Jail health woes have no easy cure
Ahmed Elsweisy felt nauseated, 24 hours into every diabetic’s worst nightmare.
He’d been arrested on a DWI charge and booked into the Harris County Jail early one morning in September without insulin — and nobody seemed to care.
Elsweisy, 28, a muscular sales clerk at a big box store, had been managing his Type 1 diabetes since childhood without problems.
He barely survived his one and only stint in Harris County’s troubled lockup, which is, by default, one of the area’s largest medical institutions.
Hundreds of diabetics like Elsweisy face complications obtaining timely and proper insulin injections during and after intake, jail critics say. Thousands of mentally ill inmates on psychotropic medications often overwhelm the jail’s limited capacity to manage their drugs and administer proper care. Tuberculosis is prevalent and can be spread by inmates into the city’s general population, medical experts say.
Sen. John Whitmire, D-Houston, set to hold legislative hearings in January, calls the jail “unsafe and unhealthy” and said the institution’s inability to control the spread of tuberculosis and other infectious diseases not only endangers inmates but “overflows onto the streets of Houston” threatening public health once inmates are released.
“I’m alarmed,” he said. “Every public official should be alarmed because those are the people you and your children are going to be exposed to. You’re going to sit next to them on the Metro bus or train.”
The Department of Justice targeted inadequate medical care at the jail in a 2009 report, finding that poor care and failures by jail medical staff to treat chronic conditions, including diabetes, tuberculosis and mental illness, had been factors in 20 deaths.
Six years later, a Houston Chronicle investigation has found that serious issues remain related to inmate care. Despite reforms in staffing and procedures that have improved medical care in key areas, the Justice Department continues to focus on shortfalls in mental health treatment and on jailers’ use of force against disruptive prisoners, according to John Odam, general counsel for the Harris County attorney.
The jail, said Harris County Judge Ed Emmett, is “a glass with a hole in the bottom.”
“It’s not something you ever solve,” said Emmett, who heads the Commissioner’s Court, which approves the Sheriff’s Office budget. “You keep working on it, and anytime you work with people in these circumstances there are going to be problems. And when there is an incident, we deal with it openly and swiftly.”
Former sheriff Adrian Garcia, who oversaw the jail from January 2009 until he resigned from office in May to run for mayor of Houston, said Thursday in an interview that he strived to meet the recommendations made by the Justice Department and had been successful in correcting shortcomings identified in its report.
As part of its investigation, the Chronicle reviewed thousands of pages of autopsies, court records and sheriff’s disciplinary files. Records show at least 75 inmates have died in jail custody since the Justice Department report, about three-quarters of whom were awaiting adjudication. The number of deaths decreased about 11 percent during Garcia’s administration compared to the last five years under Garcia’s predecessor, Tommy Thomas.
Most of the deaths since 2009 were attributed to natural causes. Ten died of hepatitis B or C. Ten were suicides. Eight had HIV or AIDS. Five died from the deadly “superbug” staph infection MRSA. Three were ruled homicides.
The Chronicle identified at least 19 cases in which inmates died of illnesses that were either treatable or preventable, or in which delays in care, or staff mis- conduct, could have played a role in their deaths.
“It’s appalling, at this time with Houston being the medical center of the world, that we’d have people dying in the jail from diseases that are completely treatable,” said James Douglas, president of the Houston Branch of the NAACP.
Incarceration in Harris County, he said, should not become “a death sentence.”
County and union officials say the problems of delivering medical care in the jail are a complex mix of insufficient staffing and training, jailer burnout and an aging physical structure in need of more cells and space for a medical facility.
Tuberculosis presents serious screening and treatments problems, inside and outside the jail, the Chronicle found. Jail officials reported 23 tuberculosis cases to the state health department in 2013, nearly double the number in the entire Texas prison system.
“For sure I wouldn’t want to be in that jail, because I have major concerns about how they are doing TB skin tests,” said professor Edward A. Graviss, director of the molecular tuberculosis laboratory at the Methodist Hospital Research Institute. “It’s like being in a Third World country; you have to assume everyone is infected with TB. I would screen them a little bit differently, but again, it’s your tax dollars at work. Do you screen them faster, or do you put fewer people in jail?”
