JPS overlooked signs of a health-care crisis, even though inmates and their families cried out for assistance
By Jennifer Autrey: Star-Telegram Staff Writer
After James Wright had a brain abscess removed, he didn't always get his antibiotics.
When he asked to have his incision cleaned, he was placed in an unsanitary waiting room where gnats dived into his oozing wound. He couldn't get a doctor's appointment even though he said his headaches were killing him.
By the time a doctor finally saw him, another pus-filled abscess had developed.
His struggle to obtain health care was not unique. Wright was an inmate at the Tarrant County Jail, where nightmare medical experiences happened all too often, a Star-Telegram investigation has found.
JPS Health Network, the same organization that runs Tarrant County's public hospital, operated a jail health-care system that by 2004 was in tatters. But administrators overlooked numerous telltale signs of the medical crisis, the Star-Telegram found during a review of JPS documents.
One teen-ager with a known heart defect was given Pepto-Bismol for chest pain, only to collapse and die from a split heart valve. An AIDS patient sobbed in his cell, saying he couldn't get his medication. He, too, died in custody.
Relatives of inmates who died last year are left to wonder whether their loved ones were given the right treatment or medication.
It wasn't just the acutely ill who suffered.
Even routine care wasn't reliable. Requests to see doctors were stuffed into filing cabinets, unread for weeks. The inmate who discovered a lump in her breast had no better chance of her request being noticed than the one who griped about his shower shoes.
Inmates reported that broken arms weren't set. One inmate was given an over-the-counter laxative, but his attorney pointed out that the inmate was suffering from diarrhea.
Wright Lassiter III, a vice president who recently left JPS, said no one should think that such problems indicate that something was fundamentally wrong with medical care at the jail. "I think the biggest issues in the jail were gaps. You do things right most of the time, but then there were gaps in how things were accomplished," he said.
Yet JPS' rank-and-file employees at the jail complained about crucial positions left unfilled amid rapid turnover. They worked with broken equipment and out-of-date supplies. Their pleas for help were directed to managers who either accepted the status quo or couldn't change it.
To be sure, the blame is shared.
Sheriff Dee Anderson, who runs the jail, issued ultimatums to JPS while he didn't fix problems in his own department. Doctors came in late and didn't always work scheduled shifts.
Nonetheless, JPS was culpable for many deficiencies, according to consultants hired by the county last fall. Among their findings: Medical records were "in a state of chaos" and some of the sickest inmates couldn't count on life-sustaining treatments.
For all this, JPS officials displayed little sense of urgency. For many months, Chief Executive Officer David Cecero could not find time to meet with the sheriff. Real change came only after the consultants' damning report.
Cecero doesn't see much point in rehashing the problems.
"I think it is more appropriate and more important to talk about where we are at today," Cecero said in a July interview.
JPS, he said, has increased its correctional health budget by millions of dollars, adding staff and new equipment.
But some inmates say there can still be long waits for medication. And it was just this April that Wright was delayed in seeing a doctor for his abscess -- months after JPS told the public the system was well on the way to being fixed.
Troubling allegations
Few people might weep for the James Wrights of this world.
But most of the 3,200 people in Tarrant County Jail -- even those convicted of serious crimes -- will eventually be released. Without medical care, some could pose public health threats and increase the burden on taxpayers.
That began weighing on Anderson soon after he became sheriff in 2001.
Grievances over medical care were cascading into Anderson's department. And inmates' relatives were calling, pleading for him to intervene with JPS' jail staff. Some of their appeals touched the sheriff.
"Your brother could be in my jail. Any of us could have a relative there," he said.
Anderson said that the more he investigated complaints, the more concerned he became. An inmate's request to see a doctor might not be reviewed for six weeks, he said.
He remembers one case in which an inmate told the JPS employee at the receiving desk on a Friday night that he was a diabetic and needed insulin daily. The inmate was told he couldn't have his insulin until he saw a doctor the next Wednesday.
