In September 2018, three men mysteriously died in the same area of a downstate Illinois prison — in just three days.

Documents obtained by WBEZ paint a picture of how those deaths happened over the course of three days, as Menard Correctional Center staff ignored warning signs and one employee falsified documents. The deaths raise questions about staff accountability, prison transparency and drugs behind bars.

Illinois’ Department of Corrections said it acted swiftly following the deaths and their internal investigation concluded that IDOC staff could not have prevented them.

But advocates and a family member of one prisoner who died said the department has not been transparent about deaths behind bars, making it difficult to hold staff and officials accountable.

Three days, three deaths

Kevin Curtis died on Sept. 5, 2018 at age 31. According to records, Lisa Goldman, the treatment unit administrator at Menard, said that prior to Curtis’ death, he looked “catatonic” and was severely dehydrated.

She wrote in an incident report that she told staff doctors that in her clinical opinion Curtis needed to be evaluated, and that she was concerned about him in the high heat of the prison in his current state.

She said her concerns, however, were ignored, and he died shortly after that. The investigation noted Goldman “was not a medical physician and only provided her professional opinion as a mental health professional.”

In addition to the warning from Goldman, staff had another potential opportunity to notice something was wrong: Curtis was on suicide watch, which meant a guard was supposed to check in on him every 10 minutes. However, the guard in charge of doing those checks, Nickolas Mitchell, told investigators that he had not actually done all his checks because he was helping with meals. Mitchell said after Curtis’ death, he falsified his report log to make it look like he had done the required checks.

A coroner’s office would eventually determine that Curtis died of “probable intoxication with an unknown substance.” The toxicology report was inconclusive, but the substance appeared to resemble a synthetic cannabinoid — a human-made drug that is similar to marijuana, but “can be unpredictable and, in some cases, more dangerous or even life-threatening.”

The next day, Sept.6, 2018, the man in the cell next to Curtis died from the same cause.

Edwin Freeman, age 45, was also on suicide watch, which — again — meant he should have been checked every 10 minutes. Logs of those checks show that he was found unresponsive at about 9 a.m. He was transferred to the prison infirmary and eventually was taken to a hospital, where he was pronounced dead.

In a letter forwarded to WBEZ, a prisoner claims he could hear both men screaming that they were hot and could not breathe. He said one man shouted that his insides were burning. The prisoner wrote that guards ignored the men’s “pleas, cries, screams and banging.”

On the third day, a third prisoner in the cell near Freeman’s also died from “probable intoxication with an unknown substance,” according to documents from the coroner’s office.

Documents from the Department of Corrections investigation into Timothy Murray’s death are the only ones that include interviews with other prisoners. One prisoner said he could hear Murray banging on his cell door for help after the morning meal. However, security staff did not come until the afternoon meal was distributed. A second prisoner said he thought he heard Murray calling for help from guards, but could not be sure because of noise from fans.

Murray was just days shy of his 33rd birthday when he was found unresponsive in his cell.

According to prison documents, one nurse at the prison said the skin on Murray’s arm looked like it was slipping off and he had a very distinct odor; rigor mortis appeared to have already set in.

Prison death transparency and accountability

The internal investigations by the Illinois Department of Corrections largely absolved staff. The only staff member called out for misconduct in the investigations was Mitchell, who admitted to falsifying logs and not checking on an inmate who was on suicide watch.

However, Mitchell is still working for IDOC.

A spokeswoman for the department said one staff member was temporarily suspended, but she did not provide more specifics. She said the department stood “by the investigation and the conclusion that IDOC staff could not have prevented the deaths.”

Alan Mills is a lawyer with the Uptown People’s Law Center, a nonprofit that does prison litigation. He said it can be very difficult to tell if the department is sufficiently holding staff members accountable and changing policies as needed.

Many other state agencies act publicly, “but the Department of Corrections acts in private, behind locked doors — that’s the whole point of the Department of Corrections,” Mills said.

Lindsey Hess, a spokeswoman for the state prison system, said lifesaving measures were provided to all the prisoners and the department “acted swiftly” after the deaths. “Autopsies were conducted, the institution was thoroughly searched and air quality tests were conducted. Their deaths were part of an isolated case and no further drug-related deaths have occurred at IDOC,” Hess said.

In response to an open records request, IDOC said it does not collect data regarding responses to overdoses. The department said based on death certificates from a three-year period that includes the time of these deaths, they don’t have a single record of any death in which overdose was determined as the primary cause.

But prison death records are often incomplete. At least 166 people died while in Illinois prisons from January 2017 to September 2018. In around half of those cases, IDOC’s research department had no cause of death listed, according to Department of Corrections documents.

Jennifer Vollen-Katz is executive director of the John Howard Association, a prison watchdog group. She said it’s impossible for the public to actually evaluate the reliability of the Department of Corrections information, or track causes of deaths behind bars, because IDOC is not transparent about deaths behind bars.

“We should be concerned that we don’t know very much about how people in custody, people who are removed from their families and their communities and the public eye, are dying,” Vollen-Katz said.

Vollen-Katz said many other states provide better information about prison deaths than Illinois does. Last legislative session, she pushed for a law that would have forced prisons to provide more information about deaths in custody, but it did not pass. That law would have forced agencies to investigate and report all deaths in-custody to the state attorney general within 30 days and ensure the records were available under open records laws. It would also mandate that the attorney general issue an annual report evaluating trends and information on deaths and custody.

The law also would have insured family were notified about deaths and given a “factual account of the cause of death and circumstances surrounding the death in custody. “

Yolanda Jackson, the mother of Kevin Curtis, said she was given very little information about her son’s death and had to wait months to get even basic information about how he died. She said the prison did not tell her that staff members had raised concerns about the health of her son prior to his death and that staff falsified documents related to his death. She said the lack of transparency is what allows abuses to flourish.

“A lot of prison officials hide behind that, because they don’t have to disclose certain info about inmates, because they feel like they belong to the state,” Jackson said. “There is no regard to their family members and loved ones who care about them.”

Shannon Heffernan is a criminal justice reporter for WBEZ. Follow her at @shannon_h.