Dehydration, missed meds and indifferent staff: Charges detail what led to prisoner deaths at Waupun

Donald Maier desperately wanted water.

He cried out for it. He tried to drink it from a toilet. He seized. 

Despite his pleas, his convulsions and his serious health history, no staff members entered a prison cell in Waupun to check on him, court records show.

Maier, 62, died Feb. 22 from probable dehydration and failure to thrive due to malnutrition, one week after prison staff began intermittently shutting off the water to prevent him from flooding his cell.

His death was ruled a homicide.

The circumstances of his death and that of three other men at Waupun Correctional Institution drew outrage Wednesday, as a local sheriff and prosecutor announced criminal charges against nine people who had been employed at the prison, including the warden, Randall Hepp.

Criticism came from all sides: the Dodge County Sheriff's Office slammed former Department of Corrections Secretary Kevin A. Carr, and Gov. Tony Evers blasted the Sheriff's Office for closing the death investigations.

The families of those who died in custody demanded more accountability, while advocates and politicians pushed for more urgent reforms and actions, including the closure of the aging prisons at Waupun and another in Green Bay.

“This isn’t just a bad warden," said David Liners, executive director of WISDOM, an advocacy organization that supports those incarcerated.

"This is a bad system that needs to be overhauled,” he said.

TIMELINE:What happened at Waupun: Prisoner deaths, investigations, lawsuits and resignations

At a news conference this week, Dodge County Sheriff Dale J. Schmidt detailed what led to the deaths of Dean Hoffmann, 60; Tyshun Lemons, 30; Cameron Williams, 24; and Maier, between June 2023 and February 2024.

Court records and information shared by Schmidt corroborated reporting by the Milwaukee Journal Sentinel about the deaths of Williams, who died of a rare stroke after repeatedly crying out for help, and Hoffmann, who died by suicide after prison staff failed to provide his medication regularly, as prescribed.

Three Waupun employees face charges in Williams' death. Seven prison employees, including Hepp, have been charged in the death of Maier. The DOC did not respond to questions Wednesday about Hepp's arrest and departure from the prison's top spot as warden.

No charges were filed in the case of Hoffmann or Lemons, who died of an accidental fentanyl overdose. 

Hoffmann’s family has filed a federal civil rights lawsuit against the prison and employees there. Lemons' family has questioned how the drugs that killed him entered the prison. Schmidt said the investigation into Lemons' death showed "no concerns of staff misconduct."

The spate of deaths came as the prison dealt with chronic understaffing, lockdown conditions and a federal investigation into a suspected drug and cell phone smuggling ring by staff at the facility. The federal probe resulted in 11 state employees being placed on administrative leave, with five later resigning or being fired.

The prison also had seen turnover in its leadership. Former DOC Secretary Kevin A. Carr stepped down in March. Gov. Tony Evers appointed Jared Hoy, the deputy secretary, to take over as secretary last month.

Sheriff described dire conditions for prisoners: 'These people were not cared for'

Maier died Feb. 22 in a suicide observation cell where he had been placed nine days earlier, following a visit to the hospital services unit.

He was cold to the touch and rigor mortis had set in, according to court records and officials.

Schmidt, the sheriff, could barely conceal his outrage as he described Maier's death.

"'Persons in our care' is not a phrase I would use in Waupun Correctional Institution," Schmidt said, referring to the DOC's own language for prisoners.

"These people were not cared for," he said. "They’re people, and they were not cared for."

Maier was found in a cell with a strong odor of bodily fluids and urine, and garbage and clutter strewn around, the sheriff said.

Maier suffered from mental health and medical conditions, and likely had only received his medications once during those nine days. Staff had described him as "not being able to ... effectively communicate his needs," a criminal complaint says.

The complaint outlined the following sequence of events:

Staff turned off water to Maier's cell Feb. 16 after he flooded it. Employees did not note the shutoff in formal records. It was unclear if anyone offered Maier other water during the other times when his water line was shut off in the following days.

Prison staff later witnessed him drinking from the toilet, speaking incoherently and making repeated statements about wanting water.

At one point, Maier told prison staff he wanted "water, water, water, all the water in the world."

His last known record of eating was Feb. 17 when staff removed an empty food tray from his cell. The next day, Maier flooded the cell again and staff shut his water off. No food was brought to Maier that day, and there are no records that Maier ate at any point after that.

Over the next four days, multiple staff members observed his condition deteriorating. As they looked into the cell, staff saw Maier appear to have a seizure and noted he was shaking and unresponsive later.

Still, no one entered his cell to check on him or tried other interventions.

On Feb. 21, a doctor tried to visit Maier but was told by staff that he refused the meeting. The doctor raised concerns over the man's frail condition, but no action was taken. Later that day, a staff member noticed the water was still off and turned it back on.

By then, Maier was on the floor of his cell.

He never got back up.

Warden Randall Hepp, other correctional staff facing felony charges

Seven people were charged in connection with Maier's death, including Hepp, who faces one count of felony misconduct in public office.

Hepp did not oversee his staff to ensure they were following directions, "which led to the demise" of the victim, according to the criminal complaint.

The complaint alleged staff was poorly trained on policies and procedures regarding missed meals, water restrictions, medication refusals, round checks and more. 

During his interview with investigators, Hepp said he did not talk with staff about the policies around shutting off water to a cell and did not know that it was taught at DOC academy, either. Most of the policies were sent to staff by email.

"I think learning has been sacrificed for convenience," he told investigators.

