The pain is too much to bear.

Barely conscious, the handcuffed inmate moans and whimpers loud enough for inmates in the surrounding cells to hear. His naked 5-foot-9-inch frame is doubled over on a lumpy vomit-stained mattress, his head hanging off the edge. Dried blood streaks from opposite corners of his swollen, cracked lips.

It’s 8:30 Monday morning and three correctional officers march down the stark beige halls of the segregated unit at Warren Correctional Institution in Warrenton. They stop at the cell door topped by a painted-black “15” and peer through its reinforced Plexiglas window at the bare, limp body of 28-year-old Toney Andrew Moore. The officers enter the cell and tell Moore to get up so they can prepare him for a morning court appearance. The Oxford native faces felony charges stemming from an escape from Umstead Correctional Center in Butner two weeks earlier.

After Moore mumbles that he is unable to rise, two of the officers straddle the moaning inmate. They try to pull him to his feet, but can’t. Moore slumps to the concrete in a heap and whimpers his last breath.

Moore’s life is over, but it’s just the start of his family’s two-year struggle to make sense of his death. On Nov. 19, 2001, the state finally settled a suit filed by the family, paying $198,000 to Moore’s 10-year-old son, Anthony Rodriguez Crowell. The payoutthe largest to date to an inmate’s estate by the North Carolina Department of Correction (DOC)was based on Warren Correctional’s medical neglect of Moore during the 10 days leading up to his death. The late inmate had complained of and exhibited symptoms of kidney failurevomiting, loss of appetite, stomach pain, hiccupping and an inability to urinate. Though he repeatedly begged prison staffers for medical assistance, he was never allowed to see a doctor for his symptoms.

While prison officials did little to help Moore, a series of public records suggests that the state did a lot to avoid a lawsuit, its consequences and the associated negative publicity. At least one individual and an official document corroborate the Moore family’s contention that Warren Correctional officials initially tried to call the death a suicide. In addition, the state’s Office of the Chief Medical Examiner (OCME) in Chapel Hill issued two versions of the autopsy almost two years apart. Both versions contained inaccuracies and questionable assessments regarding the cause of Moore’s death and his drug use, which state officials say contributed to his demise.

“We saw a lot of holes in their responses,” says Michael Smith-Muhammad, president of the Granville County NAACP. Along with consistently questioning the state’s tactics since Moore’s death, his organization has rallied on several occasions to publicize its troubling circumstances. Labeling the initial autopsy as “bogus,” Smith-Muhammad feels that the state’s handling of the death was “definitely a cover-up.”

However, the top administrator at the prison where Moore died says he has nothing to hide.

“I don’t believe we did anything wrong,” says Ted (T.C.) Smiley, the prison superintendent at Warren Correctional at the time of Moore’s death. Now the town manager for Warrenton, Smiley insists “our treatment and practices were totally appropriate.”

While Smiley and the DOC maintain they did nothing wrong, the attorney representing Moore’s family says the state is simply refusing to publicly accept the facts.

“The state doesn’t pay $198,000 to someone when they haven’t done anything wrong,” says attorney Stewart Fisher. The Durham-based lawyer stresses the settlement was brought about by “the cumulative effect of all the evidence” showing that the state was negligent in its treatment of Moore. Fisher characterizes Smiley’s unwillingness to admit fault as “disgusting.”

Even more disturbing is the state’s refusal to acknowledge its mistakes and learn from them. Toney Moore’s death isn’t the first to raise questions about how the state cares for its inmatestwo similar cases made news in the mid-1990sand there’s no guarantee it will be the last.

“This was a man who was clearly crying out for help,” says Fisher, of Moore. “He died because no one gave it to him.”

The chase is on.

It’s just after midnight on a Wednesday in late December and Moore races a white Honda Civic westbound on Lake Devin Road in Oxford. Behind him, officer Chad Coffey pushes his Granville County police unit closer to the reported-as-stolen vehicle he suspects is driven by the escapee. Two days earlier, Moore walked out of an unlocked door at the minimum-security Umstead facility where he had 16 months remaining on a four-year robbery sentence.

