Coroner's Inquest - what is it?

At 1:00PM a Coroner's Inquest was conducted into the death of Thomas Puchmelter while he was confined in the McHenry County Jail. Puchmelter attempted suicide while in his cell on the evening of Friday, February 18, just as shift change was occurring between the evening shift and the night shift. He was hospitalized and was pronounced dead on Sunday.

Puchmelter had been arrested by the Crystal Lake Police Department and transported to the McHenry County Jail. Records are a little fuzzy in the 94-page report compiled as part of the investigation into his death. When he was found in his cell at about 10:40PM, efforts were made to keep him alive and he was transported to Centegra Hospital - Woodstock.

A deputy coroner conducted the inquest and explained the duties to the assembled jurors, whose charge was to determine the manner of his death. Eight jurors were present; six were selected by the deputy coroner, and two were seated as alternates. The jury consisted of four women and two men; the two alternates were men.

The deputy coroner made opening statements that public inquests, rather than closed hearings, were usually held in "high profile" cases and that it wasn't a civil or criminal trial. The jurors could ask questions, but the family and audience could not. In determining the manner of death, the jury's choices would be 1. of natural causes; 2. homicide; 3. suicide; 4. accidental; or 5. undetermined.

The jury was sworn in, and the deputy coroner presented facts. Among the facts were that Puchmelter had been pronounced brain-dead on February 20 at 1:35PM, that he had been arrested on February 16 and brought to the jail on February 18. I thought I heard her say that he was found in a medical pod in distress on February 18.

MCSD Det. Michelle Asplund was present and answered most questions by reading from her investigative report.

Unlike a previous inquest I attended in 2007, members of this jury asked keen questions. One woman juror was particularly curious about what Puchmelter's reaction to being served an Order of Protection in the jail was. She asked if it was customary that a prisoner be served an O.P. in jail and then be left alone. A question was asked about his reaction to the O.P., but there was no one present who could answer that question.

A question was asked about the dates and times of medications that were administered to him, and whether he had a prior record. A question was asked whether jail officers knew his background.

When the jury went out for deliberations (they were sent to a hallway adjacent to the meeting room (were there chairs there? Or were they expected to stand in the hallway and quickly made an obvious decision?)), I asked if I could approach the deputy coroner, because I wanted to explain that an error in dates had been made in her explanation to the jurors. I was politely directed to wait until the proceedings ended.

The jury returned in just a few minutes with the verdict of death by suicide.

I had a conversation with an attorney from the State's Attorney's Office and pointed out what I believed were problems on the evening shift that resulted in an opportunity for Puchmelter to hang himself in his cell.

The report by the Sheriff's Department on the investigation into his death omitted (1) any reference to a suicide watch (there was none); (2) his emotional reaction, if any, to being served the O.P. on Friday; (3) to any anticipated effect of his not getting all his medications at the 9:00PM dispensing; (4) to the transfer of any information about Puchmelter from the evening-shift corrections officers to the night-shift COs.

I recall seeing a page of instructions for the conduct of a coroner's inquest, when I attended one about four years ago. I especially recall that witnesses were to include those who had first-hand knowledge of what had happened. In that previous case, no deputies who were on the scene of the officer-involved shooting were present to testify. Instead, a supervisor showed up to report what he had been told about what happened. That's not the same thing!

And today no one who was actually present before he died showed up. The detective who was called after he was found in his cell was the one who testified what she had learned from her investigation. That is not first-hand knowledge, which is what the Coroner is supposed to provide the jury.

I have no quarrel with how the detective did her job. Her report is detailed and thorough, and she was compassionate with the inmate's mother.

So the questions remain unanswered about where the system broke down on the evening shift. Why did they not inform the night shift of the inmate's emotional state after being served with the O.P.? Why didn't they report that his medications had not been fully dispensed? When they locked him in his cell early (9:00PM), did they check on him?

And why didn't the Crystal Lake Police Department inform the Jail personnel of the risk of suicide, which the inmate's mother had told them about?

Corrections officers, if they are to be able to perform their difficult jobs properly, must have all the information. Hopefully, procedures will be tightened up and awareness of inmate risk will be increased.

After the conclusion of the inquest and the release of the jury, I asked the deputy coroner about the date in her report for when Puchmelter was brought to the jail. Indeed, there was an error, which she quickly recognized. She also showed me in her report where the typewritten sentence read that he was in medical distress, not "in a medical pod in distress."