A prison doctor has been fired and two other staffers are in the midst of being dismissed after an inmate at the Kentucky State Penitentiary starved himself to death, a case that has exposed lapses in medical treatment and in how hunger strikes are handled at the facility.
Prison officials have asked prosecutors to investigate after The Associated Press began asking questions about the inmate's death.
James Kenneth Embry, 57 and with just three years left on a nine-year sentence for drug offenses, began to spiral out of control in the spring of 2013 after he stopped taking anti-anxiety medication.
Seven months later, in December, after weeks of erratic behavior — from telling prison staff he felt anxious and paranoid to banging his head on his cell door — Embry eventually refused most of his meals.
By the time of his death in January of this year, he had shed more than 30 pounds on his 6-foot frame and died weighing just 62.6 kilograms, according to documents reviewed by the AP.
An internal investigation determined that medical personnel failed to provide him medication that may have kept his suicidal thoughts at bay and didn't take steps to check on him as his condition worsened.
The internal review of Embry's death also exposed broader problems involving the treatment of inmates — including a failure to regularly check inmates on medical rounds and communication lapses among medical staff.
The AP, tipped off to Embry's death, obtained scores of documents under Kentucky's Open Records Act, including a report detailing the investigation into Embry's death, an autopsy report and personnel files.
Along with interviews with corrections officials and correspondence with inmates, the documents describe Embry's increasingly paranoid behavior until his death and the numerous opportunities for various prison staff to have intervened.
"It's just very, very, very disturbing," said Greg Belzley, a Louisville, Ky.-based attorney who specializes in inmate rights litigation and reviewed some of the documents obtained by the AP.
"How do you just watch a man starve to death?"
According to the report of the internal investigation, Embry stopped taking medications for anxiety in May 2013. Seven months later, he told the lead prison psychologist, Jean Hinkebein, on December 3 that he felt anxious and paranoid and wanted to restart those medications.
But the psychologist concluded Embry didn't have any significant mental health issues even though Embry repeatedly talked about wanting to hurt himself. Hinkebein and an associate considered his comments vague, and his request for medication was denied.
Seven days later, on December 10, Embry began banging his head on his cell door and was moved to an observation cell where he refused meals and told the prison psychologist, "I don't have any hope."
He soon began refusing most food, though he drank tea on occasion while continuing to make threats to hurt himself in the ensuing weeks.
A nurse checked on Embry on Jan. 4, finding him weak and shaky, and advised him to resume eating. Embry responded that it had been too long for him to start taking food again.
Nine days later, on the very day he died, an advanced practice registered nurse named Bob Wilkinson refused a request from other medical staffers to move him to the infirmary at 11.51am. and said the inmate should be taken off a hunger strike watch, according to the internal investigative report.
Guards found Embry unresponsive in his cell hours later, his head slumped to the side. He was pronounced dead at 5.29pm.
Lyon County Coroner Ronnie Patton classified Embry's death as a suicide and listed dehydration as the primary cause of death, with starvation and several other medical ailments as secondary causes.
The documents obtained by the AP show a prison system with a dated protocol for handling hunger strikes, staff who weren't familiar with its provisions, and others who said they were told not to follow them.
In Embry's case, those in charge of his well-being were simply counting on him to cave in and start eating again on his own, the records show.
On January 16, three days after Embry's death, Steve Hiland, the lead physician at the maximum-security prison, signed off on a nurse's note about Embry consistently refusing food and being taken off of the hunger strike watch because he drank tea.
During the internal investigation, Hiland said he believed a hunger strike consisted of missing "six or eight meals" and ended when the inmate ate or drank anything at all.
In a revealing exchange, investigators asked Hiland how he thought inmates are supposed to be removed from a hunger strike.
Hiland told them that prison staff "usually don't have to worry about it because they (the inmates) eventually give up."
When Embry stopped eating regularly, the Corrections Department's existing guidelines recommended multiple checks of the inmate's vital signs three times a week, repeated visits with a physician and ongoing evaluations by a psychologist.
Medical staff would later tell internal investigators they were either unfamiliar with the protocols for handling a hunger strike or that Hiland and Wilkinson forbade those procedures from being used.
There is no mention of whether anyone considered force-feeding the inmate.
Corrections investigators determined Embry continued to refuse most food, though he drank tea on occasion while continuing to make threats to hurt himself in the ensuing weeks.
Investigators concluded that Embry refused 35 of 36 meals before his death.
The state has placed Hinkebein, who is also in private practice in Central City, Ky., on administrative leave, and said it is in the process of firing her and her associate. Hinkebein declined to comment, saying she's still a state employee.
The internal investigation found that Hiland and Wilkinson didn't check on inmates as they should have during routine visits.
The report also documented multiple communication problems among medical staff and allegations that other nurses were intimidated by Wilkinson, a contract staffer who works for Nashville, Tenn.-based Correct Care Solutions.
Phone and email messages left with the company seeking comment from managers there and from Wilkinson were not returned.
Hiland said the Corrections Department used Embry's death as an excuse to fire him so that Correct Care Solutions could fill his $164,554-a-year job more cheaply. Since firing Hiland last month, the state has given the Corrections Department's medical chief, Douglas Crall, direct oversight of medical care at the penitentiary.
The state has also hired the company on a one-year contract worth $US14.8 million to provide nurses for all 12 of Kentucky's prisons.
"I never saw this guy, never met him," Hiland said of Embry. "I was convinced it was a way to get rid of me. I was told I should have known about it."
Hiland, who maintained a private practice in Eddyville, a town of 2500, while he was in charge of health care at the nearby penitentiary, didn't address the state's claims directly, saying only that he was on vacation when Embry died and did nothing wrong.
It's not the first time his work has been called into question. The doctor has been sued in federal court 103 times since 1992 by inmates and their attorneys.
While many of the lawsuits filed were dismissed, Hiland reached an undisclosed settlement with the family of one inmate who died after Hiland repeatedly diagnosed him as faking illness.
US District Judge Thomas B. Russell Jr., in declining to dismiss the family's lawsuit against Hiland, wrote that the attention paid to the inmate's medical complaints was "so cursory as to amount to no treatment at all."
The Kentucky Attorney General's Office criminal review of Embry's death is ongoing, Daniel Kemp, a spokesman for Attorney General Jack Conway, told the AP.
Once the investigation is complete, corrections officials will decide whether to file complaints with the licensing boards overseeing the doctors and Wilkinson, department spokeswoman Lisa Lamb said.
"We are still reviewing all possibilities, which is one reason we asked an outside agency to look at our investigation in order to see if any other actions were warranted," Lamb said.
Embry, a heating and air conditioning repairman by trade, had no family or friends visit him at the prison, and no one claimed his remains. He is buried in a potter's field near the penitentiary.