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Oregon Jail Deaths Linked to Deficient Care, Misconduct

By Mark Wilson

In a March 13, 2008 report, the Multnomah County District Attorney’s Office concluded that at least two prisoners at the Multnomah County Detention Center (MCDC) – Oregon’s largest jail – died of inadequate medical care and neglect.

In February 2005, Jody Norman arrived at MCDC during the early morning hours. He had a history of drug abuse and heart problems and, after arriving at the jail, he complained of chest pains, investigators found.

Jail nurse William Lee James didn’t call a doctor as required by jail procedures. Instead, he falsified official forms to make it look like a doctor authorized him to issue Norman prescription medication, according to Oregon State Board of Nursing records.

Norman died in his cell several hours later from complications of his heart condition. The prosecutor’s office did not learn of Norman’s death until nearly two years later, through the nursing board. A special grand jury studying the county’s jail system questioned why jail officials failed to report Norman’s death.

The District Attorney has charged James with falsifying Norman’s medical records, a felony offense. James is no longer licensed to work as a nurse in Oregon, but he is working as a registered nurse in California. His license there is not being evaluated by the California Board of Registered Nursing, said Heidi Goodman, the agency’s assistant executive officer.

On January 3, 2008, Holly Jean Casey, a 36-year-old transient with a history of drug abuse, was booked into the jail on a theft charge. As deputies took her to jail, she coughed and said she was suffering from pneumonia. During booking, she reported that her immune system was impaired due to the removal of her spleen.

Once in her cell, Casey complained of breathing difficulties. At 11:00 p.m., a jail nurse gave her an inhaler and told her to call for help if her problems worsened. But when Casey started calling for help throughout the early morning, nobody answered.

At 5:00 a.m., a guard told a nurse Casey was still complaining of stomach and breathing problems. The nurse did not respond. A guard saw Casey on her cell floor during his regular rounds, but didn’t do anything because he assumed she was sleeping. Another guard entered her cell at 7:30 a.m., and found that Casey had died of pneumonia.

“She should have gotten better help than she did,” said Shannon Calhoun, Casey’s aunt. Investigators agreed, finding that Casey and Norman died of preexisting conditions that were ignored or not properly treated by jail nurses. Findings of the investigation raise serious questions about the jail’s health care practices.

The District Attorney declined to prosecute jail staff for Casey’s death, claiming that the facts make it difficult to prove liability by any one person. It referred information to the state nursing board for possible administrative action, said Chief Deputy District Attorney Norm Frink. The County Health Department also opened up a personnel investigation into the nurse who handled Casey’s case, said director Lillian Shirley. “I take this very seriously,” said Shirley after meeting with sheriff’s officials to plan ways to prevent similar incidents.

The District Attorney’s office is also prosecuting former jail nurse Kimberly Joers on three dozen counts of tampering with drug records. Joers was hired to work at the jail in the summer of 2007, just one month after she was fired from a Portland hospital for misconduct involving the loss of a narcotic medication, according to the prosecutor’s investigation.

Several months later, the jail fired Joers for the conduct that led to her pending charges, but jail officials again failed to notify prosecutors, investigators found.

Casey’s family is disappointed by the State’s refusal to prosecute. They’ve hired an attorney. “We feel like there was negligence there,” said Calhoun. “We’re not going to drop it.”

Source: The Oregonian

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