‘Systemic failures’ led to jail death

“Catastrophic systemic failures” at the Island County Jail led to a 25-year-old man’s death from dehydration April 8, Island County Sheriff Mark Brown said.

By Jessie Stensland

Whidbey News-Times editor

“Catastrophic systemic failures” at the Island County Jail led to a 25-year-old man’s death from dehydration April 8, Island County Sheriff Mark Brown said.

An exhaustive investigation by Detective Ed Wallace offers an unblinking look at how negligence and errors by both corrections deputies and jail administration contributed to Keaton Farris’ tragic death. The report was released Thursday.

Two corrections deputies who falsified logs were placed on administrative leave and have since resigned. Lt. Pam McCarthy was placed on paid administrative leave pending a disciplinary review. Chief De Dennis, the jail administrator, was suspended for 30 days without pay and his continued employment is uncertain, Brown said.

Farris’ father, Coupeville postman Fred Farris, said he is struggling to understand how this could have happened. He is filled with grief, anger and disbelief.

“It’s not OK,” he said. “What happened is unconscionable.”

Fred Farris and his family entrusted the jail employees to care for his son. He is agonizing over his decision not to bail out his son; people convinced him that the young man would be safer in jail since he was dealing with a mental-health issue.

The family has organized a peaceful protest to be held on Father’s Day – this Sunday – as a way of sending a message to the jail and sheriff’s office.

The goal, Fred Farris said, is to ensure that such a needless tragedy never happens again.

He asked that people gather in the Community Greens near the library at 10 a.m. Then, everyone will march through town. He said people should wear a black T-shirt.

The organizers will be handing out water bottles and selling T-shirts dedicated to Keaton Farris.

Island County Coroner Robert Bishop reported that Farris died from dehydration, but malnutrition was a contributing factor.

Farris was suffering from mental health issues and had been both combative and non-responsive with jail staff in three different counties, Wallace’s report indicates.

The 51-page report outlines a complicated series of missteps. The water to Farris’ cell in the Island County Jail was turned off for days because he put a pillow in the toilet at one point and later flooded his cell. He was given water during his meals but it was only a fraction of what was necessary to survive.

The staff did not check on him as often as protocol dictated. The logs didn’t include necessary information and observations.

Medical staff wasn’t called to examine Farris until the day before he died and the nurse didn’t relate any concerns to jail staff.

“Once the nurse was notified she failed to do a proper evaluation of his condition even after Farris advised her that he was not doing well,” Wallace wrote.

The detective figured out that Corrections Deputies Mark Moffitt and David Lind had falsified their logs by comparing the entries to surveillance video.

At this point, it’s unclear whether anyone may face criminal charges. Brown said Wallace’s report has been sent to the Island County Prosecutor’s Office. Prosecutor Greg Banks said he will review it carefully.

The sheriff said he doesn’t excuse himself from blame. He said he failed in his supervisory role over the jail.

Brown said he immediately implemented changes at the 58-bed jail to ensure inmate safety and is planning on bringing in an expert in jail administration to do a comprehensive analysis of the facility, especially those confined to “safety cells.”

“I want to know why the problems were so glaring and why I didn’t see them,” he said. Brown breaks into tears when he talks about the death of the young man who once played high school football and was a track star in Coupeville, the town where the sheriff’s office resides.

The sheriff said he brought Farris’ father into his office soon after the tragedy and had one of the most difficult conversations of his life.

“I promised him I would investigate this as if he were my own son,” he said, struggling with his emotions.

Brown said his mission is to find the truth, disseminate it to the public, repair the problems and — hopefully — regain the public trust while offering closure to Farris’ family. He said he doesn’t know if the family will sue and such an eventuality isn’t guiding his actions.

Brown conceded that larger issues are at play in the death, particularly how jails are ill equipped to deal with people with mental health issues. At this point, however, Brown said he’s focusing on the problems at his jail and what he can do to fix them.

Sgt. Chris Garden, a veteran member of the department with training in emergency medicine, has taken over as interim jail administrator. He will be working closely with Undersheriff Kelly Mauck.

Missing from Wallace’s report, Fred Farris said, is the family’s interaction with the jail. He said he and other family members went to the jail just about every day to see Keaton Farris, but were turned away.

