Sun Sentinel Palm Beach Edition
Sun Sentinel investigates
DEATH ON THEIR WATCH Some withered away in cells. Others hanged themselves. Broward jail officials have failed to protect some inmates endangered by their mental illnesses
William Herring told his caretakers at a Broward County jail that God would tell him when he could eat. Then the young man starved himself to death before their eyes.
He was 23, struggling with bipolar disorder and schizophrenia, and had been arrested for sleeping on a bus stop bench. He was kept alone in a cell where he refused to take his mental health medicine, eat or drink, at one point losing 18 pounds over 15 days.
As his health declined, jail medical staff sent him to a psychiatric clinic and a hospital, where he received mental health medication over his objection. But no such efforts were made when he returned to the jail.
The day before he collapsed and fell into a coma, a jail nurse made this notation in her log: “Dazed stare. (Right) eye had a tear in the corner.”
The medical examiner ruled Herring’s December 2012 death a suicide by fasting, influenced by his mental illness.
Just five months earlier, another mentally ill man had died after withering away in isolation at the same jail.
Armor Correctional Health Services of Miami, the private company paid to handle jail health care, has failed to protect some Broward inmates endangered by their mental illnesses — with deadly consequences, a Sun Sentinel investigation has found.
An examination of inmate deaths since
2010 and a review of thousands of pages of court, medical and jail records shows:
Armor has left severely mentally ill inmates unmedicated and malnourished, despite having the authority to help them. Lack of medication can worsen mental health symptoms, leading mentally ill people to not eat and to harm themselves.
Despite longstanding concerns about the impact of isolation on mentally ill inmates, seven killed themselves or suffered dramatic weight loss while being held alone in cells.
Armor staff acknowledged mishandling the care of at least four mentally ill inmates before their deaths.
Though the Sheriff’s Office pays Armor $25 million a year in taxpayer money to provide health services in the jails, Armor does not share its death investigation reports with the Sheriff ’s Office.
County taxpayers since 2004 have paid more than $1.5 million for federal court monitoring of Broward jails. Yet attorneys appointed to oversee the jails weren’t aware of Herring’s death until the Sun Sentinel inquired about his case.
Court-ordered monitoring of Broward jails was supposed to improve medical care for inmates when it began nearly four decades ago, after inmates complained of crowding and mistreatment.
Lt. Col. Keith Neely, the director of detention for the Sheriff ’s Office, said jail conditions have improved and monitoring is no longer needed. He said in an earlier interview he has no complaints about Armor’s care.
“Is it perfect, does everything work the way it should work every day? Probably not,” Neely said. “But I’ll tell you what, it’s pretty close.”
Armor declined to make medical officials available for an interview. And Dr. Dana Tatum, the company’s chief behavioral health officer, did not answer written questions about the company’s care of mentally troubled inmates, issuing a statement instead.
“Our professionals are regularly tasked with the unappreciated job of caring for those that the community and their families have abandoned,” Tatum said in the statement. “Those professionals do this job every day to a standard beyond what can be found in the public health system.”
Problems persist
About 40 percent of the inmates in the county’s four jails are on mental health medication. As of mid-November, about 3,900 inmates were in the jails, according to records.
Most inmates on medication are sent to the North Broward jail in Pompano Beach. They live in open cells with three beds and no door, or in closed single-person cells with doors that can be locked if an inmate is violent or vulnerable. Those at risk of suicide are put in isolation cells in the jail’s infirmary or in an open area where they can be watched constantly.
Their health care is entrusted to Armor, which employs nurses, doctors and other medical staff who work in the jails. Armor staff members screen incoming inmates for mental and physical health concerns, monitor them during their stay, and prescribe and distribute medication.
In a statement Saturday afternoon, Armor estimated that in the past decade it had screened 543,000 people, had 462,000 mental health encounters and admitted 59,000 patients to its in-house infirmary.
“The reality is the high quality care at the jail has been a safety net for the county, largely unappreciated except by the many who would have perished if not for the care and treatment they received at the jail,” the company said.
The treatment of mentally ill inmates has been a key part of federal monitoring of Broward’s jails, which began in 1979. But it has been 10 years since monitors brought in a mental health expert to examine conditions at the jails, once a common occurrence.
Colorado psychiatrist Jeffrey Metzner evaluated mental health care multiple times in the 2000s, filing his last report in 2006. That last visit was the first time Metzner reviewed Armor, which took over Broward’s jail health care contract in 2004.
Metzner said in his 2006 report that Armor was handling mental health care better than the prior company at Broward jails, but issues remained.
Jail medical staff did not have timely follow ups with psychotic inmates, especially if they regularly refused medication, he wrote. He also found that medical treatment plans did not address what to do when inmates refused medication.
