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WSR Prisoner Murdered by Neglect
On December 12, 1994, Stanley Watson died of a heart attack at the Washington State Reformatory (WSR) in Monroe, WA. While heart attacks do happen and can be fatal Watson's death could have been easily prevented, so easily that his death amounts to negligent homicide. On December 11, 1994, Watson went to the WSR hospital on two separate occasions complaining of chest and back pains. The first time he was given no treatment whatsoever by Dr.Meloche. Watson was given an appointment to see a physician's assistant the next day, but he would be dead by then. He was told to return to the clinic if his symptoms got worse.
The second time he returned that day he was seen by nurse M. Yeager. He complained of continued chest pain, and classical heart attack symptoms. He was given nitroglycerin and Nifedipine and sent back to his cell. The next time Watson was seen by WSR medical staff it was in response to Watson's collapse at his work place, the kitchen, from where his lifeless body was transported to Valley General Hospital. Efforts to resuscitate him were unsuccessful and he was pronounced dead at 8:11 AM on December 12, 1994.
That would have probably been the end of it except that a complaint was filed with the Department of Health (DOH), supported by affidavits from two prisoners to whom Watson, in the last hours of his life, had complained to about not receiving appropriate medical treatment. The DOH initiated an investigation that revealed shoddy treatment and gross negligence.
On March 8, 1995, the DOH issued its final report. The final summary of the five page report states: "Documentation in the medical record did not meet Washington State Reformatory infirmary standards as evidenced through lack of dated entries and orders, missing authentication of entries and failure to record self-administered medication distribution."
"Appropriate follow through with inmate's hypertension and medication was not documented in the inmate's medical record."
"Facility did not have policies/procedures/protocols for handling of the life threatening emergency of myocardial infarction." [i.e. a heart attack]
"Facility lacked documentation of appropriate licensure and CPR/First Aid of two personnel involved with inmate's care. See statement of deficiencies."
The statement of deficiencies of the WSR hospital is four pages long. Watson was given an EKG on the eleventh. The DOH states: ". . .it was learned that at the time of the inmate's death, it was policy to have EKGs read by a computer. The computer system was old and had a history of significant problems in accurately interpreting EKGs. No qualified staff read the EKG that was completed in the clinic on 12/11/94. The EKG was determined 'normal' by the computer when it was not normal. This policy and practice did not support safe care."
"Two of the four personnel involved with the investigated case did not have current licenses on file at WSR. One was a physician assistant and the other a Registered Nurse. The PA license on file had expired on 9/9/93 and the facility had no verification of any license for the RN."
"Three (3) of four (4) medical personnel attending the deceased inmate did not have documentation of current CPR/First Aid. During this complaint investigation, a notice was observed posted in the infirmary nursing station asking how many staff needed CPR/First Aid updates. Six (6) of the seven (7) names of those responding stated they needed an update."
"The facility did not have protocols/procedures for the assessment, care and transfer of inmates who might be at risk for infarction. This patient showed typical symptoms of MI. No assessment except vital signs was documented on the first clinic visit of 12/11/94. Differential screening was done on the second visit including administration of Nifedipine, nitroglycerin, monitoring of vital signs and a computer read EKG. All documentation, except the computer read EKG, suggested a possible MI, yet the patient was not transferred to a hospital where further assessment, not provided at the infirmary, could have been provided."
Despite having a history of hypertension he was given no follow up care upon arrival at WSR. "Documentation and practice did not support continuity of care and physician orders for medications were not followed." Other problems with WSR medical records was that signatures were not legible, infirmary entries and medication records were not dated and not even the last two occasions Watson was seen at the hospital were the entries timed.
In their report, the DOH noted "None of the four medial personnel who attended SW were available for these surveyors to interview during the investigation survey." How convenient. One of the PAs who attended to Watson in his dying hours was PA Teodoro. According to a reliable PLN source, Teodoro began working at WSR after being "asked to leave" his prior place of employment at Fircrest, a home for the developmentally disabled, due to his inept care of patients there. Unfortunately for prisoners he's now been hired by the DOC.
