WINDSOR, NC (Gavin Off and Ames Alexander/The Charlotte Observer) - Just an hour before she was beaten to death with a fire extinguisher, Sgt. Meggan Callahan worried that her officers were not prepared if an inmate attacked.
About 250 inmates lived on Callahan's unit at Bertie Correctional Institution. Some were serving time for murder or rape. Others were gang members. All had behaved well enough in prison to be in medium custody, where they lived in open dormitories rather than small cells.
The freedom inmates had – and the threat that it could pose – was one reason some officers didn't want to work there. The others: The unit was often understaffed, and many of the officers there were untrained rookies, a Charlotte Observer investigation found.
Citing security reasons, prison officials refused to release surveillance video of the attack on Callahan or information about staffing at Bertie on the day she died. They did not allow reporters to tour the prison and refused to make officials at Bertie available for an interview.
But more than a dozen current and former Bertie officers told the Observer that the prison had been dangerously short-staffed for a long time. They also disclosed previously unreported details about the prison and what happened there on April 26, the day Callahan was killed.
Only four of Callahan's officers were working that day, according to a Department of Labor report. That's half the recommended number, several current and former officers said.
At Bertie and in prisons across North Carolina, severe staff shortages endanger officers and inmates, the Observer found. At some of the state's most violent prisons, more than one of every four positions is vacant.
State lawmakers and prison leaders helped create the understaffing problem. They built many prisons in rural areas where it's hard to recruit employees. They pay officers in maximum-security prisons about $8,000 less than the national average, and, for years, failed to train new hires promptly.
All of that has left the prisons in a perilous cycle: The dangers and low pay of prison work make it harder to attract staff. That, in turn, makes the prisons more dangerous.
"The inmates pretty much understood that they could take over because we didn't have enough staff," said former officer Derrick Matthews, who until recently worked on Callahan's unit. "They'd say things like, 'We know we have the upper hand.' And then you think, 'They're pretty much right.' "
Sgt. Joe Gurganus said Callahan sounded concerned when they spoke on the phone around 4:30 p.m. on the day she died. Gurganus, a supervisor on the floor below her, said Callahan was especially worried about the inexperience of her staff.
"She didn't know which ones would have her back because they were new and they were not properly trained," Gurganus said.
About an hour after the conversation, Gurganus heard an alarm:
Code 7: Officer down.
A passion for helping others
Callahan, 29, grew up in Edenton, a historic town on the banks of the Albemarle Sound about a half-hour's drive from Bertie.
She loved children, her friends say. She supported the Special Olympics and the National Alliance on Mental Illness. Her passion for helping others is largely what attracted her to public safety work, said her mother, Wendy Callahan.
Callahan began working at Bertie in 2012 and was promoted to sergeant four years later.
She was protective of her staff and concerned about their safety, her mother told the Observer in a May interview.
"She told me over and over (the prison) was understaffed," Wendy Callahan said. "And it was dangerous."
Late in the afternoon on April 26, routine prison tasks occupied two of Callahan's crew. One officer was manning the control booth. Another was helping an inmate who worked as a janitor, according to a labor department report and three officers who were at the prison that day.
That left Callahan with just two officers to watch roughly 250 inmates.
Of Callahan's two remaining officers, one had been on the job less than a year, state data show.
The other officer joined the prison just two months earlier and had not been through the four-week basic training course, officers said. Included in the training she hadn't received: How to subdue an attacking inmate.
Free to move about
Inmate Craig Wissink was serving a life sentence for first-degree murder stemming from a 2000 robbery attempt in Fayetteville.
But at Bertie, Wissink was not known as a troublemaker.
During his 13 years in prison, Wissink had been cited for six infractions, records show. They included disobeying an order, interfering with staff and substance possession.
Wissink's relatively good behavior gained him a spot in Bertie's Upper Tan Unit, where the dorm's common area – with tables, TVs and a microwave – was flanked by rows of bunk beds. Inmates there were free to move about the dorm.
Upper Tan was Callahan's unit.
For reasons that aren't clear Wissink was angry at Callahan, several officers told the Observer.
Authorities believe Wissink targeted her, said Anthony Jernigan, who heads the State Bureau of Investigation for northeastern North Carolina.
Around 5:35 p.m. – about an hour after Callahan's conversation with Gurganus – Wissink set a fire in a dormitory trash can, according to a prison disciplinary report obtained by the Observer.
Then he walked across the room and waited.
A brutal attack
Callahan was wrapping up her 12-hour shift when she and two officers responded to the fire. About 60 inmates congregated nearby.
Here's what happened, according to documents from the medical examiner, and the departments of labor and public safety:
Callahan ran from her office to the control room to grab a fire extinguisher. Then she made her way to Wissink's dorm.
One of the two officers who responded with Callahan went into the dorm but stopped. She stood in the doorway as Callahan rushed to the fire.
Callahan took the 50-gallon trash can into a bathroom area.
Then Wissink attacked her from behind.
When Callahan tried to run, he threw water that had been heated in a microwave at her face. That stopped Callahan.
Wissink tried to cut her with a piece of glass – one of the homemade weapons that inmates call shanks.
Then he grabbed the fire extinguisher, stood over Callahan and repeatedly beat her in the head.
'This is a riot'
As the alarm sounded across the prison, six officers – armed with metal batons – rushed into Upper Tan, according to the labor department report.
Wissink back peddled and sprayed a wave of white fire retardant before dropping the canister. He was holding the shank to his throat when an officer shot pepper spray into his face, the report states.
Among the first officers to arrive was Santo Francello, who had worked at Bertie for six months and ran from across the prison when he heard the alarm.
Francello said smoke, fire retardant and pepper spray clouded the air when he reached Upper Tan. He could barely see.
