A nurse refused to even look at the prisoner, according to the guard's testimony. Other health workers had turned him away hours earlier.
But the guard could see what they missed.
Montgomery, son of a Pentecostal bishop and father of two young girls, was hours from death.
His family says the prison's mistakes amounted to a death sentence. And today, that large University Place family hopes that its wrongful-death lawsuit, originally set for an October 2002 trial, will force the state to finally address years of warnings that holes in prison health care threaten prisoners, prison staffers and taxpayers.
Over the past five years, the state has spent more than $1.26 million in judgments, settlements and damage claims stemming from poor prison health care, according to the state Office of Risk Management.
Although the state denies medical malpractice in the Montgomery suit and points blame at Montgomery and the nearby Tacoma hospital where he died nearly three years ago, some who cared for Montgomery at McNeil Island Correctional Center that night acknowledge that his care was poor.
The family's lawyers and some health workers say it's the inevitable outcome of ignoring problems documented for years.
In June 2002, a state consultant's report said Washington prisons lack medical oversight and guidance, and estimated that workers miss diagnoses more than a fourth of the time for some conditions. Each year, state Health Department inspections find problems such as inadequate staffing and training at McNeil and other prisons.
It's been going on for years:
Ø In the three years before Montgomery's death, Health Department inspectors reported at least three times that McNeil's staff was inadequately trained in areas such as CPR, first aid and emergency care.
Ø At least twice, they warned that staff shortages at McNeil stretched clinicians too thin.
Ø Health inspectors complained four times in three years of shoddy patient records.
All the while, consultants to the prison agency said administrators failed to provide clinical oversight or basic standards of care to nurses, doctors and physician's assistants.
When Montgomery died, the top administrator of medical care at McNeil was not a doctor, or a nurse, or even a college graduate. She was a custody unit supervisor who had been promoted to acting health care manager. A doctor and other clinicians were on staff, but it was the administrator who set policy and oversaw the operations.
`The good, the bad'
Phillip Montgomery was the eighth of 10 children from a stable family of Christian activists. At his 1999 funeral service, about 500 people crowded into the Greater Christ Temple Church founded by his parents, Curtis and Elinor Montgomery, more than four decades ago.
They remembered young Phillip, the creative child who sketched architectural designs, built rock gardens and even constructed a 60-square-foot miniature village with ponds, bridges and a church.
And they remembered how Phillip, like his siblings, inherited his father's athleticism. But for Phillip, ninth-grade basketball tryouts proved an early and possibly formative disappointment, said his younger brother, John Montgomery.
Phillip struggled with the stricter regime at their new school, his brother said, and he was cut from the team. "He kind of went into a funk after that. We were taught that hard work pays off."
It wasn't long before he slipped into a cycle of trouble. He was the only one of his siblings to go to jail, use drugs or even to smoke cigarettes, his mother said.
Montgomery's adult record began at 19, when he cut a bathroom window screen, crawled into an apartment and stole a $3 roll of quarters.
His run-ins with the law nearly every year for the next decade mostly followed the same pattern. Caught red-handed, usually with a two-bit haul, he'd plead guilty. All the while, according to court documents, he battled a drug problem.
Police once caught him in a sports car that had been reported stolen, after he tried to trade the stereo for food at a 7-Eleven.
Early on Nov. 5, 1998, Montgomery entered a Federal Way apartment through an unlocked sliding glass door. He ran away after the renter confronted him, and police caught him a short time later. He pleaded guilty to attempted burglary and was sentenced to 53 months in prison on March 12, 1999.
During his prison stays, Montgomery wrestled with his past. His writings home matured over the years: missives of regret, poems of gratitude, promises to seek God.
In one, he talked about his recent transfer to McNeil, how he was scheduled to see a doctor, how he had faith things would get better. "I guess there's some truth to the saying that God will cause the sun to shine on the good, the bad and the ugly. At the moment, I'm not sure which category I fall under.
"But I (am) pretty sure I'm covered."
A few months later, he was dying.
Treatment by phone
Those final fall day days, Mark Bolf watched his cellmate fade in and out of consciousness, sometimes writhing and crying from the intense stomach pain. "I thought (the prison) would do something," said Bolf, who begged for help. "It came to a point when I spoon-fed him oatmeal, and then he got a vacant look in his eyes."
Shortly after 7 p.m. on Sept. 6, 1999, Montgomery showed up at the McNeil Island medical clinic, complaining of vomiting, diarrhea, abdominal pain and inability to urinate. He had a fever of 102.5.
