When corrections officials aren’t forthcoming with records, coroners can offer families the details needed to find closure or pursue accountability.
By Ivy Scott
The Marshall Project
https://www.themarshallproject.org/
When Alan Lancaster died in January 2023 at South Central Correctional Center in Licking, Missouri, his family went looking for answers.
The Missouri Department of Corrections recorded his death as an accident and offered few additional details. His family requested records from the prison’s investigation into his death, documents such as the internal investigative report that might paint a fuller picture of Lancaster’s last moments. But their requests for more information were “largely ignored,” according to their lawyer, Joe Allen.
It wasn’t until they reached out to the county coroner who handled Lancaster’s body that his family learned the 39-year-old had been in a restrictive housing unit for over two weeks when he died from a fentanyl overdose.
In March, Lancaster’s mother, Mary Harris, filed a wrongful death suit against the prison system. The coroner’s records, including a death certificate ruling Lancaster’s death a homicide, provided the basis for Harris’ lawsuit alleging that prison officials failed to properly care for her son.
“Alan was in solitary confinement and somehow dies of a fentanyl overdose,” Allen said. “How do you get fentanyl while you’re in solitary confinement?”
When someone dies in a Missouri prison, the prison system is required to provide certain information to families about the death. Staff should notify emergency contacts of the death and explain how to access the deceased’s medical records, according to the Missouri DOC’s communications director. For more information, families or their attorneys can submit records requests. State law dictates that even if certain records are normally closed, the DOC should provide families access to those documents “for purposes of investigation.”
But families of people who died in prison and their attorneys told The Marshall Project – St. Louis that the DOC doesn’t always follow its own policies. Left with unanswered questions about how their loved ones died, some have instead turned to the coroner. While coroners are elected officials generally responsible for investigating violent or unexpected deaths in their county, Missouri’s statute requires coroners to “fully investigate the essential facts” surrounding every death in custody, regardless of how it happened. The information from their investigations can help families find a sense of closure — and when deaths are suspected to be the result of abuse or neglect, a coroner’s investigation can also play a role in holding the prison system accountable.
Unlike states such as New York that have medical boards to review deaths behind bars and mandate policy changes, coroners provide the only guarantee of outside scrutiny when someone dies in a Missouri prison. And although people who die in custody each year are particularly vulnerable to disappearing from public record, the statutes governing exactly how coroners conduct their investigations contain almost no record-keeping requirements.
Historically, these policies have granted coroners wide discretion in how thoroughly to investigate, resulting in an uneven standard of prison death investigations across the state.
Now, in Missouri and across the country, a coalition of forensic scientists, public health researchers and legal experts is pushing for more robust policy and oversight to hold every prison death investigator to the same high bar.
“The coroner really is, in many places, the only opportunity for outside review or oversight,” said Dr. Roger Mitchell, president of the National Medical Association and co-author of the book “Death in Custody.” “So states need to take control over their death investigation apparatus, ensuring that there’s uniformity.”
When Tanekka Guest’s husband, Christopher, died at South Central prison in October 2023, she struggled to learn the truth about his death from prison officials. All the warden told her when he broke the news was that her husband died in his sleep, Guest said.
“I was like, ‘How? What happened?’” she recalled. “The warden just said, ‘I’ll let you know more information when we get it.’”
Guest said she called the prison nearly every day for a month to speak to the warden, but he was never available. Eventually, she spoke to an investigator, who told her she would receive a flash drive with the contents of her husband’s tablet. Neither the flash drive nor the information she was promised ever came, she said.
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