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Trail of Sorrow

[whitespace] Carolyn Telzrow Wrongful death? Carolyn Telzrow, 47, a former nurse, hanged herself on March 9 in a Sonoma County Jail infirmary cell. Telzrow, who suffered chronic back pain, reportedly cried, "Help me. Help me," for two hours before her death. Another inmate says those pleas went unheeded by staff members.


Investigation reveals health-care provider at Sonoma County Jail has an ugly past

By Greg Cahill and Paula Harris

LAST YEAR, nearly 800 inmates nationwide filed lawsuits alleging negligence by the St. Louis-based firm that provides private health care to Sonoma County Jail inmates, the Independent has learned. Correctional Medical Services--named in the wrongful death of Joanne Holmes, a Santa Rosa woman who died at the jail last year from complications of heroin withdrawal--was also the subject of a 1993 federal probe in Virginia that concluded the firm violated inmates' rights and that some of its past services were grossly deficient.

In March, the Sonoma County Board of Supervisors approved a $35,000 review of conditions and operations at the Sonoma County Jail, including medical practices. That decision followed six in-custody deaths, three suicide attempts, two escapes, and one attempted escape, all in the course of 18 months. The state evaluation of policies and procedures at the jail, delayed until the end of the month, is being conducted by the state Board of Corrections.

Meanwhile, the firm's track record raises serious questions about the performance of CMS, which is contracted for nearly $3 million a year to provide health services at the county jail. The firm won the contract in 1992.

The Independent has learned that a 1993 investigation by the U.S. Justice Dept. concluded that CMS' medical services in Norfolk, Va., were "grossly deficient" and "violated inmates' constitutional rights." Federal investigators also found that CMS' method of screening incoming inmates for health problems at the jail was "woefully inadequate" and that the company failed to evaluate and monitor inmates with tuberculosis, asthma, seizure disorders, high blood pressure, diabetes, and AIDS.

In addition, the federal probe found that CMS staff were "not appropriately trained"; that medications were haphazardly administered and often expired; that records "fail[ed] to meet any known professional standard"; and that its doctor diagnosed inmates without examining them.

At the Sonoma County Jail, inmates and former medical personnel have described similar problems. In March, Lynn Berry O'Connor, the director of nursing, quit after complaining that she felt her professional standards were being compromised by CMS. "I was trying to make a statement," she says of her departure. [The statement] was made to the company in regard to staffing difficulties. The staff must have extensive background clearance, and it's hard to get [qualified] staff if people leave. I was tired of dealing with staffing hassles.

"It's hard trying to do medicine in a jail environment."

The position of director of nursing has not yet been filled.

Other county jail sources agree that the facility is understaffed, and medical employees spend so long on admission and administration that inmates' regular medical needs are not being met. One source, speaking on condition of anonymity, reports that staff members are dispensing megadoses of medications (such as antibiotics) once a day instead of the prescribed three or four times a day, and that some inmates are not getting their specific medications, such as insulin.

IN THE PAST, experts in the field of prison health care have strongly criticized CMS for a variety of alleged systemic deficiencies, and a string of lawsuits has linked the company to numerous inmate deaths nationwide. In the last few years, allegations of the firm's medical neglect leading to inmate deaths and injuries have surfaced in Arkansas, Alabama, Georgia, New Mexico, and Virginia.

The cases echo similar incidents at the Sonoma County Jail. Sonoma County Deputy Public Defender Mike Perry says his client Joshua Voss, 23, charged in a murder case, was not placed on antidepressants at the jail even though he had attempted suicide prior to being arrested in May. "I met with him in jail and he seemed suicidal, so I called the jail medical staff because I was concerned that he wasn't on some kind of antidepression medication," recalls Perry.

"Two doctors decided it wasn't called for, and a couple of weeks later he tried to kill himself in jail.

"He's now on medication."

Perry also recalls a case two years ago in which another client, a woman in custody, had lymphoma "the size of a grapefruit" near her spinal cord, and who couldn't sleep and had numbing of the legs. "I nearly fell over when I saw [the growth]," Perry says. "The medical staff had shined her on. I called the doctor immediately and they finally took her into surgery, but I was shocked that they'd allow something like this to go on."

He adds: "We're seeing more and more people in jail with assorted psychiatric problems who are not given medications their own doctor has prescribed. They are usually given a previous generation of less expensive drugs."

