Quality of Jail Medical Care Questioned

The Board of Supervisors will soon consider a new $22.9-million contract with a medical company that has treated local inmates since 1987 but has an unusually high rate of inmate deaths in Ventura County.

Law enforcement officials say they will ask the supervisors in January to approve a four-year contract with California Forensic Medical Group, a Monterey firm that provides health and psychiatric care in lockups for 21 California counties.

They cite low cost and high quality as chief reasons for rehiring the firm instead of accepting a rival $23.7-million proposal from Prison Health Services of Nashville, the nation’s largest provider of health care in jails and operator of the medical facility at Rikers Island in New York City.

California Forensic “provides an excellent level of service, far higher than required by state standards,” said Chief Deputy Kenneth Kipp, who oversees jail operations. Independent evaluators also give California Forensic good marks for medical care in local jails.

However, critics contend that California Forensic places profit above patient care and that the Sheriff’s Department overlooks the situation because it is not liable for malpractice lawsuits. The health firm’s insurance covers such losses, including two wrongful death lawsuits settled for a total of about $1.5 million in 1999.

Earlier this year, a Ventura County Superior Court judge harshly criticized California Forensic in a hearing for an inmate who requested temporary release partly to see his own doctor because of a painful swelling in his jaw.

“I have never been impressed with them, [and] I probably never will be impressed with them in the future,” Judge Arturo Gutierrez said. “They seem to dodge the issue as far as medical care. They don’t want to spend money to do it. My response is sue them.”

Gutierrez could not be reached for elaboration, and Kipp said the judge did not respond to his letter requesting an explanation.

California Forensic co-owner Dan Hustedt said his company is responsive to inmates’ needs.

“Anything that is going to severely affect an inmate’s health has to be taken care of,” Hustedt said. “We try to make the program as high quality as we can at all times.”

But state records show that Ventura County’s three jails have not fared well by one gauge of inmate care since California Forensic won the county contract 14 years ago, taking over for the county government’s own hospital and mental health agencies.

The death rate for Ventura County jail inmates from 1987-2000 was fourth-highest among the state’s 20 largest jail systems. Only Stanislaus, Los Angeles and San Francisco counties had higher death rates per year per 1,000 inmates. California Forensic also provides medical care in Stanislaus County jails.

For the seven years before California Forensic gained the Ventura County contract, typically one local inmate died each year. But that number has doubled on average during the firm’s tenure, and peaked at six in 1997.

Of the 30 deaths since 1987, one was a homicide, eight were suicides and 21 were classified as deaths by natural causes. The inmates’ average age at death was younger than 40.

Deaths in many cases were caused by chronic conditions, such as alcoholism and drug addiction, the coroner reported. Medical experts say the health of inmates nationwide worsened over the last decade as jails were flooded with mentally ill inmates and those with tuberculosis, hepatitis and AIDS.

Those trends are seen in Ventura County too. But a spate of 11 deaths in 1996 and 1997 focused attention on the quality of health care here.

Of particular note were the deaths of two young inmates, Raul Madera and Noel Perez. Each died after minor infections spread, and their families collected about $700,000 and $800,000, respectively. Attorneys maintained that California Forensic was understaffed and tried to keep costs down by not sending the inmates to a hospital until too late.

“They function like an HMO, and our concern was that medical care was falling through the cracks,” said lawyer Sonia Mercado of Los Angeles. “They had just one doctor. The psychiatric care was also really wanting.”

Ventura lawyer Earnest Bell, who has filed legal claims against the jail, insists that California Forensic delays costly hospitalization and surgery so it won’t have to spend money on the treatment of inmates serving only a few months in jail.

Bell sued California Forensic last week in federal court, alleging that a former Ventura County inmate was kept from getting an abortion last year while in custody. The county and the firm denied the charges.

“Based on the number of people who call me from jail, I would say the treatment’s bad,” Bell said. “I would give them a D minus.”

But Hustedt said his company is constantly reviewing treatment and responds when things such as inmate deaths occur.

“We react with changes based on our experience, and we do a lot of risk management and training,” Hustedt said.

One change since the deaths of Madera and Perez was the hiring of a second physician for the Ventura jails.

But Hustedt said it is not California Forensic’s job to solve every chronic medical problem an inmate may have.

“If the problem is something that can’t wait, then it has to be taken care of,” he said. “If it’s elective, that would have to wait.”

County officials say criticism of California Forensic misrepresents the level of treatment available in local jails.

County records show that sick inmates received 12 surgeries through the first nine months of this year. Inmates spent a total of 92 days in the county hospital, and 77 were treated in a hospital emergency room. Also, 292 inmates received specialty medical services, such as orthopedic or gynecological treatment.

California Forensic oversees jails in Ventura, Santa Paula and Ojai with about 50 employees, including the equivalent of 1.75 physicians and a 25-hour-a-week psychiatrist. By contract, a doctor is at a jail seven days a week, and on call 24 hours a day.

