Medical Care in County Jails Beset by Serious Ills

The run-down hospital at Men’s Central Jail is infested with rats and roaches. Medical records--some too messy to read--are kept by the thousands on long shelves and are often lost or misplaced. Every day, carts packed with scores of vials are trundled from one cell to another by nurses dispensing medication. Inmate transfers and paperwork snafus often introduce chaos to this fragile order: Some prisoners go days, even weeks, without the pills and elixirs they require to stay well.

Occasionally, there have been alarming incidents resulting in severe injury and even death. Over the last five years, at least three inmates in Los Angeles County’s overburdened jail system have undergone limb amputations after gangrene and infections were allowed to rage out of control; one man lost an eye because he did not receive follow-up care for a puncture wound; another inmate, who was awaiting trial on arson charges, died from an asthma attack after deputies declined to immediately take him to the jail medical clinic for treatment.

The incidents symbolize one of the most difficult challenges facing the Sheriff’s Department, which runs the nation’s largest county jail system: providing adequate medical care to an inmate population with ailments ranging from asthma to diabetes to tuberculosis and AIDS.

The Sheriff’s Department has begun taking steps in recent weeks to try to improve care for mentally ill and other patients. But thousands of sick inmates--many of them stricken with maladies that have never been treated--are booked each week, requiring jailers to also serve as medical experts in what has become, for many prisoners, the hospital of last resort.

Any misstep can set the stage for suits alleging malpractice or wrongful death. There have been more than 65 in the last three years. Complicating matters, if diseases such as tuberculosis and hepatitis are left unchecked, the health of the jail staff--and ultimately the public--is placed at risk.

Finally, jail watchdogs say, there is the moral issue to consider: Decent medical care in the jails should simply be taken for granted in the most medically advanced nation on earth.

“Things need to change,” said attorney Merrick Bobb, who serves as special counsel to the Board of Supervisors studying problems in the Sheriff’s Department. “The situation as it currently exists is not something I believe the Board of Supervisors, the Sheriff’s Department and the general public intends to tolerate for much longer.”

The Sheriff’s Department is currently under order from the U.S. Department of Justice to improve care for hundreds of mentally ill inmates--or face a federal lawsuit. In addition, Bobb has issued his own report calling for vast improvements in the treatment of all sick inmates.

But given the extent of problems, officials say, they will be difficult to cure.

“We have so many people coming in that have such serious medical and mental health problems,” said Asst. Sheriff Mike Graham, who is heading up a task force looking into the matter. “We are trying to deal with those problems while also keeping inmates from escaping and getting people to court on time. . . .

“There are so many things that need to be improved in this system, it’s overwhelming,” he said.

Although Sheriff Sherman Block said some inmates receive better care in jail than they ever did on the outside, he acknowledged that there are cases in which the medical system breaks down.

“These people are coming in from the streets bringing a whole range of medical problems that have never been attended to,” Block said. “Sometimes things do fall through the cracks.”

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With a constantly changing inmate population, major metropolitan jails struggle to provide sufficient medical care, experts say.

“They all have their problems,” said Larry Solomon of the National Institute of Corrections, a watchdog group based in Washington, D.C. “Jails are difficult places to deal with medical issues because of the fact that people are coming in as unknown quantities. Inmates could have any kind of medical problem. . . . It’s different than a prison, where there is some kind of record.”

In Los Angeles County, new inmates end up waiting many hours in the bustling Inmate Reception Center to see a doctor employed by the Sheriff’s Department. There is rarely enough room in the jail system’s medical wards, which have 385 beds, for everyone who needs treatment. That forces staff members to put sick inmates in pill modules or other cells where they are watched by deputies and occasionally seen by nurses.

The numbers of sick and injured are staggering. Last year alone, more than 2 million outpatient visits were logged at jail medical clinics. Jail doctors issued more than a million prescriptions.

The latest statistics show that about 800 inmates had HIV, more than 360 of them diagnosed as suffering from full-blown AIDS. Tuberculosis was found in 115 inmates, hepatitis C in 317, and 1,196 inmates had syphilis.

Although the department spent some $30 million several years ago to build a medical facility at the Twin Towers jail next to Men’s Central, the 200-bed facility has remained largely unused because the sheriff says he lacks the funds to operate it. (Recently, the department began treating women there, because Sybil Brand Institute, where all female inmates had been housed, has been closed.)

For the most part, seriously ill inmates--an average of 6,000 a year--are housed in the dilapidated hospital wards at Men’s Central Jail. The conditions are Dickensian: Many inmates are paired up to share bunk beds in cells the size of broom closets.

In some cells, cold air blows constantly from air ducts, the ceilings leak, the walls are cracked and the plumbing is old, making it difficult at times to get hot water. Occasionally, a rotten-egg smell fills the air.

It’s not unusual for inmates to go without their medications because their charts were lost or they were meeting with their attorneys when nurses were handing out medicine, a process called “pill call.”