"This is a riot," he remembers thinking.
He said both officers who responded with Callahan were behind a heavy sliding door, where they were away from Wissink.
One officer had fallen and hurt her knee, SBI agent Jernigan said.
Francello rushed to the back-up officers already on the scene. In front of them – between the common area and bunks – Wissink was on his knees. The shank rested nearby.
Wissink sobbed as he let officers handcuff him and escort him out of the unit, Francello said.
Others tended to Callahan. About 25 to 30 officers responded to the attack, Francello estimated.
Gurganus says he wanted to respond to the alarm. But policy doesn't allow sergeants to leave their units.
Gurganus, a former Marine who served two tours overseas, was standing at the bottom of the Tan Unit stairs when officers carried Callahan down on a backboard. He helped lift her onto a stretcher.
"Seeing her," he said, "brought flashbacks of things I had seen in Iraq."
Callahan died around 6:20 p.m. – less than an hour after the attack.
An autopsy report said Callahan suffered burns to her face, chest and left arm. She died of "traumatic head injuries," the report concluded.
If more officers had been on duty, they might have deterred Wissink from attacking, Gurganus said. A properly trained staff, he added, "would have saved her life."
'In big-time danger'
Even before Callahan's death, many Bertie officers were concerned about staff shortages and poor training.
Some, including Ron Bagley, a former Tan Unit officer, resigned partly because of the dangers.
Full staffing was a "rare, rare, rare thing," said Bagley, who quit in 2016.
The month Callahan died, roughly one of every five officer positions at Bertie was vacant, data show.
Former Bertie lieutenant Gail Boyd said she often did not have enough staff.
"I had to pull from here or pull from there, and that was on every unit," said Boyd, who also left in 2016. "It puts officers in big-time danger."
Erika Jordan, a former officer who left Bertie in 2015, still gets emotional talking about Callahan.
The two were close friends and often ate together at Burger King, she said. They hugged after passing the sergeant's exam.
Jordan said Callahan was worried about the prison's policy of putting untrained officers on Tan Unit.
Bertie generally places rookies on Tan Unit, nine officers, including Gurganus and Francello, told the Observer.
Prison leaders think inmates there are less dangerous than those in maximum security, they said.
But untrained officers know little about controlling violent inmates, Jordan said.
"Everybody over there should have been certified," she said. " … She's gone for nothing."
The Observer asked to interview top Bertie officials, including David Millis, the prison's acting administrator at the time of Callahan's death. The state refused the request.
A prison official told Department of Labor investigators that "all post (sic) were properly manned" when Callahan was killed, according to a state document.
But two prison experts, told of Tan Unit's staffing the day of the attack, called it woefully inadequate. Better staffing, they said, might have saved her life.
Martin Horn, a former secretary of corrections in Pennsylvania who lectures at John Jay College of Criminal Justice in New York, said all prisons have inexperienced officers, but they should be teamed with veterans. Leaving two new officers in charge of a large unit is "indefensible," he said.
"Would you put a trooper on the road with no training?" Horn asked. "Yet you put untrained officers on a cell block with 250 known criminals."
Brian Dawe, a former prison officer who runs the American Correctional Officer Intelligence Network, said he believes prison leaders are partly to blame for Callahan's death because they left her unit so poorly staffed.
"That young officer's blood is on their hands," he said. "And it should stain their careers for the rest of their lives."
A purpose born of tragedy
On May 4, a horse-drawn caisson and military honor guard led a funeral procession for Callahan. More than 500 mourners – including Gov. Roy Cooper – gathered for the funeral in Edenton.
The sergeant was laid to rest with full law enforcement honors, in front of correctional officers from across the state.
About 275 people – some from as far away as California – signed Callahan's obituary on the Internet. Many of them were prison officers.
"Be at peace my friend," wrote Raymond Suarez, a Bertie officer. "We will take up the watch."
Wissink was charged with first-degree murder and is being held at Polk Correctional Institution north of Durham.
Tan Unit was closed after the killing, its inmates sent to other units and prisons, Francello said.
A month after her daughter's death, Wendy Callahan spoke with an Observer reporter and conveyed a message to state leaders: The prisons need to hire more officers, increase their pay and train them better.
In August, following an Observer investigation into prison problems, state officials began training officers within their second week on the job. Previously, officers could work for more than six months without training.
"Maybe there's a purpose to Meggan's death," Wendy Callahan told the Observer. "It's for people to understand they need more help there."
Less than six months after Callahan was killed, an even deadlier attack occurred at another prison just an hour away.
Four prison workers were fatally wounded during an October escape attempt at Pasquotank Correctional Institution. Inmates stabbed the workers with scissors and beat them with hammers, a prison employee told a 911 dispatcher.
According to state data, about 28 percent of Pasquotank's officer positions were vacant that month.
'I still see her face'
In the four months after Callahan's death, 25 officers left Bertie, records show. That's about twice the number who left in the four months prior to her death.
In June, Francello moved to Vermont, his home state, to work at a prison there. The attack on Callahan was the tipping point, he said.
"I realized that I would rather go back to where I was working before – where I felt safer," Francello said.
Matthews, who worked on Tan Unit, left Bertie a month later. He said that Callahan's death drove home the dangers of working in a North Carolina prison, where officers are badly outnumbered.
"I don't want to be in a field where every day I risk my life," Matthews said. "I want to be able to go home to my family."
Gurganus went on leave a week after Callahan died.
Since his days fighting in the Marines, Gurganus has struggled with post-traumatic stress disorder, he said. Consumed with rage toward inmates after Callahan's death, he enrolled in an intensive outpatient program for his PTSD.
"I still see her face," he said of Callahan. "Just like I did with situations from Iraq, I have to work through it."
Gurganus said he refuses to go back to Bertie.