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Unlike states such as New York that have medical boards to review deaths behind bars and mandate policy changes, coroners provide the only guarantee of outside scrutiny when someone dies in a Missouri prison (Juan Bernabeu for The Marshall Project).<\/p>\n
When Alan Lancaster died in January 2023 at South Central Correctional Center in Licking, Missouri, his family went looking for answers.<\/span><\/p>\n The Missouri Department of Corrections recorded his death as an accident and offered few additional details. His family requested records from the prison\u2019s investigation into his death, documents such as the internal investigative report that might paint a fuller picture of Lancaster\u2019s last moments. But their requests for more information were \u201clargely ignored,\u201d according to their lawyer, Joe Allen.<\/span><\/p>\n It wasn\u2019t until they reached out to the county coroner who handled Lancaster\u2019s body that his family learned the 39-year-old had been in a restrictive housing unit for over two weeks when he died from a fentanyl overdose.<\/span><\/p>\n In March, Lancaster\u2019s mother, Mary Harris, filed a wrongful death suit against the prison system. The coroner\u2019s records, including a death certificate ruling Lancaster\u2019s death a homicide, provided the basis for Harris\u2019 lawsuit alleging that prison officials failed to properly care for her son.\u00a0\u00a0<\/span><\/p>\n \u201cAlan was in solitary confinement and somehow dies of a fentanyl overdose,\u201d Allen said. \u201cHow do you get fentanyl while you\u2019re in solitary confinement?\u201d<\/span><\/p>\n When someone dies in a Missouri prison, the prison system is required to provide certain information to families about the death. Staff should notify emergency contacts of the death and explain how to access the deceased\u2019s medical records, according to the Missouri DOC\u2019s communications director. For more information, families or their attorneys can submit records requests. State law dictates that <\/span>even if certain records are normally closed<\/span><\/a>, the DOC should provide families access to those documents \u201cfor purposes of investigation.\u201d<\/span><\/p>\n But families of people who died in prison and their attorneys told The Marshall Project \u2013 St. Louis that the DOC doesn\u2019t always follow its own policies. Left with unanswered questions about how their loved ones died, some have instead turned to the coroner. <\/span><\/p>\n While coroners are elected officials generally responsible for investigating violent or unexpected deaths in their county, <\/span>Missouri\u2019s statute<\/span><\/a> requires coroners to \u201cfully investigate the essential facts\u201d surrounding every death in custody, regardless of how it happened. The information from their investigations can help families find a sense of closure \u2014 and when deaths are suspected to be the result of abuse or neglect, a coroner\u2019s investigation can also play a role in holding the prison system accountable.\u00a0<\/span><\/p>\n Unlike states such as New York that have medical boards to <\/span>review deaths behind bars and mandate policy changes<\/span><\/a>, coroners provide the only guarantee of outside scrutiny when someone dies in a Missouri prison. And although people who die in custody each year are <\/span>particularly vulnerable to disappearing<\/span><\/a> from public record, the statutes governing exactly how coroners conduct their investigations contain almost no record-keeping requirements.\u00a0<\/span><\/p>\n Historically, these policies have granted coroners wide discretion in how thoroughly to investigate, resulting in an uneven standard of prison death investigations across the state.\u00a0<\/span><\/p>\n Now, in Missouri and across the country, a coalition of forensic scientists, public health researchers and legal experts is pushing for more robust policy and oversight to hold every prison death investigator to the same high bar.\u00a0<\/span> \u201cThe coroner really is, in many places, the only opportunity for outside review or oversight,\u201d said Dr. Roger Mitchell, president of the National Medical Association and co-author of the book \u201cDeath in Custody.\u201d \u201cSo states need to take control over their death investigation apparatus, ensuring that there\u2019s uniformity.\u201d<\/span><\/p>\n When Tanekka Guest\u2019s husband, Christopher, died at South Central prison in October 2023, she struggled to learn the truth about his death from prison officials. All the warden told her when he broke the news was that her husband died in his sleep, Guest said.\u00a0<\/span><\/p>\n \u201cI was like, \u2018How? What happened?