lawsuits for $3.46 million.
In the months after the historic string of deaths, county officials made several policy changes, including new protocols for investigating jail deaths in order to “determine the appropriateness of care, and to identify trends of further study,” the policy says.
A death kicks off a series of reviews, with the first by the staff sergeant on-duty at the time of the death. Medical officials at the jail are also required to conduct a “clinical mortality” review of each death within 30 days.
The jail administrator, Gibson, is then supposed to conduct an administrative review of each jail death.
The administrators’ review is intended to identify “facility operations, policy and procedures” that should be improved following each death.
Questions are still left unanswered in the three 2020 deaths. Michael Wormick, a 56-year-old homeless man, died of heart disease on July 8, 2020. He had been diagnosed with schizophrenia. It’s unknown what kind of treatment he received during the two weeks he was jailed on a felony grand theft charge.
Lea Daye, a homeless transgender woman, died of a fentanyl overdose in the jail on Aug. 8, 2020. During her three months in jail, she wrote a letter intended for her family that criticized jail conditions before her death. Daye’s cellmate, Christopher Neal, is charged with involuntary manslaughter in connection with Daye’s death.
Shone Trawick, who struggled with alcoholism and mental illness, was beaten to death in his cell on Nov. 9, 2020.His family settled a lawsuit against the county for $1.1 million. The lawsuit questioned why Trawick, at 5-foot-8 and 140 pounds, ended up in the same cell as a much larger man who is accused of killing him. That man, Edmond Hightower, is 6-foot-7, 285 pounds and had a history of mental illness and attacking fellow inmates.
Hightower was jailed at the time on accusations that he severely beat his mother’s boyfriend. Trawick was serving a six-month sentence for two misdemeanor convictions.
Family members of all three inmates who spoke with cleveland.com and The Plain Dealer previously said questions left unanswered by the county added to their heartache.
The most recent inmate death highlighted the importance of knowing what led to a death and what jail policies and procedures can be changed to prevent similar deaths.
Adam Weakley, 30, who was homeless at the time of his arrest, died Jan. 15 after he was found unresponsive in his cell.
Cuyahoga County Medical Examiner records reviewed by cleveland.com and The Plain Dealer said Weakley was “down for hours” before someone found him. Investigators found no obvious signs of trauma or drug use, according to the records.
Weakley was diagnosed with HIV, schizophrenia, episodic mood disorder and ADHD. He previous contracted COVID-19 in December 2020, was fully vaccinated in March 2021 and tested negative for the virus three days before his death, the records say.
The medical examiner has not ruled on Weakley’s death. Cuyahoga County officials have not released records or answered detailed questions regarding Weakley’s death, including how the jail was staffed at the time of his death and how long he’d been unresponsive before he was taken to MetroHealth.