On Feb. 24, inmate Drue Harris, 30, hanged himself in the jail's infirmary. Authorities claim Harris left a crude note scrawled in soap on the door of his cell indicating that he was severely depressed. But family members contend that Harris was in great pain following a head injury suffered shortly before his arrest and that, despite his requests, he was not X-rayed or examined by medical jail personnel.

Harris' death was followed 13 days later by the suicide of Carolyn Telzrow, 47, who hanged herself March 9 after jail staff apparently failed to arrange for a local agency to administer methadone that her family doctor had prescribed for pain management after Telzrow had broken her back in a horse-riding accident.

Inmates report Telzrow cried in pain and begged for help for two hours before her suicide.

Mary Hickerson, Telzrow's sister, has filed a complaint with the California Medical Association against CMS physician John Hibbard, and has filed an additional complaint with the Sonoma County grand jury, asking them to review the circumstances surrounding Telz-row's death.

On June 4, 1997, Joanne Holmes died in custody after suffering a seizure and other complications of heroin withdrawal. According to a wrongful death suit filed by her estranged husband, Robert Holmes, and her children, county jail medical staff "failed to evaluate and treat her true condition."

Holmes, a longtime heroin user, had special medical needs related to her addiction. "[Medical staff] failed to provide immediate medical attention after [Holmes] became visibly ill," the complaint alleges, "and failed to provide medical assistance even after the decedent pleaded for such ... assistance due to her declining condition."

Former inmate Jean McMillan, 44, says that, six months pregnant, she was kicked and harangued by jail medical staff and correctional officers while incarcerated last April. A Sonoma County judge eventually ordered McMillan, who had a high-risk pregnancy, released, saying she "could not thrive" in the facility.

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A record of jailhouse deaths and other problems.

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PRESS ACCOUNTS SHOW that in some cases in-custody deaths have soared at facilities in which CMS provides care. From 1983 to 1993, according to Virginia and New Jersey newspaper reports, 17 sick inmates died in custody at the Norfolk City Jail in Norfolk, Va. Most of those deaths occurred after 1989, when CMS took over the jail's medical services.

Six inmates died there in 1993 alone.

The jail canceled its contract with CMS in 1994, following the death of inmate Jerome J. Walton Jr., 28. According to an internal jail memo, Walton died because CMS personnel simply "forgot" to schedule him for crucial dialysis treatment.

Susan Adams, a CMS spokes-woman, responds that the Norfolk City Jail contract was terminated for several reasons and that the company was not at fault. "CMS was unfairly blamed for a lot of problems in the Norfolk jail," she says. "There was inadequate funding, it was an antiquated facility, and there was extreme overcrowding.

"The sheriffs controlled those issues, not CMS."

Adams would not comment on the U.S. Justice Department finding, or on any of the other cases chronicled in this story. She would not provide information about current complaints or lawsuits, and would not confirm a 1997 published report that more than 800 prisoners around the country had claims against CMS.

"Over 96 percent of cases are dismissed" was all she would say.

Still, news reports in recent years have disclosed a number of cases in which CMS has been accused of providing shoddy services. In 1992, three inmates under the care of CMS died in New Mexico's State Penitentiary. One inmate, Roy Hilton, 46, had twice requested heart surgery--in writing, as required by prison protocols. His requests were denied and he filed a grievance.

In a letter he wrote the same day, Hilton sadly noted, "If I don't get medical attention very soon, I will surely die."

Ten days later he suffered a heart attack, fulfilling his own tragic prophecy.

A court-ordered review blamed CMS' health-care standards for the deaths of the three New Mexico inmates. The court's consultant, Dr. Lambert King, medical director of St. Vincent's Hospital and Medical Center in New York City, wrote: "The failure to provide adequate medical care for this patient was not simply an isolated error in medical judgment, but rather prolonged medical mismanagement and lack of responsiveness on the part of physicians employed by CMS, including CMS' regional director.

"There was a systemic failure to meet numerous standards of care."

King also found "serious deficiencies" in the care CMS gave to another unnamed New Mexico inmate, known as Case No. 41616, who eventually hanged himself because he was depressed over recurring head pain.

King said there was no evidence of a thorough neurologic examination by any on-site physician.

He notes: "Although it cannot be stated with absolute certainty the degree to which chronic pain contributed to this patient's psychiatric problems, it is highly probable that this patient's psychiatric deterioration was exacerbated due to continuing pain and needless delays in obtaining an expert neurological examination."

