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Board of Commissioners Clears PHS In Three Leon County (Florida) Jail Deaths

by John E. Dannenberg

After three jail deaths between May 2003 and October 2004, the Leon County Board of Commissioners met to consider the Sheriffs reports on the three deaths and any implications regarding the jails healthcare provider, PHS. Two of the deaths were in litigation. In spite of highly suspicious circumstances in the overmedication death of one prisoner, the Board approved the report clearing PHS.

PHS was hired in 2002 for approximately $3.5 million/yr. to provide medical, mental health, and dental services for the 1,250 prisoners in the Leon County Jail. Approximately 90-100 prisoners visit the jails clinic daily, including those receiving medication. Medications are shipped daily from Secure Pharmacy Plus, PHSs subsidiary.

Leon County maintains oversight of PHS through Alliance Medical Management Corp. Leon County Jail is one of 21 county lockups in Florida accredited by the National Commission on Correctional Health Care. Accreditation must be renewed annually, although site evaluation only occurs every three years. In addition, a medical review committee is convened whenever three prisoner complaints surface on the same subject. In 2002, the Board approved mental health peer review oversight of the jails mentally ill, hiring both a Mental Health Coordinator and Florida Partners in Crisis, Inc.

The Three Deaths

On October 31, 2004, prisoner Steven Tomaino, 32, hung himself in his cell before dinner. He had not given any suicidal indications either to staff or other prisoners, and had no mental health record. However, the required hourly cell checks were not made that day. It was determined that guard Patricia Harris had made false entries in her log to the effect that she had conducted searches at 1650 and 1750 hrs. When confronted with prisoner and fellow guard statements that she had not searched, she finally admitted that she doesnt have time for that. She had left to make a personal phone call that day, and falsified her log -- at Tomainos expense. She was found administratively guilty of gross violation of integrity.

Clyde Fuller, 26, died in a restraint chair on June 12, 2003. He had been disruptive during booking and screamed and spat at staff. After he was pepper sprayed, he was placed in the restraint chair in the back of the jail medical unit, where he was discovered dead approximately 23 minutes later. On his intake medical inquiry, Fuller answered that he had seizures as a currently treated medical problem, but that he had not taken his prescribed medication. He also stated that he had not taken any drugs or alcohol prior to his arrest. The autopsy showed marijuana and significant cocaine in his system, plus revealed ongoing heart and vascular disease. His death was ruled to fit sudden custody death syndrome.

On May 16, 2003, 40 year-old Ruth Hubbs also died in a jail medical unit cell, two days after being booked. She appeared to be acting overmedicated, talking incoherently to herself for hours while sitting on the floor. She had been prescribed Doxepin, but her autopsy showed an extensive overdose condition. It could not be determined whether she secretly saved (cheeked) pills and took an overdose or if PHS had overmedicated her. PHS physician Dr. Sadat Mansouri indicated he had switched Hubbs medication from Prozac to Doxepin and increased her dose from 100 mg. to 250 mg. per day, in addition to prescribing 600 mg. of lithium for bipolar disorder. He said that the drug switch was made expressly to cut costs, even though Doxepin was an older drug. Dr. Mansouri stated that these drugs would not build up over time in the body and become toxic. But the toxicology report showed 3.9 mg./liter of Doxepin in Hubbs blood, whereas the recommended therapeutic level was 0.02 mg./liter Researching the pharmacy records, there was an unaccounted-for excess of 900 mg. of Doxepin taken by Hubbs in the two day period prior to her death. As we reported in the April, 2006 issue of PLN, on August 29, 2005, PHS settled the wrongful death lawsuit filed by Hubbs parents for $350,000.00.

PHS cant explain

No one from PHS could explain how Hubbs got this excess. No one, except former PHS Director of Nursing Emily Beck, who told Hubbs attorney that Hubbs medical file had been materially altered, with some key reports removed. Beck called PHS a train wreck waiting to happen. Beck stated that she believed Hubbs death was preventable and that Hubbs received substandard care from PHS. The investigative report also found that PHS used employees who were not licensed, certified or didnt hold RN or LPN degrees to evaluate mental health patients, counsel them, and dispense narcotic medications to them. Moreover, there was no medication-cart inventory. When one medication is substituted for another, there is no accounting for the disposition of the now unused drugs. At last report, the State Attorney Generals office was reviewing the case for possible criminal charges and a Grand Jury review.

Source: Board of County Commissioners Agenda Request 43 (August 30, 2005), with Sheriffs reports.

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