Lincoln Hills nurses didn’t get gravely ill teenager to hospital
Inmate with appendicitis given crackers, Sierra Mist for days
MADISON - Nurses at the state’s troubled juvenile prison failed to detect for three days in 2016 that a 14-year-old inmate’s appendix was about to burst and gave him crackers and Gatorade instead of rushing him to a hospital — putting him at risk of dying, records show.
Prison officials fired one nurse over the situation but didn’t discipline others, including a nurse who failed to contact a doctor about the boy even though he should have under Department of Corrections policies because his pulse was so elevated.
The doctor who performed emergency surgery on the inmate said she saw widespread problems with the way he was treated at the prison.
“I mean, if this had happened at the hospital, I would demand that the nurse be fired for absolute incompetence,” physician Kristen Wells told a sheriff’s investigator without naming the nurse she was referring to. “She has no idea what she’s looking at. What we call it in the hospital setting is ‘failure to
rescue.’ ”
The inmate’s medical care at Lincoln Hills School for Boys was so poor that parents without a medical background would have gotten him to a hospital days earlier, Wells told an investigator with the Lincoln County Sheriff’s Office. Even parents who lacked insurance or feared getting in trouble with immigration authorities would have gotten the boy to a hospital by Feb. 11, 2016, a day before Lincoln Hills officials did, she said.
“Even if they’re paying cash and they’re worrying about getting deported, (their) sick kids are still in by the 11th,” she told the investigator in reports released to the Journal Sentinel under the state’s open records law.
The incident is the latest to come to light at the juvenile prison complex north of Wausau. Lincoln Hills and its sister facility, Copper Lake School for Girls, have been under criminal investigation for more than three years for child neglect and prisoner abuse.
Gov. Scott Walker and lawmakers in March decided to close the prison by 2021 and spend $80 million to replace it with smaller, regional facilities. That deal was finalized amid multiple lawsuits and after Walker’s administration agreed to pay $18.9 million to a teen inmate who was severely brain damaged in 2015 when guards did not check on her when they should have and she hanged herself in her cell.
Treatment sparked criminal probe
Lincoln County District Attorney Galen Bayle-Allison in 2017 reviewed the sheriff’s investigation into the medical treatment of the boy but declined to prosecute anyone. Bayle-Allison on Friday noted that Wisconsin’s child negligence law at the time required prosecutors to prove criminal intent, and he said he could not do that in this case.
The boy was first seen on Feb. 6, 2016, according to the sheriff’s reports and Department of Corrections documents.
On Feb. 9, 2016, the inmate vomited eight to 10 times and was bent over when he walked. Nurse Paul Fretschel checked him and gave him Sierra Mist.
Wells, the doctor who later operated on him, told an investigator the boy should have been seen by a doctor at that point.
On Feb. 10, the boy — who is not named in the documents — was unable to straighten his legs, likely because he was in so much pain. Wells told the sheriff’s investigator that sending the inmate to the hospital that day was a “no brainer.”
Nurse Kurt Dieter Bartz that day found that the inmate’s pulse was above 120 beats a minute — a level that requires Department of Corrections nurses to contact a doctor or nurse practitioner. He didn’t do that and instead told the boy to drink Sierra Mist and snack on crackers.
Nurse Corey Brandenburg saw the teen that evening and told him to take heartburn medication, drink Gatorade and eat crackers.
On Feb. 11, the boy was lethargic, had a fever and had severe abdominal pain. The teen went into the bathroom in the nurse’s office and 20 minutes later called for help when his legs went numb and he fell on the floor. Brandenburg and Fretschel got him off the floor and Brandenburg assessed him and gave him Gatorade and crackers again.
The boy was sent back to his cell, where he refused to eat his food because he said he was just going to throw it up anyway. He asked to speak to security Supervisor Clyde Maxwell, who talked to him and determined his problems were the result of “peer issues.”
Maxwell briefed Brandenburg on what happened. Brandenburg “thought he maybe should have called the on-call provider” at that point, in part because the inmate’s pulse rate was high, according to sheriff ’s office records.
