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Investigation Report Concerning Death of Inmate Farris, Island County Sheriff's Office, 2015

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Sheriff Mark C. Brown

Post Office Box 5000
Coupeville, WA 98239-5000
360-678-4422, 629-4523 x7310, 321-5113 x731 O
MarkB@co.island.wa.us
Fax 360-679-7371

Island County Sheriff Releases Investigation Report
Concerning Death of Inmate Keaton Fan-is
Coupeville, WA June 17, 2015 - Sheriff Mark Brown made public today the investigation
report on the death of Island County inmate Keaton Farris. Mr. Farris was being held in the
Island County Jail on a felony arrest wan-ant out of San Juan County. He arrived at the
Island County Jail on March 26 from Skagit County Jail. Farris was found dead in his cell
on April 8, 2015. According to the Coroner's report, the cause of death was dehydration
and a contributing factor of malnutrition.
"I am truly sorry for this tragic death. Mr. Panis did not receive the attention and care he
needed. Our highest priority is the safety and well-being of our inmates and staff and this
report describes a systematic breakdown of policies, procedures and communication that
led to this tragedy," stated Sheriff Mark Brown.
"My role as Sheriff is to maintain the trust of the community in the day-to-day operations of
the jail. I have already made some policy and personnel changes to correct these problems.
We are actively working to establish better supervisory oversight and better chain of
command control in the jail to ensure tasks are completed. For example, we have created
packets that are posted outside of each safety cell with the appropriate logs for accurate and
regular observation and reporting. We have prioritized work with our health department
and jail medical officer to detennine what steps can be taken between the jail and medical
personnel to make sure everyone serving the jail understands their role and authority to
properly see and treat inmates," continued Brown
"Members of my jail staff are being held accountable for their lack of leadership and
supervision. As a result, effective today, Chief De Dennis has been suspended for 30 days
without pay, and will return conditioned upon the review and recommendations of an
outside expert who will be hired to provide a review and recommendations of our jail
operations, including policies and personnel. During this time, Sgt. Chris Garden will be
placed in charge of jail operations. Pending a disciplinary review, Lt. Pam McCarty has
been put on paid administrative leave. The two con-ections deputies that had been placed
on administrative leave for policy violations have since resigned," Brown stated.
"We are determined to do everything possible to minimize the chances of this kind of a
tragedy from occurring in our jail ever again. I have met with Mr. Farris senior to
personally express our sincere condolences. We are all truly sorry for their loss,"
concluded Brown.

###

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Mr. Keaton Farris Timeline
Chronology based on Investigative Report

March 20, 2015
1755 hours, Keaton FARRIS contacted and taken into custody by Lynnwood Police Department.
2040 hours, FARRIS booked into Lynwood County Jail.

March 21, 2015
0348 hours, FARRIS booked into Snohomish County Jail pending transport to Skagit County.

March 24,2015
1440 hours, FARRIS transferred from Snohomish County Jail to Skagit County Jail.

March 26, 2015
10 15 hours, FARRIS transported to Island County Jail by San Juan County.
1135 hours, FARRIS arrives at Island County Jail and placed in the blue padded safety cell.

March 30,2015
15 52 hours, FARRIS is moved from the safety cell to cell D-1.
Unknown time, Water in cell D-1 turned off due to FARRIS putting pillow in toilet, water to be turned on
only at meal times.

Aprill, 2015
0800 hours, FARRIS transported to San Juan County for court appearance.
1600 hours (approximately), FARRIS arrives back at Island County Jail and placed back into cell D-1.

April 4, 2015
1615 hours, FARRIS flooded cell D-1 and is moved upstairs into cell H-2 with the water turned off.

April 5, 2015
1600 hours, Safety Cell procedures started for FARRIS in cell H-2.

April 6, 2015
0930 hours, Jail nurse evaluates FARRIS through cell door.
1030 hours, Mental Health Doctors evaluates FARRIS through cell door.

April 7, 2015
Various times, multiple checks not conducted on FARRIS while in safety cell.

April 8, 2015
0030 hours, FARRIS found deceased in cell H-2.

FACILITY SUMMARY

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

Facility Summary Island County Jail

The Island County jail is a 58 bed (61 bed maximum habitable capacity) indirect
supervision jail built in 1983 and occupied in 1984, located at 503 North Main Street in
Coupeville Washington. An indirect supervision jail does not have the Correction
Deputies stationed in the block with the inmates. Since being built the facility has gone
through several technological upgrades and a remodel allowing a secure walkway to the
Island County Law and Justice building.

The Island County Jail has tlu·ee general use levels (floors) and a basement/mechanical
room that requires an additional key or control room authorization for access. Floor one
is the location of the garage sally port, breathalyzer room, kitchen and laundry facilities.
Floor IH (housing) contains cell blocks as outlined below. Floor 2 is the "main" floor of
the facility containing cell blocks, the facility control room, a holding cell, administrative
offices, interview rooms, visitation rooms, medical h·eatment room, booking station,
shower room, storage room, a multipurpose room and a deck station.

Floor lH:

"A" Block is an open dorm style block consisting of five beds a common area and
shower where the inmate workers (trustees) are housed.

''B" Block is an open donn style block with 5 beds primarily a common area and

shower used to house female inmates.

~er~alcy ofpe1j w y under tire laws of tire state of Washington, that the foregoing is true and correct (RO Y 9A.7Z. 085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

"C" Block is a block of three individual cells and a common area with a shower. One
cell has the capability to house two imnates. "C" block shares a common sally port with
"D" Block.

"D" Block is a block of two individual cells with one bed each. There is a common
area with a shower. "D" block shares a common sally port with "C" Block.

FLOOR2:
"E" Block is an open donn style block consisting of 8 beds, a common area and a
shower. "E" Block is housing for minimum secmity male inmates. "E" Block shares a
common sally port area with "F" block.

"F" Block is an open donn style block consisting of 8 beds, a common area and a
shower. "F" Block is housing for minimum to medium security inmates. "F" Blocks
shares a common sally port area with "E" Block.

"G" Block is a block of three individual cells and a common area. One of the cells has
the capabili.t y to house two imnates. "G" block is for special needs or medical
segregation of inmates. "G" block shares a common sally port that contains a shower
with "H" block.

"H" block is a block of two individual cells and a common area. "H" block is for
special needs or medical segregation of inmates. "H" block shares a common sally port
that contains a shower with "G" block.

ojpe1j111y under tlte laws oftlte state ofWasltington, tltat the f oregoing is true and correct (RCW 9A.72.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

"f" Block is a block of 10 individual cells, 5 cells on an upper tier, 5 cells on a lower
tier with a common area and a shower. "I" Block is designated for medium to maximum
security inmates. "I" block shares a common sally port area with "J" Block.

"]" Block is a block of 10 individual cells, 5 cells on an upper tier, 5 cells on a lower
tier with a common area and a shower. "J" Block is designated for minimum to medium
security inmates. "J" block shares a common sally port area with "I" Block.

The deck station is the common work area near the sally port for "G/H" Blocks where
the daily log, pass down log, irunate books and employee mail boxes are. CoiTections
Deputies are able to access the Spillman database from this location and monitor the
security cameras.

Interview rooms "A" and "B" are two rooms designated for interviews and attorney
visits. They both have two doors, one that accesses from inside the secure area of the
facility the other from the lobby area. Interview "A" has a large glass window on one
side where the control room can observe the occupants.

Visitation rooms 1 through 5 are segregated, no contact visitation through a glass
window speaking over a phone, the inmate enters the room through the secure side of the
facility, the visitor through the lobby side. The conversations in these rooms are
recorded.

The booking area is where new inmates are booked and current irunates released.
There are two computers that allow access to the Spillman database along with a
computer that displays a housing roster.

- = " ''"">fpeJjwy uuder !he laws of!he state ofiVashiugtou, that tlreforegoiug is true aud correct (RCW YA. 72.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

To the right of the booking area is the shower area where inmates shower and change
from street clothes into jail uniforms. Attached to the shower area is a storage room
where clean laundry is kept along with the inmate' s street clothing and large personal
items (until they are released).

Across from the booking station is the medical office where sick call is conducted and
the nurse sees patients when she is in the facility. Next to this office is the blue padded
cell, also referred to as the behavior modification module or ''blue" room where inmates
that pose a danger to themselves or staff are held. This cell has padded walls, no furniture
or fixtures (sink or toilet). Next to this cell is the holding cell where irunates are placed
pending booking, release or movement within the facility. This cell has a bench and
sink/toilet fixture, no bed.

The multipurpose room or "library'' is a common area where the inmate workers can
take breaks and the general population does bible study and views movies on the
weekends.

The administrative offices are the individual offices used by Chief DENNIS, Lt.
McCARTY and the acting supervisor. Correction deputies have access to these areas as
well .

The control room controls all entry and exit for the secure area in the facility via
electronic locks and cameras. The Corrections Deputies carry keys that allow access into
the sally potis, blocks, cells and other areas of the facility but not outside the secure area
(an emergency key can be provided by the control room that allows manual entry and

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-I05352

exit). The control room also has the ability to electronically open the sally port, block and
cell doors. The opening and closing of the doors is not logged. Each cell and common
area in the blocks has an emergency button that aletts in the control room and allows two
way voice communications. Each corrections deputy also canies a portable radio that
allows communication with the control room. The Corrections Deputy in the control
room has the ability to monitor and play back the various surveillance cameras.

ln addition to monitoring the doors, cameras and alarms, the corrections deputy in the
control room also has the responsibility of answering the phones, confinning arrest
warrants, clearing the incoming visitors and assisting the public in the lobby.

As of April 7, 2015, there were 18 total employees (The Jail Chief, Jail Lieutenant and
16 conections deputies) in the corrections division responsible for 24 hour a day 7 day a
week operations. On that same date there were 52 inmates held in the facility.

~~lty ofperjwy under the laws ofthe state of Washington, that/he foregoing is /m e and correct (RCW 911. 72.085)

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DETECTIVE WALLACE REPORT

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

I am commissioned by the Sheriff oflsland County to enforce the laws of the state
of Washington and the County oflsland. At the time of this incident I was working as a
Detective for the investigations division of the Island County Sheriff's Office. I am
certified by the Department of Treasury/Homeland Security as a Seized Computer
Evidence Recovery Specialist (S.C.E.R.S.), the Department of Homeland Security as a
Mobile Device Investigator, the Cellebrite Corporation as a Physical Analyst and the
Paraben Corporation as a Handheld Examiner (PDA, cell/mobile phone and Hybrid
devices).
On 04/08/2015 at approximately 0040 hour Corrections Deputy BOONE reported
finding an inmate non responsive in "H" block, cell H2 of the Island County Jail. Patrol
Deputies MIRBAL and ADAMS responded along with Medic and Aid units. I was called
out as the duty Detective at 0048 hours.
I arrived at the jail at approximately 0114 hours and contacted BOONE, MIRABAL,
ADAMS, and Corrections Deputy LIND; the Medic/Aid units had left prior to my arrival.
BOONE advised that inmate Keaton FARRIS was in segregation in cell H2 due to
behavior issues and was subject to hourly checks. When BOONE checked on FARRIS at
approximately 0030 hours he found FARRIS sitting naked on the floor with his back to
the comer ofthe door. BOONE stated this wasn ' t uncommon for FARRIS based on his
past contacts with him. From his position BOONE couldn't see any signs of movement
or breathing. BOONE opened the handcuff/feeding port (a smaller secure door in the
main door) and attempted to get a verbal response from FARRIS as well as a physical
response by using his baton to push FARRIS (BOONE did not initially open the main
door due to FARRIS's prior assault attempts on officers in the facility).
When FARRIS still didn't respond BOONE opened the door (LIND was also present)
and tried to wake him. BOONE stated that FARRIS's body was rigid, his color didn't
look right and his eyes were open. BOONE stated he advised CotTections Deputy

lcertify wrder penalty ofpetjwy under tire laiVS of tire state of Washington. tlratllreforegoing is true and correct (RCW 9A. 72.085)

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Personnel Number

Location

Date

Page I of

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-I05352

SHARMA who was working in the control room to contact the dispatch center and send
medical units. (SEE ATTACHED REPORT BY BOONE). As BOONE was providing
the information, Doctor BISHOP, the Island County Coroner anived.
BISHOP and I entered the cell block and I observed FARRIS sitting with his back to
the lock side of the door to cell H2 (the door opens outward and to the right). FARRIS
was naked and had EKG pads from the medical response on his arms and legs. His eyes
were open and I noted discoloration of the skin on his left hand that appeared to be
lividity, I noted no obvious signs of injury or trauma. The interior of the cell was littered
with food scraps and I observed FARRIS's jail smock under the built in ledge next to the
bed. All of my observations were made from the doorway of the cell; the cell was not
entered until BISHOP had finished his initial photographs and video recording.
While BISHOP was taking photographs and video, I retrieved FARRIS's inmate book
from the booking station along with the handwritten observation logs. I scanned the book
to have an immediate digital copy then returned to take the original documents later.
When BISHOP completed his documentation we entered the cell. I observed what
appeared to be paper plates and food scraps in the "sink" along with additional food
scraps in the toilet bowl. I also noted that there was no water in the toilet bowl and the
food scraps were dry. When I asked about the water, BOONE advised that the water in
the cell had been shut off because FARRIS had flooded his previous cell.
BISHOP conducted a temputure check at approximately 0150 hours and detennined
that FARRIS's core body temputure was 89 degrees Fahrenheit. BISHOP 's initial
assessment was that FARRIS's time of death was prior to 2030 hours. I assisted BISHOP
in removing FARRIS from the cell and noted additional lividity that appeared to be fixed
and that his body was in full rigor. FARRIS was released to BISHOP and I sealed the
door to cell H2 with evidence tape. After releasing FARRIS I contacted the inmate in cell

Hl

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advised that he had been asleep and everyone

ffpe1j t11y under tire /all's of the state ofWashingrorl, that the foregoing is true and correct (RCW 9A.71.085)

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Page 2or S

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-!05352

coming into the cell block woke him up. - d i d n' t recall hearing any unusual
or any noise coming from H2.
H block in the Island County Jail is a segregation block that contains two individual
cells, HI and H2. The cells share a small common area that isn't accessible to the
inmates when the cell doors are locked. H block shares a common entry area/sally port
with G block where the single shower for both blocks is located. H block and G block
are separated from this cmm110n area by locked doors and this common area is separated
from the jail hallway by another locked door.
While we were moving FARRIS, the jail supervisor (Lt. McCARTY) arrived.
requested that McCARTY have the on duty jail staff write reports about the incident and
have them to me as soon as possible. I also requested that any staff that had contact with
FARRIS in the past 24 hours provide a repmt and that cell H2 would remained sealed
until I advised otherwise.

