An expert witness retained by Davis County says county jail staff members acted appropriately in their care of a misdemeanor drug arrestee who fell off the top bunk of her cell and suffered a severe spleen injury that proved to be fatal.
Dr. Kennon Tubbs, a family practice physician responsible for contract medical services in six county jails in Utah, said it was unlikely that jail nurses could have detected the seriousness of the injury just after Heather Miller’s fall.
Miller, 28, was hurt in the Farmington jail on Dec. 21, 2016. Her mother, Cynthia Stella, in January 2018 filed a wrongful death and civil rights suit against Davis County, Sheriff Todd Richardson, jail nursing chief James Ondricek, and nurse Marvin Anderson, who cared for Miller.
“This diagnosis is elusive and can be insidious in nature,” Tubbs said in a report filed in U.S. District Court in Salt Lake City on Sept. 28. “It is not surprising that the diagnosis was missed during initial evaluation by Anderson.”
Nurses did not check Miller’s vital signs after the fall just before 6 p.m. and moved her to another cell with little monitoring, where she experienced massive internal bleeding for hours, according to Stella’s suit.
The jail had no policies on how medical staff and deputies should handle inmates after a fall, the suit said.
Tubbs, of Draper, has contracts to provide medical services in the Utah, Juab, Duchesne, Daggett, Wasatch and Summit county jails, plus four county jails in Wyoming. He previously was a medical provider at the Utah State Prison for 15 years.
Tubbs was added as a defendant Sept. 20 in another federal suit over a death in the Duchesne County Jail. Madison Jensen, 21, died Dec. 1, 2016, of severe dehydration due to drug withdrawal four days after she was booked in drug use charges.
Tubbs on Thursday declined to comment on the Jensen suit.
The deaths of Miller and Jensen were among a record 27 fatalities in Utah’s county jails in 2016, according to information gathered by the state.
The controversies over jails have spawned several wrongful-death suits, triggered state-ordered studies of prisons and jail deaths overall and drug withdrawal deaths in the county jails, and led the Utah Sheriffs Association and the Utah Department of Corrections to work on a more transparent jail inspection system.
In his report on the Davis jail death, Kennon acknowledged Anderson did not check Miller’s vital signs and that he should have.
“However, Miller's diagnosis likely would not have been apparent to Anderson based on findings of vital signs,” the report said.
Tubbs said Anderson did check Miller’s left side, where she said she felt pain, and there was no external injury, something also noted in the state medical examiner’s autopsy report.
“I suspect that during the original evaluation the bleeding was minor and not even enough to cause pain,” Tubbs’ report said.
He said the fact that Miller apparently did not notify officers during subsequent well-being checks at 6:30 and 7:30 p.m. “shows that even Miller herself did not recognize the seriousness of her bleeding,” Tubbs said. “Unpredictably, over the next few hours the bleeding had a gradual, cumulative and lethal effect.”
Corrections deputies noticed Miller was “thrashing around” in her cell at 8:20 p.m., and a nurse called for emergency care at 8:43 p.m. Miller was pronounced dead at McKay-Dee Hospital in Ogden at 10:06 p.m.
Miller had been arrested the day before. Tubbs said in his report that her methamphetamine use — the autopsy found the drug in her body — was an "aggravating factor" in her death.
"Methamphetamine usage also altered Anderson's assessment as he attributed Miller's vague symptom of 'dizziness' to potential drug withdrawal symptoms rather than a possible sign" of internal bleeding, Tubbs said.
“It is regrettable that Miller died from these unusual circumstances, but it is reasonable to assume that many nursing providers would have made similar assessments and treatment decisions given the knowledge that was present at the time,” Tubbs’ report said. “The health care provided was compassionate and rendered in a timely manner.”
He added, "In my opinion the nurses or custody staff at Davis County were not deliberately indifferent to Miller's medical needs."
Reached Saturday, Stella's attorney, Tad Draper, blasted Tubbs' report and said the jail doctor legally overreached in his conclusion.
"We're going to file a motion to exclude his illegal legal conclusion," Draper said. "Deliberate indifference is a legal standard and that is a question the jury will decide. He's just grandstanding for either the judge or jury to make a conclusory statement."
Draper described Tubbs as "just another crony" of the incarceration system.
In an interview Thursday, Tubbs was reluctant to comment beyond the expert witness statement he provided.
But he did say that falls from top bunks “happen all the time in jails and prisons across the nation.” He said he was not able to document any other spleen injuries from those falls.
That indicated to him that the “tragic and very unusual” injury “would not be the first line of thinking of any type of nurse.”
In the report, Tubbs said spleen lacerations cannot be diagnosed in the field or at the jail and require hospital tests to detect.
He recommended that the Davis jail make vital sign checks mandatory in such situations and that the nurse bring an emergency kit for the checks. Anderson did neither.
He also urged the Sheriff’s Office to streamline paramedic access to the jail in life-threatening situations. According to investigative reports of Miller’s death, emergency crews complained jails staff delayed their efforts to quickly reach the inmate.
An outside investigation of Miller’s death conducted by the Weber County Sheriff’s Office faulted the Davis sheriff’s staff for not preserving the potential crime scene. The two cells she occupied that evening were cleaned, and the medical unit where she underwent emergency procedures also was not protected.
The Utah Attorney General’s Office did a follow-up investigation and made no mention of a tainted crime scene. It found no evidence of nursing staff conduct that would support the filing of criminal negligence charges.