Danny Ray Burden fell asleep in mid-sentence as he was booked into the Grant County jail, toppling over on the bench where he sat. Prodded awake, he coughed, shook and pleaded for emergency medical attention.
A blood test showed that the 41-year-old diabetic badly needed insulin, and a doctor ordered it. But Burden never received it. Instead, deputies put him in a cell, where they found Burden unconscious just three hours after he had entered the jail on March 27, 2013. He died a week later.
Burden's relatively minor crime — failing to make $3,380 in restitution — suddenly became a capital offense. And he took his place in a long line of victims at Grant County's deeply and chronically troubled jail.
"It doesn't need to happen to anyone else," Danny Burden's brother, Mark, a retired Kentucky State Police detective, said in a deposition in his pending lawsuit against the jail. "You know the Grant County jail. There's been issues up there for a long time. It's not anything new. There's nothing changing up there; something needs to change."
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During the past dozen years, the now-decaying 350-bed jail has been plagued by abuse, indifference, ineptitude and malfeasance, the Kentucky Center for Investigative Reporting found.
Inmates have died needlessly or have been raped, abused and neglected. Lax security, flawed medical care, inadequate training and a raft of other administrative failures flourished. In an effort to cover up misconduct, some jail employees concocted bogus stories, ordered others to lie or destroyed incriminating evidence.
This litany of failures has occurred largely under the watch of the U.S. Department of Justice, the Kentucky Department of Corrections and the Grant County government. All of them, despite red flag after red flag, have been unwilling or unable to achieve lasting change at the jail.
Danny Burden's was just one of several deaths there in recent years. Two inmates committed suicide in 2010, after what the Department of Justice, or DOJ, later called "serious breakdowns in jail medical care."
Other serious lapses have involved inmate safety. A teenager arrested on a traffic charge in 2003 was raped by inmates who had been encouraged by guards to attack him. And a mentally ill man serving time for a probation violation was sexually abused in 2002 by another inmate after being falsely labeled by guards as a child molester — a devastating accusation in a jail.
Kentucky State Police and local grand juries have investigated jail-related wrongdoing over the years. A current state police case centers on former jailer Terry Peeples, according to a document obtained by KyCIR.
One grand jury report, in 2011, cited inadequate supervision and training of jail staff, and recommended that Peeples "immediately contact" the Department of Corrections to request assistance to implement a training program for all jail staff. But the state said it had no record of Peeples making such a request.
Peeples, voted out of office last year after serving one term, has been accused in more than a half-dozen lawsuits of misdeeds, including sexual harassment of staff, demanding that employees lie on his behalf and threatening to fire some who challenged him.
Peeples' predecessor, former state trooper Steve Kellam, also had issues on his watch, including inmate abuse, a major DOJ investigation and the two in-custody suicides.
Peeples and Kellam, who was jailer from 2001 through 2010, refused repeated requests to be interviewed for this story.
In all, inmates and staff have filed more than 50 lawsuits against them and the jail during the past 15 years. Nearly $5 million has been spent to settle claims, with more payouts likely.
Of the 19 comparably sized jails in the state, only five had total settlements exceeding even $1 million during the same period, KyCIR found. Just one other jail's total was greater than $4 million.
"Nobody has been able to manage that jail," said James Crawford, the longtime commonwealth's attorney for Grant County. "They simply have not done it. If they had, you wouldn't have had that volume of litigation. I don't see how anybody, just looking at the lawsuits, could call it anything else but troubled."
The president of the Kentucky Jailers Association, Oldham County's Mike Simpson, told KyCIR that former Grant County jailers were "bad actors" and said the association doesn't condone them or what took place at the jail.
In early 2003, a vicious assault inside the jail helped set the stage for what could have been major reforms at the Grant County jail. Court records describe the attack.
Booked into the jail about midnight on Valentine's Day, a teenager was mocked by guards for the blond highlights in his hair and the heart shapes on his boxer shorts.
The guards said he looked "like a girl." They called him a "sissy." And they agreed that he "needed to be scared," according to a federal appellate court opinion. So they locked him in cell 101, dubbed the "hallway from hell" for inmate-on-inmate violence.
"I got some fresh meat for you," a guard told the dozen inmates in 101. Told to "f--k" with the teenager, the inmates — all convicted felons — roared their approval.
When the sexual abuse began, the teen cried out for help. No one responded. He remained in cell 101 for five hours, until morning. No guard checked the cell during the night, even once, even though state regulations require hourly observations.
After word of the assault leaked out, the guards fabricated stories in an attempt to cover up their complicity. It didn't work. Three inmates and three jail deputies eventually went to prison for their roles in the teen's ordeal.
Within months, the U.S. Department of Justice undertook a rare — and major — step, initiating only its second civil-rights investigation of a Kentucky jail or prison since 1980.