The Chronicle also found that diabetics like Elsweisy may face some of the greatest risks of all. As one of the largest county jails in America, with capacity to hold 9,434 inmates, Harris County’s lockup is home on any given day to about 680 diabetics, according to a 2015 Bureau of Justice Statistics estimate. Critics said jail staff has a troubling track record of delivering adequate diabetic care, beginning with intake procedures in which any insulin a diabetic may have in his possession is confiscated.
Over the past nine months, the Chronicle also reviewed more than 1,000 disciplinary reports provided by the Sheriff’s Office and found 35 failures to complete cell checks, sometimes for inmates in solitary confinement. Additionally, jailers were disciplined more than 120 times for misconduct involving abuse of authority or misuse of force since 2009, including 13 instances in which jailers failed to seek medical attention for inmates.
One was detention officer Rima E. Fortune, who received a 10-day suspension in September 2012 for denying food to then48-year-old Barbara Hammond, a diabetic. Fortune admitted she withheld food from inmates as punishment for a previous fight and defended herself by saying she thought the jail served only two meals a day.
Garcia said cases of neglect were never acceptable, and he acknowledged that some cases of inmate care had been mishandled.
“There were always things that made me angry,” he said. “But I remained at the table not to say look at the improvements I made, but can we still make improvements going forward?”
BBB After 24 hours in jail without insulin, Ahmed Elsweisy said he made yet another desperate plea for the medication he normally takes five times a day.
“‘Hey look,’” he remembered telling a jailer. “‘This is getting really bad and I’m going to get sick.’ He goes, ‘There’s about 22 diabetics in here, and if we let you have yours then weneed to get theirs.’ ”
His pleas were ignored until it was almost too late. Jail staff made Elsweisy wait about 30 hours, giving him insulin only after he passed out in a cell and became violently ill a dozen times, he said. Finally, with Elsweisy vomiting and on the verge of a life-threatening coma, the jail had him taken to Ben Taub General Hospital, medical records show.
There, in the emergency room, doctors found his high blood glucose levels had resulted in diabetic ketoacidosis, a complication that can lead to coma and death.
Scott Siscoe, a criminal defense attorney who is representing Elsweisy on the DWI charge, called his client’s experience a “totally avoidable medical crisis” that demonstrates a lack of adequate training and supervision.
Ryan Sullivan, a spokesman for Sheriff Ron Hickman, who replaced Garcia in May, said Elsweisy was not seen by medical personnel for more than 16 hours after arriving at the jail. He disputed Elsweisy’s account that he waited many additional hours for treatment but said it became necessary to send the inmate to a hospital.
“The medical records and the facts documented by the Sheriff’s Office do not support his allegations,” Sullivan said.
At the jail’s main clinic at 1200 Baker St., inmates wait in line for care but often are displaced when other inmates become seriously ill or injured and need emergency treatments, said Richard Newby, a veteran sergeant who retired in March after a 28-year career.
“I don’t think the medical system has expanded enough to meet the needs of the jail population — some areas have not increased in terms of size or staffing,” he said.
State law prohibits Medicaid payments for jail inmates, shifting the cost of extensive medical treatments — $57 million out of the jail’s overall $443 million budget — to local taxpayers, county officials noted.
Bob Goerlitz, president of the Harris County Deputies’ Organization, said that to improve medical care in the jail, county officials must make a monetary investment, a move that often is difficult for the public and politicians to recognize as a benefit.
“It’s a necessary evil that the government has to pay for,” he said.
In terms of care for diabetics, problems stretch back to at least 2009, when state jail investigators were called to see why a diabetic inmate had not been given her insulin for two days in a row, according to Texas Commission on Jail Standard records.
Six diabetics are among the 75 jail deaths reviewed by the Chronicle.
Linda Pugh, one of the founders of the nonprofit Inmate Assistance League, said that jail medical staff employ a one-sizefits-all approach to diabetics and frequently limit insulin to a dosage once a day even if the inmate’s blood sugar level crashes.
“It affects a lot of people,” said Pugh, herself a diabetic. “They have to have better medical care because these people come in and they don’t all take the same kind of insulin, and jail staff should provide the medication that the inmate ... was receiving, but they won’t. They just switch.”
