North Carolina prisoner with a history of mental illness who was found dead in a transport van after being transferred to another prison died due to dehydration, according to the North Carolina Medical Examiner’s Office.

However, the state pathologist who conducted the autopsy on Michael Anthony Kerr, 54, said records provided by the Department of Public Safety were so scanty and incomplete that she was unable to determine whether his death was accidental, a suicide or a homicide.

Prison records indicate that Kerr was held in solitary confinement for 35 days prior to his death and had spent the last five days of his life handcuffed and largely unresponsive. Prison officials repeatedly turned off the water to his cell because he had flooded it, and put him on a diet of milk and nutraloaf. The milk was later ordered withheld.

“They treated him like a dog,” said Kerr’s sister, Brenda Liles.

Kerr died on March 12, 2014 as he was being transported from the Alexander Correctional Institution to the Central Prison hospital in Raleigh, a three-hour trip, for mental health care. The medical examiner’s report noted that when Kerr arrived in Raleigh he was unresponsive and could not be revived. According to the News Observer, the route taken by the transport van went past emergency rooms at eight hospitals.

Department of Public Safety (DPS) spokeswoman Pamela Walker said she could not discuss the medical attention that Kerr needed, nor why he was not taken to a closer hospital.

In the wake of Kerr’s death, the department fired nine employees; two more resigned and 19 others were disciplined.

Deputy Director of Prisons Gwen Norville allowed state pathologist Dr. Susan Venuti to look at a “Sentinel Event Review” conducted by the department, though refused to let her keep a copy nor did she receive any other reports.

“The nature of his dehydration, whether as a result of fluids being withheld, or the decedent’s refusal of fluids, or other factors, is unclear,” Venuti wrote. “Since the circumstances surrounding the development of dehydration leading to death in this incarcerated adult are uncertain, the manner of death is best classified as Undetermined.”

Liles said she received a call in early March 2014 informing her that her brother was being mistreated. She said the caller – whom she refused to identify – told her that Kerr had not been treated for his mental illness since being placed in solitary confinement in the “Red Unit” at Alexander Correctional Institution in February.

Then on March 4, she said, both her brother’s caseworker and psychologist called and promised to try to have him moved to the Central Prison in Raleigh, which maintains a medical and mental health hospital.

Liles received a letter from a prisoner housed in the cell next to her brother’s which indicated that instead, prison officials actually did nothing to help Kerr. The letter, from prisoner David Chambers, described how Kerr spent his last days unresponsive, handcuffed, covered in his own waste, and attended by callous prison guards and healthcare workers. The handcuffs, which had become embedded in his wrists, had to be removed with bolt cutters.

On March 11, 2014, Chambers wrote that Kerr was not eating and not responding to anyone. The next day, before he was loaded into the transport van where he would die during the trip to Central Prison, Kerr reportedly said one word: “Please.”

Among the employees fired following Kerr’s death were Captain Shawn Blackburn and Psychological Program Manager Karis Fitch. At least five nurses and two psychologists were also among those who were terminated or resigned.

“The belief at that time from Dr. [Christine] Butler, the treating psychologist, was that Kerr was trying to manipulate a transfer to Central Prison,” observed psychological manager Michael Youron, who was fired. “I believe DPS pretty much just looked for scapegoats,” he added. “They just wanted to find someone to blame.” Dr. Butler later resigned.

Several employees, including nurse Jacqueline Clark, appealed their terminations. On March 4, 2015, the Office of Administrative Hearings found in Clark’s favor and ordered her reinstated with back pay plus $22,335.42 in attorney fees.

“We have been righteous with our investigation and dismissals,” contended Secretary of Public Safety Frank L. Perry.

However, state agencies have faced obstacles in trying to determine why Kerr died. An agent for the State Bureau of Investigation had to get a court order to obtain Kerr’s records.

In October 2014, the U.S. Department of Justice opened an investigation and a federal grand jury filed subpoenas for documents related to Kerr’s treatment and death, and how the state had handled the case.

Observers said they were confounded by the state’s refusal to be more forthcoming.

“I have been a criminal defense lawyer for 20 years, and I’ve never seen a situation where a state agency does not fully cooperate with the medical examiner in a death investigation,” noted Bradley Bannon, president of NC Prisoner Legal Services.

Perry denied that the DPS was trying to hide anything. If information was withheld, he said, it was for “a righteous reason like privacy or respect for HIPAA [the federal law covering privacy of medical records]. I don’t think anyone intentionally withheld anything,” he insisted.

“We are very concerned about the case of Mr. Kerr,” said Vicki Smith, executive director of Disability Rights North Carolina, an advocacy organization that also provides legal services for the disabled. Smith pointed to abundant research that shows solitary confinement causes a prisoner’s mental health to deteriorate.

“There is a common trajectory of people who see the symptoms of their mental illness criminalized,” she noted. “The root of this is untreated mental illness.” Disability Rights North Carolina wrote to the Department of Public Safety requesting a meeting and asking the agency to preserve all evidence related to Kerr’s death.

Kerr, a U.S. Army veteran, was serving a 31-year sentence for possessing and discharging a firearm as a habitual felon. His sister said his mental problems began when two of his sons were murdered in separate incidents, one in May 2007 and the other just 13 months later in June 2008.

“That’s when he began to have those nervous breakdowns,” Liles said. “He had two or three.”

She was furious to learn of her brother’s death. “On the 3^rd and the 4^th [of March], I was calling the prison and fighting for my brother. They said they were going to get him some medical attention, but they didn’t do it,” she stated. “Anybody that had a hand in murdering my brother, they need to go to jail.”

Sadly, this was not the first time a mentally ill North Carolina prisoner had died due to dehydration after prison staff cut off the water to his cell. Glen R. Mabrey, Sr., 47, a Vietnam veteran, died at the Central Prison under similar circumstances in February 1996. Six nurses were disciplined in that case. See: Mabrey v. Farthing, 280 F.3d 400 (4th Cir. 2002).

Sources: www.indyweek.com, www.newsobserver.com, www.wkrg.com, www.wncn.com, www.wral.com, www.huffingtonpost.com, www.truth-out.org

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