In 1993, the care provided by CMS at the Greensville jail in Virginia was criticized in a report by the state Joint Legislative Audit and Review Commission. It called CMS' performance "a failure" and denounced the state Department of Corrections for failing to adequately monitor the contract.

The report also stated that CMS was not complying with the terms of the contract and was depriving inmates of sufficient access to medical care.

In 1995, jail officials in Arkansas ordered an outside evaluation of the Pulanski County Jail after Marvin Glenn Johnson, a 28-year-old diabetic who had reportedly begged for insulin during 30 hours of incarceration, died under the care of CMS. According to the Gloucester County Times, in Woodbury, N.J., Johnson coughed up blood, leading guards to alert CMS staff that the inmate needed emergency care. Their pleas went unheeded.

The county later hired B. Jaye Anno, of Consultants in Correctional Health Care, to review the case. Anno, a Santa Fe, N.M.-based expert on prison health care, cited many of the same problems in Arkansas that the U.S. Justice Department found in Virginia. Specifically, CMS had shortcomings in medical training, record keeping, and monitoring of inmate status.

According to a Garden State News Service report, Anno's review concluded: " At a cost of $100,000 per month, we believe that inmates are receiving only limited health care."

Anno could not be reached for comment this week.

DESPITE CMS' poor track record, Sonoma County officials defend CMS and have continued to retain the firm. Sonoma County's contract with CMS was amended March 1 and continues through Feb. 28 of next year.

Under the terms of the contract, the county will pay CMS $2,904,108 a year ($242,009 per month) to provide an on-duty physician, dentist, nurses, administrators, and clerical staff.

"My assessment of [CMS' service] is very good," says Assistant Sheriff Sean McDermott. "We're very pleased with the service they provide here. [The company] has been open with communications with us and is very responsive to our needs."

He says that a doctor is routinely on-site and on call and that medical staff are on-site 24 hours a day. However, McDermott did not know how many medical staff members are on-site compared to the jail's increased inmate population of between 1,010 and 1,040 inmates.

Sonoma County Supervisor Mike Reilly, who served last year as liaison between the Board of Supervisors and the Sheriff's Department, says he was unaware of any serious problems in CMS' background, adding that supervisors have been routinely approving the contract as a simple renewal. "Obviously, we have a lot of contracts and depend on other departments to do research on anyone they contract with," he says.

ACCORDING to McDermott, CMS underbid several providers of jail medical services who vied for the contract in 1992. "We evaluated the proposals," he says. "I was not involved in the evaluation or selection, but [the selection] was not taken lightly. It was a complete evaluation."

Reilly says he knows there has been "some turnover" in jail medical staff in the past months, and hopes the state evaluation will shed light on the problems. "I don't know if it's a situation where people are working short simply because of turnover or whether there's some kind of congenital shortage of medical personnel to be able to provide the coverage that's needed," he says.

"Hopefully, the study will give some kind of indication of that."

At press time, Jack Pederson, head of the Board of Corrections review team, says the panel is running two weeks behind its schedule. He thinks the report will be complete by the end of June. The team, which inspected the county jail for two days in May, included a physician and two psychiatrists who reviewed the circumstances of the jail deaths, medical records, and policies and procedures relating to medical and mental health at the jail.

However, the Independent has learned that the panel has not contacted key family members of those involved in the in-custody deaths, and has not considered the impact of actions by more than two dozen correctional officers under investigation by the Sheriff's Department's internal affairs division for downloading pornographic material from the Internet while on duty.

One guard has been fired in connection with that scandal. That officer was on duty the night Drue Harris committed suicide, though it is unclear whether he was engaged in the Internet activity at the time.

For some, the CMS track record and events at the Sonoma County Jail raise serious questions about the viability of private health-care services at public facilities like the county jail. Dr. Terry Kupers, an Oakland-based physician and psychiatrist who testifies in class-action lawsuits filed in connection with inadequate inmate health care and who testified in a 1982 settlement about conditions in the Sonoma County Jail (before the $41 million new facility was built), says he "has concerns" about the trend to privatize health services at jails.

"People want to make a profit so they thin out staff... . The ante gets very high for what is considered an emergency," he says. "In other health-care facilities, there are checks and balances and people sue.

"But that's not true in jail."


This is the first of a two-part series investigating conditions at the Sonoma County Jail.

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From the June 25-July 1, 1998 issue of the Sonoma County Independent.

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