She also said jail medical staff typically will conduct several tests of blood sugar, then decide on a proper dosage — though often diabetics’ need for insulin fluctuates.
“They’ll do three (blood) sticks in row, and they won’t test them again,” Pugh said. “They should never give insulin without testing their blood.”
The American Diabetes Association recommends that inmates receive a blood glucose test within 1-2 hours of intake, a practice critics say is followed infrequently in the jail, where diabetics can wait up to 72 hours for an examination by a jail doctor.
Sullivan, Hickman’s spokesman, said all inmates are screened by an intake nurse and, in some cases, are provided with insulin immediately.
BBB Every year, about 100,000 people are processed by Harris County Jail officials. Most get released within 72 hours. Amedical screening is supposed to identify mentally ill inmates and those with chronic or infectious diseases. The jail relies on the least-expensive TB skin tests, which cost about $1 apiece, and chest X-rays that only detect the disease’s presence in the lungs, said Graviss of the Methodist Hospital Research Institute.
He had been part of an extensive study of tuberculosis in Harris County from 1995 to 2004 in which researchers found that 47 percent of the 5,748 TB cases were persons whohad been in the Harris County Jail.
Graviss and three other researchers then published a study in 2011 that questioned whether TB was being spread from lowincome Houston neighborhoods where it flourishes by passengers riding Houston’s sprawling public bus system. During interviews with those TB patients riding the buses, they found the majority of those with the disease were African-American men between the ages of 40 and 59, 44 percent of whom had been in the Harris County Jail.
Some people arrive sick when they get to jail, Graviss and other experts explained, but others could fall ill in an unhealthy environment that includes high numbers of active tuberculosis cases compared to other large Texas jails.
In 2013, when its 23 reported cases were more than all Texas prisons combined, more than 10 percent of the 28,161 inmates given a TBskin test did not stay in the jail long enough for a nurse to do the required follow-up observation, key to determining if the inmate had been exposed to the deadly disease. Graviss worries the inmates could have left the jail with an active TBcase, leaving health workers to perform the difficult task of tracking a diseased inmate and making sure he takes his medication. In fact, that year 20 percent of the jail inmates who were released could not be located by city health workers to continue their treatment, city health officials confirmed.
He and other public heath experts advocate transition to using a more reliable TB screening blood test, because it avoids a sub-
jective reading — using a ruler — of the reaction by a health worker days later. The blood test results, by contrast, are completed in 24 hours. The blood test also prevents a false positive in people who have had received a vaccine to prevent TB.
However, each blood test costs between $25 and $35, increasing the initial amount of money spent by the county jail on TB testing.
Graviss argues that the cheaper approach taken by Harris County could endanger inmates and contributes to the spread of the disease among the public.
“Of course you should be screening, and they do that at the jail, but the problem is they have so many people in and out of there so fast and they can’t keep up,” said Graviss. “So they need a better screening methodology or protocol so they can screen them fast.”
Garcia said inmates often come into the jail with preexisting conditions, some so sick that they require almost immediate transfer to local hospitals. They are not always forthcoming or truthful about their medical conditions, he said.
“It goes back to the issue of when you come into a jail, people may not tell you exactly what they’re complaining about,” Garcia said. “It’s not until you find them unresponsive that you find out what they were contending with.”
One of his most important accomplishments, he noted, has been the digitization of all medical records in the jail, a multiyear endeavor funded by about $6 million in federal stimulus dollars, streamlining initial screenings and treatment.
BBB Patrick Green, 27, a Baylor University graduate, had struggled with a heroin addiction but was otherwise healthy when he first went to Harris County Jail in December 2014 for violating the terms of his deferred adjudication for two earlier drug charges.
He died at Ben Taub General Hospital on March 24, after falling ill from bacterial meningitis in his cell block. His mother, Kathryn Green, a staff attorney with the 14th Court of Appeals in Houston, said hospital and EMS records do not indicate that her son had received any medical treatment for the bacterial infection while he was in jail. However, the family has not been able to review their son’s jail medical records because the Harris County attorney is withholding them, claiming an exemption under Texas open records law for “possible litigation.” When requesting the records, the family told officials they were considering a lawsuit.
