South Dakota Training School, Plankinton, SD
On Wednesday, 7-21-99, at approximately 1 p.m., Agents from the DCI were assigned by Attorney General Mark Barnett at the request of Governor William Janklow to investigate the circumstances surrounding the death of a young female inmate at the State Training School in Plankinton, SD. Agents were advised that the victim in this case, who will be referred to as G.S., had been taken to Avera Queen of Peace Hospital in Mitchell, SD. Special Agent Dennis Marek, Mitchell, SD, has been assigned case agent status on this investigation, file No 9902706.
Place of Incident
The South Dakota Training School (hereafter referred to as STS), was established at Plankinton by the territorial legislature of 1886 and received its first student on November 3 of 1888 as the Dakota Reform School. The 1907 Legislature changed the name of the institution from the Dakota Reform School to the SD Training School.
On 7-16-99, G.S. was examined by Merridy J. Fett, R.N., a nurse contracted to Department of Corrections by Sioux Valley Hospital to provide nursing service, who completed what has been described as 'a basic work up physical' which included blood pressure, height, and weight. (G.S. was 5'4', 224 Ibs.)
G.S. participated in physical exercise on the afternoon of 7-19-99 which included instruction as to the proper form and kinds of calisthenics to be done in the program. On 7-20-99, physical fitness training was restricted to the gymnasium, where G,S. participated in calisthenics and jogging around the gymnasium.
On 7-21-99 at 5:45 a.m., the female inmates from Cottage B got up to do their physical training. At approximately 6 a.m. physical training began with the students being directed to drink water and warm up for physical training by doing a series of stretching exercises (temperature 68 degrees, humidity 81%.) At approximately 6:30 a.m. to 6:45 a.m., 16 students and 3 staff members began the walk/run (temperature 70 degrees, humidity 67%).
The staff members were: Raelene Layne, Group Leader at Plankinton and in charge of Cottage B; Tamara Wagaman, Youth Counselor and in training to be a group leader, Roxanne Frey, Youth Supervisor. Layne was the most senior with 3 years experience. Wagaman has been employed 2 years, and Frey had only been working for about 3 weeks. Layne was in charge of the activity and Wagaman and Frey had the most contact with G.S. during the incident. They ran/walked beside her during the entire exercise. None of the staff had more than elementary training in first aid and none of them were ever trained or had dealt with heat exhaustion.
The course of exercise for the run/walk has been described as having four corners and is approximately 2.7 miles.
Shortly after the run/walk started, G.S. fell behind. She was able to keep up with the group for the first hundred yards, but then dropped out and stated that she couldn't do this anymore. Wagaman and Frey told her that there is no such thing as 'can't' and were yelling at her to keep her feet going and to show effort. G.S.'s response was, 'a kind of sniffling' and saying she couldn't go on.
At the first corner of the course, .6 miles, Layne and the other girls stopped to wait for G.S. to catch up. Once G.S. arrived at the corner, the group took off again. G.S. did not take a drink at this corner.
Approximately 50 yards past the first corner, G.S. wanted to stop again. Wagaman told her to take a small drink and pour some water over her face. G.S. took a drink. At this point, Frey put her hand on the small of G.S.'s back so she would continue to go forward. Students S.F., N.C., H.D and S.G said Wagaman and Frey interlocked arms with G.S. to keep her moving forward.
Layne and the other girls arrived at the second corner, 1.1 miles, and again had to wait for G.S. to catch up. When G.S. got to the second corner, the group took off again and G.S. fell behind right away. G.S. asked for a drink, but Wagaman and Frey would not let her have a drink until she got to the third corner. Students M.S. and J.E. said that Wagaman and Frey interlocked arms with G.S. between the second and third corner and paced/pulled her along.
Once they arrived at the third corner, 1.9 miles, G.S. had a drink of water. After rounding the third corner, the group was heading back in the direction towards the STS. Student M.S. said Wagaman and Frey interlocked arms with G.S. between the third and fourth corner, pulling her to go faster.