\u2019\u201d she recalled. \u201cThe warden just said, \u2018I\u2019ll let you know more information when we get it.\u2019\u201d<\/span><\/p>\n Guest said she called the prison nearly every day for a month to speak to the warden, but he was never available. Eventually, she spoke to an investigator, who told her she would receive a flash drive with the contents of her husband\u2019s tablet. Neither the flash drive nor the information she was promised ever came, she said.\u00a0<\/span><\/p>\n \u201cThey said they would let me know when they had the cause of death \u2014 they never did that, never told me any information,\u201d she added. \u201cIt was just one pushback after another.\u201d\u00a0<\/span><\/p>\n Details about her husband\u2019s cause of death ultimately came from the county coroner, who called Guest to explain what happened: After a period of suicidal ideation, her husband overdosed on fentanyl and died. Guest said the biggest difference between her communication with the coroner and the prison was the follow-up. <\/span><\/p>\n For weeks, Guest said she called the prison and never received any details. But every time she called the coroner, she got an answer. If she left a voicemail, it was promptly returned.\u00a0<\/span><\/p>\n \u201cTalking to her was so comforting because she kept it 100% honest,\u201d Guest said. \u201cShe said everything she could to put your heart and mind at ease.\u201d\u00a0<\/span><\/p>\n Karen Pojmann, the DOC\u2019s communications director, said the prison system \u201cdoesn\u2019t withhold death information from families.\u201d Autopsy reports, conducted by the medical examiner, are available to anyone who requests them, she said. Reports from the department\u2019s internal death investigations are technically open to the public, but Pojmann said they can be closed or heavily redacted \u201cfor a variety of reasons, including \u2026 sensitive information that could compromise the security of the facility.\u201d\u00a0<\/span><\/p>\n Although no agency or department keeps an official count, there are <\/span>numerous reported instances<\/span><\/a> of <\/span>families filing lawsuits<\/span><\/a> in <\/span>recent years<\/span><\/a> against the Missouri Department of Corrections to <\/span>try to get information<\/span><\/a> about the deceased\u2019s final moments in prison. Families in Missouri describe being repeatedly <\/span>stonewalled by prison officials<\/span>.<\/span><\/a>\u00a0<\/span><\/p>\n In one instance, an appeals court ordered the DOC to pay a mother over $60,000 in penalties and court fees for failing to provide video footage and the prison\u2019s internal investigation of her son\u2019s suicide in 2021. In another case, a court ordered the DOC to pay $5,000 after ruling that officials \u201c<\/span>knowingly and purposefully violated<\/span><\/a>\u201d public records law by refusing to provide video and other investigative records to another woman whose son was beaten to death in prison that same year.\u00a0<\/span><\/p>\n \u201cThey don\u2019t hear back from the Department of Corrections, or they\u2019ll deny a lot of records requests,\u201d said Lori Curry, executive director of the advocacy group Missouri Prison Reform, of families\u2019 experiences with the prison system. \u201cIt can really break your spirit to try to find out the truth about something and continually run into brick walls.\u201d<\/span><\/p>\n The coroner\u2019s independence from the prison system can mean they are emboldened to be direct and honest with families about how someone died, death in custody researchers noted. Coroners have the ability to freely hand over information like autopsy reports and death certificates. By contrast, limited oversight and the risk of being held legally liable for a death behind bars creates an incentive for prison officials to either cover up or misattribute causes of death.<\/span><\/p>\n After Christopher Scroggins died at South Central in June 2022 at the age of 23, the Department of Corrections listed his manner of death as \u201cunknown.\u201d But when an attorney representing the family requested the coroner\u2019s records, he learned that Scroggins\u2019 death was actually due to a fentanyl overdose.\u00a0<\/span><\/p>\n The attorney, Geoff Meyercord, said he wasn\u2019t afraid to sue the DOC for more details if necessary, despite facing what he described as considerable pushback and roadblocks. But protracted litigation, and having to relive the death again and again, can be a significant emotional burden for families, he said. Particularly for families who are just looking to answer basic questions about their loved one\u2019s death, it\u2019s often just easier to ask the coroner.