Dying behind bars: Conflicting opinion on inmate's death, part of larger problem, advocates say

Benjamin McCoin's death was not an accident.

A 63-year-old inmate convicted of attempted murder-by-dynamite with a history of paranoid schizophrenia, McCoin died on March 19 shortly after detention officers at the Montford Psychiatric Unit tried to forcibly move him to another cell.

A recent review of the state autopsy shows McCoin's death was a homicide.

What this new finding does is reverse a previous decision paid for by the state. And, it means ultimately someone could be culpable for McCoin's death.

McCoin's death is not the only conflicting opinion and reversal after a local review. Nor is it the only death at the Montford Unit this year that the Texas Office of the Inspector General is investigating. Advocates for reform say the deaths are not isolated, but instead are part of a larger problem about how those in custody are treated, especially the mentally ill.

Documents obtained by A-J Media show McCoin sustained an acute hip fracture after a Montford extraction team went to his cell because he refused medical and psychiatric medications.

Later, McCoin complained of hip pain and was taken to the unit's infirmary. He was then sent to University Medical Center for treatment where he collapsed and died in Emergency Room 2, documents show.

State law requires an inquest to determine the cause of death. McCoin's body was taken to Tarrant County, which has the contract with the Texas Department of Criminal Justice to conduct local autopsies.

On March 25, Susan J. Roe, M.D., in Tarrant County said McCoin's death was accidental.

But Roe's autopsy report raised questions and concerns.

Lubbock County Medical Examiner Sridhar Natarajan conducted an Oct. 2 review, changing the manner of death, which he said he will file with the Lubbock County district attorney this week.

"It was a fairly entangled set of circumstances," Natarajan said.

"Homicide doesn't mean murder. In simple terms, it means death at the hands of another individual."

'Differing causes of death'

A Montford doctor originally reported McCoin's death as natural.

Patricia Aristimuno, M.D., said McCoin died from "sudden cardiac death," noting tobacco use could have been a contributing factor. A Tarrant County autopsy later found McCoin had heart disease with 80- to 85-percent blockage in addition to the hip fracture.

In his review of the case, Natarajan noted the cause of death was attributed to "blunt trauma due to forceful restraining."

McCoin also had a laceration on his forehead. And he had an abrasion on his wrist and "crusted areas" on an ankle and knee indicating various stages of healing.

The body condition, medical experts say, indicates McCoin had been restrained.

"When you see something on the wrists and ankles, that could be a restraint injury," said Judy Melinek, M.D., forensic pathologist and author of the New York Times bestseller "Working Stiff."

"If the restraint caused fatal trauma, that's not an accident, it's homicide."

Melinek, a contract pathologist for the Alameda County Coroner's Office in California, reviewed the autopsy reports for the A-J.

Perhaps more troubling than what the autopsy reveals is what the report doesn't say.

Roe, in the Tarrant County autopsy, did not examine the extent of hip damage McCoin suffered.

"Why didn't she cut down on the hip to see hemorrhaging or how bad the injury was?" Melinek said.

"That's not as complete as it should be. That's a big oversight."

The state has been investigating the death since March.

A-J Media has requested, but not yet received, a copy of the use-of-force video from the Lubbock County Medical Examiner's office.

Montford Warden Robert Stevens declined to comment.

Nizam Peerwani, M.D., Tarrant County chief medical examiner, did not return multiple phone calls and emails seeking comment.

Jason Clark, a TDCJ spokesman, called Natarajan's review unusual.

"It's certainly a unique situation where you have differing causes of death between two medical examiners," Clark said.

Not an isolated incident

More than 60 inmates since 2005 have died in state custody at the Montford Unit, which includes the West Texas Hospital for prisoners, according to the Texas Attorney General Custodial Deaths Report.

Data collection on custodial deaths began following the federal Death in Custody Reporting Act of 2000. In-custody deaths include anyone in the process of being arrested, en route or incarcerated in municipal or county jail, state prison or other correctional facility.

The causes of death can vary - whether natural because of age or disease, by suicide or at the hands of other inmates. Some die from neglect, abuse or inadequate facilities as was documented by a University of Texas School of Law report earlier this year, which found 14 inmates in prisons across the state have died of heat-related injuries since 2007.

And still others - as was the case with McCoin - die at the hands of prison staff.