Luckily for the inmate, Anderson said, he was released from custody by Monday. By that time, the inmate was so ill that he went straight to the hospital to have his blood sugar adjusted.
Anderson had another worry. As sheriff, he's bound by federal law to provide adequate medical care for inmates. Yet he had no authority over JPS and its health care system, because county commissioners contracted with JPS to provide the service.
Anderson feared losing a court case, and he was already seeing lawsuits with troubling allegations.
Arthur Delgado Jr. said a jail nurse confused him with somebody else. She couldn't be persuaded otherwise, even when the treatment she claimed he was getting didn't match his symptoms.
He wanted to see the doctor to be checked for diabetes. But the nurse told him he had already been seen.
"When I tried to protest, she showed me my file indicating the date seen and medicine creams ordered," Delgado wrote in his 2002 lawsuit. "When I stated, 'That was not me,' she treated me with total disregard."
The sheriff wasn't the only one concerned.
Registered nurse Thomas Williams started work in October 2003 and immediately noticed expired intravenous fluids and 20-year-old defibrillators.
"When I walked into the jail, the problems were like neon signs," Williams later wrote to JPS administrators. He declined to be interviewed by the Star-Telegram.
The jail doctors, who work for a physicians group through a contract with JPS, reported that they were hampered at their jobs.
"I'm having multiple complaints about the doctors not having enough staff, medical records are awful. It just goes on and on," said Dr. Wayne Williams, an administrator with North Texas Affiliated Medical Group.
But if the doctors, the Sheriff's Department and JPS' own medical staff knew the situation was deteriorating in 2002 and 2003, JPS administrators didn't grasp it. They told the sheriff he just didn't understand health care.
Anderson came to believe that nothing would be improved unless he met directly with Cecero. Yet, Anderson said, Cecero kept canceling meetings. When they finally got together, in October 2003, Cecero left the hourlong meeting and talked on the phone for 20 minutes.
Cecero said he left to take a call from a county commissioner and thought he was leaving the discussion in the good hands of his chief operating officer. But Anderson was livid.
A month later, Anderson wrote Cecero that since the meeting, health care services at the jail had gotten even worse. He blamed poor physician coverage and a lack of leadership from JPS management. The sheriff notified Cecero that "immediate corrective action must be taken" and hinted that if things didn't change, he would try to have JPS replaced.
Cecero assured the sheriff that all the issues of concern would be resolved in 2004.
Warning signs
Inmates began dying.
In the first three months of 2004, the Tarrant County Jail had three deaths in custody -- the same as in all of 2003. The year before, two inmates died.
Eventually, ten inmates would die at the jail in 2004 -- none because of violence. In comparison, Dallas County Jail, with twice the average jail population, had 12, according to statistics provided by the Texas Attorney General's Office.
Even though some inmates arrive at the jail with severe health problems, the health system is required to investigate whether its medical policies and procedures are a factor in any unanticipated death. Results from such investigations are not public in Texas, so it is impossible to know what JPS did.
But a Star-Telegram review of several of the deaths found warning signs that the system was struggling.
Christopher Brown's death might have raised questions about whether inmates could get their medicines and see a doctor.
In the weeks before Brown's death at 31, he pleaded for help, according to documents released by the Sheriff's Department.
"I have full blown AIDS ... I am starting to get sick now. I don't know what the problem is in medical, but for the last two or three weeks I have been told that I would see the doctor the following Monday, and I don't," he wrote.
A week later he wrote: "What is wrong with me is a very serious illness, and I feel that if they would have seen me from the beginning, things wouldn't be as bad, because I would have my meds."
The Star-Telegram couldn't determine how JPS responded because Brown's family members declined to authorize the release of his medical records.
Kendric Carter's death might have shown JPS that things weren't working properly in the medical records department.
On June 17, 2004, a doctor realized he had recently treated Carter, but Carter's medical chart was missing.
"I cannot adequately [treat] patient without chart!" the doctor wrote in Carter's clinic notes. "Find chart and show me -- today!!"
Carter, 30, died from hepatitis B on Aug. 5, 2004, while still in custody.
