Lincoln County Jail staff waited 34 minutes to summon ambulance.
By Joel Currier
St. Louis Post-Dispatch
LINCOLN COUNTY — With eyes bulging and fluids dribbling from his mouth, jail inmate Charles Benoit suffered seizures for more than 30 minutes before anyone called an ambulance.
For 15 months, the accused killer had been locked up at the Lincoln County Jail, where he awaited trial in the slaying of a Troy, Mo., motel owner.
The day of his death, March 10, Benoit was expected to plead guilty and head to prison for the rest of his life. He had said he was sorry for his actions and dreaded the reality of so many years behind bars.
Benoit, 43, had been stashing his medication. The pills, doxepin, were supposed to calm his nerves and help him sleep.
Instead, Benoit died from an overdose.
Jail officials acknowledge that jailers did not consistently supervise inmates taking high-risk medication. Jailers also didn’t regularly search cells for hidden drugs and lacked suicide training. Officials say they have changed the jail’s operations and begun suicide prevention training.
“Those are common practices that a good correctional facility will do regardless if it’s a small jail or a larger metropolitan jail,” said Lindsay Hayes, a consultant with the National Center on Institutions and Alternatives, which researches jail suicides and develops prevention programs.
The Missouri Highway Patrol recently released a 170-page report into Benoit’s death that concluded there was no criminal conduct by any of the jail’s staff. However, several of the jail’s
officers told investigators that an ambulance for Benoit should have been called much sooner.
By the time inmates found Benoit convulsing, he was beyond being saved by any medical treatment, said Dr. Christopher Long of the St. Louis County medical examiner’s office, which performed an autopsy. Long, director of the forensic toxicology lab, said Benoit had taken “enough doxepin to kill a horse.”
But jail staff didn’t know that, and the patrol’s report shows Benoit’s seizures lasted 34 minutes before anyone summoned an ambulance.
“Maybe we should have acted a little quicker, and I say that with a big emphasis on maybe,” said Interim Sheriff Kent Hanshew. Benoit’s death “gave us an opportunity to improve some things in the jail,” he added.
The patrol’s report provides a detailed account of the frenzied night at the jail:
At 4:36 a.m. inmates playing cards spotted Benoit writhing in his bunk bed.
Someone punched the call button for help, and a guard charged into the cell two minutes later. Still shaking, Benoit struggled to breathe and bled from his mouth after biting his tongue.
Sgt. Lindell Riffle, the jail’s night supervisor, ordered inmates to carry Benoit to an observation room. In interviews with investigators, several inmates said they heard Riffle say he refused to call an ambulance because he didn’t want to look “like an idiot.”
Sheriff’s Department policy prohibits Riffle from commenting.
“We kept telling them, ‘This dude’s going to die if you don’t do anything,’” said inmate Dustin Hollingsworth, 22, of Elsberry, who helped carry Benoit from his bunk to the booking room where he died.
An ambulance was called at 5:10 a.m. only after Benoit had begun turning blue, stopped breathing and lacked a pulse. Paramedics arrived in four minutes and began CPR, but they could not revive him.
Inmate Kurt P. Murphy, 35, of St. Louis, believes corrections officers should have moved faster to help Benoit. “Until he quit breathing, they would not call an ambulance,” he said. “It was just really wild.”
Benoit’s death has prompted the jail to make several key policy changes.
They include:
- Providing suicide prevention training to all corrections officers.
- Conducting daily, random inspections of jail cells for prohibited items like drugs.
- Requiring a nurse to dispense high-risk medication and observe inmates to ensure they take it.
- Appointing a second commander to supervise inmate welfare.
- Issuing new portable radios to improve communication.
Jail administrator Larry Doyle, the Republican candidate for sheriff in November, said his staff lacked formal training to identify signs of depression or suicide. But he insisted they followed the jail’s old policies properly by contacting the jail nurse for instruction before providing Benoit medical treatment. The nurse told jailers to observe Benoit’s condition.
Hanshew and Doyle say the changes should help prevent future incidents.
“I think the changes that we implemented since that time have, if they’ve done nothing else, given us a better understanding of what we need to look for,” Doyle said.
Hanshew, who requested that the Highway Patrol investigate Benoit’s death to avoid any conflict of interest, said the jail needs to improve.
“Now we know we need to be aware of people that have been sentenced or are going to be sentenced,” Hanshew said. “We have to do a little better job in just about everything when it comes to taking care of inmates.”
Though Benoit’s death was not ruled a suicide, jail officials don’t believe it was an accidental overdose.
Jail suicide rates have declined over the last two decades, but suicide remains the second-leading cause of death in county and municipal jails, behind natural causes, according to a 2005 report by the U.S. Department of Justice.
Any jail lacking basic suicide training for its staff would make the facility “inconsistent with national practices,” said Hayes, the consultant with the National Center on Institutions and Alternatives. In particular, jailers should pay closer attention to inmates when they are facing potentially life-changing court hearings.
“There’s a high correlation between the receipt of that (new) information and the suicide attempt,” he said.
Hayes said drug overdoses represent a small fraction of jail suicides; nine of 10 suicides are hangings.
Benoit, a high school dropout, was charged nearly two years ago with first-degree murder in the killing of Saunak Kapadia, 56, of Troy. Kapadia was found beaten and strangled in an SUV parked in a commuter lot at the Budget Inn and Suites at 14 Frenchman Bluff Road. Benoit had lived at the motel and performed odd jobs there.
His two teenage sons visited Benoit regularly at the jail. Benoit often complained of insomnia and frequent headaches. A psychologist diagnosed him with depression and an anxiety disorder in January and recommended antidepressant medication to treat him.
Three weeks before his death, he wrote a letter to his sister saying he was ready to accept punishment for the killing.
“I put enough shame on our family, I won’t put more,” he wrote. “I love you all very much, but I did this alone. I should face it alone.”
Benoit’s sister and father declined to comment for this story.
As officers cleaned out Benoit’s bunk the day he died, they found a handwritten poem: “I’m so tired I don’t even try. There’s a time to live, theirs [sic] a time to die. Time for wonder and I wonder why. There is a reason.”
“I think the changes that we implemented since that time have, if they’ve done nothing else, given us a better understanding of what we need to look for.” Jail administrator Larry Doyle
Copyright 2008 St. Louis Post-Dispatch, Inc.