FARMINGTON — The Davis County Jail went six years without documented protocols for providing health care to inmates, Sheriff Todd Richardson said in a wrongful-death lawsuit deposition.
After the death of Heather Miller, who fell off her bunk and bled to death internally from a severed spleen Dec. 21, 2016, Richardson ordered his staff to write new protocols governing how jail nurses should handle specific situations, from minor issues to emergencies, the sheriff said.
The county, Richardson, plus the jail nursing director and a nurse who failed to check Miller’s vital signs, are being sued in U.S. District Court by Miller’s mother, Cynthia Stella of Reno, Nevada. The suit was filed Jan. 3, 2018, and is in pretrial litigation.
According to court documents filed Nov. 21 in Salt Lake City, Richardson was interviewed in a deposition Aug. 24 regarding jail policies, procedures, and how personnel responded to Miller’s death.
Daniel Baczynski, one of Stella’s attorneys, asked Richardson why he had ordered the old set of protocols eliminated after he became sheriff in 2011.
The jail’s policy manual provides broad and general instructions for medical care, but treatment protocols and first aid procedures were axed, Richardson said, according to the deposition transcript.
He said state health care professional licensing officials at the time “didn’t want us to carry the protocols written the way they were. So the protocols were ... eliminated.”
“So my understanding was that they wanted to get rid of the procedural order to make it so that the nurse would have to call the physician on a case-by-case basis on what he wanted to have done,” Richardson said.
“There was a couple instances inside the jail. And so (licensing officials) came back and did a review, and ... they didn’t like the flexibility that the nurses were given, so they tightened it up.”
He said the Miller incident and instances regarding screening of new inmates prompted him to direct jail commanders in early 2017 to work with the jail’s contract medical director to write new protocols.
Those protocols are being written now from “ground zero,” the sheriff said.
In the lawsuit, Stella’s attorneys accuse the sheriff’s office of violating its own policies, because the policy manual all along has mandated the jail must have specific health care protocols:
“To provide a means for the identification of medical conditions and the care of minor ailments of the inmates in the Davis County Jail treatment protocols and first aid procedures will be developed by the jail physician, psychiatrist and/or dentist under the direction of the health authority to be utilized by authorized personnel,” the policy reads.
An example of a protocol drafted by the county’s expert witness, Dr. Kennon Tubbs, which is in place at the Utah County Jail for abdominal pain, calls for the nurse to assess the area of pain, check vital signs, get a history of the complaint and follow up as needed.
Davis jail nursing supervisor James Ondricek is under fire in the lawsuit because nursing activities are governed by his expectations for proper care, with no written basis.
The nurse who checked on Miller, Marvin Anderson, is criticized in the suit for not bringing a medical bag and not taking Miller’s vitals signs, then having her put in another cell with no top bunk but with no further medical evaluation.
Richardson said he and his staff later did a “verbal” review of Miller’s care and they concluded the jail policies “had worked” and the care Miller received was “within our policy.”
No one was disciplined, Richardson said. The Utah Attorney General’s Office investigated the death and concluded there was no evidence of negligence that would warrant criminal charges.
Richardson said he had been comfortable with how medical care had been managed after the old protocols were deleted because care still relied on “core nursing standards.”
In their Nov. 21 motion for summary judgment on the lawsuit, Stella’s attorneys said the county and its employees were guilty of deliberate indifference to Miller’s plight.
“Davis County Jail operates in the dark,” the motion said. “It has no medical protocols. It provides no training. It performs no formal internal reviews of the medical care that is being provided. And it does not discipline its nurses, even when the care falls far below Davis County Jail’s own expectations.”
A checklist for nurses to follow is essential for jails, according to the National Institute on Corrections, Stella’s lawyers said.
How do you ensure that employees are complying with the practices and policies in the manual, Baczynski asked the sheriff.
“I mean, that’s why we have supervisors out there,” Richardson said, adding that audits by multiple outside agencies are useful too.
About three hours after Miller fell, corrections deputies delivered her to the jail’s medical unit in a rush after they found her barely responsive.
“She was in a wheelchair and she was totally flaccid,” Anderson said in his deposition. “She was pale. I thought — I thought she was dead. I’m like, really, guys, you’re bringing her here dead?”
Anderson said he told the deputies to call paramedics. “Obviously, I could tell that she did not look good,” he said.
In the deposition, Anderson said he deals with many inmates who are withdrawing from drugs, and that’s what he thought of Miller.
The 28-year-old was arrested in Clearfield Dec. 20, 2016, on a drug possession charge. An autopsy showed she had methamphetamine in her system.
“What I see at the jail is a lot of what she presented of this — the way she acted, the detoxing, whatnot. And so that’s what kind of took me into that, that feeling of where she was. I didn’t get this feeling that she was having this traumatic injury.”
“I’m biased ... to what I see,” he said.
Does that affect the way he’s able to provide medical care, Baczynski asked him.
“In the jail setting, it is,” Anderson said.
Davis County has not yet filed a response to the summary judgment motion. Britton Butterfield, an attorney representing the county, said Wednesday he had no comment.
Miller’s death was one of six in the Davis jail in 2016, a year in which Utah’s county jails reported at least 27 deaths, a record.
The deaths led to several wrongful-death lawsuits around the state and prompted the Utah Legislature to pass a bill requiring annual reports of jail and prison deaths and a study of medical care offered to opioid-addicted inmates. And the Utah Sheriffs’ Association and the Utah Department of Corrections announced they would write new jail inspection standards.
Richardson, first elected in 2010, chose not to run again this year.