A desperate Moore suddenly swerves off of Lake Devin and onto a dirt path. Coffey follows. Tires spin and dirt spews as Moore tries to lose the determined officer.

For several minutes, the car chase snakes over paths and a surrounding grass field. As the vehicles careen toward some nearby woods, Moore attempts a sharp turn. The Civic shifts its weight to one side and flips over twice before stopping abruptly in an upright position. As Coffey’s unit slides to a halt, a dazed Moore stumbles out of the Civic and takes off toward the woods. The officer jumps out of his vehicle and pursues Moore into the woods where, according to the report filed by Coffey later that day, the officer “tackled the subject, and after a long fight managed to get the subject handcuffed.” At some point during the altercation, the officer uses pepper spray on Moore. Once backup units arrive, Coffey and a number of officers carry Moore out of the woods.

After being seen by Granville County Emergency Medical Services and the emergency staff at Central Prison in Raleigh for neck pain and a lacerated hand, Moore is transported to Warren Correctional. He is placed in the segregation unit of this medium-security prison as punishment for escaping the less-secure facility at Umstead.

By Jan. 2, after five days back in custody, Moore knows something is wrong with his health. He has consistently complained to the nursing staff about his lack of appetite and inability to urinate. At 10 a.m., after hearing these complaints, nurse Debra Simmons advises the inmate to “drink at least eight to 10 glasses of water.” Moore responds, as written in the nursing notes from that day, “I know I need to drink, but I ain’t been hungry since I got locked up.” Before continuing her rounds, Simmons tells the custody officers to keep an eye on Moore’s drinking and bathroom patterns. However, there’s no record that the officers followed up.

Over the next two days, Moore continues to complain to attending nurses that he is not hungry and can’t sleep. On Jan. 4, one of the nurses brings Moore’s complaints to the attention of the facility’s mental-health staff. Psychological Services Coordinator Birchie Warren reviews the inmate’s file and his largely uneventful medical history. The psychologist then dismisses the request for medical treatment, characterizing Moore’s complaints as “depressive symptoms” rather than medical. He then schedules Moore for a psychology consult on Jan. 12.

By Jan. 6, Moore’s symptoms are becoming unbearable. He hasn’t slept for two nights and he has barely eaten any solid food. As a result, he completes a Sick Call Requesta form filled out by inmates and relayed by a nurse to a doctor. The form is routed by the nursing staff back to mental health. Once again, Warren does not refer Moore to a physician.

At 8 p.m. on Jan. 7, nurse Rubie Boisvert examines Moore in his cell, who says that “I just ain’t been right since I got here.” The inmate cries as he tells the nurse that he is unable to taste anything, that he vomits up a burgundy-colored substance when he eats, that he’s only urinated three times in a week, and that his most recent bowel movement was greenish and runny. Boisvert notes his weak and distressed appearance, audible gastric disturbances and the white patches on the inside of his mouth. There is brownish vomit in his toilet and uneaten food by his bed. Boisvert gives Moore antibiotics and leaves him with a chem-strip to urinate on to allow for a urinalysis. Again, no doctor is summoned and a urine specimen is never retrieved by the staff or followed up.

The next morning, Moore refuses to see nurse Simmons during her 6:30 rounds. “I don’t want to see the nurses or anybody else,” says the agitated inmate. “I just want to see a doctor.” Two hours later, Simmons has Moore escorted to one of the facility’s medical rooms after seeing blood on his shirt from a nosebleed. He now complains of severe stomach pain.

As she treats his nose, Moore becomes irate. “I want to see a damn doctor now,” he screams. When the nurse ignores him, Moore tells her that if he can’t see a doctor, “I guess I’ll go back to my cell and hang myself.” Simmons informs mental health of the threat. Psychologist Warren places the inmate on suicide watch. He orders that Moore’s clothing, mattress, sheets and personal belongings be removed from his cell.

