Lucy Combs got the call from the Alexander Correctional Institution on Nov. 15, 2020. Her son, Jerry—known to friends and family as George—was dead.

Lucy threw her phone on the kitchen floor and screamed three times. When she picked the phone up, a prison employee was still on the other end. He told her someone would call her tomorrow, and then he hung up.

The 74-year-old lives alone in North Wilkesboro. That morning, she’d gone to church and listened to a sermon about following God’s light. Then she drove her 2003 Chevrolet Camaro a few miles down the road to the post office to drop off a letter to her son, and went home to write him another.

The next day, Lucy called the prison in Taylorsville where George, 55, had been incarcerated since February 2020. She spoke to the warden, who told her he wasn’t at the prison when George died, and he had no further information.

She said she called the prison multiple times over the next few weeks seeking more information about what happened to her son. Each time she called, the person on the other end of the line told her they didn’t have the information she was looking for, and that the person who did was unavailable.

Eventually, she stopped calling.

“I figured they’d just tell me a bunch of lies or something,” Lucy said. “I don’t know.”

Now it’s been a year and a half since George died, and she still doesn’t understand how he died.

When an incarcerated person dies in a North Carolina state prison, what happens next is laid out, alphabetically, in a policy and procedure manual for the Department of Public Safety (DPS), the state agency that oversees prisons.

At step “K,” employees are to “notify immediate family of death of inmate.” But there is no script for the kind of information they’re expected to give, nor any written guidelines for following up with family members when they have questions.

In cases where a family member’s death is sudden, the initial notification can be traumatizing. And a lack of communication from the prison in the days, weeks, and months that follow can leave family members with little to no sense of closure.

The Assembly spoke to six families who lost an incarcerated family member within the last two years. Aside from the initial phone notification, the families say they received little to no information about the circumstances of the deaths—months and even years later. Advocates and legislators say North Carolina DPS’s death notification policy is in need of overhaul.

“It gets aggravating sitting here thinking about it,” said Lucy, as she started to cry. “I really don’t see, you know, how he passed just all of the sudden. I just—I don’t know.”

Seven months after George’s death, DPS issued a correction on its website stating that it had updated its COVID-19 death count to “accurately reflect the Nov. 15, 2020 death of an offender in his mid-50s with underlying health conditions who passed away at the prison and whose positive [COVID-19] test result was received three days later.”

The agency does not publish a list of the incarcerated people who died of COVID-19 specifically, but it does publish a list of all the people who died while incarcerated. In the 2020 report listing 140 names, Jerry Combs Jr. was the only person who died on Nov. 15.

Top: Lucy Combs keeps a photo of her son, Jerry, framed on a wall at her home. Bottom left: She looks through letters from her son, who died while incarcerated at Alexander Correctional Institute. Bottom right: A photo of Jerry “George” Combs’ casket. // Photos by Travis Dove

Lucy said she received his death certificate in the mail approximately two weeks after that first call. It listed the primary cause of death as “cardiovascular disease.” COVID-19 was not mentioned anywhere. She said the prison agency never contacted her after its website was updated.

The DPS policy and procedure manual states that after an incarcerated person dies, the “Officer-in-Charge” shall notify a variety of officials “as quickly as possible.” These officials include the facility head, county medical examiner, director of division of prison, and chief of health services. The incarcerated person’s designated emergency contact is last to be notified.

Although not stated in the manual, DPS prisons communications officer John Bull said standard policy is “to be mindful of the family’s pain.”

But some families say that is not always the case. Jeffrey Jacobs, 43, died of apparent suicide on Jan. 19, 2022 at Bertie Correctional Institution in Windsor. His mother, Ruthie Caruthers, said she received a call from a prison chaplain who told her how he’d died, and that someone would call her back later that day. But no one ever did.

Caruthers’ daughter, Emily, said she called the prison multiple times in the weeks after, searching for more information. She said the lack of information has contributed to rumors circulating among family and friends about whether the cause was actually suicide.