Those problems continued, the Sun Sentinel found.
“We’ve given up”
Under state law, people have a right to refuse medication and treatment unless there is imminent danger to themselves or others. When the threat is less immediate, as with a mentally ill inmate who refuses to eat or take medication over an extended period, a jail’s medical staff can ask a judge to intervene and order treatment.
John Martin, an Armor psychiatrist, estimated in a 2015 deposition that, on any given day, at least 30 inmates have psychiatric symptoms so severe they cannot consent to medication: “... they are people who need help. They need to be treated.”
Martin said in that deposition Armor staff quit asking judges for assistance with such inmates after repeated rejections: “We have failed. On numerous occasions. So we’ve given up.”
But the Sun Sentinel found no evidence to support Martin’s claim that judges had rejected Armor’s requests to authorize mental health treatment for inmates who needed help, but were too sick to realize it. Court records show only one such request from Armor, and it was approved within 24 hours. That was 10 years ago.
“For someone to see a clinical condition they’ve been trained to recognize, to realize that with treatment the condition can be improved and to not pursue the legal remedy is negligent at the very least,” said Dr. Robert Trestman, a University of Connecticut professor and expert in psychiatric care in correctional facilities.
Martin declined to speak to a reporter and Tatum did not address questions about Martin’s deposition.
Jail medical staff also could ask for a guardian to make medical decisions on behalf of an inmate who is not fit mentally. Armor spokeswoman Yeleny Suarez said the company does not track how many times it has asked a court to appoint a guardian for an inmate. In its review of petitions filed in court, the Sun Sentinel found no evidence the company has requested a Broward judge to do so.
Maria Ann Brooks, an Armor clinical coordinator for behavioral health, was asked in a 2015 deposition if her company had requested guardian advocates for any Broward inmates between 2008 and 2013. She said the company had not, and would request a guardian only in an emergency.
When asked if Armor has a policy to provide care for someone who needs prolonged help, she replied: “We’ve never experienced someone needing long term treatment . ... We’ve always been able to keep someone safe.”
Starved himself to death
Kathy Kaether knew her son might harm himself based on what he thought God told him to do. The talks with God about fasting were a symptom of his mental illness, and she worried his health was in danger.
Kaether said she contacted a nurse at the North Broward jail. She recalled the nurse’s answer: “We’re just as concerned as you are and we don’t want anything to happen to him either.”
Herring grew up in Deerfield Beach and began showing signs of bipolar disorder as a teenager, Kaether said. He would get paranoid, have unusual mood swings and obsess over things, especially politics. He wanted to study political science and had taken classes at Palm Beach State College before he was arrested for burglary in 2011.
He was on probation when he was arrested again, for sleeping on a Fort Pierce bus bench in October 2012. Though the offense was minor, he was ordered held without bond in the Broward jail because he had violated his probation.
During Herring’s nearly four weeks in custody, jail medical staff repeatedly noted his refusal to take his medicine and eat. Despite his declining health, the staff ’s treatment orders reflected little urgency: Continue to monitor. Offer food and fluid. Continue suicide watch.
People in jail who are mentally ill need to be given treatment rather than be allowed to fast in a way that harms their health, according to the World Medical Association, an international organization that provides ethical guidelines to physicians.
“The fact that a 23-year-old man starves to death in the 21st century in jail is outrageous,” said Broward County Public Defender Howard Finkelstein, who was unaware of Herring’s case until he was told by the Sun Sentinel. “There is no explanation for that. None.”
While Armor has declined to seek court assistance to treat inmates over their wishes in the jail, the company has sought help outside the jail via the state’s Baker Act, which allows people to be held involuntarily in a psychiatric facility for up to three days if they are a threat to themselves or others.
After five days in jail, Armor sent Herring to a psychiatric crisis center. Medical staff at Henderson Behavioral Health noted he was uncooperative, fasting and refusing medication during his three days there. They sent him back to the jail with no medication, according to Henderson records.
After another week of refusals, Herring became so dehydrated, jailers sent him to Broward Health North in Deerfield Beach, where a doctor declared him a danger to himself and ordered a shot of the antipsychotic medication Haldol every eight hours for two days.
“The gentleman is critically ill and will need to be monitored closely in the intensive care unit,” another doctor
wrote, according to medical records.
After six days, hospital staff recommended Herring be discharged to a psychiatric facility, according to medical records. But a sheriff’s deputy said Herring needed to return to the jail’s infirmary.
Back in jail, Herring again refused medication, food and drink and was put back in isolation in the jail’s infirmary. Martin, the jail psychiatrist, did not give him an emergency injection, as doctors at the hospital had done. After three days, Martin wondered if Herring might get help at a hearing the following day.