That afternoon, Moore’s mother Betty Marrow and sister Tami Moore arrive for a visit. The staff orders the inmate to dress before he’s led in chains to the unit’s non-contact visiting room. Moore and his relatives can see each other through a Plexiglas window.

“He looked very thin, was crying and telling us that he couldn’t eat,” says Tami, who is a correctional officer at Polk Youth Institution in Butner. At one point, she recalls, “he stood up, pulled up his shirt and told us to look at his stomach. It was concave.” During the visit, says Tami, her brother also states that arresting officer Coffey emptied “almost a whole can of pepper spray” into his mouth.

When Moore is taken back to his cell, his upset mother complains to Superintendent Smiley about her son’s unhealthy appearance. Smiley calls psychologists Warren and Stevette Barnett to Moore’s cell an hour later. The inmate complains of stomach pain, coughing, nose bleeds and difficulty eating and sleeping. In addition, he informs them that he only threatened suicide to draw attention to his condition.

Warren decides that Moore should be taken off of full suicide watch and his belongings are returned to him. Before the superintendent and psychologists leave the cell, Warren tells the inmate that he can see a doctor only “if the nursing staff determines that your condition warrants that.” Barnett notes in her report that Moore is depressed, and that his somatic complaints are “exaggerated” and “stem from feelings of guilt and shame associated with his escape.”

At 8:30 p.m., Moore is transported back to the medical clinic after corrections officers see him vomiting in his toilet, with blood coming out of his nose. Nurse Lavonia Perry gives the inmate Dramamine for his stomach problems. Moore immediately vomits the medication up. Once again, he is returned to his cell without seeing a doctor.

That night, Moore is unable to sleep. Agitated by his worsening symptoms, he repeatedly shouts for medical attention while banging on his door and metal cot. The racket is heard around the unit. In a witness statement given later by Casey Thomas, an inmate in Cell 11, Thomas recalls hearing Moore constantly “begging and pleading for help” throughout the night.

Just before 11 a.m. on Jan. 9, lead nurse Dorothy Fowler finds Moore lying on the floor of his cell in a fetal position, crying. He hasn’t touched the liquid-diet tray given to him hours earlier. Three-and-a-half hours later, Moore is sent back to the medical clinic with sharp right-sided abdominal pains and uncontrollable hiccups. This time, nurse Perry calls the Central Prison emergency room and speaks with a triage nurse. The nurse tells her to monitor the inmate closely and call back if his situation does not improve. Again Moore is returned to his cell.

That evening, the desperate inmate constantly flushes his commode to get attention. When that fails, his desperation escalates. “I walked over to inmate Moore’s cell to do a 15-minute check and found him at the door with an ink pen to his neck,” states correctional officer Robert Champ in documents filed during Warren Correctional’s internal investigation. “He stated that he was going to kill himself.” Champ and four other officers enter the cell, confiscate the pen and other items, remove Moore’s clothes and handcuff him. He is placed on suicide watch after a nurse contacts psychologist Warren by phone.

At 10:30 p.m., nurse Sencelra Williams arrives at Moore’s cell in time to see Moore stand up on the toilet and jump off in an attempt to injure himself and solicit a doctor. He already has blood stains on his head, hands and knees from a previous attempt. From the floor, Moore begs Williams for a doctor. The nurse examines him, cleans his wounds and gives him Dramamine for stomach discomfort, but does not request a doctor. During the visit, notes Williams in the internal investigation, Moore complained to her that Warren Correctional “was not taking care of him because he escaped from another camp [prison]” and that the prison system was “embarrassed” by coverage of the incident in local newspapers.

Just past midnight, Williams speaks with Warren by phone and a memo is issued instructing staff to continue Moore’s suicide watch. Among the instructions are orders to “limit contact with inmate Moore” since he “is desperate and will attempt to escape at the expense of staff.” In addition, the Jan. 10 memo states that Moore “is to remain in Segregation at all times” and should only be removed in the event of his “impending death.”

