FARMINGTON — Three expert witnesses condemned the medical treatment given Heather Miller, who fell from a Davis County Jail bunk and bled to death internally, court documents show.
“Had Ms. Miller’s blunt abdominal injuries been recognized earlier, it is my professional opinion that this condition would have been surgically treated and she would have a very high likelihood of survival,” Dr. Ken Starr, an authority on emergency rooms, said in his report filed in U.S. District Court in Salt Lake City.
Starr and two other witnesses retained by attorneys representing Cynthia Stella, Miller’s mother, accused the jail of sloppy and unlawful responses to the woman’s fall, including not taking her vital signs.
Miller, 28, died Dec. 21, 2016. Hers was one of six deaths in the Davis jail that year and one of the reasons that state legislators in March 2018 passed a law requiring Utah’s county jails to file annual reports of in-custody deaths. The jails also were told to provide information on how they care for inmates who may be drug-addicted.
Stella, who lives in Reno, Nevada, filed suit against Davis County and its sheriff’s office in January this year. The county has denied allegations of indifferent and negligent care, and the two sides have brought in expert witnesses as the pretrial litigation continues.
“If Heather’s vital signs were obtained earlier, her serious and life-threatening condition would have been rapidly recognized by the jail medical staff,” wrote Starr, of Arroyo Grande, California. “Unfortunately, by the time her condition was adequately assessed, it was too late.”
The jail nurse who responded to Miller’s cell, Marvin Anderson, is named as a defendant in the suit. In investigative interviews after the death, jail personnel said Anderson did not take an emergency kit with him to the cell and did not check the woman’s vital signs.
Miller’s vital signs were not checked until paramedics responded to an emergency call after jail deputies found Miller in distress more than two hours later. She was pronounced dead at an Ogden hospital later that night.
“If vital signs had been obtained there would certainly be evidence of her deterioration within one hour of her injury, hence the ‘golden hour of trauma care,’” Starr said.
Deborah Schultz, a registered nurse who audits and inspects detention facilities for the Santa Barbara County Public Health Department in California, said in her expert witness report that the Davis jail lacked sufficient policies and procedures on medical emergency situations.
But most of her criticism addressed jail personnel’s direct actions that night.
“It is in my professional opinion that virtually no medical care was administered by nurse Marvin Anderson to Heather Miller after her fall from the top bunk, demonstrating complete disregard for Utah’s Nurse Practice Act,” Schultz wrote. “Nurse Anderson and the jail staff failed to act on the behalf of Heather Miller’s best interest, even with the glaring symptoms of an injury present.”
She added, “Anderson’s actions, or should I say lack of actions, could also be construed as medical malpractice. I believe by providing no medical care to Heather Miller while incarcerated at the Davis County Jail, contributed to her early and untimely death.”
The Nurse Practice Act outlines standards dealing with decision making, critical thinking and clinical judgment.
A third expert witness, Todd Vinger, a retired undersheriff from Nevada, said he faulted the jail for a “deliberate lack of response” after Miller’s fall and a “lack of attempting to check for any vital signs.”
Putting Miller in another cell after the fall, with no medical monitoring, rather than taking her to the jail’s medical unit for observation was “lazy,” Vinger said.
According to investigative reports, there was some confusion on the night of Miller’s death among jail staff about whether a bed was available in the medical unit.
Vinger criticized an apparent lack of a jail health and safety policy and procedures manual, even though the written jail policies call for such a manual. He called that “extremely irresponsible” and “an indifferent choice to the health and safety of the inmates,” especially when it is “a common and best practice within jails nationwide.”
On Sept. 28, Davis County filed in court a copy of the expert testimony of a Utah and Wyoming county jail medical services provider, Dr. Kennon Tubbs, defending the care of Miller.
Tubbs said county jail staff members acted appropriately in their care of Miller, a misdemeanor drug arrestee. He said it was unlikely that jail nurses could have detected the seriousness of the injury just after Miller’s fall.
Diagnosis of a split spleen “is elusive and can be insidious in nature,” Tubbs said. “It is not surprising that the diagnosis was missed during initial evaluation by Anderson.”