Report faults jail care
County memo says two in-custody deaths will not be charged as homicides
A 43-year-old man told nurses he had chest pain. He received anti-anxiety medication, only to die of a heart attack.
A 36-year-old woman told nurses she had pneumonia - and that her spleen had been removed, making the disease particularly dangerous to her. Already coughing, she was given an inhaler, which did not stop her from asphyxiating on her own lung fluid early the next morning.
Both were inmates at the Multnomah County Detention Center, and both told the admitting nurses not just of their current symptoms but of red flags in their medical history. And in both cases the nurses did not consult with doctors before administering medications which, in the end, did not work.
These, at least, were the findings of criminal investigations into the deaths of Jody Gilbert Norman and Holly Jean Casey, released Thursday by the Multnomah County district attorney's office.
Despite the findings, the March 10 memo detailed why no one would be prosecuted for the inmates' deaths, although it raised questions about the quality of care received in jails.
In the memo, Senior Deputy District Attorney Don Rees wrote that 'after reviewing the facts and circumstances surrounding the deaths of inmates Holly Jean Casey and Jody Gilbert Norman I conclude that no single person or persons can be held liable for any degree of criminal homicide as defined in (state law).'
Reese added, 'To the investigators who worked on these cases and I, the deaths of inmates Casey and Norman seem to raise serious questions about inmate management and health care practices within the Multnomah County corrections system and the level of health services.'
While prosecutors will not charge anyone with homicide, they are pursuing charges against two nurses who worked in Multnomah County jails. One, William Lee James, is alleged to have altered patient records to falsely suggest he consulted with a doctor prior to prescribing anti-anxiety medication to Norman. Another, Kimberly Joers, is accused of falsifying drug records.
Moreover, Casey's ex-husband has retained two local attorneys, Hala Gores and Matt Kaplan, to sue the county.
One nurse still on leave
Asked about the jail deaths, county health Director Lillian Shirley, who oversees the corrections health division, said, 'This is something that we take extremely seriously and put a lot of planning time around analyzing what went wrong.'
Shirley added, 'Now that the criminal complaint is done we can proceed with our personnel investigation, and I promise you it will be completed within a week.'
The first of the two deaths investigated occurred in 2005, after Norman, a petty thief, was admitted to jail while complaining of chest pain and a history of angina. The nurse, James, gave him Ativan and indicated in records that he'd spoken with a doctor before administering the drug.
Contacted in December, James told the Portland Tribune he was following an unofficial policy at the corrections health division and said he felt terrible about Norman's death.
Shirley denied that her department had tolerated the practice described by James.
The second death, that of Casey, occurred Jan. 4 of this year.
Casey, with a history of drug abuse, was booked for failing to appear in court on a second-degree theft charge. She was given an inhaler after reporting difficulty breathing at 11 p.m. She 'reportedly' showed some improvement, but then continued to complain about stomach and breathing problems, the Rees memo said.
At about 5 a.m., the deputy on duty advised a jail nurse that Casey was continuing to ask for medical care, but the nurse 'declined to contact or treat Casey,' Rees wrote.
She was found to be dead at 7:30 a.m.
The nurse involved, Glenda Baxter, remains on leave while the county decides whether to discipline her for the treatment of Holly Jean Casey, according to Shirley.
Asked hypothetically about the standard of care when a patient with no spleen complains of pneumonia, Dr. Scott Fields, the vice chairman of the family medicine department of Oregon Health and Science University, cautioned that 'confounding factors' can complicate cases, and that it's hard to generalize when a pneumonia diagnosis depends on detectable symptoms.
However, he said the spleen 'happens to be very important' for removing the bacteria responsible for strep pneumonia, meaning a patient lacking that organ could receive special attention.
He said he would evaluate that patient to confirm signs of pneumonia - check the heart rate, listen to the lungs and perhaps do an X-ray. Once the symptoms were confirmed, antibiotics would be administered.
Cases include Chasse in 2006
These are hardly the first controversial deaths to occur at or be involved with Multnomah County jails.
In 2003, an unemployed bricklayer who was well-known in the Portland music scene, Nick Baccelleri, died when corrections health personnel gave him an overdose of methadone rather than his prescribed medication. The county paid $200,000 to his family in that case.
In the past three years, according to County Attorney Agnes Sowle, the county has paid out $233,000 to settle four claims against the corrections health division. The largest of those, for $200,000, was paid to the family of Anthony Delarosa in January 2007.
According to a lawsuit filed by his estate in 2006 that accused corrections health of inadequate medical care, Delarosa died on Oct. 1, 2004, while suffering heroin withdrawal symptoms. He vomited and slipped into a withdrawal coma in his cell, but, according to the lawsuit, the jail defibrillator either was missing or did not function properly.
And in 2006, a corrections grand jury faulted the jail's handling of James Chasse Jr. on Sept. 17 following a controversial altercation with two Portland police officers and a county sheriff's deputy that led to his in-custody death.
According to the grand jury's report, the jail nurse was not informed of the extent of Chasse's injuries, the inmate was not taken immediately to the closest hospital when it looked as if his injuries might be life-threatening, and the jail lacks a protocol requiring arresting officers to specify the extent of any physical force used on an inmate being booked.
Jail's not 'a well population'
Shirley said that after any death at the jail, her department takes action to prevent any contributing factors in that death from happening again.
She noted that her unit examines some 40,000 inmates each year, many of them in poor health, drunk or on drugs, and with prior medical problems. So are deaths inevitable?
'This is a very tough job,' Shirley said. 'Every day with the prison population, the people that are charged to take care of their health have to make a tremendous amount of decisions. And we're not talking about a well population here.'
Rees' memo also notes that Joers, the nurse prosecuted for tampering with drug records, was an admitted drug abuser who was hired by the county just one month after being fired from a Portland hospital for 'misconduct involving the loss of a narcotic medication.'
Two weeks ago, in a separate case, a former county jail nurse, Catherine Earp, filed a threat of lawsuit, saying she had been forced to resign after blowing the whistle on poor oversight in county jails and observing substandard medical care.
The county has not yet responded to her allegations.