Warren denies giving these particular instructions, but he doesn’t deny dictating the memo. Nurses Williams and Fowler maintain that all instructions came from Warren, who does admit to characterizing Moore as an “escape risk.”

Throughout the night, unable to sleep once again, Moore bangs his head and his hands on his cell door and screams for medical treatment. Off and on, this pattern continues through the day of Jan. 10, alternating with weeping and moaning. At one point, inmate Rafeal Mcleanwhose cell is adjacent to Moore’s and can best hear his pleaspens a letter to Moore’s family saying that he is sick, trying to harm himself and “in his cell totally naked.”

In the early morning hours of Jan. 11, a weak, naked, handcuffed Moore mumbles more complaints of stomach and back pain to correctional officers who enter his cell and try to pull Moore to his feet. Again, the guards ignore Moore’s pleas to see a doctor.

Inside Moore’s body, his kidneys are shutting down. Something has traumatized the pair of purple-brown organs. Pain vibrates about his back, midsection and groin, consuming his every breath.

Two hours later, Moore is dead.

At 11:20 a.m., pathologist Robert Thompson, with the Office of the Chief Medical Examiner, receives a phone call from William Powell, the acting medical examiner in Warrenton.

Moore’s body is now on its way from Maria Parham Hospital in Hendersonwhere it was taken from nearby Warren Correctionalto OCME, where the autopsy will take place. Powell informs the pathologist of the preliminary information he has gathered regarding Moore’s death. Thompson records the information on a Case Encounter Form. On the form, Thompson lists the manner of death as “suicide.”

Powell did not return The Independent‘s repeated phone calls. However, OCME pathologist Thomas Clark speculates that someone at the prison may have thought it likely Moore “saved his medication and took it all at once.”

Especially, says Clark, since the inmate had threatened to kill himself just days before his death.

At 11:30 a.m., Moore’s mother receives a phone call from Superintendent Smiley.

“Until the day I leave this world, I’ll never forget that day he called me and told me my son killed himself,” says Marrow. Given that Moore was already on suicide watch, she and her family feel that labeling the death a suicide was a convenient way for Warren Correctional to cover up its negligence.

“I have no idea why she would say that,” replies Smiley, who denies ever mentioning suicide when he spoke with Moore’s mother. Since the cause of death was uncertain at that time, he says, “I called and told her that her son had passed away.”

Over the next week, a number of phone calls and letters from inmatesincluding the letter Mclean wrote the day before Moore’s deathcause the family to question what really happened in Cell 15. On Jan. 18, Marrow receives a letter from segregation unit inmate Ronald Smith telling her, among other things, to “please don’t believe what they say because they (are) lying. … Toney did not commit suicide, mam.”

“We started putting things together,” says Marrow, noting that “if it wasn’t for the inmates, we may have never known what really happened to Toney.” The family contacts the Granville County NAACP and talks with Smith-Muhammad. By that time, says Smith-Muhammad, his organization had already received “a number of letters regarding Toney’s death.”

In late March, OCME releases its official results of the autopsy. Now, the cause of death is listed as “cardiac hypertrophy,” or an enlarged heart, and the manner is described as “natural.” The autopsy also reveals “a small amount of cocaine metabolite” in Moore’s urine. Though “insufficient to cause the death,” writes pathologist Clark, “this metabolite does show that cocaine was used within the week prior to death. It also suggests that cocaine use contributed to the enlargement of the heart.”

Neither Moore’s family nor the NAACP are convinced.

“The information we gathered about Moore’s complaints prior to his death didn’t appear to be consistent with their findings,” says Larry Hall, a Durham-based attorney and counsel for the NAACP.

Over the next year, the NAACP continues to provide legal counsel to the family while keeping Moore’s death in the public eye. Hall eventually refers the case to Fisher and a lawsuit is filed in October 2000.

Two months later, OCME issues a revised autopsy on the Moore case. It now attributes Moore’s death to kidney failure. The justification given in the updated report states that “additional and corrected information was provided by the Office of the Attorney General, resulting in a reconsideration of the cause of death.”

