PART 2: Timely medical care "would have prevented" jail inmate's death
LOUISVILLE, Ky. (WDRB) – The death of a 27-year-old inmate who was found unresponsive in her cell at Louisville Metro Corrections in August 2012 "would have been prevented had she received timely and appropriate medical care," an investigator concluded.
Corizon, the jail's healthcare company at the time, provided "negligent" care and failed to follow procedures for treating inmates undergoing narcotics withdrawal, Dr. William Smock found in reviewing the death of Samantha George on August 8, 2012.
"There is compelling evidence of a significant deviation from the standard of care and medical negligence on the part of the medical providers," Smock, a medical examiner and police consultant, wrote in his report.
But Smock found no indication that the staff of Brentwood, Tenn.-based Corizon acted maliciously or willfully in denying care to George, who died from severe complications of diabetes about 24 hours after she arrived at Metro Corrections from a Bullitt County detention center.
Based on those conclusions, Assistant Commonwealth's Attorney Mark L. Miller notified police last month that his office won't prosecute the case or present it to a grand jury.
"In reviewing the totality of information provided in this investigation, there is no indication that anyone acted intentionally to harm Ms. George," Miller wrote in a January 16 letter to Louisville Metro Police. "Certainly, mistakes were made."
Arrested on a felony theft charge, George spent one night at a Bullitt County jail before being taken to Metro Corrections shortly before 7 p.m. on August 7, 2012, according to police and prosecutors' reports on the events leading up to George's death.
The documents, obtained by WDRB.com under an open records request, are part of three recently concluded investigations into deaths at Metro Corrections in 2012.
The reports, coupled with interviews of Corizon medical staff, provide the following account of George's final hours:
George was booked at Metro Corrections at 6:40 p.m. and screened by a nurse, who is only identified as "Strong," shortly before 9 p.m. George was found to be a diabetic with an antibiotic-resistant MRSA infection.
Strong "failed to place an observation form to Inmate George which would have required her to be monitored at more frequent times," according to a summary of the police investigation into George's death. Strong declined to be interviewed as part of the investigation, a police spokeswoman said.
Alone in her jail cell, George was vomiting and nauseated when nurse Kristen Laws checked on her around 3 a.m. George received an insulin shot to help lower her blood-sugar levels, which Laws said were "high." George was also being monitored for detoxification.
At 6 a.m., Laws called a physician who ordered Phenergan, a medicine meant to ease George's nausea. Medical staff gave George the Phenergan and ice chips at around 6:20 a.m.
Laws told police investigators that she asked the doctor, whom she doesn't identify, if he wanted to send George to an emergency room. The doctor told her that he would see George later that day, Laws said.
"I think another nurse saw her and checked her again before she went to court, so I don't think the doctor ever saw her that day," Laws said in her police interview.
George's condition was "slightly better" when she was checked around 8 a.m., according to the Commonwealth's Attorney's summary of the police investigation.
But medical examiner Smock, in his review of jail cameras, noted that George bumped against an elevator door frame and was holding her stomach when walking into an elevator shortly before 8:30 a.m. After sitting down in arraignment court around 8:45 a.m., George twice put a trash bag to her mouth and bent over, and three times she leaned on or bent over a desk, Smock observed.
Jail workers, nurses and corrections officers looked into George's cell 11 times starting at 10:35 a.m., but no one entered the cell until 4:08 p.m., about five minutes after a corrections officer knocked on the cell door and noticed George naked from the waist down and unresponsive, according to Smock's report and a police interview with the officer.
Medical staff and emergency personnel responded to George's cell and attempted to revive her, but she was taken to University Hospital and pronounced dead at 7:19 p.m., according to a summary of the police investigation.
Smock concluded that the Corizon staff failed to start the appropriate detox monitoring and follow the correct procedures for someone detoxing from narcotics.
Miller, the Assistant Commonwealth's Attorney, wrote in his letter to police that a doctor should have seen George during the morning of August 8.
There is no interview with a physician included in the investigative records.
Corizon officials declined to comment.The company decided last year not to rebid for its contract to provide medical services at the jail.
In an interview with WDRB, Metro Corrections Director Mark Bolton declined to comment on the George case.
Chad McCoy, a Bardstown attorney who is representing George's estate in a lawsuit against Corizon, Bolton and jail and medical staff, said George's diabetes was so severe that her blood-sugar levels needed to be checked almost every hour.
The lawsuit is pending in Jefferson Circuit Court.
"I'm glad to see that the government's investigation matches exactly what our investigation showed, which is that her death and others like hers is easily preventable," McCoy said.
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