Crisis inmate: Mistakes were made

In Uncategorized on June 23, 2015 at 5:18 pm
Keaton Farris; Courtesy

Keaton Farris; Courtesy

Written by Alex Ashley

More than two months after the death of 25-year-old Coupeville and Lopez Island resident, Keaton Farris, sparked an intensive internal investigation of Island County Jail, the sheriff released a published statement, dated June 17.

In part, it read: “I am truly sorry for this tragic death. Mr. Farris did not receive the attention and care he needed…Members of my jail staff are being held accountable for their lack of leadership and supervision…”

Attached was a 52-page document that gave a chronology of events leading up to Farris’ death.

It was a beautiful day on Whidbey Island as Island County sheriff Mark Brown followed a flight of concrete stairs down to a dimly lit conference room on the lower level of the Island County jail facility.

But behind all the pleasantries lurked the elephant in the room: Keaton Farris, a relatively healthy 25-year-old inmate, was found dead in his cell on April 8.

He was booked into jail 14 days earlier as he awaited a mental health competency evaluation in preparation for a court appearance. He had forged a stolen check and been charged with identity theft.

His cause of death, said Island County Coroner Robert Bishop, was dehydration and malnutrition.

The Island County jail, a 58-bed facility, is classified as an “indirect supervision jail,” which means corrections deputies are not stationed in the block with the inmates.

“But Keaton Farris was a crisis inmate,” Brown said — the first of many times he underscored the point – which means, in Brown’s words, that “he posed a threat to either staff or himself.”

A “crisis inmate” is one who requires more than the usual attention to ensure their safety and wellbeing.
“He was not afforded that appropriate degree of oversight,” Brown said.

On March 20, Lynnwood police responded to a report of suspicious man at Union Bank.

“I was projecting my thoughts at the people inside,” Farris told the officer, according to court documents, when asked what he was doing at the bank.  “I’m off my meds right now and I’m pretty anxious right now but your badge is calming me down.”

Officer Koonce ran a check on Farris, they determined that he had a valid felony arrest warrant out of San Juan County.  He was arrested and booked into the Lynwood County Jail.

A day later, he was transferred to Snohomish County Jail.

Three days after that, he was transferred to Skagit County Jail.

According to documents provided by the Island County Sheriff’s Office, when Farris finally arrived at Island County Jail two days later, on March 26, it was with great resistance.
“He didn’t exactly walk in,” Brown said. “He arrived strapped into a restraint chair.

“He had to be carried in.”

After Farris’ death, Detective C.E. Wallace, Jr., from the Island County Sheriff’s Office, was assigned to conduct an intensive internal investigation.

Usually, Brown said, an investigator from an outside agency leads internal investigations.  In this case, even though Wallace is from the same agency, he is from a completely different division.

In the 51-page report, Wallace details each step of his investigation.

“As Dr. Bishop concluded,” Brown said, “Farris died of dehydration and malnutrition.  But how he got there is very, very disturbing.”

After exhibiting severe behavioral issues (flooding his previous cell with water, putting his pillow in the toilet and fighting with staff), Farris was transferred to the “H block,” which is designed for special needs or medical segregation of inmates. They’re known as “safety cells.”

According to the jail’s safety cell procedures, an inmate is supposed to receive a medical assessment within 12 hours, and a mental health evaluation within 24 hours.

Farris received neither until one day before his death, and even then it was through the feeding slot in the cell door.

Why, if Farris exhibited such severe “behavior issues” and “psychosis” was his mental health not reviewed by a professional sooner?

In Wallace’s report, Chief De Dennis, the Jail Commander (a position appointed by the sheriff to run operations of the jail) commented: “It’s not gonna happen that way, cause we don’t have medical staff that’s available every, you know, 24 hours.”

“There appears to be no protocol, policy or procedure that would allow medical staff to override a lockdown to conduct a medical evaluation,” Detective C.E. Wallace, Jr. wrote in his internal investigative report, “so the nurse may not have been able to force the issue to examine the issue further.”

It seems contradictory to the department’s 12 and 24-hour rule on medical assessments.

Still, according to Wallace’s report, even after Farris informed the nurse he was not doing well, no referral for emergency treatment was made, and staff didn’t document Farris’ statement about his health.

Denial of adequate healthcare started long before that incident, however.

Records from the Lynnwood jail indicate that when Farris was initially booked, his property inventory was stamped with an “FTC/220” code, rather than Farris’ signature.

“FTC” stands for “failure to comply,” and “220” stands for mental health issues.

His medical screening showed that he “presented symptoms consistent with psychosis” and listed “bipolar 2” under “chronic health conditions.”

At one point, the jail nurse reported: “During my attempts to speak with him, he lay naked on the floor of his cell, talking continuously to himself, as if he were speaking to a person in the cell.”

A mental health memorandum for Farris indicates “do not release” and “gravely disabled,” requiring that he receive an assessment from a mental health professional prior to leaving the jail.

Despite all of this, however, Farris was never given access to his prescription medications during his stay at the Island County Jail.

Records indicate Farris’ medications were sent with him from Lynnwood to Snohomish; from Snohomish to Skagit.  For some reason, though, they were never sent with him to Island County Jail.