“The attorney general’s office supplied us with all of the medical records and jail notes,” says Clark, who was present at the autopsy. “It was the first time we had seen them.” Clark goes on to say that autopsies are frequently performed with “little or no clinical information” on a subject, and that additional information is seldom provided.

Chief Medical Examiner John Butts notes that such revisions, while not common, do occur “from time to time.” New information on a case, he says, can lead to results being revisited. “Once we finish our reports,” continues Butts, “they are not written in stone.”

The revised autopsy placed more blame for the death on Moore himself. According to Clark’s written interpretation, it is now “more likely that this case represents cocaine-induced renal failure. It is clear that this man used cocaine while in prison, within 2 or 3 days of his death. …”

Attorney Fisher interprets the revised autopsy differently.

“They were trying to mitigate the family’s claims for damages,” he says. Since Moore admitted using cocaine during his escape after being captured, Fisher contends the state was trying to make Moore appear “largely responsible for his own death.” He points out that the medical experts that reviewed the autopsy on behalf of the Moore estate contend the window for cocaine use is much larger, especially given that kidney failure affects one’s ability to urinate.

“There is no evidence of cocaine use after Moore was incarcerated,” says Fisher. “Unless it were being given to him by prison officials, how could he have accessed any drugs?”

Ultimately, Fisher says he’s more concerned with the state’s actionsor lack thereofwhen Moore was still alive.

“The nurses clearly did not comply with their duty,” says Fisher. He stresses that the nursing staff, rather than consulting with mental health staff, “should have been the ones to decide whether or not Moore got medical care.” He notes that the indicative symptoms of kidney failureincluding loss of appetite, reduced urination, hiccups, vomiting and bleedingwere never recognized. “A urine test was never done,” continues Fisher. “A doctor would have ordered one immediately.”

“There’s really no reason why an inmate who complains of a serious or life-threatening situation should not be allowed to see a doctor,” says Keith Acree, a public information officer and spokesperson for DOC. While unaware of the specific details of the Moore case, Acree confirms that prison nurses are empowered to determine if an inmate needs medical attention.

Several medical experts interviewed by Fisher during the preliminary stages of litigation confirmed that if Moore was diagnosed and treated for kidney failure anytime prior to Jan. 11, he likely would have survived and even recovered most or all of his kidneys’ functions.

“If I remember correctly, there weren’t any problems with him until the weekend before he died,” says former Superintendent Smiley. “We treated him like we would have treated any other inmate.”

When told nursing notes and other records show that Moore had exhibited and complained of serious symptoms for at least a week prior to his death, he responds, “I don’t remember all of the details of the case. I’ve been retired from that position for over a year and a half.”

Fisher can’t forget the case.

“Whenever I think about Moore, I get this image of him naked in his cell, handcuffed on the floor in a fetal position, crying out for help,” says Fisher. “That’s just a horrific way to die.”

“If that’s the way we treat prisoners,” says Fisher, then “it’s a sad state of affairs in the North Carolina prison system.”

This was not the first time an inmate’s death has raised questions about prison health care in North Carolina.

A couple of prominent cases within the past five years have brought increased public scrutiny of the medical treatment of state prisoners. In 1997, a federal audit of Central Prison in Raleigh was largely prompted by the death of inmate Glen Mabrey a year and a half earlier. Mabrey, a Vietnam veteran with post-traumatic stress disorder, died from dehydration after being segregated in a mental-health cell for four days. The inmate’s water was cut off due to ongoing psychotic episodes where he’d flush his toilet to flood his cell. His water deprivation proved fatal because at the time, Mabrey was taking medication that increased his body’s need for fluids. Although staff officers regularly brought his food trays back and forth, there is no record of anyone with medical experience monitoring his liquid intake.