The reasons cited were unclear, conflicting and sometimes simply false, he said.

He said family members would have noticed something was wrong and gotten him help; he said his son lost more than 20 pounds during his short time in jail.

“It wouldn’t have happened if we were able to see him,” he said.“That’s the whole thing.”

Brown said that the jail policy doesn’t allow visitations when an inmate is in crisis or at risk. He said such individuals can’t be moved to visitation rooms and visitors aren’t supposed to be brought to cells. In fact, he said, McCarthy violated the policy when she allowed Keaton Farris’ aunt to visit his cell early in his incarceration.

Brown said he’s interested in looking at policies at other facilities. He said it might make sense to allow visitors to visit certain inmates at their cells, especially if it would calm them.

Fred Farris said his son had a happy, normal childhood growing up on both Lopez Island and Central Whidbey. He was a goofy kid who adored his sisters.

“He was someone who wanted everyone to like him,” his father said.

“He went out of his way to be fun, silly.”

Keaton Farris was diagnosed with bipolar disorder two years ago after experiencing a sudden onset of symptoms, his dad said.

It was difficult to deal with, Fred Farris said, but he was convinced his son would figure it out and live a happy life.

He noted that Keaton Farris had never been in a jail before this incident and jail before this incident and had no criminal record.

Records from San Juan County Superior Court show that prosecutors charged Farris, a Lopez Island resident, with second-degree identity theft on March 2 after a man reported that a check was stolen, forged and cashed at a bank. A $10,000 warrant was issued for Farris’ arrest.

Lynnwood police picked him up on the warrant March 20. Officers responded to a report of a suspicious man at a bank. Farris told an officer that he was “off his meds” and that he was projecting his thoughts at people inside the bank, Wallace wrote,

“Records from the Lynwood jail indicate that he had prescription Lorazepam when he arrived. Under a cooperative agreement between jails, he was transferred to Snohomish County jail, where staff members indicated in paperwork that he was ‘gravely disabled,’ was presenting symptoms of psychosis and needed a mental health evaluation before leaving the jail.”

“A medical slip of paper indicated that he tested positive for amphetamines, THC and Lorazepam and possibly suffered from bipolar disorder, Wallace wrote.

Farris was transferred to Skagit County on March 24. He was originally supposed to be transferred the day before, but he apparently resisted and was tasered in Snohomish County.

In Skagit County, he was non-communicative and resisted jailers; he was placed is restraints. A Skagit official warned the Island County jail lieutenant that two corrections deputies would be needed to transport Farris because of his unpredictable behavior. That message wasn’t passed down, and a lone Island County corrections deputy arrived, but wasn’t able to transport Farris. The San Juan Sheriff’s Office finally transported Farris to Island County on March 26. The Island County Jail holds inmates from San Juan County under an interagency contract.

Farris arrived at Island County Jail without his medication or any of the medical and mental-health information that the other jails collected. Brown said he doesn’t yet know what happened, but he hopes to work with the other agencies in the future to ensure such information is shared.

On March 27, Farris grabbed a corrections deputy by the hand and tried to pull him through the “feed slot” when the deputy was trying to give him water, the report stated.

Farris was initially placed in a blue-padded safety cell but was moved to a single-person cell March 30.

His cell was designated as a “safety cell,” which means heightened monitoring is required.

On March 30, water to Farris’ cell was turned off after he placed his pillow in the toilet and was “playing in the water in his sink,” Wallace wrote. It was turned off again when he flooded his cell on April 4.

In his investigation, Wallace estimated that Farris’ consumption of water and other fluids during his time at the jail was about 185 ounces based on  the amount of liquid in the Dixie cups the jail uses.

Under National Institute of Health guidelines, Farris’ intake should have been 1,563 ounces. FEMA guidelines state that 791 ounces would be necessary for survival in an emergency situation.

“The number could be lower since we cannot confirm that he consumed all the water/fluids provided,” Wallace wrote. “It could be higher as well since there were windows of opportunity where he would have been able to provide himself water.”

