York prison-death grand jury offers recommendations to fill gaps in system
York County prosecutors and the investigating grand jury that determined Everett Palmer Jr.'s death wasn't a crime wanted to go further, District Attorney Dave Sunday said.
"We asked ourselves … how could things be different? … Is there a better way to do this? Where can we plug in the gaps?"
Palmer, 41, of Seaford, Delaware, died April 9, 2018, in York Hospital after being taken there by ambulance from York County Prison.
On Tuesday, after a more than two-year investigation, Sunday announced the grand jury found that no one in York County Prison had assaulted Palmer or violated prison protocols. He had been held there for two days on a 2016 DUI warrant, for which his bail was set at $5,000, or 10% cash.
The grand jury found, as did autopsy results, that Palmer died of "complications following an excited state, associated with methamphetamine toxicity, during physical restraint," with "probable sickling red cell disorder" as a contributing factor, according to a 22-page autopsy report from Forensic Pathology Associates in Allentown.
Palmer and some of his friends engaged in a methamphetamine binge in Boyertown and he was "tweaking" when he got to the prison — but that wasn't known until after his death, the grand jury determined. Tweaking means he was acting irrationally due to drug toxicity.
Mental health and prisons: As Pennsylvania Department of Corrections Secretary John Wetzel noted at a Tuesday news conference, it's so common for prison employees to see people with mental-health issues being locked up that they assumed Palmer had those issues rather than drug toxicity — especially because Palmer told them he hadn't used drugs recently.
"None of us should feel good about that," Wetzel said. "You have someone who died in a prison cell for $500."
The attorneys representing Palmer's estate, which has sued the county prison and county officials in federal court, did not return a message seeking comment.
Wetzel was closely involved in the Palmer probe and agrees corrections officers and medical staff in the prison acted appropriately and followed protocols when they removed Palmer from his cell and administered physical restraints on him because he was physically harming himself.
Palmer was banging his head against a metal door and was actively looking for a way to kill himself in his cell. He was being constantly monitored in a single cell, the DA said.
Hard questions: Sunday said Palmer's death wasn't a crime, but it was senseless, which is why those involved in investigating it wanted to address systemic issues that, if reformed, might avoid future prison deaths.
"Questions were asked such as, Why do individuals with mental-health issues find themselves in this set of circumstances? How did the prison not know he was on methamphetamine prior to getting him? What can be done with regard to mental health in a prison setting? Why was he there in the first place, based on the bail that was set in this case? Was that appropriate?" Sunday said.
"At that point we chose together to take a very deep dive into macro-level societal issues pertaining to, in particular, individuals with mental-health and substance-abuse (issues) and their connection to the prison," he said. "As a result of that, the grand jury returned … 24 very detailed recommendations."
Not all 24 recommendations will come to fruition, according to the DA, and some deal with issues already being modified in York County.
The recommendations include drug screenings for all people being committed to the prison, upgrades to cell-extraction policies that would require prison medical staff and an ambulance to be summoned prior to removing an inmate from a cell, and trainings on crisis intervention and recognizing developmental disabilities.
Sharing information: The grand jury also suggested that comprehensive drug and alcohol programs within the prison be developed and that government, health care and other agencies share information and work to reduce the number of people with mental-health issues who are jailed.
Many of the suggestions call for the kind of comprehensive mental-health services that have been reduced in this country due to lack of funds to pay for them.
Wetzel, who oversees the state Department of Corrections, said between a third and half of people imprisoned suffer from mental-health issues, and that the picture painted by the grand jury in its recommendations is a holistic one.
"I think it's incumbent upon us as officials to step up and really try to respond," he said. "There's got to be a path forward. And why not now?"
Wetzel said prison video footage of Palmer injuring himself "is so disturbing" and that York County Prison staff "took every step" because they were concerned about Palmer.
"And with good reason," he said. "I've watched over a thousand use-of-force videos. This is one of the most escalated individuals I've seen in 30 years."
'Important work': Wetzel said despite safeguards, gaps in the system exist — and Palmer fell through those gaps. He urged the officials and the community to create a cohesive plan that fills in those gaps.
"I think it's important work," he said.
First assistant district attorney Tim Barker said such reforms might not have saved Palmer's life.
"The sad reality is that no series of initiatives will prevent all crime, will rehabilitate all individuals or save all lives, no matter what we wish," he said.
Diverting low-risk nonviolent people from pretrial detention saves taxpayers money and helps keep them from becoming worse problems to society, according to Barker, who said it costs $92 per day to house an inmate in York County Prison.
— Reach senior crime reporter Liz Evans Scolforo at firstname.lastname@example.org or on Twitter at @LizScolforoYD.
The grand jury's 24 recommendations
- A negotiator or de-escalator should be engaged prior to a cell extraction
- Medical staff should be required to be present prior to a cell extraction
- EMS should be summoned to the prison prior to a cell extraction
- York County Prison should reconsider the use of electronic stun devices during cell extractions
- An inter-county database for inmate drug and alcohol and mental-health issues should be developed
- A presumptive drug screen should be conducted on people being admitted to the prison
- Prison staff should develop and implement trainings on how to recognize developmental disabilities
- Communication between York County Prison and behavioral health systems should be improved
- The use of previously prescribed medications should be continued upon entry to the prison
- Crisis-intervention team training should be expanded among prison staff
- Prison inmates should be trained as certified peer counselors
- Medical-assistance benefits should be continued during pretrial detention
- Comprehensive drug and alcohol programs should be developed at York County Prison
- The provisions of Pennsylvania's Title 37 law, which deal with county prisons, should be updated
- Criminal justice initiatives in diversion should be pursued and expanded through the use of risk and needs assessments and the sequential-intercept model, which helps communities identify gaps in services at each "intercept point" a defendant has with the justice system
- Collaboration and partnerships must continue between government agencies and health-care and other service providers, including through the Criminal Justice Advisory Board, the York County Reentry Coalition, the Community Action for Recovery and Diversion program — and through the Stepping Up initiative, which seeks to reduce the number of people with mental-health issues who are jailed
- The critical need for housing, especially among those needing mental-health treatment, must be addressed
- Improve information-sharing between agencies and health-care providers, both within York County and outside of it
- Probation services should: conduct risk/needs assessment screenings to assist district courts in making initial bail determinations; release appropriate defendants on supervised bail; and use a 24-hour bail service and a centralized court
- Motivational interviewing should be used by screeners by the sheriff's office, probation services and the prison
- Drug screenings should be expanded to assess substance-abuse issues
- A co-responder model should be adopted and crisis intervention practices should continue throughout law enforcement, the county prison and the probation office
- Establish a York County wellness, diversion and reentry center, and expand local behavioral-health services
- Criminal-justice initiatives and behavioral-health services must be properly funded, and a criminal-justice reinvestment strategy should be developed in York County.