Mario Paschall's death could have shown JPS that equipment was broken or obsolete -- and might have called medical judgment into question.
John Peter Smith Hospital had monitored Paschall since age 5 because he had Marfan syndrome, an inherited condition that, among other things, causes the aortic valve to enlarge, similar to the bulge in a defective tire.
One serious risk of Marfan syndrome is aortic dissection, a ripping in the layers of the aortic wall that allows blood to leak. This tearing causes excruciating pain in the chest and can be fatal.
When Paschall, 19, arrived at the jail in August 2004, he told the medical staff about his heart valve.
Late that month, he started vomiting and developed a searing pain in his chest and abdomen. Williams, the nurse, first guessed that Paschall had flatulence, then later suggested that the inmate might have gall bladder problems and sent him to JPS.
But doctors there did not determine the cause of the pain. They sent him back to jail a few hours later with a prescription to help combat nausea. The next night, when Paschall said he was still hurting, a licensed vocational nurse at the jail gave him Pepto-Bismol.
Paschall was found on the floor of his cell the next morning. A nurse called for a defibrillator. It didn't work.
The teen-ager was pronounced dead at the hospital a few hours later. Cause of death: aortic dissection from Marfan syndrome.
A 'Nazi atmosphere'
First one jail doctor threatened to quit. Then another. Then the third.
So in the summer of 2004, Wayne Williams, their supervisor, decided to spend two weeks at the jail to find out what was going on.
His diagnosis: JPS didn't have enough employees to do the job.
Turnover was rapid -- among the highest of any JPS department. Williams said that when employees left, JPS often didn't fill those positions but eliminated them.
Anderson said he found the same problem. But Lassiter, who served as JPS senior vice president for operations until leaving for a hospital in California, says that's not true and that the health network never reduced jail staffing.
Nonetheless, doctors said they saw jobs left unfilled, pinching every part of the operation.
The sheer volume of inmates needing medicine overwhelmed a dwindling nursing staff, so the prescriptions weren't always faxed to the pharmacy, said Dr. Matt Loewen, formerly an acting medical director at the jail.
The medical records department couldn't keep up with its workload. It had one part-time and two full-time employees to maintain charts and provide them to doctors before appointments.
"These individuals have been left without supervision for the past year, following the departure of the medical records supervisor," consultants later found.
The job of screening new inmates was left to licensed vocational nurses, who did not have adequate training. The jail had one nurse to sort through all the inmates' requests for medical care.
Making matters worse, doctors believed that Anderson asked his staff to spy on them and instilled a "Nazi atmosphere," Wayne Williams wrote in a memo.
As fed-up doctors left, their shifts were left unfilled. At one point, there were two doctors to treat 3,200 inmates.
In his frustration, Anderson lashed out. He blamed doctors for showing up late and taking long lunches.
Anderson blamed JPS for not reining in the doctors' group, and he didn't understand why Cecero wasn't jumping on all the problems.
Inmates' families believed they knew why JPS didn't correct shoddy medical services.
"They didn't give a damn," said Geneva Thompson.
Her son, Ronnie, was left incontinent after several surgeries related to colorectal cancer. But he wasn't allowed to take his adult diapers when he was booked in jail in February 2004, and the jail medical department didn't provide him any.
When his mother went to visit him, she found him sitting wet from his own waste.
Geneva Thompson called the jail medical staff. Its explanation? The jail was out of diapers.
She said she called JPS for 10 days, but nothing changed. She finally called the sheriff. His chief deputy allowed Thompson to provide her son's supplies.
Ronnie Thompson said that a supervisor belittled him.
When he saw a doctor after several requests, Thompson said she told him: "You can go call your mommy and tell her you've seen the doctor now."
Major changes needed
By summer 2004, the sheriff decided to take control.
He notified the county that he had contacted a company that said it could greatly improve jail health services. County commissioners were upset with Anderson's move.
They feared public embarrassment if the Star-Telegram found out.