Farris’ inmate book states that he was supposed to be observed each hour, but the log showed long stretches of time in which nobody checked on him. The last time that a corrections deputy confirmed he was alive was at 5:30 p.m. April 7. A deputy tapped on his door at 8:30 p.m., but Wallace wrote that it was likely he was dead at that time because of the lack of response and based on the estimated time of death determined by the coroner.

Corrections deputies discovered Farris was dead at 12:30 a.m. on April 8.

In his report, Wallace describes confusion among the jail staff regarding policies and procedures. The jail administration was in the process of instituting the Lexipol manual concerning jail policies. The part of the manual regarding safety cells was implemented, Brown said, but staff didn’t receive training and information wasn’t adequately disseminated or explained.

Wallace details a series of instances in which the corrections deputies failed to follow the “safety cell procedures.”

Wallace wrote that the Farris wasn’t offered fluids hourly, as required. A safety cell log wasn’t started immediately and was incomplete. Supervisors didn’t inspect the logs as required. The safety checks were not sufficient to assess the inmate’s well-being.

The policy requires that his medical and mental-health status be assessed within 12 hours, but he wasn’t evaluated until his 11th day in custody.

Wallace also described confusion among jail staff about McCarthy’s alleged directive that the door to Farris’ cell should not be opened because of his combative history.

During his time in the cell, a corrections deputy observed Farris lying on his bunk with a piece of cloth in his mouth. He was concerned about the possibility of him choking and alerted McCarthy, who told him to leave Farris alone because of the possibility that he would assault a deputy.

The Sheriff’s Office contracts with Island County Public Health to provide a nurse at the jail four days a week.

The nurse was asked to see Farris on the day before he died. But she only interacted with Farris for two minutes and didn’t have a “hands on encounter,” but instead talked to him through the small door in the door.

According to Wallace’s report, Farris told her he needed a medical professional and that he was “not good.” Nevertheless, she didn’t alert the staff to any concerns.

The nurse who visited Farris told Wallace that she didn’t think she had enough time to properly evaluate him, but apparently didn’t convey that concern to the staff. She said she did not ask for the cell door to be opened because “she had heard the staff talking about him being violent, disruptive and uncooperative,” Wallace wrote.

In addition, a psychologist from Western State Hospital evaluated Farris for competency to stand trial and he also didn’t convey any concerns about the young man’s health to the jail staff.

San Juan County Prosecutor Randy Gaylord said Farris was originally supposed to be transferred to Western State for the evaluation, but it was delayed because of the lack of “beds” at the facility, which is a well-documented problem in the state. As a result, the psychologist tried to examine him at the jail.

Wallace’s report indicates that the psychologist attempted to interview Farris through the feeding slot on the closed cell door. Farris was lying naked on the cell floor and talking to himself continually.

His report, issued after Farris’ death, found that the young man was not competent to stand trial.

Fred Farris said there’s plenty of blame to go around. He said officials in San Juan County also have “blood on their hands” because they were ultimately responsible for his son’s well-being while in custody.

He questions why neither the nurse nor the psychologist did more to help his son. He wants to know what happened to his son’s medicine and medical history as he was transferred from jail to jail.

Mostly, however, Fred Farris said he wants to know what the sheriff is going to do to fix the unbelievably long list of problems at the Island County jail.

Island County commissioners received Wallace’s report and were briefed by the sheriff and attorney’s from the county’s insurance pool.

Commissioner Jill Johnson noted the multiple opportunities to help Farris that were missed from the time of his arrested until his death. A press release from the board also emphasized this point and stated the three commissioners are outraged and heartbroken.

“Our best way of honoring Keaton and his family is to do everything possible to see that no other family has to endure what the Farris family is experiencing,” the press release states.

The commissioners said they are committed to working with both the Sheriff’s Office and the Health Department to fix the problems.

While the sheriff’s office is an independent department, the county commissioners set the budgets for all the county agencies. Brown has been outspoken about a need for more personnel, both on the road and in the jail; he has received additional funds for more staff members in both places but not as much as he wanted through a proposed law-and-justice levy.

Brown stresses, however, that Farris’ death was not caused by a lack of manpower, but rather a “perfect storm” of negligence, failures and shoddy oversight.

Part of the solution, however, may be more staff members in the jail, Brown said.