As state agency struggles to monitor jails, investigation raises questions of oversight

It was around 11p.m. on the night of Saturday, Oct. 29, 2016, when Choctaw County jailers pushed their way into the cell of the unresponsive inmate.

Once inside, jailers found one end of a torn blanket tied to a bar in the cell. From the other end hung the lifeless body of James S. Legros Jr., a 29-year-old New Hampshire native who was in the jail on a misdemeanor public intoxication complaint.

An autopsy by the Office of the Chief Medical Examiner determined Legros’s manner and cause of death to be suicide by hanging. The medical examiner’s report noted several bruises on Legros’s body and a contusion on the left side of his forehead, though it is unclear how or when he received them. Park said no force was used on Legros when he was arrested or when he was in the jail.

A subsequent investigation by the Oklahoma Department of Health, the regulatory authority for jail standards in the state, found no violations of state jail standards.

However, a deeper look into the events surrounding Legros’ death reveals not only flaws in the Oklahoma State Department of Health’s investigation into Legros’ death, but also points toward a state oversight system strapped to monitor Oklahoma’s 131 jails and lockup facilities and investigate prisoner deaths.

Often, those in the field say a lack of oversight and enforcement of the state’s jail standards causes agencies to simply ignore deficiencies, endangering prisoners and increasing the risk of a lawsuit.

Though jails are often referred to as the new form of mental institutions by mental health and criminal justice reform advocates, the ability to adequately identify mental illness among prisoners or inmates who might pose a suicide risk varies from facility to facility.

And, according to those advocating reform of the state’s criminal justice system, there is a need throughout the state for alternatives to jail for public intoxication. As the system stands now, they say, it is far too easy for a misdemeanor complaint of public intoxication to become something far greater and far more tragic.

Busted in Choctaw County

Hugo is a town in southeastern Oklahoma of about 5,000 people and located a few miles north of the Red River in Choctaw County. It is one of the poorest counties in the state, according to U.S. Census data, and has among the state’s high rates of unemployment, fatal drug overdoses and poverty.

Several circus companies are headquartered or spend the winter in Hugo, giving the town its moniker “Circus City USA.” The town’s Mount Olivet Cemetery even has a section dedicated to circus workers and performers.

The circus is what brought New Hampshire native James Legros Jr., who went by “Jimi” to Hugo.

Over the years, Legros traveled all over the country working for several circus companies, mostly as a sound and light technician, but also doing some animal care and public relations work, according to his Facebook page and various media outlets to which he spoke over the years.

Legros, who had been working for a circus in Florida, landed a job as a lighting engineer at the Hugo-based Carson & Barnes Circus in August 2016, according his Facebook page. Carson & Barnes management did not respond to requests to speak to The Frontier about Legros.

“I have been with the show for about a month now,” Legros responded to one of his Facebook friends in September 2016. “I have a bunch of lights to play with!”

It was about a month after making that Facebook post, around 4 p.m. on Tuesday Oct. 25, 2016, that Choctaw County Sheriff’s deputies Jeff Epley and Chris Orzoco were dispatched to a location just a few blocks away from Carson and Barnes Circus on a report of a man, later identified as Legros, who appeared to be intoxicated and running in the roadway.

When the deputies arrived at the scene, Legros ran out of a field and up to the passenger side of Orozco’s patrol vehicle, according to the report.

Epley wrote that after being told several times to step to the back of the vehicle, Legros finally did so, but that he was sweating profusely and seemed “very agitated.”

Though Legros said he had only had a little bit to drink, Eply wrote that he showed several signs of intoxication — speaking very quickly, sweating profusely despite the mild temperature and mood swings.

“I suspected Mr. Legros of being under the influence of methamphetamine and possibly ‘bath salts,’” Eply wrote.

“Bath salts,” is the commonly used term for synthetic forms of the stimulant cathinone. It is similar in their chemistry to amphetamines, cocaine and MDMA, though the effects can be much more powerful and long-lasting. Effects of its use can include paranoia, hallucinations, panic attacks, and extreme agitation or violent behavior, according to the National Institute on Drug Abuse.

“We have a problem around here with people mixing bath salts in with their meth,” Choctaw County Sheriff Terry Park said. “They might can handle their meth to some degree, but when they mix in that bath salts …”

Orozco asked Legros if he had taken any drugs, which Legros at first denied, the report states. But when he was asked if he had taken meth, deputies reported that Legros replied “yeah, I did a lot of drugs, like A LOT of drugs.”

After that, Eply wrote, Legros replied “yes” when asked whether he had taken bath salts, meth, and K-2 (the common name of a drug often referred to as synthetic marijuana).