Follow-up:
On the morning 04/08/2015 I began reviewing FARRIS's inmate book and
observation logs. FARRIS's final observation log goes from April 7, 2015 at 0715 hours
until April 8, 2015 at 0030 hours. The log has an area for how often the subject will be
observed and provides the option of every 15 min, 30 min or hourly, with hourly being
the option circled in FARRIS 's log. The log has observations documented from 0715
hours, 0920 hours, 1017 hours and 113 0 hours. There are no documented observations
for 3.5 hours then they stm1 again showing 1500 hours, 1600 hours, 1635 hours, 1730
hours, 1845 hours, 1945 hours, 2030 hours, 2230 hours, 2330 hours and the final entry of
0030 hours where FARRIS was found not breathing.
I contacted McCARTY and requested that she pull the jail surveillance videos so I
could confirm the times on the log and detennine if there were any checks made that

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-I05352

weren't logged. Reviewing the videos, it was obvious that the activities being shown,
such as meal times, were not accurately reflected using the date/time stamp shown on the
recordings (the recordings appeared to be at least two hours ahead of actual time). I
requested that McCARTY provide a facility schedule for the evening events (meals,
medication etc.) as well as a chronological history for FARRIS's stay in the facility (See
attached).
To dete1mine the amount of discrepancy between actual time and the time displayed
on the recordings I wrote the ctment date and time, 4/8/ 15 @ 1534 hours (based on the
date/time provided from the AT&T network on my cell phone) and held it up in front of
one of the jail cameras. I download the video file and dete1mined that the recordings
were showing the correct date but the time displayed was 2 hours and 51 minutes ahead
of actual time. (See attached video from DVR_ l7-32 Camera 17). Using that offset the
corresponding activities appeared to match.
Camera 18 and Camera 27 are positioned at opposite ends of the long hallway that runs
in front of the sally port entry into GIH block. Camera 18 is on the east end of the hall
facing west, camera 27 is on the west end of the hall facing east. The video quality is
poor but clear enough to see when the G/ H block door is opened and someone
enters/exits. The sally p01i door for G/H block is almost directly across from the
work/deck station area where the inmate books are kept.
Using the video, I compared the enh·ies on the log to actual checks physical checks
into G/H block between 1500 hours on April 7, 2015 to 0030 hours on AprilS, 2015 (the
approximate window of death provided BISHOP initially). With the videos [can only
confirm someone entered the sally p01i area but no activity past that.
I confirmed that entry was made into the block dming the logged 1500, 1600, 1635 and
1730 checks. With the exception of the 1730 check, the actual times of the check were

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-I05352

within a few minutes of the logged times, the 1730 check (meal pickup) actually occurred
at 1702.
There were two checks logged by persotmel number 1105 (MOFFIT) at 1845 and
1945 hours but no one entered the block at those times or until 2037 (actual time) hours
when the 2030 check was logged by MOFFIT.

The next logged checks are at 2230 and

2330 by personnel number 1136 (LIND) but there is no entry into to the block at those
times, or at all until F ARRlS is found deceased.
Between 2053 and 2054 hours actual time (2334 and 2335 hours recorded time) a
cotTections deputy, who appears to be MOFFIT, stops at the block door and appears to be
writing on the log but does not enter the block. Also, two deputies enter the block at
2100 hours actual time (235 1 hours recorded time) but no entry is made in the log.
Based o n the video recordings between 1702 hours actual time and the time FARRIS was
located there were blocks of several hours where he was not being checked/observed,
1702 to 203 7 hours actual time and 2100 to 0040 hours actual time. (See Attached
Timeline). This was an initial review of the logs, a full review of all the logs and any
video documentation will be conducted. An internal investigation into the falsified log
entries was initiated and being conducted by Detective FELICI.
On this date I also requested that the !COM dispatch center provide copies of the
recordings ofthe initial call from the j ail as well as the radio traffic associated with the
call. These were submitted for transcription.
In addition to the radio Logs I requested Spillman System Logs (syslog) for any access
into or modification of FARRIS's records, along with the syslog entries for McCARTY,
HIATT, PffiCHOWSK.I, PREND ERGAST, REED, MOFFITT, LIND, SHAR.l\1A and
BOONE showing Spillman activity from April 7, 2015 at 0001 hours to April&, 20 15 at
0300 hours.

e1jwy u11der the laws ofthe stale of Washi11gto11, that the foregoing is true a11d correct (RCW 9A. 71.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

Initial timeline in the faci lity, provided by McCARTY:
03/26/20 15 at 1135 hours FARRIS arrived at the Island County Jail by San Juan County
deputies and was placed into the padded safety cell.
03/30/2015 at 1550 hours FARRJS is moved to Cell Block D, cell D-2.
04/01 /20 15 at 0800 hours San Juan County Deputies pick up FARRIS for court in San
Juan County.
04/0 1/2015 at 1600 FARRIS is returned to lCSO jail by San Juan County Deputies,
placed back in D-2.
04/04/2015 at 1615 hours FARRJS is moved back into padded safety cell after flooding
cell D-2.
04/04/2015 at 1630 hours is moved to H Block, cell H-2.
04/05/2015 at 1600 hours safety cell procedures are started for FARRIS in H-2.

After receiving the initial timeline from McCARTY, I requested all videos the ls1and
County Jail had showing FARRIS or his housing areas from 03/26/2015 until 04/ 08/2015
at 0300 hours. In addition to the previously described cameras showing the door to H
Block, this request would include the jail vehicle sally port and entrances, the jail
elevator, and the deck camera pointing in the direction of the visiting rooms (the camera I
conducted the time confinnation test on). The facility does not have cameras showing the
door or area around the padded safety cell or D block; however, there is a camera in an
adjacent hallway that should show people approaching D block but not necessarily
entering the block.
On 04/09/20 15 I e-mailed requests to the Snohomish County Sheriffs Office and the
Skagit County Sheriffs Office for their records concerning FARRIS.
On 04/ 1412015 I provided access to cell H-2 for San Juan County Prosecutor/Coroner
Randy GAYLORD and Sheriff Ron KREBS to examine. GAYLORD entered the cell to

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

get a better view of the interior but did not move or touch anything. When he fmished the
door was sealed again. At this time I requested that Sheriff KREBS provide me any
reports he had regarding his agency's contact with FARRIS. Those reports an·ived the
following day via e-mail.
On 04/ 16/20 15 I provided access to cell H-2 for Rebecca ROE and Kathy GOATER,
attorneys for Schroeter Goldmark & Bender who represent the FARRIS family along with
their investigator Kathy LEODLER, also present was Lt. McCARTY. LOEDER took
photographs of cell H-2 along with the additional photographs in vario us locations in the
facility. When they completed their documentation I released cell H-2 for cleaning. Prior
to H-2 being placed back into service I took measurements and tested the call buttons in
the cell and common area of H block. Both buttons worked properly, sounding an aleLt in
the control room and allowing voice communications back and forth.

FARRIS Tirneline:

Lynwood PD:
FARRIS was contacted by the Lynwood Police department on 03/20/2015 at 1759
hours when the officer responded to a report of suspicious male at the Union Bank on SR
99 (Case number 15-02160). The officer (KOONCE) contacted a subject matching the
description given and identified him as FARRIS. When asked what he was doing at the
bank FARRIS advised KOONCE " I was projecting my thoughts at the people inside".
FARRIS also stated "I'm off my meds and I'm pretty anxious right now but your badge is
calming me down". KOONCE ran a check on FARRIS and detennined that he had a
valid felony atTest warrant out of San Juan County. FARRlS was taken into custody and
transported to the Lynwood Jail for booking.

~[pe1jwy under the !all's of the state of Washington. that the foregoing is true and correct (RCW 9A. 71. 085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C. E. Wallace Jr. 1067

Case # 15-105352

FARRIS was booked at the Lynnwood jail on 03/20/2015 at 2040 hours by officer
HODGINS . He was photographed and it is indicating that his weight at the time was 175
LBS.

I contacted the jail who advised me that FARRIS was not actually weighed; they

either estimated his weight or took it of his Department of Licensing records . FARRIS
property was inventoried on the Lynwood Jail form, but on the line where the inmate was
supposed to sign, "FTC/220" is written. The jail advised me that FTC stands for Failure
to Comply and the 220 is a code for mental health issues. The property inventory also
indicates that he came into the facility with medication of some sot1. I was advised that
they also had medical infonnation and observation notes regarding FARRIS but due to
HIP AA could not provide the information to me without a com1 order or family consent.
FARRIS's father provided consent for the release of the records and they were provided.
The additional records consisted of medical screening conducted dm·ing booking
(dated 03/20/2015 at 2040 hours) and a medication list. "Yes" answers on the screening
include, #5 Is the person cooperative, #11 Does tllis person have any medication or pills
(Lorazepam), # 12, #13, #14 Currently taking any medication, any medication with you,
taken any medication in the last 48 hours (all indicate back to #ll Lorazeparn), #18 Are
you sick, ill, injured (yes, Panic Attacks with a comment of Anxiety), # 19 Do you have or
have you ever been treated for : (yes, mental illness) and #26 Do you have medical, dental
or vision insurance. FARRIS answered ''No" to all the suicide related questions. The line
where the inmate is supposed to sign contains "FTC/220". These records also contained
a prescription medication record showing that FARRIS came in the facility with 4
Lorazepam .05 tablets and left with the same amount indicating that none were given to
!lim wllile he was at the facility.

~n:rff'der/iii;;;;i;;;;;;;;;{wy under tire laws oftire state ofWas!Jiugton. tlrat the foregoing is true and correct (RCW !lA. 71.085)

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Page 8 of

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

Snohomish Countv:
On 03/21/2015 FARRIS was transported to the Snohomish county jail where he was
booked at 0348 hours and held pending transpmt to Skagit County. FARRIS was moved
multiple times while in the Snohomish County Jail and was released on 03/24/2015 at
1358 hours for transpott to the Skagit County Jail.
1 reviewed the documents provided by Snohomish County dming FARRIS's booking
screening. These documents noted that Bipolar 2 and Astluna were listed under chronic
health conditions. In an enh·y under clu-onological notes dated 03/22/2015, at 0956 hours
it was noted that FARRIS was moved to the "OU" due to his mental status and was unfit
for "MHU" (Medical Housing) and seems to have mental health issues. The officer noted
that when he approached the cell FARRIS was housed he saw that FARRIS was wearing
a pair of nitrile (rubber) gloves. FARRIS was directed to remove them, which he did.
When F ARRlS failed to explain where he had gotten the gloves the officer placed him in
lockdown status in cell 9. When FARRIS entered the cell 9 he jumped like he was
strutled. When asked a second time where he got the gloves FARRIS admitted that he
had taken them off the desk but stated that "someone" had told him he could have them.
The officer commented "it must have been the voices in your head" and FARRIS agreed.
As the officer was documenting this exchange, FARRIS pulled the towel off his cellmates
head and almost statted a fight, that's when FARRIS was moved to "OU". A response to
tllis infonnation was posted on the same date at 1000 hours stating an MHP (mental
health professional) will follow up on 3/22/20 15. There is also a Mental Health
Memorandum/Inmate release information for FARRIS that has the "Do not release" and
the "gravely disabled" blocks checked stating that the inmate wi ll need a jail mental
health evaluation prior to leaving the jail. There is also an entry on this fonn that says

"liM is unwilling or unab le to communicate verbally. He is presenting symptoms
consistent with psychosis. An MHP will need to evaluate liM upon release in order to

·!!Ji.e.t:-pe,rmhj'l:Pfp
. etjw y under tile laws of tile stale of Washing toll, tllat tlle foregoing is true and correct (RCW 9A. 72.085)

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Page 9of ) }

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-I05352

determine if a DMHP should be called for an IT A." This fonn is dated 03/22/2015 and
signed by MHP HOOVER.
An e-mail from records technician SHANNON to MHP HOOVER was sent on this
date at 1718 hours indicating that FARRIS had a pink slip (this appears to be the Mental
Health Memorandum) and he was due to be transferred to San Juan County tomorrow
(3/23/2015) on the Cooperative Transport. At 1753 hours MHP HOOVER replied that
liM Keaton is ok to transport.
On 03/23/2015 at 0807 hours it was noted that Per MHP HOOVER, start 30 minute
behavior watch. No restrictions and 1 hour medical/detox watch remains. At 0917 hours
it was noted to continue 30 minute behavior watch. There are no other notes referencing
FARRIS's condition or behavior; however I was advised that there is additional medical
information that could not be released to me due to HIP AA concerns.
On 03/24/2015 at 1358 homs the final jail release for FARRIS was done.