"If this communication reaches the FWST, there will be a lot of finger pointing -- and explanations required," Commissioner Marti VanRavenswaay wrote to Cecero in a July 15, 2004, e-mail.
JPS reassured commissioners that any deficiencies were being addressed. And several commissioners believed that inmates could be manipulating the system.
"Incarcerated people don't have much else to do besides file lawsuits," Commissioner Roy Brooks said.
When Anderson wouldn't relent, commissioners hired experts in correctional health care to sort it all out. Consultants with the American Jail Association quickly warned that dramatic changes would be needed.
Cecero told commissioners that they should not be alarmed by the findings because some problems detailed in the report had already been corrected.
The major items, though, "will take time and money, if we all feel the suggestions are necessary," Cecero wrote in a Nov. 30 e-mail to VanRavenswaay.
Even though the report chided Anderson for his role in the problems -- such as moving inmates without notifying JPS so their charts could accompany them -- the sheriff ballyhooed it.
Saying he hadn't realized the extent of the dangers uncovered by the consultants, he sent Cecero a list of changes that he demanded be addressed within 30 days.
Behind the scenes, Cecero and top administrators derided Anderson's threat. "More games by the Sheriff and his staff," Cecero e-mailed one hospital board member.
"Frankly, I'd love to assist in getting him in so much 'hot water' with commissioners that they will let us drop the jail," Harold Samuels, the chairman of the hospital board, wrote to Cecero.
Regardless, JPS stepped up its efforts. By the time the consultant's report was made public Jan. 8, JPS administrators could say that solutions were in the works.
Employees were being added. Temporary workers would be hired to fill the gaps -- both in the nursing ranks and other areas, including medical records. New equipment would be ordered. Inmates' medical requests would be reviewed, even if JPS had to bring in an army of workers to do it.
In March, a new physician, Alan Byrd, began overseeing the medical care at the jail. He says that inmate requests for treatment now are screened within 24 hours.
A cordial relationship
Why did it take indignant outbursts from the sheriff and a critical report from outsiders before extensive changes took place?
Cecero says JPS didn't have the system and the people in place to alert top administrators to the problems.
He hadn't known about staffing problems at the jail. Staff turnover and vacancies are not the kind of details that reach him, he said.
Cecero also said that his health network had not been sued over its jail care in more than a decade. In fact, JPS or its employees were named in 11 federal lawsuits by inmates since Cecero was hired in 2001, although most were dismissed quickly.
And Cecero said he never heard from inmates or their families. JPS has a system for patients to file complaints, and at least eight inmates did just that, including one who addressed his complaint to Cecero. Another inmate, Ambrosio Salinas, said he wrote to Cecero in February about not getting prescribed antibiotics.
Apparently, the complaints didn't make it to Cecero's office.
"What I'm saying is no one has written to my attention directly," Cecero said. "But if there had been, we would deal with it straight up and directly."
Cecero said JPS employees at the jail were not adequately trained. He also said that the jail lacked proper medical resources and blamed his own staff for that.
"They didn't ask for them," he said.
The hospital system relies heavily on its management team to alert it to needs, Lassiter said. "And I would tell you that the needs of the correctional health function were not being advocated for as strongly as I would expect a department head to advocate for."
The on-site supervisor was scolded by her superiors in early 2004 for failing to communicate to senior management information that may have "potential unfavorable consequences" for JPS, documents show.
Cecero said he has put more competent people in place. Four managers are no longer involved with jail operations, including the on-site manager and a vice president who had overseen the jail.
Changes in management and staff were designed to change the culture at the jail, too, Lassiter said. "In some cases, we had folks who had been there a long time and liked things the way they were," he said. "We are trying to ensure there is as much sensitivity to the incarcerated population as there would be for the nonincarcerated population."
Lassiter and Cecero said that medical care at the jail now meets or exceeds requirements for accreditation with the Texas Commission on Jail Standards, a state oversight agency. Officials from JPS and the sheriff's office meet regularly, and Anderson said his working relationship with Cecero now is cordial.
