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Oregon Prisoner’s Preventable Death Reveals Culture of Systemic Indifference

 by Mark Wilson

Michael Barton was sentenced to a six-year prison term by the Jackson County Circuit Court in April 2017, for second-degree robbery of a bank. Surveillance video immediately called his mental state into question when it showed Barton waiting politely while bank employees not only collected the money he demanded but also called the police. 

Staff attorney Joel Greenberg with Disability Rights Oregon (DRO), who now serves as Barton’s lawyer, noted that his client – who has a documented history of mental health problems and diagnoses of bi-polar disorder and possible dementia – left the bank with little apparent understanding that he would be pursued and arrested. In fact, Barton told Greenberg that he robbed the bank because he had run out of psychotropic medication and could not afford to renew his prescription. 

While housed at the Oregon State Penitentiary (OSP) by the state Department of Corrections (DOC), Barton struggled with even the simplest tasks, like opening his unlocked cell door and getting water from his sink. He was moved to a mental health unit where he began experiencing flu-like symptoms. He was seen by several medical providers in January 2018, all of whom “ignored his increasingly panicked requests to be admitted to the infirmary,” Greenberg said.

“I don’t want him in my infirmary where he can make other people sick,” one provider reportedly declared when refusing to admit him. 

Others misinterpreted Barton’s inability to understand or follow directions as malingering, according to Greenberg. As his condition worsened, Barton became too weak to leave his bunk to get water. Called to check on him, nurses stood at his cell door, never entering to take his vital signs or conduct any other type of examination. They failed to recognize Barton’s semi-comatose state, graying skin, swollen limbs and emaciated body, according to a report that DRO released on July 22, 2019. 

Other prisoners became alarmed as Barton’s meal trays lay untouched on his cell floor. They said he needed help lifting his head to sip water for his medication. One unidentified witness made a series of requests on February 4, 2018, to help Barton obtain urgent medical attention. Medical staff dismissed those requests, however, saying he could wait until his scheduled appointment the next morning. 

But the following morning, when a prisoner working for the medical unit came to take him to his appointment, Barton could not get up on his own. He had to be lifted into a wheelchair, where his head flopped to one side as he fell unconscious and his bladder emptied. He never regained consciousness. As four liters of fluid were drained from his chest cavity, the 54-year-old went into multi-system organ failure and was rushed to a Salem hospital for emergency surgery. He was pronounced dead at 7:31 p.m. on February 6, 2018. 

The DOC’s chief medical officer, Dr. Reed Paulson, concluded that Barton likely died from influenza B, which led to MRSA empyema, which resulted in sepsis, which led to severe septic shock, cardiopulmonary arrests, multisystemic organ failure and severe anoxic brain injury. That diagnosis could not be verified or refuted because a medical examiner failed to perform an autopsy.

Barton’s family was not contacted after his death, which they learned about through a friend’s social media post. The news media and public also were not informed of Barton’s death through the DOC’s normal death notification process. Citing those irregularities, a prisoner and a DOC employee alerted the DRO, according to the organization’s July 2019 report. Barton’s family still did not learn the circumstances of his death until DRO staff contacted them four months after he died. 

“They are very concerned and hopeful that some substantive changes will be made so that this kind of thing doesn’t happen again,” said Greenberg. “They were quite adamant we use Mr. Barton’s name. They thought it was important that he be recognized as a person with a name and family rather than someone with a pseudonym.” 

To produce its report, the DRO – Oregon’s Protection & Advocacy agency, which advocates for people with physical and mental health disabilities – interviewed five eyewitnesses to Barton’s suffering and death, and conducted its own investigation into DOC reports, the most damning of which was an internal peer-review of Barton’s medical care conducted by Paulson. 

Eight out of 14 aspects of Barton’s care were questioned during that review, including preventative measures, staff response and the appropriateness of Barton’s housing and care. Paulson found that even after Barton was diagnosed with pneumonia, staff missed “opportunities for more earlier intervention” that might have saved his life. He called the OSP infirmary “extremely ill-constructed” for patients with the flu, due to other patients who are medically fragile or immune-compromised.

“This creates an understandable hesitation in staff,” Paulson wrote, which was why medical staff also “did not recognize that this patient was critically ill.”

He recommended reducing “mental fatigue and numbing” among medical staff by increasing staffing levels, adding that the case “clearly demonstrated ... that the fault does not lie in one person’s mistake, but rather highlights system failure that has affected many staff.”

The DRO agreed that Barton’s death illustrated a systemic failure. Unlike Paulson, however, it attributed fault to the individual employees who were indifferent to Barton’s suffering. 

“The conduct of the nurses who responded to Mr. Barton’s cell during the last days of his life was surely negligent, if not deliberately indifferent, to the harms that ended his life,” Greenberg stated. “One medical provider after another failed to consider the impact of his mental illness and obvious dementia when called to assess his medical condition and complaints.”

DOC Director Colette Peters sent Greenberg a letter claiming that she welcomed the DRO’s investigation, but added she was disappointed the DRO gave prison officials just a single business day to review its report and respond to what she characterized as significant factual inaccuracies before releasing the report to the media. Peters also said she was “deeply troubled” that quotations from Paulson’s internal peer-review were included in the DRO’s report. She said she did not believe the DRO conducted a fair or completely accurate investigation; she also took umbrage with the DRO’s findings of staff negligence and a negative culture.

Greenberg responded, “The reason we wrote the [DRO] report and the reason we are making it public is not to embarrass [the DOC] but to provide them with some information that they did not have.”

“DRO’s investigation of the circumstances that led to Mr. Barton’s death led us to conclude that he died because of negligence,” he added. “Barton suffered a painful, prolonged and preventable death from a treatable disease because he was neglected, disrespected and not believed” while confined in a prison system with “a culture that allows its nurses to see patients with cognitive and mental health disabilities as less than human.” 

Greenberg said he hoped the DOC’s indifferent culture “can be reformed and changed for the better,” and offered to work with prison officials “to make sure that that happens.” 

To that end, the DRO has called on Peters to hire an independent prison health expert to review the investigations into Barton’s death, identify the factors that contributed to it and recommend necessary changes to policies and practices, eventually issuing a public report on the level of medical care provided to mentally ill and developmentally disabled state prisoners. The DRO also wants the DOC to implement any necessary changes within one year of the report’s publication. Peters did not comment on these recommendations. 

“The department will need time to fully review and assess the findings and determine any appropriate action,” said DOC spokeswoman Betty Bernt. 



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