He spent most of that time in solitary confinement, naked and shackled on his ankles and wrists. Wounds caused by those restraints, according to his autopsy, provided the entry points for the bacteria that killed him.

He never received psychiatric care, though jail employees said they were well aware of his mental state. He never saw a city judge for a bond hearing.

Inmates reported that Carpenter was handcuffed to his bed and unable to reach his food, though guards said he refused to let them remove his handcuffs to eat. He lost 23 pounds in the jail, according to one Sheriff's Department report. There is little indication that guards checked on Carpenter several times an hour as required. Carpenter's body lay in his cell for hours before it was discovered.

No heads rolled over Mr. Carpenter's death:

No jail employees were ever disciplined in the case, though a report said that 32 jail employees, including the now-retired deputy warden, were responsible for Carpenter's death because they did not follow jail procedures.