Emily and her mother, who both live in Arkansas, have also been trying to track down some of Jacobs’ belongings they say are missing, including his watch and a necklace. Caruthers said each time she calls the facility to ask, she gets put on hold, and then transferred to someone who says they can’t help her.

“We are family,” Emily said. “We want to know. We would like to ask questions. You know, just tell us exactly [what happened] because y’all was there, we wasn’t.”

Experts on this issue say that the best way to do death notifications is in person as soon as feasibly possible, and that the officials responsible for delivering them spend time afterward answering questions.

“There should be two people who go to do that notification, and then there’s some time spent answering some questions with the family and giving them what information that can be released or not, and telling them kind of what to (do) next,” said Darren Drake, director of Death Investigation Academy, a Missouri-based company that provides death notification training to public safety officials across the country.

Drake said that it is important for officials to have access to standardized step-by-step guidance that includes information on who notifies the family and how the notification is done.

“Without that, it’s just left up to the decision of whoever’s reading the checklist,” Drake said.

Sixty-one-year-old Billy Bingham died of COVID-19 in August 2020, while incarcerated at Albemarle Correctional Institution in New London. DPS did not report his death as being attributed to COVID-19 until seven months later. Billy’s brother Jay Bingham says that aside from the initial phone call from the prison, his family was never informed of any details regarding the circumstances of his brother’s death.

James Mosley’s brother, Thurman Mosley, died of COVID-19 in December 2020 while incarcerated at Alexander Correctional Institution. Like Bingham’s family, Mosley said that DPS never contacted him again beyond the initial notification of death. He was left wondering what happened, why, and how. DPS also did not initially report Thurman’s death as caused by COVID-19.

“I have not heard any follow-up or any kind of condolences,” Bingham said. “It’s disappointing, because I haven’t gotten any closure.”

Cierra Cobb, an advocate with the legal nonprofit Emancipate NC, said that it is extremely important for DPS to have a better death notification policy that can help families reconcile their grief.

“They also should have some type of victim advocacy for them as well, to help them get through that,” Cobb said. “Passing in prison where you can’t physically be there for them, you can’t take care of them. You can’t tell them bye. It’s extremely important that they give these people some type of support.”

In January 2020, Amanda Wooten’s phone pinged with a notification from the North Carolina Statewide Automated Victim Assistance, an information-sharing system run by DPS. The message said that her father, Doyle Helms, had died earlier that month at the Alexander Correctional Institute.

But Helms had actually died on December 31. Wooten knew this because she had spent hours on the phone arguing with the prison in Taylorsville to get permission for her and her mother to visit him at the medical center he’d been taken to after he was diagnosed with COVID-19.

By the time Wooten and her mother were granted visitation, Helms was on a ventilator and unable to speak. Wooten’s mother received a phone call on New Year’s Eve notifying her he had died.

Wooten’s relationship with her father was complicated; he had been abusive to her, but she felt like his prison sentence had given him time to think about what he did. Seeing the wrong date of death on the automated notification made her feel like her father wasn’t human to prison officials.

“I was angry,” Wooten said. “As I’ve calmed down, the reality of it is, nothing’s gonna change.”

Advocates and legislators say that a more robust DPS death notification policy would include things like in-person notifications whenever possible and an organized system for responding to questions and supporting family after the notification.

Lucy Combs keeps a photo of her with the casket of her son, Jerry, who died while incarcerated at Alexander Correctional Institute. // Photos by Travis Dove
A photo of Lucy and Jerry taped to a cabinet at her home in North Wilkesboro. // Photos by Travis Dove

Jamie Lau, Durham-based attorney and faculty adviser for the Duke Law Innocence Project, said that in November 2021, he received a call from a prison chaplain asking for the contact information of the family of one of his clients, who had just died. Lau said his client had been incarcerated for years and their emergency contact information had not changed. He was unsure why the prison would not have the information, as chaplains are generally on staff.

Lau said that in addition to a more robust death notification system, it’s important to have a process to incorporate the family in end-of-life decisions and processes.