It should

also be noted that none of the blocks on the paperwork where the inmate is supposed to
sign were filled out, indicating that FARRIS was unwilling or unable to sign. "W11o?" is
written on the inmate block for the form authorizing people to pick up property or
clothing.

Skagit County:
On 03/24/2015 FARRIS arrived at the Skagit County Jail via the prisoner transport
shuttle. A jail incident report dated 03/25/2015 at 0531 hours states that FARRlS arrived
at the Skagit County Jail in a restraint chair and would not speak. It was also noted in the
pass down document that FARRlS had mental health problems. The shuttle staff advised
the Skagit jail staff that FARRlS had been Tasered at the Snohomish County Jail the
previous day (03/23/20 15) and the shuttle staff had initially declined to transport FARR[S
due to his actions and not having the appropriate transport vehicle.

o perjwy under the laws ofthe state of Washington. thattheforegoilrg is true and correct (RCW 9A. 71.085)

/o(.1

Persomrel Number

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Page

tO of ?

I

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C. E. Wallace Jr. 1067

Case# 15-105352

On 03/24/20 15 when the shuttle returned, FARRIS was brought out to the shuttl e
staff in a restraint chair and was being described as passive aggressive. FARRIS was
placed in a secure section of the transpo rt bus and the shuttle staff reported that there
were no issues with him during the transport to Skagit County.
When he was brought into the facil ity, FARRlS walked on his own and complied with
commands but would only stare and not respond verbally. When it was detetmined that
Island County could not pick him up immediately, FARRIS was housed in "Gry 9" (an
observation cell near the booking station where inmates can be easily observed by the
corrections staff) due to his lack of communication, behavior, and the limited information
Skagit County had regarding him.
Skagit Cow1ty contacted Lt. McCARTY and she advised that Island County would
pick FARRIS up in the morning. Deputy FADDIS (Skagit County) advised her that she
should send two officers to transport FARRIS due to the information they had been given
and his unpredictable behavior.
On 03/25/2015 Island County Corrections Deputy BOONE an·ived to pick up FARRIS
and two other inmates. FADDIS told BOONE that based on their observations of
FARRIS he bad recommended (to McCARTY) that they send two people to transport
him. BOONE advised that infonnation had not been passed down but managed to
arrange a way to transport all three subject ifFARRIS did not cause any problems.
The first two irtmates were prepared for transport without issue but FARRIS
inunediately began struggling when they tried to place him in restraints (transport
restraints are a leather belt that goes around the waist and locked in the back with a set of
handcuffs in the front along with a set of leg restraints which allow the inmate to walk but
not run). FARRIS co ntinued to actively resist and attempted to bite one of the Skagit
correction deputies. FARRIS was eventually placed in restraints but could not be
h·anspotied by j ust one con·ections deputy (BOONE). BOONE took the other two

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

imnates and advised Island County would try and make arrangements to get FARRIS
later.
At 0645 FADDIS called Island County to see ifthey had a plan to transport. FADDIS
was advised that McCARTY would not be in until 0700 hours and that she would cal l
him when she anived. At 0746 hours McCARTY called FADDIS and advised that she
intended to have San Juan County pick FARRIS up and transport him to Island County
and was waiting for a call back to verify the arrangements. McCARTY also advised that
if she couldn't arrange it with them she would get two Island County deputies to pick him
up and transport.
FADDIS advised McCARTY that something needed to be figured out because
FARRIS was still sitting in restraints and FADDIS was not comfortable with him sitting
in restraints that long. A short time later FADDIS received a call from San Juan County
advising that they were waiting for pennission from their Sheriff to transport FARRIS.
FADDIS contacted the Skagit Jai l Nurse (BAERG) and requested that she check FARRIS
to see if remaining in restraints would cause any issues.
At 0800 hours BAERG attempted to examine FARRIS but was only able to determine
that he was breathing fine and he legs were fine but she could not examine his arms
because he would Junge at the staff when they tried to examine him. BAERG's medical
notes stated, seen in gray (cell location), able to visuaLize feet, toes pink +swelling,
unable to see hands, handcuffed in back. The notes also indicated that FARRIS refused
his Lorazepam at 1120 hours. The lower patt of the medical slip has a portion dated
3/21 /2015 (the time FARRIS would have been at Snohomish County) that indicated
+benzos, +amphet, +THC (positive for drug usage) and MHP (mental health), Bipolar,
observation unit @sno (Snohomish County), disorganized, bizarre thought content.
After BAERG left, FADDIS indicated that FARRIS got up on his own and began
pacing the cell. Deputy LaQUET attempted to speak with him but got no response. At

~~ ojpe1j w y under the Jaws oftire state ofiVasfringtotr, thattheforegoiug Is true and correct (RCJV 9;1. 71.085)

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12 of

5'I

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-£05352

approximately 0910 hours FADDIS received a call from Lt. SEATON of the San Juan
County Jail who requested that Skagit County Contact mental health services
(CDMHP/DCR Certified Designated Mental Health Provider/Dedicated Crisis
Responder) about FARRIS. SEATON also advised that the San Juan County public
defender and prosecutor's office were going to attempt to have a competency hearing for
FARRIS.
Since they were still trying to coordinate what to do with FARRIS , at 0920 hours
FADDIS directed the jail staff to remove his restraints. The staff attempted to get
FARRIS to voluntarily comply, but be refused and had to be taken to the ground to
remove them. A call was made for a DCR to respond to the jail to speak with FARRIS.
At 0945 CDMHP/DCR CANNIFFE called back and after being advised of the situation
declined to respond at tllis time due to the vagueness of the nature of the request and the
jurisdictional issues. FADDIS provided this inf01mation to SEATON who advised he
would contact llis admitlistration. FADDIS attempted to contact McCARTY but received
a voicemail that she was out of the office and unavailable. At 1125 hours FADDIS
contacted SEATON again and was advised that they were trying to work out some sort of
Competency heating for FARRIS. At approximately 1200 hours SEATON called back
stating that Island County would pick FARRlS up the following moming (3/26/20 15). At
1550 hours SEATON advised that San Juan County would pick FARRIS up at
approximately 0800 hours on 3/26/2015.
On 03/26/2015 at approximately 1015 hours San Juan County arrived to transpo1t
FARRIS to Island County. FARRIS was still housed in grey 9 and was lying on the floor
with llis against the cell door. FARRIS would not respond to verbal commands when
asked to stand up and began to ramble. After several attempts to get him to comply
Deputy HlNES reached down to lift FARRIS off the floor so he could be restrained for
transport. F ARRJS stated "you cannot touch me" and pulled away from HINES . Deputy

mlly-:f}, perjwy under tlte lows oftlte slate of Washing ton. that the fo regoing is true and correct (RCW 9A. 72.085)

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Page13 of S

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# l5-I05352

SHULER assisted and they picked F ARRlS up by the arms and escorted him out of the
cell. FARRIS was passively resistive to being placed into restraints and stiffened (tensed)
his muscles requiring the deputies to force his arms behind his back. When they
attempted to place leg restraints on FARRIS he kicked at one of the deputies. F ARRlS
continued to be resistive as he was escorted to the vehicle for transport.
Additional medical records/notes provided by Skagit County show that FARRIS
arrived with 4 tablets of .5mg Lorazepam provided by Swedish Hospital in Edmonds. An
entry on the inmate medical history dated 3/25/2015 at 0032 hours states "Subject
brought in on the day shift from Sno Cotmty. Subject arrived in a restraint chair. Subject
would not speak to anyone. Subject was housed in Sno County's mental health ward.
Leaving for San Juan County in AM. Unable to screen. DCF"

Island County:
On 03/26/2015 at approximately 1135 hours FARRIS arrived at the Island County Jail
and was placed directly into the blue padded safety cell. A handwritten record of restraint
from his an·ival stated "Inmate + Officer Safety. Inmate acting agitated appears distressed
due to transport from Skagit County by San Juan County S.O." There is no signature on
the form but it listed the names of the San Juan County deputies along with McCARTY
and PIECHOWSKI from Island County. There is no additional narrative attached to this
form. A safety cell observation log is started at this time.
A hand written entry from the pass down log from this date (no time indicated but it
would have been prior to ll35 hours) by 1156 BOON stated "When IIi\!! FARRIS comes
in he is to be a two p erson movement and remain handctif.fed during the movement. Also
AD seg. (administrative segregation) for officer safety. " A booking record was started for

FARRIS on this date as well at 1440 hours showing him housed in the BMM. As prut of

ofpeljwy Ullder the laws ofthe state oJWasllillgtan. that the foregoing is true and correct (RCW 9A. 72.085)

Personnel Number

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14 of ./ /

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

this booking record the property that FARRIS an·ived with was inventoried. There is no
indication that he arrived with any of the medication (Lorazepam).
On 03/27/20 15 there is another hand written entry from the "pass down log" by 11 68
BINGHAM that stated "Attempted to give cup of water through feed slot on the padded

safety cell - FARRJS - FARRIS grabbed Dep. E VANS hand and tried to pull him into the
slot. FARRIS splashed water all over us through the door before it was closed. Officer
Safety at all times." A hand written incident and discipline repoti was completed by
BINGHAM which outlined the incident as well.
On 03/30/2015 at approximately 1505 hours McCARTY allowed FARRIS's Aunt
Tamra FRALIC to enter the facility and speak with FARRIS through the door of the
padded blue room hoping it would help calm him so he could be moved into a general
population cell. At approximately 1552 hours FARRIS was removed from the padded
safety cell to cell block D, cell D-1 (downstairs from the deck station) and not placed
under safety cell procedures. At an unknown time on the same date there is a handwritten
entry in the pass down log by 1155 KELLY that stated "the water to D-1 inmate FARRIS

is off He has his pillow in the toilet and is playing in the water in his sink. I suggest
only turning on the water at meal times." There is no other reference to the water being
h1rned off in the cell or documentation to provide FARRIS water/fluid other than at
mealtimes.
During his interview Deputy LIND mentioned an incident with FARRIS that would
have occun·ed around this time while he was in cell D-1. LIND stated that Deputy
PIECHOSWKJ had called him down to D-block stating "you need to take a look at tllis".
When LIND atTived he observed FARRIS naked, face down on his bunk with his head
hanging over the edge with some sort of fibrous mass hanging out of his mouth. LIND
thought that FARRIS was trying to swallow a cleaning rag and may be choking o r
gagging on it. Since FARRIS hadn't had a cleaning cart in his cell PIECHOWSKI

~pe1jwy under the la ws of

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the state of Washington , that /he f or egoing is /rue and COI'rec/ (RCW 9A. 71.0 85)

Persouuel Number

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Page

15 of

)/

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

thought it was the stuffmg fro m his pillow that he had tried to flush. LIND told
PIECHOWSKI that whatever it was FARRIS was choking on it and they needed to get it
out of his mouth.
They went upstairs to get gloves and PIECHOWSKI said that since the Lt.
(McCARTY) was there he was going to let her know what was going on. LIND followed
PIECHOWSKI to McCARTY's office and heard him tell her that they needed to go into
the cell becau se he looked like he was choking on something. LIND advised that
McCARTY replied and was specific when she said " Do not open that door. Leave that
m an alone." LIND stated that he went back to work and wasn't sure ifPICHOWSKI
went back down to D block to check. This incident is not documented anywhere and
PIECHOWSKI did not mention it during his interview.
I contacted PIECHOWSKI a second time and specifically asked about this incident.
PIECHOWKSI remembered F ARRlS had a wl1ite rag or some sort of material over his
mouth and was kind of gagging but he wasn't sure if he was gagging on or into the rag.
PIECHOWSKI states that he either called LIND or he came down on his own while
PECHOWSKI was how to deal with the situation. PIECHOWSKI said they continued on
with whatever they h ad been doing at that time and a short time later mentioned it to
McCARTY who was at the deck station. McCARTY decided that it wasn' t worth the
risk of assault to the deputies or FARRIS to go in and remove a cloth fro m his room.
PIECHOWSIG stated that it was slightly conceming that he had the cloth in his m outh
but it didn't appear that he was choking on it (his color was good, he didn't appear in
distress).
During her interview I asked McCARTY about this incident. She stated that that it
sounded familiar but she doesn' t specifically recall it. I outlined what PIECHOWSKI and
LIND had told me and that they had possibly asked her pennission to go into the cell to
take the rag away. McCARTY again said that she didn't remember the incident

g~

eljw y under tlte laws of the state of Washington. that theforegoiug is true aud correct (RCW 9A. 72.085)

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16 of

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-!05352

specifically but it sounded right. I asked if she remembered telling them not to go into the
cell and to leave FARRIS alone or something to that effect and she stated "I don't
remember tl1is."
On 03/31/2015 there is a handwritten medical treatment form with a time of 1020
hours on it. Written on the form is "Father 's call, vispealidone (SP?), Lithium. Mr.

