David M Mathis md cchp-cp faafp

Death in jail shortly after arrest

A 40-year-old male was picked up with suspicion of body packing before officers opened the car door. Officers transported the arrestee to the jail. Initial screening was accomplished by an LPN. Receiving screening was never performed. Detainee died in custody several hours later from drug OD. Autopsy confirmed body packing as the cause of death.

Issues:

1. Should officers have taken the arrestee to the ER for Medical Clearance?
2. What responsibilities does the LPN have as a result of the initial screening?
3. Who is licensed to assess the detainee?
4. Who is on call?
5. Do the Jail Policies and Procedures support a lawsuit?
6. What is the Standard of Care?
7. Who is responsible for the death? The county? The officers? The LPN? The on-call provider?

Lockdown — Delay in Treatment?

30-year-old male with a history of being tired and occasional chest pain and shortness of breath. Nursing protocols followed for Fatigue Protocol. Inmate was seen three times with mildly elevated heart rate. These visits were never acknowledged or signed off by the Responsible Physician.

Next, inmate complains of chest pain and low-grade fever, receives routine triage by the RN with a five-day follow-up delayed by a lockdown for another five days. Then seen by the Responsible Physician, with no acknowledgment of the prior nursing protocols and no heart examination.

Thereafter: Acute Man Down with a stroke and a heart attack caused by intravenous drug use.

Issues:

1. Was the LPN following the protocols licensed for assessment?
2. Were correct documentation procedures followed by Responsible Physician?
3. Should EKGs have been done?
4. Should Physician have recognized symptoms of subacute bacterial endocarditis and prevalence of intravenous drug use in prison?
5. What happens in medical cases when a lockdown occurs?

Medical Observation by Video

35-year-old housewife arrested for indecent exposure and violent behavior. Cleared by the local emergency room with a Fit for Confinement letter. LPN in booking relays information to the on-call physician. On-call physician chooses to withhold asthma inhaler until after behavior improves related to acute heroin/methamphetamine intoxication. LPN is only part-time and leaves. Custody officers see the patient on video. The patient has seizure-like activity and has a cardiac arrest. Postmortem examination shows death from asthma.

Issues:

1. Was assessing inmates within the LPN's scope of practice?
2. Should the physician have ordered the LPN to repeat history and vital signs with call back?
3. Custody officers performing medical observation by video. How reliable is this observation?

Medical Records and Documentation

42-year-old inmate with a 10-year history of lower back pain and occasional sciatica. The inmate received several physical therapy courses of treatment with symptom improvement. He was weightlifting and complaining now of neck pain and loss of muscle on the right side of his body. The neurosurgeon consulted regarding sciatica and recommends brain MRI because the inmate complains of headache. Brain MRI shows left frontal brain loss of uncertain age.

Issues:

1. Inmate claims CVA symptoms five years ago that were never corroborated in the medical record.
2. No muscle asymmetry was ever documented by physical therapy or medical providers.
3. Were there indications for lumbar surgery with sciatica?
4. Was the neurosurgeon's recommendation for the brain MRI outside of the referral for sciatica? Should it have never been done?

Utilization Management / Deliberate Indifference?

30-year-old inmate repeatedly complaining of low back pain without medical findings. The inmate requests an MRI but doesn't satisfy the InterQual criteria for an MRI. MRI was done six months later when the inmate complained of lower extremity weakness. The MRI documented incurable sarcoma.

Issues:

1. The vendor contract with the state requires satisfying InterQual criteria to approve an MRI.
2. Deliberate indifference? Known low back pain, requested MRI, multiple providers failed to perform testing.
3. Plaintiff claims delayed treatment prevented cure of the sarcoma.
4. Inmate had been labeled as a malingerer by medical staff and family claimed punitive damages.

EMS Delayed by Security

50-year-old male with end-stage liver disease has persistently normal vital signs and complaining of chronic abdominal pain, falls from his bunk. He complains of abdominal pain. He is triaged by an RN and then LPN because of the abdominal pain. There is no change in his appearance. Vital signs are normal. The inmate dies six hours later secondary to a ruptured spleen.