After failing a field sobriety test, Legros was taken to the Choctaw County Jail on a misdemeanor complaint of public intoxication, the report states.

State jail regulations require that during the booking process prisoners undergo some form of health and psychiatric screening. However, Legros became “agitated” upon arrival at the jail and could not effectively answer jail staff questions, Eply wrote in his report. Other statements from jailers say that Legros “was too intoxicated to ask” the screening questions to.

Choctaw County Sheriff Terry Park told The Frontier that Legros was in such bad shape that he did not even get his mug shot taken.

“He couldn’t even answer questions,” Park said. “We couldn’t even take pictures of him at (booking) because of his state.”

So the medical and mental health screening was skipped, Eply’s report states, and Legros was changed into jail clothes and put in a segregation cell.

The Choctaw County’s two segregation cells are often used to hold people who are intoxicated, Park said. Both cells have cameras inside of them, the video from which feeds to three separate locations — the front desk at the jail, the jail administrator’s office, and the Hugo Police Department’s dispatch center. An agreement between the City of Hugo and Choctaw County Jail designates the dispatch center as the jail’s “command center,” Park said.

Legros was booked into the jail at approximately 4:30 p.m. on Tuesday, October 25, jail records show.

His initial court appearance was scheduled for Thursday, October 27, according to court records.

He would not show up for that appointment.

In the Jail

During his time in the jail, Legros’ behavior was erratic, Park said.

“He was amped up,” Park said. “One minute, he may sit down on the bunk. The next minute he would be running back and forth, hollering at the other inmates.”

A few hours before Legros was was scheduled to make his initial court appearance, one of Legros’ friends called the jail, asking about bailing him out, Eply’s report states.

Eply wrote that he called the person back and said Legros would be freed as soon as he was no longer under the influence of narcotics and with a promise to appear on his court date. So far — nearly two days after his arrest — Legros had not shown signs that he had sobered up, Park said.

When it was time for Legros to make his initial court appearance, there was an issue, jailers said.

In a statement with a description of  “INMATE CONFUSED,” one jailer wrote “When we were going to cuff and (put) leg irons on him, he refused. He stated ‘I’m not wearing them just let me go. You’re going to kill me. They are going to say I tried to escape.’ He started crying.”

A second jailer’s account states that when a Hugo police officer was called in to assist the jailers, Legros became extremely concerned that the officer would shoot him. Legros was eventually allowed to return to his cell, according to the jailers’ statements.

Park said the judge agreed to postpone Legros’ court appearance.

Though prisoners who are brought in on intoxication complaints are usually released within 48 hours if they’re sober, Park said Legros was in no condition to be released. While Legros was not directly making threats to harm himself or others, he was displaying paranoid and erratic behavior, Park said.

“I’ll take the blame for it — I didn’t feel at 48 hours he should be turned loose back in society,” Park said. “Never at any time did this man say ‘I’m going to kill myself.’ He kept saying people were trying to kill him. I wouldn’t turn him loose.

“The judge didn’t want to see him because his state of mind. I told the jailers to watch him every so many minutes.”

The next day, October 28, Eply met with the Choctaw County Jail Administrator, Edna Casey, according to Eply’s report. At that point, Legros had been held in the segregation cell for nearly three days.

Casey said she was going to speak with Park because Legros was “all over the place” and had slept very little if at all, the report states, though if Legros showed improvement he would be released over the weekend.

Park said he spoke with Casey, and came to the decision that if Legros was not sober enough to be released over the weekend, he would be taken to the Hugo branch of the Carl Albert Community Mental Health Center and evaluated for transfer to an inpatient mental health facility.

“That Friday afternoon, I told them to take everything out of his cell except maybe what he was wearing,” Park said.

However, at some point a jailer allowed Legros to have a grey flannel blanket because she thought he was cold, Park said.

Despite the precautions, Park  said Legros was not being placed under suicide watch.

“When they’re on bath salts and things like that they do crazy things like stop the toilet up (with sheets or blankets),” Park said.

The reason for delaying Legros’ evaluation until that Monday, Park said, was because the Hugo branch of Carl Albert Mental Health Center is closed over the weekend.

“We were going to take him Monday morning to Carl Albert,” Park said. “Monday morning, he was to be taken by the jail staff to be evaluated or checked. But that didn’t happen.”

Around 7 p.m. the next night, October 29, Legros allegedly asked a jailer during shift change if she had any cocaine, to which the jailer replied she did not, according to the jailer’s report. “I want cocaine!” the jailer reported Legros saying.

Legros had been held in the segregation cell for more than four days at that point. He still had not undergone a health or psychiatric screening.

Around 11 p.m. that night, one of the two jailers on duty began administering night time medications to the prisoners, according to jail documents. As the jailer passed by Legros’ segregation cell, she attempted to speak with him but got no response, her statement says.