The result: a scathing report in May 2005 that identified an array of constitutional violations at the jail, including preventable inmate-on-inmate assaults and "deliberate indifference" to inmates' "serious medical needs." Numerous other management deficiencies, including inadequate staffing and training, also were cited.
In some instances, such DOJ investigations are resolved quickly. If not, the department can take the defiant agency to court. But neither closure nor litigation has occurred in Grant County, where the DOJ's inquiry has labored on for 12 years, with no end in sight.
Documents obtained by KyCIR show a clear picture of a county aggressively fighting oversight, denying wrongdoing and failing to meet its legal obligations. Meanwhile, the Justice Department responds with rebukes but no show of force, no push for a consent decree or a lawsuit to compel compliance.
In an Aug. 8, 2006, letter to the DOJ, then-Grant County Attorney Edward Lorenz flatly denied any constitutional violations at the jail: "The center is a well-run facility and is viewed as a model facility by the state and the federal courts who utilize this facility to house prisoners."
The county's defiance continued for the next two years, as it refused to sign off on DOJ's 16 proposed "remedial measures" to address inadequacies in medical and mental-health care. In December 2007, Lorenz wrote that "the facility is simply not violating any provisions of the Constitution, any federal law, any state law, either in a criminal or civil sense."
The county reiterated that position in July 2008, adding that continuing the case "is becoming a misuse of taxpayer dollars."
In 2009 the county capitulated after the department optimistically predicted that just two more inspections of the jail, one a year, would be sufficient to conclude the case. Indeed, the DOJ said, compliance might be attained even sooner. But the Justice Department's timetable proved to be wildly wishful thinking.
Although Grant County agreed to address the shortcomings, the Justice Department's three inspections of the jail since 2009 have found barely any improvement or none at all. And in at least one key instance — on-site mental health care — conditions have regressed, the DOJ found.
Meanwhile, the DOJ's impatience has mounted, but its approach has remained the same: inspect jail, write critical letter to the county, wait a couple of years, repeat process.
After its December 2009 inspection, the department's assessment was relatively benign: The jail had "largely been an active and cooperative partner," but "significant work remains to be done."
But after the second inspection, in October 2012, the DOJ's concerns were mounting: In addition to the "serious breakdowns in jail medical care" that had led to the two inmates' suicides, the department said, "serious, longstanding constitutional problems" had not been addressed.
DOJ attorney Christopher Cheng followed that broadside with another in July 2013, complaining that problems at the jail "date back to the beginning of our investigation," that the county had not even bothered to respond to the second inspection's findings, and that its attitude suggested "indifference toward the constitutional rights of the jail's inmates."
The department's frustration and concern boiled over after its June 2014 inspection.
DOJ said it found "atrocious" documentation of inmate medical problems, "no real physician supervision" of patient care, "grossly deficient" mental health staffing and "compelling evidence" of the county's "utter disregard for its constitutional obligations."
As a result, Cheng asserted in a letter to the county on Oct. 14, inmates are "at continued risk of serious harm." And he said the DOJ's spurned offers of assistance were "further evidence of (the county's) deliberate indifference."
A year later, the county has yet to respond.
The county also has failed to comply with virtually all of the 16 measures it agreed in 2009 to implement — and which the DOJ had confidently predicted could be accomplished in two years or less.
After three inspections over five years, the department found that the jail had resolved just two of the 16 areas, and none of the most important ones.
Although the Grant County case is now among the DOJ's longest-running civil rights investigations of a county jail, the department would not say why it has not acted more aggressively to force compliance.
Instead, the Justice Department issued a statement to KyCIR that said it continues to be "actively engaged in the monitoring of its agreement with the Grant County jail" and that constitutional violations "do not develop overnight and often require years to correct."
A department spokeswoman refused repeated requests from KyCIR to answer questions or to elaborate. Cheng declined to comment.
State finds little fault
The Grant County jail couldn't hold Anthony Artrip, a convicted bank robber with "fear no evil" tattooed on his stomach and a record of two jailbreaks.
After Artrip climbed a basketball goal on June 24, 2007, and fled the jail with the aid of a sling fashioned from bed sheets, deputies acknowledged they had searched Artrip's cell before his escape. But they failed to find the sling, which Artrip had managed to conceal from guards for three weeks, records show.
That security blunder was among the reasons neighboring Pendleton County and the U.S. Marshals Service decided to remove their inmates from the jail. Nearly eight years later, they have not returned.
But neither that escape nor a host of other cases involving jail inmate safety and security appear to have fazed the state Department of Corrections.
By law, the department is responsible for enforcing jail standards, which include inmates' rights. And the department's own mission statement proclaims its intent to ensure "a safe, secure and humane environment for staff and offenders."