Between the third and fourth corner, another student started to have problems near the front of the group. Wagaman went forward to help this student, leaving Frey alone with G.S. Frey was able to keep G.S. moving until they reached the fourth corner, 2.4 miles. This is where they all regrouped and headed back towards the cottages.
After the fourth corner, G S fell behind again. Students M.M. and C.L. tried to interlink their arms with G.S. to try and keep her up with the group. It was at this point that G.S. laid down/collapsed for the first time, and C.L. was trying to hold her up.
It is unclear how much water G.S. consumed during the exercise period. Her bottle was covered in a leather case so even when she drank, the staff could not tell how much water she took. The other students would take water when they had stopped and wait for G.S. to catch up. When she caught up the group would start the walk/run again so G.S. did not get to rest or drink water.
While the majority of the students finished the course at approximately 7:35 a.m. to 7:45 a.m. (temperature 70 degrees, humidity 81%), two students appeared to be having problems. When student N.C. finished the run she laid down on the ground. It was her first time completing the course. When G.S. got near the finish line (approximately 7:45 a.m.) she laid down/collapsed on the ground too. Frey stated N.C. and G.S. Looked the 'same' except N.C. was not breathing hard. N.C. also got up and moved around with 'no problems' G.S. did not get up and was 'acting like she did not want to do this.'
At this point in the incident, Layne, Wagaman, and Frey felt that G.S. did not get up because of her attitude. It appears that they came to this conclusion based on the statement of student T.B. T.B. told Wagaman that she was in placement at The Turning Point in Sioux Falls with G.S. While there T.B. witnessed G.S. pull the same kind of behavior to get out of work. None of the staffed witnessed any prior behavior from G.S. to come to this conclusion on their own.
From this point on everything that the three witnessed reinforced their belief that G.S. was 'faking' her symptoms. Her hyperventilating was believed to be self-induced. She lost bladder control and staff viewed it as purposeful. Her inability to get up and continue was viewed as her unwillingness to participate.
At about 7:55 a.m. Layne called nurse Fett to check on G.S. rapid breathing (temperature 70 degrees, humidity 81%). Fett was not yet at work. At approximately 8:05 Fett arrived at work, was flagged down and checked on G.S. This check consisted of Nurse Fett taking vital signs and getting staff information, and concluding that G.S. was hyperventilating. Nurse Fett advised that she spent approximately 20 minutes with G.S. and then went and got paper bags to assist G.S.'s breathing. Nurse Fett then went back to her office to call PA Cody.
Upon arriving at her office, she became busy and did not reach Cody until approximately 9:15 p.m. (temperature 71 degrees, humidity 81%). When she did reach Cody, they agreed G.S. was hyperventilating. Nurse Fett did not return to G.S. until approximately 10:05 a.m. when she was again called by staff to reassess this as a medical problem.
At approximately 9:15 a.m., G.S. got up with the assistance of the other students and tried to walk the remainder of the course. G.S. was unsteady and after about 100 yards, G.S. again collapsed in the road. G.S. was panting heavily, lost bladder control and did not appear to be able to drink water when offered. Layne contacted Ramsey and Johnson, described G.S.'s behavior and was advised to 'wait out' G.S. (temperature 71 degrees, humidity 81%).
At approximately 10:00 a.m., Layne noticed goose bumps on G.S.'s arms. She again called Nurse Fett to evaluate G.S.'s medical condition (temperature 73 degrees, humidity 81%).
At 10 05 a.m. Nurse Fett returned to the location and again checked G.S.'s respiration and pulse. It should be noted that over two hours passed. G.S.'s respiration and pulse had risen and G.S. had only moved approximately 100 yards in that period of time. G.S.'s vitals were getting higher versus getting lower.
Nurse Fett spent approximately 25 minutes with G.S. and then left the scene to call PA Cody. At about 10:30 a.m. Superintendent Ramsey and Program Director Johnson arrived at the scene (temperature 75 degrees, humidity 81%). Ramsey attempted to talk to G.S. Johnson returned to the school to get a backboard to move G.S.
