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Mentally Ill Oregon Prisoner’s “Needless & Preventable” Death From Flu Complications Nets Record $3 Million Settlement

Barton, 54, was serving a 30-month sentence for a 2017 Medford bank robbery when he began experiencing flu­-like symptoms in January 2018. He had not received an influenza vaccination that year, nor the year before.

“He was seen by a number of nurses and medical providers who ignored his increasingly panicked requests to be admitted to the infirmary,” said Joel Greenberg, a staff attorney with Disability Rights Oregon (DRO).

A July 2019 DRO report also found Barton had struggled in prison with even basic tasks, such as opening his unlocked cell door and getting water from his sink, because he suffered severe mental illness and dementia. In fact, surveillance video of the bank robbery he committed showed Barton waited “politely” while bank employees called police, walking out with a red bank-bag full of money and little apparent understanding that he would be captured.

In prison, Barton was moved to a mental health unit. But when he fell ill, staff from the medical unit misinterpreted his inability to understand or follow directions as malingering, according to Greenberg.

As Barton’s condition worsened, nurses called to check on him stopped at his cell door, refusing to enter to take his vital signs or conduct an examination, even as he became semi-comatose, with graying skin, swollen limbs and an emaciated body, according to the DRO report.

 Medical staff made no chart notes of any treatment or observations after Barton was diagnosed with pneumonia, even though they found in the days preceding his death that he had “significantly diminished lung sounds,” along with “ineffective airway exchange, low blood oxygen levels, and blood pressure 30-40 points below baseline,” according to court filings.

“If any public hospital treated patients this way, it would be investigated and shut down,” noted Dawson.

An internal ODOC investigation later concluded that the infirmary was “extremely ill-constructed for admitting influenza patients.”

Meanwhile, the complaint continued, other prisoners became increasingly alarmed as Barton’s meal trays lay untouched on his cell floor. He needed help lifting his head to sip water. Yet staff ordered a prisoner assistant to stop helping Barton drink water that he needed to take his medication.

On February 4, 2018, numerous requests were made to get Barton urgent medical attention. Staff dismissed those requests, however, saying that he could wait until his scheduled appointment the next morning.

When a prisoner arrived to take him to that appointment on February 5, 2018, Barton could not get up. The assistant had to lift him into a wheelchair. He made it just a few steps when Barton’s head flopped to one side as he lost consciousness and emptied his bladder. He never regained consciousness.

An EMS crew arrived to transport Barton to a hospital emergency room. He “was barely alive” when he arrived in the emergency room, the complaint added, suffering bedsores and malnourishment on top of his more acute problems, including “cardiac arrest, septic shock, acute kidney failure, poor neurological function, mottled color of his left leg down to his toes, and deep vein thrombosis.”

“An X-ray showed a ‘complete white out’ of his left lung,” the complaint noted, and as four liters of MRSA-infected fluid were surgically drained from his chest cavity, Barton went into multi-system organ failure and died on February 6, 2018.

When the medical examiner declined to conduct an autopsy, ODOC’s chief medical officer listed Barton’s cause of death as “Influenza B, leading to secondary MRSA pneumonia ... leading to MRSA empyema, leading to sepsis, leading to severe septic shock, leading to cardiopulmonary arrests, leading to anorexic brain and multisystem injury, leading to multisystem failure with severe anoxic brain injury. Altogether leading to death.”

That is, Greenberg summarized, Barton “died of a MRSA infection and subsequent complications that occurred after he caught the flu.”

He and DRO got involved when prison officials did not follow their ordinary death notification process, and a prisoner and an ODOC employee alerted DRO of a potential cover up. Barton’s family did not even learn of his death until DRO was able to contact them four months later, in June 2019.

ODOC physician Reed Paulson conducted an internal review of Barton’s medical care, questioning eight of its 14 aspects, including preventative measures, staff response and the appropriateness of Barton’s housing and care.

“It is clearly demonstrated in this case that the fault does not lie in one person’s mistake,” he wrote, “but rather highlights system failure that has affected many staff.”

DRO agreed with Paulson that Barton’s death exposed a systemic failure, but it did “not agree with the idea that no fault should be attributed to individual actors,” its report concluded.

“Mr. Barton died of negligence that occurred when one medical provider after another failed to consider the impact of his mental illness and obvious dementia when determining treatment for his condition and symptoms,” DRO insisted.

ODOC Director Colette Peters objected to the report’s findings, complaining that Greenberg and DRO gave ODOC just a single business day to review and respond to what she characterized as significant factual inaccuracies before releasing the report to the media. She was also “deeply troubled” that DRO quoted Paulson’s internal review, though she did not dispute that the quotes were correct. Most notably, Peters took umbrage with DRO’s findings of staff negligence and a culture of indifference.

“The reason we wrote the report and the reason we are making it public is not to embarrass (ODOC) but to provide them with some information that they did not have,” Greenberg countered, adding that he hoped the agency’s culture “can be reformed and changed for the better.”

In February 2020, six months after DRO released its report, Stephen Brown sued prison officials for $20.3 million on behalf of his late brother’s estate, accusing them of deliberate indifference and negligence. The State of Oregon declined to indemnify one defendant, Physician’s Assistant Karyn Guido, singling out her conduct as indefensible.

The parties settled on August 19, 2020. The state agreed to pay Barton’s estate $2,750,000, and Guido paid another $250,000, for a $3 million total settlement. The state also agreed to “waive any rights to recover proceeds from the settlement payment for Michael Barton’s ‘cost of care’ pursuant to ORS 179.620.”

Though the defendants declined to admit liability, Peters took a much more repentant tone in announcing the settlement than she had in her earlier response to Greenberg’s report.

“This should never have happened to any adult in our custody and for that we sincerely apologize,” she said in a statement that also acknowledged Barton’s death was “needless and preventable.”

Noting that the amount of the settlement “is unprecedented for our department,” Peters also claimed that this “reflects how far removed the facts of this case are from our standards and expectations of care.”

“We are committed to learning from this case,” Peters insisted. “While it may be of little comfort to the family of Mr. Barton, we are committed to ensuring that nothing like this happens again within our facilities.” See: Brown v. Oregon, Case No. No. 3:20-cv-00270-SB, U.S.D.C. (D. Or. 2020). 


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Related legal case

Brown v. Oregon