On the afternoon of Aug. 1, Multnomah County Corrections Deputy Kirk Evanoff was making his rounds on the seventh floor of Portland’s maximum-security downtown jail.
He’d been working more than 14 hours, the tail end of a double shift. Thanks to short-staffing, he was responsible for checking on 64 cells, double the typical number.
Some time that afternoon, he peered through the window of Cell 26. Clemente Pineda was lying facedown on the floor near the door.
This wasn’t remarkable to Evanoff, even though the 36-year-old Pineda had been that way since lunch. As Evanoff later told WW, inmates often appear incapacitated due to the powerful drugs smuggled in to the jail.
Evanoff asked Pineda if he wanted meds. Pineda didn’t respond, Evanoff says, so he and the accompanying health care aide moved on. At no time while Pineda was facedown on the floor during Evanoff’s shift that afternoon did the inmate receive medical care, the deputy tells WW.
Shortly before Evanoff’s shift ended, he wrote a note describing Pineda’s state. “[He] was unresponsive during medpass but is most definitely breathing,” it said.
Around an hour after Evanoff’s shift ended, Pineda stopped breathing. Jail employees rushed to resuscitate him, but it was too late. Pineda’s was the sixth death of an inmate in Multnomah County jails since May.
On Aug. 11, Evanoff was fired. The county offered no explanation, Evanoff says, but he believes he was made a scapegoat. “I followed policy,” he tells WW. “He showed no signs of distress and was breathing.”
In the days following Pineda’s death, Evanoff’s log message was circulated by jail staff shocked by the circumstances of the death. His documentation undermined the official story.
The county had said in a press release that Pineda was “found unresponsive in their cell” at around 4:15 and “corrections deputies immediately began lifesaving measures.” But Evanoff’s note implied that jail staff were aware of his condition far earlier.
Sheriff Nicole Morrisey O’Donnell declined an interview with WW. “The death of Clemente Pineda is an active and ongoing investigation, and we cannot comment further,” a spokesman for her office said.
There will be explanations, eventually. O’Donnell has called in state and federal agencies to help figure out what went wrong. But it will be months, if not years, before the public learns what they find.
The quick firing of Evanoff prior to completion of an investigation is likely an attempt to shield the county from liability. Whether or not staff is ultimately found negligent, imposing discipline helps protect the county from claims it violated inmates’ civil rights.
“That’s the jail covering their ass,” explains Matthew Kaplan, a litigator with experience filing wrongful death lawsuits against county jails.
On the other hand, it could provide prospective litigants with powerful ammunition. “[Evanoff] might be a great witness,” Kaplan says. “He’s a disgruntled employee saying, ‘I just do it how they train me.’”
That’s certainly what he’s saying in the days after his firing—and his account fits into a larger picture of a county jail system where dysfunction has turned deadly.
Internal documents and WW interviews with current and former staff reveal the jails’ struggles to adapt to a series of interconnected crises: the influx of the deadly new drug fentanyl, the increasing severity of inmates’ mental illnesses, and a staffing crisis that some say has made the jail more dangerous.
In recent weeks, the sheriff has gone on a publicity tour touting recent changes, including an aggressive new strip search policy.
But not all of her appearances have been publicized. Earlier this month, WW has learned, Sheriff O’Donnell showed up at staff meetings with a stern warning: Falsify jail logbooks and you will get fired. It’s believed to be a response to suspicions that deputies failed to follow protocol prior to one of the deaths, then forged their logs to suggest they had.
Whether this crackdown will be enough to stop the death toll from rising further remains to be seen.
“These deaths are devastating,” County Chair Jessica Vega Pederson tells WW, “and something that has to change immediately.”
But to know what to change, one must first know what went wrong.
The county has acknowledged, under questioning from WW, that two of the deaths this year were suicides. In both cases, the men had shown signs of mental illness.
This isn’t uncommon: 32% to 80% of inmates in Multnomah County jails are believed to have a mental illness, according to a 2018 report by Disability Rights Oregon.
But it raises the question of whether the men received appropriate care.
Donovan Wood, 26, who died in May, had threatened to slit his throat prior to his arrest, his sister indicated to police.