“At bare minimum, when a person is nearing death and reaching end of life circumstances, the department should begin incorporating the family and having discussions with the family and allowing them greater access to the person at that time,” Lau said.

When Debra Burnette got the call that her brother, Carl Moseley, had died in Central Prison’s Healthcare Complex in Raleigh on Feb. 18, 2022, she was surprised, but not shocked. Moseley had been diagnosed with cancer eight months earlier, and Burnette had spent the previous few days on the phone with a chaplain who she said promised her multiple times that staff would call when her brother was nearing death.

But they never did, she said. Instead, Burnette received a phone call notifying her he had passed. The next day, she called the chaplain back to ask why she didn’t call her earlier, like she’d promised. Burnette was directed to a voicemail. She called the chaplain again the day after that and left another voicemail.

“I never heard back from them to this day,” Burnette said.

Rob Taber, a senior fellow at the progressive policy non-profit Carolina Forward, said better policies and processes for contacting next of kin “creates greater trust between the state and its citizens.”

“A visit from a qualified care team rather than a stiff letter of notification will improve outcomes not just for the family but for the community at large, while also providing greater measures of accountability for how the department functions as a custodian of North Carolinians,” Taber said.

In addition to the next-of-kin notifications, a variety of documents are completed following an in-custody death. These records include the official notice of death, an inventory of personal items belonging to the decedent, and an incident report, which “should be thorough and consistent,” according to DPS policy. These documents are compiled into a packet and sent to the DPS regional director, deputy director of prisons, and deputy director for health services.

But the packet is not sent to the next of kin. Advocates say sharing these documents is another way to improve the policy.

“That is their loved one,” Cobb said. “That is their mother, brother, sister, daughter, father. They should definitely know what happened. Everything should be transparent.”

Several lawmakers The Assembly contacted for this story were generally unaware of the current system, or efforts to change it.

But state Sen. Toby Fitch, a Democratic member of the General Assembly’s joint legislative oversight committee on justice and public safety, said he wants to pursue changing the policy.

Fitch said he plans to either introduce a new bill or amend existing legislation to address the issues with the death notification system. Fitch acknowledged that one way policies could be improved is providing families with a number they can call to set up a follow-up conversation with prison officials. Fitch said this conversation could be in person or virtual, however the family chooses.

Sen. Bob Steinburg, a Republican member of the General Assembly’s joint legislative oversight committee on justice and public safety, said that he was not previously aware of the policy, but “would be willing to look into it.”

“You are dealing with a human life,” Fitch said. “Regardless of whether they’re in for doing something, or for allegedly doing something, their families deserve respect.”

Lucy Combs outside her home. // Photos by Travis Dove

Lucy Combs has tried to develop new routines after George’s death. Every morning, she goes on a 30-minute walk. Every afternoon at 3, she sits on the porch and reads all her mail, even the junk. She watches a lot of Dr. Phil and talks on the phone with her brother and sisters.

Every few days, she visits the Mountlawn Memorial Park in North Wilkesboro, where there are gravestones for both George and her other son, Jeff.

Jeff disappeared in October 2008, while Lucy was at work. He left behind a vague note about theft, but was never seen again. Lucy climbed down wells searching for his body, which was never found. She sought to have Jeff legally declared dead; his headstone now states the date he went missing.

That she still doesn’t know what exactly happened to George either wears on her. She knows that if she really wanted to, she could pick up her phone and dial the prison again. She could keep calling and calling and praying that one day, she’d be patched through to someone who could finally explain.

In the drawer of her bedside table sits the second-to-last letter she ever sent to George, enclosed in the envelope she’d licked, stamped, and sent off on Nov. 10, 2020. The prison mailed it back with one word written on the front in green marker: DEAD.

Arabella Saunders is a journalist from the Outer Banks. Her work has appeared in HuffPost, VICE News, NC Policy Watch, and North Carolina Health News. She is a recent graduate of UNC-Chapel Hill’s School of Journalism and Media.

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