"Most of the really horrifying things happen because they basically lock people up and throw away the key," said Brian McGiverin, a prisoners' rights attorney in Austin with the Texas Civil Rights Project.

"The bigger, additional problem with jails is the issue of failing to screen folks."

The Montford facility, which is one of three psychiatric units in the state, had averaged about two inmate deaths a year from 2005 to 2012. But then in 2013, the number jumped to 24 deaths. So far this year there have been 18 custodial deaths.

The Texas Department of Criminal Justice explains the rise in custodial deaths statewide to a reporting requirement change. Clark said that before 2013, deaths in an in-patient setting were not included.

Montford is the only state facility in Lubbock. The average age at the Lubbock psychiatric unit is 47, slightly higher than the state average of 39. But it's been higher. In 2012, the average inmate age at Montford was 62.

The unit does not specifically provide care to older inmates like the Rufus H. Duncan Geriatric Facility in Diboll does, but Montford is offering hospice care to six offenders.

McGiverin, who tracks inmate deaths, said he was not aware of the increased number across the state.

But the numbers were not a revelation to everyone.

"It really didn't come as a surprise that the Montford Unit has that many deaths," said Lance Lowry, president of the Texas chapter of the American Federation of State County Municipal Employees, which advocates for greater training for correctional officers.

"This isn't an isolated incident.

"For a facility to have that many deaths, it definitely does raise flags."

Reviewing additional deaths

McCoin's death is one of four Natarajan has reviewed in the past year.

In two of the cases the state said were natural deaths - including McCoin's - Natarajan has changed the cause, out of concern.

The second involved 27-year-old Marsele Dauntri Thompson, who in January was found unresponsive in his cell. Tasha Z. Greenberg, M.D., in Tarrant County reported finding "no evidence of trauma or foul play."

And yet, the autopsy records evidence of a contusion on Thompson's forehead in the process of healing, as well as abrasions around his eyes and and additional contusions on his arm and thigh.

Correctional officers were supposed to be conducting 15-minute checks on Thompson, a schizophrenic on water restriction for his personal safety. However, when officers discovered Thompson sitting nude in his cell with his legs crossed, his body was cold.

Generally, a body is stiff and warm at two hours. It's stiff and cool between four and six hours.

"When the body was found it was cold, in rigor," Nataranjan said. "That's not going to happen within a 15-minute check. It doesn't match with 15-minute checks."

Natarajan reported the death undetermined.

"If I'm not able to explain it, I'm not going to give a cause of death," Nataranjan said.

The Texas Office of Inspector General is also investigating Thompson's death, Clark said.

'Those people should not be dying'

The issue of in-custody deaths is not a state one alone.

On Sept. 29, A-J Media requested from the Lubbock County Medical Examiner's office copies of the autopsies conducted on inmates who died in local and state custody over the past five years.

Among the findings:

¦ Of the four state cases reviewed by the Lubbock County Medical Examiner's office, two of the death certificates were amended because of conflicting findings. Two were ruled undetermined.

¦ More than half of the Lubbock County Sheriff's Office deaths were ruled natural, the majority of which related to heart disease, obesity or stroke.

¦ Half of the sheriff's office natural deaths involved inmates younger than 40. One was a 28- year-old inmate who reportedly died from obesity.

¦ Two-thirds of the inmate deaths under the auspices of the Lubbock Police Department were homicides, mostly by gunshot. Not all the autopsy reports indicate who fired the weapons.

¦ At least one police homicide death was attributed to methamphetamine use.

¦ One police department death ruled an accident was attributed to "blunt head trauma due to fall."

¦ The Lubbock Police Department has had two suicides since 2008.

Of the state and local cases the A-J reviewed, the most troubling - advocates say - are those involving inmates in county jail, 90 percent of whom in Lubbock are awaiting trial.

Lt. Bryan Taylor, a sheriff's spokesman, said all in-custody deaths are investigated. The Lubbock police did not respond to requests for comment.

Understaffing, shrinking budgets and a lack of training are among the contributing factors to the high number of in-custody deaths, McGiverin in Austin said.

"What you're describing sounds particularly bad," McGiverin said.

"Those people should not be dying. People in jail are all pre-trial. They're not even guilty of anything. It's appalling."

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