AG's Davis jail death investigation reveals possible missteps, lack of urgency

Wednesday , May 10, 2017 - 6:53 PM

MARK SHENEFELT, Standard-Examiner Staff

FARMINGTON — Paramedics complained they were denied rapid access to an inmate who lay critically injured in the Davis County Jail and later died, an investigation by the Utah Attorney General’s Office discovered.

Then, after Heather Ashton Miller was pronounced dead Dec. 21, 2016, at McKay-Dee Hospital due to a torn spleen, a jail official rebuffed a Davis paramedic’s urging that an in-custody death investigation be started, according to the reports, obtained through a public records request.

RELATED: Weber detectives: Davis jail staff tainted crime scene after inmate's death

READ MORE: Investigating jail deaths in Northern Utah

The investigation into Miller’s death found a series of missteps, miscommunications and possible policy deviations among jail deputies and nurses after Miller, 28, fell from the top bunk in her cell — plus an allegation by one jail guard of a “lazy” response by medical staff.

But even so, the Utah Attorney General’s Office announced April 28 it would not file criminal charges against jail guards or medical personnel. The state investigated Miller’s death at the request of the Davis County Attorney’s Office after an initial investigation by the Weber County Sheriff’s Office.

The state probe punctuates a wave of controversy over a rising number of deaths in Utah jails. In deaths at jails per capita, Utah leads the nation.

Chase Harvey, one of two Davis County deputy paramedics who responded to the 911 call about Miller, told investigators he phoned ahead to jailers, asking they bring Miller to the jail entry “so they could just load her into the ambulance and head off to the hospital.”

In his interview with investigators, Harvey said he called ahead because he knew the normal process of deputies checking in their police gear and walking to the medical unit would take at least five extra minutes. But he said they were told to “just respond to medical.”

“Chase said that, in hindsight, the extra time this would have saved probably would not have made a difference because of Ms. Miller's condition, but he was still frustrated with this response from the jail,” the investigator wrote in his report.

Harvey said when they finally reached Miller in the medical wing, Harvey “immediately knew that she was not in good shape,” not breathing well and her pupils not responding to light.

The paramedic said he was further surprised that jailers handed them a form requiring Miller to appear in court as a condition of her release. The investigator wrote that a jailer “told them to make sure Miller got it, even though she was in bad shape. This frustrated Chase.”

Reports said the other paramedic, Deputy Nicholas Pollock, “expressed his general frustrations with the incident, which were that it seemed that the jail staff seemed to lack a sense of urgency in this case and that he was frustrated that they would not bring the patient to the sally port area for treatment, which could have given them more treatment time with the patient.”

Harvey was with his supervisor, Sgt. Claine Hawkins, at McKay-Dee Hospital when Hawkins called the jail to report Miller probably was not going to survive “and they needed to initiate proper response for in-custody death investigation. Sgt. Hawkins was told that the patient didn't pass away in custody and that they didn't need to worry about it.”

THREE FALLS, TWO SCREAMS

Investigators reported Miller fell three times in the jail — from the bunk to the cement floor, a 5-foot drop; again when she tried to stand up after the first fall; then two hours later, after she had been moved to a cell with an open lower bunk.

The first fall drew an immediate response from other inmates and a guard doing rounds nearby. The fall made a loud noise, followed by Miller’s scream. Other inmates told investigators they heard another scream two hours later in Miller’s second cell.

Investigators said the third fall apparently caused a cut on Miller’s chin.

The attorney general’s investigation delved into step-by-step interactions with Miller by jail nurses and guards.

Nurse Marvin Anderson checked Miller in her cell after the first fall. Anderson said Miller “didn't act as though she was in much pain,” an investigator wrote.

In another interview, a jailer who responded to the first fall, Cpl. Tracy Johnson, said Miller “was grabbing her side and saying ‘it hurts.’"

Anderson said he told Miller they would take her to another section to have a bottom bunk. She put her shirt on and looked at her hair in the mirror, Anderson said, according to the report.

“He said that throughout the interaction in the cell she didn't act as though she was in pain.”

The nurse told investigators he asked Miller if she was coming off drugs, and she said “meth.” As they helped her out of the cell, she said she was dizzy and nauseous. He went to get her a wheelchair, but when he returned, she was scooting down the stairs on her backside, one step at a time, the reports say.

“Marvin felt that she was probably coming off of drugs. He took her to the Lima pod and asked her to tell him if things got worse and she told him ‘OK,’” the investigator wrote.

The nurse said he has a “jump bag” with first aid equipment, “but he didn't take it with him because he didn't know how injured Miller was when he was called. Marvin said Miller did not have any visible marks anywhere and she didn't respond to any touching with indication of pain.”

DIFFICULT TO DIAGNOSE

Miller’s spleen injury would have been difficult to diagnose in the jail, State Medical Examiner Erik Christensen said in his interview with attorney general’s investigators.

“There is some indication that the blood tried to clot, but the severity of the injury made it impossible to clot completely and that, without medical care, the injury was fatal,” the report said.

A ruptured spleen is typically diagnosed with an ultrasound, a blood count or surgery, Christensen told investigators.

