Death of 27-year-old inmate "preventable" - WDRB 41 Louisville News

PART 3: Death of 27-year-old inmate "appears to have been preventable"

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Savannah Sparks Savannah Sparks

LOUISVILLE, Ky., (WDRB) – Metro Corrections Officer Ben Dewitt had seen jail inmates struggle through drug withdrawal, but never one "this bad." 

Savannah Sparks could not sit up. She had been vomiting constantly, sweating profusely and defecating on herself.  Sparks' wrists were bent and her fingers looked "smashed together."

"The girl seemed real sick – she couldn't eat anything, she couldn't drink anything. I was worried about her," Dewitt said in a newly released interview with police.

Sparks, 27, had been a daily heroin user and spent the last four days suffering withdrawal symptoms. In the middle of the night on April 12, 2012, a nurse at Louisville Metro Corrections thought Sparks was dehydrated and decided she needed to see a doctor.

But Sparks, of New Albany, Ind., was not seen by any medical staff in the jail until she died more than 12 hours later, even though she was supposed to be monitored because of her ongoing detox, according to police records released in the investigation of her death.

Sparks' death might been prevented but for a number of mistakes by the Metro Corrections staff and employees of Corizon, the jail's contracted medical provider at the time, according to a summary of the investigation by the Jefferson Commonwealth's Attorney's office.

"Had there been greater observation of her medical situation on a daily basis, perhaps there would have been medical intervention to respond to her withdrawal symptoms," assistant Commonwealth's Attorney Mark L. Miller wrote in a letter summarizing the police investigation.

The police investigation could find "no explanation" as to why no medical professional checked on Sparks the day she died.

The nurse in charge of scheduling doctor visits at the jail told police that she put Sparks on the doctor list for the following day, April 13, because no doctor was at the jail on the 12th. And the last nurse who had seen Sparks, in the early morning hours, did not ask for the nurse practitioner on duty that day to be sent to Sparks' cell.

The scheduling nurse, Melissa Greer, said no one gave her any indication that Sparks was in need of emergency care. "She had a bad detox," Greer said. "… I mean we have those all the time. It wasn't something that made me feel like, you know, 'Oh my God, I need to tell somebody else!'" Andrea Smith-Miller, the nurse who told Greer to have a doctor check on Sparks, said she later asked Greer why Sparks wasn't put on the list.

"I think she said, ‘I forgot,'" Smith-Miller told police. "I'm not quite sure. … Ms. Sparks wasn't put on the list. I'm not even gonna try to cover it up. She wasn't put on the list."

The Commonwealth's Attorney's Office ultimately concluded in a Jan. 21, 2014 letter to police that while there were mistakes and failures to provide Sparks with adequate medical care, the negligence was not criminal.

"Although Ms. Sparks death is a terrible tragedy and appears to have been preventable, and although there may have been some failures on the part of the medical staff in this case, there is insufficient evidence to find that anyone acted criminally," Miller concluded.

Dr. William Smock, a forensic examiner who acted as a consultant to Metro police in the investigation, concluded that the medical staff failed to provide adequate and appropriate care for Sparks. Her cause of death was "severe dehydration and acute renal failure from opiate withdrawal."

From April 7, when Sparks was admitted to Metro Corrections, until her death on April 12, security personnel noted Sparks was "suffering severe withdrawal symptoms including: vomiting, diarrhea, cramping and lethargy," Smock wrote.

But "these symptoms were unobserved and/or went unnoticed by medical personnel," he wrote. While the regular doctor was not at Metro Corrections on April 12, Smock said there were other medical professionals who could have seen Sparks had she been added to the doctor's list.

"This was not done until after Sparks' death," he said.

Miller added that there were many mistakes or missed opportunities to provide Sparks with adequate medical care. He said a sheet identifying Sparks as going through withdrawal was removed from Spark's cell, which was partly why no one checked on her and responded to her deteriorating condition.

And Miller concluded that had the jail used the evaluation currently in place for patients experiencing withdrawal from heroin, "the initial assessment and subsequent level of observation" likely would have been more appropriate for the withdrawal symptoms Sparks was experiencing.

Also, Miller concluded that correction officers who noticed Sparks' symptoms should have alerted medical staff.

Any of these things, Miller wrote, "may have prevented her death."

Sparks was arrested on April 7, 2012, by Shively Police on outstanding warrants. She was documented as being in severe detox, having urinated, defecated and thrown up on her clothes after being arraigned on April 9.

Marked as a "detox monitor," Sparks was put into a single cell and was to be evaluated by medical personnel at least once during each eight hour shift, according to a summary of the police investigation.

"There was no explanation of why she was not evaluated during the day" when Sparks died, the police summary said. "No one on the medical staff remembered taking her off the detox monitor and no one could conclusively say why it happened."

A wrongful death lawsuit was filed against the jail and Corizon, the Tennessee company that had been providing medical services at the jail. The case against Corizon has been resolved, but neither side would disclose the terms of the settlement. The lawsuit against jail officials is still pending.

The lawsuit, filed on behalf of Karen May, Sparks' grandmother, claimed Corizon and dozens of Metro Corrections staff, including Corrections Director Mark Bolton, were negligent in treating Sparks.

Just before Sparks died, corrections officer Ann Tinker discovered Sparks unresponsive in her cell, with vomit on the floor. Tinker, who remembered Sparks from a few days prior, noticed a "visible" deterioration in her condition, noting Sparks looked "emaciated" and her vomit was green.

"And I was holdin' her up (begins to cry) and her hands and her arm were just, like turning blue and her hand was, like twisted," Tinker told police later. "And I felt her just cold on her arm."

About an hour later, Sparks was pronounced dead at University Hospital.

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