Grand jury report: Palmer had five contacts with police prior to prison
Everett Palmer Jr. had five separate contacts with police in the hours before he was admitted to York County Prison on an old DUI warrant, but none of those out-of-county officers perceived he was suffering from life-threatening methamphetamine toxicity, according to an investigating grand jury's findings.
Palmer, 41, of Seaford, Delaware, died in prison custody nearly three years ago. Last week, York County District Attorney Dave Sunday released the findings of the grand jury, which spent more than two years investigating the former Hanover man's death.
The grand jury determined prison staff didn't abuse or assault the former Hanover resident, according to its 174-page report.
"To say I've seen thousands of cases like these is not an exaggeration," Pennsylvania Department of Corrections Secretary John Wetzel told The York Dispatch. "You had a guy who was just in so much crisis."
Palmer was abusing alcohol, steroids and drugs including meth, the grand jury found, and its report lays out in great detail the man's actions, calling them bizarre and paranoid. The report uses the word "bizarre" eight times in describing Palmer's actions.
He was hearing voices, seeing things and dodging imaginary bullets. Despite that, he was able to keep himself together each time he approached police to tell them he was being followed and watched, according to the grand jury report.
"That's a cry for help," said Wetzel, who started his career as a corrections officer in 1989, became warden of Franklin County Jail and was chosen to lead the state corrections department by former Gov. Tom Corbett.
Palmer didn't tell police he was suffering behavioral side effects of methamphetamine toxicity — which he had done online searches about nine days before his death — or that he had previously been diagnosed with bipolar disorder, for which he wasn't taking his prescribed medications. The grand jury report indicates there wasn't much the officers were able to do for him.
"I think they probably all knew he was mentally ill," Wetzel said. Between a third and a half of of all people incarcerated suffer from mental-health issues, he said.
Boyertown trip: Palmer drove up to a Boyertown officer stopped near a Wawa convenience store in Berks County at an unspecified time on April 6, 2018, to say he was being followed. That was less than 24 hours before he was admitted to York County Prison.
Then between midnight and 1:30 a.m. on April 7, 2018, Palmer called 911 twice and had Boyertown officers respond to the home where he was visiting. Each time he complained he was being watched or followed but said nothing about drug use or mental-health issues, the report indicates.
One Boyertown officer suggested that if Palmer was being watched, perhaps he should leave the jurisdiction and maybe those watching him wouldn't follow, according to the report. The officers later said Palmer was paranoid, and one said he concluded Palmer was having drug-induced hallucinations, the report states.
Palmer's friend kicked him out of her home that morning because of his erratic behavior. He drove to Lancaster County, where he approached a West Lampeter Township police officer to report that people were following and listening to him. It was that officer who discovered the outstanding York County warrant, and he called state troopers to pick up Palmer and take him to York County's central booking unit.
Neither the West Lampeter officer nor the state troopers witnessed behavior that indicated Palmer was a danger to himself or to others, the grand jury report indicates.
Committing people: To involuntarily commit someone for mental-health evaluation against their consent, the person must pose one of those two dangers. Otherwise the Constitution protects someone's right to be free of governmental interference.
"It's very difficult to do a differential diagnosis of methamphetamine tweaking," Wetzel said, noting that the Mental Health Act of 1976 is about 45 years old.
"It's not the tool law enforcement needs to divert people to crisis (services)," he said, adding that police have nowhere else to take someone with mental-health issues who hasn't allegedly committed a crime or threatened physical harm.
Palmer was admitted to the prison on April 7, 2018, and died two days later in York Hospital 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.
A grand jury empaneled to investigate the circumstances of Palmer's death determined he had consumed a large quantity of meth prior to being locked up on $5,000 bail on his 2016 warrant, which was issued because he failed to attend court proceedings on a drunken-driving charge filed after he crashed his car in Hanover.
The grand jury report indicates Palmer, a military veteran, was tweaking on meth, meaning acting irrationally because of drug toxicity.
What two guards said: The report does indicate that two York County Prison corrections officers taunted Palmer in the early-morning hours of April 9, 2018, as the man was suffering, screaming and pacing in his cell. He had spread dirty toilet water on himself and on the floor of his cell and was yelling at people who weren't there.
Corrections officer No. 1 (CO1) told Palmer, "hey, I think they're listening to you through that food," after which corrections officer No. 2 said, "they're listening to us … the po-po," according to the grand jury report, referencing a slang term for police.
Palmer later yelled that he needed a tool and CO1 told him, "hey, I think the Phillips is in the toilet. You gotta reach in there … it's in the hole," the report states.
Later, after Palmer was extracted from his cell and placed in a restraint chair, CO1 was one of the officers who administered CPR to Palmer when it became clear something was wrong with him, according to the grand jury report. The cell extraction was done after Palmer began ramming his head into his cell door.
The district attorney said the taunting of Palmer by the two corrections officers did not rise to the level of a crime. Their names were redacted from the grand jury report, as were the names of other grand jury witnesses.
'Reprehensible': "My reaction was that the comments were disgusting and reprehensible, and they fly in the face of everything that we in the criminal justice system are doing to address issues of mental health in a prison setting," Sunday said. "I have personally spoken to Warden (Clair) Doll about these issues, and I know he takes this very seriously."
Wetzel said he hated to see the taunting and noted it's always a small number of people who give their colleagues a bad name, no matter what the profession.
"As a whole, the staff tried to deescalate him," Wetzel said, adding he supports expanding crisis-team training in prisons. "You didn't see corrections officers not showing a sense of urgency."
Doll told The York Dispatch in an email that prison officials are in the process of reviewing the entire grand jury report, including the statements made by two corrections officers.
"These types of comments are inappropriate and are violations of our Code of Ethics," Doll wrote. "We do not condone these behaviors and have processes in place to appropriately address them. Because it involves personnel (issues), I cannot comment further."
Wetzel said York County Prison "has a good reputation statewide as a good operation."
Palmer's estate has sued York County Prison and others in federal court, initially claiming prison guards drugged and beat Palmer, then allowed him to die. The estate in July amended their lawsuit, which now claims one guard provided meth to Palmer and that inmate abuse and use of excessive force by guards is the prison's "widespread custom and practice."
The estate's attorneys, John Coyle and Lee Merritt, have not returned messages seeking comment.
Creating solutions: Solutions for such inappropriate comments or behaviors include creating mechanisms so inmates can report misconduct, and then having prisons be responsive to such reports, according to Wetzel. Giving meaningful access to outside groups also acts as a check and balance, Wetzel said, and noted that the Pennsylvania Prison Society has access to state prisons.
Wetzel said the Palmer grand jury's report has been creating buzz nationally and that it's the perfect case to galvanize officials and citizens into action.
"I honestly believe that this grand jury report is a great start for a blueprint that's responsive to the behavioral-health issues we see (in prisons)," he said. "There's not a box that doesn't get ticked by this case."
The grand jury's deep dive into Palmer's death gives York County and Pennsylvania a unique opportunity to make reforms, according to Wetzel, who said its report was discussed last week at a meeting of the Pennsylvania Sentencing Commission.
Reforms range from those made within individual prisons to larger legislative fixes, the state corrections secretary said.
"I just hope we don't waste this opportunity to make the system better," Wetzel said.
Both Wetzel and Sunday praised the 24 recommendations made by the grand jury.
"These recommendations come at a time when the issue of mental health is at the forefront of criminal justice conversations," Sunday said. He's received phone calls from officials around the state asking about implementing some of those recommendations, he said.
Wetzel said he believes York County could serve as an example of how to find a path forward.
"I thought the grand jury really nailed it," he said.
— 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.