Final Investigation - Inmate Death at Somerset County Jail 05-28, ME DOC, 2014
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Department of Corrections State of Maine Department of Corrections State House Station 111 Tyson Building Augusta, ME 04333-0111 Operations Division Phone: (207) 287-2711 FAX: (207) 287-4370 Email: Bob.Lancaster@maine.gov Memorandum To: Ralph Nichols, Director of Operations, MDOC From: Robert Lancaster, MDOC Compliance Manager Kimberley Robbins, R.N., CCN/M, Health Services Coordinator Date: June 23, 2014 Subject: Inmate Death at Somerset County Jail – 5/28/14 On Wednesday, May 28th, 2014, I was contacted by Acting Commissioner Fitzpatrick and informed that Central Office had received a voice message from Somerset County Jail that an inmate death had occurred during the night. Subsequently, I contacted the Department of Corrections receptionist. I was informed that a voice message from Lt. Jacques of the Somerset County Jail was received at 3:26am on 5/28/24 that an inmate had died at the jail. I subsequently called the jail and eventually made voice contact with Sean Maguire, Compliance Manager for Somerset County Jail. During our discussions I ascertained the following information: a) Decedent – Joseph Daoust, d.o.b. – 3/7/1987. b) Date and Time of Death – 5/28/14 – no exact time could be provided. c) Method of Death – unknown – ropes or ligatures were not found nor was there any blood at the death scene. d) Medical History – insignificant to none. e) Incarceration Status – Mr. Daoust was a pre-trial detainee for Franklin County Jail, with admission to Somerset County Jail on 5/14/14. Mr. Maguire assured me that all notifications were performed in accordance with the Office of the Attorney General’s, Death Investigation Protocol. He also related that the Maine State Police were onsite performing their investigation. When questioned, Mr. Maguire related that all files and incident reports have been secured and I made arrangements to travel to the Somerset County Jail on 5/29/14. Some reports were electronically received on 5/28/14 and reviewed accordingly. On May 29th, 2014, Kimberley Robbins, R.N., CCN/M and I met with Chief Deputy Dale Lancaster, Corey Swope, Jail Administrator and Sean Maguire, Compliance Manager prior to reviewing the documentation. We were able to review the inmate file, the inmate medical file, Unit Logs, Central Control Logs, incident reports, staff training records and videos of the cell extraction of Mr. Daoust once discovered “unresponsive.” Records revealed that Joseph Daoust was admitted to the Somerset County Jail on 5/14/14, in accordance with the Franklin County Court’s order for the charges of Criminal Threatening with a Dangerous Weapon (Class B), and 2 counts of Aggravated Furnishing of Scheduled Drugs (Class C). Mr. Daoust was initially classified as maximum and on 5/20/14; his classification status was reviewed and changed to minimum security. Information revealed that Mr. Daoust was a methadone user for the last four years, also takes Klonopin, Seroquel and has a prescription for medical marijuana. Medical records revealed that Mr. Daoust was placed on a Clinic Opiate Withdrawal on 5/17/14 however no further “COWS” scale was completed after that date. Also, Medical Administrative Records (MAR) reflected that Mr. Daoust began refusing recommended/prescribed medication after one week of incarceration. In review of the MAR’s, it was discovered that some dates of administration were difficult to assess as the record reflected that the initial administration was crossed out and an “R” (refusal) was written over the original recording. This practice should be reviewed and changed accordingly. Mr. Daoust did not have any significant behavioral problems until the second week of his incarceration. He began having incidents of property destruction and disobeying staff directives, his behavior became increasingly more acting-out and subsequently placed in Administrative Segregation. Reviews by mental health personnel on 5/27/14 were recorded as “volatile, very unpredictable, recommend full restrictions remain in place.” On the evening of 5/27/14, logs reflect that Mr. Daoust was not adhering to the orders of staff. He refused to wear the security gown assigned to him and engaged in