Conversely, Brown said it is their policy to send a five-day supply of needed medications with any inmate they transfer to another facility.

It wasn’t just Farris’ medications that didn’t arrive with him to the Island County facility; he also arrived without any medical records – records that would have painted a clear picture of a young man who was troubled, at times delusional and in need of extra care.

Could they have explained his unmedicated behavioral issues?

Could they have saved his life?

Brown is unclear why a consistent, standardized procedure isn’t followed that allows facilities to have access to the same medical information for inmates when they are transferred.

Sometimes they get a file on the inmate’s medical history, sometimes they don’t.

“That question is huge,” Brown said.  “I’d like to know the answer to that as well.”

As Farris’ incarceration at Island County Jail progressed, his condition deteriorated. He became weaker, and one could postulate that his world gradually became further and further from reality.

In his investigation, Detective Wallace estimated Farris’ water intake, a deficiency that would later take his life.

“Island County Jail uses number 77 wax paper Dixie cups to provide water and fluids to inmates that are not receiving standard meal/tray service,” Wallace wrote.

Using a syringe, he calculates that these cups hold an average of five ounces.

Between March 26 and March 30, “it appears Farris took water 15 times,” he writes.

At most, Farris consumed 75 ounces of water in an approximate 100-hour period.

According to the Institute of Medicine, Farris should have taken in 521 ounces.

On April 8, corrections deputy Boone went to check on Farris and found him sitting naked on the floor, his back to the corner of the door.  He pushed his baton through the handcuff/feeding port, trying to evoke a verbal response from Farris, but got nothing.

When Boone opened the door, he found Farris: his body rigid, his skin discolored, his eyes open and his body in full rigor mortis.

He was dead.

Later, Wallace’s investigation into Farris’ death found details that didn’t add up.

The corrections deputies’ reports documenting their care of Farris, for example – deputies Lind and Boone – were found at first to be inaccurate, and later, forged.

Such logs are specific to each inmate, meant to provide a record of who checks on them, and when.

“They lied,” Brown said.  “They went back later and altered the logs to make it look like they’d been there” (caring for and checking on Farris) when they hadn’t even been in the room.

There was a gap that incriminated them as being neglectful, and they went back afterward and tried to fill that gap.

Wallace’s scrupulous review of surveillance footage showed that the times they’d forged on the logs and the time stamp on the video footage were off by about two and a half hours.

Before the investigation began, Brown gave both deputies a chance at a “loudermill hearing,” which basically gives government employees a chance to tell their side of the story before disciplinary action is inflicted.

“They resigned,” Brown said.  “Immediately.”

“They forged the logs?”

“Yes,” Brown said.
“If a citizen falsifies documents related to a police investigation, is that a crime?”

“Yes, it is,” Brown, said.

Although no legal action has been taken against the deputies at this time, Brown said Banks has launched his own investigation, reviewing the entire case for more than a simple resignation for the deputies involved.

According to Wallace’s report both officers admitted to Wallace prior to their resignation that they had, in fact, falsified the records.

Chief De Dennis has been suspended without pay for 30 days. His return is conditioned upon the review and recommendations of an outside expert.

Pending disciplinary review, Lt. Pam McCarty has ben put on paid administrative leave.

In the end, Detective Wallace classified Farris’ as “a non-criminal death” and closed the case, subject to change if additional evidence comes to light.

Brown doesn’t think there was criminal intent.

Still, at what point does gross neglect of an inmate in the care of a county jail become a crime rather than a simple slip-up?

“When I initially heard about this,” Brown said, “my initial reaction was to go viral with the failures of my staff. But as I read (Wallace’s) report, it focused on a problem much bigger than staff failure.”

Brown said Farris’ tragic loss is a symptom of a problem that runs deeper than one instance.

He has reached out to the Washington Association of Sheriffs and Police Chiefs, asking for help to bring in a corrections expert to audit the jail – procedures, staffing, medical protocols – and help them make crucial adjustments.

The Island County Board of Commissioners is working with the sheriff’s office and health department “to fix the system,” Island County Commissioner Helen Price Johnson said.

“We’ve just received the…investigation report,” she wrote, “and we see that there were multiple opportunities for intervention from the time (Farris) was arrested until his death.”

“We are outraged,” she writes, “and we are heartbroken.”

Brown has been in law enforcement since 1974, serving for many years as a Washington state trooper before being elected as Island County sheriff in 2007.  And 68 years old, he’s the second-oldest sheriff in Washington.

“In my more than 40 years in law enforcement,” Brown said, “this is without a doubt the biggest challenge I’ve had to face. I accept responsibility for this failure: a failure to my community, a systematic failure. It would be wrong to look at it any other way.”

Sunday, more than 250 people gathered in protest of Farris’ death, quietly marching through Coupeville – signs quoting Keaton Farris’ Facebook post: “I see your hate and I raise you one love.”

Leading the procession was Keaton’s dad, Fred Farris.

It was Father’s Day.

Brown got emotional as the weight and gravity of Farris’ death swept over him.

“I’ve broke down several times,” he said. “I’m doing better today.”

The reason Brown said he refused to do television interviews in connection with the case.

“I promised his father I would investigate this case as if it were my own son,” he said, “and that’s what I’m doing.”

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