The last time Dana Palmer was conscious, she was belly-down in a jailhouse shower, frothing at the mouth, naked and unresponsive.
Guards at Silverdale Detention Center said Palmer had swallowed a bag of drugs on Feb. 22, 2017. The guards had cut her clothes off to search for other contraband. The 45-year-old mother of four died within an hour. And the medical examiner ruled it an accident, attributing Palmer's death to methamphetamine toxicity and choking on "foreign bodies" in her throat.
But her family points to a different culprit in their ongoing lawsuit against the local jail's private owner: pepper spray. And a full investigative file the Times Free Press recently obtained reveals far more detail about what happened that night.
Palmer "was perfectly fine" the day before she died, one nurse told law enforcement in an interview.
Others described Palmer, who struggled with drug addiction and bipolar disorder, as a compliant inmate. But around 4 p.m. Feb. 22, a corrections officer shot a one-or-two second burst of pepper spray into her eyes and mouth after Palmer refused to listen to orders and swallowed a bag of drugs she was hiding in her waistband.
CoreCivic, the private company that has managed Silverdale for Hamilton County since 1984, denied pepper spray was an excessive use of force in a recent motion in Hamilton County Circuit Court.
CoreCivic spokeswoman Amanda Gilchrist said the company's use of force policy follows a standard typical in correctional facilities.
"Our use of force policies and training are consistent with standard detention practices and adhere to the independent standards of the American Correctional Association - the national gold standard for correctional management," Gilchrist said.
But criminal justice experts and inmate advocates say Palmer's story reflects a force-first approach often used in CoreCivic facilities. According to 2017 statistics from the Tennessee Department of Correction, of Tennessee's 14 prisons, the four that CoreCivic operates had the highest uses of chemical force on inmates. These facilities have comparable populations.
"If she was choking, it begs the question: Was the use of chemical force what caused her to asphyxiate?" said Jeannie Alexander, a former prison chaplain who runs No Exceptions, an inmate advocacy nonprofit in Nashville. "If they sprayed her because she was combative, that's one thing. But if they sprayed her because she swallowed a baggie, that just seems so negligent. And it screams of a lack of training."
The investigative file reveals a divide on what the pepper spray did to Palmer. Some of the nine interviewed corrections officers and nurses said they didn't know how it affected her. Some didn't mention it at all in their retelling.
Others described its potency and said Palmer appeared visibly distraught by it.
"I believe by the time I got down there OC had been deployed, because I could smell it," one corrections officer said. The file only refers to many employees by their last names, meaning the Times Free Press can't verify the correct spellings. "It affects me, I have a very weak stomach," the officer continued. "I was walking up the hall because I was gagging, about to puke."
After a different corrections officer sprayed Palmer, she wrestled the 5-foot, 4-inch, 195-pound woman to the ground. With help from others, she said she put cuffs on Palmer's wrists and legs and unsuccessfully looked for the baggie in Palmer's throat.
"Once we got her restrained, she was still fighting, still resisting," the pepper-spray officer said. "She was refusing to spit the object out."
But a different corrections officer suggested Palmer was reacting negatively to the pepper spray. Palmer was having trouble breathing, the officer said, and had to be lifted by her armpits because she wasn't "all there."
"I just saw her breathing being hard," the officer said. "I was told they had deployed OC on her as well. Sometimes, when OC is deployed, you have a hard time breathing and catching your breath."
From there, officers walked Palmer down a hallway to a nearby shower. According to the interviews, medical staff and guards planned to search Palmer for more contraband and then "dry cell" her.
"If she ingested something and they're afraid she's destroying evidence, they'll often put a prisoner in a dry room with no toilet and wait till they go to the bathroom," said Alex Friedmann, managing editor of the Prison Legal News.
It's hard to tell how bad Palmer's medical condition was at this point because the accounts are conflicting.
"After we got the restraints on her and walking, she was fine," said one case manager.
Did the case manager notice any obvious signs that Palmer was struggling to breath? Sheriff's Office detective Shane Forgey asked.
"Not at that time, no sir," the case manager said.
Once they got Palmer to a shower cell, the case manager said Palmer refused to remove her clothes. "She became uncooperative, but she wasn't struggling. She just didn't want to do anything."
This was around the same time Palmer stopped breathing.
"There was like, some, I don't want to say slobber, but around her mouth," one nurse recalled in her interview, before trailing off.
A different nurse who'd been on the job four days said she ran out of the shower as this was happening: She'd forgotten a red bag with equipment that would allow her to measure vital signs.
"When I came back in [five minutes later], they were in full-blown CPR mode," she said.
According to a medical examiner's report, the facility called 911 around 4:40 p.m., a minute after officials initiated CPR. The report doesn't say when an ambulance picked Palmer up, but it places her at Erlanger hospital's emergency room at 5:14 p.m. Seventeen minutes later, a doctor declared Palmer dead.
Medical practices in Core- Civic facilities have recently come under fire in Tennessee.
State legislators delayed the regular reauthorization of the correction department, which oversees about 21,000 inmates at 14 prisons statewide, after a November 2017 audit outlined a number of issues at the CoreCivic-owned Trousdale Turner Correctional Center and chalked it up to understaffing.
Shortly before the audit, a Chattanooga judge began holding hearings on inmate allegations of delayed medical care at Silverdale. And earlier this month, Chattanooga attorney Whitney Durand filed a lawsuit against CoreCivic, saying the facility failed to provide his seizure-prone client with a bottom bunk. Two days later, Durand said, his client had a seizure in the middle of the night, fell from a top bunk and needed several head surgeries.
The county plans to demolish its downtown jail and expand Silverdale to house about 1,700 local inmates, so Sheriff Jim Hammond is working to address current problems. He wants to secure a $678,000, five-year grant that would help local health and wellness agencies get an estimated 40 percent of people with untreated mental illnesses or addictions out of jail and into treatment.
But there's still work to be done.
In May 2017, the same year Palmer died, the facility failed to meet six correctional standards related to security, sanitation, inmate supervision, accurate record keeping, medical services and staffing. Jason Clark, the corrections superintendent for the sheriff's office, said the facility had corrected many of these deficiencies in a Feb. 1 letter to the Tennessee Correctional Institute. At the time, Silverdale was down 16 correctional officers.
"There is a new correctional academy starting on [Feb. 12] with approximately 22 correctional officers," Clark wrote in the letter. "The facility increased the correctional officer starting wage in mid-September and has seen a positive impact on hiring and retention."
Friedmann, Alexander and other criminal justice experts say jail reform needs to continue otherwise stories like Palmer's will continue.
"If you're only trained to respond with force no matter the situation, if that's your hammer for every nail, then that's what's being used," said Valena Beety, a former federal prosecutor who heads the West Virginia Innocence Project and teaches at the West Virginia University College of Law, "even when it's not effective or helpful and is frankly dangerous."
CoreCivic and Palmer's attorneys, Herbert Thornbury and Lawson Konvalinka, return to court June 4 to address evidence-related issues.
Contact staff writer Zack Peterson at email@example.com or 423-757-6347. Follow him on Twitter @zackpeterson918.