“We kept hollering and slamming on the door cell saying, 'Hey man this guy is dying right here.' It kinda freaks me out, you know, that we could be in here and something simple could become complicated because nobody seemed like they cared about us.”
Jeffery Simmons, 45, complained about chest pain while being booked into the Hamilton County Jail.
It was 3:23 a.m. May 11, 2017, when a nurse working in the booking area that morning was called to assess Simmons. She stated he appeared to be "a little sweaty," but his vital signs were normal and she cleared him for booking within a few minutes.
Two hours later, Simmons was found unresponsive on the floor of his cell. Officers pulled him from the cell and performed CPR until an ambulance arrived. Three hours later, at 6:21 a.m., he was pronounced dead.
A preliminary autopsy report showed Simmons' urine tested positive for methamphetamine. Additional lab results concluded the cause of his death was an accidental overdose with a "contributory factor of Coronary atherosclerosis."
Investigators with the Hamilton County Sheriff's Office concluded no department policies or employee actions contributed to his death.
Corrections officers and medical personnel said they didn't interact with Simmons much before the fatal incident and indicated the first real sign of trouble was when he was found lying on his back in the cell.
But inmates who were in the cell with Simmons told investigators he was in bad shape when he joined them and his condition only declined from there. They said he was begging for help, sweating profusely and hyperventilating as his condition worsened. They said they banged on the cell door and yelled for medical attention for more than an hour, but his pleas were ignored.
Now, almost a year later, his family is trying to sort out the details of Jeffery Simmons' last hours.
Simmons wound up in the jail early that morning on charges of possession of drug paraphernalia and ice methamphetamine.
Deputies had been dispatched to his home on a report of a noise complaint, and when they arrived they found his nephew and girlfriend, both of whom were in possession of a white, crystal-like substance consistent with meth.
They gave consent to search the home, and inside deputies found Simmons. A search of his room yielded two more plastic bags containing what appeared to be meth, a glass pipe and some marijuana. All three suspects were detained and taken to the county jail in downtown Chattanooga.
It was in the intake area that Simmons said he was feeling chest pains and that his family had a history of heart disease, according to the investigation report. The nurse who checked him, Audrey Adams, told investigators she noted no distress and no medical treatment was given.
"He was just a little sweaty. His breathing wasn't labored, so I was like, 'Your pulse is good, your blood pressure is good, your breathing is not labored, so right now I can't do anything,'" she told investigators. "I said, 'I'm going to be down here on the floor so I can keep an eye on you if you need anything or call me.'"
Surveillance footage from the intake area obtained by the Times Free Press shows the assessment Adams conducted on Simmons. She can be seen entering the room at 3:25 a.m., approaching Simmons while he's seated on a bench and then leaving three-and-a-half minutes later.
Adams said the next time she saw the inmate was around 5:30 a.m. when he was found, barely breathing, on the floor of his cell.
Testimony from Simmons' fellow inmates and the corrections officers give conflicting accounts about the hours leading up to his death. However, both groups said the incident began escalating around 5:30 a.m. when deputies served breakfast to the inmates. Simmons was already lying on the floor of the cell at that time and didn't get up for food when officers opened the cell.
"As we made our way to that cell, I opened the door, everybody come out except for Mr. Simmons," Deputy Ramsey said. "He was on the floor. He was breathing. He was talking."
Deputies are only referenced by last name in the internal affairs investigation provided to the Times Free Press.
Ramsey told investigators that Simmons said he couldn't get up and needed help. But he and the other officers elected to finish serving breakfast at the other cells before pulling him out, although it was clear he was "obviously not feeling well then," he said.
"At that time, it didn't look like it was something that dire. If I had had any idea he was having a heart attack at that moment, I would have pulled him out myself," Ramsey said.
Deputy Wofford said she walked near Simmons' cell shortly after his fellow inmates were served breakfast and noticed the inmates were motioning and calling to her as she came to the cell.
"I didn't have a key, but I looked in the door and I could see his feet and part of his legs so I called and said, 'Hey, who has a key? I need somebody with a key over here quick.' So Officer Ramsey came over and he opened the door and he looked and I looked and I thought, 'Well we need to get medical over here.'"
Ramsey confirmed Wofford's account and told investigators he saw Simmons was unconscious at that point.
"He was still breathing, but it was definitely shallow, so at that point, I decided to try to drag him out of the cell," he said. "I asked another inmate to help me get his arms and I got his legs and we carried him out."
"By the time I sat him on the ground, I looked down and he was not breathing and that's when I called for medical on the radio and got down and started chest compressions."
Testimony from other officers on the scene support the essence of Ramsey and Wofford's accounts, but multiple inmates said there was cause for concern about Simmons' life well before the crisis at breakfast. According to the inmates, he was ignored and left to die.
Over the course of several separate interviews, inmates told investigators that Simmons was complaining about chest pain in the cell for an extended period of time. They said he appeared to be in pain and they banged on the cell door all the while, trying to get him help.
"They brought him in pretty late, and at first we thought he was drunk or something because he came in like something was wrong with him," said inmate Kenneth Weaver. "He was hyperventilating and he was like, 'I need some help, I need some help.'"
"I guess within three or four minutes, he just broke out in a mad sweat. Took his shirt off and he was just dripping sweat. And everybody else started waking up then."
Weaver said another inmate began banging on the door and Ramsey eventually pulled Simmons out for a few minutes, but he started having another episode when he was brought back to the cell.
