Death in Detox: How the system failed Kellsie Green
A grainy, black-and-white image is positioned on a piece of paper next to personal and identifying information belonging to Kellsie Green. Scrawled across the top of the page in red marker is the word "deceased."
It's the last photo ever taken of the 24-year-old woman alive.
"This is what can happen," said John Green, Kellsie's dad.
He received the piece of paper taped to a box of Kellsie's things after she died in the custody of the Department of Corrections in 2016 while detoxing from heroin.
"You know, if we don't fix that, that's what parents have to look forward to," said John.
He's referring to the opioid epidemic, a lack of detox and rehabilitation resources in Alaska and the insufficient treatment his detoxing daughter received in jail before dying.
After three years of fighting the state in civil court, John and Kathi Green have won their wrongful death suit against the DOC. The State filed an offer of judgement, essentially inviting the judge to rule against them in the case. The deal includes a $400,000 payout, the maximum amount allowed under state law, and the release of certain evidence in the case that was previously sealed.
John and Kathi are divorced, but have been united in their years-long fight for answers and accountability. They wanted to understand what happened to Kellsie and why.
Here is the story her parents hope will force change.
A wonderful little girl
She grew up in a happy, Christian home. There was no way Kellsie didn't know she was loved, her parents are certain.
"Kellsie was a nut. Kellsie was very animated. She loved animals, she loved music, loved to play the guitar. She loved people," John said.
Kathi describers her as a wonderful little girl who loved spending time with her mother, even as she became an adult.
"We were best friends. We'd have girls night, we'd bake, we'd do our nails and she was my fair buddy. She'd go to church with me. We got baptized together Easter Sunday, 2015," Kathi said tearfully, her voice breaking.
But Kellsie's story includes dark chapters her parents wish they could have kept from her.
Kellsie was raped as a teen.
John and Kathi said they took her to counseling and therapy for years, but she eventually turned to marijuana to cope, which led to her inadvertent, initial use of heroin.
"How did she start using? She was at her apartment and she had some friends over and they asked her if she wanted to try to smoke some hash. She thought she was smoking hash," said Kathi, "And evidently, it was heroin and she liked the feeling and that's how she started."
Before long, their little girl who was terrified of needles had become a woman with an insatiable need to inject heroin.
"Kellsie knew she was an addict," said John, adding, "She knew she didn't want to be an addict."
She used Suboxone and methadone to treat her addiction, and even went to Arizona for rehab, but didn't finish her treatment there.
"She tried," said Kathi. "We tried all over the Valley to get her help to get off of this stuff and there was no openings anywhere."
Hardest decision of your life
Even though she was struggling with addiction, Kathi would often let Kellsie stay with her. She was terrified of what would happen if she didn't. But in January 2016, Kathi didn't feel like she could let Kellsie come home. She had discovered her gun was missing. She suspected Kellsie had taken it, along with some checks that had also disappeared.
At the time, Kellsie had a warrant out for her arrest. She had failed to complete court-ordered community service after driving with a suspended license.
"We thought that if she went to jail they could help her get off the drugs and then we could go from there," Kathi explained. "I had no idea how bad jails are."
Kathi and John decided to call Troopers and tell them where Kellsie was.
A desperate choice Kathi described as the "hardest decision of your life" as a parent.
At the time of her arrest, a trooper report states Kellsie was in possession of heroin and syringes.
According to DOC records released through the conclusion of the civil case, Kellsie was booked in the Anchorage Correctional Complex on Jan. 5, 2016. Her recent heroin use is noted in her booking records, but Kellsie had to submit a handwritten request to be placed on detox protocol the next day.
By Jan. 7, Kellsie was seen by medical providers in the jail, and the detox protocol was initiated. She was given medication to ease the symptoms of withdrawal.
On Jan. 8, Kellsie reported she was vomiting blood, while corrections officers note in their reports that they didn't see any. That day, Kellsie was placed in medical segregation and given a liter of fluid through IV. She was then cleared to return to her cell.
A corrections officer noted Kellsie did not want to leave the medical unit, and protested returning to her cell.
Kellsie's call button was activated multiple times on Jan. 9, according to DOC records. Kellsie reported being dehydrated, unable to stop vomiting and soiling herself, and in need of medical treatment.
