INDIANAPOLIS – A new report shows death rates at the Marion County Jail are two to three times higher than the national average.

Peter Eisler, a national enterprise correspondent at Reuters, spent two years collecting data from across the country. He submitted 1,500 public record requests and compared each state’s ten largest jails.

“We found there were a subset of jails that had had very, very high mortality rate and had those outside mortality rates year in and year out for a long period of time,” Eisler said. “Nothing had ever been done about it.”

Eisler and his team found in many states, there was little to no oversight at county jails. In half of the states they examined, there was no outside mechanism to do so. At jails that did have oversight, Reuters journalists determined the systems were “relatively toothless.”

“We identified more than 7,500 people who had died in these jails we looked at,” Eisler said. “More than two-thirds of those people who died were still awaiting trial, so they were innocent under the eyes of the law.  They had not been convicted of the crimes with which they had been charged.”

Eisler went on to explain that many of the deaths recorded were considered preventable. Those included deaths from illness, drug and alcohol-related incidents and suicides.

“A lot of these places are underfunded, and they are understaffed. They don’t have the training they need or the resources they need. Sheriffs had been asking for more money to upgrade their facilities in facilities that were overcrowded. There is a whole debate to be had about whether a lot of these people who are awaiting trial should even be in jail, debates over bail reform and so forth. What we found was the communities just don’t really want to spend a lot of money to run a good jail,” he explained.

“If a school needs a new wing and a jail needs a new wing, the county commissioners are by and large going to lean toward putting the money into the school. Meanwhile, you have people dying in these jails from–as you mentioned–preventable causes.”

Eisler traveled to Indiana during his research. He said the Hoosier State, as a whole, showed mortality rates consistent with the national average. He called Marion County, however, an “outlier jail.”

“The death rate at that jail has been two or three times higher than national averages over the past years in the last decade and in several years, it had some of the highest death rates of any of the jails we looked at in the country,” he pointed out.  “Suicide rates there were particularly high in some years.”

Eisler said the building’s old age, a poor architectural concept, and a long history of staff shortages at the Marion County Sheriff’s Office contributed to the mounting death rates.

“The staff there for many years were not paid for what is equivalent to what people were paid for in neighboring suburbs, that sort of thing, which makes it very difficult to attract quality people,” he said.

The Marion County Sheriff’s Office did not shy away from that, either. In 2019, CBS4 had an exclusive interview with Sheriff Kerry Forestal about the ongoing staff shortage. Months later, the City-County Commission voted to allocate more money toward deputy recruitment and retention. Deputes were told they would receive a three-percent raise.

 Despite that, though, Deputy Chief Tenesha Crear told CBS4 retention remains a challenge.

“Simply because a lot of the other 91 surrounding counties pay more than Marion County currently and the inmate population is more challenging here than some of the surrounding counties,” she said. “So individuals who come here sometimes come here and get trained and then they go somewhere else with a less risk field population.”

Officials confirmed as of March 31, 2021, they had 369 deputies working at the jail and 138 vacancies needing to be filled. Crear also said around the same date, while they had about 800 inmates at the jail, only 18 deputies were working the floor and doing rounds at any given time.

“Are there times where things should have occurred that haven’t? Absolutely,” she admitted. “You attribute human error to any profession.”

Crear said it would be difficult for her staff to prevent every single death, especially suicides.

“The only thing that would be able to prevent a suicide is one-on-one–one deputy per one inmate–and we don’t have that,” she said.

Crear said in 2019 alone, the Marion County Jail recorded 780 threats of suicide and six suicide attempts. Records show two people died by suicide, including inmates Ann Ottinger and Bridget Fitzgerald. Reuters and Deputy Chief Crear pointed out the number of suicides among women has been growing in recent years.

“We identify and realize that is a very vulnerable population, so we have increased some programming around that area. Our medical contractor is also inclusive and understands the female population is vulnerable,” Crear told CBS4.

The high number of suicides comes years after MCSO instituted a “zero tolerance initiative.” In 2016, then Sheriff John Layton noticed suicides were increasing at the jail. He and former Public Safety Director David Wantz headed up a commission to focus on prevention, surveillance and intervention of such deaths.

Staff members placed several suicide prevention signs around the jail telling inmates that if they or anyone they knew were having suicidal thoughts, they could call a hotline and report it. The jail has also urged families with loved ones incarcerated at the jail to report their concerns.

“I would ask they look at this when their loved one is here as a partnership. When the individuals in our facility call their loved ones, there is a recording and it asks them, ‘If your loved one is at risk of harm or suicide, please call the number,’ and that is there for a reason,” Crear stressed.

