The link below will take you to an article from the Yamhill News-Register covering five deaths that occurred in a six year period at the Yamhill County Jail. In addition to the closed Jed Hawk Myers case, I am currently representing family members in three cases against Yamhill County and Wellpath, their contracted medical provider, for Civil Rights violations resulting in the death of folks who had not been convicted of any crime. It doesn’t take very long to realize there is some commonality to these cases.
In the case of Kathy Norman, both the Yamhill County Sheriff’s deputies and the Wellpath Licensed Practical Nurse (LPN) on duty were fully aware that Ms. Norman was beginning to detox from alcohol; they had been told by the ER providers, the transporting police officer, and Ms. Norman herself. They also knew that detoxing from alcohol can be easily and successfully treated with medication. They knew that the condition of folks detoxing from alcohol can change rapidly and can be deadly. Nonetheless, they accepted custody of Ms. Norman and then never evaluated her detox symptoms or took any vital signs. The Norman case has some similarities to the Jed Hawk Myers and Debbie Samples cases from 2015 and 2016. All these cases involved detainees who were identified to be medically vulnerable and who needed to be lodged in a cell with video surveillance. In both the Myers and Norman cases, they were put into these cells without any vital signs being taken, and no effort by anyone to return to get that crucial information. In both the Norman and Myers cases deputies simply looked through the very narrow glass window in the cell door to do “security checks”. Security checks involve a deputy looking long enough (about 2 seconds) to make sure the person in the cell is present and alive. These are not checks designed to obtain medical information. In both Myers and Norman, it took them being on the floor and not breathing before anyone entered their cells to check on them. In both the Samples and Norman cases, hospital providers communicated to the jail staff the need for specific care and conditions to watch out for; Samples being suicidal and Norman detoxing from alcohol. Tragically in both situations, that advice went largely ignored and resulted in the preventable deaths from the exact conditions the Sheriff’s office was warned of. Myers, Samples, and Norman needed to be checked on more frequently and with more attention until they were stable, or sent to an appropriate medical provider where they could get the necessary care. Jail policies call for different levels of checks in terms of increments of time. All inmates are checked by deputies at less than one-hour intervals; medical and suicide checks can be in 30 or 15 minute increments. None of the victims were looked at any more often than any other detainees with no medical issues.
The county will say they have contracted with Wellpath and that they rely on them to deal with all medical issues. “They are the experts…” But jail policies and Oregon laws state that ultimately inmate healthcare is still the county’s responsibility. After all, it was only five months prior to Ms. Norman’s death that Sheriff Svenson wrote an editorial in the Yamhill County News Register taking full responsibility for Mr. Myers’ and Ms. Samples’ deaths. “The buck stops here”, he wrote. Apparently, that is just until the next jail death or his re-election comes along, as there have been three more deaths since that confessional editorial. After Ms. Norman’s death, Sheriff Svenson was quoted in the local paper saying there is “zero indication” the staff was negligent in anyway. He went on to praise the medical provider saying, “the contractor is doing a great job.” and “it’s nice to know there is a nurse in the jail at all times. It’s been very good.” While it is good to have someone with some medical training, it is too much for one LPN to take on alone. There are times when the LPN is not able to closely monitor those in medical because the nurse often has to spend hours passing out medication to the other inmates and/or may be over at the juvenile facility. How can this be Sheriff Svenson’s response when both medical and Yamhill County deputies knew Ms. Norman was detoxing, yet they took no vitals, took no detox history, did no detox evaluation, did not closely monitor her, withheld medication, and never called the ER staff for more information they might need to treat her. They just locked her into the cell, never entered her cell to check on her condition, and failed to give her lifesaving medication.
There are many other questions to be asked in Ms. Norman’s case. Does the Wellpath medical program put LPNs in a situation that runs contrary to limits on their defined scope of practice as laid out by the Oregon Nursing Board and Oregon laws? Can a doctor legally make medical decisions such as prescribing medications or holding off on them without having treated or examined a patient? In Kathy Norman’s case, the on-call doctor was contacted by the LPN but was not provided updated vital signs, a detox evaluation, a detox history, and other crucial information left off of the ER discharge paperwork that was only a phone call away. Nonetheless, he ordered the nurse to withhold even starting the detox medications or evaluation until the following morning, by which time it was too late.
As part of my investigation into Kathy Norman’s death, I went back through some of the Yamhill County Board of Commissioners (BOC) hearings to find out if they approved using a lesser qualified LPN rather than a Registered Nurse (RN) as had been initially promised by Wellpath. In the Myers case, there was only an unqualified Med Tech evaluating injures. It was both the Myers and Samples cases that rightfully fueled the need to significantly upgrade medical services in the jail. Initially the county went into the agreement with Wellpath (formally Correct Care Solutions) by contracting for RNs full time. In reviewing the BOC hearings, the contract with Wellpath was amended multiple times early on because Wellpath could not deliver the RNs promised. The first amendment was brought before the BOC just two weeks into the contract. The Sheriff’s office wrote a 2/15/17 proposal assuring the Board that LPNs would be “suitable” and that “LPNs are commonly used in conjunction with RN’s in Oregon jails.” The proposal mentions multiple times that it will also save the county money by approving this change. I am not sure if the sheriff’s office was being intentionally deceptive to the BOC, but they knew that LPNs were going to be scheduled to work alone at night. On January 14-15, 2018, when Kathy Norman died, there was just the one LPN working alone, not in conjunction with an RN. While Wellpath did have an on-call doctor who was contacted, that is still not the same as having an RN being present to supervise and direct the LPN. Just three days after Kathy Norman died, the BOC approved a third amendment to the contract with Wellpath that made it so that RNs and LPN’s were interchangeable for staffing purposes, as if they were equally qualified and had the same scope of practice. The fact this could be approved by the BOC just three days after Kathy Norman’s death is disturbing and concerning. Nobody on the BOC thought to at least review the contract with Wellpath and take a closer look at the Sheriff’s office, especially after the very recent tragedies that had happened with Myers and Samples. How many detainees have to die before the BOC stops rubber stamping the Yamhill County Sheriff’s Office and creates some oversight? Earlier this year the BOC renewed the contract with Wellpath for an additional three years.
While I am still investigating the deaths of both Brent Cordie and Shane Rader, it is clear there is already a similar pattern of practice developing as Mr. Rader also died in one of the video surveillance cells. In the Myers case, there was an outside investigation by Multnomah and Lincoln County Sheriff’s offices in which both had discussed the over reliance by Yamhill County on video surveillance in the jail; that physical checks are needed in certain situations. I was recently given a tour of the jail and as I walked past one of the dorms, I heard an inmate knocking on the glass asking a deputy for mental health help. The inmate yelled out that he had been requesting help for six days and had not heard anything. This occurred right in front of the office where a mental health professional works. While I am aware that folks in custody serving time or facing criminal charges often present with health, addiction, and mental health issues, Yamhill County and its contractor, Wellpath, are responsible for the same standard of care that would be given in the outside community. If the jail cannot provide that care, they should not accept custody of that person. The very nature of incarceration dictates that the medically vulnerable are dependent on both medical and jail staff to ensure their medical needs are being met. That does not appear to be happening at the Yamhill County Jail.