A nurse did visit Kellsie in her cell that day to collect a urine sample. Later, surveillance footage shows Kellsie return from a shower and collapse on a bed on the floor of the common area. Her cellmates quickly help move her back into her cell.
Kellsie insisted she needed IV fluids. Corrections officers told her she was on the list to go to medical the following day, and to continue drinking water.
Overnight, officers again responded to the call button. They decided to move Kellsie to a cell by herself in the early morning hours of Jan. 10.
"We were informed by her cell mates here that it was the fact that they kept hitting the call button saying, 'Hey, she’s dying, she’s really sick, she needs to go to medical, she can’t stay here, you gotta go to medical,' they say that’s what prompted the 4:00 a.m. room change," said Jason Skala, the attorney representing Kellsie's parents in the civil suit.
In taped depositions for the civil case, an unidentified DOC employee testified that it is not a best practice to put detoxing patients alone.
DOC Employee: I would have recommended not to move her into a cell by herself.
Skala: Why is that?
DOC Employee: Because detox patients are always better with a cell mate because the other cell mate can watch the other in case there's a problem and hit the button. If the person's having an issue and can't hit the button, we can't help them.
The corrections officer who made the decision to move Kellsie defended the decision during depositions, insisting that Kellsie perked up and thanked her. It's a claim Kellsie's mother doesn't believe.
"Are you kidding me?" Kathi responded, in tears. "If you look at the photos you know that's not true."
Later that morning, less than six hours after she was moved, a corrections officer found Kellsie dead.
There has been conflicting testimony about the condition she was found in from those involved, but John has decided on the version he believes.
"Kellsie was found against the door, underneath the call button. She'd taken off her clothes. At some point in time had gotten off the bed, crawled over to the underneath the call button, was unable to reach it to call for help and was found cold, stiff, her eyes open," he said. "She was dead when they found her, regardless of what they said."
Video shows first responders taking Kellsie out of the facility on a gurney. Her arms, stiff with rigor mortis, are held frozen above her head.
Her official cause of death was dehydration, renal failure and heart disrythmia.
Renewed call for justice
Troopers investigated Kellsie's death, but the Office of Special Prosecutions ultimately chose not to move forward with criminal charges.
"Even though it was referred for criminal prosecution, there wasn’t one," said Skala, the family's attorney. "The official line from the state at that time was that all of the people involved were following the then-existing protocols in place at the time, and so long as they were doing that, there can’t be criminal liability because they were discharging the duties of their job."
Through litigating the civil case, Skala said he found multiple instances in which the DOC did not follow its own policies. Proof of the violations can be found in the taped interviews DOC employees gave under oath. Their faces have been blurred and names of those involved have been bleeped.
In one interview, a woman admits they didn't follow the detox protocol:
Skala: Would you agree that medical followed their then existing medical protocol, followed the detox protocol when administering medical care to Kellsie Green?
DOC Employee: I will have to say no.
Skala: OK, and why would you say no?
DOC Employee: Because the standard protocol, when you read through, it dictates that we get vital signs before each dosing of medication and that was not done.
A copy of Kellsie's chart confirms, no vital signs were recorded.
In another taped deposition, Skala asks an employee whether the DOC followed its video retention policy.
Skala: Do you believe that you complied with the video retention policy of the DOC in place at the time following the death of a prisoner?
DOC Employee: Per the policy, not completely.
Skala says the DOC gave investigators video for the 24 hours leading up to Kellsie’s death. The policy states that’s the minimum amount required, and that the DOC must also turn over any other video relevant to the death.
The employee in charge of preserving the evidence testified multiple days' worth of other video wasn’t even reviewed.
Skala: How would the DOC comply with its own policy unless they reviewed the entire video?
DOC Employee: I don't… I don’t know...
Skala believes the process of turning over video to investigators needs to change.
"If you’re the suspect, you shouldn’t have anything to do with control of the evidence they look at," he said.
He said the evidence also points to an environment that was understaffed with employees who were not properly trained. One nurse characterized the training he received as "trial by fire." Another said they were encouraged to ignore parameters for administering the medicine clonidine, a drug used to treat high blood pressure, which can help quiet the jittery symptoms of withdrawal.
