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One morning in late November, Henrietta Napolis was finishing breakfast at her home on Kauai’s North Shore when the phone rang. When she answered it, a somber voice greeted her on the other end of the line.

The caller identified himself as the warden of the , where Napolis’ 47-year-old grandson, Gregory Silva, had been held. “I have some bad news to share,” Neal Wagatsuma began.

“How bad is it?” Napolis replied, steeling herself for what Wagatsuma was about to say.

Wagatsuma had the worst news of all: Silva, who had only months to go after spending 17 years behind bars, had died an hour earlier in his cell, apparently from a drug overdose.

“That was a real shock to me,” Napolis said. “It’s just so ironic that he survived many years at bigger facilities and his life ended after coming back to this little jail here in Kauai, just when he was looking forward to getting out.”

Silva’s death is part of a recent upsurge in the number of unnatural, non-illness-related fatalities among Hawaii inmates.

In a span of 19 months starting in April 2015, eight other Hawaii inmates have died behind bars — five from suicides, two from homicides and one from accidental “” — according to records obtained by Civil Beat through a public records request.

Two additional inmates were killed on the Big Island while they were on work furlough, the records show.

By contrast, a total of 30 Hawaii inmates died from unnatural causes between 2001 and 2014 — an average of a little more than two deaths per year, according to the latest released in December by the .

The rash of inmate deaths comes at the time when an increasing number of jurisdictions across the country are working to stem the number of fatalities — particularly suicides — behind bars.

Last week, for instance, Texas Gov. Greg Abbott signed into law a that addresses the conditions that led to the high-profile death of , a 28-year-old African-American woman who hanged herself in jail after being arrested during a routine traffic stop.

Dubbed the Sandra Bland Act, the measure diverts those with mental health problems from county jails to treatment and requires independent law enforcement agencies to investigate inmate deaths.

Mateo Caballero, legal director of the , says similar efforts are long overdue in Hawaii.

“People who are sent to jails and prisons are there under state protection, and they are there to rehabilitate,” Caballero said. “But, given the conditions in jails and prison in Hawaii, that’s not what’s going on. That should be of great concern to all of us.”

Caballero adds that the issue highlights why the ACLU of Hawaii has called for a federal investigation into what it calls “unconstitutional and unsafe conditions” endured by Hawaii inmates.

“Violence or situations in which people end up getting hurt are a symptom of just how crowded and how bad the conditions are in jails and prisons in Hawaii,” Caballero said.

Clarence Nishihara, chair of the , says he’s willing to call a legislative hearing, saying the number of inmate deaths “is a source of serious concern.”

“It raises the question as to the level of care that inmates are receiving and whether it’s adequate,” Nishihara said. “We’d like to be sure that we have the kind of procedures and counter-measures that can prevent these situations from occurring.”

Lots Of Questions, Few Answers

For Napolis, what makes Silva’s death even more painful is the mystery at its heart. What really happened inside the jail? If Silva died of drug overdose, was it accidental or intentional? And how did he manage to get drugs in the first place?

To this day, Napolis has few answers.

“What happened to him — we don’t know,” Napolis said. “All we know is what the warden told me when he called me in the morning and said, ‘Greg passed away.'”

Napolis says Wagatsuma told her that Silva had taken “a large amount of ice” — methamphetamine. But the cause of death, the warden said, had yet to be determined.

Within weeks of Silva’s death, Napolis also got in touch with two others — another jail official and a police detective — but she says neither man knew any more than Wagatsuma. The detective told her that he’d be in touch once Silva’s toxicology test is done.

Nearly seven months later, Silva’s death certificate shows that he died of “acute methamphetamine toxicity.”

But Napolis says she is still in the dark — the detective has yet to get back to her, and she doesn’t have a copy of an autopsy report.

“They owe us an explanation about his death,” Napolis said.

In many ways, Napolis’ experience isn’t unusual. Like Silva, many Hawaii inmates die behind bars without the public knowing why — or whether their deaths could have been prevented.

That’s because the Department of Public Safety isn’t required to publicly release information about inmate deaths.

Under its “,” the department is only required to give a “prompt and sensitive notification” to family members when an inmate dies or is in “immediate danger” of death.

But Toni Schwartz, public safety spokeswoman, says the department has an informal protocol in which it notifies the chairs of the House and Senate public safety committees about inmate deaths.

Schwartz says the department also issues a press release after each homicide, but not for other deaths such as suicides.

“We do not generally send public notice out on suicides because of the risk of copycat actions by others who see the news coverage,” Schwartz said.

But neither family members nor committee chairs are given any follow-up information from the “clinical mortality review,” which is conducted by the department to examine the circumstances surrounding inmate deaths to see whether any “corrective actions” should be taken.

The Justice Department, meanwhile, collects the number of inmate deaths across the country, but it only publishes its findings years later, and in aggregate, making it difficult to tease out any unusual patterns at a local level.

Kat Brady, coordinator of the , says the paucity of information is troubling.

“We pay for (prisons and jails), and they are in our communities, so we have a right to know what’s going on in there,” Brady said. “It seems like the department is trying to hide something. That, to me, is very, very disturbing because we’re talking about people’s lives here.”

Pushing For More Transparency

In 2011, a year after two Hawaii inmates were brutally murdered at a privately run facility in Arizona, state Sen. Will Espero introduced , which would have required notification to the Legislature within 48 hours of inmate deaths.

“The genesis of my bill back then was that I was hearing about these deaths third-hand, through family members and advocates,” said Espero, a former chair of the Senate Public Safety Committee. “If you think about a death in any other state-owned facility — whether that being an office building or school — we expect almost immediate notification and transparency, and it should be no different with correctional facilities.”

Espero adds that his bill would have allowed the Legislature to monitor the Department of Public Safety more effectively in the event of inmate deaths.

“It was really an effort for better oversight,” Espero said. “With the information, we can see if there are any trends or patterns and whether the department needs to do more to get down to the root causes of them.”

“We pay for (prisons and jails), and they are in our communities, so we have a right to know what’s going on in there.” — Kat Brady, coordinator of the Community Alliance on Prisons

But Espero’s bill, which won the backing of the Legislature, was vetoed by then-Gov. Neil Abercrombie.

Still, Schwartz says the department has since taken proactive steps on its own to stem the number of inmate deaths and updated its training curriculum for suicide prevention early last year.

The updated curriculum, Schwartz says, is based on “proven practices” that focus on teaching correctional officers — who receive 36 hours of initial training and take a biannual refresher course — about “indicators, signs, symptoms, response and what action/referral non-medical staff can take.”

“We are confident that our practices are sound and we take suicide detection and prevention very seriously,” Schwartz said. “Our policies are routinely evaluated, and training is ongoing with all our staff for suicide prevention.”

But Brady is skeptical.

“The department keeps saying, ‘Oh, we have policies and procedures and gotten training.’ Yet, (the deaths) still keep happening,” she said. “So what all this means is only that they can check the box that says they have a policy. But it doesn’t at all tell you what actually happens.”

For his part, Gregg Takayama, who chairs the , says he’s open to consider a bill similar to Espero’s old bill.

“I’d be willing to take a look at it legislatively,” Takayama said. “It’s understandable that there are public concerns about how many deaths there are in our correctional facilities because inmates are our responsibility as wards of the state.”