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Jails in Oregon and Washington State Have High Prisoner Death Rates

by Matt Clarke and Mark Wilson

The Spokane County jail in Washington State recently marked its ninth prisoner death since June 2017. But it was hardly unique. A study released in May 2019 by Columbia Legal Services (CLS), a nonprofit law firm, counted 210 prisoner deaths in local jails across the state between 2005 and 2016, an average of one every three years in each of the 54 facilities – there are 59 local and regional jails in Washington – for which data could be obtained.

One of those deaths was that of Lindsay Kronberger, a 24-year-old who suffered nine days of untreated heroin withdrawal symptoms while video cameras recorded jail staff openly mocking her before she had a heart attack at the Snohomish County jail in 2014. Another was the death of Christopher Parker, 33, a diabetic who was high on methamphetamine when he was placed in a restraint chair at the jail in Spokane County in 2013. A third death was that of Matthew Smith, a 28-year-old with Crohn’s disease who died in 2016 due to untreated sepsis at the Tacoma County jail.

All three of those fatalities resulted in lawsuits, and jail officials in Tacoma County severed their contract with Alabama-based NaphCare, a private healthcare provider. NaphCare, which posted $66 million in revenue in 2018, has also lost contracts with jails in its home state and in Virginia. Yet it has taken over the provision of medical services in three Oregon jails that terminated contracts with Corizon Health, one of the nation’s largest private prison healthcare companies, after Corizon was sued for the wrongful deaths of three detainees. [See: PLN, Dec. 2015, p.22].

One of those cases resulted in a $10 million payout by Corizon to the family of 26-year-old Madeline Pitkin, who died on the floor of a medical observation unit in the jail for Washington County, Oregon from untreated heroin withdrawal in 2014. [See: PLN, Jan. 2018, p.38]. Corizon paid another $7 million settlement to the family of Kelly Conrad Green II when the 28-year-old died shortly after he rammed himself into a wall during an untreated psychotic episode at the Lane County jail in Oregon. [See: PLN, Sept. 2016, p.20].

A third lawsuit is still pending against Corizon over the 2016 death of Bryan Perry, a 31-year-old Army veteran and Purple Heart recipient who succumbed to an untreated methamphetamine overdose. Three guards at the Clackamas County, Oregon jail filmed him on a cell phone and laughed at him while he was dying in a padded cell.

“I cannot comment on the pending lawsuit, which focuses primarily on Mr. Perry’s medical care provided by the Jail medical contractor,” stated Sheriff Craig Roberts. “But I will say this: The laughter, substance, and tone of several comments heard from my employees in that video were inappropriate, and do not conform to our professional standards.”

Corizon CEO Steve Rector insisted that the jail death cases were unusual for his firm, saying the “amount of this settlement [for Pitkin’s death] is unprecedented for our company and reflects how far removed the facts of this case are from our standards and expectations of care.”

However, as reported by The Guardian, Corizon was sued over 1,300 times in the five years before 2017, not only for wrongful deaths but also for sexual misconduct by doctors and nurses, “including a female employee who paid inmates for sex.” Many of those cases have been reported in Prison Legal News. [See, e.g.: PLN, Sept. 2017, p.32; Mar. 2014, p.1].

NaphCare’s chief legal officer, Brad Cain, said the firm had improved opioid-specific protocols over the ones used by Corizon in the jails where NaphCare had taken over medical services. He added that because NaphCare is a “family-run business” it can offer better service than a corporate behemoth like Corizon.

But NaphCare still paid $3 million to settle a lawsuit filed over the 2015 death of Jamycheal Mitchell, a 24-year-old detainee arrested for stealing $5 worth of merchandise from a convenience store, who was found dead and covered in feces in his cell at the Hampton Roads Regional Jail (HRRJ) in Virginia. [See: PLN June 2019, p.58]. In fact, the company’s track record is similar to other private correctional healthcare providers that are primarily concerned with making a profit. [See: PLN, Oct. 2003, p.1].

NaphCare’s successor in Virginia was Correct Care Solutions, now part of Wellpath, which was sued over the death of another HRRJ prisoner, Henry Clay Stewart, Jr., in 2016. Despite days of begging staff for help, the 60-year-old died due to a ruptured stomach ulcer. At the conclusion of a two-year investigation in December 2018, the state’s Department of Justice concluded that HRRJ had violated the state and federal constitutional rights of Stewart and Mitchell. The lawsuit over Stewart’s death settled in July 2018 for $625,000, most of which was paid by Correct Care Solutions. [See: PLN, May 2019, p.44].

The report by Columbia Legal Services, titled “Gone But Not Forgotten: The Untold Stories of Jail Deaths in Washington,” identified jails in Clark, Cowlitz, Okanogan, Spokane and Whatcom counties as having disproportionately high prisoner death rates. The report cited 20 jail deaths in Spokane County between 2005 and 2016, while King County – with a jail population twice as large – had 33 deaths. Pierce and Clark counties reported 22 deaths each. Clark County had the dubious distinction of the highest jail suicide rate.

“We are continuing suicide mitigation efforts, and our most recent change is we’ve removed all sheets from the main jail and replaced them with blankets,” said Clark County Jail Chief Ric Bishop, who added the facility installed suicide-resistant beds in medium- and maximum-security areas and completed a five-year crisis intervention training for staff, resulting in zero suicides since July 2016.