At 10:40 a.m., Physician's Assistant Cody, and Dr. Kleinsasser, staff psychiatrist for South Dakota Human Services Center, arrived at STS for a scheduled meeting and tour. Upon approaching this incident, these medical professionals examined G.S. and ordered that an ambulance be called (10:47 a.m.). The ambulance received a call requested by staff member Layne, and proceeded to the location, arriving at the scene at 10:53 a.m. The ambulance attendants administered oxygen, then loaded and transported G.S. at 11 a.m. to Queen of Peace Hospital in Mitchell (temperature 77 degrees, humidity 54%). Staff member Layne accompanied them on this trip.
According to the estimates by the staff, the run/walk started at 6:30-6:45 a.m. and ended at 11 a.m. when G.S. was transported by ambulance to Queen of Peace Hospital in Mitchell. G.S. collapsed at the end of the course at approximately 7:45 and remained near where she fell for 3 and a quarter hours. During this time, G.S.'s condition progressively worsened and the symptoms she exhibited were: Rapid shallow breathing described as 'panting.' Paleness Inability to get up and stay on her feet. When she did walk, she was described as staggering and 'looking drunk' Progressive loss of her ability to communicate. Her speech was described as 'mumbling' and 'incoherent' Twitching of the muscles Loss of bladder control on 2-3 separate occasions Frothing at the mouth Inability to drink or hold down water Eyes rolling back into the top of her head Lividity setting into her legs and arms Complete unresponsiveness Dilated pupils
While G.S.'s condition progressively worsened, the staff took the following actions: Staff called Nurse Fett the first time G.S. went down Staff instructed G.S. to slow down her breathing Staff held a brown paper bag over G.S.'s mouth to help regulate her breathing Staff verbally encouraged/harassed G.S. to get up and complete the course. Staff refused to allow students to form a human shield in an attempt to shade G.S., remarking that the students should not make things 'easy' or 'comfortable' for G.S. Layne took 12 of the students back to the school to finish stretching out and left G.S. with 3 other students and Wagaman and Frey. Staff brought toast and water out for the rest of the students. Staff brought pop out for themselves Staff called nurse a second time when they noticed goose bumps on G.S.'s arms
According to ambulance records, at 11:14 a.m. G.S. coded en route to the hospital, and a defibrillator (electronic shock) was administered to the heart. This failed to revive G.S. so CPR was started. The ambulance arrived at the hospital at 11:22 a.m. CPR and resuscitation attempts were unsuccessful. At 12:38 p.m. CPR is ended and G.S. was pronounced dead.
G.S's core body temperature taken rectally at the hospital was 108 degrees, which is the maximum measurement for the thermometer.
Davison County Coroner George Bittner, 805 West Havens, Mitchell, SD 57301, filed death certification #140 on August 9, 1999, listing G.S.'s cause of death as hyperthermia.
An autopsy was conducted by Dr. Brad Randall of LCM, Sioux Falls, SD. The autopsy report also concludes the cause of death as hyperthermia.
The investigation is continuing.
This case summary has been compiled by agents and employees of Division of Criminal Investigation, Deputy Attorney General Robert Mayer, Aurora County State's Attorney John Steele, and Aurora County Sheriff David Fink under the direction of DCI Director Doug Lake.
As of this date, there have been 29 people interviewed during the course of this investigation. They are:
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- Clay Ramsey, Superintendent STS
- Raelene Sterling Layne, Group Loader and in charge of Cottage B, STS
- Tamara Wagaman, Youth Counselor STA
- Roxanne Frey, Youth Supervisor STS
- Merridy Fett RN Sioux Falls Hosp.
- .Jim Cody, PAC
- Dwight Schamber, EMT
- Josephine Schamber, EMT
- Eric Granlund, STS
- Diana Baca, STS
- Dale Edwin, SD Bureau of Personnel
- Don Johnson, Program Manager, STS
- Jeff Haiar, Asst. Director for the Juvenile Boot Camp for Custer.
- Bradley Kleinsasser, Staff Psychiatrists for the George S. Mickelson Center for Neural Sciences, Yankton
- Len Sanderson, JCA
- Jennifer Osterlook College Intern
- Fifteen juvenile females who currently reside at the state training school
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