FARRIS- " Based on the logs there is no other documented interaction between
FARRIS and anyone, other than meal service until 04/01/2015.
On 04/0 l/2015 at approximately 0800 hours SEATON and URNACH arrived at the
Island County Jail to transport FARRIS to San Juan County by car and ferry for court
(inmates are normally flown between the locations). When the deputies attempted to
restrain FARRIS for h·ansport he resisted and had to be taken forcibly to the ground.
FARRIS did not communicate with the deputies during the transport. When they arrived
at San Juan County FARRIS was placed in a restraint chair where he remained until his
transport back to Island County.
FARRIS's attorney was escorted back to see him but he refused to answer any
questions or communicate with her. At approximately 1230 hours FARRIS's mother was
escorted in to see him. When she walked into the room FARRIS looked up and said "hey
mom" but he refused to engage her or answer any of her questions. At approximately
1345 hours FARRIS was moved out of the cell and showed no sign of resistance. He
allowed them to place him in a transport belt (hands in front) and he was transported back
to the lsland County Jail and placed back into his cell without incident.
On 04/4/2015 there is handwritten entry in the pass down log by 1150 BECKER that
stated "Moved FARRIS to H-2, water is turned off. nothing in cell''. A handwritten record
of restraint form along with a typewritten narrative indicated that FARRIS had flooded
his cell in D-b lock and was found laying on the floor making swimming motions and
dunking his head completely in the toilet. F ARR[S would not respond to verbal

tJU.l4~ri11R\>

ofpetj w y under the laws ofthe state of Waslti11gton, that the foregoing is lrlle and correct (RCW 9A. 72.085)

Pe~~~le/Number

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1. 7 of)-;

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-I05352

instructions and had to be escorted upstairs to the intake shower so he could be wanned
up and the cell mopped . After the shower, FARRIS was placed in the blue padded cell
while the water in cell H-2 was tumed off and the toilet drained. The report indicates that
WHESTEL, BECKER and BINGHAM were the corrections deputies. There is also an email from BINGHAM to Chief DENNIS and McCARTY the outlined the earlier issue
with FARRIS to include his concern about him being wet and cold and FARRIS being
locked down in cell H-2 with the water turned off. The daily activity worksheet also
showed that FARRIS was showered, given dtinking water and moved to H-2 with the
water turned off. The safety cell procedures/logging was not started at this time. Based
on the logs there is no other documented interaction with FARRIS other than meal
service until 04/05/2015.
On 04/05/2015 at approximately 1600 the safety cell procedures are started on
FARRIS in cell H-2. This is also noted on the daily activity worksheet along with and
entry under the sick call block "Farris-Staffas per safety cell regs" which indicated that
the staff requested he see the nurse/medical staff as per the safety cell procedure. There is
no indication that FARRIS saw medical staff on 04/05/2015.
On 04/0612015 under the sick call block on the daily activity worksheet is another
entry that stated "FARRJS-as per safety cell regs" along with others stating "FARRJS-

safety cell procedures started'' and "FARRIS-moved to H-2 water shut off". At 0930
hours on this date FARRIS saw the jail nurse (BARKER). BARKER entered under the
notes " Responded to the safety cell to observe Mr. FARRIS this morning. H e is lying on

the floo r with his elevated on the wall with his f eet elevated on the toilet. His color is
good. Respirations regular at 16/min. He responded to my questions with appropriate
answers. D. YOUNG PA-C noti.fied!NB. " BARKER does not mention in her medical
notes, but later advised in her statement that FARRIS stated something to the effect of

perjruy under tire laws oftire stme ofWaslrington. tlrat tire foregoing is true and con ·ect (RCIV 9A. 72.085)

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Page

18 of 5'/

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

"oh good a medical professional" or "I need a medical professional" when she introduced
herself and answered "not good" when she asked how he was doing.
At I 030 hours Doctor HENDRICKSON from Western State Hospital attempted to
interview FARRIS for his comi ordered competency examination. In his report
HENDRICKSON states

During my attempts to speak with him, he lay naked
on the floor of his cell, talking continuously to himself, as if he were speaking to a person
in the cell". Based on his report it does not appear that HENDRICKSON made any
recommendations to the jail staff regarding FARRIS's condition after his interview.
HENDRICKSON also stated as part of his report that he had interviewed FARRIS's

-

FRALIC indicated that FARRIS had first exhibited

'!!!!!.!!.!Jl"=Y!:!a Pe'jw y under the laws ofthe state of Washington. tlrat lheforegoing is /rue and correct (RCW 9A. 71.085)

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Page19 of 5

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-!05 352

-

HENDRICKSON's repott was completed on 04/08/2015 the day after FARRIS died.

contacted HENDRIKSON by phone and asked how he was allowed to interact with
F ARRlS during his interview. HENDRICKSON stated that he attempted to do his
interview tlu-ough the feeding slot on the closed cell door.
On 04/07/20 15 the daily activity worksheet indicates "H-2 FARRIS-Safety cell

procedures started/water shut off". This is also the date where there are documented
multiple gaps where the hourly checks were not being conducted and several documented
checks were determined not to have been done. According to the observation log, the
0800, 1200, 1300 and 1400 hours checks were not conducted at all and as stated earlier
we were able to detennine that several checks that were logged were not conducted, to
include the check logged at 2330 hours approximately one hour before FARRIS was
found deceased.

•p-pemtiJ.~
' 'i[,p etjwy under the laws ofthe state of Washington, tlrot tlre f oregoing is true and correct (RCIV 9A. 71.085)

/o4"7

Per.m mrel Number

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Page 20 of~~

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE

Water/Fluid lntake:
The Island County Jai l uses number 77 wax paper Dixie cups to provide water/fluids
to inmates that are not receiving standard meal/tray service. Using a syringe I determined
that these cups hold 7 ounces of fluid total (to the very top of the rim) but most likely
contained an average of 5 ounces of fluid when provided to an inmate (allowing space for
movement so the fluid doesn 't spill).
FARRIS was placed directly into the blue padded safety cell when he arrived at the
Island county jail where he would not have had the ability to obtain his own water/ fluids.
Using the Safety cell observation logs as a guide to when he would have been provided
fluids, between March 26,2015 at 1135 hours and March 30,2015 , 1550 hours it appears
that FARRIS took water 15 times. Assuming FARRIS drank all the water that was

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

offered (and the logs do indicate that he spilled some) that is at most 75 ounces of fluids
during an approximate 100 hour period. As a guide line, the Institute of Medicine
determined that an adequate intake (AI) for men in FARRIS's age group is roughly about
3.7 Liters ( 125. 11 ounces) oftotal fluids a day; this is both from foods and fluid intake
(referenced from the attached chart via the institute of Medicine). Using this standard
F ARRTS should have taken in 521 ounces of fluid during the same period for it to be
considered adequate intake. FEMA recommends an intake of 64 ounces of water per day
for survival, using this standard FARRIS should have taken in 266.24 ounces of
water/fluids.
FARRIS was moved to D block on March 30, 20 L5 at 1550 hours. An entry in the
hand written pass down log, dated March 30, 2015, by Deputy K.ELL Y states that the
water to cell D- L(FARRIS) is turned off due to his pillow being in the toilet and playing
in the water. KELLY suggests that the water only be tumed on during meal times.
(K.ELLY confinn ed this in his interview). FERRIS was moved out of D block on April 4,
20 15, at L6 15 hours and placed in the padded safety cell after flooding his D block cell.
Since FARRIS was not placed under safety cell procedures in D block there are no
logged checks so, to determine fl uid intake I have to base estimates on the daily facility
log (typewriter Log) to detennine if be took his meals/fluids or not using the same 5 ounce
estimate.
FARRIS took 10 meals during his time in D block (approximately 120 hours), for an
approximate total of 50 ounces of fluid. Based on the NIH chart his intake during that
time period should have been 625.2 ounces, based on the FEMA standard his intake
should have been 312 ounces. If the logs are coiTect and the water in his D Block cell
was tumed on during meal periods, there is a possib ility that he may have consumed
add itional water on his own during those times. Additionally, FARRIS was in the
custody of the San Juan County Sheriff's Office on Apri l 1, 2015 between approximately

·~'11T0n1Zii'ofpe•jwy

under rhe laws ofrhe srare ofiVaslriugron, rharthe foregoing is true and cotnct (RCW 9A. 72.085)

lot..1

Personnel Number

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Page

22 of

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wal lace Jr. 1067

Case# 15-105352

0800 and 1600 hours for court. There is no documentation but there is a possibil ity of
additional fluid intake at that time.
On April4, 20 15 at 1630 hours, FARRIS was placed into H block, cell H2 with the
water turned off, however, safety cell procedures were not statted on him until April 5,
2015 at 1600 hours (23.5 hours later). There are no logged checks for that 23.5 hour time
frame so, to determine fluid intake I have to base estimates on the daily faci lity log
(typewriter log) to determine if he took his meals/fluids or not using the same 5 ounce
estimate. FARRIS took 3 meals during that time period for a total of 15 ounces of fluid .
Based on the NIH chatt his intake during that period should have been slightly less than
125 ounces based on the FEMA standard his intake should have been slightly less than 64
ounces.
On Apri l 5, 20 15 at L600 hours the safety cell observations began on FARRIS in cell
H2. Using the logs FARRIS took water/meals 9 times for a total of 45 ounces in the 56.5
hours between the time the observations were started until he was found deceased. Based
on the N[l-f chart his intake during that period should have been approximately 292
ounces, based on the FEMA standard his intake should have been approximately 149
ounces.
Compiling the resul ts, based on the instances that we have documented where
FARRlS was provided waterlfl uids, his total intake for the time he was in the Island
Coun ty Jail appears to be approximately L85 ounces. This number could be lower since
we cannot confirm that he consumed all the water/fluids provided; it could higher as well
since there were windows of opp01tunity where he would have been able to provide
himself water.
Using the NrH chart as a guideline, FARRlS' s total intake should have been
approximately 1563.2 ounces of water/fluids to be co nsidered adequate during his time in

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

the facility. Using the FEMA guidelines F ARR1S 's total intake should have been
approximately 79 1.24 ounces for survival situations.
lt should be noted that the water intake outlined are estimates based on documentation
available and the NIHIFEMA amounts are provided are for comparison. I cannot
determine what state of dehydration/malnutrition FARRIS may have been in when he
arrived at the Island County Jail.

Safety Cell Policy/Procedures:
The Island County Jail has a policy regarding the use of safety and sobering cells, this
policy is 538, specifically subsections 538. 1, 538.2, 538.3 and 538.4 from the Lexipol
Custody Services Manual. Even though tllis policy is marked with "DRAFT" in the
footer, it is attached to a memo from Chief DENNIS indicating that it is in effect. This
memo and policy were retrieved from a book at the deck station with a cover sheet/memo
titled Safety Cell Documentation dated 11104/2014. The memo states that the chief is
attempting to make the transition to Safety Cells as painless as possible and that most
important part of the procedure is documentation, followed by a statement saying "We
have been lax in documenting what we did and why we did it." There is no indication in
any of the documentation that would lead me to believe that policy 538 is only out for
review and not the cunent policy in place.

Emplovee Interviews:
As patt of this investigation employees who interacted with FARRIS while in the
Island County Jail were interviewed being asked the same general questions then specific
questions regarding their interactions with FARRIS. These interviews were recorded and
transcribed.
When asked, the correction deputies stated in various ways the basic parameters of the
safety cell policy, and indicated that the cmTent policy was the one that had been

ifi'pe1j111y under the laws ofthe state of Washington, that the foregoing is true and correct (RCW 9A. 72.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detecti ve C.E . Wallace Jr. 1067

Case # 15-!05352

implemented by Chief DENNIS via memo (some knew it was a Lexipol Pol icy). None
stated they had any formal training in the policy. The deputies stated t11at t11ey knew
safety cell checks were mandat01y and the majority thought they could be di sci plined for
not conducting them. They also stated that the safety cell checks should be one of the
highest priorities of their duties. The deputies summatized in various ways how they
conduct a safety cell check, some stated that they looked for signs of movement or
breathing, others stated that they would attempt to elicit a response from the inmate.
Several off the deputies indicated that FARRIS was aggressive/risk to staff but only a few
could indicate why he was d eemed that or tell me of an incident (grabbing deputy
EVANS) where he acted aggressively towards staff other than struggling while being put
in restraints or being passive aggressive. None of the deputies indicated that there was a
policy or procedure in place on how to deal with an imnate who was refusing to drink
fluids.