Others facing charges include:

• Jamall Rabb Russell, 39, a correctional officer, was charged with abuse of residents of penal facilities and misconduct in public office.
• Sarah Anne Margaret Ransbottom, 35, a correctional officer, was charged with misconduct in public office.
• Jeramie Heyward Chalker, 41, a correctional sergeant, was charged with misconduct in public office.
• Alexander John Hollfelder, 31, a correctional sergeant, was charged with abuse of residents of penal facilities.
• Brandon James Fisher, 29, a correctional lieutenant, was charged with two counts of abuse of residents of penal facilities.
• Jessica Ann Hosfelt, 47, a registered nurse, was charged with abuse of residents of penal facilities.

According to the complaint, Russell was responsible for providing food trays to Maier and his actions resulted in eight of 12 meals not being consumed over four days. Russell did not follow procedures for a hunger strike, nor did he provide Maier with his medications.

Russell also was found to have skipped cell checks but signed paperwork saying he had completed them. Chalker and Ransbottom also signed their initials on paperwork indicating they had completed rounds when they had not done so.

All of those charged made their first court appearances on Wednesday after being booked into Dodge County jail. They were released on signature bonds and are expected back in court next month.

Cameron Williams' mother wants those charged to get maximum sentence

Officials provided more details about the death of Williams, which matched previous reporting in the Journal Sentinel.

The news organization had pieced together what happened in his final weeks with information from prisoners and family members. Prisoners held in the same unit as Williams said his pleas for help were ignored in the days leading to his death.

Schmidt confirmed that despite multiple "medical episodes" including stumbling, collapsing while being escorted back to his cell, "loud, labored breathing," "strange behavior," and instances of being unresponsive, no medical assistance was provided, nor was any documentation reported to a supervisor.

He also detailed multiple attempts to wake Williams and numerous medical passes and hourly rounds where he did not respond — some of which the sheriff said correctional staff skipped or "simply walk(ed) down the hallway without even looking."

The sheriff said by the time prison staff finally entered Williams' cell, he had been dead for at least 12 hours.

Gwendolyn Peachey Vick, 50, a registered nurse, and Tanner Leopold, 27, a correctional sergeant, each face one count of abuse of residents of penal facilities. Fisher, a correctional lieutenant also charged in the Maier case, faces two counts of abuse of residents of penal facilities in Williams' death. They were released on signature bonds and are due back in court next month.

Vick did not speak with sheriff's investigators but told an internal investigator that Williams was a "frequent flyer," who often called for medical care. She told guards to hold off on entering his cell to see if he continued to "play possum," according to statements quoted in the criminal complaint.

"Obviously, looking back I would have made a different decision," she said, according to the complaint.

Last month, Williams' family filed a federal civil rights lawsuit against the Department of Corrections and prison officials, alleging his constitutional rights protecting against cruel and unusual process were violated.

His mother, Raven Anderson, spoke with Schmidt, the sheriff, earlier this week. Although she said she was "happy" about the charges, she wants to see those charged convicted of the crimes and sentenced to time behind bars.

The charges of abuse of residents of penal facilities and misconduct in public office are class I felonies that carry a maximum potential sentence of up to 18 months in prison and two years of extended supervision.

“I want them to get the maximum sentence,” Anderson told the Journal Sentinel. “I don’t want them to get a slap on the wrist.”

"My son is never coming back.”

Despite policy violations in Dean Hoffmann's suicide, no 'criminal activity'

Hoffmann, who had a documented history of mental health challenges, including bipolar disorder and suicidal thoughts, died by suicide on June 29, 2023.

Records obtained by Hoffmann's family and previously reviewed by the Journal Sentinel showed prison staff failed to provide his bipolar and antidepressant medications as prescribed more than three-quarters of the time in the two and a half months leading to his suicide.

At the press conference, Schmidt said between June 1 and June 20, there were three days where Hoffmann did not receive medication and seven days where he had only one of the two staff-distributed medications. Staff were not required to wear body cameras during medical passes in general population, according to Schmidt.

Schmidt said his office had to rely on medical records for their investigation. Those records showed Hoffmann's antidepressants and bipolar medications were provided by staff, including correctional officers and registered nurses, and not self-administered.

"I can't tell you if they just weren't given or the individual said 'I don't want them,'" he said.

Schmidt said Hoffmann had two other medications that he self-administered during this time and were not distributed by staff.

While in restricted housing — or solitary confinement — between June 21 and 29, Schmidt said all four medications were administered by staff. He said that it is unknown if all medications were distributed on June 23, and additional video surveillance confirmed that "at least some medications" were not distributed on June 28.

"Documentation of medication being distributed, however, was vastly inaccurate and did not match what the video evidence of the distribution showed," Schmidt said. "They simply did not keep accurate medical records when they were distributing those medications."

He blamed the inadequate documentation on the electronic medical record system and staff bypassing reporting requirements.

"While there are policy violations, none of the policy violations in this incident rose to the level of criminal activity," he said. "The behavior by DOC officials remains concerning and it has been addressed with DOC administration."

Hoffmann's ex-wife, Deborah Hoffmann, has been frustrated by the entire investigation and said that she and her family had not been notified of Wednesday's news conference until contacted by the Journal Sentinel the day before.

"Disappointed is an understatement," Hoffmann said Tuesday. "They kept telling me to be patient and then when we met it was to tell us it was being closed. They provided us nothing along the way."

Following the press conference, Megan Kolb, Hoffmann's daughter, questioned why no charges were filed in his death.

"Because my dad's (death) is ruled as a suicide, it just feels like it's not important, and his mental health was not important," she said. "It's not important to our government or our judicial system."

Contact Vanessa Swales at 414-308-5881 or [email protected]. Follow her on X @Vanessa_Swales.