That same year, a class-action suit filed by the nonprofit Prisoner Legal Services and 14 female prisoners at the Correctional Institution for Women (CIW) in Raleigh charged that delays in diagnosis and treatment resulted in at least three avoidable deaths and additional problems. In one case, an inmate named La Shonda Lowery complained of severe chest pain accompanied by numbness and weakness in her right arm. Though she had a history of chest pain and put in 10 sick-call requests in 14 months, during this period Lowery wasn’t seen by a doctor. Instead, her nurse treated her for indigestion, just before the 34-year-old inmate died from a heart attack. Currently, Prisoner Legal Services and DOC are involved in a joint resolution to the case where Legal Services is monitoring CIW’s ongoing reforms. Among these are efforts to give nurses more time to care for inmates and effectively track the time between an inmate’s sick-call request and a doctor’s response.

Acree stresses that such DOC improvements, regardless of the CIW suit, were already being implemented. “Medical care is a large and important part of what we do,” says Acree, noting that “we take it very seriously.”

But not seriously enough to confront the issues raised by Toney Moore’s death.

For Fisher, the reasons behind Moore’s neglect run deep and outside the reach of any current DOC reforms. He believes Moore was handled the way he was because of his previous escape attempt. The attorney offers the Jan. 10 suicide-watch memo dictated by psychologist Warren as evidence. “The memo shows it,” maintains Fisher. He contends that the Warren Correctional staff, even though Moore was deathly ill, was “treating him as if he were trying to escape.”

His theory is shared by others. In his Jan. 18 letter, inmate Smith told Moore’s mother his belief that Smiley instructed the nursing staff not to help Moore “because he had escaped” and would “do anything to escape again.”

While not totally discounting the possibility that such attitudes toward escapees exist in the prison system, DOC’s Acree stresses that it’s “certainly not our policy.”

Even so, Fisher feels the significance of the Jan. 10 memo cannot be underestimated. In her deposition, lead nurse Fowler states she felt the nurses couldn’t summon a doctor just prior to Moore’s death since the memo “tied our hands nice and tight.”

For Fisher, the memo was “the closest thing we had to a smoking gun.”

Though in death, Moore has made a substantial amount of noise, for most of his life he was known as the quiet type.

“As a child, he stayed pretty much to himself,” says aunt and estate administrator, Edith Scott. While he had a “happy” childhood and enjoyed farm life, she says, Moore was never one “to expose his feelings to anyone.” In school, continues Scott, Moore was a polite, average student who was “too shy to ask for help.”

After graduating from J.F. Webb High School in Oxford in 1990, Moore did a brief and unsuccessful stint at a barber training school in Fayetteville before returning home to help work the family farm. In 1991, his girlfriend at the time gave birth to his son, Anthony.

A year later, Moore lost his younger brother, Frederick, who was killed in a boating accident at Grassy Creek Lake in Bullock.

“He was very close to his brother,” says Scott, noting its negative impact on Moore. After that, she says Moore “started doing things he just normally wouldn’t do.” Scott suspects that, about this time, Moore started experimenting with drugs.

A month later, Moore and another man were picked up by local police after breaking in to the house of a neighbor. Moore was convicted a year and a half later, beginning his unfortunate relationship with the state’s penal system. Being incarcerated, says his sister Tami, “really messed up his mind.”

After violating parole in 1996 with additional charges of robbery and possession of stolen goods, Moore did some initial time at Warren Correctional before being moved to Umstead, the site of his 1998 escape.

For Moore, that escape was the beginning of the end. And now that his case is settled, it looks as though the state has escaped as well.

It avoided a public trial and official liability by settling out of court. Fisher reveals that the family accepted the terms because of the unpredictable nature of a long legal battle with the state.

The upside is that the agreed amount will ensure that Moore’s son Anthony “is provided for and has the opportunity to go to college,” says Fisher, noting that it’s something “his father never did.”

The downside is that the quiet settlementit drew no significant media attentionprovides little reason for the state to challenge or seriously examine the way it cares for its inmates. Nothing is being put in place to ensure that what happened to Moore won’t happen again.

For Marrow, that’s certainly a hard pill to swallowand not just because Moore was her son.

“He was a human being,” says a glassy-eyed Marrow. “They should have treated him like one.”