State waited 2 years to tell nursing board that inmate nearly died
7 weeks later, after news report, board processed complaint
MADISON - Gov. Scott Walker’s administration waited more than two years to tell the state Board of Nursing about a 14-year-old inmate who nearly died when nurses didn’t get him to a doctor for three days, according to state agencies.
Once the complaint was filed in July, the Board of Nursing — which itself is overseen by the Walker administration — waited seven weeks to process it, according to the board. Officials entered the complaint
into the board’s electronic system on Tuesday, the first business day after the Milwaukee Journal Sentinel published an article about the February 2016 incident.
Registered nurses at the state’s juvenile prison, Lincoln Hills School for Boys, gave the teen Sierra Mist, Gatorade and crackers for days when he was repeatedly vomiting because his appendix was at risk of bursting. A doctor who performed surgery on him called the nurses’ actions inexcusable and said they should have known to get him to a doctor three days earlier.
A spokesman for Walker’s Department of Corrections wouldn’t say why the agency held off seeking the review for 30 months. Likewise, Board of Nursing officials did not explain why the board waited a month and a half to process the complaint.
“Our internal goal is to process complaints within 30 days. This is an example of not meeting that goal,” said Nate Ristow, the assistant deputy secretary at the Department of Safety and Professional Services that provides staff from the Board of Nursing.
Jeff Roman and Sharlen Moore, co-founders of the group Youth Justice Milwaukee, said the situation shows why the state should keep young offenders in their own communities instead of a rural prison more than 200 miles from Wisconsin’s largest city.
“Again and again, we hear stories that prove that for young people, simply being at Lincoln Hills is a risk to their lives,” they said in a statement. “This case proves that any institutional setting simply cannot adequately keep young people safe — and in this case, it almost couldn’t keep one young man alive.”
Walker and lawmakers this spring agreed to an $80 million plan to close Lincoln Hills and Copper Lake School for Girls, which sit on the same campus north of Wausau. The facilities are to be shut down by 2021 and replaced with smaller regional facilities.
Walker and legislators finalized their plans just after Walker’s administration agreed to pay nearly $19 million to a Copper Lake inmate who was severely brain damaged after she hanged herself and guards didn’t check on her as soon as they were required to.
The prison complex has been under a criminal investigation for prisoner abuse and child neglect for more than three years.
Treatment delayed
The boy with appendicitis was taken to a hospital for emergency surgery on Feb. 12, 2016, after he had repeatedly told nurses he was vomiting, rated his pain a nine on a scale of 10 and collapsed in the bathroom in the prison’s medical unit.
That spring, prison officials fired nurse Kitty Hasse over several incidents, including the one involving the boy with appendicitis. Hasse did not see the boy and told internal investigators she repeatedly tried to get him to the nurse’s office the day before he went to the hospital; other staff disputed parts of her account.
The prison superintendent at the time, Wendy Peterson, did not discipline the three nurses who saw the boy in the days before he went to the hospital.
Peterson and her aides — as well as top officials at the Department of Corrections — also did not alert the Board of Nursing at the time. Department of Corrections spokesman Tristan Cook didn’t say who was responsible for that decision.
The agency alerted the Board of Nursing to the matter through Walker’s Department of Safety and Professional Services this July 16, Cook said. That was after the Journal Sentinel asked about the incident and sought copies of documents under the state’s open records law.
“Any delay in referring staff who have violated work rules is not acceptable to us and Secretary (Cathy) Jess has directed department staff to ensure that referrals are submitted on a timely basis as investigations are completed,” Cook said in a statement.
Ed Wall was secretary at the time of the incident and John Litscher was secretary when the internal investigation of it was completed in May 2016. Jess was Litscher’s top deputy and took over as secretary this June.
Cook stressed that the Department of Corrections has taken a number of steps in recent years to address problems at Lincoln Hills, including providing more mental health services to inmates, establishing more oversight of medical care and placing a nurse practitioner at the facility 40 hours a week.
Lincoln County District Attorney Galen Bayle-Allison in 2017 decided not to charge anyone over the incident, in part because the state’s child negligence law at the time required prosecutors to prove criminal intent — a standard he said he could not meet.
In addition to Hasse, the nurses who had some role in the matter were Kurt Dieter Bartz, Corey Brandenburg, Paul Fretschel and Laurie Ramsey.
The Department of Corrections did not allege any particular nurse did anything wrong and called its filing a referral. The Board of Nursing called it a complaint.
Two days before the boy was taken to the hospital, Bartz recorded the boy’s pulse rate was above 120 beats per minute, a level that requires Department of Corrections nurses to contact a doctor or nurse practitioner. Bartz didn’t do that, according to department records.
Brandenburg decided not to contact a doctor the next day, when the boy’s heart rate remained elevated, he fell in the bathroom and he refused to eat. The day after that, the boy was found covered in vomit in his cell and Ramsey helped get him to the hospital for emergency surgery.
Fretschel saw the boy three days before he went to the hospital and helped Brandenburg a day before the boy went to the hospital when he fell in the bathroom at the nurse’s station.
Fretschel said Friday he was confident he treated the boy appropriately. He said he thought the 2016 internal investigation was handled appropriately and there was no need for the administration to go to the Board of Nursing now.
“I think they’re just trying to cover their ass,” he said. “They’ve never been proactive about anything. Now they’re trying to make themselves look less bad.”
Fretschel, who is now retired, said it’s difficult to treat juvenile offenders because they sometimes lie about their condition.
He dismissed the comments of the doctor who treated the boy and said he didn’t see anything that he considered an obvious sign that the boy needed to be seen by a doctor.
“She may be a good surgeon, but she doesn’t know jack about working with these kids,” Fretschel said.
Bartz, Brandenburg, Hasse and Ramsey did not respond to questions from the Journal Sentinel.
Doctor decries treatment
The doctor who performed emergency surgery on the boy, Kristen Wells, in 2016 told a Lincoln County Sheriff’s Office investigator that the treatment of the boy at Lincoln Hills amounted to “absolute incompetence” and was “what we call it in the hospital setting ... ‘failure to rescue.’ ”
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.
Wells did not specify which nurses she thought acted inappropriately and she has not responded to questions from the Journal Sentinel.