Records indicated that he had been diagnosed with hepatitis C years earlier.
Many people infected with hepatitis C eventually develop chronic liver disease, and many suffer liver failure. A consultant for the state estimates that nearly 10 percent of Washington prisoners are infected with the virus.
But according to sworn depositions, other court records and interviews with the Seattle Post-Intelligencer, the prison health workers who cared for Montgomery missed the signs that his liver was failing.
In fact, they'd ignored such clues for months, according to testimony from a Montgomery family witness, Dr. Roderic Gottula, former medical director of Colorado's prison department. Gottula was also appointed an independent health services monitor at Washington's women's prison after the state settled a class action lawsuit there in the 1990s.
Tests in June and July 1999 showed Montgomery was in liver failure, Gottula said. "I see nothing in the records that ... show me that they addressed it at all," he said.
Registered nurse Carol Hoke, who first cared for Montgomery on that September evening, said she was never trained in how to spot such symptoms of complications of hepatitis C.
As was often the case, only nurses manned the health clinic that night. In urgent situations, they call physician's assistants and doctors for advice.
So Hoke turned to physician's assistant Perry Bartram, who monitored Montgomery's care by cell phone from a SeaTac motel, where he was spending an evening with his wife. Bartram said the state had not trained him in hepatitis or liver disease.
It was the closest Montgomery would come to a doctor that night.
The state can't get enough doctors to staff its prisons. The Corrections Department employs only five doctors for more than 16,000 prisoners. Beyond that, Corrections contracts with dozens of private, part-time doctors.
As a result, physician's assistants and nurses make many clinical decisions. In some reports, consultants have warned that physician's assistants make too many decisions with too little supervision from doctors.
Bartram ordered Hoke to hydrate Montgomery with a saline IV. He figured Montgomery might have a kidney stone or the flu Hoke said something about the flu going around, Bartram said.
The family has filed a lawsuit against the state in Phillip's death nearly three years ago.
Hoke flushed Montgomery with nearly 2 liters. He still couldn't urinate. Hoke later acknowledged in a deposition that such inability indicated renal failure.
While Hoke missed the signs, Bartram apparently suspected liver failure. He ordered urgent blood tests to be rushed to a Tacoma lab by ferry and taxicab.
There, the system failed again. Those tests would prove critical but futile.
Paper towel charts
Inaccurate and inadequate record keeping is among the most common failings that state Health Department inspectors find in prison health systems.
Often, health workers fail to document vital health data, such as which medications are administered or critical health conditions, including allergies to drugs. They blame short staffing a routine deficiency cited in Health Department inspections.
The next several hours of Montgomery's care proved no different.
For security reasons, nurses were prohibited from taking charts into exam rooms, nurse Hoke said. Instead, they kept exam notes on "nursing stationery": paper towels.
For Montgomery, "I can remember at least three paper towels," Hoke said in an interview in her Spanaway mobile home.
Looking back during a recent court deposition, it was clear that the towels didn't all make it onto his chart.
Hoke also failed to note in the clinic logbook that urgent lab tests were pending for Montgomery. Hoke and some of her colleagues stopped using the logbook, she said, after it degenerated into a "battle book" of intershift gripes between stressed-out clinicians.
Three times in the previous two years, state health inspectors had reported that McNeil workers kept inadequate log records.
Around midnight, Hoke wrapped up her shift and went home.
Over the years, Hoke had complained in two dozen memos to supervisors, she said, that the lack of staff forced dangerous shortcuts.
Several months after Montgomery died, Hoke said, she was forced to leave her job over an accusation that she had an inappropriate relationship with an prisoner. She denies the accusation.
Shortly after Hoke left that night, Bartram had Montgomery sent back to his cell with a painkiller and instructions to drink fluids and to see a doctor during regular "sick call" hours later that day.
"Truthfully, Phillip Montgomery should have been taken to the hospital that night?" Jack Connelly, the Montgomery family's attorney, asked Bartram.
"Hell, yes," Bartram testified in the deposition.
"It is fair to say ... Montgomery did not receive good medical care, correct?"
"Yeah, I think I have to say that."
No one looked
By the morning of Sept. 7, Montgomery's every struggled breath produced a hellish rattle, said Bolf, his cellmate.
"I was trying to find things in the Bible to help him," said Bolf, who sometimes lent Montgomery a radio so he could listen to his father's sermons.
