Usually, when a person dies inside an Alaska prison, a curtain of official silence quickly falls, making it difficult for anyone on the outside to learn what happened.
But a review ordered by Gov. Bill Walker three months ago and released as a report Monday describes in detail recent instances in which Alaskans died in custody of the state.
In one case, the report found, a 33-year-old man with a heart condition yelled that he couldn't breathe while correctional officers restrained him, trying to cut off his sweatshirt with scissors. He died minutes later.
In another, a man in jail for being drunk in Juneau tried to alert guards that he was having a heart attack. One staff member reported hearing another tell him, "I don't care, you could die right now and I don't care." An hour and a half later the man was pronounced dead.
A third case details the decline of a schizophrenic, bipolar detainee whose last days were spent naked in a cell without visits from mental health or medical staff. The man at one point was reduced to washing off with water from his toilet. A camera captured food being thrown at him by guards.
The report also reveals that four 17-year-olds spent nearly a year in solitary confinement at a Kenai adult prison after being transferred there for trying to escape from a juvenile jail. It exposes the failures to prevent suicides even after inmates had spoken of their intentions or tried to hang themselves with sheets or shoelaces, and suggests that the prison system adopt the same "zero suicide" policy that has prevailed in the juvenile justice system for two decades. The report is critical of Alaska State Troopers, a neutral outside investigator of prisoner deaths, for missing video evidence and witness statements in at least one death case it reviewed.
Together, the case studies paint a picture that Gov. Bill Walker called "disturbing" at a press conference Monday in which he announced the second firing this year of a corrections commissioner. The review revealed a broken system, Walker said.
Dean Williams, the Walker aide who led the three-month review, cautioned that the cases described in the report are not an indictment of correctional officers or managers as a whole. Prison officials and workers must maintain order in institutions packed with a bursting population of difficult and violent people in the criminal justice system.
The problems described in the report also reflect some of the broader dilemmas faced by correctional systems, not just in Alaska but nationwide.
Overtaxed, understaffed prisons are increasingly playing risky multiple roles: part detention, part mental hospital, part holding tank for intoxicated people who have no other place to go, the report noted. The results can mean death.
'He couldnt breathe'
Larry Kobuk went to the Anchorage jail on the night of Jan. 27 after being arrested for stealing a vehicle and trying to run from police.
Kobuk, 33, originally hailed from the Norton Sound area. He had lived in Anchorage for about a decade, and had amassed a lengthy list of criminal convictions, mostly on misdemeanor charges.
Family members of Kobuk couldn't be reached.
Upon his booking at the jail, he told a nurse he suffered from a disease that puts people at risk of sudden cardiac arrest.
After a search, police told correctional officers they needed to remove the two sweatshirts Kobuk was wearing. He refused to cooperate, the report said.
In a booking cell, four guards held him face down, trying to strip off his clothes to get the sweatshirts. The correctional officers were "on his back," pressing him to the floor in an attempt to cut off the sweatshirts with scissors, the report said. Outside the cell, a nurse and two police officers looked on.
Later, a police officer reported that he "heard Mr. Kobuk yell several times that he couldn't breathe" as officers restrained him. Three of the guards said they heard the same thing.
It's not clear whether they knew he suffered from a heart condition.
When the final sweatshirt had been cut off, a guard looked at Kobuk's face: He wasn't breathing.
Kobuk was left in the cell face down. A minute and a half later guards returned with ammonia, trying to rouse him, and attempted CPR.
In its investigation of the incident, the corrections department found that its own officers didn't use excessive force while restraining Kobuk. But the threat posed by Kobuk didn't appear to "warrant the level of force used," the review found.
To jail as a drunk, not a criminal
Charged with no crime, Joseph Murphy went to jail because he was drunk.
On Aug. 14, the 49-year-old was taken to the Juneau jail on what's known as a "protective custody" hold -- meaning he was deemed to be incapable of caring for himself.
The law allows the state to hold such detainees for 12 hours or until they sober up. In Anchorage, they might go to the city-run sleep-off center. But in communities without a sobering center, they often end up on the doorstep of the jail. It's either there or the hospital.
Murphy was not drunk enough to be in the hospital. His blood alcohol was .16 when he arrived.
He spent the night uneventfully, alone in a cell. Early in the morning, around 5 a.m., he appeared sober enough to be released under the terms of the protective custody law, the report said.
But staff at the Lemon Creek Correctional Center apparently erroneously believed that a 12-hour hold is a minimum, not a maximum, and that Murphy had to be detained until 6 a.m.
The report says that Murphy began to yell about chest pain and bang on his cell door. About 6 a.m., someone told him he'd be out in an hour and if he needed emergency services someone would "gladly call," according to the report.
Things quickly went downhill. Expletives were exchanged with guards. Soon, Murphy could be seen on the video patting his chest, banging on the door and getting on his hands and knees.
In the video "he appears to be sweating," the report says.
At 6:19 a.m., he collapsed on the floor and stiffened. A guard delivering a breakfast tray noticed him on the ground.
Correctional officers started compressions but it was too late. Murphy had died of a heart attack.
His obituary said he had worked for the National Park Service in Kotzebue, once saving a man lost on sea ice in a whiteout storm. He had also served in the Alaska Army National Guard, deploying to Iraq in 2005 as a machine gunner.
'Apparent disregard for Mr. Mosleys condition was profound'
Of the deaths detailed in the report, none has been as closely examined as that of Davon Mosley. A state senator once considered using a legislative subpoena to get information about his death.
Mosley died on April 4, 2014. He was a mentally ill 20-year-old who had moved to Alaska from California with his girlfriend and their children less than a year before, but was arrested in Alaska on a California warrant. In jail, he was transferred to a segregation unit for challenging a guard to a fight and making "menacing statements."
He began acting strangely and threatened to kill himself. Pepper-sprayed, he tried to wash himself using water from his toilet.
When California correctional officers showed up to transport him back to face charges, they "refused to accept custody of him" because he was in such poor shape, the report said. At that point, California dropped the charges against Mosley. He should have been legally free to go. But the paperwork had been lost.
The report concluded that Mosley received "very little in the way of mental health care" during his decline. He was naked for days and was taken in the hallway naked -- an "unacceptable standard of care," according to the report.
"The apparent disregard for Mr. Mosley's condition was profound," the authors wrote.
Vernesia Gordon, the mother of Mosley's three children, has been one of Mosley's staunchest advocates. She said she was pleased by the report.
"I'm glad it went this far. Honestly, I didn't think it was going to," she said Monday. "I'm not at peace with it. But I feel a little bit better."