SOUTH BEND — Reviews of deaths in Pacific County jail on Dec. 13, 2022, and Oct. 7, 2024, have been quietly completed and submitted to the Washington State Department of Health.

The reports make three formal recommendations: staff the jail around-the-clock with a registered nurse and other health professionals at least five days a week and keep them on call; immediately transport inmates who meet a specific medical criterion to another jail or facility that has a higher level of care; or close the jail and contract with another facility to hold inmates.

The panels finished the inquiries three weeks before a 90-day extension to the reviews — a second this year — was set to run out. The Pacific County Commission (BOCC) approved a 120-day extension on Feb. 11 and approved another 90-day extension on July 28.

The review panels were conducted on Oct. 1 and were composed of PCJS Director Jim Byrd and Dr. Marc Stern. The panels did not include any other members. Such internal reviews are permitted by the 2021 state law mandating that jails file reports of deaths in custody to the Department of Health within 120 days.

This law was passed in response to abnormally high rates of inmate deaths in the state’s county jails. In 2019, the most recent year for which complete statistics are available, Washington’s death rate was fourth highest in the nation, according to the Bureau of Justice Statistics.

Pacific County is far from alone in taking longer than the law requires to conduct reviews. A story by The Seattle Times (tinyurl.com/ST-2023-Jail-Deaths) “surveyed Washington’s county jails and found that at least 31 people have died in 15 county jail systems since the law went into effect. As of [March 2023], 11 of those counties have not filed a report to the state….”

Byrd took over the Pacific County jail on Jan. 1 after commissioners voted unanimously on Dec. 26, 2024, to remove the jail from the Pacific County Sheriff’s Office’s supervision.

Byrd and Stern reviewed materials from the deaths of Crystal R. Greenler, on Dec. 13, 2022, and Curtis S. Kirschbaum on Oct. 7, 2024, including reports, surveillance footage and jail policies.

Investigators pulled in from the Lewis County Sheriff’s Office uncovered systematic failure, with findings including that a former corrections officer had fallen asleep, didn’t perform cell checks and fabricated records.

According to the investigation report, Greenler was brought into the jail sick and only continued to worsen. Despite efforts by cellmates, who included a nurse, little was done to help her. Greenler’s family settled a wrongful death lawsuit against the county in October 2024 for $2.95 million.

Second death

Systematic issues were also found in a preliminary policy review regarding Kirchbaum’s death. He committed suicide by hanging in the jail. He was found by another inmate and was declared deceased by emergency responders.

According to the panel’s report, he was provided two towels when he should have only been provided one and used a “structural design flaw” between metal bars to hang himself.

A policy review for his death was completed by the Thurston County Sheriff’s Office. The review was completed and submitted on June 1, 2023. The report was discovered by county officials on Aug. 6 after a flash drive was handed to Byrd by PCSO Chief Criminal Deputy Randy Wiegardt.

Pacific County Sheriff Daniel Garcia was called out during a BOCC meeting on Aug. 12 for, in essence, not disclosing the report’s existence. Garcia responded during a subsequent meeting on Aug. 26, claiming that the county knew full well it existed.

“The investigations were completed by [June 1, 2023], and then they were shared with the — at the time — civil attorney and the [public records department] on [July 6, 2023],” Garcia said. “So, about one month later they were [disclosed for public records] and they were supplied for [public disclosure].

“So, when you look at what a review panel is, it is quite in-depth, and these are very important to be done. So, what was done were investigations and of those investigations one was a review of the policy, which was to be submitted to the review panel for their purposes of knowing what was our policy and what was done and how it was done,” Garcia added.

However, according to an extensive public records request submitted by the Observer, there is no record of the sheriff’s office providing the report to the county before it was discovered on the flash drive on Aug. 6.

Root causes

As for the panels, Byrd and Stern noted multiple issues in a root-cause analysis, including jail mismanagement, inexperience, health care shortcomings, lack of documentation regarding communication with health care providers, and a health care grievance process for inmates.

“At the time of incident, corrections and medical staffing levels were not appropriate to operate the facility,” the report for Kirschbaum’s incident states. “Corrections staff provided first aid and life saving measures within policy. Hourly Inmate Safety Checks were not being conducted in accordance with Policy 505.” “[Kirschbaum] had made a suicidal statement prior, that was not taken seriously nor was it acted upon appropriately. The information was not logged or passed on to any other staff members. Decedent was in possession of two towels when only one towel should be issued at a time,” the report adds.

Empower officers

The reports also suggest amending policies to allow corrections officers to take immediate action outside the typical scope of their responsibilities.

“Generally, officers should never fail to fulfill a task asked of them by a licensed health care professional for the care of an incarcerated individual,” the report states. “However, the Jail Policies and Procedures and corresponding initial and annual training curricula for officers should be amended to empower officers to do more than what is requested of them by a health care professional if, in the reasonable lay judgement of that officer, such action is necessary in the best interest of the incarcerated individual.”

“If time permits, the officer should escalate the proposed action through the appropriate chain of command. However, if time is of the essence, any officer should be empowered to take action to provide necessary care. Commonly, the action at hand is evacuation of the patient to a hospital. The training curricula should include table-top exercises that simulate scenarios in which officers must make such decisions,” the report adds.

Recommendations

Also amongst the findings is a recommendation to update a jail policy to require corrections officers to conduct hourly checks of inmates.

“The Jail Director has already made the maximum degree of improvements to the system of health care delivery that existed at the time of the death(s) given the current budget and operational structure of the jail,” the report says.

“Additional improvements or changes to the operation of the jail, however, are required to ensure a minimal level of patient safety to prevent future deaths. In other words, the current improvements are necessary, but not sufficient,” the report adds.

There is nearly identical verbiage throughout each report.