“None of these things would have been done by a nurse at a jail,” he said. “Internal injury is often difficult to diagnose through an external examination because the patient often does not know where the pain is.”

Anderson told investigators he and Johnson agreed Miller could be housed in the Lima unit, a maximum security area, but they didn’t think she needed to go to the medical unit, which had a bed open.

“He didn't look at Miller as though she was suffering from any trauma,” the investigator wrote. “He and the other staff members believed she was withdrawing. Marvin said that typically an inmate taken to the infirmary is visibly sick or injured.”

Story continues below the photo.

‘WE NEED TO GET HER OUT OF HERE’

Down in Lima, Johnson said when Miller was brought into the second cell, “she looked out of it and looked like someone on heroin who is nodding out.”

After 8 p.m., Deputy Zackery Lloyd walked by Miller’s cell and saw she was naked from the waist down and was lying with one leg on the toilet. She had blood on her chin.

Lloyd told investigators he then walked into the unit control pod to call the medical unit. He said he talked to nurse Dan Layton and was asked if Miller was “moving and breathing.” Lloyd said she was, and Layton told him to “keep an eye on her.”

Lloyd told the investigator, "I wanted them to come down and look at her," but didn't explicitly ask.

The deputy said he got another jailer, and they went back to check on Miller. The inmate was cold, sweating; her hair was soaked and her skin was pale.

Sgt. Roberta Wall responded to the cell and said they needed to take Miller to medical. While one deputy went to get a wheelchair, Wall and Johnson tried to get Miller to put on some clothes.

Miller was “moving but not responding,” so they covered her with a blanket and the four deputies wheeled her to medical.

Johnson said Anderson met them at the door of the medical unit and was surprised by Miller’s worsened condition.

“We need to get her out of here,” the nurse said, and Wall called for paramedics.

‘JUST NOT THINK TOO MUCH ABOUT IT’

Austen Rogers, who was working in the pod control room that night, told an investigator he was “the talk of the jail” because in his own report of the incident he “basically called the nurses out for being lazy,” according to the reports.

Rogers said it was “weird” that a victim of a fall who was having a hard time walking was made to scoot down stairs on her backside.

“He felt that something was wrong, and if she couldn't walk or stand, she should have gone to medical,” the investigator wrote.

The reports say when Lloyd later called medical from the control room pod to report the cut chin, Rogers said he heard Lloyd ask a nurse on the phone, “So I should just not think too much about it," and was told, "Yeah."

James Ondricek, jail nursing supervisor, told investigators that jail nurses respond to reports of falls from a top bunk about once a month. He said he had never before seen an internal injury from such a fall, according to the reports.

He said he would expect the responding nurse to check for visible injuries, most commonly head injuries, the reports say. If there are no visible injuries, they will "monitor them," including checking vital signs.

Ondricek said the decision to move an inmate to medical for further observation would be made by the watch commander, although medical staff can advise or recommend movement, according to the reports.

DEFINITION OF CRIMINAL NEGLIGENCE

State investigators concluded it did not appear the conduct of jail guards and nurses who cared for Miller “could reasonably be believed to be criminally negligent” as defined by state law, reports said.

State law says a person “is criminally negligent … when he ought to be aware of a substantial and unjustifiable risk … The risk must be of a nature and degree that the failure to perceive it constitutes a gross deviation from the standard of care …”

Jail staff did not violate jail policy that speaks to care of inmates, investigators said.

Davis County Sheriff Todd Richardson declined to comment Wednesday on the Miller case because of impending civil litigation — attorneys for Miller’s family have served notice of intent to sue the county.

But he did respond in general to several issues brought up by the investigations, including the Davis jail’s apparent reluctance on the night of Miller’s death to invoke the process of an in-custody death investigation.

He also reacted to the Weber County investigators’ report that said the Davis jail destroyed potential evidence by cleaning up Miller’s cells and the medical unit before the outside investigators arrived.

“If we were to treat every accident as a crime scene, there would be no place to house inmates,” Richardson said. “The reality is we do our best when there is any type of foul play, but on general accidents, we don’t normally hold that as being a crime scene. If we did there would be (police) tape all over that jail.”

Richardson said the jail will look for “improvements that we can do to speed the process of transporting out” when an inmate needs emergency hospitalization.

“There is no delay,” he said, “because we have 24-7 medical care in the jail. Our intent is to provide that medical care with the nursing staff we have in the jail.”

Richardson criticized Weber County’s investigation of the Miller case, saying it was “an inaccurate report.” But he would not give specifics.

“When we ask for a third party to do an investigation, I am expecting a proper professional investigation,” Richardson said. “That’s what the attorney general’s office put together. They interviewed every one of our employees and nurses. Weber County’s investigation was packed full of opinion, not fact. … It was not a full investigation.”

Weber County Sheriff’s Office spokesman Lt. Nathan Hutchinson declined to comment on Richardson’s criticism.

You can reach reporter Mark Shenefelt at mshenefelt@standard.net or 801 625-4224. Follow him on Twitter at @mshenefelt and like him on Facebook at https://www.facebook.com/SEmarkshenefelt.

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