Watson's death is far from unusual. In the July and October, 1994, PLN we reported on the murder of Gertrude Barrow. She was a prisoner at the Washington Corrections Center for Women who died after an ulcer ruptured. She was repeatedly denied medical attention by DOC medical staff and just hours before she died a DOC nurse was telling her to clean up her own vomit. What makes deaths like Barrow and Watson's all the more tragic is the fact that they were easily treatable and completely preventable. All that was required was a minimum of medical care. Instead a confluence of untrained, incompetent and, more importantly, uncaring, DOC medical personnel condemned these, and other, prisoners to death as surely as if they had pointed a gun to their heads and pulled the trigger.
Barrow's death resulted in settlement of a class action suit on WCCW medical conditions and significant improvement [See: PLN, April 1995]. The current DOC budget calls for a reduction in the amount spent on prisoner health care. This is in addition to recent legislation which seeks to charge prisoners $3 each time they seek medical attention, of the type that killed Barrow and Watson. It is likely that this type of problem will only get worse.
Currently the ACLU is investigating the lack of adequate medical care at the Reformatory; this facility receives prisoners from other DOC prisons who have serious or complicated medical conditions. If you can supply documentation (grievances, letters from DOC officials, affidavits, etc.,) showing inadequate medical care at the Reformatory you should contact the ACLU at: Julya Hampton, ACLU, 705 2nd Ave, Seattle, WA 98104.
Washington prisoners should also consider filing their complaints of inadequate or incompetent medical care directly with the Department of Health which, as shown above, does investigate credible claims and creates a good litigation record for this type of incident. Complaints to the DOH should be in letter form, briefly state the facts (names, dates, places, etc.,) of why the medical care was inadequate or deficient. You should support your complaint with affidavits from witnesses with first hand knowledge of the incident(s) and any other supporting evidence you may have. Once the investigation is completed you will be contacted and provided with a copy of the completed report. You can write DOH at: DOH, Facilities & Services Licensing, P.O. Box 47852, Olympia, WA 98504-7852. Prisoners in other states should consider a similar course of action with their state's medical regulatory agencies.
The second time he returned that day he was seen by nurse M. Yeager. He complained of continued chest pain, and classical heart attack symptoms. He was given nitroglycerin and Nifedipine and sent back to his cell. The next time Watson was seen by WSR medical staff it was in response to Watson's collapse at his work place, the kitchen, from where his lifeless body was transported to Valley General Hospital. Efforts to resuscitate him were unsuccessful and he was pronounced dead at 8:11 AM on December 12, 1994.
That would have probably been the end of it except that a complaint was filed with the Department of Health (DOH), supported by affidavits from two prisoners to whom Watson, in the last hours of his life, had complained to about not receiving appropriate medical treatment. The DOH initiated an investigation that revealed shoddy treatment and gross negligence.
On March 8, 1995, the DOH issued its final report. The final summary of the five page report states: "Documentation in the medical record did not meet Washington State Reformatory infirmary standards as evidenced through lack of dated entries and orders, missing authentication of entries and failure to record self-administered medication distribution."
"Appropriate follow through with inmate's hypertension and medication was not documented in the inmate's medical record."
"Facility did not have policies/procedures/protocols for handling of the life threatening emergency of myocardial infarction." [i.e. a heart attack]
"Facility lacked documentation of appropriate licensure and CPR/First Aid of two personnel involved with inmate's care. See statement of deficiencies."
The statement of deficiencies of the WSR hospital is four pages long. Watson was given an EKG on the eleventh. The DOH states: ". . .it was learned that at the time of the inmate's death, it was policy to have EKGs read by a computer. The computer system was old and had a history of significant problems in accurately interpreting EKGs. No qualified staff read the EKG that was completed in the clinic on 12/11/94. The EKG was determined 'normal' by the computer when it was not normal. This policy and practice did not support safe care."
