Death Behind Bars: Some fatalities preventable; black deaths on the rise

By: Danielle GordonSome commit suicide, hanging themselves with bed sheets or pieces of clothing in the small lockups of Chicago and suburban police stations. Others die of overdoses after swallowing drug evidence, or collapse while being restrained by police.

In Cook County Jail, where prisoners may remain months or years awaiting trial, many deaths—in this most unnatural of settings—are from natural causes such as heart disease, AIDS, liver failure or lung cancer.

Between January 1990 and September 1998, 177 African Americans, 80 whites and one Asian American died in police custody or jail in Cook County; 90 percent were men.

While deaths among whites remained constant, the number of blacks dying rose nearly every year, as more succumbed to natural causes, according to data from the Cook County Medical Examiner’s Office. The office did not specify which victims were of Hispanic origin.

But several of the deaths in custody may have been preventable, including some of the 78 homicides and suicides, show interviews with family members, advocates and lawyers.

And in 14 incidents, death was related to the victims being restrained by police, according to The Chicago Reporter’s analysis of data from the medical examiner’s office, which investigates all deaths that occur in custody.

Experts and advocates say the deaths under questionable circumstances and the rising number of natural deaths among African Americans require further investigation.

"The bottom line is that custodians have a duty of care. When you go into an institution, you should come out no worse than when you went in," said Joseph R. Rowan, president of Criminal and Juvenile Justice International Inc., a suicide-prevention organization in Roseville, Minn.

The number of deaths in custody does not include an additional 139 fatal shootings by Chicago police

between 1990 and 1998. Last year, 71 people were shot, the most this decade (see Police Shootings Hit Decade High).

"It takes a long time for parents to come to terms with [deaths related to police actions]," said Mary D. Powers, coordinator for Citizens Alert and the National Coalition for Police Accountability. Citizens Alert is a Chicago non-profit group that provides support to families of victims of deadly force and assists individuals in filing complaints against police.

"Someone once said to me it feels like Santa Claus beating up your kid; it feels like a betrayal," Powers said.

The number of African American deaths in custody rose from seven in 1990 to 22 in the first nine months of 1998. In the same period, the number of white deaths fell from seven to six.

The overall rate of deaths per 100,000 inmates in Cook County Jail and Chicago lockups increased from 3.7 in 1990 to 7.1 in 1998. The largest increase was among black inmates, whose rate jumped from 2.6 to 8.0. The rate for whites dropped from 7.1 to 5.8.

The rise in African American fatalities came even as the proportion of blacks in Cook County Jail fell from 76.9 percent to 70.6 percent, according to data from the Cook County Department of Corrections and the U.S. Department of Justice 1990 National Survey of Jails.

Health issues play a big role. "It’s amazing we don’t have more deaths," said Charles A. Fasano, a staff associate who monitors conditions at Cook County Jail for the John Howard Association, a non-profit, statewide jail and prison watchdog organization based in Chicago.

"These are people with high-risk lifestyles. Intravenous drugs, unsafe sex, bad things done to them and not good previous health care. [Jails and prisons] are inheriting society’s problems," Fasano said.

But blacks and whites in custody tend to die of different causes. Blacks are dying from drug overdoses or natural causes, particularly AIDS, alcohol-related diseases, asthma, cancers and heart problems. Suicide is the leading cause among whites.

African Americans often are sick when they enter the criminal justice system, experts say. And there could be "different systems dealing with whites with medical or drug problems than for blacks," said Michael J. Mahoney, president of the Howard Association. While blacks go to jail, "whites may be diverted to medical, mental health or other systems."

Still, deaths in custody don’t mean there is "anything inhumane going on," said Cook County Chief Medical Examiner Edmund R. Donoghue. "It’s due to AIDS and heart disease, and there is not a lot that can be done about it."

And ironically, those in jail may be getting the best medical care they’ve ever received. In some cases, incarceration could actually prolong their lives, Fasano said.

Showing Restraint
Of the 14 victims of restraint-related deaths, only two cases were officially ruled homicides. Eleven were considered accidents, including eight people whose primary cause of death was cocaine overdose. The cause of one death remains undetermined.

Last May and June, 33-year-old Denny Williams and Omar Ramirez, 32, died in separate incidents. In both cases, the medical examiner ruled that cocaine intoxication and being restrained contributed to their deaths. Ramirez was placed on his stomach in a Chicago police van while handcuffed, the medical examiner found.