Sometimes, the only way an inmate gets medication or other treatment is if a family member, friend or doctor on the outside makes repeated calls to jail staff. Even then, there’s no guarantee.

“We are trying to run one of the largest local jail systems in the nation,” said Asst. Sheriff Graham. “When you have an organization as big and complex as this, you are always going to have problems. It’s a matter of getting out ahead and trying to anticipate the problems.”

Amid inquiries from The Times and pressure from jail watchdogs, custody staff recently began looking into the most recent medical malpractice suits. They are also probing the circumstances surrounding in-custody deaths over the last two years to determine if the proper medical care was provided in each of the cases.

In 1996, 37 inmates died in custody. Their average age was 40. Five of the deaths resulted from pulmonary emboli, two were caused by infections, six were AIDS-related, eight were suicides and one was from asthma. The other deaths were blamed on maladies ranging from seizure disorders to liver disease.

The death rate in L.A. County jails was recently listed as 1.9 per 1,000 inmates, exactly the national average for large jail systems, according to a report prepared by the Criminal Justice Institute Inc. in Washington, D.C.

Meanwhile, more than 65 lawsuits and claims alleging problems with medical and psychiatric care have been filed against the Sheriff’s Department over the last three years. Of those cases, 18 resulted in settlements, and 24 were dismissed. The others are pending.

Since 1995, the county has paid out more than $4 million to resolve cases involving a variety of snafus in the jails.

The number of lawsuits and the settlements can be somewhat misleading, civil rights attorneys warn. Some inmates don’t pursue litigation, largely because they have a hard time finding an attorney to represent them.

And lawyers who do get involved are more apt to settle the matter out of court. It’s easier than taking the chance of putting an unsympathetic victim, such as a career criminal, before a jury, they say. As a result, the amounts paid out in jail medical malpractice cases are usually lower than those against hospitals.

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Take the case of Pedro Gonzalez, who was hit in the eye with a nail while working in the Pitchess Detention Center carpentry shop in 1994. Gonzalez, serving time on drug charges, removed the nail himself and complained to deputies and nurses that he needed medical assistance. However, his request was “ignored and dismissed,” his attorney Carol Watson wrote in her court filings.

Sheriff’s officials acknowledge that Gonzalez did not receive the care he needed: A doctor’s order asking that he be seen by a staff ophthalmologist was filed away for days. As a result, Gonzalez’s eye was not attended to until it was too late. An infection set in and he lost sight in his left eye.

The case was settled for $150,000, a fraction of what someone who was not in jail may have received, his attorney said.

“At least at that point in his life, he had a drug problem,” Watson said. “I was really worried about getting him in front of a jury.”

In another case, a diabetic inmate named Joe Villa--who was serving a six-month sentence in 1995 for a hit-and-run accident--fell in Men’s Central Jail when his crutch gave way. When he complained, he was ignored by deputies and nurses, according to his suit against the county. After gangrene set in, his left leg had to be amputated.

“The care that he got was egregious,” said Villa’s attorney, Keith M. Krupka. “The foot never would have been lost had he been given the appropriate care.”

Nevertheless, he agreed to a settlement for $60,000.

“It is the law in California: If you are a prisoner in the jail, you have rights,” Krupka said. “When you try a case to the jury, it shouldn’t be any different, but it is. Jurors have certain perceptions.”

Sheriff’s officials have declined to comment on the Villa case.

In June, the county agreed to pay $395,000 to the mother of a man who begged for his asthma medication but was not attended to promptly, sheriff’s officials say, because a guard thought he was feigning illness to get out of his cell. After four hours of making repeated requests for help, deputies finally let a trusty take the man to the medical clinic. By then it was too late. At 2:35 a.m. on Dec. 5, 1994, Daniel J. Bertoia--who was awaiting trial on arson charges--was pronounced dead, suffocated by an illness that had been previously controlled with treatment.

Two years ago, the Board of Supervisors approved a $1-million settlement to Antonio Mendoza, a diabetic whose leg had to be amputated after he was left in restraints for five days.

Attorneys representing the Sheriff’s Department argued that Mendoza’s “severe alcoholism and undiagnosed diabetes” caused the amputation “at least in part.” They said Mendoza--who was serving an eight-day sentence in 1993 for drunk driving--had to be restrained because he became a danger to himself and others while withdrawing from alcohol.

Nevertheless, the county lawyers ultimately recommended that the Board of Supervisors settle the case out of concern that a jury would award even higher damages. They acknowledged that there were serious problems with the care that Mendoza received.

“How does this happen in a medical facility?” said his attorney, Sonia Mercado. “Even if you are a hard-core mass murderer, we have no right to punish you more than the law will allow. . . . To allow a man to sit there for days while his leg rots is appalling.”

A year ago, the county agreed to pay $2.5 million to a mentally ill man who was released from jail and, disoriented, was crippled when he wandered into the path of a train.

