Secrecy, Inaccurate Records Stymie Families’ Search for Truth in Missouri Prison Deaths

Tammy Reed doesn’t believe the body described in her son’s autopsy is his.

In 2024, she filed a federal civil rights lawsuit against the Missouri Department of Corrections (MODOC) over Brandon Pace’s April 2023 death at the Tipton Correctional Center in central Missouri. Pace died after an officer from the Correctional Emergency Response Team sprayed Pace with a “fire extinguisher-sized” can of pepper spray, according to the lawsuit, which was first reported by the Missouri Independent.

Two weeks later, pathologist Keith Norman Norton, M.D., evaluated the remains of a “well-developed, obese man,” ruling that Pace’s death was accidental and caused by methamphetamine intoxication. The autopsy stated Pace had no reported medical history aside from drug use.

But Reed says the man described in the autopsy report bears little resemblance to her son. For one, Pace stood 5’10”, four inches taller than the height listed in the autopsy report. His BMI was 28.7, a far cry from the 33 documented on his autopsy, she says. Even more concerning to Reed, the autopsy claims that Pace’s back and chest were free of tattoos or other markings.

“Brandon’s tatted out. I mean, he—you could hardly put another tattoo on his body,” Reed said.

The autopsy report also omits key details about Pace’s medical history. In addition to his struggles with substance abuse, Pace had several chronic medical conditions—including hepatitis C, heart disease, high blood pressure, and paranoid schizophrenia. 

Also not mentioned in the autopsy is the pepper spray—which the lawsuit says was used on Pace at close range after he had been restrained by the hands and legs. The specific canister of pepper spray that a correctional officer allegedly used on Pace delivers an “excessive dose” that is intended to be used for large rioting crowds.

Reed’s lawsuit against MODOC faults the department for blocking her other efforts to get to the bottom of her son’s death. The autopsy report notes that Tipton’s warden at the time, Brock Van Loo, told medical examiners that video showed Pace consuming an “unknown substance” shortly before his death. But MODOC has denied Reed’s requests to view the footage, according to the lawsuit.

“The MODOC refused to provide Plaintiff information about Mr. Pace’s death and failed to respond to lawful records requests,” it states—specifically that “… The MODOC did not provide any documents, video footage, or information to Plaintiff regarding the events leading to Mr. Pace’s death.”

Reed isn’t the only person seeking answers about a loved one’s death in Missouri prisons. Whether due to clerical error or deliberate obfuscation, MODOC has made it needlessly burdensome for loved ones of deceased people who were incarcerated in its prisons to receive answers regarding deaths in correctional centers.

“I want to know what happened to my son,” she says.

When someone dies in a Missouri prison, state law requires prison officials to immediately report the death to the coroner or medical examiner responsible for investigating deaths for the county where the death occurred. 

Autopsies must be performed for deaths suspected to be suicides or resulting from violent or suspicious circumstances. MODOC is legally required to maintain records of each autopsy’s findings.

According to MODOC communications director Karen Pojmann, all deaths are investigated by the MODOC investigations unit. The department, she says, also notifies local law enforcement.

“Generally speaking [in an investigation], the area where the death occurred is sealed off and any [witnesses] are interviewed and evidence [is gathered] on the scene by the local staff, and then we have a team of investigators,” Pojmann said. 

Pojmann said the department requests autopsies “for almost every death,” except “if someone is known to be terminally ill.” 

While the decision to conduct autopsies is left to the discretion of the county coroner or medical examiner, she said that the department’s requests are generally honored.

After conducting an investigation, the coroner or medical examiner will categorize the manner of death as “natural,” “accidental,” “suicide,” “homicide” or “undetermined,” according to the Centers for Disease Control’s Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting. Overdoses are usually labeled “accidental” deaths, because the vast majority of deaths caused by drug use are unintentional.

Details surrounding a cause of death go into more detail to clarify the circumstances leading to any given manner. In the case of a heart attack, the manner would be “natural” while the cause may be described as “myocardial infarction, preceded by a history of cardiovascular disease.”

In the circumstances surrounding Pace’s death, however, MODOC officials in Moniteau County—which is served by a coroner and not a medical examiner—failed to follow many of these policies and best practices, according to her suit.

Reed’s lawsuit states that during the hours before Pace died, correctional officers as well as medical personnel ignored his pleas for help—and that he never received medical treatment or monitoring, despite false reports made by certain defendants that this was the case. 

Correctional officers Randy Witt, Billie Webb, Jo Mollar and Earl Roach are four of more than 27 defendants comprising both individuals and entities against whom Reed has filed a complaint. The document says that Witt and Webb bore witness to Pace “begg[ing] for help for over four hours until his death.”

“At some point,” it continues, “Defendant Webb said to Defendant Witt, ‘He’s saying he can’t breathe,’ referring to Mr. Pace. Defendant Witt responded, ‘I don’t give a fuck.’”

When Pace was found dead hours later, he was still handcuffed in his cell.

After he died, the complaint reads, “other Defendants retaliated against inmates who dared to speak about the officers’ callousness and blatant neglect that caused Mr. Pace’s death.”

The lawsuit alleges that another incarcerated man, who said to Roach “They killed that guy,” was told “He was kinda like a dog that ran out on the street and we were just the car that hit him.”

“Defendant Mollar learned what that inmate had said to Defendant Roach, and she threatened that inmate by saying ‘You don’t know how to keep your mouth shut. You’re a security risk,’” according to the suit. It goes on to detail that the man was no longer tasked with his role as a porter within Tipton “in retaliation for what he said.”