Records show he and other Harris County inmates have died in jail from a variety of treatable infections, including swine flu, sepsis, peritonitis and pancreatitis. Bacterial meningitis, which can quickly become fatal, responds to antibiotics. Death can be averted if treatment is begun promptly, said Randall Kallinen, a civil rights attorney the family hired to obtain Green’s medical records.
“We’ve heard he was feeling ill and couldn’t get off his bunk,” his mother said. “In fact, that is why the cell mate asked the jail personnel to come take him to the infirmary, because he was not able to get out of his bunk.’’
An inmate death report filed by sheriff’s officials with the Texas Commission on Jail Standards stated Green was taken to the jail infirmary at 7:25 p.m. that day after cell mates alerted jailers he was incoherent and could not get out of his bunk. There was no medical treatment noted by jail officials on the report, which they filed March 26.
An ambulance was called to the jail an hour later, and Green was driven to Ben Taub ,where he went into cardiac arrest at 11:20 p.m. and was pronounced dead a minute before midnight, the report states.
BBB Andre Bonier was found dead in the mental health unit at the Harris County Jail early one morning in October 2014 from what appeared to be natural causes.
The 52-year-old suffered from bipolar disorder and schizophre- nia since he was a young adult. Homeless, he was in and out of jail.
At first, his death did not seem suspicious.
Then, in September, two jail medical workers were charged with felonies for falsifying records that showed they’d checked on Bonier in his solitary cell the day of his death — monitoring required by state rules.
Suddenly, the circumstances surrounding his death were anything but routine, raising questions about both the mental health and medical care he received.
Bonier’s mental illness — the cause of his erratic behavior — often led to him living on the streets of Houston, taking shelter beneath freeway overpasses, his family said. He was arrested in February 2013 by Metro Police Department officers for trespassing, interfering with the duties of a public servant and harassment of a public servant. After four months in the jail, a judge found him incompetent to stand trial and had him admitted to the Harris County Psychiatric Center. By August, his competency had been “restored,” although he stopped taking his medications once he returned to the jail, court records show.
In November 2013, he pleaded guilty to the harassment charge and was sentenced to two years in state prison. But before he was transferred from the jail, he was charged in January 2014 with assaulting a detention officer. Again, Bonier was found incompetent to stand trial, and he again was admitted to a psychiatric center.
Once more, his competency was restored. Bonier was sent back to the jail, where he again stopped taking his medications, forcing prosecutors in September to seek another court order asking him to do so. A little over a month later, he was found dead at 5 a.m. in the mental health unit on Oct. 14, 2014, according to his autopsy. The medical examiner determined that he died of acute pancreatitis — a sometimes severe but treatable condition that his brother, Michael, fears went undiagnosed for too long.
“My brother died by himself, and that was my worst nightmare. He suffered a horrible death,” he said, questioning why his brother was not hospitalized. “I think since he was listed as homeless, they didn’t care. They didn’t do anything; they didn’t check him.”
BBB About 2,200 inmates at any given time taking psychotropic medication in Harris County Jail. Sheriff Hickman recently increased the number of mental health beds from 290 to 404. Still, the Justice Department has expressed ongoing concerns about how the mentally ill inmates are housed. The department also has requested that the jail cease the practice of charging inmates small co-pays for mental health care.
Overall, 23 inmates who died in jail between 2009 and mid-2015 had either a confirmed mental illness or had their competency questioned at some point, representing 31 percent of those who died in custody, according to court records and autopsies.
“We could use a [mental health unit] of 3,000 beds,” said Garcia, who acknowledged the jail remains woefully short of space for the mentally ill.
Garcia said he made strides in mental health care, noting that enhanced training for six sergeants and 124 deputies assigned to the mental health unit won the department the top award in 2013 from the National Commission on Correctional Health Care.
Overall, Garcia said his administration was able to cut costs in appropriate areas of medical care — using generic medications whenever possible, for example — and reinvest the savings into other medical services and more full-time staff. The move to generic drugs alone saved $3 million, he said,
“All these things, no doubt, helped us a great deal,” Garcia said. “Did it prevent and solve everything? No. But it did create a better environment than the one I inherited.”