The 31-page CLS report found the ages of the 210 prisoners who died in local jails from 2005 to 2016 ranged from 18 to 82, with suicide being the leading cause of death. Most of the deaths occurred within two weeks of a prisoner’s arrival at the jail, and the vast majority were among pretrial detainees.

The report blamed some jail practices for the high suicide rate, including insufficient use of anti-suicide blankets as well as a practice of isolating suicidal prisoners and then monitoring them inadequately. Suicidal prisoners face a higher risk of despondency when they are stripped of their belongings and left alone in cells with no running water and only a “grated hole in the floor” to use as a toilet, and often forced to wear a suicide smock and remain shackled.

“Not only can these practices increase the dangers that someone may take his own life, they also may deter potentially suicidal people from making their intentions known,” the CLS report warned.

The second leading cause of death was illness, reflecting not only the difficulty that jail staff have in delivering even minimal healthcare – the report identified 62 deaths related to deficient medical or mental health treatment – but also how the lifestyles of many prisoners may exacerbate health issues or make diagnoses more difficult. Some jail deaths were caused by serious medical conditions such as sepsis, staph or pneumonia, which guards mistook for symptoms of drug withdrawal.

“Health care needs to be provided in a much more comprehensive and appropriate way in many county jails,” said the report’s lead author, Nick Straley, an attorney with CLS’ Institutions Project.

Drug withdrawal and overdoses were also significant causes of jail deaths. The report recommended that jails keep a “ready supply” of Naloxone on hand to counteract opioid overdoses, and implement a medication-assisted withdrawal program for prisoners.

The CLS report’s findings were similar to those in a joint investigation by Oregon Public Broadcasting, KUOW and the Northwest News Network that was released a few months earlier. The resulting news article, “Booked and Buried: Northwest Jails’ Mounting Death Toll,” identified 306 jail deaths in Oregon and Washington between 2008 and 2018, at least 70% of which involved pretrial detainees and 70% were suicides.

The CLS report and joint news investigation also found that Native Americans constituted a disproportionate percentage of both the jail populations and prisoner deaths in Washington and Oregon. The Native American population in the two states is less than 2%, but over 4.5% of Oregon jail deaths were Native Americans. The CLS report also found Native Americans disproportionately represented among Washington jail deaths, but cautioned that the small sample size made it difficult to draw accurate conclusions.

“I’ll be frank here: This is an issue of race,” said Margaret Severson, a University of Kansas professor of social work and jail consultant who co-authored a ground-breaking study of Native American jail suicides in 2005.

Severson noted that Native Americans “tended to be less candid” when jailers asked them about their physical and mental health or drug and alcohol use. Her study attributed this to both a cultural reluctance to answer “intrusive” questions and a perception of a white, uniformed officer as an authority figure who “may symbolize longstanding oppression.” In other words, Native Americans often do not trust government officials and have good reason for not trusting them. In the context of a jail intake screening, however, with respect to questions about medical and mental health issues and drug use, that distrust may have fatal consequences.

Severson’s study suggested that suicide risk assessments be “tailored to the cultural backgrounds” of prisoners. The American Correctional Association’s standards also call for mental health programs in jails to consider prisoners’ “gender, cultural, and age issues,” but the ACA, a private corrections industry group, has no real ability to enforce its standards.

The CLS report blamed the Washington county jail deaths not only on poor staff supervision but also on a lack of diversion options for pretrial detainees with serious medical and behavioral problems.

“We have locked up too many people for the wrong reasons,” Straley said. “We have utilized jails now as the primary mental health facilities in our state and we have criminalized substance use disorders.”

The report made eight recommendations to curb jail deaths, including 1) increase diversion programming; 2) eliminate cash bail; 3) stop isolating suicidal prisoners; 4) require thorough prisoner health reviews and examinations; 5) implement overdose and drug withdrawal protocols with medicine-assisted treatment; 6) adopt statewide jail standards with increased funding to meet the standards; 7) train jail staff in de-escalation and crisis intervention; and 8) require reporting of all serious incidents and deaths.

“Implementing these relatively few reforms will dramatically reduce the number of people injured, disabled, or killed in our jails,” the CLS report concluded.

Washington is one of 17 states that lack state oversight of local jails. Oregon lawmakers recently passed a bill to establish oversight of jails, which was signed into law in May 2019.

“For too long, our state has been in the dark about what is happening within our jails,” said Oregon House Majority Leader Jennifer Williamson, who sponsored the legislation, HB 3289.

Supported by the Oregon State Sheriffs’ Association, the new law requires the Oregon Criminal Justice Commission (OCJC) to convene an advisory council comprised of a diverse group of stakeholders to study a broad range of local and regional correctional facility data. The council members include representatives from a sheriffs’ organization, a district attorneys’ association, a criminal defense association, a civil rights and civil liberties organization, a disability rights organization, the Oregon Health Authority, the Department of Justice, the governor’s office, one member of the House of Representatives and one member of the Senate.

The council is also charged with analyzing each jail’s standards, policies and procedures, first to determine whether they adequately protect the rights of prisoners under the state and U.S. constitutions, and secondly to assure they conform with national best practices in jail administration.

Oregon Governor Kate Brown said the law will help the state better understand barriers to adequate prisoner healthcare.

“My hope is that we can build the right kind of access to mental health and substance use treatment so that fewer people end up in jail as a result of an addiction or a mental health crisis,” Governor Brown stated. 



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