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.
Incident
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:
- 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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