repetitive attempts to hyperventilate. Logs reflect that Mr. Daoust continued his hyperventilation activity and then began to develop large amounts of saliva in his mouth to “inhale and cause self-harm.” Officer Bussell’s reports reflect that he conducted a check at approximately “01:48 on 5/28/14” at which time he “determined that inmate Joseph Daoust was no longer responding to me and I could no longer determine if inmate Daoust as living, breathing flesh”. His report reflects that he requested that Sgt. Ducharme and any staff report to the Alpha Unit. Subsequently, Sgt. Ducharme entered the unit along with four additional officers. After conferring with Lt. Jacques, Sgt. Ducharme declared a “Signal 1000”then ordered the CERT Team to suit-up for the cell extraction of Mr. Daoust. At no time during this process do video tapes display that any attempts to determine that Joseph Daoust was “living or breathing” when on the floor in his room. Mr. Daoust was cuffed and shackled then lifted into a wheel chair then transported to the Admissions Unit to be placed on a diagnostic machine which will measure oxygen levels, pulse, temperature and blood pressure. It should be noted that the on-call nurse was contacted at home and advised to report to the jail as they had a medical emergency or “it may be more than that.” Records do not reflect that the local Emergency Medical Services were contacted until such time as the nurse had arrived and conducted a medical assessment. Upon arrival the EMS Unit took over a performed emergency medical procedures until such time as Mr. Daoust was pronounced deceased at 02:46am on 5/28/14. Standards and Policy Review: A review of the “Detention and Correctional Standards for Maine Counties and Municipalities” does not reveal any violations of governing standards. A review of the Somerset County Jails Policies reveals several areas of the failure to assess and operationalize emergency medical services response: A) Policy 4.1, Emergency Management, Procedure B – Emergency Situations; 1-q –establishes “Death of an Inmate” as an emergency situation. Procedure C-Emergency Codes; 2-d; identifies a Medical Emergency as “Code Blue.” A review of all reports, logs and video tapes do not verify that a Code Blue, medical emergency, was ever announced during the discovery of Mr. Daoust being unresponsive. Only a “Signal 1000” was announced by Sgt. Ducharme. Additionally, there were 2 staff members on duty in the Alpha Pod when Officer Bussell assessed Mr. Daoust as being unresponsive and he only requested available assistance from Rovers and Sgt. Ducharme. Certainly an announcement of a Code Blue would have commenced a more appropriate medical response. B) Policy 4.20: Emergency Response-Death of a Prisoner; A review of this policy reflects that on-duty staff did not initiate any verifiable attempts to determine if Mr. Daoust had a pulse or was breathing prior to removing him from his cell. In accordance with training, staff could have initiated such action then determined that lifesustaining measures should be initiated, as stated in Procedure A, 1-c. C) Policy 12.7: Emergency Medical and Dental Care: A review of this Policy reveals an appropriate definition for an “Emergency Medical Situation” however the Corrections Officers actions in accordance with Procedure B – Emergency Response were not operationalized. Staff waited for the on-call nurse to arrive from her residence and conduct a medical assessment before initiating life-sustaining actions and contacting the local Emergency Medical Services unit. In conclusion, reporting logs/documents/videos/incident reports could not identify a consistent time of discovery by Officer Bussell. Logs also did not reflect the time of call to the on-duty nurse or the time of call for the Emergency Medical Services Unit. It is recommended that a review of the Control Log contents and requirements may provide for better timeframe identification. BL/tms cc: Dr. Joseph Fitzpatrick, Commissioner, MDOC Jody Breton, Associate Commissioner, MDOC Gary Laplante, Director of Security, MDOC Sheriff Barry Delong, Somerset County Sheriff’s Department Chief Deputy Sheriff Dale Lancaster, Somerset County Sheriff’s Department Corey Swope, Jail Administrator Kimberley Robbins, R.N., CCN/M, Health Services Coordinator