HAZARD — Larry Trent was just one of the 154 or more inmates who died in a Kentucky jail during the past 6½ years.
Arrested July 5, 2013, in his car outside a doughnut shop in Hazard, Trent, 54, told police he drank "about four beers and mouthwash" before driving to the store with his 10-year-old grandson.
Booked into Kentucky River Regional Jail, Trent couldn't post bond, so he remained in custody. Four days later, he was dead, allegedly the victim of a fatal beating by two jail deputies.
Within 48 hours of Trent's death, jail administrator Tim Kilburn completed a required report for the state Department of Corrections and classified Trent's death as a homicide. A few weeks later, the two deputies were charged with manslaughter, accused of killing Trent by "striking, kicking and restraining" him.
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The case is pending, and a federal civil-rights investigation is active. But Trent's estate already has received a $2.375 million legal settlement — one of the largest in the state during the past 15 years.
The Department of Corrections doesn't investigate jail deaths. "That would fall to law enforcement," department spokeswoman Lisa Lamb said.
However, the department's responsibilities do include ensuring the safety of inmates and staff, and enforcing jail standards, such as those related to training. But state documents provided recently to the Kentucky Center for Investigative Reporting give no indication that the department found anything related to Trent's death that merited its attention.
For example, the documents list Trent's cause of death as an "altercation" in the jail. An internal Department of Corrections memo written after Kilburn's report says little except that Trent "became combative" and that "use of force was necessary" to subdue him. And although the accused killers also were trainers for the jail staff, department records don't indicate a need for more or better training.
Trent's death is by no means the only in-custody death involving an inmate that raises questions about the aggressiveness and thoroughness of Department of Corrections' oversight.
A monthslong investigation by Kentucky Center for Investigative Reporting, or KyCir, found that numerous jail inmates in Kentucky have died or been injured because officials at all levels of government failed to ensure their health and safety.
The causes of more than 40 percent of all Kentucky jail deaths during the past 6½ years are listed ambiguously in department records as "natural, "unknown" or "autopsy pending," although some of those cases appear to have involved lapses by the jail staff, misconduct or indifference.
And the department's own findings and follow-up in those cases were sketchy or nonexistent, despite evidence that the deaths were preventable.
When KyCIR recently asked the department for more current, specific information about the unclear causes of death in old cases, officials said they had none. The department refused to say whether it followed up on jail deaths, and if not, why not.
"The Department of Corrections has been responding to your questions regarding county jails to the best of our ability for the past 10 months," a statement read. "We do not have anything further to add on this topic."
In another case, the state's list of deaths shows that Valerie Jones, a disabled veteran, died of "heart disease" after being jailed in LaRue County in September 2009. But a lawsuit filed by Jones' family alleged that she was not treated properly for severe pain and that she was left in her cell when she desperately needed medical attention.
More than five years later, state records still list the autopsy in her case as "pending." The lawsuit was settled in 2011 for $92,859.
The death of Danny Burden isn't listed at all in the department's compilation of jail deaths. Burden was discovered unconscious in the Grant County jail in March 2013 and later died at an area hospital. A civil suit filed by his family is pending. A state police inquiry found that Burden, a diabetic, badly needed insulin but did not receive it.
The Department of Corrections, however, found nothing to warrant concern — or action. The department would not comment on the omission of Burden from its list of jail deaths.
A KyCIR examination of the Grant County jail, one of the state's most troubled and the focus of a U.S. Department of Justice investigation for more than a decade, shows lax government oversight and little action after Burden's death and the deaths of least two others that seemingly could have been prevented by jail staff.
During the past 6½ years, there has been a death of a Kentucky jail inmate, on average, about once every 15 days. But deaths in jail generally are not of interest or concern to the general public, said Louisville attorney Greg Belzley, who has filed several dozen lawsuits over the past 15 years alleging wrongdoing in inmate deaths.
No lawsuit often means no accountability, Belzley said. When a jail inmate dies, "People may look it and say, 's---, another one gone, thinning the herd,'" Belzley said. "There is no question that some deaths that aren't litigated involve wrongdoing that never gets exposed."
There has been at least one inmate death since 2009 at about three-fourths of the state's jails. Oldham County Jailer Mike Simpson said no one has died in his jail since the 1990s. And while he didn't think that fatality could have been prevented, Simpson said, "when something like that happens, we all have a little bit of ownership."
Incomplete death count
In Kentucky, the Department of Corrections' incomplete death data show that at least 33 of the 154 deaths have been suicides. Suicide is the single-most frequent cause of deaths in jails across the country, and has been for at least 15 years.
That's at least partly because large numbers of people in jails have significant emotional problems, because jail staff often aren't trained to deal with them, and because jail conditions can exacerbate or trigger those mental-health issues, said Preston Elrod, a professor in the School of Justice Studies at Eastern Kentucky University.
Among the deaths reviewed by KyCIR were two suicides that occurred in 2010 at the Grant County jail. The Justice Department has asserted in a document obtained by KyCIR that the two suicides resulted from "serious breakdowns in jail medical care."
Carl Lewis hanged himself in the jail April 11, 2010. He had been placed in a cell by himself with a bed sheet, despite the fact he was deemed a suicide risk and had what the Justice Department later called a "history of suicidal ideation."
Justice Department documents show Lewis was given antidepressant medication in a quantity "that was likely too low to be effective." He received no other mental-health treatment in jail, the federal agency found.
The jail's own inquiry into Lewis' death, by contrast, concluded that "all operational procedures, medical procedures ... were followed professionally and correct." Neither Kentucky State Police nor the Department of Corrections found any fault with the jail in Lewis' death or the other Grant County jail suicide in 2010, involving Derrick Rose.
"Any time you have a fatality in a jail, there should be a very careful investigation and assessment of what went wrong, what happened," said Elrod, the EKU professor. "Unfortunately, in so many instances, the only way you're probably going to get closer to an understanding of what happened is if there's a lawsuit where the parties become compelled to produce evidence."
Judge raises questions
That was what appeared to have happened in the case of Shannon Finn: There was minimal if any investigation by the Department of Corrections, yet significant revelations came out in court.
On March 17, 2009, Finn was arrested and booked into the Warren County Regional Jail for a probation violation. The following day, he began to shake, sweat and act erratically. He was put on a "detox protocol" and given medication for alcohol and drug withdrawal.
Three days later, a deputy found Finn, 34, lying in a puddle of blood and yellow liquid in his isolation cell. Soon after, he was pronounced dead.
The family filed a civil suit, and a jury exonerated jail staffers at trial. However, U.S. District Judge Joseph McKinley concluded in a pretrial opinion that there was ample evidence of questionable conduct.
Among other things, McKinley noted that a jail deputy did not intervene after discovering Finn on his knees, shaking and mumbling. And a nurse neither contacted the jail's medical director nor sent Finn to the emergency room, McKinley wrote.
Despite jail policy that characterized alcohol withdrawal as a medical emergency, deputies had received no training about its symptoms and dangers, according to the judge.
The department's listing of jail deaths says only this about Finn: "Found unresponsive — KSP (Kentucky State Police) investigating."