Early one winter morning in 2012, officers at an eastern North Carolina prison found inmate Willis Gravley hanging from a bed sheet. He’d been dead for hours.

His death raised a question: Why didn’t officers at Bertie Correctional Institution stop Gravley from killing himself – or why, at least, didn’t they find his body earlier?

Prison investigators later found that officers in Gravley’s unit had been skipping a crucial part of their job for years: doing the required 30-minute security checks. Instead, officers falsified prison records to indicate they had made their rounds, according to dismissal letters issued to some officers involved.

In some of North Carolina’s most dangerous prisons, officers routinely fail to make their rounds, a Charlotte Observer investigation found.

State leaders are partly to blame. They’ve allowed many prisons to become dangerously understaffed. The staff shortages – caused partly by the low pay and perennial dangers of prison work – leave some employees hard-pressed to complete all their duties.

Negligence or inaction on the part of prison staff may have contributed to the deaths of at least eight N.C. inmates since 2009, records and interviews suggest. Prison officers found the bodies of some of those inmates stiff in their cells hours after they died.

Prison leaders say they don’t track how much the state has paid to injured inmates or to the families of those who died. But it’s a problem that has proved costly to taxpayers. In one highly publicized case, the state agreed to pay $2.5 million to the family of Michael Anthony Kerr, an inmate who died of dehydration in 2014 after lying for days in his own feces and urine.

Kerr, a habitual felon with mental health problems, died while being transported from Alexander Correctional Institution in Taylorsville to Central Prison in Raleigh. After his death, the state disciplined or fired at least 25 employees. Records show prison mental health officials were aware of Kerr’s deteriorating condition weeks before he died, but did not transfer him to a facility that could provide better care.

Such negligence adds to the dangers inside North Carolina’s prisons. A recent Observer investigation found that some officers smuggle drugs and cellphones to inmates. Others have sex with them or beat them in areas not monitored by security cameras.

Most of the state’s 8,000 correctional officers are honest and diligent, state prison leaders said.

“As a general rule, our staff do a very good job of keeping check on inmates,” said George Solomon, who retired as the state’s director of prisons earlier this year.

Lawmakers and state prison leaders say they’re taking steps to make sure officers complete their rounds. They’ve increased pay and expanded recruitment efforts to attract more qualified officers. In some units, they’ve put in place technology to ensure that officers make their security checks. And prison leaders say they are quick to take action when employees neglect their duties.

“Conducting rounds and documenting security checks on inmates are required by policy and are an important part of prison operations,” Kenneth Lassiter, N.C.’s director of prisons, said in December. “ … When supervisors are aware of officers not following policies, appropriate action is taken, up to and including dismissal.”

‘He’d been down for a while’

When investigators looked into Gravley’s death, they found that the officers responsible for the inmate’s unit had not done their required security rounds in the seven hours before his body was discovered. They were supposed to check that unit every half hour.

Ricky Morris, a former lieutenant with the Windsor Police Department who investigated the suicide, said that by the time he was called to the scene, Gravley’s body was no longer warm.

“He’d been down for a while,” Morris said.

Gravley was sentenced to life in prison in 1993 for the stabbing death of his girlfriend. He died in his cell at the age of 36.

A medical examiner concluded Gravley had killed himself. The investigation that followed his death resulted in the dismissal of six staff members and the reassignment of the prison’s top administrator.

“The investigation determined it was a routine unapproved practice for staff assigned to Gray Unit to falsify the required thirty (30) minute security checks …,” states a dismissal letter written to the former manager of the prison unit. “Your willful violation of policy compromised the safety and security of the inmates … ”

A preventable death?

Prison records also raise questions about whether a former officer at Scotland Correctional Institution in Laurinburg skipped security rounds – and whether that contributed to an inmate’s death last year.

Steffone McCallum, the officer, was fired for failing to document rounds in the solitary confinement unit where inmate Scott Sica was found dead, hanging from a shoelace. Sica died in April 2016 from “autoerotic asphyxiation,” an act in which a person temporarily cuts off the oxygen supply to the brain to heighten sexual pleasure, according to his autopsy report.

“Based on your poor judgment and failure to abide by policy, management cannot substantiate that rounds were made … to observe inmate (Sica’s) behavior, which could have prevented his death,” McCallum’s dismissal letter reads.

McCallum could not be reached for comment. But in statements to prison investigators, he contended he made security rounds in the hours before Sica’s body was discovered.

Following Sica’s death, a prison manager at Scotland sent out an email to staff members. Officers beginning their work days must help departing shifts with security rounds “to ensure that there is a live breathing body in each cell on controlled and restrictive housing units,” it said.

More than a dozen current and former staff members told the Observer it was common for state prison officers to skip rounds and falsify paperwork.

“You could falsify it at any time,” said Marcus Mercer, a former officer at Lanesboro Correctional Institution, located southeast of Charlotte. “Most supervisors don’t check the log book anyway.”

Mercer said he resigned from the prison last year after inmates stabbed him in the cheek with a homemade knife and made threatening calls to his cellphone.

When officers miss their rounds, inmates have more time to make and acquire weapons or to harm themselves, he said.

“Usually that’s when bad things happen,” Mercer said. “Fights in the cells. Inmates trying to commit suicide.”

State: We’re addressing problems

State prison leaders say technology upgrades have helped ensure that staff members regularly check on some inmates. In solitary confinement units, officers now scan electronic tablets at each cell to document that they observed the prisoners.

But staffing challenges make problems inevitable, experts say.

Statewide, about 16 percent of officer positions were vacant in October.

At some prisons, the vacancy rates were much higher. At Polk Correctional Institution, north of Durham, more than 30 percent of positions were unfilled.

“That is an absolutely shocking number that should be raising alarm bells at the legislature and the governor’s office,” said David Fathi, director of the ACLU’s National Prison Project.

At Pasquotank Correctional Institution, where four workers were fatally wounded in an October escape attempt, the vacancy rate was 28 percent.

And at Bertie Correctional, where Sgt. Meggan Callahan was killed in April, the rate was more than 25 percent.

Experts say better staffing might have saved those employees.

But finding people who are willing to work as prison officers isn’t easy. The hours are long, the pay is low, and the work is dangerous.

“Correctional officers are caught in a spiral of impossible demands,” said Jennie Lancaster, a former high-ranking state prison official. “ … They are the forgotten actors on the law enforcement stage.”

Prison leaders say they’re beefing up their recruitment efforts. They’re holding hiring events and partnering with schools and military bases to fill jobs.

State lawmakers have boosted pay in recent years in an effort to attract and retain qualified staff.

Officers at maximum-security prisons are now paid an average of about $38,000 a year – still about $8,000 less than the national average for correctional officers and jailers. More salary increases may be needed, legislative leaders say.

A recent study by Duke University recommended additional efforts, including forming recruitment committees at each prison and offering referral and signing bonuses to employees.

This year, N.C. prisons hired an average of 147 officers a month, but lost 153 officers, records show.