LOUISVILLE, Ky., (WDRB) – On the morning of Jan. 13, 2014, a nurse at the Kentucky State Penitentiary ordered inmate James Kenneth Embry moved to the prison infirmary after he refused 12 consecutive meals during a lengthy hunger strike.

But a medical director overruled the decision after jail staff questioned the move, saying that while Embry refused food that day, he took at least one drink of tea, meaning he was no longer officially on a hunger strike.

Later that day, medical staff arrived to find Embry, 57, unresponsive, slumped over in his solitary jail cell in Eddyville. He was initially handcuffed as nurses tried in vain to revive him.  

The cause of death was starvation and dehydration. The Lyon County Coroner ruled it a suicide. Embry had refused 35 of his last 36 meals, shedding more than 50 pounds during a hunger strike that began months earlier. At 6 feet 1 inch tall, he weighed about 120 pounds, down from 174 in September.

The failure to send Embry to the infirmary was the last in a series of mistakes over several months that cost Embry his life – allowing a man to starve to death while surrounded by jail personnel and medical staffers.

While the Embry case drew national headlines when he died – two medical staffers resigned and the lead doctor was fired, among other fallout– there has been little mention of it in the last four years as a wrongful death lawsuit stalled.

Now, the lawsuit has finally begun moving forward again with depositions being taken and a trial date set for January.

WDRB News has also obtained a prison video of the last moments of Embry’s life, showing him emaciated, his pelvic bones jutting from his body as medical personnel try to revive him.

Records released in the civil case and obtained through open records requests – including an internal and criminal investigation -- expose lapses in medical treatment and a failure by the jail to follow procedures.

For example, an internal investigation concluded that “virtually none of the procedures” outlined in how to deal with a hunger strike were followed in Embry’s case.

Prison officials failed to follow their own policy, removing Embry from hunger strike status if he drank anything, then list him as being on a hunger strike again after he refused four meals in a row.

 “The death of Inmate James Embry occurred as the result of a systemic failure at the Kentucky State Penitentiary involving many interacting issues,” the investigation concluded.  “In summary, the failure of many interacting systems to address a correctable situation and to follow written standing orders and protocols led to the ultimate death of Inmate Embry.”

Embry was supposed to be medically monitored every day – weighed, vital signs taken, his blood and urine tested.

“They never did any of this stuff,” said Bob Blakemore, a Tulsa attorney representing Embry’s family in the federal wrongful death lawsuit. “They never medically monitored him even though they knew he stopped eating.”

All of the employees involved in the case no longer work for the Kentucky Department of Corrections, according to the agency. One employee resigned while under investigation, and another was allowed to resign after appealing to the state personnel board. A contract medical employee with Correct Care Solutions had his access to the institutions revoked at the time.

“This case is so disturbing, to the absolute core,” said Greg Belzley, a local attorney representing the Embry estate in the lawsuit against the health care provider and multiple prison and medical staffers involved. “One or two dozen people watch a man on a daily basis starve himself to death.”

Criminal investigation

Embry’s death prompted not only an internal investigation but a probe by the Kentucky State Police.

Lyon County Commonwealth’s Attorney G.L. Ovey considered criminal charges against prison staffers. But on July 13, 2015, after hearing testimony about Embry’s death, a Lyon County grand jury “found no evidence of any criminal conduct,” according to state police records.

While the Department of Corrections did not respond to questions for this story, one of the defenses put forward is that prison staff believed Embry was pretending to be mentally ill and refusing meals in an effort to force the prison to move him to a different area of the prison.

The lead doctor at the prison concluded that Embry did not seem to have significant mental health symptoms and while he talked about hurting himself, he “had not presented” medical staff with a plan “that led them to feel that these claims were legitimate,” according to the internal investigation.

“How do you fake losing 35 pounds,” Blakemore told WDRB. “How do you fake starving to death? How do you fake dehydration.”

Embry had a reported history of mental illness but stopped taking his medication while in prison in July 2013.

However, in December of that year, Embry told a prison doctor he was “anxious and paranoid” and asked to resume taking his medication. That request was denied after the doctor noted Embry did not seem to have any serious mental health symptoms. The internal investigation noted that placing Embry back on his medication was never even considered despite his behavior and history of being on medicine to address his issues.