T he following are summaries from specific interviews in regards to this investigation.

HIATT:
Deputy 1-IlATf was on shift the day that FARRIS died and based on the estimated
time of death would have been one of the last deputies, along with deputy MOFFITT to
check on FARRIS prior to his death. HIATT was also present when Nurse BARKER did
her eval uatio n of FARR IS. HlA TT stated that during each checkofF ARRIS be would
offer him water; this was correct up until the logs on 417/20 15 where many of his logged
do not indicate FARRIS was offered water. HlATT also stated that there was an order in
place not to open FARRIS's cell door without a minimum number of deputies present.
In regards to the medical evaluation by BARKE R, HIATT states be was there with
another deputy but can' t remember who. BARKER saw FARRIS based on a staff request

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under the laws ofthe state of Wasilington. that the foregoing is true and co1·recc (RCW 9A. 71.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

to see him . HIATT stated that BARKER observed FARRIS through the cell door and he
wouldn't respond to her. HIATT remembers FARRIS moving while she was observi ng
him and BARKER saying "his color looks good". HIATT did not open the cell door and
stated that BARKER did not ask for the door to be opened to examine FARRIS.
Breaking down the checks conducted on 4/7/2015, HIATT stated that FARRIS took
his food at 1130 and he conducted a check at approx imately 1210 hours that be didn' t log.
During the dinner meal pickup at approximately 1730, HIATT described observing
FARRIS sitting in what sounded like the position he in when he was found deceased.
HIATT states that he was in the cell block with deputy MOFFITT and observed FARRIS
sitting with his back to the left of the cell door with his feet pointed towards the center of
the room. E-IIATI stated that he tapped on the door with his keys and asked if he wanted
water. HlATT observed FARRIS raise his hand then put it back down but FARRIS did
not respond.
HIATI and MOFFITT left the block and the next time HIATT entered the block was
at approxi mately 2030 hours (2037 actual time) for evening medication drop off. HIATT
was providing medication to the inmate

in the cell next to FARRIS and he

observed MOFFITT looking into FARRIS's cell. After completing-

· HIATT stopped to look into FARRIS's cell. HlATT said he tapped on the

door with h.is keys but didn't get a response. HlATI tapped again and MOFFIT said
something to the effect of "he was moving when [look in" or some other comment about
FARRIS moving so HIATT walked out and continued his rounds. This is now in the

window of time provided by BISHOP for FARRIS's death. It was also determined that
the solo safety checks that L\llOFFITT fogged at 1845 and 1945 hours were not conducted
so the last time that it can be confirmed that FARRIS was alive was during the 1730
hours check vvhere HIATT observed him raise his hand.

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

There is another period between the 2030 hour check and a Jogged 2230 check that no
checks were conducted on FARRlS. HlATT states that it was the end of a 17 hour shift
for him and he forgot to do the other checks. HLA TT indicated that there were other
deputies on the deck at this time, but they did not do the checks either. The investigation

determined that even though there were additional checks logged, NO checks were
conducted on FARRJS after 2030 hours until he was found deceased at approximately

0030 hours. Given the totality of the information available, including his lack of reaction
to HlA TT tapping on the door, it is more likely than not that FARRiS was deceased at

2030 hours

MOFFITT:
At the time MOFFIT provided this statement he was on administrative leave, under
internal in vestigation for fa lsifying FARRJS 's safety cell check logs 0410 712015.
Deputy MOFFm was on sruft the day that F ARRJS died and based on the estimated
time of death would have been one of the last deputi es, along with deputy HLATI to
check on FARRIS prior to hi s death. Ln his statement MOFFIT outlined his
understanding of the safety cell policy and he was told that McCARTY had ordered
FARRIS 's cell door not be opened for any reason. MOFFIT reviewed the safety cell logs
and admitted that he falsi fl ed the log at 1845 hours and 1945 hours and did not do the
checks. ln regards to the check at 2030 hours, MOFFIT stated that he was in H block
while HlATT was providing medication for the other inmate. MOF FLT remembers
HlATI asking if FARRIS had been checked and MOFFIT advised him that he had
checked FARRIS.
MOFFIT desctibed FARRIS as lying on the floor in front of the door almost in a prone
position with his hands across llis chest or stomach and his head in the comer. MOFFIT
thought FARRIS was sleeping and that he may have seen one of his fingers t"vitch.

Ofperjruy under the laws ofthe state of Washiug ton , that thejoregoi11g is true aud correct (RCIV 9A.71.085)

Pers!n~e~Z.mber

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-!05352

LIND:
At the time LIND p rovided this statement he was on administrative Leave, under
internal investigationforfalsifYing FARRIS's safety cell check logs 0410712015.

Deputy LIND was working mid shift the day that FARRIS died and was working when
Deputy BOONE located FARRlS deceased. Ln his statement U NO outlined his
understanding of the safety cell policy and that there was an order in place that FARRIS
cell door not be opened. Ln regards to the cell door, UNO stated that there was an order
in place that the cell door not be opened with less than two people, then another order
passed down from McCARTY that the cell door not be opened at all and advised of the
incident regarding the rag described earlier in this report.
LIND admitted that he falsified the check log and did not actually conduct the checks
listed at 2230 and 2330 hours. LLND also admitted that those checks along with the
check logged at 0030 hours were all written down after they had fo und FARRIS
deceased.

BOONE:

Deputy BOONE was working mid shift with Deputy LIND the clay that FARRIS died
and was the deputy that found l1im deceased. BOONE was also the deputy who initially
responded to Skagit Count to transport F ARR[S to Island County. ln his statement
BOONE outlines his understanding of the safety cell policy and that there was a standing
order that FARRIS's cell door not be opened unless there were two people present.
BOONE also believes that there was verbal pass down to try and get FARRlS to drink
water.
[n regards to the incidents at Skagit County, BOONE stated that FARRIS began
actively fighting and resisting when they tried to handcuff him for transport and while

e1j w y under the laws ofthe sw te of Washington. thai the fo regoing is true a11d correct (RCW 9A.71.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

doing that, attempted to bite one of the Skagit Deputies and wrapped his legs around the
Skagit Deputy's legs so they couldn't put leg restraints on him. BOONE stated that he
did not know of any incidents of FARRIS doing anything to, or acting out with Island
County con·ections staff.
BOONE stated that on the night of the

i

1
\

moming of the 8111 at approximately 0020

hours he entered H block to do his checks. BOONE observed FARRIS down by the door
ofhis cell then walked over to H-1 to check. The inmate in cell H-1

was

awake either reading or writing something. When I contacted - the night

FARRIS was found deceased, he advised me that he had been asleep and the com1notion
of eve1y one coming in woke him up. BOONE retumed to cell H-2 and checked again
because he did not see any movement from FARRIS the first time.
BOONE stated that due to the way FARRIS was situated against the door or in the
corner he couldn't see any movements that would indicate that FARRIS was breathing.
BOONE called LIND over to see if he could see anything. When LIND didn't notice any
movement, BOONE opened the cuff p011, incase FARRIS was " playing possum" (acting
like he was asleep) and attempted to talk to him or get a response. FARRIS didn't
respond so BOONE used his expandable baton (not wanting to reach his ann inside the
cell) and pushed on him to h·y and initiate a response. When FARRIS didn't respond to
that, BOONE reached in , felt his head and tried to shake him to wake him up.
When he touched FARRIS, BOONE stated his head and neck were very ridged. They
opened the cell door and BOONE observed the FARRIS's color was completely gone and
that he was stift/rigid. BOONE radioed the control room and had them call for a medical
response. Deputy MlRIBAL anived first with an Automated Extemal Defibrillator
(AED) and elected not to use it due to the state FARRIS was in. Medical arrived a short
time later and ran a hemi monitor which detected no signs of life.

·=--=IL o[pe1jw y under the laws ofthe state of Washington. thai rheforegoing is true and correct (RCW 9A. 72.085)

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

When asked about the log entries that LIND admitted weren't done, BOONE didn't
know if LIND conducted the checks but stated he saw LIND writing on the log sheet after
they had located FARRIS.

BARKER:
BARKER is a registered nurse employed by the Island County Health Depmtment that
provides medical/sick call services on Monday, Wednesday, Thursday and F1idays
dividing time between the Lsland County Jail and the Island County Juvenile Detention
Facility.
BARKER stated that FARRIS was initiall y brought into the facility while she was on
vacation, and that she did not see FARRIS until a staff initiated sick call on the morning
of 04/06/2015. As stated earlier in the report, BARKER observed FARRIS tlu·ough the
window in the cell door. She stated that his color looked good, his respirations were fine,
and he was moving.
When BARKER introd uced herself as "Nancy the Nurse" FARRIS mumbled
something to the effect of"medical professional" or " I need a medical professional".
When BARKER asked how FARRIS was doing he stated "not good". When she asked
where he was, FARRIS stated "jail". After this brief interaction (she estimates about 2
minutes) BARKER stated she was escorted back to the medical office and that she did
not have a hands on encounter with FARRIS. BARKER did not ask for the cell door to
be opened because she had heard the staff talking about him being violent, disruptive and
uncooperative.
AA:er meeting with FARRIS , BARKER completed the facility sick call then entered
her notes/observations into the Spillman system. Concluding the interview BARKER
stated that she did not believe she was allowed enough time to properly evaluate FARRIS
but doesn't feel that should could have told the staff to open the door so she could

vlJlldiH'-J=rttv:Gifpe1jwy uuder riJe laws ofrlre srare of Waslriugron, rlrarriJe foregoing is rrue aud correcr (RCW 9A. 71.085)
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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

conduct a proper eval uation (in a second recorded statement BARKER outlined how she
would have liked to do the evaluation). BARKER stated that FARRIS atTived at the
facility with no medical history or indications that he was taking any medications.

McCARTY:
Lieutenant McCARTY is the jail supervisor and cmTently the only civil service
supervisor in the jail. The other jai l Lieutenant is an acting position that is rotated
monthly between the cotTection deputies. McCarty outlined her understanding of the
safety cell policy and indicated that the cunent policy is the one that was put out in
November (2014). McCARTY believes that it is the policy from Lexipol.
When asked what the prio rity of the safety cell checks (facility wide) sho uld be,
McCARTY stated that nonnally the priority would be the check but there are times when
people get busy and forget. McCARTY also stated that there was no mandate in place to
watch FARRIS eat or dtink. McCARTY outlined FARRIS 's movement from the "blue
room" downstairs to D block and eventually up into H block.
We discussed the water being turned off in D block and why that was done. I asked
McCARTY where the water being shut off was documented and she stated, "we just did
it" and that she wasn ' t aware of it being documented in any log. The water being shut off

in cell D-1 was documented in the pass down book by KELLY on 03/30/2015.
McCARTY also stated that FAR.RIS was not under safety cell protocols while he was in
cell D-1.
When FARRIS was moved from D-1 to H-2 McCARTY stated that she didn't think
FARRIS was under safety cell protoco ls initially because he was moved on Saturday and
they didn't utitiate the protocol until Sunday even though the water was tumed off in the
cell. McCARTY stated that the water being turned off in H-2 was documented in the

·ti!L..D<mttttv

ifpe1jwy under the laws of

the state of Washington, thar the foregoing is true and correct (RCIV 9A.72.085)

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Page 3 I of

sl

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# l5-I05352

pass down book. We discussed the multiple log books, and activity sheets the staff keeps
and the purpose of each.
McCARTY stated that there was no protocol in place to watch FARR[S eat or drink
but he was considered a two man movement and his cell door was not to be opened
without two people present due to hi s resistive nature. When asked if she knew of any
instances of FARRIS being aggressive towards Island County staff, she stated "only when
we'd go to move him" then clarified that he was resistive toward the end (of the move)
and that she heard he threw water. I asked s pecifically if she knew about FARRIS
grabbing any of the coiTections officers. McCARTY stated that she didn ' t reca ll, she just
reca lled the water incident, but it should have probably just been documented in the pass
down (book) or the safety cell sheet. FA /UUS 's inmate book at the deck station contained

an Incident and Discipline report dated 0312 7/2015 that states FARRJS reached out and
grabbed Deputy EVANS by the ltand. It also states "Officer Safe ty Issue" and "Two
officer response".
I provided McCARTY the safety cell logs and had her review them for her entties.
McCARTY explained why she allowed FARRIS's aunt to visit him in the padded safety
cell (an attempt to get his cooperation), McCARTY said after the visi t they were
eventually able to move FARRIS to D block, which went easier than his previous move,
but he was still not following verbal comn1ands and sat on the ground, crawled out a little
bit, and was eating the food crumbs off the floor. McCARTY's described it at as "getting
pretty sad".
We continued to discuss FARRIS 's behavior, specifically how he was nonconummicative but every once and a while he'd answer with "yes" or " no" o r he'd shake
or nod hi s head but wouldn' t communicate in full sentences. I asked if she thought it was
a mental health issue and McCARTY answered ''Yeah I believe so, yeah."

