13 Investigates: Report shows dead inmate looked like he was 'laying on himself for hours'
HOUSTON, Texas (KTRK) -- Sarah Borchgrevink wants to know exactly what happened between the time she last spoke with her incarcerated brother and days later when he was found dead in a Harris County Jail cell.
Borchgrevink's 28-year-old brother, Matthew Shelton, died on March 27, 2022, of diabetic ketoacidosis, a complication that occurs when someone living with diabetes doesn't have enough insulin.
"How could he come into the jail with his diabetic supplies and nobody give him medication or help him," Borchgrevink told 13 Investigates when we interviewed her in October 2022. "I firmly believe that something happened before the 27th. I feel like that's when they discovered him, but nobody could tell me anything about when was the last time they saw him."
Shelton died in jail five days after turning himself in on a DWI charge last spring. He's one of 32 people who have died in custody since 2022. The deaths range from inmates being "found unresponsive" to those having medical crisis and three suicides.
ABC13's investigative team has been covering jail deaths extensively over the last year.
RELATED: 13 Investigates: Decade-high inmate deaths just one concern at Harris Co. jail
When an inmate dies in custody, law enforcement agencies are required to report it to the state. The reports include a brief summary of what happened, but details beyond what is publicly reported to the state often require a formal open records request. The request process can drag on for months, and sometimes results in no information being released.
More than one year after Shelton died, an attorney for his family said they're still waiting on answers from officials.
"We have none of his medical records. We don't have the nurse records. We don't have the clinic records. We don't have any of the medication distribution records. We have no photographs, videotapes. We have no statements - none of the investigation that the law requires into an in-custody death," John Flood, the family's attorney, said. "We've asked for it and we haven't received it yet. We look forward to getting it and understanding everything."
13 Investigates recently obtained portions of the Houston Police Department's independent investigation into Shelton's death.
The HPD report reveals a doctor indicated Shelton "looked as if he contracted rigor mortis."
13 Investigates requested the entire investigative file from HPD, but the department told us it would take a year to get the video and audio in his case due to a backlog of requests. Instead, HPD released a 42-page written report.
The report was written by an HPD officer who summarized the audio interviews and jail surveillance video that was not released to us.
The officer's synopsis of an interview with a responding doctor indicates that doctor said Shelton had "blue" skin with "demarcations as if he was laying on himself for hours," according to HPD's report.
HPD looked into Shelton's case because, in Texas, outside agencies are required to investigate all deaths that occur in county jail facilities.
An HPD officer who viewed surveillance video from the jail filled out a report summarizing what the video showed. The HPD report says a detention officer delivering meals entered Shelton's cell about 3:42 p.m. on March 27, 2022, but left 20 seconds later and appeared to go check on other inmates.
That detention officer seen in the video told HPD in a follow-up interview that she was "scared" after finding Shelton "very cold and stiff to the touch" in his jail cell, according to the report. The detention officer went on to say in that interview that she immediately called for help.
But the HPD report analyzed by 13 Investigates shows timestamps in the report indicate 28 minutes went by between the time the detention officer left Shelton's cell and the time another guard was seen running to respond.
"All there were, were just a few little clues as to what had happened, which is so frustrating for the family," Flood said.
After 13 Investigates began looking into Shelton's death last year, the Texas Commission on Jail Standards issued the Harris County Jail a notice of non-compliance for violating state standards by not providing Shelton with the insulin and blood pressure medication ordered for him by jail physicians.
The notice from the state, dated Dec. 19, 2022, says, "Documentation reviewed after a custodial death revealed that while insulin was reviewed, ordered, and provided while the inmate was at intake, it was not reviewed, ordered, and provided once the inmate was housed."
RELATED: State calls out jail after 28-year-old diabetic Harris County inmate dies
We wanted to know more about Shelton's time in jail, so last fall, we asked the sheriff's office for all reports and documents related to his death.
The jail wouldn't release that information to Shelton's family or 13 Investigates, first saying it was an active criminal investigation.
There have been no charges related to his death, but now that the investigation is closed, the sheriff's office still won't answer our questions, claiming there's pending litigation.
Last month, Harris County Sheriff Ed Gonzalez sat down with 13 Investigates' Pooja Lodhia to address issues at the jail.
She asked him about why details in Shelton's case have not been released.
"A lot of these families are upset because they have not seen video of their loved one's death. Why not release that information? I know you don't have to legally, but why not just for the sake of transparency?" Lodhia asked.
Gonzalez said jail death cases are under investigation by outside agencies, like HPD, who handled the independent investigation into Shelton's death.
"If it was our investigation, then we control, kind of, the cadence of that investigation and different steps that may go on investigation, but they're being reviewed," Gonzalez said.
Inmate healthcare
Harris Health System took over healthcare for the jail just weeks before Shelton was found dead, admitting in state documents that medication delivery was a "high risk concern" when they took over.
Harris Health's new protocols for medication distribution had a "go-live" date of March 28, 2022, according to a report filed with the Texas Commission on Jail Standards earlier this year.
The "go-live" date was one day after Shelton died.
One year into taking over healthcare at the jail, Harris Health spoke with 13 Investigates about the transition and its commitment to inmate care.
"We need to do a better job of the delivery of medications and we need to do a better job of taking care of chronic illnesses and sick call visits. Those aren't new, and they aren't a result of the deaths. Those were identified early on," Harris Health System Vice President Michael Hill told us last month.
RELATED: 13 Investigates: Harris Health vows to 'do better' with inmate care
The Harris County Jail has 9,587 inmates in custody, as of Thursday. The average length of stay is nearly 200 days, which Harris Health says can cause a bottleneck of some medical services.
Dr. Reggie Egins, Harris Health's chief medical officer of correctional health, said nurses and physicians treating jail staff are always busy, from scheduled appointments and emergencies, to patients with chronic illnesses or those requiring constant care.
"It is a continuous clinic. We see at least 600 patients a day, and you can imagine we have 10,000 potential patients here. Every detainee that walks into this facility can become a patient," Egins said. "If you think about it, the largest hospital in the Texas Medical Center, I think, probably has a little over 1,000 beds. And so if you have to think about us having to prepare for taking care of potentially 10,000 patients, this does become a big piece."
The Harris County Jail currently has 111 openings for detention officers and 201 openings for deputies. That means more than one in 10 jail positions are unfilled, so finding officers to escort inmates to receive medical care has been difficult.
Hill said the sheriff's office is committed to making sure nurses have the escorts they need to deliver medication on time, including a contingency plan when staffing is low.
Egins said nurses also do an audit every evening and overnight to make sure any patients who return to the jail facility overnight continue to receive their medication.
Additionally, the sheriff's office and Harris Health meet on Mondays to recap the previous week.
"Any issues that have come up over the past week, we identify those issues, we bring them to the table, and we try and find a corrective action plan to prevent any serious events because these may have been good catches that we found," Egins said. "What we want to do is implement a plan by which it doesn't result in a serious event."
Shelton's family says they're waiting to learn exactly what happened in his last days at the jail.
"For this to happen and then for there to be no answers - that's almost even worse than actual death itself," Borchgrevink told us last fall.
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