52 deaths since 2016: Why Shelby County Jail's mortality rates have been rising in recent years

This story includes discussions of suicide, which may be distressing. If you or anyone you know needs help, you can call the Suicide & Crisis Lifeline at 988.

Marcus Donald, 38, was scheduled for release from the Shelby County Jail in late November.

He’d already spent more than six months in the jail, commonly referred to as 201 Poplar, after his arrest, ultimately pleading guilty to misdemeanor assault.

But instead of going home with credit for time served, Donald was placed in a holding cell with another inmate.

That inmate, who had previously been charged with murder, strangled Donald to death, according to family and attorneys. He has been charged with Donald’s murder.

Donald is one of at least 52 people who, since 2016, has died in the Shelby County Jail or died in a hospital after transportation from 201 Poplar. Nearly 70 people have died in the custody of the Shelby County Sheriff’s Office in that time period, including individuals shot by deputies outside of the jail and two women who died in Jail East, the county women's jail.

Deaths outside 201 Poplar and deaths in Jail East are not included in this analysis but are described in the attached list of all individuals who have died in the custody of the sheriff’s office.

In the past three years, during which Shelby County Sheriff Floyd Bonner, now a frontrunner for the next mayor of Memphis, has held office, the number of deaths and the mortality rate — deaths compared to the average daily population — have gone up sharply at 201 Poplar, mirroring a stark increase in jail deaths across the country.

Of the people who died in 201 Poplar, many, like Donald, struggled with mental illness.

Out of all the deaths in the jail for which The Commercial Appeal was able to identify a cause, 21 involved cardiovascular issues either as the main cause or a contributing cause.

The second most common cause of death was suicides, with 12 deaths. And in eight deaths, drug use was noted as either the cause or contributing cause. In one incident, according to a lawsuit, an individual took drugs in the backseat of a deputy’s car but was taken to jail, not the hospital. In another, a substance that tested positive for fentanyl was found in the man's cell.

Autopsies have not been completed in a handful of the 52 deaths.

Out of the detainees for whom The CA was able to identify race, the vast majority were Black.

Now, deaths in the jail are facing increased scrutiny as Bonner runs for mayor of Memphis. Coupled with that is increased criticism following the death of Gershun Freeman, who died after corrections officers pepper sprayed him, hit him and kneeled on his back for multiple minutes.

“In Memphis, we need a change. Criminals, they’re people too,” said Elvis Ellis, Donald’s grandmother. “If you’re in jail, you’re still people. There’s a lot of people in jail for things they didn’t do or just in there, but they’ve still got feelings and they’ve got families. We do everything we can for them.”

Mental health issues led to jail stay

Marilyn Donald, Donald’s mother, knew her son struggled with mental illness.

Growing up, he was inquisitive and sweet. He played football in high school, loved his dog and had pets ranging from iguanas to hamsters. He converted to Judaism a few years before his death, embracing the religion, its holidays and keeping Kosher.

But during the COVID-19 pandemic, Donald’s mental health issues began to escalate. Neighbors told Marilyn her son was behaving oddly. He thought the neighbor’s dogs barked too loud. He threw tomatoes at the UPS driver. Sometimes sheriff’s deputies came out to talk to him.

On the Friday after Mother’s Day in 2022, a deputy called Marilyn on her cell phone, saying they would take her son for a mental health evaluation. She agreed.

An affidavit says Donald had pointed a gun at and then followed a neighbor.

Deputies arrested him and took him to 201 Poplar, where according to records he waited months for an inpatient mental health stay. COVID-19 pushed back court dates with illness and social distancing requirements and his time in jail lingered.

At 11:15 a.m. on a Friday, a doctor called Marilyn from Regional One, saying her son was at the trauma center. Once she arrived at Regional One, she learned her son had been strangled the night before.

The sheriff’s office told The CA it could not answer questions about Donald’s time in 201 Poplar due to pending litigation.

There have been a variety of lawsuits that have been filed related to deaths in the jail. While some have been settled, others continue to work their way through the court system.

Mortality rates rise in Shelby County, nationwide

The mortality rate in the Shelby County Jail fell just below the national jail mortality rate of 1.67 per 1,000 inmates in 2019, the last year for which such national data was collected by the federal government.