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# l5-I05352

We next discussed the possible choking issue with the rag or cloth while FARRIS was
in D block. I asked McCARTY if she remembered the incident where PIECHOWSKI
and LIND came to her because FARRIS had something in his mouth. McCARTY stated
that it sounded familiar but she didn't specifically recall it but it sounds right. She also
didn't remember telling PrECHOWSKl or LIND not to go into FARRIS' s cel l.
We continued with FARRIS being housed in H block. I asked her if the water was
time FARRIS was put in H block? McCARTY answered "that's what [ was to ld". When
I asked what the delay was in starting the safety cell procedure when placing somebody in
a block with no access to water, McCARTY answered "I don't know." " l wasn't there."
We next discussed the jail nurse (BARKER), McCARTY advised that she works
approximately 32 hours per week in the jail and is an employee of the Island County
Health Department. McCARTY advised that there is no protocol in place for the medical
staff to ovenicle a lock clown so they can be evaluated, but the nurse could let them know
what she wanted and they could maybe work from there but lockdown is a "safety thing"
so the nurse couldn't have access if that was the case. McCARTY was standing outside
H block when BARKER did her evaluation of FARRIS and she confinned that it was
done through the closed door.
l asked why the safety cell protoco ls weren't started when FARRIS was moved to D

block and the water was turned off. At that point in time McCARTY said that FARRIS
was in "general population" hoping that might spur some communication from him and
they didn' t see reason for a safety cell. When [asked if that meant he was allowed out of
l1is cell and into the block day area or if he was still locked in his cell, she confirmed that
he was still in a locked cell but he had access to a call button (that rings in the control
room).
When [ asked about FARRIS's being moved to H Block with the water off and why
the safety cell protocols weren' t started, McCARTY stated "I don't know". When I asked

pe1jwy u11der the laws of the state of Washington. tlwtthe foregoing is true a11d correct (RCW 9A. 72.085)

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Page 33

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-I05352

McCARTY if the protocols should have been started, she answered, "I would think to be
on the safe side yeah" and " I can Monday night quarterback not you know I -I don't
know. He wasn't moved because he was a threat to himself at that point".

In the e-mail

from Deputy (acting Lieutenant) BINGH.lLM to DENNIS and McCARTY after the move to
H Block, BINGHAlvf clearly outlines that the move was done for safety. "FARRIS was
sha!dng, his fingers were pruning up and it was evident that he was ve1y cold and naked.
Venturing on the side ofsafety and his health, we once again brought him upstairs and
placed him into a warm shovver.for about 20 mins. After which time he was escorted to
H2 and locked down. "
We discussed policy 538.1, the Safety and Sobering cell procedures and whether or
not it is the cutTent policy. McCARTY stated that was her understanding that Policy
538.1 is the current policy they should be using, even though it states " Draft" on the
bottom.
We then discussed policy 538.3 Safety Cell Procedures section by section. In regards
to section "A" placement of imnates into a safety cell, McCARTY defined "shift
supervisor" as a lead officer, acting Lieutenant, herself or the Chief (DENNIS).
McCARTY explained how the lead officer is selected and that they, along with the acting
Lieutenant get paid for being in those roles.
In regards to sections "B" and "C" of the procedure, we discussed the amount of time
between checks and that each check shall be documented and a supervisor shall inspect
the logs for completeness every two hours and document this action on the log.
McCARTY admits that there was no supervisory oversight on any of the logs and when I
asked why she stated "Cause I didn't do my job". When asked who else would be
responsible for the log checks, she stated the acting Lieutenant, lead officer, and the
Chief.

/oC--1

Personnel Number

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ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

We continued with section " 0", the inmate clothing and the reasons fo r placing an
inmate in a safety (also known as a suicide) smock, why FARRIS was issued one instead
of a standard jail unifonn and section "E", the inmate shall be offered water and Juices at
least hourly and the imnate shall be g iven suffi cient time to drink the fluids before the cup
is removed. I provided McCARTY the safety cell logs and asked if that occutTed.
McCARTY advised that it did not look like (based on the logs) that FARRlS was offered
water every hour. McCARTY confirmed that an inmate in a cell with the water turned
off has no way to provide themselves water. When I asked how it could be determ ined
that FARRLS was offered water in the first 23 ho urs he was in H block with the water
turned off and no safety cel l checks being logged she stated that there was a carafe of
water sitting out on the deck with cups and she couldn't imagine the staff would have put
a carafe of water out if it wasn't to give an imnate water.
Section "F" states inmates will be provided meals and the meals will be documented
on the logs. McCARTY stated that she knew that FARRIS was given water or j ui ce at
evety mea l because that would be part of the meal. Section "G", states that the shift
supervisor shall review the appropriateness fo r continued retention in the safety cell every
8 hours, and the reason for continued retention or removal shall be documented.
McCARTY stated that she did not document that, but the lead officer should have
because the lead officer is considered the shi ft supervisor as well " that's why we pay
them, to make those decisions".
Secti on " H", states the requirement fo r a medical assessment of the inmate in the
safety cell shall occur within 12 hours of placement or the next daily sick call whi chever
is earliest. [ asked if that had been completed and McCARTY stated that a medi cal
assessment is doing tl1 ei r (the deputies) best to make sure he' s medically ok and that the
officers can conduct medical assessments per this policy because they don't have
someone (nurse/doctor) available every 12 hours or on the weekends.

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. I 067

Case# 15-!05352

Section " H" continues stating that continued assessment of the inmate in the safety
cell shall be conducted by a qualified health care profess ional and shall occur at least
every 24 hours thereafter. I pointed out that based on the policy FARRIS was s up posed
to be eval uated by a medical professional every 24 hours and asked if he was. She stated
"NO" and advised that they don't have a medical professional availab le.
Section " I" states a mental health assessment shall be conducted within 24 hours of an
inmate's placement in the safety cell and documented. McCARTY stated that we did not
have as assessment done within the first 24 hours and San Juan County was supposed to
set one up for FARRIS.
After reviewing the policy with McCARTY I asked her why weren ' t we following our
own policy. In summary, McCARTY stated that it was a new policy with things (duties
and requirements) that weren't covered under the old policy and they (the corrections
deputies and supervisors) didn't follow it because they were unfamiliar with the new parts
at that point in time and they hadn't used the new policy enough to become familiar with
it.
We discussed the secutity cameras in the jail and the fact that many weren't being
recorded due to a Digital Video Recorder that had failed. I asked how long that recorder
wasn't working and she stated " months". We continued with the safety cell logs on
4/7/20 L5 and 4/8/2015 and 1 asked about the period of approximately 3 Y2 hours where
not checks had been conducted. McCA RTY stated that she believed people e ntered the
block a nd looked at FARRIS during those times but got busy in between and forgot. 1
provided McCARTY all of the logs, asked her to review them to see if she saw a pattern
in the amount of water FARRJS was offered while he was under the safety cell protocols
and if she thought that the amount he was provided would be enough to sustain someone
that didn't have the access to feed or water themselves. McCARTY examined the logs
and answered "NO. "Now that I look back through them it looks like he was given a lot

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of""""" q{Wo>l<l"gl~ '''"'~~:::='"' UI~

PerSOIII/el Number

LO::t;/1

"d~;;;RCW9A.71.1185) ~
~

Page 36 ofS

I

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# I 5-105352

more water when he was in the padded safety cell up at the booking area . It does not look
like took that much water while he was in-he did when be first got to H block but then it
looks like he didn' t."
I asked McCARTY if she had anything else she'd like to add to her statement and she
stated "I don't, no. I'm son·y" and followed up with"[ know he took water that day but
obviously not enough."

DENNIS:
ChiefDENNIS is the Jail Commander, a position appointed by the Sheriff to run the
operations in the jail. I asked DENNIS to break down the command structure of the jail
and he advised that directly below him is McCARTY who is the Administrative
Lieutenant. There was an operations Lieutenant (who retired). DENNIS and McCARTY
now split his duties. Below McCARTY is the acting Lieutenant and then the lead officer.
DENNIS confinned that in the absence of a supervisor, the lead officer is the supervisor.
We discussed how the lead officers are selected and the fact that they can basically make
the decisions of a Lieutenant absent any disciplinary requirement.
I asked if there was a policy regarding safety cell procedures, and DENNIS coiTected
me stating that policy refers to the Sheriffs Office as a whole, the Jail (conections
division) has procedures with the current (safety cell) procedure being the one dated
October 20 I 4 that's at the deck station.
DENNIS provided an overview of the procedure and I asked if this procedure came
from the Lexipol manual. DENNIS stated that the majority of it came out of the Lexipol
Manual and not just the safety cell procedures. I asked if the safety cell checks were
mandatory and DENNIS confinned that they were and there are consequences for not
doing them. He stated that he has reptimanded officers for not doing them, but never put
anything in writing. I asked what the primity of the checks are and gave examples of

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

various duties in the jail occurring when a safety cell check was due. DENNIS advised
that the safety check would be a priority and they (the COJTections staff) can stop all the
other activities (to complete the check) then retum to them later.
DENNIS continued that there was no mandate in place to watch FARRIS eat or drink.
I asked if he knew if the water had been turned off in any of FARRIS 's cells a nd DENNIS
advised that there was one time when it was indicated that he was floodin g his cell so the
water was tumed off but DENNIS did not know of any other time that the water was off.
When asked where it would be documented if an officer decided to tum off the water in
the cell DENNIS stated that they would document it in the pass down log and worksheet,
along with a annotation of the cell number and the reason.
DENNIS confim1ed that FARRIS was determined to be a two man contact due to one
aggressive incident with the staff that labeled him a hostile inmate. DENNIS said there
was not an order in place to not open his cell door; it could be opened with at least two
people present. We discussed the medical staff (Nurse BARKERIPA YOUNG) and their
room in the facility. DENNIS confirmed that both are contract positions not j ail
employees. DENNIS also confinned that there is a medical ovenide in place, " If the
medical staff said they want them out (the inmate in a cell) we take them out". This

contradicts McCARTY's statement that there is no medical override available.
During my questions regarding FARRIS's movement from location to location in the
facility, DENNIS stated that it was his understanding that FARRIS was under safety cell
protocols during his time in D block. I asked if just the water being turned off was
enough to initi ate safety cell checks and DENNIS replied "Ifthe water's turned off the
checks are to be made because he doesn 't have access to sufficient amounts of water so
on our hourly checks we provide em the opportunity for liquids". DE

IS also stated

that he was unaware that safety cell checks were not started for almost 24 hours after
FARRIS was placed in H block.

~pe1j111y

Name

under the lan•s oftire state ofWaslringtou, that tlleforegoiug is true and correct (RCIV 9tl. 71.085)

Perso~~e~

Zrmber

~;;fa~

VI({(.

~S;;~ ,-

Page 38 of

~

/

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-!05352

We continued by going over sections of 538.3 and how it was implemented or not
implemented in regards to FARRIS. Section "A" states that the placement of an imnate
into a safety cell requires approval of the shift supervisor or medical staff. DENN1S
stated that he didn 't know if FARRIS 's placement was approved by a shift supervisor or
medical staff
Section "C" states that direct visual observations shall occur at a minimum of hourly
and each check shall be documented . Supervisors shall inspect the logs for completeness
every two hours and document this on the safety cell log. DENNIS stated "that won't
(happen) and that doesn 't always happen because there isn't a supervisor on shift all the
time." DENNIS did state that the acting lieutenant could review the logs ifhe was on the
deck but not the lead officer because he was in the control room.
Section "E" states that inmates shall be given the opportunity to have fluids at least
hourly and each time an inmate is provided an opportunity to drink it will be documented
on the safety cell log. DENNIS stated that to his knowledge this section was being
followed and he mentioned the same carafe and cups in front of H block as McCARTY.

Tlze logs show that FARIUS was not being offered water hourly as required.
Section "G" states the shift supervisor shall review the appropriateness for continued
retention in the safety cell at least every eight hours. The reason for continued retenti on
or removal shall be documented on the safety cell log. DENNIS stated that he did not
know ifFARRIS was evaluated every eight hours or not and, that (the monitoring and
evaluations) would have been the responsibility of the supervisor that was on shift.

Evaluations did not occur as per this section.
Section " H" states that a medical assessment of the inmate i.n the safety cell shall
occur within 12 hours of pl acement or at the next sick call and continued assessment of
the inmate in the safety cell shall be conducted by a qualified health care professional and
shall occur every 24 hours thereafter and the medical assessment shall be documented.

~"'''~
ame

1

ofperjwy under the laiVs ofthe slllle of Washi11gton. that the foregoing is true and c;ou1 (RCW 9A. 72.085)

fob1
PerSOIIIIel Number

Ct.f.)C.vJ'-.
Locadon

GJ(

z:~

~~----

Page 39 of

5

J

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. I 067

Case# 15-105352

DENNIS stated "It's not gonna happen that way cause we don' t have a medical staff
that's available every you know 24 hours." DENNIS explained they will often take the
nurse, doctor or mental health professional down and open the feed slot so they can
communicate with them and ask how they are doing, what their needs are and make some
observations. DENNIS explained that a tme assessment of going down there and actually
assessing the inmate is very difficult because that doesn't happen all the time and there is
no way it will happen all the time cause some of the imnates are extremely dangerous and
"I will not expose the medical staff to that."
Section " I" states a mental health assessment shall be conducted within 24 hours of an
imnate's placement of a safety cell and the mental health professionals recommendations
shall be documented. DENNIS stated that FARRIS was not eva]uated within the 24
hours peliod and explained "Uh, not evetybody put in a safety cell and-and I understand
what that says, but that's not necessarily the gospel. Evetybody put in a safety cell is notdoes not necessitate a CMHP (Certified Mental Health Professional) ." DENNIS then
goes into an explanation as to why it will not happen.
I also asked if they staff has received any training in treatment of dealing with mental
health people (inmates). DENNIS stated that he has had 40 hour ctitical intervention
training and he has provided the staff bullet points to look out for in dealing with
someone, but the staff is not qualified to detennine mental health. I asked if medical
records are provided when an inmate aiTives from another facility and DENNIS that they
(medical records) do not normally accompany an inmate, "they have to beg, bmTow or
steal to get them." DENNIS also stated that if they receive an inmate and the inmate has
a medical condition or there is a suspicion that the inmate a mental health condition then
they will request the records. Nurse BARKER however tries to always send records out,
along with medications if an inmate is transfetTed.