Instead, Brandenburg decided to arrange to have the inmate seen by another nurse the next day.
The next morning, Feb. 12, the boy’s cell was covered in vomit and guards rushed him to a hospital in Tomahawk and then another one in Rhinelander, where Wells performed surgery.
“Wells stated this was an emergency situation and (the inmate) could have died if untreated any longer,” a sheriff ’s report says.
Wells had to consult with a pediatric surgeon at the University of Wisconsin Hospital in Madison and within three days the inmate had to have another surgery, according to sheriff ’s office records.
Inexcusable response
When she talked to the sheriff’s investigator, Wells compared the Lincoln Hills nurses’ treatment of the boy to how a parent would have handled it.
“A parent in this situation could have been excused on the 9th,” she said. “The nurse shouldn’t have been. The nurse should have been on top of it and on the 10th, nobody gets excused. The kid’s sick at this point. At this point, the only parents that don’t bring in the kids, they’re afraid of insurance issues. They’re afraid of immigration issues and everybody brings them in on the 11th regardless.”
Wells, who did not respond to interview requests from the Journal Sentinel, was referring to treatment provided by Fretschel, Brandenburg and Bartz — none of whom were disciplined by Walker’s administration. It is not clear from the sheriff ’s report who Wells was referring to when she accused one nurse of “absolute incompetence.”
Full details about the boy’s medical condition is blacked out in the records, but two people familiar with the case said he had appendicitis. In her interview with a sheriff ’s investigator, Wells extensively discussed how the appendix works and what can go wrong with it.
“Eventually, you will succumb to the infection, and that’s exactly what was happening with him,” she said of the teen.
On Feb. 11 Lincoln Hills staff tried for hours to get the inmate to the prison’s health clinic. Staff members disagreed over who held up getting him medical attention that day and whether he was supposed to see a doctor or just nurses.
Guard Jamie Malone told internal investigators she called the nursing unit twice that day to try to get the boy to a doctor but was told he wasn’t scheduled to see one.
Supervisor John Holzinger told internal investigators the inmate “did not look healthy” and “was hunched over, walking strangely and was holding his stomach.” Holzinger said he was told the inmate would be seen by a doctor and was surprised later when he hadn’t been taken there.
Nurse Kitty Hasse told investigators she tried to get the boy to the prison’s health clinic throughout the day, but guards said they were too busy to get him there earlier. Hasse and the other nurses disagreed about what time the inmate got to the clinic that day.
Wendy Peterson, who was superintendent of the prison at the time, fired Hasse in May 2016 over the situation and three other incidents. In the other cases, Hasse was accused of not assessing an inmate who swallowed part of a plastic spork; not checking on a teen inmate who was deliberately pounding her head against a wall; and not providing adequate care for another inmate who had injured herself.
That same month, Peterson sent letters to Fretschel, Bartz and Brandenburg telling them that “no formal disciplinary action will be taken against you” for their work in February 2016.
Internal investigation reports show Bartz and Brandenburg had not completed their work orientations at the time, even though Bartz had been on the job for four years and Brandenburg for 10 months.
Department of Corrections spokesman Tristan Cook said the nurses involved were given additional training, but he could not discuss the matter in detail because of medical privacy laws. He called the internal investigation “comprehensive and thorough.”
Cook called Hasse’s behavior “unacceptable,” but did not criticize Bartz or the other nurses involved.
Cook said since the incident occurred, Lincoln Hills has made doctors available at the prison more often; improved notification to parents and outside agencies when inmates are injured; implemented electronic medical records; and assigned a nurse coordinator to oversee all medical care provided to teen inmates.
Hasse declined to talk about the incident and Bartz and Brandenburg did not respond to interview requests. Fretschel, who is now retired, defended his handling of the matter.
“I don’t think anything was done wrong,” he said. “I have always been proud of the health care we provided at Lincoln Hills. I believe we provided a level of care greater than what the community would have provided.”