Another inmate, Jackie Swafford, said the incident went on for more than an hour. He said the man was sweating bullets, yelling that his chest was hurting and begging someone, anyone, for an aspirin.
"All of us kept banging on the door and the guards would come over and look in the window and they'd [say], 'He's all right, he's just coming off of drugs.'"
He said he kept an eye on Simmons, who eventually laid on the floor and started to turn colors, but Swafford was also ignored when he banged on the door. He said officers told him Simmons was all right because he was breathing.
"He started taking his legs and he'd curl his foot in like he was trying to stretch his leg out and he was curling his feet in and his arms were curling in," he said. "It was just horrible because I knew the poor man was in pain."
Inmate Jonathan Arwood also said he knew there was a problem with Simmons because of how much the man was sweating.
"As cold as it is in that cell — at that time of night it gets freezing cold — the man had no shirt on. Sweating bullets, I'm talking about. Leaning back, discoloring. We're still telling deputies, 'Hey, the man needs attention.' [the inmates]were ignored," he said. "This went on for an hour or so."
He said Simmons was sitting with his head tilted back at first, but other inmates told him to lie down so he did, gasping for air and changing colors while the rest of them got breakfast. When he came back, he saw Simmons had urinated on himself.
Inmate Robert Jackson interpreted Simmons' symptoms the same way others did, but was told he was coming down off of meth.
"[Simmons] was sweating bullets and stuff like that. I said, 'Look here, y'all, he might not be playing or nothing because, look at him, it's cold as hell in here. Why's he sweating so hard?'"
"He was having a heart attack," he said. "I said, 'Nah man, look at him. He ain't coming down like that — not sweating and turning purple. Something's going on."
Inmate Stephen Henshaw said he was also told by officers that Simmons was fine, despite his complaints that he thought he was having a heart attack.
"One of our guys said, 'That was just [a nurse] that seen him. He needs to go back to medical." They wouldn't do it. They didn't care. They did not care if that man was lying there dying or not," he said.
A spokesman for the Hamilton County Sheriff's Office declined to answer questions about those testimonies, but one of the inmates, Christopher King, said the experience was traumatic.
"We kept hollering and slamming on the door cell saying, 'Hey man, this guy is dying right here,'" he said. "You think they would do a little more. You think they would have checked him out a little bit better, especially in the condition that he was in being on cold concrete and everything else. I think it was a little bit negligent."
"It kinda freaks me out, you know, that we could be in here and something simple could become complicated because nobody seemed like they cared about us."
Health care services and resources at the downtown county jail have been provided by Erlanger hospital, which staffs both the jail clinic and a medical station in the booking area. The sheriff's office has contracted for medical services with the hospital since 2001, according to a copy of the agreement provided to the Times Free Press by Erlanger.
According to the contract, medical staff are employed to conduct preliminary health screenings of inmates, administer medication and provide appropriate emergency medical care when necessary.
Medical personnel have some discretion when it comes to treatment of inmates with health concerns, but are also required to follow guidelines laid out by the sheriff's office and Erlanger. In the case of inmates experiencing extreme, life-threatening complications from either an overdose or withdrawal, policy dictates the patient should "be immediately transferred to Erlanger Hospital."
Dr. Ron Buchheit, a physician who has worked in the emergency room at Erlanger for seven years, said he couldn't speculate about Simmons' condition because he never interacted with the patient, but he did say someone who dies from an overdose should exhibit some telling symptoms beforehand.
"Going from no signs, normal blood pressure, normal heart rate and then showing no signs in between and then dying — that seems odd. With meth, you're going to show signs," he said. "Their heart rate starts to elevate substantially. Their blood pressure shoots up. They can get profusely sweaty."
Buchheit has treated a number of patients experiencing overdoses over the last several years and said the severity of each emergency largely depends on the amount of drugs ingested and the patient's medical profile.
He said doctors are typically focused on mitigating symptoms in overdose situations, but complicating health factors, such as heart disease, can add gas to the fire.
"The goal of treatment is to decrease the agitation. When you take large quantities, you can get hypothermia, you get high blood pressure and tachycardia," he said. "We're looking to calm the patient down so their heart rate and blood pressure can go down."
"[An overdose] can lead to heart attacks as it progresses or worsens, so it's a pretty significant problem. If you've got cardiovascular disease, it will obviously, definitely, make that worse."
Simmons' sister, Tina Honeycutt, doesn't think her brother had to die the way he did.
"With that many [inmates] having the same story, without them being able to compare stories, obviously that's what went on," she said. "I just feel that he would be alive today if he had gotten medical help. He would have had a really good chance."
She said the death has taken a toll on her whole family, especially since another one of her brothers died of cardiovascular disease a few months after Jeffery. She said her father has been particularly affected and his health is failing as a result.
"Every time he closes his eyes, he says he can't get his mind off Jeff. I really think it's going to put him in his grave. We understand what Jeff done. It was Jeff's fault for doing what he did, but it's their fault for not getting him medical attention," she said.
Her husband, Joe Honeycutt, said he doesn't have any love for drug users or addicts, but believes it's the responsibility of law enforcement to ensure the people in their charge receive proper medical attention.
"Why didn't somebody step up to the plate and do the right thing? You don't let somebody die. It doesn't matter what they've done, they're a human being."
Contact staff writer Emmett Gienapp at email@example.com or 423-757-6731. Follow him on Twitter @emmettgienapp.