' ofpe1j111y under the laws oftire state of Washington. that tire foregoing is tme and correct (RCW 9tf. 71.085)

Name

PerLS§llrnuber

(C~£~~,/1,

ifIs

Page 40 of

s-f

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Case# 15-105352

Detective C.E. Wallace Jr. 1067

We went over the safety cell logs and I asked DENNIS to tell me ifhe could locate
any supervisory sign ofts or evaluations as per the policy. DENNIS stated that he could
see where the supervisors had seen FARRIS but couldn't say if that was the supervisor
conducting the overall check. I advised DENNIS that during my interviews, the staff
stated if they had offered FARRIS water they would have documented it on the logs, if
they had not it would not be there. DENNIS stated that he agreed because the staffs are
supposed to document exactly what they did. I asked DENNIS if based on the logs
FARRIS was offered water every hour as per the procedure? DENNIS stated that
according to the logs he was not. DENNIS also stated that he would have to look to see
where FARRIS was at the time and if the water was on because the logs do not say if the
water was off. The logs do not state clearly state the location. (cell) FARRIS vvas in or !f

the water was turned off in that location.
I broke down the logs by date and location for DENNIS starting with the March logs
when FARRIS was in the padded safety cell. DENNIS confirmed that there is no source
of water at all in that cell and he was not offered water hourly as per procedure. From the
padded safety cell I advised DENNIS that FARRIS was moved into D block where the
water was eventually turned offbut no checks were conducted. I asked if that was proper.
DENNIS advised that if the water was turned of, it was tumed off for a reason, but
FARRIS should be checked hourly and he should be receiving or at least offered water
hourly and if not, it should be documented. DENNIS also said that it should be
documented because an individual who doesn't eat or doesn't take any kind of liquid,
they're going to see the nurse or the nurse is coming down to see them and then at that
point what that pe1iod of time is-we may just transfer them to a hospital from that point
right there and say we cannot manage that individual here, he has to go to the hospital.
I continued wi th FARRIS being moved to H block with the water turned off and no
logs being started for almost 24 hours and asked if that was proper. DENNIS advised,

pe1jwy under the laws oft he state of Washi11g10n, chatcheforegoing is true and correct (R CW 9A. 72.085)

/6~·1

Persounet Number

Cx.,. 11 /t,
Locat~ • (.

' f(/tS-- Date

Page 41

of

s-1

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

"No, if that water's htrned off he' s going on safety checks cause the individual cam1ot be
in there even if it's shut offfor an hour."
I asked DENNIS to take into account all the logs and the periods of time we could not
document FARRIS being offered water. I also asked him to assume in the best case
scenario every time FARRIS was offered water he drank the entire cup. I asked DENNIS
if he felt that FARRIS was adequately provided water while he was in the facility, based
on the above assumptions and records. DENNIS answered "Looking at this log I would
say he probably not." DENNIS then explained how he would offer the inmate water and
watch them drink and provide them with as much liquid as they wanted.

r asked DENNIS as Chief of the Jail, taking into account all ofthe records and
documentation, would the fact that he was probably not recei ving enough water have
been caught if the checks were being done by the supervisor? DENNIS answered, "Yeah
if the supervisor was aware of the requirement and was doing it, it would have been
caught, absolutely." "If we had a supervisor out there then absolutely. He'd come by or
she'd come by and look and say, OK needs more water here and I'd give him water and
also see ifthe checks being made because we would notice if the check's not made."
We then discussed not being able to confirm any checks ofFARRIS in D block
because of the non-functioning DVR. DENNIS stated that he was aware the DVR was
not functioning and had not been functioning since approximately February (2014).
DENNIS said that he has been trying to get it fixed but due to replacement costs it has not
happened.
When I asked if there was anything else he would like to add, DENNIS advised that
looking at the sheets and the policy he "somewhat" implemented for our use (he

advised earlier in his stament that it was implemented, not somewhat,), he would
definitely " tighten it up", which is what he was doing working with Undersheriff
MAUCK on the Lexipol manual. He said that the Lexipolmanual is " nice" but it is not

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wall ace Jr. 1067

Case# 15-!05352

fully implemented because a large portion of the man ual just does not apply to us
(Island County Jail) because they wrote it for facilities much larger than us.
From DENNIS 's statement: "They wrote it fo r facilities much larger than us. They
have a medical staff, they have a psychiattic staff urn they have other things that we just
don't have and so what I'm doin is I'm takin everything that we do have and combining
it into a - a usable Lexipol Manual that's why you'll see some "draft". I'll send them out
there. I'll ask for comments on em. We'll update it and the staffs doin pretty well. Uh
tltis year and- and tltis is a tragedy that uh and I - [felt- I don't know if it - what the

uh cause of death was. I haven't got that infonnation but I lookin at this I can honestly
say that uh uh this inmate probably had some dehydration issues goin and uh had we
monitored closely, uh offered rum water- we can't watch him drink the water but there
has to be some period during the observations when you say you know things just ain't
right. Uh he's not dtinkin the water. He takes the cup but we don't see him dtink it.
Bting it to our attention and say this is a type of individual perhaps we might just want
to have Doc Young look or urn perhaps take him to the hospital. I felt somewhat
comfortable and I didn't realize it was an issue of this magnitude now that it's been you
know I have access to all the documents cause these were pretty well gone when I got
back so I couldn't b1ief myself but seein sometlling of tltis magnitude uh I was
comfortable in saying well the staff went down to talk to him. They- they observed
him back pedalin in his flooded cell. I had Nurse Nancy go down and talk to him . She
reported back that he appeared to be OK but when I had Western State Hospital doc go
down there who's- I really uh uh trust and put a lot of confidence - a PhD uh uh
psychiattist and MD talk to the individual had no in - indication whatsoever there was
something wrong there in that picture other than the fact that yeal1 he uh needs to come
down to Western State. I felt no OK OK. So he's doin alright down there. We'll just
give him to Western State as soon as possible. Urn the documentation could be better

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-!05352

but looking at it I'm saying yeah it- it reflects a true picture and when I look at this I
say "uh-huh OK" and I see mistakes and I see errors and I see room for improvement,
definitely. Yeah. There's no excu- there's no excuses here. There's a- a man died and
what our party contributed to that I want to know what that was and I want to take
ownership in that and I want to con·ect that and I believe my staff out here does also.
Uh I don't think anyone out there would say "Hey we did our job and did it to the best
of our ability". I'd say each member out there is probably questioning themselves as
long- as well as I sayin what could I have done and uh I could always say more staff,
more cameras and etc., but I won't say that because that'd be makin excuses for what
happened here. So I - I think we have some ownership in this and I think that should be
the message we present to the family that yes uh there was some uh some errors made
along the way. A degree of ownership I think it's collective. It - it collects wherever it
came from. We should have got information from the time he was picked up, every
stop he made along the way. I know there was difficulties in Snohomish County. I
know there was difficulties uh you know with his housing and- and what went on there
I don't know. It was same - some difficulties in Skagit County. What they were I don't
know and I do know that I called San Juan and said "We don't have the manpower to
get this individual. You have to go get him. They did and brought him to us."
We concluded the statement by discussing FARRJS ' s transport to Island County,
and DENNIS being able to have Doctor HENDRICKSON do an evaluation and
BARKER's medical evaluation. I advised DENNIS that the feed slot on FARRIS's cell
door was not opened and BARKER had to do her evaluation through the window of the
cell door because the staff were told they could no open the door or the feed slot and
asked if that was normal. DENNIS advised "I've seen it happen before uh but to do an
assessment uh I think the - the officers were kinda uh the officers should have taken the
individual out and brought him up to uh the nurse so the nurse could make an

/66?

Personnel Number

t"'a:e
~r /1r

Page 44

of

<)/

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

observation in a well lit area, clean area." I don't know how much observation she could
make through there, but her school's a lot different than mine too and what she sees and
I see you know."

Additional Information:

At the request of the Attorney for the FARRIS family searches were conducted for
telephone calls to/from 3

The inmate phone system (SECURUS) only

allows outgoing collect or calling card calls. A search between 03/1 5/2015 and
04116/2015 located no calls to that number. I also contacted Island County Central
Services and requested a system wide check of the county phone system for calls to that
number. A search between 03/20/2015 and 04/09/201 5 located four calls from that
number. Two calls to the extension 7384 (the Superior Court jury infonnation liue) one
on 3/30/2015 at 1756 hours and another on 04/06/2015 at 1734 hours and two calls to
extension 5111 (the main phone tmnk/switchboard) on 3/31/3015 at 1011 hours and 1333
hours.
Forensic images were made of the hard drives of the county computers assigned to the
jail using FTK imager version 3.4.0.1 and stored. With the exception of the state access
terminal in the jail, all ofthe images were physical images. Since the access terminal
could not be taken off line for imaging due to its function in the control room, a logical
image was made of that drive. Analysis of the images will be addressed in an additional
narrative. Based on the provided Syslogs there is no indication that any information
regarding FARRIS in Spillman system was altered after his death.
The information release provided by the FARRIS family attorney was provided to
Snohomish County shortly after it was received on 5/8/2015. As of 5119/2015 I had not
received any documents so I emailed again, asked for a status update, and outlined some
specific items/information 1 needed. A short time later I received an e-mail apologizing

try ojpe1jw y under tire la111s a/tire state of Washington. tlrat tlleforegoing is tme and correct (RCW 9A. 72.085)

Per!2,,~e/Zumber

Lt;;t'::dlc

7Lr; r

Page 45 of

sI

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detecti ve C. E. Wallace Jr. l 067

Case # l5-I05352

for the delay and providing an estimate that I should have the information by the end of
the week.
As of 6/8/2015 I still had no t received the documents. I requested Sheriff BROWN
contact Snohomish County to expedite the process . BROWN was advised that the
records would be provided by the aftemoon of 6/8/2015. On the morning of 6/9/20 15 I
received an e-mail containing the documents fi:om Snohomish County. The documents
provided were the same documents I had received from them earl ier in the investigation
and did not contain any of the speci fie information I requested. I am still ttying to obtain
the correct documents.

Findings:
The Island County Jail deputies and supervisors failed to follow policy 538.3 in
regards to Safety Cell Procedures, specifically:

538.3 (b) A safety cell log shall be initiated every time an inmate is placed in a safety cell
and should be maintained the entire time the irunate is housed in the cell. When FARRIS

was moved into cell H-2 with the water turned offfor his safety afterflooding cell in D-1,
safety eel/logs were not started for almost 24 hours. According to Chief DENNIS,
turning off the water in cell D-1 (or any cell) should have initiated safety eel/ logging as
well.

538.3 (c) A safety check consisting of direct visua l supervision that is sufficient to assess
the inmate's well-being and behavior shall occur as indicated on the log but hourly as a
minimum. Each safety check of the inmate shall be documented. Supervisors shall
inspect the Jogs for completeness every two hours and document thi s action on the safety
cell log. In some cases the checks conducted by the staff were not sufficient to assess

~' ofpe1jury rmde;:; ;ws of tire state of iJiaslliug~~~a~:;~regoiug is true
Name

PerSOtlllel

Number

Location

a;
Di )

:~re;~:CJV 9A. 72.085)
Page 46 of

s- I

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case # 15-105352

FARRIS's well being and hourly checks were not being conducted and documented as
required. Supervisors did not inspect the logs as required.

538.3 (e) Irunates in safety cells shall be given the opportunity to have fluids (water,

juices) at least hourly. Deputies shall provide the fluids in paper cups. The inmates shall
be given sufficient time to drink the fluids prior to the cup being removed. Each time the
inmate is provided the opportunity to drink fluids will be documented on the safety cell
log.

FARRJS was not offered the opportunity to have fluids hourly while under safety

cell procedures.

538.3 (g) The Shift Supervisor shall review the appropriateness for continued retention in

the safety cell at least every eight hours. The reason for continued retention or removal
from the safety cell shall be documented on the safety cell log. No reviews occurred.

583.3 (h) A medical assessment of the inmate in the safety cell shall occur within 12

hours of the placement or at the next daily sick call, whichever is earliest. Continued
assessment of the inmate in the safety cell shall be conducted by a qualified health care
professional and shall occur at least every 24 hours thereafter. Medical assessments shall
be documented. FARRJS was not medically evaluated until his eleventh. day in custody.