County officials admit that the man, William Penuela, was grievously mistreated by employees of the Sheriff’s Department and the county Mental Health Department, which provides psychiatric counseling to mentally ill inmates, after his arrest in 1991 on suspicion of vandalizing a Glendale church. (The worst mentally ill inmates are placed in a 40-bed forensic inpatient ward, while dozens of others are housed in dank, single-person cells on suicide watch.)

For two weeks, Penuela languished without the pills he needed to control his paranoid schizophrenia. The case prompted an inquiry from the U.S. Department of Justice’s civil rights division, which led to the demand for improvements.

In an extensive report, issued in February, the department’s panel of experts likened the mental facilities at Men’s Central Jail to something out of medieval times.

“A discharge from mental health housing may be the only way to improve an inmate’s mental health,” according to the panel of mental health experts who toured the jails last year.

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Investigators also took issue with the care provided to Andra J. Reynolds, a schizophrenic woman who was transferred from Patton State Hospital to Sybil Brand Institute for Women in June 1996. Reynolds was found not guilty by reason of insanity in the 1987 fatal stabbing of her 4-year-old son. The woman, who said she killed the boy “to save him from the mark of the beast,” was ordered confined to a state mental hospital. She had been transferred back to Los Angeles County to attend a court hearing on whether she should be released.

However, while in the jail, “it appears that there were problems with the patient receiving the proper dosage of prescribed medications,” according to the report prepared by the Department of Justice experts.

As a result, the experts said, the woman started acting out, prompting sheriff’s deputies to place her in restraints. From there, she suffered the deadly pulmonary embolism, which originated in her “lower extremities,” according to a corner’s report. It also appears, the Department of Justice report said, that the inmate suffered from a rare, but potentially life-threatening disorder associated with the use of antipsychotic medications.

“A diagnosis of neuroleptic malignant syndrome was considered and testing was ordered to determine the proper diagnosis, but the testing does not appear to have been carried out,” the report said.

Furthermore, the woman’s medical charts were kept in a haphazard manner, the experts wrote. “The inmate’s medical chart indicates that she was pronounced dead at 2035 hours, but also indicates that CPR was begun and doctors called to her cell at 2100 hours,” the report said.

The woman’s family has since filed a wrongful-death suit against the county.

Sheriff’s officials say they are taking steps to keep more complete records on inmates who are restrained and placed in observation cells.

Graham said he also wants to send a strong message to jail deputies: Medical services are everyone’s responsibility.

“We have to change the entire culture not only of medical and mental health staff, but also our custody staff,” he said.

Meanwhile, Block has launched a campaign to raise private funds for computers to replace the handwriting-driven medical record-keeping system. However, even if the donations are secured, it would take several years before the computers, which would better track the dispensing of medication and keep all medical records, would be online.

That concerns local AIDS activists, who say numerous prisoners with HIV have reported going days without access to their life-prolonging protease inhibitors.

The Sheriff’s Department is under court order to have safeguards in place to ensure that it is providing medication to HIV patients. The decree came as part of a settlement from a 1994 case in which the county agreed to pay $17,500 to an inmate who went 10 days without the medication AZT.

Last September, the Los Angeles County Commission on HIV health services formed an ad hoc committee to look into HIV and AIDS services for inmates in the county jail. Committee members say they are deeply troubled by what they have found.

“You have to beg for drugs to keep you alive,” said Terry Grand, who is heading up the committee. “It’s horrible.”

“I think people do tend to forget that being an inmate in jail does not necessarily mean you were found guilty,” said Jacqueline Snyder, who works with AIDS patients at the Jeffrey Goodman Special Care Clinic in Century City. “If you are someone who is indeed guilty of a crime, then withholding medical care is not part of the punishment.”

To improve matters, sheriff’s doctors have begun handing out seven-day supplies of medication to some chronically ill inmates--including AIDS or asthma sufferers--as they are bookedinto jail.

Block says he hopes to fully open the medical and mental wards in Twin Towers by early next year--a move that would enable the department to improve the quality of care in a facility that has been specially built to handle modern medical needs.

The 200 medical beds in the Twin Towers wards--which feature an advanced air-filtration system aimed at preventing the spread of communicable disease--will include 50 beds for mentally ill inmates. To offset the cost of opening the new hospital facility, however, the sheriff will shut down wards at Men’s Central Jail. The department hopes to eventually refurbish the cells.

“We want to do whatever we can to ensure we are running a constitutional jail,” Block said.

Once the Twin Towers medical facilities are fully opened, officials hope to address another issue: Should the Sheriff’s Department hire an outside contractor to provide medical care in the jails?

Block said he has asked officials from the county Department of Health Services, which runs the county hospitals, to audit the services and issue an estimate on how much they would charge to take over the operation.

“Let’s face it, delivery of medical treatment is not one of our primary areas of responsibility as a law enforcement agency,” Block said. “But, as the operator of the largest jail system in the United States, it becomes a very important responsibility.”

He added: “When a problem comes to my attention, I will fix it. When I don’t make an effort to fix the deficiencies, then shame on me.”