SUNDAY EDITION: Investigation finds jail deaths preventable - WDRB 41 Louisville News

SUNDAY EDITION: Louisville jail deaths could have been avoided, investigation finds

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Savannah Sparks Savannah Sparks
Samantha George Samantha George

LOUISVILLE, Ky. (WDRB) – Savannah Sparks was a daily heroin user. LaKenya Porter had congestive heart disease and could not even stand. Samantha George had severe diabetes.

All of these women entered Louisville Metro Corrections in 2012, and all died while in the custody of the jail.

But despite their medical problems, two of the women's deaths could have been prevented and the lack of care while in jail contributed to the death of the third woman, according to recently concluded investigations by the Louisville Metro Police's Public Integrity Unit.

In reviewing the investigations, the Jefferson Commonwealth's Attorney's office found no criminal conduct but criticized Metro Corrections as well as Corizon, the private company that provided the jail's medical care at the time.

The investigations, which were completed late last month, include dozens of interviews with medical staff, jail officers, reviews by a forensic medical examiner and conclusions by the Commonwealth's Attorney's office. WDRB obtained the records through an open records request of Louisville Metro Police.

The records provide the first extensive details since six Corizon employees resigned in December 2012 after an internal Metro Corrections investigation found "errors" and "mistakes" that "may" have played a part in the deaths of George and Sparks.

Until now, very little information had been known about Porter's death. Corrections Director Mark Bolton has said she died of natural causes, and neither jail officials nor Corizon would comment last week because of the potential of litigation.

A spokeswoman for Corizon said she could not comment on any of the cases "because of patient confidentiality and ongoing litigation."

Last year, Tennessee-based Corizon decided not to rebid for its $5.5 million annual contract, though it had been the medical provider at Metro Corrections for most of the past two decades.

Bolton has said Corizon was not pressured to leave, and the company has not commented on the move.

In total, seven inmates died in Metro Corrections in 2012. Criminal investigations have concluded in each of those cases, with no charges being filed.

The following three stories provide the accounts of the events leading up to the deaths of Sparks, George and Porter.

LAKENYA PORTER

LaKenya Porter was so weak she could not stand. Her legs, which were seeping a yellowish fluid, had to be propped up on milk crates as Metro Corrections staff wheeled her across the floor to be fingerprinted and booked into the jail on July 21, 2012.

"I feel like I'm getting ready to die. Please don't let me die in jail," a Metro Corrections nurse remembers Porter telling her.

Porter died later at University Hospital following a "negligent" lack of care during her 27 hours at Metro Corrections, according to newly released records from Metro police, which investigated the death, and from the Commonwealth's Attorney's office, which evaluated the investigation for criminal charges.

Porter, who had been diagnosed with liver failure and congestive heart failure, never should have been taken into jail in the first place, investigators concluded.

Officials with Corizon said Porter needed more care than the jail could provide. And during her incarceration, Porter was never given her medication or seen by a doctor.

As "negligent" as the medical and jail staff were, there is no evidence those mistakes caused Porter's death two days later at the hospital, according to the Commonwealth's Attorney's office, which declined to pursue criminal charges in Porter's death.

But Dr. William Smock, a forensic  examiner who acted as a consultant for Louisville Metro Police in the investigation, concluded that Metro Corrections' decision to overrule three medical providers, including the jail doctor, and admit Porter to jail, "directly compromised (Porter's) health and welfare."

And he said the failure of medical staff to provide Porter any of her prescribed medication or have a jail physician evaluate her also "contributed to her death."

It all started after the 33-year-old Porter was discharged in stable condition from Jewish Hospital after being evaluated for "multiple complicated medical issues" including morbid obesity, liver failure and heart failure, according to the Commonwealth's Attorney's summary of the investigation.

Jefferson County Sheriff's deputies took Porter to jail in an ambulance. She was brought in on a stretcher as she was "unable to bear weight." Porter had four outstanding arrest warrants, including felony charges of fleeing and evading police, wanton endangerment and speeding 25 mph over the limit.

The jail's medical staff concluded Porter's level of care was too high to be admitted into the jail, in part because she was unable to stand on her own.

But Metro Corrections Deputy Director Dwayne Clark overruled the medical staff and ordered Porter to be booked.

Clark later told investigators he was not aware of how serious Porter's condition was.

Billie Jo Brewer, the Corizon nurse who remembers Porter pleading with her not to let her die in jail, told police she objected to the decision, but to no avail.

"I was taught in my six years of being in corrections that you don't, you don't fight with corrections," Brewer said. "They override everything, so she was brought in, unfortunately."

While the doctor at Metro Corrections ordered several medications for Porter, "it does not appear that she received any of these," including antibiotics, during her entire jail stay, according to the Jan. 22 prosecutor's summary of the police investigation.

And at 2 a.m. on July 22, the charge nurse at Metro Corrections "again" called the jail's doctor, identified only as Dr. Kad, about taking Porter to the hospital emergency room. The charge nurse noted Porter "was not an appropriate fit for level of care at the jail," according to the police investigation. But the jail doctor "refused," saying Porter "would not be admitted" to the hospital.