583.3 (i) A mental health assessment shall be conducted within 24 hours of an inmate's

placement in the safety cell. The mental health professional's recommendations shall be
documented. FARRIS did not receive a mental health evaluation until his eleventh day in
custody .

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

The Island County Jail deputies and supervisors failed to follow Island County
Corrections Facility Procedures Manual (dated 11 /9112) specifically:

2.02.008 Prisoner's Inability to be Processed: This procedure appears to be the
precursor ofpolicy 583.3 but contains many of the requirement outline in the newer
policy.
If a prisoner's physical condition of behavior prohibits the completion of the admissions
process, the following procedures shall be completed.

If the imnate is a danger to the coiTections deputy or them self the deputy may place the
inmate in the BMM (Behavior Modification Module) BMM is struck out and a note states

change all BMM to Safety Cell or other appropriate temporary housing until the inmate
returns to a cooperative state. At such time, the deputy shall resume processing the
prisoner.

In the event it should become necessary to place an individual in the BMM (struck out)
the following procedures wi ll be initiated.

An inmate who will remain in the BMM (struck out) for a period exceeding 24hrs will be

screened by medical staff. FARRJS was not seen by medical staff until his eleventh day in

custody.

3.02.000 Supervision and Management of lnmates:
Sight and sound surveillance of all inmates will be maintained. Sight and sound

surveillance (hourly checks) were not maintained on FARRJS.

/o(;/

Personnel Number

C"-!{;tv,l t
Lodaion

Page48of ~ ~

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

3.02.002 Cell Checks:
The Corrections Deputy shall conduct periodic personal observations of all inmates under
his/her supervision. Cell checks will be conducted at least hourly, on an iiTegular
schedule. Special management inmates (i.e. Suicide Risk, Medical, etc.), will be checked
at least every 30 minutes (struck out) and replaced with hour, more often as necessary.
FARRIS qualified as a special management inmate and required hourly checks were not
conducted.

A copy of policies 538.1.1 Defmitions (Safety Cell and Sobering Cell), 538.2 Policy
(Safety Cell and Sobering Cell) and 538.4 Sobering cell procedures are part of this
m anual. There is a line drawn through the page with change all and draft procedure in the
deck station for review handwritten on it. There is also a copy of policy 538.3 Safety Cell
procedures with "Draft in deck station" handwritten on the bottom. As stated earlier,
based on the memos from Chief DENNIS dated 10/30/2014 and 11/04/2014 and his
statement these policies were in place and not drafts out for review.

4.04.002 Emergency Mental Health Services:
If a deputy observes an inmate exhibiting signs of emotional instability or psychological
distress, the irunate shall (struck out) and replaced with may , if the situation dictates be
placed in administrative segregation until contacted by a mental health professional.
FARJUS exhibited these sings and was placed in administrative segregation (safety cell).

The deputy shall describe the inmate's behavior on an Inmate Medical Fonn then provide
the infotmation to the mental health professional responsible for emergency referrals.
Some ofFARRIS's behavior was documented in the logs but not on the Inmate Medical
form, no emergency ref erral was made.

lo6/

Personnel Number

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C. E. Wallace Jr. I 067

Case # l5-I05352

The mental health worker shall interview the iruuate then advise the medical staff if it
appears that treatment is required . No emergency referral was made; no interview was

conducted with FARRJS.

In most cases the documentation regarding the safety cell check was not adequate and
other documentation regarding FARRIS was scattered between various logs and activity
sheets. The supervisory staff failed to properly coordinate the information.

The medical staff (nurse) was not called in to examine FARRIS until one day
before his death. Once the nurse was notified she failed to do a proper evaluation of his
condition even after FARRIS advised her that he was not doing well. There appears to be
no protocol/policy/procedure that would allow the medical staff to override a lockdown to
conduct a medical evaluation, so the nurse may not have been able to force the issue to
examine FARRIS further, however, she failed to bring any concerns regarding his health
to the attention of the deputies or supervisors and she failed to document that she was not
allowed to properly examine FARRIS or his statement that he was not doing well.

The records provided show that FARRIS's medication transferred with him from the
Lynwood jail, to the Snohomish County jail to the Skagit County Jail but they did not
arrive at the Island County Jail with him. Based on the Skagit County documentation,
FARRIS was refusing to take nis medication so there should have been pills left when he
was released from the facility, I cannot locate any indication of the disposition of that the
medication. The report from the San Juan County Deputies that transported FARRIS to
Island County didn't indicate that they were provided medication for him.

ofpe1jwy under rlre laws ofrlre swre of Washinglon. rlrartlre foregoing is I me arrd correc/ (RCW 911. 72. 085)

Pers~~~~~umber

s~f:;,~/fc_

i~~~

Page 50 of

'?/

ISLAND COUNTY SHERIFF'S OFFICE
NARRATIVE
Detective C.E. Wallace Jr. 1067

Case# 15-105352

Island County Jail supervisors and staff violated multiple policies/procedures in
regards to Keaton FARRIS 's custody. Based on the totality of the information, to include
the Coroner's determination

this

investigation is closed as a non-criminal death. This finding is subject to review if
additional evidence becomes available.

Nnm e

C c..()(..,./fc
Localiott

Page 5 1 of")

f

ISLAND COUNTY SHERIFF'S OFFICE
SUPPLEMENTAL REPORT
Detective C.E. Wallace Jr. 1067

Case# 15-I05352

I am commissioned by the Sheriff ofisland County to enforce the laws of the state
of Washington and the County of Island. At the time of this incident I was working as a
Detective for the investigations division of the Island County She1ifrs Office. I am
certified by the Department ofTreasULy/Homeland Security as a Seized Computer
Evidence Recovery Specialist (S.C.E.R.S .), the Department of Homeland Security as a
Mobile Device Investigator, the Cellebrite Corporation as a Physical Analyst and the
Paraben Corporation as a Handheld Examiner (PDA, cell/mobile phone and Hybrid
devices) .
Forensic images were made of the hard drives of the county computers assigned to the
j ail using FTK imager version 3.4.0. 1 and stored. With the exception of the state access
tenninal in the jail, all of the images were physical images. Since the access terminal
could not be taken off line for imaging due to its function in the control room, a logical
image was made of that drive. The images are in .EO l format and named as follows
(based on their location in the facility), Booking Station, Booking Station 2, Cobra
Banking, Control Room, Deck Station, Housing Computer, Jail Access Term, Jail
Commander, Jail Nurse, Lt. Office McCarty, Lt. Office East and, Lt. Office West.
Using Internet Evidence Finder (IEF) version 6.6 I scanned the images for files,
artifacts and information pertauling to the usage of the computers. Each image was
scmmed independently and a global date/time filter ran on the results. The filter was set
to extract usage information between 04/07/2015 at 0000 hours and 04/08/20 15 at 0300
hours. The filtered information was generated into an HTML report for each image. The
rep01ts were burned onto a compact disk and added to the case file. The Housing
Computer and Jail Access Tetm contained no information from the specified date/time
range so no reports were generated for these images.

rjwy under the laws ofthe state of Washing/off, that the foregoing is true and correct (RCW 9A. 72.085)

/ur.'1
Name

PersO/IIlel Number

Gc.-pcv.l(c_
Locdtiou

~/rsf~
Date

.

Page I 0 f /

Video timeline:

The date on the recordings is correct, the time is 2 hours and 51 minutes ahead of actual tin1e
(actual time on test recording is 1534 hours, displayed time on recording is 1825 homs).
April 7 to April8, 2015. No checks logged between 1130 hours and 1500 hours.

Logged Time:

Time on Camera:

Actual Time:

Deputy:

1500 homs

1750 bOW'S

1459 homs

Moffit

1600 hours

1848 homs

1557 hours

Pendergast

1635 homs (meal)

1925 hours

1634 hours

Moffit

1730 hours (P/U)

1953 hours

1702 hours

Moffit

1845 hours

No check seen

No check seen

Moffit

1945 hours

No check seen

No check seen

Moffit

2030 hours

2328 hours

2037 hours

Moffit

2230 hours

No check seen

No check seen

Lind

2330 hours

No check seen

No check seen

Lind

April 7, 2015

April 8, 2015
0030 hours Log states does not appear to be breathing, no initials.

Additional info:
April 7, 20 15
2334:06 hours to 2335:48 hours (2053:06 to 2054:48) deputy (possibly Moffit) stops as door,
appears to log something, leaves towards the deck station then comes back and appears to log
something else, no entry into the block.
2351 homs to 2352 homs two deputies enter H block (2100 hours to 2101 hours actual time) no
log entry made.

C t.vlo(/

Dietary Reference Intakes (DRis): Recommended Oieta•·y Allowances and Ade qu ate
Inta kes, Total Water and Macronuh·ients

Food and Nutrition Board, Institute of Medicine, National Academies
Water"

Carbohydrate

Total
f-iber

Fat

Linoleic
Acid

a -Linolenic
Acid

Proteinb

(Lid)

(g/cl)

(g/d)

(g/d)

(g/d)

(g/d)

(g/d)

0.7*
0.8*

60*

NO

95*

NO

4.4*
4.6*

0.5*
0, )-·

11.0

1.3*

130
130

7*
10*

0.7*

13

25*

0.9*

19

I 2*
1.6*
I 6*
I 6*
I 6*
1.6*

34
52
56
56
56
56

Total

Life Stage
Group
In fan ts
Oto6mo
6 to 12 mo
Children
1-3 y
4- 8 y

1.7*

19*

9.1*

Males
9-13 y
14- 18 y
19-30 y
31 - 50 y
51-70 y
> 70y

2.4*

130

31 *

3.3*
3.7*
3.7*
3.7*
3.7*

130

38 *

130

130

38 *
38*

130
130

30*
30*

2. 1*
2.3*
2.7*

130
130
130

25 *

2.7*

130
130
130

NO
ND
NO
NO

ND

12*
16*
17*
17*
14*

NO

14*

26*

NO

10*

1.0*

34

26*

ND

II *

46

NO
NO
NO

1 2~

1.1 *
1.1 *
1.1 *
1.1 *

Females
9- 13y
14- 18 y
19- 30 y
31- 50 y
51 - 70 y
> 70y

2.7*

2.7*

25*
2 1*
2 1*

NO

12*

II *
II *

1. 1*

46
46
46
46

Pregnancy
14- 18 y

19-30 y

3.0*
3.0*

31-50 y

3.0*

175
175
175

28 *

28 *
28*

ND
NO
NO

1.4*

13*
13*

1.4*

13*

1.4*

71
71
71

Lactation
14-18
3.8*
210
29*
ND
13*
1.3*
71
3.8*
210
29*
ND
13*
1.3*
71
19- 30 y
31-50 y
3.8*
210
29*
NO
13*
1.3*
71
NOTE: This table (take from the DRJ reports, see www.nnp.cdu) presents Recommended Dietary Allowances (RDA) in
bold type and Adequate Intakes (AI) in ordinary type followed by an asterisk(*). An RDA is the average daily dietary
intake level ; sufficient to meet the nutrient requirements of nearly all (97-98 percent) healthy individuals in a group It is
calcul ated from an Estimated Average Requirement (EAR) lf sufficient scientific evidence is not available to establish an
EAR, and thus calculate an RDA, an AI is usually developed. For healthy breastfed infants, an AI is the mean intake. 1l1e
AI for other life stage and gender groups is believed to cover the needs of all healthy individuals in the groups, but lack of
data or uncertainty in the data prevent being able to speci fy with confidence the percentage of individuals covered by this
intake.
• Total water includes all water contained in food, beverages, and drinking water.
b Based on g protein per kg of body weight for the reference body weight, e.g., for adults 0.8 g/kg body weight for
the reference body weight.
'Not determined.

SOURCE· Dietary Reference Intakes for Energy, CarbollJ'Cirate, Fiber, Fat, Fatly Acids, Q,o/esterol, Protein, and
Amino Acids (200212005) and Dietary Refermce Intakes for Water. Powssilm~ Sodium, Chloride, and Sulfate (2005) 1l1e

report may be accessed via www.nap cdu

Video Timeline
Death Investigation - Farris
By: UndersheriffMauck

On 04/ 13/15 at the request of Detective Wallace I reviewed Jail video footage between the times
of 12:00 AM on 04/ 07/08 tlu·ough approximately 1130 AM on 04/07/08. The camera from
which the footage was recorded shows the hallway that mns in front ofH/G blocks. I compared
the footage to Keaton Fanis 's safety cell observation log to verify when/if checks had been made
by deputies as documented on the observation log sheet. The actual time is estimated based
upon my understanding fi·om Det. Wallace that the camera time is approximately 2 hrs 51 min
ahead of the actual time. The results are as follows:

Logged Time
0055
0200
0300
0410
0555
0633
0715
0920
1017
1130

Time on Camera
3:47
4:48
5:53
7:14
8:57
9:23
10:04
12:18
1:07
2:29

Actual Time
0056
0157
0302
0423
0606
0632
0713
0927
1016
1138

Deputy
Boone
Lind
Boone
Lind
Hiatt
Hiatt
Boone
Hiatt
Hiatt
Hiatt

 

 

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