TROY, Mo. - A Lincoln County Jail inmate suffered seizures for more than 30 minutes before anyone called an ambulance, a published report said Monday.
By the time help arrived it was too late for accused killer Charles Benoit, who had been locked up in the Lincoln County Jail for 15 months. He died on March 10, the day he was expected to plead guilty and go to prison for life for killing a motel clerk.
Details of his final moments were outlined in a story in the St. Louis Post-Dispatch.
Benoit, 43, died of an overdose of the medication doxepin, which he had been stashing away. The pills were supposed to calm his nerves and help him sleep.
The newspaper said jail officials acknowledged that jailers did not consistently supervise inmates taking high-risk medication or regularly search cells for hidden drugs. They also lacked suicide training. Officials say they have changed the jail's operations and begun suicide prevention training.
"Those are common practices that a good correctional facility will do regardless if it's a small jail or a larger metropolitan jail," said Lindsay Hayes, a consultant with the National Center on Institutions and Alternatives, which researches jail suicides and develops prevention programs.
The Missouri State Highway Patrol recently released a 170-page report into Benoit's death that concluded there was no criminal conduct by any of the jail's staff. But several of the jail's officers told investigators that an ambulance for Benoit should have been called much sooner.
Benoit was found by other inmates, convulsing. By then, he was beyond being saved by medical treatment, said Dr. Christopher Long of the St. Louis County medical examiner's office, which performed an autopsy. Long said Benoit had taken "enough doxepin to kill a horse."
But jail staff didn't know that, and the patrol's report shows Benoit's seizures lasted 34 minutes before anyone summoned an ambulance.
"Maybe we should have acted a little quicker, and I say that with a big emphasis on maybe," said Interim Sheriff Kent Hanshew. Benoit's death "gave us an opportunity to improve some things in the jail," he added.
Inmates playing cards saw Benoit writhing in his bunk bed at 4:36 a.m. A guard was called and found Benoit struggling to breathe and bleeding from his mouth after biting his tongue.
Sgt. Lindell Riffle, the jail's night supervisor, ordered inmates to carry Benoit to an observation room. Several inmates told investigators they heard Riffle say he refused to call an ambulance because he didn't want to look "like an idiot."
Sheriff's Department policy prohibits Riffle from commenting.
"We kept telling them, ‘This dude's going to die if you don't do anything,"' said inmate Dustin Hollingsworth, 22, of Elsberry, who helped carry Benoit.
An ambulance was called at 5:10 a.m. after Benoit had begun turning blue, stopped breathing and lacked a pulse. Paramedics arrived in four minutes and began CPR, but they could not revive him.
Benoit's death led to several policy changes. All corrections officers now get suicide prevention training. Daily, random inspections of cells are now conducted. A nurse must now dispense high-risk medication and observe inmates taking those medications.
Benoit was charged nearly two years ago with first-degree murder in the killing of Saunak Kapadia, 56, of Troy. Kapadia was found beaten and strangled in an SUV parked in a commuter lot near the Budget Inn and Suites. Benoit had lived at the motel and performed odd jobs there.
Though Benoit's death was not ruled a suicide, jail officials don't believe it was an accidental overdose.
As officers cleaned out Benoit's bunk the day he died, they found a handwritten poem: "I'm so tired I don't even try. There's a time to live, theirs (sic) a time to die. Time for wonder and I wonder why. There is a reason."