The Shelby County Jail mortality rate has grown since then, with 4.5 deaths per 1,000 inmates in 2020, 4.9 deaths per 1,000 inmates in 2021 and with 5.8 deaths per 1,000 inmates in 2022.

“I think that what’s going on is that conditions in jails and prisons are getting worse, and at the same time there is a renewed focus on jails and prisons as places to put people with mental illness and substance use problems,” said Wanda Bertram, communications strategist with the Prison Policy Initiative. “We have especially in the last few years had an extremely overburdened healthcare system, not enough doctors, not enough nurses, not enough hospital beds.”

Nationwide, deaths increased significantly during the COVID-19 pandemic, but were ticking upward even prior, said Aaron Littman, acting director of the UCLA Law Behind Bars Data Project.

In written answers to questions from The CA, The Shelby County Sheriff’s Office called the jail “a microcosm of our community.”

“As the COVID-19 pandemic, the influx of opioids/fentanyl, and the mental health crisis that caused increasing suicides came to Shelby County, deaths in the jail mirrored what was happening in the community,” the sheriff’s office said.

In 2022, 24,212 people were booked into the sheriff’s office’s adult facilities, the department said. Out of those individuals, 18,691 were men, booked into 201 Poplar.

“Each of those people were questioned by a nurse about injuries and other matters before entry to the jail and then met privately with a nurse who performed a multipage health assessment once probable cause for admission was established,” the sheriff's office said. “Detainees are questioned about their physical health, mental health, medications, suicide factors, drug and alcohol usage, and other things necessary to provide proper medical care and safe conditions.”

It can be hard to compare data across different jails since how jails are used varies from one community to another, said Josh Spickler, executive director of criminal justice reform organization Just City. Policies that impact how a community uses a jail include whether the community is over-policed, how bail is set and whether arrestees are quickly given representation.

“We still should not have as many people in our jail as we do,” Spickler said. “A lot of people end up there because they can't afford to pay their way out.”

Staffing shortages, jail conditions could contribute to deaths

Causes of death identified in autopsies of 201 Poplar inmates range from suicides to preexisting health conditions to the rare homicide and, in one instance, a “cannot be determined” cause after an inmate was found in the shower with a head injury.

While the causes vary, there are some common factors in jails, including 201 Poplar, that exacerbate the overall mortality rate, experts say.

While 201 Poplar has a medical clinic, it has no infirmary or outpatient housing unit, something noted in a court-ordered independent inspection of the jail in 2021.

The jail was never built to have such units, wrote the sheriff’s office. Regional One does have a prison ward.

The county contracts with Wellpath, formerly known as Correct Care Solutions, for inmate medical care. Wellpath is the nation’s largest for-profit provider of health care to correctional facilities. In 2019, CNN investigated how “the company’s substandard care … has led to deaths and other serious outcomes that could have been avoided.” Memphis was one of the 120 locations in 32 states from which CNN investigated complaints and problems.

In jails, people are disempowered and disenfranchised, and have only one place to go for their care, meaning they can be treated poorly without a means of airing grievances, Littman said.

That dynamic is “so commonly repeated that it’s just the norm, which is that a corporation makes money by providing either no care or poor care and nothing happens about it because the people who are harmed don’t have any power,” Littman said.

Other factors could include the age of the facility — opened in 1981 — and staffing shortages.

For years, the Tennessee Corrections Institute has warned Shelby County, in jail inspection reports, about aging infrastructure, saying the county should plan for a facility “that can meet the increased demands of the current correctional environment.”

The sheriff’s office told The CA that the age and physical structure of the jail has no impact on the physical health of detainees.

When Demarcus Jarrett, 29, died in 2020 with internal bleeding and an adverse medical reaction, a single guard was assigned to cover four pods, according to attorney Brice Timmons, who handles many wrongful death cases. There was also no supervisor at the time, telephones were down on that level of the jail and the radio was inoperable. The guard left two pods unsupervised for an hour and fifteen minutes, returning to find Jarrett had collapsed, Timmons said.

