Inmate's death must bring action

In the final weeks of his life, James Embry, known to the Kentucky Corrections Department as Inmate #171356, began a rapid slide into despair.

Locked in solitary confinement at the Kentucky State Penitentiary at Eddyville — initially at his own request — Mr. Embry grew increasingly anxious, despondent and suicidal.

His pleas for anxiety and paranoia medication were denied. He refused to come out of his cell to shower or to exercise.

He stopped eating.

And as prison medical staff looked on, he slowly died of starvation.

Mr. Embry, 57, who stood 6 feet tall and weighed 170 pounds just four months before his death, weighed 120 pounds after he was found dead in his cell on Jan. 13 — hours after a nursing supervisor refused a nurse's request that he be moved to the infirmary.

He had no visits from family or friends during his six years in prison and was buried in an inmate cemetery on the grounds.

His death, detailed this week by Brett Barrouquere with the Associated Press, should shock the conscience of Kentucky.

But more than that, it should shock the state into action.

Members of the General Assembly, charged with oversight of prisons, should demand a full accounting from top state corrections officials including Kentucky Corrections Commissioner LaDonna Thompson and Justice and Public Safety Cabinet Secretary J. Michael Brown.

The death of Mr. Embry has prompted a flurry of action by corrections officials.

An investigation and report by the department provides a detailed account of what went wrong in Mr. Embry's final days, the repeated missed opportunities to help him, and how staff supposed to be in charge of his health care presided over his breakdown and death.

The prison doctor has been fired. The state is in the process of firing a prison psychologist and her associate.

Corrections has produced an "action plan" to address instances where officials failed to follow policy, to improve medical procedures and to tighten oversight to ensure compliance. Corrections officials have been directed to analyze inmates' mental health needs and how such inmates are housed.

And corrections officials have asked Attorney General Jack Conway's office to review the matter to determine whether further action is warranted.

But legislators should look more deeply into how Kentucky treats all its approximately 12,000 prison inmates, particularly those with mental health problems.

In Mr. Embry's case, even after he repeatedly voiced feelings of hopelessness, despair and a desire to hurt himself, a prison psychologist dismissed them saying he provided no clear plan for ending his life and he was vague about his intentions.

And after he stopped eating, staff debated over whether Mr. Embry was on an actual "hunger strike" even though he rejected 35 of his 36 meals prior to death, because he took occasional drinks of tea or juice and once accepted a cookie.

But most importantly, lawmakers should review Kentucky's use of isolation cells in its prisons.

The practice of holding inmates in isolation — allowing them out only briefly for recreation and showers — has become increasingly controversial as advocates and mental health experts argue whether the damaging effect on the mental health of inmates outweighs security benefits.

Mr. Embry requested isolation late last year, saying he feared for his safety. But his mental health needs went unmet and within 46 days he was dead.

His death, the corrections department concludes, was the result of a "systemic failure" at the prison.

Lawmakers and state officials must make every effort to ensure such a failure doesn't happen again.