"Two of the four personnel involved with the investigated case did not have current licenses on file at WSR. One was a physician assistant and the other a Registered Nurse. The PA license on file had expired on 9/9/93 and the facility had no verification of any license for the RN."
"Three (3) of four (4) medical personnel attending the deceased inmate did not have documentation of current CPR/First Aid. During this complaint investigation, a notice was observed posted in the infirmary nursing station asking how many staff needed CPR/First Aid updates. Six (6) of the seven (7) names of those responding stated they needed an update."
"The facility did not have protocols/procedures for the assessment, care and transfer of inmates who might be at risk for infarction. This patient showed typical symptoms of MI. No assessment except vital signs was documented on the first clinic visit of 12/11/94. Differential screening was done on the second visit including administration of Nifedipine, nitroglycerin, monitoring of vital signs and a computer read EKG. All documentation, except the computer read EKG, suggested a possible MI, yet the patient was not transferred to a hospital where further assessment, not provided at the infirmary, could have been provided."
Despite having a history of hypertension he was given no follow up care upon arrival at WSR. "Documentation and practice did not support continuity of care and physician orders for medications were not followed." Other problems with WSR medical records was that signatures were not legible, infirmary entries and medication records were not dated and not even the last two occasions Watson was seen at the hospital were the entries timed.
In their report, the DOH noted "None of the four medial personnel who attended SW were available for these surveyors to interview during the investigation survey." How convenient. One of the PAs who attended to Watson in his dying hours was PA Teodoro. According to a reliable PLN source, Teodoro began working at WSR after being "asked to leave" his prior place of employment at Fircrest, a home for the developmentally disabled, due to his inept care of patients there. Unfortunately for prisoners he's now been hired by the DOC.
Watson's death is far from unusual. In the July and October, 1994, PLN we reported on the murder of Gertrude Barrow. She was a prisoner at the Washington Corrections Center for Women who died after an ulcer ruptured. She was repeatedly denied medical attention by DOC medical staff and just hours before she died a DOC nurse was telling her to clean up her own vomit. What makes deaths like Barrow and Watson's all the more tragic is the fact that they were easily treatable and completely preventable. All that was required was a minimum of medical care. Instead a confluence of untrained, incompetent and, more importantly, uncaring, DOC medical personnel condemned these, and other, prisoners to death as surely as if they had pointed a gun to their heads and pulled the trigger.
Barrow's death resulted in settlement of a class action suit on WCCW medical conditions and significant improvement [See: PLN, April 1995]. The current DOC budget calls for a reduction in the amount spent on prisoner health care. This is in addition to recent legislation which seeks to charge prisoners $3 each time they seek medical attention, of the type that killed Barrow and Watson. It is likely that this type of problem will only get worse.
Currently the ACLU is investigating the lack of adequate medical care at the Reformatory; this facility receives prisoners from other DOC prisons who have serious or complicated medical conditions. If you can supply documentation (grievances, letters from DOC officials, affidavits, etc.,) showing inadequate medical care at the Reformatory you should contact the ACLU at: Julya Hampton, ACLU, 705 2nd Ave, Seattle, WA 98104.
Washington prisoners should also consider filing their complaints of inadequate or incompetent medical care directly with the Department of Health which, as shown above, does investigate credible claims and creates a good litigation record for this type of incident. Complaints to the DOH should be in letter form, briefly state the facts (names, dates, places, etc.,) of why the medical care was inadequate or deficient. You should support your complaint with affidavits from witnesses with first hand knowledge of the incident(s) and any other supporting evidence you may have. Once the investigation is completed you will be contacted and provided with a copy of the completed report. You can write DOH at: DOH, Facilities & Services Licensing, P.O. Box 47852, Olympia, WA 98504-7852. Prisoners in other states should consider a similar course of action with their state's medical regulatory agencies.
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