“The jail has become a warehouse for people and there is zero accountability for anything that happens there,” Timmons said. “You can look at this case, you can look more recently at the case of Gershun Freeman.”

And when Antonio Davis, 33, died of acute methamphetamine toxicity with contributing hypertensive cardiovascular disease, no officer was assigned to his pod and officers who did observe abnormal behavior in Davis did not contact medical or mental health, according to a lawsuit.

With regard to drug-related deaths, they could be increasing nationwide due to an increase in access to drugs in facilities or because the drugs people have access to are more dangerous and likely to cause death, Littman said.

Jail needs 300 more correctional staff, Shelby County Sheriff has said

In February 2022, TCI found deficiencies in medical services in 201 Poplar, saying 14-day physicals were not up to date for inmates. That deficit was corrected by an April 2022 reinspection.

The sheriff’s office freely acknowledges the difficulty in maintaining enough correctional staff, with stress, significant overtime hours and overall labor shortages hitting the jail particularly hard. Bonner has spoken about his desire to have at least 300 more corrections deputies.

Staffing shortages have also meant detainees are kept in their cells “for days if not weeks at a time,” meaning limited or no outdoor exercise, wrote an independent consultant in a 2021 court-ordered report. The sheriff’s office told The CA it disputes that report.

That same report found a housing unit by the nurses’ station that housed “the most medically fragile inmates” was dirty, with unclean floors and showers.

At that time, the jail had 157 security staff vacancies, but actually needed more than 300 additional positions, the consultant wrote.

In other cases, staff violate — or don’t even know — their own policies, attorneys say.

When Steven Gomez, 20, ingested drugs in the back of a police car, he was taken to jail, not to the hospital. That was despite police officers finding an empty baggie and pill bottle in the car.

Upon arrival at the jail, staff took him in, in violation of policy. Within 24 hours, he began having symptoms. He died a few days after being resuscitated.

In discovery for a lawsuit currently on appeal, attorneys found that neither the Memphis police officers who arrested Gomez nor the sheriff’s office employees who did intake were trained on their own policies, said attorney Sean Guy.Gomez had a daughter who was just four months old when he died.

Today, she’s about five years old and is growing up without a father, said Danielle Harthcock, the girl’s mother and Gomez’s fiancée.

“No child should have to experience something like that, especially that young,” Harthcock said. “She’s never gonna be able to have memories of her own of him. All she’ll get is our memories that we give to her. It’s like she just had it stripped away from her before she could even talk, even walk, not be needing someone else. It’s very difficult. It’s definitely hard. I feel like I have to carry the burden of both mom and dad a lot of the time.”

Amy Gomez, Gomez’s mother, recalls him calling her from the jail, presumably before he was taken to Regional One.

He just said, “Momma, I’m so sorry. I didn’t mean for this to happen. I’m in trouble and I need your help,” she recalled.

“There’s not a day that doesn’t go by that I don’t talk to him. There’s not a day that goes by that he’s not constantly on my mind. I miss the sound of his voice. I miss his hug. I miss his kindness and his generosity,” she said. “Parents should not bury their children. It’s wrong on every level.”

Staffing could also have been a factor in Donald’s death.

It is not common for inmates to kill other inmates, as in Donald’s case — only 2% of all deaths in local jails nationwide in 2018 were determined to be homicides — but homicide rates in jails are rising nationwide, and less supervision has meant an increase in violence.

Locally, inmate assaults have been increasing since 2019, according to data shared by the sheriff’s office with the Shelby County Commission in May. That includes assaults on both inmates and correctional officers, said chief jailer Kirk Fields.

In 2018, there were 702 assaults. In 2019, there were 595 assaults. In 2020, there were 734 assaults. In 2021, there were 798 assaults. In 2022, there were 855 assaults.

A former inmate who was jailed at the time of Donald’s death said his friend would still be alive if staff had provided supervision or not put Donald in a murderer’s cell at all. The man asked not to be named out of fear of retaliation.

“If you were following the actual protocols and policies, the incident wouldn’t never have took place,” he said. “It for sure could have been stopped if they were doing rounds. He could have told them at any moment, ‘I fear for my life’ and they could’ve moved him out of the cell. If they were doing their rounds, they would have seen it was an issue.”