The jailer asked Legros to stick his leg out so she could see where he was, she wrote, but Legros did not respond.

She then asked a sheriff’s deputy to accompany her and another jailer to Legros’ holding cell while they entered it.

When they opened the cell door, they found Legros against the wall of his cell, hanging from the blanket he had gotten earlier, the jailer’s statement read.

Legros was declared dead by paramedics at 11:27 p.m. He had been in the jail for around 100 hours.

The Investigation

Within a few hours, the Oklahoma Department of Health was notified by the jail about Legros’ death. The Oklahoma State Bureau of Investigation was also alerted, Park said.

Two-and-a-half months after Legros’ death, on January 11, a Department of Health worker performed the required post-death inspection of the jail, according to department records. Another four months later, on May 10, the department issued a short, one-and-a-half page investigation report.

Based on the Jail Inspection Division’s investigation, “no deficient practice was cited. The jail is deemed to be in substantial compliance,” the report concluded.

Despite documentation by the Choctaw County Sheriff’s Department showing that Legros had spent more than four days in the jail, the Health Department’s report states that Legros was booked into the jail on Oct. 29, 2016, was too intoxicated to answer any medical screening questions during booking and died on the same day of his arrest.

State jail regulations do not give a specific time frame for when medical and psychiatric screening must be conducted if an inmate is unable to complete the screening during initial booking, only that “the screening should be completed at such time as the inmate is deemed competent for the screening.”

In addition to Legros, there are also other cases in Oklahoma in recent years in which prisoners who later died allegedly did not receive medical or psychiatric screening upon intake into the jail because they were too intoxicated.

“Granted, there are challenges for sure when people are under the influence of substances to be able to get accurate information out of them when it comes to medical and mental health screening,” said Melissa Baldwin, criminal justice specialist for Mental Health Association Oklahoma. “So there are times you may need to screen and then screen again in a certain number of hours.

“But not doing any screening for four days is completely unacceptable,” she said.

There was another issue that did not appear in the Health Department’s report — Park told The Frontier that he later fired one of the jailers who was on duty the night of Legros’ death for allegedly providing false documentation that she had performed a check on him prior to discovering his body.

“I wound up terminating a jailer who documented that she checked at a certain time and he was OK,” Park told The Frontier. “Upon reviewing the video, she didn’t check him at that particular time.”

Park said the jailer had looked in through the cell door’s “bean hole,” the small door through which jailers pass meals to prisoners and only seen Legros’ feet. However, Legros had hung himself by tying the blanket around a bar inside the cell and leaning forward with his feet still on the ground, Park said.

“If you looked through the bean hole, you would see feet just sitting there,” Park said. “She looks in the bean hole and sees his feet and thinks he’s OK and goes on to the next check.”

After being asked by The Frontier about the discrepancies between the Health Department’s findings and other evidence in the case, James Joslin, service director for the Department of Health’s Health Resources Development Services, of which the Jail Inspection Division is part, said the department was unaware of the issues and is now conducting a review of its investigation.

Jail Oversight

There are 131 jails and lockup facilities spread throughout the state, according to the Department of Health’s latest figures.

The Department of Health’s Jail Inspection Division is required by law to provide annual inspections of each of those facilities to ensure the state’s minimum jail requirements are being met, which includes requirements for booking and release procedures, security measures, sanitary conditions, diet, clothing and living area, jail staff training, safety and segregation of some prisoners, medical care, prisoner supervision, emergency exits, inmate education of facility rules.

In addition, the division conducts investigations into complaints made about the facilities as well as all deaths that occur while in jail to ensure all jail requirements were followed, according to the Department of Health.

According to the department’s 2017 Protective Health Services Annual report, last year the Jail Inspection Division conducted 172 mandated inspections, 414 complaint investigations and 22 jail death investigations.

To do accomplish this, the state relies on a single full-time jail inspector, plus one part-time inspector, Joslin said.

Though the Jail Inspection Division also consists of a director and an administrative assistant, both are also responsible for work on and oversight of three other Department of Health programs, Joslin said, including one of the Department of Health’s medical facility licensure programs.

It is this seemingly dire situation that has caused the Department to come under fire in media accounts previously.

“These are the resources we have and we’re going to do the best we can,” Joslin said. “We are doing what we can to maximize what we can do with the resources we have. The decisions about resources and what’s adequate resources to do this job is made by the Legislature.

Joslin said that while the law requires the agency to do annual inspections, it does not require the Jail Inspection Division to do jail death or jail complaint investigations.

“We think that with one and a half (jail inspectors), we can meet the statutory requirement to do the annual inspection,” Joslin said. “Beyond that we’ll maximize the work we can do given the resources we have. To address the other activities, we do what we can with what we have.”