In fact, it wasn't until the power went out in the jail 20 hours later -- about 10 p.m. -- that Porter was taken to University Hospital. She died there on July 24.

"She should have never been incarcerated," concluded Assistant Commonwealth's Attorney Mark Miller, who investigated the Porter case for possible criminal charges.

Bolton, the director of Metro Corrections who has said previously that Porter died of "natural causes," declined to comment further this week because of possible litigation. Porter's family has not filed a lawsuit against Metro Corrections or Corizon.

Miller's letter also said "clearly there was a significant misunderstanding and miscommunication on Ms. Porter's medical status upon discharge from Jewish Hospital.

"Although diagnosed with an end stage liver failure and congestive heart disease, along with other serious health issues, she was being discharged to her home in stable condition."

A Jewish Hospital official reviewed documents provided by WDRB and declined to comment.

Brewer, the nurse, said Porter never should have been released from Jewish Hospital but that the hospital had told her they may be able to find Porter a bed if she needed to be readmitted.

"I mean, everyone acted like that was the last resort, was her comin' to jail," Brewer told police.

Porter's case, according to records, was one of the first times witnesses could remember in which the jail overruled the recommendations from the medical staff not to admit an inmate, according to interviews.

In her interview with police, Brewer said she objected so vehemently to Porter being admitted to the jail, that "I almost went to an unprofessional point. Everyone could see my frustration. I actually cried and got tearful upstairs."

After Porter was admitted, Brewer said she was so scared for her she had someone sit at her door and monitor her.

When Porter asked Brewer not to let her die in jail, Brewer said she responded, "I promise I won't."

Because it was on a weekend, no jail doctor ever saw Porter, Brewer told police, adding that Kad said he would check on her on Monday.

At 2 a.m. on July 22, Brewer called Dr. Kad about sending Porter to the emergency room because of her condition but he replied that she "wouldn't be admitted" and ordered she remain at the jail, according to records.

Instead, nurses changed her dressings and linens, helped her use the restroom and took care of her as best they could, Brewer told investigators.

There is no interview with Dr. Kad in the records provided to WDRB by police.

At around 10 p.m. on July 22, after the power went out at Metro Corrections, the order was finally given to take Porter to the hospital. One nurse told police Porter was unable to get proper treatment without power.

But Brewer told police "She was just as bad as when she come in the door. I don't understand what changed then to, you know, when she went to the hospital. I was very upset about that."

On the evening of July 23, Porter went into cardiac arrest but was resuscitated at University Hospital.  Porter's health continued to deteriorate and she died on July 24 of "refractory shock."

Brewer said she cried when she learned Porter had passed away.

"I just felt like I did everything I could," she said. "…I know I felt like, I, you know, at least I kept my promise to her – she didn't pass away in jail. She just didn't need to be in custody at all."

But Metro Corrections Deputy Director Dwayne Clark, who made the decision to overrule medical staff and admit Porter, said he was told by Lt. Darrell Goodlett only that Porter was "obese and can barely walk" so he decided to admit her, according to his interview with police.

However Brewer said she heard Goodlett tell Clark how ill Porter was and that the medical staff had recommended not taking her.

And Goodlett said in his interview with police that he told Clark that Porter's level of care was high and the jail nursing staff would have a hard time taking care of her.

Goodlett said Clark asked if Porter was hooked up to any equipment. She wasn't.

Clark told him to take her into custody "and if we have to turn around and send her back to the hospital while she's in our custody, that's what we'll do," Goodlett recalled Clark saying.

Clark told police he knew that a nurse had advised not to admit Porter but didn't know that the jail doctor, Kad, had agreed.

And Clark said he learned that Porter had been discharged from the hospital already and probably needed care the jail could provide.

Asked in an Oct. 18, 2012, interview with police if he would do anything differently, Clark said he still believed Metro Corrections had an obligation to admit Porter but he maybe should have tried to get a judge's order to release her from jail.

Jefferson County Sheriff's Deputy Steve Jesse, who helped transport Porter on warrants for wanton endangerment, fleeing and evading and speeding, told police he heard from a nurse at Jewish Hospital that Porter was fine when she learned she was going to be discharged, until realizing she was going to jail.

And Jesse said when the jail medical staff decided not to admit her, he told them how he had watched Porter walk to the bathroom and that she would be fine in a wheelchair.

However, Vanessa McDaniel, the first nurse who saw Porter at the jail, told police her legs were swollen and weeping and she was having trouble communicating.

"She had a lot of medical issues going on," said McDaniel, who added Brewer and Kad both agreed that Porter shouldn't be admitted.

Porter had been at Jewish Hospital since July 3 and an evaluation by a physical therapist noted she had "multiple physical conditions" that would require rehab after she was discharged from the hospital, according to a report in the investigation of her death.

A family member, who asked not to be identified, said anyone looking at Porter could tell she was very ill.

"I know how sick she was," he said. "Me, you, anybody could look at (her) and tell you they shouldn't have took her to jail."

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