As for suicides, someone in jail is more than three times as likely to die from suicide as someone in the general U.S. population (and still twice as likely when the population is adjusted for age, sex and race and ethnicity), according to the Prison Policy Initiative.

Currently, there are 18 forensic beds available at the Memphis Mental Health Institute for inmates. That’s an increase from just eight in 2022. Only MMHI provides inpatient forensic evaluations for Shelby County inmates, with the exception of cases requiring maximum security. Shelby County Commissioners have made plans to expand mental health evaluations with an allocation of $2.7 million this year, but that is not yet in effect.

“How do you keep somebody from committing suicide who has a serious mental illness?” asked Bertram. “The solutions to mental health crises in a jail setting are typically limited to putting somebody in restraints, taking somebody’s amenities away, taking their bedclothes away, or their clothes, and I think that at the same time jails are not equipped to provide the things that could actually increase a person’s wellbeing, things like time outside, nutrition, contact with loved ones. Jails don’t typically do a lot in the way of bringing outside social workers inside to actually mentor or help people who are held there.”

Federal data on jail deaths incomplete, no longer tracked

Much of what happens behind bars happens in secret, deaths included. For years, the Shelby County Sheriff’s Office refused to release details of deaths in custody, saying incident reports were “deemed confidential and not public information.” While the office occasionally released information about individual deaths, data on all deaths, including the cause, was not made public.

The CA began asking for information on deaths in custody in 2020. It was only after state law changed in 2022 requiring records to be kept and available for public inspection that the sheriff’s office provided the paper with a list of names of people who had died in custody since 2016.

Since then, The CA has reviewed all completed autopsies for those decedents, including individuals shot by deputies who were not included in this analysis.

Difficulties in tracking jail deaths are not unique to Shelby County. The Death in Custody Reporting Act was passed by Congress two decades ago, but according to Vera Institute of Justice, it’s never been properly implemented and, “Simply put, the federal government does not know how many people die in U.S. jails and prisons each year.”

After 2019, the Department of Justice stopped collecting and publishing data on deaths in custody entirely.

Memphis mother hopes for investigation into in-custody deaths

Public officials have a constitutional duty to run safe facilities, Littman said, and that includes learning from data to take action when systemic problems exist.

“I think one question is what actions if any jail administrators have taken in response to these deaths and whether they’re attempting to identify systemic issues and address them or not,” Littman said. “Whether or not it’s fair to blame officials for any individual death, it is certainly fair to blame them for repeated disregard of systemic issues that are contributing to those deaths.”

Max Rose, executive director of Sheriffs For Trusting Communities, said that while people die in jails everywhere, there are major differences in death rates between individual jails.

A sheriff should take all deaths as a moral and policy failure and ask what should be done differently, Rose said.

“The biggest job of a sheriff is managing a jail,” Rose said. “If Sheriff Bonner can’t do the one thing he’s charged with doing, he’s fundamentally failing at his job.”

In comments to The CA, the sheriff’s office said many of the individuals detained at 201 Poplar only receive medical and mental health care while incarcerated, not while free.

Every death in jail is investigated “both administratively and criminally,” the Sheriff’s Office said.

Marilyn Donald, who continues to grieve the loss of her son, said she has never heard from Bonner or anyone in leadership at the jail.

With an attorney and prosecutors, she watched video footage from the jail that showed guards walking by her son’s pod as other inmates waved sheets and towels to try to get the attention of guards.

“Finally, after 90 minutes, the guards decided to render aid to my son,” she said. “If they had acted earlier to provide him with resuscitation, my son would be alive today.”

With the U.S. Department of Justice announcing in late July an investigation into the patterns or practices of the Memphis Police Department, Donald sees some hope. Maybe, the DOJ will investigate the sheriff’s office too, she said.

Katherine Burgess covers government and religion. She can be reached at katherine.burgess@commercialappeal.com or followed on Twitter @kathsburgess.

This article originally appeared on Memphis Commercial Appeal: Why Shelby County Jail in Tennessee has seen 52 deaths since 2016