John Lambert dropped out of high school in his freshman year, battled addictions to cocaine and alcohol, and was in and out of treatment centers as well as court for minor scrapes with the law.
Last year, when he was locked up in Cook County Jail for possessing cocaine and violating probation, his frustrated family decided not to bail him out, thinking he was better off where he could not abuse drugs or alcohol.That proved to be fatal mistake.
"It's a homicide," Mitra Kalelkar, the deputy chief medical examiner who conducted the autopsy, said in an interview.
The investigation would seem to be straightforward -- Lambert had a lone cellmate the night of his fatal injuries.
But the cellmate, David Jamison, told investigators that Lambert sustained the injuries when he fell from the top bunk in their cell.
More than a year later, no one has been charged in his slaying.
"You know what it feels like to know that if you could have bailed him out, he would be alive?" said Lambert's sister, Heather Brenka, her voice cracking with emotion.
Lambert's death was among numerous examples cited in a scathing Justice Department report this summer that found violence rampant at the nation's largest jail. The investigation also ripped the jail for dispensing medical care so substandard that some inmates died needlessly.
A Tribune investigation raises questions why Lambert was incarcerated in Division IX, one of the jail's maximum-security divisions, with a dangerous cellmate during his 22-day stint there.
In addition, jail paramedics did not respond to emergency calls from guards for help after Lambert was found unconscious in the cell. An hour and half passed before he was taken to a hospital and later underwent brain surgery.
The delay in treatment could have cost Lambert his life because he died of a blood hemorrhage that cut off oxygen to his brain, a condition treatable by prompt surgery, one medical expert said.
"Time is of the essence in this condition, perhaps more than any other," said Dr. Gail Rosseau, a Chicago neurosurgeon and spokeswoman for the American Association of Neurological Surgeons.
Watchdog wants inquiry
Charles Fasano, a veteran official with the John Howard Association, a prison watchdog group, criticized Lambert's placement in maximum security and called for an inquiry into why the jail paramedics were unavailable to treat him.
"Even with a shortage of nurses and paramedics [from budget cuts], there should be no excuse for the failure of a health-care professional to respond to an emergency," Fasano said.
The Cook County Bureau of Health Services, which is responsible for medical care at the jail, declined to comment because of a pending federal lawsuit by Lambert's family. The state's attorney's office also declined to comment.
Penny Mateck, a spokeswoman for the sheriff's office, which runs the jail, defended housing Lambert in Division IX as well as the thoroughness of the investigation by sheriff's police. Investigators worked weeks on the case, she said, but prosecutors declined to file charges.
But a confidential sheriff's police investigative report obtained by the Tribune indicated that officers conducted most of the interviews of inmates and jail staff in just one day. In addition, investigators did not appear to conduct any further interviews after the medical examiner's office concluded in September 2007 that Lambert had been killed, the report shows.