“There may be information they have – historical information they have about their loved one – that we don’t or that wasn’t self-reported when the individual came into our custody.”

Some Hoosier families question that self-reporting policy, though

Tamara Mitchell lost her husband to suicide in 2017. She said he had a history of suicidal attempts and ideation, but had told the Marion County Jail staff otherwise when he was booked.

“There needs to be more on the intake process, from not even the jailers but outside, an independent person. They’re not going to talk to the guards or jail staff. It should be an independent social worker or therapist who can look at somebody’s background and know more about the signs about when they’re being deceptive,” she said.

Orville Mitchell served in the Navy, as a juvenile corrections officer and as an accountant before he lived near Indianapolis. In 2015, he was out celebrating a promotion when he was stabbed six times. Tamara said that set off a mental illness and that her husband’s mental health spiraled afterward.

“It was nightmares and paranoia at first and you know, major depression,” she recalled.

Then, Orville started hallucinating.

“I would wake up in the morning and my curtains would be stapled to the window frames. He would chase imaginary people, get lost on his way to work,” she said. “The way his doctors always explained it to us was that bipolar is inherently there and something triggers it. So, the stabbing was a trigger.”

Tamara, who works in the healthcare industry, struggled to find her husband help. He often refused to seek psychiatric help and hated being on medication. Eventually, though, he became addicted to pain killers. Tamara said her husband started shoplifting out of the blue.

Orville was 36 years old when he was arrested for the first time.

“Literally, he could walk into a store and just walk out with something and think, ‘No big deal, I’m just picking this up,’” she said. “The first time he got arrested, I think it was the TV, he went to jail. So, you get a call and you’re just like, ‘What is going on with you?’”

Tamara couldn’t say why her husband started shoplifting. She felt like they were financially stable and had everything they needed.

“I don’t know if it’s the [delusions] of grandeur or if you think things aren’t going to happen to you, but you kind of have this sense of, ‘I can do all this and nothing is going to happen,’” she said.

On April 23, 2017, Tamara reported her husband missing. It was a Sunday night and she said he had left the house, quite emotional. She told officials her husband was suicidal. According to her, the Johnson County Sheriff’s Office used a drone and found Orville’s cell phone near Camp Atterbury. It wasn’t until hours later that she realized he had been booked into the Marion County Jail.

“I was relieved! I was like, ‘OK, he is going to be safe because at least in an institution like that – especially in jail – you’re being monitored, like, really closely. I felt confident he was at least going to be OK and that he at least wouldn’t be able to hurt himself,” she said.

Four days later, Orville hanged himself in his jail cell. According to the incident report, another inmate found him. The autopsy indicated Orville had several drugs in his system, including chlordiazepoxide (used to treat anxiety and acute alcohol withdrawal), demoxepam (used as an anticonvulsant, muscle relaxant and sedative hypnotic), and amlodipine, a cardiovascular agent.

“I just wish we would have gotten more answers and the truth,” Tamara told CBS4. “I never got any answers. When I asked what their rounding policies were, how often were they supposed to round, I never got an answer on that. I kind of got a little push back, a little just…just stop…just go away.”

Tamara feels sorry for other Hoosier families who have had to suffer like hers. She and her three children remember Orville as a good father, a good husband and a good man.

“My husband, to a lot of people, will look like a junkie. A junkie and a thief and also the crazy guy. And while he maybe he was all those things, he was also a really good person that…I don’t know, given the right situation and the right people involved and the right people listening, it could have been different,” she said.

The Marion County Jail faces several wrongful death lawsuits

Another problem the Marion County Jail has had in recent years is a high number of deaths involving drugs or alcohol. According to the data obtained from Reuters, there have been six such fatalities since 2008.

Deputy Chief Crear admits most of the inmates housed downtown suffer from substance abuse.

“Over 40% of our population have mental illness,” she said.

As of this article, there were two lawsuits filed against the Marion County Jail.

In one, the estate of Rachelle Stewart was seeking monetary damages against an LPN and a correctional health care corporation. The attorney and family involved said her death was unnecessary.

Stewart was arrested on Jan. 26, 2016, for an alleged failure to appear in court. The lawsuit detailed how Stewart was a burn victim and was therefore on several pain killers. The lawsuit also claims Stewart was an alcoholic. The document stated when Stewart arrived at the Arrestee Processing Center, “she was unsteady on her feet and barely responsive to questioning.” Correctional officers reportedly helped her from the transport van and into the receiving room. There, the family’s attorney said Stewart was seen on surveillance video swaying in a chair with her head down and her hands cuffed behind her back.