But despite the agency’s effort to maximize resources it may not be enough to effectively oversee the state’s jails, said Tulsa attorney J. Spencer Bryan, who has been part of numerous wrongful death or injury lawsuits against jails throughout the state.

“Not at all,” Bryan said when asked about the effectiveness of the Health Department’s jail oversight. “They’re a completely understaffed, toothless agency.”

When a violation of jail standards is noted by an inspector, Joslin said, a notice of the deficiency is sent to the jail, along with a suggested plan for how to fix it.

“We provide generic language about that because we recognize it’s going to differ among the jails,” Joslin said.

The jail authority then has 60 days to bring the jail into compliance, he said. After that, if the issue is still not fixed and there is not a good-faith effort to come into compliance, the only enforcement option the department has is to make a referral to the local district attorney or the state Attorney General requesting that the jail be closed, Joslin said.

“It’s a pretty extreme next step and one which we have not done,” Joslin said. “I’m not aware in the time the program has been under my responsibility, which has been since about 2009, where we have made a referral to a DA or to the Attorney General.”

Bryan said he often sees jails that are cited numerous times by the Department of Health for the same deficiency make repeated promises to fix the issue, but never address the issue. And the lack of enforcement allows jail authorities to turn ignore violations.

“The Jail Inspection Division never takes any action to enforce the deficiency,” Bryan said. “In the rare circumstance they do, the administrative process to enforce it is never carried through. The counties know this, so it eliminates the incentive to comply with the jail standards altogether when they know there’s no enforcement mechanism.”

And that results in lawsuits, Bryan said.

“The only enforcement mechanism is a lawsuit by inmates,” Bryan said, “and the Legislature has done a fantastic job of putting up every procedural hurdle you can possibly imagine to prevent them from ever getting to the courthouse.”

Park said he anticipates a lawsuit stemming from Legros’s death, and though no suit has yet been filed, Legros’s family has retained an attorney.

“That just doesn’t happen without being sued,” he said.

Mental Health

According to data from the Oklahoma Department of Health, around a quarter of all jail deaths in the state between 2014 and 2016 were ruled as suicide.

Baldwin said Oklahoma’s jails are a patchwork of varying criteria to determine which inmates are suffering from psychosis or other mental illnesses.

“If you look at states who have made progress with these issues, reducing the number of people with mental illness in jails, one thing we’re noticing is my definition of mental illness is different from you’re, is different from this county’s,” Baldwin said. “Everyone is recognizing the utility of having common definitions of mental illness and common screening protocol across jails.”

Baldwin said common and valid mental health evaluation criteria should be adopted for at the state level for all jails.

“Imagine in the state if we could decide these are the valuable reliable tools we know is going to help us identify people who are ill and who need help or might be suicidal and all the jails use the same screening,” Baldwin said. “Then when your going from county to county everyone is speaking the same language.”

The state does not requires jails to have 24-hour a day access to mental health workers who can determine whether a prisoner should be transferred to an inpatient mental health facility, Joslin said, but access is “based on assessment and availability.”

Often, Joslin said, there is a dearth nearby mental health resources that jails can actually utilize.

“Access is based on assessment and availability,” Joslin said.

Jails in rural areas especially may face a lack of mental health resources, Baldwin said.

“They’ve got much greater barriers to access treatment than you do in the urban areas, for sure,” Baldwin said.

And though they are few and far between in Oklahoma, Legros’ story demonstrates the need for sobering centers or drunk tanks as an alternative setting for those who are picked up on only public intoxication complaints, Baldwin said.

“He shouldn’t have been in jail in the first place, honestly. People who are ill and in need of treatment don’t need to be criminalized,” Baldwin said. “People who have no other charges other than public intoxication, should be diverted.”

Park said that in cases where prisoners are deemed to be at risk of suicide, the prisoner is often taken to a hospital emergency room for evaluation. But since Legros was not considered a suicide risk, it was determined to take him to the local community mental health center for evaluation after the weekend.

“If he’s talking about committing suicide, you can take them to the emergency room,” Park said. “A lot of times they take them out to the hospital, and if the hospital says you have to take them to a mental facility.

“Mr. Legros, he at no time ever mentioned or gave signs about killing himself. He did say people were trying to kill him, which appears to be the result of what we think to be bath salts.”

But if Legros had undergone a health and psychiatric screening by the jail, the need for a higher level of evaluation by mental health workers may have presented itself, Baldwin said.

“There are other indicators of suicidality other than saying ‘I’m going to kill myself,’” Baldwin said. “And if you don’t do a mental health screening, then how are you going to know if those other indicators are present?”