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WA DOC Negligence Caused Prisoner Death

By Paul Wright

In the July, 1994, issue of PLN we reported on the death of Gertrude Barrow, a prisoner at the Washington Corrections Center for Women (WCCW) at Purdy. On May 16, 1994. Barrow died of a perforated ulcer with acute peritonitis after repeatedly seeking medical care from her captors. After her death the Washington DOC contracted with David Dugdale, its medical consultant, to determine which errors resulted in Barrow's death and how such deaths could be prevented in the future. Dugdale, an assistant medicine professor at the University of Washington, was accompanied by Larry Pogue, a doctor with the Group Health Cooperative and Holly Wallaston, a nurse practitioner and director of nursing at the King County (Seattle) jail. After visiting the WCCW, interviewing the medical staff and warden, the trio issued their report

The report states that there were communication difficulties between Dr. Badger (the WCCW treating physician) and nursing staff. Better communication likely would have led to better monitoring of Barrow's condition, and hence earlier detection of her deteriorating condition.

There was also misinterpretation of the clinical findings in the case because most of the clinical management was done by a physician's assistant with "at a distance" oversight by Dr. Badger. For example, a small calcification in her left kidney was misdiagnosed as evidence of a kidney stone. This resulted in Barrow being prescribed potentially harmful medications with respect to the ulcer disease. The report concludes this was due to lax oversight of PA Ingram by Dr. Badger. There were numerous errors of omission in Barrow's medical records. For example, her last three admissions to the WCCW infirmary do not have an evaluation, i.e. history and physical by either Ingram or Badger. Such evaluations are standard practice in hospitals and are mandated by WCCW policy.

The report concluded that "there appears to be a serious shortage of health care providers capable of independent diagnosis and treatment of patients." For 540 prisoners WCCW has one physician, one PA and one contract physician. "The sick call load of 40 to 60 patients per day makes it essentially impossible to do thorough evaluations of each inmate, errors of omission that occurred in Ms. Barrow's case are essentially guaranteed in such a setting." It also concluded that Badger was not supervising Ingram sufficiently well and "Dr. Badger feels that PA Ingram needs close supervision while acknowledging that he does not provide it. This is a recipe for continued, potentially life threatening yet preventable problems."

The study concluded that "Dr. Badger is ill-prepared for the position as medical director of a correctional facility. Based on a review of his job application and our interview with him, it is apparent that it has been a long time since he has been engaged in a primary care medical practice." Badger also lacks experience in administering programs. "His orientation to the special aspects of medical care behind bars was essentially non-existent--it is no surprise things have not gone well." It was recommended that Badger receive orientation from other DOC doctors on how to administer the WCCW medical program and have his clinical load lightened to lead the medical section and implement operation changes in the WCCW infirmary.

The Washington state Department of Health (DOH), which inspects DOC facilities, reached a similar conclusion. The DOH report, quoted in the September 7, 1994, edition of the Seattle Times, states that the WCCW health care system did not offer "safe, appropriate" care for prisoners. DOH investigators found 16 deficiencies when they compared the prison's policies with actual practices. The DOH also concluded that WCCW staffing levels did not allow for "reasonable" workloads. Medical personnel did not keep complete records, failed to track Barrow's ulcer condition and did not follow up on previous medical problems. The report also described WCCW hospital staff's flippant attitude towards Barrow, on one occasion Barrow vomited and a nurse gave her a towel and told her to "clean it up yourself." Barrow died later that morning. The DOH recommends that the DOC come up with a plan to correct WCCW infirmary deficiencies within 10 days. However, state laws do not permit the DOH to compel the DOC to comply with its orders nor to take any action to ensure that Washington state prisoners receive safe, adequate health care.

Gertrude Barrow died of an easily preventable illness due to the incompetence of her health care providers. The sequence of events leading to her death are recounted in the July, 1994, issue of PLN. Inadequate medical care is the norm rather than the exception in most prison systems as seen by the amount of litigation on the subject. As reported in the April, 1994, issue of PLN there is a class action suit, Hallett v. Payne, pending against prison officials at WCCW alleging that the medical care (or lack thereof) at the prison violates the eighth amendment. The suit had been in the midst of settlement negotiations which were abruptly terminated upon Barrow's death. PLN will report developments in the litigation in future issues.

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