Improved care
But more work may be needed.
As recently as late July, the Star-Telegram and JPS received anonymous letters from people who said they work on the jail medical staff. The letters listed numerous concerns, including that "inmates on seizure, blood pressure, cardiac and AIDS medication still go for weeks without medication."
JPS officials said that in the past three months, a small number of inmates failed to receive medications because of staffing issues on two occasions. On one of those dates, three of five employees did not report to work and others had to fill in, JPS spokeswoman Drenda Witt said.
"Things take time. We're not perfect, and there's still more that I want to accomplish," Lassiter said in July.
Inmates say they still had woeful experiences with JPS medical staff. On the advice of attorneys, JPS would not comment on the treatment of individual patients, citing potential litigation.
Daniel Gonzales had rectal bleeding around Christmas and saw a doctor, who told him that colon cancer was a possibility.
In June, he was sent to the hospital for a colonoscopy. But JPS failed to arrange the required all-liquid diet the day before, so the colonoscopy was unreadable. He said a second colonoscopy also was unreadable -- for the same reason.
Finally, a third colonoscopy was completed. Doctors detected no colon cancer, but believed that Gonzales might have hepatitis, his wife, Vickie, said. Gonzales, 49, was scheduled for further tests but was transferred to a state prison in August before they could be performed.
Wright, who suffered from the brain abscess, remains bitter over the ordeal he endured this spring.
A jail doctor first told him he had a sinus infection. After his abscess was removed, pain still crisscrossed his scalp. One eye drooped.
"I was supposed to be getting the medicine twice a day," Wright said. "But the medicine sometimes wouldn't be in the cart. So one of them would say, 'I'll give you a double dose next time.' But it might be a different nurse or they would forget or something."
Wright said he put in 13 requests between April 2 and April 25 to see a doctor. Finally, on April 26, a doctor saw him for his scheduled postoperative checkup.
Alarmed by his symptoms, the doctor sent Wright back to the hospital. Another abscess had developed, most likely, Wright says doctors told him, because of missed antibiotics.
But when Wright returned to jail in May, the care was much better.
He was placed in the infirmary and given antibiotics intravenously eight times daily. But his left side is still so weak he must use a walker.
"It's so sad," Wright said. "But what the heck, I'm just an inmate, right?"
IN THE KNOW
Problems at the Tarrant County Jail's medical unit
In written correspondence, physicians, JPS employees, independent consultants and others reported problems with medical care of inmates. Among their concerns:
Some jail medical equipment was broken or obsolete, such as 20-year-old defibrillators. When nurses tried to use a defibrillator on a dying patient, it didn't work.
Some equipment was locked where nurses and doctors sometimes couldn't use it. Some supplies, such as IV fluids, had expired.
Medical tests and lab tests ordered by doctors were not done or the results were not available on the doctors' next visit. Ultrasounds were a particular problem.
Prescriptions went unfilled or backlogged. After the pharmacy closed for the day, pharmacy technicians went in after hours to fill prescriptions, in violation of the law.
Medications were ordered but not always provided to patients. In some cases, these were life-sustaining drugs for patients with AIDS or kidney diseases.
Registered nurses and licensed vocational nurses were asked to make medical decisions outside their scope of practice. Only one RN was on duty at night for all four jail facilities.
Vacant doctor positions caused a backlog of inmates' appointments. Appointments for obstetric and gynecological visits were canceled half the time.
Requests to see doctors also backed up. The backlog of requests, known as kites, reached 3,000 and weren't reviewed for six weeks.
Despite the backlog, some doctors had downtime because of scheduling policies of the Sheriff's Department.
Patient charts were unavailable half the time, undermining care. In some cases, charts weren't available because the Sheriff's Department didn't always move medical records when it transferred inmates.
Improvements to jail health care
Over the past year, the JPS Health Network has implemented a number of changes at the Tarrant County Jail. As a result, spending for jail health care has increased to $11 million, compared with $7.6 million two years ago. Here are some of the notable changes.
Staffing:
A fourth physician has been added.
