Inmate families want outside investigation into deaths

The families of two Milwaukee County inmates who recently died in jail are calling for outside investigations into the unexplained deaths of their loved ones, saying they fear the county Sheriff's Office won't conduct thorough, impartial reviews.

Leon Limon, the brother of 38-year-old Kristina Fiebrink, and Gail Stockton, the mother of 29-year-old Michael Madden, said a recent spate of deaths at the Milwaukee County Jail has them concerned about the quality of any investigations by the Sheriff's Office, which runs the jail.

They are also frustrated at how little the Sheriff's Office has told them regarding when and how the investigations will be done. Fiebrink died in late August, Madden in late October.

"I just don't feel like it's going to be fair," Limon said. "They're not going to say, 'My co-worker let this girl die.'"

State law allows local agencies to investigate deaths at jails they run, so long as the death didn't directly result from an officer's actions or inaction.

Four people have died since April in the jail, which is run by Sheriff David A. Clarke Jr. In addition to Fiebrink and Madden, they include Terrill Thomas, a 38-year-old inmate who died of profound dehyrdation, and a baby who died after an inmate gave birth unnoticed in her cell.

Authorities have not publicly released any information about what factors contributed to the deaths of Fiebrink and Madden. Their family members said they have held funerals and grieved for weeks while knowing few details about why their loved ones died.

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The Milwaukee Journal Sentinel has spoken with inmates who said they heard Fiebrink and Madden suffering from medical emergencies before their deaths.

In Fiebrink's case, fellow inmate Elisha Johnson said Fiebrink was screaming and hallucinating overnight, claiming that the Devil was in her cell and trying to choke her. Fiebrink went silent in the early morning hours, then was found unresponsive in her cell, Johnson said. She was pronounced dead at about 7:30 a.m., according to the Sheriff's Office.

In Madden's case, inmates Robert Ellis and Ulysses Washington said Madden called for help after struggling to breathe and repeating that his heart hurt. Jail and medical personnel arrived promptly, but Madden started shaking and became unresponsive, Washington said. The inmates saw him wheeled away from his cell and said he never returned.

"I think something went very wrong in there," Madden's mother said.

The inmates' accounts haven't been verified by law enforcement officials. In a separate matter, Ellis is suing the jail, claiming he was served spoiled milk that made him sick.

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The Milwaukee County Medical Examiner's Office has only confirmed the cause and manner of death in the dehydration case of  Thomas, which was ruled a homicide, meaning a death at the hands of another person. A court-appointed jail monitor, Ronald Shansky, reported this month that the newborn's suspected cause of death is fetal suffocation, but the Medical Examiner's and Sheriff's offices have not confirmed that.

Shansky, who is a physician, did not list a suspected cause of death for Fiebrink in his report, and he didn't review any information about Madden because the death occurred so recently. Shansky did note Fiebrink was not seen by a medical practitioner, which should have been done, and was not placed on preventative detoxification protocol. Fiebrink, a known heroin addict with multiple bookings at the jail, died four days after her arrival at the facility.

Shansky found mistakes were made in the screening or questioned the monitoring of Thomas, the newborn's mother and Fiebrink, according to a report released last week. He did not address Madden's death because it occurred so recently.

Stockton said her son suffered from two heart conditions: aortic stenosis, a valve disease that restricts blood flow, and mitro valve prolapse, a condition that can cause blood to leak in the wrong direction. Madden wasn't prescribed any medications for the conditions, and he received a clean bill of health about 18 months before his death, Stockton said.

Madden had also been addicted to drugs for about a decade, Stockton said. It's unknown whether his heart condition or addiction contributed to his death.

Stockton said she hasn't been contacted by the sheriff's investigators to inform her about investigation procedures. Limon said he's only heard from sheriff's personnel twice since his sister's death: once when they told him she died, and once when an investigator called his phone number by accident.

"They haven't been keeping me up-to-date about anything," Limon said. "I don't know anything."

The Sheriff's Office did not respond to requests for an interview or provide written answers to a series of questions about its handling of the death investigations. The office also didn't respond to a request to provide its policy on requesting outside investigations, a document they are required by law to have. The Milwaukee Journal Sentinel filed a public records request for the policy in early October; the Sheriff's Office has not provided the records.

No clear requirement

In calling for outside investigations, the inmates' families find themselves caught in a gray area of state law.

In 2013, legislators passed a law that requires outside investigations of in-custody deaths that result "directly from an action or omission of a law enforcement officer." The agency that employs the officers involved in the death generally makes the decision about when to request outside investigators.

In some cases, such as fatal police shootings, the officer's actions obviously caused the death, making it an easy call to get outside investigators.

But in other cases, particularly those that could involve neglect or inattention by officers, it's less obvious whether an inmate died as a result of an act or omission by an officer. In those cases, the law enforcement agency is given greater discretion to decide whether to investigate itself or ask for an outside review.

Former state Rep. Garey Bies, a Republican from Door County, said he wanted to require outside investigations of all jail deaths when he shepherded a 2013 bill into law. But some police organizations, including the Wisconsin Sheriffs and Deputy Sheriffs Association, opposed that requirement. Bies dropped the jail issue, focusing on other parts of the bill.

"I didn't want to clutter up the main part we were trying to get at, which is the situations where these officers are directly involved in these deaths," Bies said.

Since the passage of the 2013 law, local police in Wisconsin have requested outside investigations in some — but not all — jail deaths.

Last year, the Rock County Sheriff's Office in Janesville asked investigators from the Dane County Sheriff's Office in Madison to review the death of a 38-year-old inmate. Dane County investigators ultimately faulted a jail nurse for giving the man antacids after he complained of chest pains; he died of complications from heart disease.

In April, the Milwaukee County Sheriff's Office called on the Milwaukee Police Department to investigate the dehydration death of Thomas.

But the Sheriff's Office is handling the three other death investigations at the jail this year. Sheriff's officials haven't said why they requested MPD investigators in Thomas' case, but not the other three deaths. All four investigations are ongoing.

More reviews, less thorough

There will be two additional layers of scrutiny into the deaths, though both reviews will be done months after the inmates died.

After local authorities finish an investigation into a death in jail, the Wisconsin Department of Corrections collects key information, such as reports and witness statements, from the local agency. The Department of Corrections then decides whether to conduct its own administrative review, which could involve interviewing witnesses.

But the Department of Corrections typically does not document the scene or speak to witnesses in the hours after the death, when information and memories are fresh. And the department's main purpose for its review is to address compliance with state and federal jail regulations, as well as nationally recognized best practices.

"Any determination of criminal charges or employee misconduct would be made by the agency operating the facility or outside agencies that may be conducting an investigation," department spokesman Tristan Cook said in a statement.

Shansky, the court-appointed monitor, also receives access to medical, investigative and autopsy reports as part of his inspection of the county's jails.

But Shansky does not go to the jail immediately after the deaths and does not interview witnesses. And his findings only apply to whether the jail is meeting required quality-of-care standards, which are set out in a legal settlement stemming from a 1996 lawsuit by inmates.