In the ensuing months, Embry repeatedly refused to eat and threatened to harm himself.  On Dec. 11, 2013, Embry was pepper-sprayed and put in a restraint chair after scratching himself with a plastic utensil.

“Instead of Mr. Embry receiving effective treatment for his condition, he was merely periodically interviewed while he slowly, inexorably, died from dehydration and starvation,” according to the lawsuit.

He repeatedly threatened to hurt himself and said he “has nothing to live for,” according to the internal investigation.

But some of the notes written by medical staff seemed to downplay Embry’s threats.

On Dec. 19, at a medical staff management team meeting, the only item on Embry’s  daily chart indicated “nothing new noted” despite Embry repeatedly saying he was going to harm himself, refusing meals and being placed in a restraint chair after trying to hurt himself, according to the investigation.

The same information was reported at a meeting on Jan 9, even though Embry had again been placed in a restraint chair and was constantly banging his head on the cell floor. He had also lost 32 pounds since his last vitals check and was “visibly weak, pale and shake,” according to the internal investigation.

On Jan. 7, 2014, a nurse wrote that Embry had no thoughts of self-harm and was refusing meals because “he is just not hungry,” according to records.

Other days, however, nurses noted Embry did have thoughts of hurting himself, but did not have a specific plan.

He repeatedly banged his head on cell doors.

He never left his cell for recreation the entire 46 days he was in segregation, and left his cell to shower only once in his last 19 days, according to the records.

Embry was repeatedly disciplined for refusing to eat and harming himself.

Starving himself was “a manifestation of his severe psychological problems,” Blakemore said in an interview. “It was a systemic issue, it took almost everyone on the medical and mental health side that came into contact with him to just ignore these serious problems he was having and the substantial risk of harm to do something to save him and they did nothing.”

The main prison physician later told investigators he left for vacation on Jan. 4, 2014 – more than a week before Embry died.

However, jail investigators found a note the doctor signed on Jan. 5, 2014, regarding Embry’s hunger strike, his thoughts of self-harm, his weight loss and “disturbing signs of distress,” according to court records.

And the internal investigation concluded that while staffers may have initially thought Embry was trying to manipulate his housing situation, “it should have become clear to staff as the behavior continued and the cumulative effect of his actions became evident, that his well-being was in serious jeopardy.”

The investigation noted that many staffers who could have helped Embry were not aware of his situation because they never interacted with him “even though they were technically conducting rounds.” Others, according to the investigation, “failed to see beyond their initial presumptions of malingering.”

Once Embry was found to be unresponsive on Jan. 13, 2013, a nurse did not show up until 11 minutes later than what the prison documented, investigators found after watching prison video.

“This time frame is very significant as lifesaving measures were not initiated until her arrival,” according to the investigation. “This response time to an emergency by Medical staff from any location of the grounds would appear to be unacceptable.”

Embry was serving a nine-year sentence for drug offenses.

The internal investigation recommended numerous changes, including urging the prison put in protocols to clearly outline what constitutes the beginning and end of a hunger strike and review the practice of prescribing and re-starting medications with inmates in segregation.

“You’ve got an individual who is mentally ill who has been put in segregation in an isolation cell … who is asking for his medications because he wants some relief from the mental illness that is choking the life out of him, and he’s not getting it,” Belzley said. “It doesn’t create a big leap to understand why that would create an overwhelming feeling of hopelessness.”

“You would hope this episode was so bad that that would never happen ever again,” Blakemore added.

Records show no family visited Embry while he was in prison. He was buried in a pauper’s grave.  His family, including two sons and a daughter, lost touch with him as he drifted in and out of jail, according to an Associated Press story. His family said he suffered from addiction and mental illness. He would end up in jail when he stopped taking his medications.

“Kenny was very strong willed so it breaks my heart that he resorted to starving himself,” Hope Keown, Embry’s estranged step-daughter, told the AP after his death. “I think he wanted to love the good life and be a family man. He just didn’t know how to shake his demons.”

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