Concern about Quality of Medical Care for Inmates

By ThinkReliability Staff

Those in the custody of law enforcement are almost completely dependent upon law enforcement for their basic needs.  One of these needs that is not always being met involves proper medical care, or even checks after the declaration of a medical emergency.   Per Dr. Ronald Shansky, a physician who performs court-ordered monitoring of inmate conditions for Milwaukee County, Wisconsin, failure to provide proper medical care is a failure to uphold constitutional obligations to those in custody.  After all, he says, “The inmate is completely dependent.  Unless the system creates the opportunity for the medical tests to be done, the medications to be provided, it’s not going to happen.”

In Milwaukee County, which was the subject of a recent investigative report by the Milwaukee Journal Sentinel, 18 people died in the custody of law enforcement in the county between 2008 and 2012.  Of these deaths, 10 were found to be related to improperly treated or monitored conditions.  By performing a detailed investigation of just one of these deaths, solutions that could reduce the risk of all custodial deaths due to improperly treated or monitored conditions can be incorporated.

We can perform this investigation by creating a Cause Map, or visual root cause analysis.  We begin with the specifics of one of the 10 cases of custodial death.  For this example, we’ll look at the death of Jeremy Cunningham.  Mr. Cunningham died the morning of June 22, 2011, while he was being held at the Milwaukee Secure Detention Facility for violation of parole.  Two important factors to note were that the inmate reported that he had alcohol and drugs in his system (taken within 8 hours) and that the inmate had a heart condition.

Next we determine the impact to the goals from the perspective of the Department of Corrections.  The inmate safety is impacted due to the death of a person in custody. Because of the constitutional obligation of law enforcement to care for those within their custody, the compliance goal is impacted.  Additionally, due to the insufficient treatment of the victim while in custody, the inmate services goal was impacted.

Beginning with the inmate safety goal, we can ask why questions to determine the causes of the impact to the goal.  The patient died because of a health issue that was not sufficiently treated.  Though the autopsy determined that the inmate died from cocaine poisoning, a pathologist who reviewed the results believes that alcohol withdrawal is more likely.  Because the cause of death is still under debate, we can use a “?” to indicate that it is not yet known (and more evidence is needed to determine the actual cause of death, though this is unlikely to occur).

Had the patient experienced the health issue but received treatment, he would have been less likely to die as a result.  Thus, the insufficient treatment from the prison staff is a cause of his death.  From available information, several opportunities were missed to assess the inmate’s health needs.  In other cases involving inmate deaths, an expectation of 30-minute check of prisoners is discussed, though it appears that requirement is not frequently being met.  This is likely because of chronic understaffing due to funding issues.  Even after the inmate’s roommate pressed the emergency call button when the inmate begin seizuring, nobody was sent to check on the condition of the inmate. (The emergency call button was pressed during the night, and the inmate was found dead in the morning.)  At the time of the death, there was no policy in place specifying what to do upon receipt of an emergency call, though the alcohol withdrawal instructions state that an ambulance should be called if an inmate experiences seizures.

Although the inmate had reported use of alcohol and cocaine within 8 hours before his incarceration, he was not monitored for withdrawal symptoms, although nurses had indicated monitoring was necessary.  Additionally, the prisoner did not receive any special care or instructions due to his heart condition.  It’s possible his heart condition wasn’t known – he died within 20 hours of entering the facility, which does not have an on-site medical practitioner, and prison medical records are delivered within 24-48 hours.

The failure of the system to provide adequate care to this inmate, as well as the 9 others who died in custody due to failure of monitoring or treatment has led to some changes being adopted by the Department of Corrections.  (Other changes are being forced by the legal system.)  These include posting notices on the doors of inmates who need extra attention, analyzing blood alcohol content upon arrival, and requiring an in-person evaluation to   respond to all emergency calls from within the prison. Hopefully these changes will reduce the failures that led to Mr. Cunningham’s death as well as some of the other deaths.

To view the investigation of Mr. Cunningham’s death, as well as a timeline outlining all 18 deaths in Milwaukee County law enforcement custody, please click “Download PDF” above.  Or click here to read more.