A correctional officer was heard on surveillance video saying a nurse would check her and that she was intoxicated. The lawsuit alleges the jail’s LPN “looked at Rachelle, helped her stand up and take one step, then helped her sit back down.” The LPN allegedly asked Stewart how much she had to drink and whether she knew where she was.

The court documents say the medical staff member did not examine Stewart nor did she take Stewart’s vital signs or conduct any tests. The LPN was heard on video saying, “She can come in.” The LPN then left the receiving room. At one point, the lawsuit claims Stewart mentioned medication, “to which the correctional officer makes a joke, and the surrounding arrestees laugh.”

The attorney said Stewart was placed in a single cell without any medical assessment. Because she had been incarcerated before, a health care assessment had been done. It reportedly indicated she had a history of substance abuse, blackouts and had problems with dizziness and seizures.

Four hours after she was booked, correctional officers found Stewart unresponsive.

The lawsuit alleges had the jail’s LPN “properly treated and assessed Rachelle, she would have determined Rachelle was suffering from a potentially deadly combination of drugs and alcohol” and that “she would have determined Rachelle needed medical treatment for her drug and alcohol consumption, which could have saved Rachelle’s life.”

Crear was not willing to comment on pending litigation.

CBS4 also obtained court records regarding a case dating back to 2018. It was then that Kyra Warner was arrested and transported the Marion County Jail’s Intake Center.

According to the lawsuit, Kyra had consumed a “large quantity of amphetamines and/or methamphetamines and/or lorazepam and/or morphine and/or Xanax and/or opiates prior to r after arrive at the jail. Within hours, she allegedly started showing signs of distress from a drug overdose.

The attorney representing Warner’s estate and family said other female inmates noticed Warner in need of medical attention. The suit alleges three nurses responded to Warner’s needs and transferred her to an isolation cell, where she sat unattended. The lawsuit indicates that was within policy and practice of the Marion County Sheriff.

The documents, though, claim Warner should have been provided medical attention and treatment. Documents go on to say that Warner was dragged down a jail hallway “with officers grasping and holding each one of her four limbs.” She was allegedly placed in a wheelchair, being that she was physically unable to walk.

The lawsuit went on to say that hours later, when Warner was still showing signs of distress, deputies tried to stand her up unsuccessfully. Warner allegedly fell to the ground and hit her head on the cell walls.

Court records indicate Warner was found unresponsive around 7:22 p.m. The attorney said around 7:45 p.m., deputies “threw a sack lunch at Kyra, hitting her on the leg, but she did not move.”

Eventually, Warner was transferred to the hospital. She died 14 days later. She left behind two children, ages three and 13.

The Marion County Jail denied many of the allegations but would not comment on the pending litigation in person.

“I can’t speak to that because I don’t know how many of those are still in litigation, however when I speak to human error. Anytime we do find there was something that could have been done after we go in and we research the incidents, we make sure we implement those policies or practices,” Crear said. “It’s an unfortunate situation and when those deaths occur in our facility. They are not taken lightly.”

The Marion County Sheriff’s Office is planning to open its new Justice Campus in 2022

CBS4 asked about the ongoing issues at the Marion County Jail, including the fact that the building is outdated and difficult to navigate. Because there are so many walls, deputies have a difficult time monitoring inmate activity via surveillance camera.

“Is there a solution?” CBS4 asked.

“Yes,” Crear answered. “The new criminal justice campus. It’s a more open concept, and there are several hundred cameras on the campus.”

The $571 million Community Justice Campus, funded through bonds, is expected to open on the southeast side in 2022. The new facility is at least 11 stories tall. It will house 3,000 beds, a new sheriff’s headquarters, an adult intervention c enter and necessary courtrooms.

The ACLU is not surprised by the findings

CBS4 reached out to the ACLU about the data obtained from the Marion County Jail. Jane Henegar, the executive director, confirmed their organization receives thousands of calls every year from family members concerned about their incarcerated loved ones.

“Transparency in the data across the country is a real problem,” she said. “There is a concern across the country and here in Indiana about the conditions of our jails. The vast majority of our jails are by definition overcrowded and that overcrowding leads to a lack of care health and safety concerns that often unfortunately manifest in tragic ways including death.”

Henegar said people who are booked into the jail and suffer from mental health or substance abuse issues often have a difficult time advocating for themselves.

“The system isn’t really set up for them to get the care within incarceration or for their family members to advocate for them,” she said. “It’s a heartbreaking situation.”