Issues:

1. Would routine chronic care with abdominal ultrasound have documented splenomegaly?
2. Should LPN be triaging trauma?
3. EMS is delayed by security procedures for 10 minutes. Plaintiff alleges the security delay prevented administration of intravenous fluids and advanced life support available in the emergency room, which would have saved the inmate’s life.

Delay in Treatment – Who is Responsible?

45-year-old inmate with ruptured quadriceps muscle is seen by provider but no lay-in (Chrono) was given. He then falls going up to the second tier. His other quadriceps muscle ruptures. MRI demonstrates the ruptures. Telemedicine (orthopedic) consultation recommends surgery. However, a different surgeon is consulted but he has never seen the MRI. The inmate is disgruntled and then refuses care from the second orthopedic surgeon. The inmate writes an appeal. The appeal is granted for a different surgeon. The delay is now six months with poor outcome.

Issues:

1. InterQual criteria is not met for the second MRI, further delaying treatment.
2. Causation regarding the poor outcome?
3. Is this willful and wanton negligence?

Suicide

Detainee is violent in the dormitory and sent to administrative segregation. Officers find a noose under his mattress and inform the LPN, who screens the inmate. The jail doctor releases the inmate from suicide watch with a cursory evaluation. There is no mental health consultation. Three days later the detainee is fighting in the cafeteria with bizarre behavior. The same LPN is consulted by Custody. The LPN places the detainee in administrative segregation not suicide watch. The detainee completes suicide using strips of a sheet.

Issues:

1. Was the LPN practicing medicine without a license?
2. Did the jail doctor have enough psychiatric training to determine that the detainee was not mentally ill and a suicide risk?
3. Was the unusual and bizarre behavior enough to warrant a diagnosis of psychosis or was it more likely related to contraband methamphetamine?

Multiple Sclerosis

Inmate with probable diagnosis of multiple sclerosis from a university neurologist prior to incarceration presents to multiple medical vendor physicians with possible seizures and poorly documented weakness. A different neurology consultant recommends another MRI, which is suggestive but not diagnostic of multiple sclerosis. The neurology consultant recommends very expensive medication and the Regional Medical Director declines the medication. The inmate now requires a wheelchair. The inmate is paroled. A neurology consultant once more diagnoses multiple sclerosis and states that delay in treatment exacerbated the inmate's disability.

Issues:

1. Was the Regional Medical Director trying to save money for his organization?
2. Did the delay in treatment cause significant harm?
3. Were the practitioners and Regional Medical Director deliberately indifferent?

Lack of Air Conditioning / Inmate Deaths

Jail detainees are kept in air-conditioning. Detainees are transferred to prison where there is no air conditioning and there is a high heat index. Inmates, particularly those with antipsychotic medications, die from heat stroke.

Issues:

1. Were the policies and procedures for transfers followed?
2. Did medical work with custody to identify inmates on heat drugs?
3. Did inmates with heat drugs and no other medical disabilities require air conditioning?
4. Did malfunctioning ice machines with no ice to the inmates contribute to their deaths?
5. Were developmentally delayed inmates at higher risk for heatstroke?
6. Should psychiatry have placed all inmates on newer psychiatric drugs that were more expensive but less likely to be associated with heatstroke?

HIV-positive Detainee

A potential detainee was fleeing from the police and entering a lake repeatedly. After approximately 30 minutes he tried to come out and the police sent a dog after him. He was bitten on the leg but freed himself from the dog and returned to the lake. A helicopter was employed and finally he was arrested and taken to the emergency room for clearance. He was cleared, placed on oral antibiotics and detained in the jail. He was also HIV-positive and immunocompromised. After 48 hours he became septic but this was not identified by the nurse practitioner. The detainee became increasingly ill and subsequently died.

Issues:

1. Did the nurse practitioner have a duty to recognize his immunocompromised state and transfer him to a higher level of care?
2. Did the Emergency Room where the dog-bite was treated play a role in his death?