A report released on January 10, 2025, by the Office of the Corrections Ombuds (OCO) of the Washington Department of Corrections (DOC) counted 26 “unexpected fatalities” during the fiscal year that ended on June 30, 2024. A report released by DOC the prior month also raised questions about systemic problems reflected in five of those deaths that occurred in six months.

The OCO had reported another 29 unexpected fatalities over the prior fiscal year, for a two-year total of 55. While that number represents a small fraction of the state’s 13,867 prisoners, the OCO nevertheless expressed “concern” that the top causes of these deaths were drug overdoses and suicides.

The DOC reported a total of 46 prisoner deaths during the year, meaning that “unexpected fatalities” accounted for more than half. Worse, the OCO noted, no Corrective Action Plan (CAP) was released following 13 of the unexpected deaths—meaning DOC officials had not reported learning anything that would help them prevent more prisoners from meeting a similar fate.

Seven of the 29 deaths were attributed to overdoses, the top cause. The DOC established a CAP for five of those. But just one recommendation involved dealing directly with prisoners: distributing Naloxone kits to those leaving prison for the Graduated Re-entry Program. Other recommendations involved improvements to reporting, lab contracting and procedures, as well as more educational signage for visitors.

CAPs were prepared after all five prisoner suicides, the second-highest cause of death. But again just one recommendation involved dealing directly with prisoners: providing access to the state’s 988 telephone crisis hotline. That, like a recommendation to provide more medication-assisted treatment (MAT) for substance abuse, would require state lawmakers to pony up money. See: Annual Review of UFR Reports, Committee Recommendations, & Corrective Action Plans, Wash. Dep’t of Corr. Off. of Corr. Ombusdman (Jan. 2025).

DOC Review

The DOC prepared its own report released on December 1, 2024, covering five “concerning” prisoner deaths. Justin Fessell’s death in January 2024 was initially classified as “expected,” so no autopsy was performed. But the OCO reclassified his death as “unexpected,” presumably because he “was relatively young, otherwise healthy, and was not identified as high risk for complications of influenza,” as the DOC noted. The DOC admitted that Fessell “benefited from no true analysis of the root causes of his death,” which may have resulted from a flu. But it was unclear why he was not vaccinated. “[W]hy his death certificate lists ‘Inhalation Drug Use’ remains unclear,” the DOC added.

An autopsy wasn’t performed until two months after the February 2024 death at Washington State Penitentiary (WSP) of Clifton Charles Carey, 43. So it was listed as “natural”— even though his body was found lying in a pool of blood on his cell floor. His nearby bed had no blood on it when photographed at the time. A staff report described a “chaotic scene” at the locked-down prison, with guards climbing atop Carey’s body to handcuff him before emergency responders tried and failed to insert a breathing tube in his neck and restart his heartbeat with a defibrillator. None of that explained how a dead body bled so much, the coroner noted. It was also determined that guards missed some checks on the tier where he was held.

The body of another WSP prisoner, William Phouthavongxay, 29, was mistaken for a discarded coat by the guard who found him lying in a dark corner of the recreation yard in March 2024. Why hadn’t the lights been fixed after numerous reports that they were out, and that the situation was dangerous? Why were surveillance cameras out, too? Why was the prisoner, who was a sex offender with an IQ estimated at just 81, not placed in the Baker, Adams or Rainier units designated for the most vulnerable? The report writers could only shrug. Tellingly, Johnny Ngo, the fellow prisoner found covered in Phouthavongxay’s blood, told guards “that it was their fault what happened, and they could have stopped it,” the report noted.

The Spokane Medical Examiner declined to autopsy Alex Kuhnhausen, 25, after he died at a hospital where he’d been life-flighted from WSP in April 2024. He had become increasingly lethargic over his last two weeks at the prison, but medical staffers noted that he was “fine.” At the insistence of his wife, Katie, he was finally admitted to the infirmary, but a medical staffer there said “that he thought Kuhnhausen’s issues were mental,” the DOC report recalled.

After the prisoner’s death, WSP medical staff noted it as “expected.” WSP administrators also did not investigate how a 25-year-old got so weak that he couldn’t stand or hold a cup to drink. The report wondered “how anyone would have relayed this as an ‘expected’ death,” much less “how executive prisons leadership didn’t begin investigating immediately”—especially because concerns had been raised after two other prisoners recently died in the Intensive Management Unit where he was held. Tier checks allegedly conducted every 30 minutes also somehow failed to notice the prisoner’s health was in serious decline.

Kuhnhausen had previously admitted injecting Suboxone. Is that what killed him? If so, how did he get it? Did guards look the other way—or worse, were they involved in smuggling the drug? Those questions went unanswered. There was no autopsy to pinpoint a cause of death, and no investigation that might have uncovered guard misconduct.

In June 2024, Danielle Reyes was found fatally hanged with shoelaces in her cell at Washington Correctional Center for Women, where she was held in close custody because she had just completed intensive mental health treatment. Guards reported conducting tier checks about 30 minutes earlier and another about an hour before that. Yet her body was already cold when found. Worse, lifesaving measures were interrupted when an active Do Not Resuscitate order was discovered—though how she got one with her mental health history was unclear.

The report identified “systemic failures” involved in Reyes’ suicide, beginning with repeated instances when staff ignored her obvious risk of suicide because she told them that she wasn’t planning to harm herself. The mismatch between the recorded checks and the time it would take her body to cool also challenged “whether it was physiologically possible for physical circumstances to meet staff statements,” as the report put it, but “none of the investigating staff could form that question.”

So did failures of DOC Secretary Cheryl Strange and senior staff “directly lead to systemic failures where the lack of proper training and supervision of employees resulted in ‘deliberate indifference’” that exposed DOC to liability for violating the civil rights of these dead prisoners? “The question should be asked and investigated by an outside body, such as the Department of Justice’s Office Of Civil Rights,” the report concluded. See: Concerning Deaths In Custody, Wash. Dep’t of Corr. (Dec. 2024).  

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