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Washington Pays $3.25 Million for Negligent Medical Care Causing Preventable Prisoner Death

by Mark Wilson

On July 6, 2021, a Washington state court disbursed $3.25 million paid by state officials to settle a lawsuit filed by the estate of a prisoner who died of a treatable condition that went ignored for months by medical staff at Monroe Correctional Complex (MCC), the state’s third-largest prison.

“Instead of providing . . . basic medical care, staff . . . watched him suffer and succumb to clear signs of infections and complications due to the open wound, which caused his untimely death,” declared the complaint, filed by the widow of prisoner John Kleutsch.

Kleutsch, 57, was one of the earliest victims of the prison’s former medical director, Dr. Julia A. Barnett, who was hired by the Washington Department of Corrections (DOC) in 2017 despite the lack of some qualifications—she was not board-certified and had not completed a DOC-approved medical residency—because of a dearth of qualified candidates. That decision had deadly consequences for at least seven prisoners who died under her “care” over the next two years.

“While Barnett was the medical director, inmates began dying … of treatable diseases and conditions,” according to Kleutsch’s complaint, which also recalled that other MCC staff “noticed but did not intervene to help these patients.”

After Kleutsch was sent to a community doctor for successful outpatient surgery for renal cell carcinoma in 2018, he returned to MCC with an open abdominal wound that required daily medical treatment to promote healing. But the complaint recalled that he “experienced significant complications.” He was admitted to MCC’s Inpatient Unit (IPU) for daily physician care, but he did not receive any. “The open wound in his abdomen grew in size,” the complaint noted, becoming “granulated, then red, puffy and oozing and tender.”

Kleutsch complained of excruciating pain and pleaded for help from July 14 through August 6, 2018. When nurse Susan Rhoads then finally examined him, she noted “tunneling” in his open abdominal wound. Concerned that fluid was leaking into the peritoneal cavity, she recommended that he be sent to a hospital emergency room. But Barnett denied the request. MCC medical staff then “watched John suffer and gave him Tylenol,” the complaint alleged.

Between August 7 and August 16, 2018, Kleutsch continued to complain of unbearable pain. An x-ray on August 15, 2018, “showed a left-sided lower lobe ‘most likely representing pneumonia,’” the complaint continued, but no IPU physician examined him after this x-ray.

Death From Undiagnosed Complications

Kleutsch continued to complain of excruciating pain between August 17 and August 22, 2018. Yet he was still treated only with Tylenol. As his condition worsened, he was eventually unable to eat, and then medical staff forgot to give him intravenous fluids for more than a day.

Dehydrated and clammy, with a heart rate of just 30-34 beats per minute, Kleutsch was finally sent to a hospital emergency room on August 22, 2018. “But it was too late,” the complaint concluded. He “had acute pancreatitis and sepsis” which “were never diagnosed or treated” by prison medical staff.

A hospital CT scan revealed he “had also been suffering from a perforated (intestine) that had never been identified, diagnosed or treated by any provider” at the prison. Kleutsch remained hospitalized five days before dying of septic shock, acute pancreatitis and a perforated intestine on August 27, 2018.

It took another few months before DOC finally placed Barnett on leave in October 2018, after which her staff submitted a vote of “No Confidence” to prison officials. In January 2019, Dr. Patricia David, DOC’s Medical Director of Quality and Care Management, told investigators that Barnett’s bad decisions “resulted in bad outcomes and even death.” DOC terminated Barnett on April 18, 2019, finding that she “failed to exercise sound clinical judgment and failed to provide adequate medical care,” resulting in the deaths of at least three MCC prisoners. Doctors who reviewed the cases described the care provided or supervised by Barnett as “shocking.” [See: PLN, Nov. 2019, p.20.]

Aided by attorneys Marta L. O’Brien and Lincoln C. Beauregard of Connelly Law Offices in Seattle, Kleutsch’s widow brought her wrongful death suit against the state and DOC in state court on March 19, 2020, alleging that medical care at the prison “was inadequate and caused [Kleutsch’s] suffering and death.” Barnett was not named as a Defendant, likely because state law requires the agency to indemnify employees for acts and omissions taken within the scope of their employment.

In a filing on March 18, 2021, just as trial was set to begin, lawyers for the state formally admitted that DOC employees provided negligent medical care which “was a proximate cause of injury to, and the death of, John Kleutsch.” A stipulated judgment was then entered on June 22, 2021, with the state agreeing to pay Kleutsch’s estate $3,250,000 to settle the claims, “without any admission of liability.” The parties each agreed to shoulder their own costs and attorneys’ fees. See: Est. of Kleutsch v.Washington, Wash. Super. (King Cty.), Case No. 20-2-06902-7.

Legislative Response Prompted

Though Barnett vowed to appeal what she called a “wrongful dismissal,” the state indefinitely suspended her medical license in November 2020. Meanwhile investigators expanded to seven the number of prisoner deaths in which Barnett’s care was faulted.

That caught the attention of state Sen. Jeannie Darnielle (D-Tacoma), who introduced legislation to provide greater oversight of unexpected prisoner fatalities. Though the bill, SB 5119, was called overkill by DOC, it took effect in July 2021.

Meanwhile, in March 2020, Dr. David left DOC to join the Office of the Corrections Ombuds (OCO), an independent oversight body created in 2018 at the urging of Gov. Jay Inslee (D). Medical complaints are the most common type OCO receives, with an estimated 41,000 in a single year from a prisoner population of 18,800.

O’Brien said Kleutsch’s case was “one of the worst medical malpractice cases I have encountered.” Noting there was “a systematic failure” by DOC, leaving prison officials little choice but to admit fault, she called it “abhorrent.” The dead prisoner’s widow agreed.

“John was treated inhumanely and suffered terribly before he died,” said Julia Kleutsch. “The Department told me nothing about Dr. Barnett failing to provide basic medical care to John or that it caused his death. No family member of an inmate should be kept in the dark the way the Department kept me in the dark about John.”

DOC officials claim that they have reformed internal medical practices and added nursing and other staff in response to some of the publicized problems. The 2021-2023 DOC budget approved by the state Legislature authorized an increase of 161 full-time staff and $39 million to improve health care delivery.

Incredibly, Barnett claims vindication with the settlement and reforms. “My heart goes out to Mrs. Kleutsch for her loss, and I too am saddened by the death of a patient I knew well. In my opinion, she sued the correct party,” the suspended doctor said. “By its actions in replacing me with three physicians, DOC has acknowledged the unacceptable level of risk it placed solely on my shoulders. Systemically, the DOC chose to have too few providers despite my and the inmates begging for more. I am happy to see Mrs. Kleutsch obtain justice.”  

Additional Source: Seattle Times

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