For years, the public had no way to know just how many people died in Missouri’s prisons, a Marshall Project investigation found, because the state Department of Corrections wasn’t counting.
Instead of annual totals, the department historically responded to public records requests with partial counts, cobbled together from multiple sources. News outlets and researchers unknowingly reported the incorrect numbers to the public: Did 125 incarcerated people die in 2023? Or 134? Maybe 137?
“Deaths are reported as they occur,” DOC Communications Director Karen Pojmann wrote in an email to The Marshall Project – St. Louis in October. “At no point during the year is the department required to present a total/comprehensive tally to any outside agency or other organization.”
The department is required to report each death to the federal government, but those records are also flawed and missing multiple Missouri deaths, a Marshall Project investigation found. Missouri’s Department of Public Safety collects death records from the prison system, but a DPS spokesman said those are closed to the public. According to its website, DPS “does not review, compile, evaluate or analyze the submitted reports.”
Some states, like Illinois, share annual reports on prison deaths openly. But in Missouri, the prison system isn’t required to report year-end totals to anyone.
The numerous discrepancies underscore how easily people in prison can disappear from the record — and how little residents, researchers and policymakers actually know about who dies in prison and how. Experts say withholding details and aggregate data from the public makes it harder to identify trends, and easier for the system to evade accountability for deaths that could have been prevented.
The lack of year-end death data is “extremely concerning,” said Dr. Roger Mitchell Jr., co-author of the book “Death in Custody” and president of the National Medical Association. “There should be mortality reviews so that we review those cases, not just to hold people accountable for things that weren’t done correctly, but so that if things can improve — we improve those things.”
In early 2024, the DOC updated its data collection method, automatically pulling each death from its “offender management system” into a single document and updating it weekly. But the new process wasn’t applied retroactively, meaning death records prior to 2024 were incomplete.
However, in response to repeated questions from The Marshall Project – St. Louis about discrepancies in previously provided death records, the department’s research team generated a new report. This report includes every death recorded by the DOC from 2018 to 2024, and marks the first time comprehensive prison death totals have been made publicly available.
A total of 844 people died over the seven-year period, according to the new report, more than has previously been reported. The department’s pattern of inconsistent record-keeping — which mirrors national trends — highlights the need for skepticism toward any death in custody data, experts say.
Even the newest data released by the state provides an incomplete picture of deaths in prison. It does not include age, race, gender or the cause and circumstances of a death. The missing details make it impossible to spot patterns or use the data to better understand why people are dying.
Sometimes, coroner records can fill in the gaps. In April, The Marshall Project – St. Louis obtained access to seven years of death investigations at South Central Correctional Center, a prison in Licking, Missouri. The archival records from the county coroner cover deaths from 2018 to 2024 and offer a critical window into the facility’s struggle to adequately address drug use and chronic health conditions behind bars.
According to its new record-keeping system, and confirmed by coroner records, the department recorded 18 deaths at South Central in 2024 — the second-highest count of any Missouri facility. South Central also had the second–highest rate of deaths per 100 people incarcerated in the state’s facilities last year, according to data from the prison.
“People [in prison] are calling South Central ‘death row,’” said Déna Notz, a former corrections officer at the prison who left after a year and became a prison reform advocate. “Because of how many people end up dying there, and how many people end up getting to the point where they could have died.”
Drug overdose was the top cause of death at South Central from 2018 to 2024, the coroner records show, revealing the scale of the drug problem inside the prison. The overdoses, most often from fentanyl, represent roughly a third of deaths in 2024. Complications from chronic health conditions such as heart disease or diabetes made up another third of the deaths that year. Outside prison walls, these conditions can be more readily monitored and treated.
The records also reveal discrepancies in the manner of death: the broad categories used on death certificates to describe how someone died. In two cases, deaths with causes that were listed as “unknown” in the DOC’s records were ruled by the coroner to be homicides.
Pojmann, the DOC’s communications director, said the in-custody death rate for Missouri is “average among corrections systems” in the U.S. and lower than that of six of the nine bordering states. The death rate also continues to decline, she said.
While the department has pointed to an aging population as one of the primary reasons for prison deaths, more than half of the people who died at South Central were 55 years old or younger.
The life expectancy for men in Missouri is ranked 40th in the country, at slightly over 71 years. At South Central last year, men died on average just shy of 53 years old.
A coroner’s death investigation can include everything from the autopsy and toxicology reports to medical records and the prison’s own notes about a death. These reports sometimes reveal the circumstances surrounding a person’s death, such as when they were found, who notified prison officials and whether the person was alone.
In the absence of details from the prison, coroner records can be illuminating. On occasion, coroner investigations can clarify, or complicate, the often sparse narratives offered by the prison. For example, the DOC reported that a man died in January 2020 from an accident at South Central, with few other details mentioned in the death log besides his name. Coroner records reveal that the man was found out of his cell, dead in a janitor’s closet from a drug overdose and soaked in an unknown liquid. (The coroner’s report reads: “urine?”)
Later that year, a 46-year-old Haitian man suffered a sudden heart attack at the prison during breakfast, and was pronounced dead that afternoon. The prison’s investigation reported “no major health history,” according to the autopsy report, despite a well-documented history in his medical records of heart disease and high cholesterol, and a previous heart attack at the prison in 2011.
The DOC reported that a man died of natural causes at South Central in December 2022. His autopsy report, included in coroner records, identified an untreated tooth infection as the contributing factor in his death.
And in September 2023, the DOC reported that a man died by suicide, again with little information besides his name. The coroner’s investigation found that the man had a known history of mental health challenges, and hung himself in his cell two months after the prison system stopped providing proper medication for his depression.
Experts say preventing future deaths across the prison system hinges on recording information about deaths in their totality, rather than one by one.
“You need the [total] number, and not just the number,” said Mitchell. “It’s the cause, it’s the circumstances, it’s the level of treatment. It’s full reviews of those deaths.”
Nationally, researchers have called for an overhaul of record-keeping for deaths in custody. Some states have medical review boards that investigate deaths behind bars and recommend changes correctional and medical staff must make to prevent similar deaths in the future.
But spotting trends isn’t possible without robust historical death data. And inadequate record-keeping presents a challenge not only for policymakers, but also for grieving families who must fight for answers about how their loved ones died. For some elected officials in Missouri, the lack of reporting requirements and external oversight is a sign that the DOC is overdue for reform.
“There should be some level of documentation and there should be some kind of scrutiny,” said state Rep. Gregg Bush, a Jefferson City Democrat who is a nurse by training.
“It’s just so unconscionable to me,” Bush said, that families of the deceased are “having to piece these things together, contextualizing the death of somebody who’s in our custody, who we’re responsible for their wellbeing.”