In December, the county converted Dorm 15 in the eastside Inverness Jail to house mentally ill inmates. Wood was transferred to that dorm shortly before his death, according to jail records. And it’s likely there that Wood suffocated himself with a plastic bag during the night.
There’s no indication yet that jail staffers made any mistakes in their treatment of Wood. But the county auditor pointed to a systemic issue with the county’s specialty housing for inmates with mental illness in a report released early last year: While the county added housing, it didn’t budget for more specialized staff. (A spokesman says there’s a “mental health team” of one sergeant and one deputy that spend time at both jails, including Dorm 15.)
The second suicide occurred six weeks later, in the downtown jail. Martin Franklin was found hanging by a bed sheet the morning of June 16.
Like Wood, Franklin had a history of mental illness. He’d been given a psychological evaluation following concerns that he wasn’t capable of defending himself at trial. A person familiar with the situation says Franklin had complained about not being let out of his cell for routine time in a common area.
There are widely held suspicions that Franklin was not adequately supervised overnight prior to the discovery of his body, multiple people close to the jail tell WW.
Whether this is true will be easy for jail administrators to check. “They’re going to have video of guards doing their rounds—or not,” Kaplan the lawyer says. “It should line up with the logbook.”
If the video exists, prosecutors will see it. The investigation into Franklin’s death has already been sent to the Multnomah County District Attorney’s Office to review for possible criminal charges, DA spokeswoman Liz Merah tells WW.
Both the locking of Franklin in a cell and the temptation to cut corners on checking that cell would seem to have a common cause: short-staffing. In fiscal year 2020, the sheriff’s office had 11 job vacancies. Two years later, in 2022, there were 44. The county is “aggressively hiring corrections deputies,” a spokeswoman says, but as of earlier this month there were still 30 empty positions.
Meanwhile, mandatory overtime has skyrocketed and morale has plummeted. “People are complaining that they’re getting hit with overtime four days a week,” Evanoff says. “They’re tired and yawning and just look so lethargic.”
Some of the remaining deaths may be drug-related, the sheriff says. It is not clear which ones. But Evanoff assumes Pineda died of an overdose.
Another likely drug-related death is that of Josiah Pierce, who died July 19. The county has not released the cause, but he was hospitalized the day before after behaving erratically, according to jail records obtained by WW and people familiar with the matter.
Over the past few years, the arrival of the uber-powerful opioid fentanyl has worsened conditions inside the jail. Inmates are detoxing in their cells. Others smuggle the drug in and overdose.
The smuggling problem was exacerbated by the jail’s phasing out of strip searches in the past few years, multiple people familiar with the situation tell WW. Instead, inmates were patted down and scanned by X-ray machines, which were installed in late 2019 and the sheriff now says aren’t capable of detecting fentanyl.
Staff has been complaining for years about the technology’s ineffectiveness and insufficient training in how to use it, several people tell WW.
On Aug. 1, the jail finally took action. It distributed a policy memo saying all new inmates would be strip searched. It subsequently expanded the policy to include all inmates transferred between the county’s two jails.
The sheriff recently outlined her plans on a walk-through of the jails with county commissioners.
Commissioner Susheela Jayapal says the new strategy is a trade-off. On one hand, she says, strip searches are “an inherent violation of privacy.” On the other hand, she was told there’s no other way to detect the small amounts of fentanyl that can cause a fatal overdose.
Meanwhile, the lack of transparency from the sheriff’s office leaves survivors in torment.
Like Allen Walker’s family, who learned from a phone call May 15 that he’d died of internal bleeding from his stomach two days before in Portland’s downtown jail.
Walker had struggled with fentanyl addiction, but he’d never previously had stomach issues, his sister, Angela Gilgan, tells WW.
“What do you mean?” Gilgan recalls saying in disbelief. “He was only 31.”
Unlike after every other death so far this year, the county offered an immediate explanation: He died of natural causes, according to a preliminary analysis by the medical examiner that ruled out “foul play, overdose or suicide,” a jail spokesman told WW at the time.
But a recent incident has left Gilgan suspicious that the jail neglected her brother.
Last month, Gilgan says, a customer came into her sister’s pawn shop with a disturbing story about an inmate who had died in a Portland jail. He’d been screaming for help, and it never came.
It left Gilgan wondering. “Maybe he did ask for help,” she says, “and they just ignored it.”