“Perhaps the judge will Baker Act him to a facility where he can be treated medically (and) psychiatrically,” Martin wrote.
Herring collapsed before the Nov. 16 hearing and spent the last five weeks of his life in a coma at Broward Health Medical Center in Fort Lauderdale.
A judge released Herring from custody on Nov. 21 while he was on life support. That enabled Kaether to freely visit her son, and relieved Armor and the Sheriff ’s Office of the cost of his continued treatment. It also meant the Sheriff’s Office did not investigate the circumstances of his death, because he was not in their custody when he died on Dec. 23, 2012.
Armor apparently didn’t investigate either. In response to a court order in a lawsuit over another jail death, the company turned over investigations from that time period, and Herring’s was not among them.
Armor is responsible to pay up to $50,000 for an inmate’s care at an outside facility, according to the company’s contract with the Sheriff’s Office. The company does not have to pay when an inmate is sent to a psychiatric clinic under the Baker Act or to a state mental hospital after being found incompetent to stand trial.
That means Armor has a financial incentive not to send inmates to outside health care providers, Fort Lauderdale attorney Greg Lauer argued in a federal lawsuit on behalf of the family of Raleigh Priester, another inmate who died.
“They’ve made a promise with the sheriff and the people of Broward County to accept $25 million a year to provide comprehensive health care,” Lauer said. “That means if you have an individual who is not eating because the Good Lord has told him not to eat, you’re not allowed to just stand by and let him die.”
Armor said in its statement on Saturday that it has made about 11,000 referrals for off-site care over the past 10 years.
“The fact Armor has an individual cap totally contradicts any claim the company is incentivized not to provide care,” the company said.
Five months in isolation
An examination of the final days of Priester, 52, reveals how Armor medical staff relied on a severely mentally ill inmate to make decisions for himself, even as he deteriorated before them. Martin, the jail psychiatrist, did not take steps to provide mental health medication although he thought that would likely prevent Priester from suffering.
Priester was arrested in February 2012, accused of throwing rocks at a Fort Lauderdale parking garage employee. Priester, a Fort Lauderdale native, had been ruled not guilty by reason of insanity in a robbery and burglary years earlier. He had been diagnosed with schizophrenia.
Martin recognized early on that Priester was seriously troubled. “He was denying any history of mental illness,” Martin later said in a deposition during the federal lawsuit. “He was denying being on medication. Denying having taken any medication in the past. He was denying everything.”
Priester’s jail medical records show he refused medical care, but it was not always clear how, the Sun Sentinel found. Sometimes he was asleep, did not show up for medication distribution, or was talking to himself. All were counted as refusals.
Martin said in the deposition that he had seen people with schizophrenia not eat if they were untreated, and that Priester could have benefited from taking mental health medication.
“The psychosis would have been controlled. He would have been — the goal would be to get him to be functioning like a normal individual,” Martin said.
Yet Armor doctors did not take steps to get him that treatment in the jail. They could have requested a guardian to make medical decisions for Priester, or filed a court order to give Priester his mental health medication over his objections. They did neither.
Jail medical staff hoped a judge would declare him mentally incompetent to stand trial and send him back to a state mental hospital, where he had spent more than 11 years of his life. But that commitment process can take months.
As Priester continued to refuse medical care, Armor staff noted his declining health. Less than three weeks after he was booked, a nurse found him banging his head on the floor of his cell.
Priester was incarcerated for two months before jail staff tried to send him to a psychiatric facility under the Baker Act.
“... he was likely to be severely harmed by not eating and not taking care of himself,” Martin said of the decision. The facility rejected Priester because of his poor physical health.
Another month passed. Priester’s blood pressure plummeted and he was taken to a hospital on May 22, 2012. Doctors diagnosed him with a blood infection, pneumonia, and ulcers on his feet. Standing 5-foot-11, he weighed about 140 pounds and was malnourished — despite jail staff reports that he regularly ate 75-100 percent of his meals.
After four days in the hospital, he gained about 11 pounds. Four days later, he returned to jail, where he again was left untreated mentally. He also did not get insulin injections — Dr. Stanley Frankowitz, the jail’s medical doctor at the time, said he did not believe Priester had diabetes. He had been diagnosed with the condition during a previous state hospital stay.
“Maybe he was a diabetic at one time before I knew him. I have no idea,” Frankowitz said in a 2015 deposition. He declined to comment for this article.
Priester collapsed in his cell and died on July 10, 2012. He had lost 30 pounds in the month and a half since he was in the hospital, records show, and weighed 120 pounds when he died.