Given the jail's long history of serious problems, the department could have removed its inmates from the Grant County jail or sought a court order to close it. It has done neither, and state officials declined to say why.
The Department of Corrections has found little to complain about there. Its two dozen inspections over the past 12 years were largely tepid affairs, the agency's own records show.
Desi Brooks, the department's regular inspector at the jail, routinely gave the jail a clean bill of health, rarely if ever expressing significant concerns about what he saw or heard, according to his reports.
Last November, however, another state inspector visited the jail and discovered a vastly different landscape. Kirstie Willard reported a "state of chaos," and a "total lack of leadership and resources available to operate the facility in an efficient, safe and secure manner."
Willard found that many staff members had quit or had been fired "in light of ongoing lawsuits and investigations." Jailer Peeples, she was told, had barely been seen in recent weeks.
Deficiencies that Willard identified included exposed wiring, inoperable lights, holes in walls, leaking pipes, a porous roof, "mold and horrible odor" seeping out of a kitchen drain and a buckled floor in the walk-in cooler.
"Staff openly admitted that virtually no maintenance had been done to the facility in three years," Willard wrote.
In all, Willard cited 19 areas of noncompliance — nearly as many as Brooks had noted during the previous decade.
Just eight months earlier, on March 13, 2014, Brooks had found the jail to be "clean and in an orderly condition." And neither of Brooks' 2013 inspections cited a single area of noncompliance or concern.
Department of Corrections officials, including Brooks, refused to be interviewed. The department agreed to accept written questions but provided responses to only some of them.
Those responses defended the department's inspection history at the jail and asserted that the state has fulfilled its legal obligations there. "We find no deficiencies in the process of enforcing jail standards," the agency said. Asked whether it had any concerns about Brooks' oversight, the department said, "No."
The department also asserted that the problems noted by Willard last November arose after Brooks toured the jail earlier in the year.
That contention was disputed by Steve Skinner, a former administrative captain at the jail, who said he accompanied Brooks on nearly all of his inspections in recent years, including the March 2014 tour.
"Things didn't change much if at all" from March to November last year, Skinner said.
And although the agency's policy states that at least one inspection each year should be unannounced, Skinner said jail officials routinely received advance notice of Brooks' inspections during Peeples' tenure. The department denied that.
Skinner filed a lawsuit last October alleging an array of problems at the jail, including misconduct by Peeples. Those allegations are part of the current state police investigation. Skinner was fired in January by Chris Hankins, the current jailer.
Steve Wood, who was elected Grant County judge-executive last fall and has since taken an active role at the jail, said he "felt like vomiting" when he first toured the building. "I am so embarrassed about the jail."
Wood said that he was incensed after reading the 2014 inspection reports and talking to jail employees, and that he couldn't understand how Brooks allegedly missed the violations Willard observed. "I just don't know why he didn't report it," Wood said. "He was either blind or didn't want" to know.
Brooks, meanwhile, was promoted to a regional administrator position last year, one week before Willard's findings at the jail called his previous inspections into question. In its written responses, the Department of Corrections defended Brooks' promotion.
Brooks' investigation into Danny Burden's death also appears to have been superficial. In an April 1, 2013, email obtained by KyCIR, Brooks indicated he spoke to just one person, a jail supervisor, before concluding that Burden "by all accounts appeared fine" when he was booked into the jail.
Although information provided to the state police by other jail staffers directly contradicted that assessment, the agency nevertheless said it stands by Brooks' handling of the matter.
Local officials hands-off
Until Wood took office in January, Grant County government disclaimed any responsibility for the jail, even though state law clearly requires local oversight.
Darrell Link, the Grant County judge-executive from 1999 to 2014, could have stepped in. But he refused to say why he had not, telling KyCIR: "I'm gonna decline speaking about the jail. I don't have any responsibility for the jail, never did."
By law, however, a fiscal court is required to provide and maintain "a safe, secure and clean jail in the county," and fiscal court members have authority over the jail's budget and personnel.
In the past, Link — now executive director of the Kentucky Council of Area Development Districts — made no secret of his lack of interest in what went on at the jail.
In a deposition shortly before the Justice Department's 2005 report on the jail, Link said he had done nothing to investigate because he believed jailer Steve Kellam's assertion that the staff had done nothing wrong.
Link also contended that litigation involving the jail was "frivolous."
"There wasn't anything that they could have done to prevent whatever possibly happened," Link said in the deposition.
Barely a year later, Grant County had agreed to pay $3.6 million to settle seven of those suits. And two former jail employees subsequently claimed in litigation that Link was indifferent to their concerns about the jail.
A $1.5 million renovation is about to begin and should conclude next year. "I'm trying to make it better, trying to do a good job, trying to get it back up to par," Wood said. "I'm a taxpayer, too."