These deaths received scant attention, and little is known about their circumstances, the Reporter found.The case of Honduran immigrant Jorge Guillen is a notable exception. It shows police may not receive sufficient training on the dangers associated with some methods of restraining suspects.

On Oct. 3, 1995, Guillen, 45, suffocated after a struggle with three Chicago police officers in a small hallway of his apartment at 1615 N. Kildare Ave. in Humboldt Park.

The 5-foot-5-inch, 181-pound Guillen died of "asphyxia due to compression of [the] neck and chest … while he was being restrained," Deputy Cook County Medical Examiner Adrienne Segovia wrote in the autopsy. Guillen’s paranoid schizophrenia also contributed to his death, Segovia found. Her ruling: homicide.

Guillen’s encounter with police began when his 16-year-old daughter, Lisbeth, made at least three 911 calls asking for help for her father, who had a history of mental illness and was "in a crisis of nerves," she told police. He was threatening the family with a wooden board and a knife, a police report said.

Three Grand Central District officers, Michael A. Ponti, Daniel L. Parise and Chris E. Andersen, responded. They later told the Office of Professional Standards, which investigates allegations of police misconduct, that Guillen attacked them with the board and reached for one of their guns.

The officers wrestled him to the ground, and Parise struck Guillen on the head with his flashlight. To control him, Andersen used the "three-point kneeling technique"—one knee on Guillen’s back, the other on the ground and his hands free to hold Guillen’s arms—court and OPS documents show.

Andersen said he kept his knee on Guillen’s back after handcuffing him because Guillen was still trying to get up. Ponti, who broke his finger during the fight, said he had used the three-point technique at least a dozen times before and had seen it used 30 to 50 times in his eight years on the force.

Guillen was pronounced dead on arrival at Illinois Masonic Medical Center, 836 W. Wellington Ave.Medical studies show that people experiencing psychotic episodes or drug and alcohol intoxication can die when improperly restrained by police. A 1992 survey of police departments nationwide by the San Diego Police Department found that the 56 departments that responded had experienced 94 restraint-related deaths since 1969.

In court depositions, the three officers in the Guillen case said most of their knowledge of the potential dangers of restraint techniques came from their training at the Chicago Police Academy and a bulletin made available at a roll call eight months before the incident. Officers are told not to remain in the three-point stance once a person is handcuffed, and never to leave a person in restraints lying on his back or stomach.

The police department continues to use the bulletin, in-service training and their internal "audio-visual system" to inform officers of the dangers of restraint, said Patrick Camden, deputy director of news affairs for the police department. No additional training is planned, he said.

"Unfortunately people who are handcuffed tend to get less attention from police, when, in fact, they may need more," said medical examiner Donoghue. "This is the time they should be paying attention to the person’s breathing."

"It may be too late for these 14 who died," said G. Flint Taylor, attorney for the People’s Law Office, which represented Guillen’s family. "But police should view this as troubling and re-examine their restraint procedures."

In December 1995, OPS recommended that all three officers be suspended. The "use of force given the totality of the circumstances was excessive and unwarranted," its report said.

In September 1996, then-Superintendent Matt L. Rodriguez dropped Ponti’s suspension. The following December, the other suspensions were overruled by the Chicago Police Board, a nine-person civilian panel appointed by the mayor. It stated that "the officers had to subdue Mr. Guillen to protect Ilsa Guillen and her children and to protect themselves."

The board also quoted the findings of Evanston Hospital pathologist Michael W. Kaufman, who was hired by the city to review the case. Kaufman concluded Guillen died "a natural death." He added: "It was Mr. Guillen himself who ‘set the stage’ and was solely responsible for the circumstances in which this ‘accident’ occurred."

Suicide Watch
Suicide is the leading cause of death for those held in jails nationwide, said Edward Harrison of the Chicago-based National Commission on Correctional Healthcare, a non-profit that accredits health services in jails and prisons.

"People come in drunk or stoned, and come down and realize they did something bad when they were intoxicated," he said.

Of the 65 suicides recorded by the medical examiner between 1990 and 1998, 61 were hangings. Most of the remainder involved poisonings.

The suicide rate varies with race. Eighteen percent of the African Americans who died in custody killed themselves, compared to nearly 39 percent of whites.