Around 8 a.m., Montgomery gave his mother's phone number to Bolf. "He finally accepted what was happening," Bolf said. "It was the hardest call I ever made."
All morning, Elinor Montgomery called the prison and begged for information. She got no answers, she said.
One of the calls reached prison guard Jack Knight, according to his deposition testimony.
The guard could see Montgomery was seriously ill unresponsive, unable to walk. When a nurse on duty refused to even go look at the prisoner, he said, he finally turned to the convicts.
Montgomery's fellow prisoners carried him down to the nurse, and then he was taken back to the health clinic that had turned him away hours earlier.
By then, Bartram had arrived for his shift.
Bartram discovered that no one had even looked at most of the urgent lab tests he had ordered although they'd probably arrived hours earlier.
A health inspection at the Monroe Correctional Center two years earlier, in March 1997, revealed that staff failed to adequately monitor lab tests sent off-site and that similar problems had been documented at other Washington prisons.
Montgomery's yet-unread lab tests indicated he was acutely ill.
Chart notes from the night before, too, suggested that Montgomery was seriously ill.
The nurses must have left out information during the phone conversations, Bartram said in his deposition, because it's not his way to put off ill people.
Sometimes, he said, nurses omitted important details when they called for direction. Sometimes the charts didn't match up.
By the time Bartram and the doctor on duty shipped Montgomery to St. Joseph Medical Center in Tacoma shortly before noon, he was barely able to speak.
The Montgomerys had no idea he was at St. Joseph. When he slipped into a coma that afternoon, his parents and brother were only a few blocks away.
State blames prisoner
When officials finally contacted the Montgomerys that evening, it was to tell them their son was dead.
"His arms were folded across his waist, and he was still warm. I held his hand, rubbed his head and stroked his forehead," Elinor Montgomery wrote in a court filing. "`Phillip,' I said, `we didn't know you were here. We would have been here.'"
An autopsy report later revealed that Montgomery's liver was scarred with cirrhosis, an indication of advanced liver disease.
Hepatitis experts told the P-I that some prison health workers ignored classic signs of severe infection particularly for a patient known to suffer liver disease. Such septic infections can be difficult to turn around but not impossible. His family complains that he never even got that chance.
In an interview, 70-year-old Elinor Montgomery, her gray-streaked, shoulder-length hair curled under in a soft wave over her shoulders, said, "Just because you are an inmate doesn't mean that you're not a human being."
Connelly, the family lawyer, said the state refused to treat Montgomery's hepatitis with the expensive anti-viral drugs a doctor had recommended after he was diagnosed.
The state's process for reviewing requests for specialized treatment is "archaic" and fails to use nationally accepted guidelines, this year's consultant report found.
And Corrections officials knew from audits and memos that prison health care staff were overworked and undertrained and did nothing about it, Connelly said.
The state's lawyer disagrees, and declines to discuss the state of Washington prison health care.
"We don't think the system had anything to do with whether or not Mr. Montgomery was provided appropriate medical care," said Assistant Attorney General Pete Berney. "This case all boiled down to one issue: Was Phillip Montgomery treated appropriately?"
"And our position is that he was."
Because Montgomery acknowledged that he used drugs, and hepatitis C is often spread through sharing drug needles, he shares some of the blame for his condition, Berney said.
The state also argues in a court document that St. Joseph Medical Center is at least partially to blame.
Berney would not discuss that issue, except to say that were a jury to find medical malpractice, it could choose to pin at least some punishment on St. Joseph.
St. Joseph insists Montgomery received proper care there. The hospital is not named as a defendant in the lawsuit.
The state's own witness, Dr. Richard Willson, Harborview Medical Center hepatology chief, testified in a deposition that McNeil's medical staff "didn't seem to be completely committed to finding out the problem that Mr. Montgomery had and responding appropriately, I think, to some of the information that was related to them."
Regarding St. Joseph's care, he said, "there seemed to be quite a delay in his evaluation and management."
Suing the state was not easy for the family, said John Montgomery, a clean-cut and bespectacled 33-year-old.
"We were taught that you reap what you sow. ... I'm the kind of guy that says, `If you don't want to go to jail, don't break the law,'" he said.
But "if Phillip had gotten the standard of care that I would receive, he would be alive today," he said. "The only way we can bring justice is by making the state feel some pain."
[Note: The Montgomery family later settled the lawsuit for $1 million. See p.15 for details.]
Reprinted with permission from the Seattle Post-Intelligencer.
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