Timothy Joe Souders lived a hard life and, on Aug. 6, died an even harder death in a segregated prison cell in Jackson.

Souders, 21, spent most of his last four days naked, without physician or psychiatric care, his arms and legs bound to a steel bed in four-point restraints. He was in a bare, all-steel isolation cell about the size of a walk-in closet.

He went to the cell Aug. 2 because of unruly behavior. He lay in urine -- "agitated, disoriented, psychotic" -- as the cell felt close to 106 degrees at times, according to a report written by a federal monitor assigned to scrutinize medical care for Jackson prisons.

Souders was found dead on his bed around 4 p.m., two hours after staff had removed his shackles. The death of the severely mentally ill inmate is a glaring example of a troubled state prison health care system, riddled with misdiagnoses, delayed or denied treatment and inadequate accommodations for people with disabilities.

The Jackson prison complex, including the Southern Michigan Correctional Facility where Souders died, has been under federal oversight for more than 20 years.

Corrections officials are investigating the death. Autopsy results might not be available for two or three weeks.

The Michigan Attorney General's Office, which represents the Department of Corrections, disputed the account by the federal monitor, whose report this week brought Souders' death to light.

"The governor's office is very concerned about the issue of prisoner health care," Liz Boyd, spokeswoman for Gov. Jennifer Granholm, said Saturday. "We want to make sure that prisoners are getting appropriate health care and that taxpayer dollars are being spent wisely. Be assured, the issue of prisoner health care will be reviewed and, if changes are warranted, changes will be made."

The Corrections Department had issued a heat alert the day Souders went into isolation. Such alerts are issued when the combined temperature and humidity index reaches 90 degrees. Alerts are supposed to trigger actions to ensure that inmates have adequate water and ventilation.

Dr. Robert Cohen, the court-appointed monitor, uncovered Souders' death during a visit to the Jackson medical complex on Aug. 8-10. Disturbed by what he found, he issued a special report to U.S. District Judge Richard Enslen in Kalamazoo, who is enforcing federal oversight of the facilities.

"Although the circumstances of Mr. S.' death overwhelmed my visit ... there are a number of additional continuing serious deficiencies in the medical program which require immediate attention, some of which may have contributed to the abject failure to provide Mr. S. with medical care," Cohen wrote.

"There is a critical shortage of medical staff" at the Jackson facilities "and serious medical staff shortages throughout the medical program. This is an emergency situation which has gone on for too long and is having an extremely adverse effect on patient care."

Souders' death was "predictable and preventible," Cohen wrote, "a terrible, unnecessary tragedy."

Souders was serving a sentence of 1 to 4 years for resisting arrest, assault and destroying police property.

Because he was taking medications for multiple medical conditions -- including manic-depression, psychosis and hypertension -- he was at high risk for heat-related injury or death, Cohen wrote.

Still, a physician did not see him from the time he was restrained until he died. He was seen and monitored by nurses, however, Department of Corrections spokesman Russ Marlan said.

Mental health staff at the Southern Michigan Correctional Facility tried to transfer Souders to Huron Valley Center in Ypsilanti, a psychiatric hospital for prisoners, but he wasn't moved, Marlan said.

At least one person involved in the transfer has been removed, Marlan said. The department is reviewing policies on prisoner restraint.

A 'lack of ... responsibility'

In response to Cohen's letter to the judge, the Attorney General's Office, which represents the Corrections Department, questioned some of Cohen's findings. The office pointed out in an e-mail to Cohen that the day Souders died, a nearby cell was only 83 degrees, with 58% humidity, which wouldn't produce a heat index of 106.

Shortly after 10 on the morning he died, Souders, 5-foot-8 and 235 pounds, was able to walk to the shower outside the cell, Marlan said. He was returned to the cell, placed in restraints and covered with a blanket, the Attorney General's Office noted.

He was released from the restraints just before 2 p.m. By 3:58 p.m., according to the Attorney General's Office, he was "found to be unresponsive and without pulse and respiration" on the bed.

"It's a tragic example of what we've been trying to illustrate to the court, and to the department, for a long, long time," said Patricia Streeter of Ann Arbor, an attorney for prisoners in what is known as the Hadix case, which triggered the federal oversight.

"There's a lack of leadership and responsibility. The doctors are overworked. The Jackson facilities have become essentially a hospital, and they're still treated like a prison with average, healthy people."

The Corrections Department has been under a federal consent decree in the Hadix case since 1985 to improve medical care and other conditions at Jackson prisons. The decree covered a range of issues, including sanitation, fire protection, crowding, medical care, access to courts, mental health care and prisoner safety.

In June, the Free Press reported on Lloyd Byron Martell, whose cancerous polyp had gone untreated. Martell, 41, was sent home last week to die.

A hard and desperate life

Souders of Adrian had bipolar disorder, among other conditions, according to court records. Over the last three years, he supported himself with Social Security checks, odd jobs and Dumpster diving. Attempts to reach a family member Thursday and Friday were unsuccessful.

Souders' prison sentence stems from convictions for resisting arrest, destruction of police property and assault. In March 2005, after stealing two paintball guns from a Meijer store, he walked with a stolen knife toward a police officer.

"Go ahead and kill me," he told the officer, who stunned him with a Taser. Souders told a probation officer that he wanted police to put him out of his misery.

While in an isolation cell in the Lenawee County Jail on those charges, he tried to hang himself with a noose made with fabric from jail coveralls. He was charged with malicious destruction of police property. This was on top of a record of five misdemeanors, including possession of marijuana.

Souders started his sentence Nov. 1 and was transferred to Jackson on March 2. While locked up, he received seven misconduct reports, including two for fighting.

In response to Souders' death, Cohen called an emergency meeting Wednesday with prison administrators, resulting in some of the Department of Corrections review.

Cohen's investigation could take weeks and will include a review of tapes, incident reports and medical records.

Critics say the Legislature, governor and correction officials have failed to properly oversee the $190 million a year the state spends on prison medical care, including the state's $70-million contract with Correctional Medical Services Inc.

"Responsibility is so dispersed between state agencies, a private contractor, line staff and administrators," said Sandra Bailiff Girard, executive director of Prison Legal Services of Michigan.

"No one is held responsible -- so there's little incentive to follow the rules."

Contact JEFF GERRITT at jgerritt@freepress.com or 313-222-6585.