Blacks are more likely to go to jail, and thus they are more psychologically prepared, said Dr. Carl C. Bell, professor of psychiatry and public health at the University of Illinois at Chicago, and a board member of the National Commission. "If you are black and go to jail, it’s a given. It happens to everyone. For a white to be in jail, they did something serious."

The suicide of Bernard Solomon, a 19-year-old African American who died at the Marquette Police Station, 2259 S. Damen Ave., continues to perplex his family. Police told them that Solomon hanged himself with his shirt on Jan. 13, 1997.

Solomon was arrested that morning and charged with possession of cocaine. It was at least his third arrest as an adult, according to court records.

His 22-year-old sister, Mary Solomon, believes he never would have killed himself. She talked to him on the phone the day he died, and he asked her to bring his girlfriend to court the next day.

"He was a very strong young man, and he had no reason to kill himself. He wasn’t scared of jail," said Solomon’s aunt, Gloria Ewing, 42. "He was probably razzing with the police and got in a fight with them."

Chicago police lockups averaged 7.3 suicides annually between 1979 and 1982, according to Rowan of Criminal and Juvenile Justice International. But there were less than two suicides per year on average between 1983 and 1994, in part because guards were better trained to identify and monitor suicidal prisoners, he said.

In the first nine months of 1998, there were four suicides in custody countywide. Another occurred in an Evanston police lockup on Dec. 20 when Phillip Walsh, a 33-year-old African American, used his pants to hang himself. He had been arrested early that morning for failing to appear at a court hearing.

The police checked on Walsh at 4:20 a.m. At 5:34 a.m., they found him hanging in his cell.

His mother, Delores Franklin, filed a wrongful death suit against Evanston on Jan. 13, charging that police failed to adequately monitor Walsh and to remove the clothing he used to hang himself.

The police "had no indication based on his conduct that he was suicidal," said Mark Smolens, a lawyer representing Evanston.

But Walsh’s suicide was caught on the videotape camera that monitors the holding area, according to the medical examiner’s report.

"If someone had been watching the monitor, which is the point of having them, this could have been stopped," said Powers of Citizens Alert.

Natural Causes
Suspects rarely stay in city or suburban lockups longer than 72 hours before appearing in court. Those who don’t post bond are bused to Cook County Jail, a sprawling, 96-acre facility at 26th Street and California Avenue.

Within the razor wire that fences in the jail campus is the county-run Cermak Health Services facility, where sick and injured inmates are treated in small rooms with exposed metal toilets and state-of-the-art hospital equipment.

Last year, 15 people died in County Jail and Cermak, and 19 others died under guard at various hospitals. About 85 percent of these deaths were from natural causes.

To receive medical care in County Jail, inmates fill out a health request form and give it to a health care worker.

In some cases, getting attention could be part of the problem. Walter Williams, a 34-year-old African American from the 5800 block of South Loomis Boulevard, died of gastric dilation, bronchial asthma and drug withdrawal in a medical dormitory at County Jail in January 1998. Williams had a history of asthma and heroin abuse.

Williams’ brother, Robert, 50, said he and his mother had planned to bail Williams out that evening. "We had gotten very close, living together and being around him all the time," Robert Williams said. He has received no official information about his brother except a death certificate, he said.

Guards told the medical examiner they checked on Williams at 3:27 p.m. They found him unresponsive 13 minutes later, and he was pronounced dead 15 minutes after that.

Some inmates interviewed by the medical examiner said the guards told them Williams was "dope sick" and "threatened that if anybody banged on the door again [to get him medical attention] that officers would tear the place up."

But Donoghue, who investigated the case, said he found no evidence that the staff was negligent. "There is no alarming tendency toward denying care. Cook County Jail has a near-ideal system."

The family of Robert Curtis Bradley thinks otherwise. In a December 1997 suit, they charged that Cermak cut off the 46-year-old African American man’s medication for a heart condition, causing his death on Jan. 3, 1997.

Cermak staff knew Bradley had a history of heart disease, the suit says. But his "medications were abruptly discontinued, with a catastrophic outcome," according to Dr. Dennis M. Killian, who practices at Cardiology Associates of Northern Illinois and is a consultant to the family in the lawsuit.

Citing state law, the county responded that it is not liable for "injury caused by the failure to make a physical or mental examination." The case is pending.

For other inmates, however, a stay in County Jail may give them some of the best care they’ve ever had.

