CLAYTON — St. Louis County Prosecuting Attorney Wesley Bell said Thursday he will not file criminal charges in the deaths of two men in the Justice Center earlier this year, although he said investigations by police and prosecutors identified systemic breakdowns in the jail that he found “troubling.”
Lapses included nurses in both cases who failed to perform basic functions to treat patients and one who barely knew jail procedures, a guard who did not conduct a proper headcount, and the availability of drugs in the jail. And, police found, the jail has no policy to guide jailers and nurses about whose job it is to call 911 during a medical crisis.
Still, Bell said on Thursday, “In these two terrible cases, the evidence does not support our office issuing any criminal charge.”
Prosecutors who reviewed the deaths of John M. Shy, on Feb. 23, and Lamar Catchings, on March 1, could not find evidence that either death resulted from acts or omissions by specific people, Bell said. His staff previously declined to file criminal charges in the death of Larry “Jay” Reavis on Jan. 18.
“You have to have the elements of a crime,” he said in an interview. “You have to have the guilty act, the guilty mind, the correlation and causation. You can’t get away from that. Now on the civil side, that’s different.”
The deaths precipitated multiple inquiries and organizational change within the jail. On April 22, then-County Executive Steve Stenger installed St. Louis County police Lt. Col. Troy Doyle to run the jail, ousting interim director Julia Childrey. Doyle said he intended to evaluate the jail’s operations and enhance its performance.
Stenger, who may be facing federal prison time in a pay-to-play scandal, resigned on April 29. His successor, Sam Page, said Thursday the county had removed a nurse who was working on a contract and reprimanded another nurse. He said he had asked an accrediting agency to expedite its review of the jail, identified companies that could do independent audits, and asked the Clayton police to determine if they had seen a pattern of deficiencies. He said he made several other policy changes and bolstered oversight of the jail and medical staffs.
Page said in a statement that the county “must do whatever is possible to prevent this from happening in the future.”
Bell said he was working on a list of recommendations and best practices for the jail. “We don’t want this to happen again,” he said. In both the Shy and Catchings cases, nurses central to the investigation refused to meet with authorities. Bell said one change he would make is “any justice service employee should be required to cooperate fully with any investigations. And if they don’t, they should be terminated.”
The county medical examiner ruled that Shy, 29, of Oakville, bled to death from an intestinal hemorrhage. He was transported to St. Mary’s Health Center in Richmond Heights twice on the day he died, but the hospital released him back to the jail each time. Shy screamed intermittently in an infirmary holding cell for the final nine hours of his life until he was found in a pool of blood.
The medical examiner ruled Catchings, 20, of Jennings, died from acute leukemia that had never been diagnosed. Catchings had been held for nearly a year but his health deteriorated rapidly in the two weeks before he was found dead in his cell. He had to be wheeled to a court date a week before he died, and no one in the criminal justice system — including the judge and his own public defender — was curious enough to ask why. The medical examiner said he probably had the most curable form of leukemia.
Breakdowns and stonewalls Clayton police reports released at the conclusion of Bell’s review revealed several areas of concern:
• St. Mary’s Hospital would not cooperate with the Clayton police investigation by letting officers speak with doctors who treated Shy. The hospital did not reply to the newspaper’s request for comment.
• The jail does not have a policy on whether nurses or guards have the responsibility to call for emergency medical assistance. Page said he had addressed that by authorizing either to summon emergency workers.
• Two nurses saw Shy lying in blood at least 15 minutes before anyone entered his cell. One of the nurses told police she was from a temp agency and knew the “bare minimum” of jail medical procedures. The other nurse refused to talk with investigators.
• Although the medical examiner said it did not contribute to his death, Shy used a small amount of fentanyl while in custody about a day before he died. It was not explained how the drugs got into the hands of a man who already was detoxing from heroin use.
• A nurse accused Catchings of faking his symptoms four days before he died. The nurse wrote in his notes that after Catchings struggled to get out of a chair, walked unsteadily to a sink and banged his head on a mirror, “I told him immediately to stop this behavior.”
• That day, a jail lieutenant asked that nurse to put Catchings on a list to see a doctor who could have reviewed his symptoms and treated him as soon as that day. But there was no evidence that was done.
• The same nurse at first agreed to talk to police, but never showed up to the interview. He still works in the jail in the same capacity.
• As Catchings became more ill, he expressed hopelessness about getting treatment, telling a jail guard that “nothing was going to happen” if he complained. Even hours before his death, he sometimes responded to wellness checks by saying he was OK.
• Catchings’ phone privileges had been revoked because he had shared his code with other inmates, and it was not clear whether he could call his mother or anyone outside the jail.
• The day before his death, concerns over Catchings’ health brought three jail commanders and two guards to his cell to check his well-being. But after a major reported seeing Catchings raise his head and indicate he was OK, he was not taken to an infirmary.
In the Shy case, Bell said prosecutors considered charging two nurses with second-degree involuntary manslaughter, but decided against it. The nurses were working after Shy’s second return from the hospital. A guard told police he did rounds with a jail captain and the two nurses and saw Shy lying on the floor of his cell moaning. There was blood on his pants. The guard said the nurses “looked concerned” but neither of them entered the cell.
The captain told police she saw Shy’s blood-soaked pants and blood on the wall. One of the nurses did not seem concerned, and returned to the nurse station. The captain ordered two guards to clean Shy’s cell and get him to the shower.
One of the nurses later confirmed to police it was 15 minutes later that Shy was found dead.
“This entire situation is troubling to me,” Bell said about the Shy case. “But we have to stay within our lane as to whether this rises to the level of a crime. And so when I refer to the entire timeline and the totality of the situation, there were a lot of hands involved, and to be able to narrow it down, therein lies the problem. At the end of the day, this is more of a civil situation that should be fleshed out in the civil courts.”
And Bell said there was not enough evidence to charge the nurse who accused Catchings of faking and disregarded a request to get him on a list to see a doctor. In an interview, members of his staff explained that it would be a leap to say those omissions caused his death. Even if Catchings had been sent to a doctor at that point, they said, he might still have died.
Catchings’ mother, Tashonda Troupe, said in a text: “I’m not shocked! I prepared myself for this day. Even though charges should have been filed, I never expected it to happen. It’s sad but inmates lives hold no value to our government.”
Her lawyer, Mark Pedroli, texted: “While I respect our county prosecutor, I think this decision was premature. … But what’s perhaps most alarming is today we learn a person of interest … who violated standing treatment orders, refused to talk to both the police and the county prosecutor yet was still able to keep his job with St. Louis County.”
Bell said, “It’s a tragedy all around, but again, we have to look at what rises to the level of criminality … this is a civil matter that should be handled in civil court.”
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