From April to June, five young people died on the Alaska Department of Corrections' watch: One suicide. One homicide. Three were found suddenly dead in their cells.
The Department of Corrections has said the cluster of deaths is not unusual because of a prisoner population that often comes to jail with significant health problems.
After each death, the department assured the public that it was conducting an internal investigation.
Family members of the deceased wanted to know more, especially after other inmates tracked them down and told stories of mistreatment and neglect in the days and hours before their loved ones died.
Did correctional officers do their jobs properly, they asked? Could the deaths have been prevented? Was anyone fired or disciplined after the deaths?
And could they see the results of investigations themselves?
The DOC maintains that it does plenty to investigate the deaths of people in its custody.
Questions are asked, officials say. Reports are written.
But for the public, getting documentation of the DOC's self-described investigative process is fruitless and quixotic task.
Thousands of dollars, hundreds of hours
On April 28, Alaska Dispatch News requested, under state open records law, copies of DOC internal investigation documents related to inmate deaths from 2000-2012, to examine how the department probes its own performance in the event of an in-custody death. (More recent investigations could not be released because they were prepared in anticipation of potential litigation for which the statute of limitations has not yet run out, the DOC said.)
On June 26 the Department of Corrections responded.
Officials said gathering the paper records from boxes dispersed across the state would cost Alaska Dispatch News fees totaling more than $4,000 and would take more 100 hours -- two and a half full work weeks -- of employee time to locate and photocopy files.
For some records, the search would have to be personally completed by Laura Brooks, a high-ranking official who is the deputy director and health care administrator, at a cost of $57 per hour, the department said.
Gathering the documents would be costly, timely and complicated because, as it turns out, what constitutes a death investigation is inconsistent.
Deputy commissioner Sherrie Daigle said that when officials refer to "death investigations" they are talking about "special incident reports," generated every time something like a riot, assault or other mayhem breaks loose in a prison.
But those "special incident reports" don't seem to contain much in the way of self-examination.
Copies of 2008 and 2009 special incident reports acquired through a previous Open Records Act request include a handful involving inmate deaths, both sudden and expected due to terminal illness.
The reports vary in size and scope. Some are a single page long. All include a brief narrative of what happened: In one case, an inmate "vomiting blood" is taken to the hospital, where she dies days later.
Calling one of the reports an "investigation" is a stretch. In the reports examined, there is no evidence that they probe whether procedures were followed or whether everyone involved did their jobs correctly.
In explaining why it would cost so much time and money to hand over death investigations, DOC officials said that the details of the deaths of the more than 130 people who have died while in custody of the State of Alaska since 2000 are found in fragments of medical records, attorney notes and incident reports forgotten in boxes scattered throughout records warehouses and institutions.
The one instance in which there may be a complete, written accounting of the circumstances surrounding a death is when a "report is forwarded to the Department's legal counsel," Daigle wrote Wednesday.
Those reports, she said, are prepared in anticipation of a lawsuit against the Department of Corrections.
So they are considered attorney-client communications -- and again can be kept away from the eyes of the public.
Silent on deaths
Right now, the Department of Corrections' 222 published policies and procedures -- which weigh in on everything from allowable snacks at the commissary to the temperature of showers -- are silent on what kinds of questions the department should ask about its own conduct after an inmate dies.
Daigle said first on Wednesday that no written policy governing in-custody deaths existed, but that the Department of Law was in the process of drafting one.
Later in the day she said she'd misspoken and a secret, unpublished regulation on investigating prisoner deaths did exist -- but that she hadn't been aware of its existence until today. The Department of Law, she said, was actually thinking of declassifying it.
But for now it could not be shared with the public, Daigle said, because the information could "threaten the safety and security of institutions."
She did not explain how.
In other states, the DOC is rarely trusted to do its own investigation, said Todd Wilcox, a Utah-based, nationally known authority on correctional health care who has testified as an expert witness in jail death civil cases.
"I am aware of states where the DOC does their own investigation and from the limited evidence I've seen those investigations are rarely adequate or intellectually rigorous," Wilcox said.
Many states utilize another law enforcement agency to investigate deaths to maintain objectivity, Wilcox said.
The Alaska State Troopers are notified of every in-custody death, Daigle said.
But their responsibility is only to determine whether a crime has been committed, not to evaluate issues related to the way the institution is run, such as whether a suicide might have been prevented by prompt mental health care.
'Little bits' of information
On Tuesday, the families of some recently deceased DOC prisoners might have a chance to ask their questions of top department officials.
Sen. Hollis French, D-Anchorage, is asking the department to account for its practices at a public hearing on Tuesday, from 10:30 a.m. to noon at the Legislative Information Office in downtown Anchorage.
Vernesia Gordon found out that her partner, Davon Mosley, had died on the same day she learned she was carrying their third child. Mosley, a 20-year-old from Bakersfield, California, Mosley suffered from schizophrenia and bipolar disorder. He was found dead in his isolation cell at the Anchorage Correctional Complex on April 4. Later, autopsy results showed he'd died of bleeding ulcers -- typically a treatable condition.
The attorney Mosley's family retained to look into the death is finding things out in "little bits," Gordon said. The attorney learned that Mosley was pepper-sprayed twice while in the jail, Gordon said.
She has already decided on a name for the baby girl with whom she is now five months along.
"Davon always wanted a girl," said Gordon. "And I want justice for him. So his daughter's name will be Justice Dae'Vonn."
Contact Michelle Theriault Boots at firstname.lastname@example.org.