The Department of Law released the following statement:
"In this case, the Alaska State Troopers referred its death investigation to the Office of Special Prosecutions ("OSP") for review. OSP reviewed the matter to determine if any corrections personnel could be criminally charged for the death of Ms. Green. Based on the evidence and the law, OSP determined that charges would not be filed and were inappropriate. In reaching this conclusion, the prosecutors reviewed all available police reports, DOC reports regarding the incident, and Ms. Green's inmate and medical records from this incarceration."
Kellsie's parents believe that decision should be revisited, based on the information uncovered during the civil litigation.
"There's proof. I pray they do the right thing," said Kathi. "Anybody else would be held accountable."
In an email Thursday evening, a Department of Law spokesperson wrote:
"A decision can always change if substantial new evidence is presented. At this time, the criminal division stands by its decision based on the available evidence."
"I want to know that justice applies to everybody," John said. "It's the same for me as it is for a corrections officer."
In a statement, a DOC spokesperson said changes were made to the detox protocols after Kellsie's death:
"The health and safety of every individual within our institutions is of utmost importance to DOC. It is department policy that all prisoners have access to and receive healthcare services comparable to those available to the general public. Many people remanded to the custody of DOC have a history of substance abuse. By default, DOC is the largest provider of drug and alcohol detoxification services. On any given day, DOC has about 40 inmates being monitored for withdrawal symptoms and an average of 10 per day on medically managed detox protocols.
Identifying at-risk inmates, managing symptoms of withdrawal, preventing serious events, and bridging patients to treatment are the main goals of the department with regard to managing Detoxification. DOC adopted a new detoxification order set in 2016, not long after Ms. Green's death. That order set is still in place. There have not been any deaths as a result of opiate detoxification since the new detoxification order set was instituted."
A prominent visitor
While the DOC employee tasked with turning over video to troopers said that much of the video showing Kellsie's final days was not reviewed, video of one more event was saved, suggesting that someone did at least look at some of it.
The video shows Bill Stoltze, a Republican senator representing Chugiak at the time, visited Kellsie after her arrest. The video does not include sound, but investigators were also given an audio recording of a phone call between the two.
The call suggests a familiar relationship between the lawmaker in his 50s and the young heroin addict. Stoltze tells Kellsie she should have finished her community service, but he is too busy with other obligations to help. She gives him phone numbers for bail bondsmen, but Stoltze says he doesn't want his name associated with posting the bail money. He might give the money to her mother, if Kellsie can reach her, he says.
"She told her mom that he gave her money. You fill in the blanks. My opinion of it is that here’s a person in a prominent position that took advantage of a vulnerable person," said John. "If he was giving her money, I'm assuming that he had to have known she was a heroin addict. Why was he giving her money? Was it for good conversation?"
Kathi believes Kellsie met Stoltze while working as a dancer at Fantasies on 5th, a now-closed strip club.
"I can’t say I blame him," she said, "but I wish he would have called me."
A couple weeks after the lawsuit was filed, Stoltze surprised his colleagues with an announcement on the Senate floor. He said he would not be running for re-election, citing medical concerns. Stoltze could not be reached for comment for this report.
A cautionary tale
Her parents say every day without Kellsie is hard.
"I love her. I miss her," said John. "And she was a challenge, man. She was a handful, ain't no doubt about it, but I would trade every one of my days for even one more bad day with her."
For both Kathi and John, sharing Kellsie's story brings them some relief. It gives them hope that something will change.
Before Kellsie left jail on a gurney, she had bigger plans. The girl who could paint and draw and sing wanted to share her own story with high school students. She wanted to tell them what she only learned about addiction once it was too late.
"What it does to you and how terrible it is, and how it grips you and it doesn't let go, and then you all you can think about is that next one and if you don't get it the terrible pain you go through and the sweating the throwing up and hurting of your bones. Just everything," said Kathi. "She wanted to let people know what it's really like."
Since Kellsie's death, John and Kathi have emerged as community advocates for change. John would like to see pretrial treated as "triage" for addicts and sentences that incorporate treatment options.
"You do the crime, you do the time. But shouldn't we make the most of that time?" he said.
The story Kellsie might have told had she lived, John and Kathi will never know. Instead, they hope systemic change will come from the story of how she died.
Copyright 2019 KTVA. All rights reserved.