D.A. Assails Nurse in Death of Jail Inmate : Justice: Despite a report calling the treatment of the retarded, asthmatic man in County Jail as ‘shocking,’ no charges will be filed.

A retarded, asthmatic man who died last August following a stay in County Jail was subject to a “shocking” lack of medical care in the jail from a “coldly harsh and judgmental” nurse and other “mean-spirited and unprofessional” staff members who chastised him for requesting help, the district attorney’s office has determined.

In a rare broadside about jail procedures, Dist. Atty. Edwin Miller said he carefully weighed whether to file formal criminal charges against a jail nurse and deputies who tended to 18-year-old John C. Maes, who asked repeatedly to be hospitalized for breathing problems.

Ultimately, Miller decided that the staff’s conduct was not so “aggravated, reckless or grossly negligent” that it caused Maes’ death and said no charges would be filed.

However, in an eight-page report released Friday that describes the events that led to Maes’ death, the district attorney’s office harshly criticized the behavior of nurse Colleen Heath, who reportedly scolded Maes repeatedly and ordered that he be placed in a padded cell, where he stopped breathing.

Maes died two days later, after being placed on life support at UC San Diego Medical Center.

“We are shocked at the overall treatment Maes received from nurse Heath and, at her behest, some of your deputies,” Miller wrote to Sheriff Jim Roache. “To be denied a full diagnosis and then to be placed naked into a rubberized room is hardly the medical treatment one would expect in an enlightened custodial institution.”

Roache said Friday that Heath had been fired by the department on an unrelated matter but no action had been taken against the deputies. He said he agreed completely with Miller’s conclusions and that the jail’s medical services unit has been reorganized since the incident.

“I thought the D.A.’s office did a thorough job,” he said. “I agreed to the analysis and conclusions and took no exception to it. I thought they had every reason to make the statements they made.”

Maes’ mother, Lily Suell of Glendale, Ariz., filed a wrongful death lawsuit against the department in December. She said Friday that she had not heard of Miller’s report or its contents, and refused further comment.

The district attorney’s report chronicles the incident:

Maes had been placed in the County Jail last July after being convicted for residential burglary. About 1:45 a.m. Aug. 14, he complained of a headache, nausea and breathing difficulties.

Deputies George Flood and Ruben Hernandez carried Maes to the infirmary on a stretcher after he said he could not walk.

Heath said Maes never mentioned his asthma condition to deputies, but because he was wheezing she offered him an inhaler. He refused and asked to go to the hospital. Flood and Hernandez said Maes asked only for aspirin.

Another jail nurse, Una Harris, recalled that Heath told Maes, “You just triggered this; there’s nothing wrong with you” and reminded Maes that he would not receive the same sympathy that Marie McPherren, another nurse, gave him during his frequent jail stays between April and August of last year.

After Maes vomited, he was returned to his cell, but 15 minutes later other inmates began complaining that Maes was making too much noise. Another 15 minutes went by until Maes was escorted back to the dispensary, complaining of breathing problems.

Heath gave Maes an inhaler but denied his request to be sent to the hospital and said, “You picked the wrong night to be sick.” He was returned to his cell a second time.

Nurse Harris said she believed that Maes’ medical condition had worsened during the second visit.

Nearly three hours later, at 5:15 a.m., Maes complained about the headache and began crying. He was removed from the tank and handcuffed to a bench.

Flood called Heath at 5:45 a.m. and she ordered him placed in a padded cell. Maes resisted and Flood and another deputy pinned Maes to the ground and removed his clothing. Maes yelled for his mother, all the while wheezing and crying. At 6 a.m., Deputy Marco Garcia realized that Maes was not breathing. He and another deputy started CPR. Maes died at the hospital two days later.

Homicide detectives later interviewed nurse McPherren, who had failed her probation and was fired from the department. She said she had sent Maes to the hospital several times for asthma attacks.

Three inmates in the jail with Maes said he was beaten but the county medical examiner’s office said there was nothing to indicate that the inmate was struck.

However, the deputies who pinned Maes down to remove his clothing may accidentally have contributed to his death, according to Dr. Harry Bonnell, chief deputy medical examiner, in an autopsy released last year.

The official cause of death, Bonnell said, was a lack of oxygen to the brain caused by bronchial asthma. Bonnell said he had an extremely low level of medication in his system at the time he died.

Medical records show that Maes was sent to the hospital eight times and treated about 70 times, mostly for asthma, between April and August of last year.

In the conclusion to its report, Miller wrote that Heath “chose to be coldly harsh and judgmental in assessing Maes’ medical complaint. This set in motion a continuing series of events which exacerbated his already deficient medical treatment and ultimately led to his death.”

Miller said a copy of his report would be sent to the state Board of Registered Nurses.

In exonerating Heath and the deputies--some of whom appeared to be “mean-spirited and unprofessional”--of criminal charges, Miller recommended to Roache that he review his staff’s medical procedure and training.

Roache said changes had been made but could not enumerate them. He referred calls to Roland Ray, medical services administrator, who could not be reached for comment.