“Thereafter … other inmates at Tipton were charged with spurious infractions because they said things such as ‘Rest in Pace’ or otherwise referred to Mr. Pace’s death,” Reed alleges.

The autopsy itself, conducted by forensic pathologist Keith Norman Norton, M.D. and two forensic technicians from the Medical Examiner’s Office, alleges that staff took Pace to a medical unit for observation where he coded and emergency medical services attempted to resuscitate him for 30 minutes.

Pace’s death was categorized as accidental. The manner of death is labeled “methamphetamine intoxication” due to the presence of 6200ng/mL in his blood. The reporting limit (or the threshold for a drug test to yield a positive result) is 5ng/mL.

Even beyond drug-related deaths, families of people within the Missouri justice system are frequently left without answers. People are dying in state custody under obscure conditions, even where the state is legally mandated to provide more information. The records that do reach the public remain both vague and elusive—and often full of clerical errors.

Despite its status as public record, obtaining offender death information from MODOC is difficult: in 2024, a Missouri appeals court ruled that the agency had violated state public records law by withholding public records from another woman whose son died in MODOC custody.

As in that case, the lawsuit filed by Reed alleges that “As part of the cover up of the events regarding Plaintiff’s son’s death, certain Defendants at the highest levels of the Missouri Department of Corrections willfully refused Plaintiff’s proper requests for records and information in contravention of Missouri’s [open records law].”

Further complicating any public or journalistic efforts to determine a manner of death from MODOC-sourced mortality data is the recent introduction of a vague, non-standard manner of death category in their offender death logs. 

Five 2024 fatalities are documented under the label “Offense Related Deaths.” Of these five investigated deaths, only two autopsies were provided by MODOC. Both autopsies formally ruled their causes of death to be homicides.

“That would be a homicide,” said Pojmann. “… I actually don’t know [why MODOC uses that label].”

She said the Division of Adult Institutions—a part of MODOC — is responsible for the maintenance of death records of incarcerated people.

At least 20 MODOC death data records between 2019 and 2024 are improperly or incompletely documented, with some entries in the death logs not matching the results of their respective autopsies and others remaining “undetermined” or “pending” after extensive periods of time.

These include Rickey Williams, who died of suicide; Jackie Helton, whose death (the result of acute fentanyl intoxication, his autopsy says) is “undetermined” on his autopsy; the homicide of Joshua Cosby; the hanging deaths of Thomas Erbland, William Stites and Austen May; and James Tooley’s fatal case of acute fentanyl intoxication—all of which are listed, in the DOC’s internal records, as “natural” in cause.

They include James Shinneman, whose cause of death—like those of Kyle Sherrod, and Othel Moore, and Jason Baker—is still “pending.” Shinneman’s autopsy records blunt head and neck trauma, bite marks, and genital trauma. Similarly, the autopsy of Robert Pliler states he died in a homicide, bearing several injuries consistent with sexual abuse. MODOC states his cause of death is “undetermined.”

Like that of Brandon Pace, Kevin Beasley’s death is listed as accidental by MODOC. Beasley’s autopsy records that he died due to homicide by means of strangling.

And though Terry Upshaw is correctly documented as having died of natural causes, the first note on his autopsy report states he’d had a “history of being found deceased in [his] cell.”

In 2024, the data provided to The Appeal by MODOC stopped recording whether autopsies were conducted and received altogether.

While MODOC’s Division of Adult Institutions is intended to be responsible for ensuring in-custody death investigations remain accurate and transparent, there appears to be little incentive for them to actually do so.

Several states’ correctional agencies struggle or neglect to provide clear information about deaths in custody—a phenomenon the DCRA sought to change. The federal act mandates that every three months, states must report all deaths occurring in jails and prisons to the U.S. Attorney General’s office.

Other journalists report consistent difficulty obtaining death records from corrections departments like Missouri’s, and further obstacles guaranteeing that data’s accuracy. Last year, The Marshall Project identified hundreds of people across the country whose deaths were inaccurate or incomplete by the Justice Department’s standards.

A significant number of these shortcomings, according to the report, had to do with manners of death that were not specified.

In 2025, the National Academies of Sciences, Engineering, and Medicine released their report “Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody.” A news release from NASEM surrounding the report calls for reform to strengthen the process of reporting in-custody deaths, calling it “fragmented” on a national scale and in need of reform.

The NASEM report, states the release, calls upon Congress to mandate that all deaths in custody be recorded in greater detail—by requiring all death investigators be licensed, for example, and that states be required to collect and report data on all in-custody deaths.

The report also recommends that funding should be allocated to the Centers for Medicare and Medicaid services, “to reimburse state and local governments for the cost of autopsies performed on those who have died in custody.” 

The medicolegal death investigation system, according to NASEM, lacks the resources to function consistently. How reliable a manner-of-death determination is, for example, can vary on a case-by-case basis. 

In Missouri, cases such as that of Pace raise concerns surrounding the state’s ability to provide clear, transparent context surrounding deaths in their custodial settings. 

Prison reform advocate and former corrections officer Déna Notz says that organizations including hers, Collectively Changing Corrections, have faced obstacles related to records requests including being “ignored, dismissed or given partial information.”

When it comes to MODOC, she says, “There’s lack of transparency, there’s lack of accountability, and there’s no due process.”