Darrell Davidson’s in-custody death investigation

Darrell Davidson’s death is one of more than 31 in-custody deaths at the Marion County Jail in recent years that has been investigated only internally by the Marion County Sheriff’s Office, which operates the jail, and without outside review by other agencies.

Although the “Gazette” was unable to locate Davidson’s next of kin for help obtaining his medical records compiled during his incarceration, the contradictions between jail reports and photographic evidence in Davidson’s case continue to indicate troubling gaps in accountability.

Davidson was booked into the jail on Oct. 13, 2023 on a misdemeanor charge of criminal mischief. Intake records noted “blisters on his feet and an abrasion to his forehead.”

Davidson had been receiving methadone treatment prior to his arrest, but according to jail records, “On the day of his booking, the methadone clinic reported that he tested positive for marijuana and therefore refused to continue dosing him while he is incarcerated”.

Federal Department of Justice guidelines state that polysubstance use is not a contraindication for treating opioid withdrawal and that withdrawal symptoms may persist for 10 days.

During the week following his incarceration, Davidson was involved in three separate use-of-force incidents. Jail records show corrections officers used pepper spray and a Taser on him, placed him in a restraint chair and struck him during altercations.

After one incident, photographs documented Davidson’s nose as “bruised, swollen and visibly broken” with “active bleeding,” yet medical staff reported only a single new injury – a Taser puncture wound on his back.

On Oct. 16, Davidson pleaded for medical help. A nurse documented him saying, “Somebody help. I can’t do this. This is inhuman. Make it be over with. I don’t know what to do. I need an ambulance. I should be in the hospital. I’m going to overdose on ibuprofen. I promise you don’t get mad at what happens next.”

Despite Davidson’s condition, jail medical director Dr. Jose Rodriguez, under contract with the private company Heart of Florida that provides medical services at the jail, “did not allow him to be transferred because he did not want inmates housed in the infirmary for medical observation anymore,” according to jail reports.

On Oct. 21, deputies found Davidson lying under his bunk. He resisted orders and was subjected to additional force. Minutes later, his condition rapidly deteriorated.

Though a nurse reportedly advised Davidson be sent to the infirmary, records show Rodriguez initially refused. Davidson was eventually admitted, where he collapsed. He was transported to AdventHealth Hospital but died later that evening.

Data obtained by the “Gazette” shows that in 2023 and 2024, post-booking emergency room visits for inmates dropped to less than half their historic levels, even as inmate deaths increased.

Although no explanation has been provided by HOF regarding the sharp decline, HOF would have benefited financially from having fewer emergency room visits under their contract with the jail.

The medical examiner ruled Davidson’s death was from natural causes, citing a blood disorder. But the office also documented approximately 50 wounds on Davidson’s body, including fractured nasal bones, a 9-inch bruise on his left torso, a 5-inch bruise to his right upper arm, a 6-inch bruise to his left forearm, and a 4-inch bruise above his left elbow.

Jail records, however, listed only four pre-existing injuries on the day he died.

Despite these discrepancies in visible wounds, the sheriff’s office determined no further investigation was necessary, records show.

To date, MCSO has not provided its internal morbidity committee report despite numerous requests.

Wider Pattern of Concerns

The “Gazette” has previously reported that a whistleblower, former jail medical liaison Mary Tolbert Coy, filed a lawsuit against Sheriff Billy Woods alleging substandard medical care at the jail and a pattern of ignoring pleas for help from inmates. The suit claims that systemic failures endangered lives.

During Coy’s tenure as the medical liaison for the inmates, she wrote compliance reports every month noting a lack of compliance with Florida jail model standards by HOF. These included not responding to sick calls, not staffing according to the contract requirements, falsifying medical records, questionable medical decisions or lack of care.

“Failure to follow their own policies and procedures,” wrote Coy in recently obtained sworn answers to interrogatories delivered in the court case.

Coy outlines reporting verbally and in writing “violations of medical standards, policies, and procedures affecting inmate health,” by HOF. Also, she reported, “deliberate indifference to serious medical needs of an inmate” and falsified medical mental health inmate records, including documented assessments for inmates who were not seen or had been released.”

When her concerns were ignored, Coy disclosed that she reached out to outside agencies like Disability Rights Florida and the U.S. Department of Justice, hoping an outside agency would intercede and provide oversight since Coy’s reporting was being discounted by her superiors.

Coy was fired in August 2024. Since then, the MCSO has not reinstalled compliance reporting on the $14 million annual HOF contract for inmate medical care.