A physician's assistant has been hired.
Sixteen registered nurse positions have been added.
Four medication aide positions have been filled.
Four emergency medical technician positions have been filled.
Two employees have been added to file medical charts.
A certified pharmacy tech has been added to track jail orders.
Equipment and supplies:
Optical scanning technology was installed to transmit prescriptions.
A new fax machine, telephones and computers have been installed.
The pharmacy has prepared starter kits of common medications.
Operations:
Weekend clinics have been expanded.
An AIDS clinic has been reinstated at the jail.
Inmates with similar health needs are being grouped together at the jail.
JPS hospital tries to group inmates together.
Requests for medical care are reviewed within 24 hours by medical staff.
SOURCES: JPS officials, Dr. Alan Byrd
Complaints about lack of care
A pronounced increase in grievances about the medical care provided to jail inmates caught the attention of Sheriff Dee Anderson. These are among the complaints from inmates, their family members or attorneys.
"I have been here two weeks come Monday and have yet to see or talk with a doctor or be called to sick call to see the doctor. I was told I would be put on the list. Put on the list! Put on the list. I am having more and more pains in my chest cause of my heart which is why I have Nitro and Metoprolol pills for my heart."
-- Letter to Sheriff Dee Anderson, Jan. 25, 2003
"I sat in the visitor booth and was told it would be a little while before I could see him, because he was having a seizure. ... He was brought in weeping and covered in urine. I got the attention of a guard and was told that he wasn't allowed a change of clothing, because someone from MHMR had to be present. I asked to see a supervisor and sat there another 20-30 minutes with no response. I got on the elevator intercom and asked again and finally saw the corporal in charge at the conclusion of my visit. He told me a completely different story than the guard and said they didn't change Matt because they didn't want to delay my visit. I told him that I would have gladly waited. He assured me that he would be changed immediately. I found out later that instead of being allowed a change of clothing Matt was strapped to a chair for hours in the same clothing after I left."
-- E-mail from an inmate's father, Sept. 19, 2002
"Since I've been here I have been denied my medicines ... I have ulcers and I haven't eaten in 3 to 4 days, because I can't keep food down. I am spitting up blood. They tell me they can't find my chart. It has nothing to do with ulcers. I was kept in the jail infirmary for three days. And was given Zantac and antibiotic and saline LV. They say that on my chart, but then again they claim they can't find my chart."
-- JPS Health Network patient complaint form, June 6, 2002
"As you are aware [my client] gave birth, via a Caesarian section, to a beautiful young boy late last Thursday. Apparently, within a day, she was placed in the general population and is only allowed to have aspirin. This is wholly unacceptable. There is a serious infection risk. Why was this patient not assigned to the infirmary?"
-- Dallas attorney Jason Charles Ciarochi, Aug. 18, 2003
"Wife called. Said he has had surgery before he was transferred here. She said he has been bleeding and couldn't get medical treatment. I gave her the number for medical. After I hung up, I called [the sergeant] and asked him to have someone check on the inmate since medical wasn't answering."
-- Sheriff's Department correspondence, Sept. 22, 2003
"I lost my toe due to an infection and I got inside this jail! Now, another doctor is trying to help me not only lose my more of my foot, but my life! I have a 10- and 11-year-old boys that I'd like to see again! Even after I returned from JPS and the doctors' calling to be sure the orders were understood, I still don't have my meds! My seizures are getting worse. Please do something about this before it's too late. I am scared! Please help!"
-- Grievance form filed with the Sheriff's Department, Aug. 7, 2003
"My client, who has been experiencing intestinal problem, was put in the medical facility for examination and diagnosis. ... He was given nothing other than over-the-counter medications, which did not solve the problem. ... His problem has gotten worse. Today ... there was delivered to him two over-the-counter medications -- Metamucil and Milk of Magnesia. Both of these are laxatives. One of Brian's symptoms is severe diarrhea."
-- Arlington attorney John V. Dowdy Jr. to the Sheriff's Department, July 22, 2003