\u00a0<\/span><\/p>\n \u201cWe always want to take the path of least resistance if we can,\u201d he said.\u00a0\u00a0<\/span><\/p>\n When families do choose to file a lawsuit against the prison for a wrongful or preventable death, <\/span>experts say coroner records can be critical<\/span><\/a> to building a case. In Lancaster\u2019s case, the family\u2019s repeated attempts to get records from prison officials or from the DOC went unanswered. \u201cAll the agencies have collectively failed and refused to comply with the law and produce the requested documents, conspiring to and engaging in a cover-up,\u201d the complaint states, causing\u00a0 the family \u201cextreme mental and emotional pain, suffering and anguish.\u201d<\/span><\/p>\n By contrast, the coroner\u2019s report was provided without protest and offered crucial details, including that a corrections officer was reportedly \u201cfired over the episode\u201d two days after Lancaster died.\u00a0<\/span><\/p>\n \u201cLancaster was murdered while in the custody and care of MDOC,\u201d the complaint alleges. \u201cThe Department of Corrections \u2026 abjectly failed in their duty of care to Lancaster, resulting in his preventable homicide.\u201d\u00a0<\/span><\/p>\n The lawyer for Lancaster\u2019s family noted he \u201c\u200awould not have made that specific statement without some supporting information.\u201d\u00a0<\/span><\/p>\n \u200aImproving record-keeping is especially valuable for deaths in custody, said Marie Lasater, the former Texas County coroner who investigated the deaths of both Lancaster and Guest. When a death occurs behind prison walls, families rarely see or even speak with their loved one in their last moments, and don\u2019t have immediate access to the basic information they otherwise would about how the person died. <\/span><\/p>\n If a death was preventable, prisons may make it difficult for families to ever find out, Lasater noted. For this reason, she added, incarcerated people need more of an investigation than a death in the free world.<\/span><\/p>\n \u201cThere\u2019s a lot more possibility for a prison death to be reported [as] something other than what it was,\u201d she said.\u00a0<\/span><\/p>\n After Howard County Coroner Trisha Clark moved back to Missouri from Florida just before the pandemic, she said she was shocked by some of her peers\u2019 practices. <\/span><\/p>\n Rather than coroners, Florida\u2019s system for death investigations relies on medical examiners, who are required by statute <\/span>to keep duplicate copies<\/span><\/a> of records, including autopsy reports and lab investigations. Florida also has a<\/span> guide to record-keeping<\/span><\/a>, <\/span>and a<\/span> commission<\/span><\/a> whose job it is to \u200b\u200bensure \u201cuniform standards of excellence.\u201d In Missouri, no such guardrails exist.\u00a0<\/span><\/p>\n Clark also works as a forensic investigator for Boone County, home to the minimum security Fulton Reception and Diagnostic Center, where five people died last year. She said many of Missouri\u2019s newer coroners understand the importance of investigating prison deaths thoroughly and independently, rather than simply rubber-stamping the prison\u2019s version of events. <\/span><\/p>\n Still, it\u2019s a challenge to get coroners in every county on board without some minimum standard of record-keeping.\u00a0<\/span><\/p>\n \u201cYou have coroners that literally have a pocket notebook where they\u2019re writing a name and a date of birth,\u201d she said. \u201cThese families are not getting a full, thorough investigation because [the coroner] is just like, \u2018Oh well, whatever.\u2019\u201d\u00a0<\/span><\/p>\n Nationally, legal and medical researchers, as well as forensic scientists, are pushing to reform the investigative system for deaths in custody. The goal, they say, is to improve public understanding of how deaths happen and reduce the number of preventable deaths. In a <\/span>recent report<\/span><\/a>, the National Academies of Science, Engineering and Medicine recommended that states require licensing for anyone performing prison death investigations, as well as an annual peer review for all coroner and medical examiner\u2019s offices of at least 10% of their cases. <\/span><\/p>\n\nThis article was published in partnership with <\/span>The Marshall Project \u2013 St. Louis<\/span><\/a>, a nonprofit news team covering Missouri\u2019s criminal justice systems. <\/span>Subscribe to their email list<\/span><\/a>, and follow The Marshall Project on <\/span>Instagram<\/span><\/a>, <\/span>Reddit<\/span><\/a> and <\/span>YouTube<\/span><\/a>.<\/span><\/div>\n<\/div>\n
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