Unlike the average American, inmates are guaranteed minimum health care by a 1976 U.S. Supreme Court ruling that "deliberate indifference" to serious medical need violates the Eighth Amendment.

Experts say Cermak goes even further. Inmates arriving at the jail are given chest X-rays to check for tuberculosis and various examinations for sexually transmitted diseases. They also answer questions about their physical and mental health.

"Intake is a critical element," said Leonard R. Bersky, Cermak’s chief operating officer. "We want to identify medical problems and nip them in the bud."

Inmates can either be treated at Cermak or sent to Cook County Hospital. Terminally ill patients are sent to Oak Forest Hospital for long-term care.

AIDS contributed to 24 of the 134 natural deaths in custody between 1990 and 1998. An additional 44 were heart-related. The average age of African Americans dying in custody of natural causes was 40; the average age for whites was 46.

The AIDS death rate among Cook County inmates appears to be on the decline, with only two such deaths last year.

On a typical day, the County Jail population includes 120 people taking medication for AIDS, 80 insulin-dependent diabetics and 1,000 with mental health problems, Bersky said. HIV testing, which is voluntary, reveals more than 110 cases a year. Last year, 34,499 people visited Cermak’s emergency room.

"We are a town with a lot of health problems, acute and chronic. We have a young population who typically hasn’t seen a doctor in the community," Bersky said. "Our role here is to make sure their health care doesn’t deteriorate because of incarceration."

To meet the demand, this month the medical center is moving to a new $42.8 million facility, which will raise the number of available beds from 82 to 131.

The money is well spent, said Steven Whitman, director of epidemiology at the Chicago Department of Public Health. "If we helped these people rid themselves of infectious diseases, not only is it the right thing to do, but we would be helping all the people they may infect in Chicago."

Final Settlement
It has been 3 1/2 years since the body of Jorge Guillen was taken by his family back to Honduras for burial.The city settled the family’s lawsuit in April for $637,500, and the three officers who were with Guillen before he died remain on duty.

The Guillen settlement was the largest of four paid by the city in 31 wrongful death cases filed against the police since 1995, according to the city Department of Law. The other settlements ranged from $5,000 to $85,000. Sixteen cases are still pending.

But only the exceptional incidents ever seem to make it to court. Pursuing these cases is tough, said Benjamin S. Wolf, director of the Institutionalized Persons Project for the Chicago office of the American Civil Liberties Union. "The best witness frequently is dead, and it’s hard to crack the folks overseeing the situation to get at what happened."

Investigations of most cases remain in the hands of the police, the medical examiner and the Illinois Department of Corrections’ Bureau of Detention Standards and Services, which monitors state jail and prison standards.

The bureau’s investigations are not made public, although some details get released as part of court cases. They also produce inspection reports of every jail and lockup facility.

Two years after Bernard Solomon’s suicide, his grandmother, Mary Edingbourugh, is still visibly distraught talking about his death. She had raised him in a cramped frame house on the 2300 block of South Kostner Avenue in North Lawndale since he was 9 years old, she said.

Edingbourugh said she told Solomon to stop hanging out with his friends on the corner of Cermak Road and Kolin Street, where he had previous run-ins with the police. But "he loved being out there with those boys," she said.

"The day before he died, he said to me, ‘Grandma, the police are trying to kill me.’ I shooed him away because that talk makes me nervous. I said ‘No boy, stop playing with me.’"

After his death, Edingbourugh said she contacted three lawyers but couldn’t get them to take the case. "We are black so [the police] think we are stupid," said Edingbourugh, who still hopes to pursue the case, although she also fears the consequences. "I am scared if I do, something could happen to my other children."

For more information on the deaths in police custody and jails, visit the following Web sites:

A February 1999 article on in-custody deaths in Australia from The Guardian, the newspaper of the Communist Party of Australia.

The Cook County Sheriff's Department of Corrections.

The John Howard Association of Illinois.

The Cermak Health facility at Cook County Jail.

The National Commission on Correctional Health Care.

The Correction Connection's Healthcare Network.

The Chicago Police Department's 1997 Annual Report.

The National Coalition on Police Accountability and Citizens Alert.

Contributing: Natalie Pardo and Karen Shields. Dwayne Ervin, Kareem R. Muhammad, Nicolette L. McDavid, Christine Starr, Cedric L. Stines and Vickey Velazquez helped research this package of articles.