The medical examiner cited heart disease as his primary cause of death.
“If you would have a pet, and that pet was treated the way he was treated as a human being, you would be arrested,” said Priester’s sister, Ceaniel Edwards. “He suffered.”
Edwards, represented by Lauer, sued Armor in federal court and settled for a confidential amount in 2015.
An Armor review concluded that Priester received adequate care in jail. “Perhaps he could have benefited from a closer (follow up) from medical?” the report said.
Troubled but left alone
Kennith Kellum, of Hollywood, had turned himself in on warrants for crimes including drug possession and resisting arrest, fulfilling a promise he made to his dying father.
As he was booked into jail in June 2010, he told an Armor health worker he had bipolar disorder and anxiety. Had the worker noticed the red mark across the front of his neck, she later said in a deposition for a state lawsuit about Kellum’s death, she would have put him on suicide watch.
Instead, jailers sent him to a solitary confinement cell because of past “negative behavior” during a previous jail stay, a detective later wrote.
Twenty-seven hours after he was put in the cell, a deputy found the 21-year-old hanging by his bed sheet.
Suicide is a leading cause of death in jails, and the risk is higher soon after people are booked and while experiencing symptoms of a mental illness.
Isolation of 23 hours a day, as Kellum faced, also increases the risk.
“There’s no question, and there’s lot of data, when you take someone with a psychosis of any kind and put them in solitary confinement it almost invariably gets worse,” said Dr. E. Fuller Torrey, a research psychiatrist and founder of the Treatment Advocacy Center, which pushes for more effective treatment for people with mental illnesses.
The National Commission on Correctional Health Care, which has accredited Broward jails, said in April that mentally ill people should not be in solitary confinement for any period of time, and anyone who is not given meaningful contact with others is considered in be in solitary confinement.
A 1995 jail monitoring agreement states that Broward inmates identified as a suicide risk should not be in a “single occupancy cell” unless they are observed 24 hours a day.
That did not happen for Kellum. He was not identified as a risk despite his mental illness and the mark across his neck — possibly left by a previous suicide attempt, a sheriff’s investigator later concluded. Kellum had “ample time” to hang himself between deputy wellness checks every 30 minutes, the detective found.
“He was aware of the deputies’ procedures, the times shift changes were to occur, as well as how they were conducted,” the detective wrote.
The Sun Sentinel found three other mentally ill inmates who hanged themselves while they were housed alone in cells. One man, who had attempted suicide by overdosing on prescription drugs just before he was booked, hanged himself on his fifth day in jail, according to a Sheriff’s Office investigation. Another had a previous suicide attempt in custody and often refused his mental health medication, Sheriff’s Office records show. The third, a 19-year-old with a history of bipolar disorder, was put in 23 hours of daily solitary confinement a year into her incarceration.
After 13 days, a deputy found her hanging from a bed sheet.
Details not included
Broward Sheriff’s Office investigations do not mention lapses in medical and mental health care detailed in Armor reviews, including delays in medical care and staff breakdowns that preceded inmate deaths.
The Sheriff’s Office reviews inmate deaths to see if a deputy committed misconduct or if a fellow inmate contributed to the death. Those investigations are public.
Armor conducts its own review when an inmate dies to document the person’s treatment and evaluate staff performance, but the company keeps those private, saying they are proprietary and confidential by law.
Yusimir Arencibia, a Sheriff ’s Office-designated health care manager, has access to all Armor inmate medical records except for the death investigation reports. She said she talks often with representatives of Armor and gets all of the information she needs for her own reviews.
But the Sun Sentinel found that critical details outlined in Armor reviews are not always included in Sheriff’s Office investigative reports.
This was the case with Steven Shogan.
Shogan, 30, had schizophrenia and was accused of stabbing a man to death in 2011. The Queens, N.Y., native had been in the Main Jail in downtown Fort Lauderdale for a year when he was moved out of solitary confinement on Jan. 1, 2013. Two weeks later, he hanged himself.
What the Sheriff’s Office investigation does not say: For the 12 days before he died, jail nurses failed to give Shogan his medicine, an oversight documented in Armor’s report.
Other confidential Armor reviews obtained by the Sun Sentinel acknowledge lapses unmentioned in Sheriff ’s Office investigations into inmate deaths: at least a 24-hour delay in seeking a higher level of care for a man who later died from a heart attack and blood infection, and a man with a head injury left untreated for days.
Suarez, the Armor spokeswoman, did not answer the Sun Sentinel’s questions about whether any Armor employees were disciplined in these cases, saying the company does not comment on employee matters. The newspaper found no mention of discipline or policy changes in Armor’s confidential reviews.