Dr. Richard Ashby, who ran the county jail infirmary until 1987 and still sits on a panel that regularly reviews jail medical practices, said care has steadily improved under California Forensic.

“I know this system from the inside out, and I know they’re doing a good job,” he said.

An indication of that quality, officials said, is that Ventura is one of 22 counties statewide accredited by the California Medical Assn. At least a dozen more county jails served by California Forensic are also accredited, according to the medical association.

“They come through with flying colors every time,” said Rebecca Craig, director of an institute that rates jails for the state medical association. “There are mistakes. That happens anywhere. But they’ve got a good quality management program, and it looks at corrective plans of action.”

Attorney Mercado questions what Ventura County’s jail infirmary did to improve after Madera, 23, of Oxnard and Perez, 19, of Port Hueneme died in custody nine months apart in 1996 and 1997.

Madera, a plant nursery employee in jail for drug possession and battery of his girlfriend, died of shock resulting from the spread of tonsillitis after 15 days in solitary confinement.

According to the coroner’s report, Madera’s father said his son’s voice was so hoarse it was unrecognizable the day after he left solitary and a week before his death. Infirmary records show he had swollen lymph nodes, was unable to swallow and was running a moderate temperature for two more days before being admitted to the county hospital.

He was treated overnight, then released back to the jail infirmary. The next day he was rushed back to Ventura County Medical Center, where he died a day later.

The Madera family maintained in its lawsuit that Madera was ill even while in solitary confinement, and that California Forensic pulled him out of the hospital to save money.

But a Sheriff’s Department lawyer, Phil Erickson, insisted that Madera returned to jail because the hospital staff misunderstood the level of care the patient could receive at the jail infirmary.

“There was a basic miscommunication,” Erickson said. “They thought it was a regular emergency-type infirmary, which it is not.”

Perez, an electronics plant worker in jail for driving under the influence of a controlled substance, died after a sinus infection spread to his brain and festered, the coroner reported.

The teenager was on antibiotics when arrested 19 days before his death. After 12 days in jail, Perez had a seizure and was taken to the county hospital, where pus was drained from his brain. His condition apparently improved for five days, and he was transferred to the main hospital floor, where he later collapsed and died.

Mercado said the problem in the Perez case was that before hospitalization, as the infection worsened, a nurse thought the inmate was feigning sickness to get her attention.

“So there was a different attitude on how they should treat these guys--they treat them as little pretrial criminals,” she said. “The standard of care is [supposed to be] the same as on the outside, but the attitude within custody was not as professional.”

Mercado said she was told the county initiated reforms after the deaths of Madera and Perez, hiring a second doctor and replacing the chief physician and head nurse who had run the infirmary.

After the two deaths, as with every inmate fatality, California Forensic called a “peer review” to determine what mistakes were made, if any, and to make necessary changes, sheriff’s lawyer Erickson said. The company also hired an outside doctor to do a review.

Kipp said personnel changes have been made in recent years at the jail infirmary because of career opportunities, not because of the deaths.

Kipp said the relatively high number of jail deaths in Ventura County is not a reflection of quality of care.

“I don’t believe that’s a condemnation of [California Forensic],” the chief jailer said. “We’re dealing with a population of people that are the sickest segment of our community. These people, generally speaking, are those who have fallen through the safety nets for medical and mental health care in our community.”

Sheriff’s Cmdr. Mark Ball, Kipp’s top assistant, said significant changes have been made since 1997 that now keep inmates from killing themselves. The jail had five inmate suicides from 1994-97 but has had only one, by hanging, in the last four years, records show.

“There are a significant number who claim to be suicidal,” Ball said. “They are put in a padded safety cell in a safety smock. They’re checked two times every 30 minutes.”

They are closely watched for 72 hours, until the urge to take their own lives fades away, he said.

Dr. Aref Bhuiya, California Forensic’s medical director for the jails, said two inmates have died since he took over in July 2000. A woman died of heroin-related illnesses and chronic liver disease, and a man died from the effects of a strong heroin addiction, he said.

“Both cases were reviewed and both were found not to be our fault,” Bhuiya said. “Cost is not an issue here. If somebody needs something, we do our best to provide it.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Deaths in California Jails

20 largest county jail systems, 1987-2000 *:

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Total Deaths Deaths per year per County deaths per year 1,000 inmates ** Stanislaus 33 2.36 2.20 San Francisco 45 3.21 1.69 Los Angeles 451 32.21 1.68 Ventura 28 2.00 1.43 Tulare 22 1.57 1.35 San Diego 89 6.36 1.31 Alameda 75 5.36 1.30 Sacramento 53 3.79 1.21 Kern 33 2.36 1.16 San Joaquin 20 1.43 1.16 Santa Barbara 14 1.00 1.13 Riverside 41 2.93 1.11 Sonoma 16 1.14 1.08 Contra Costa 23 1.64 1.03 San Bernardino 73 5.21 1.02 San Mateo 15 1.07 0.93 Fresno 28 2.00 0.84 Santa Clara 48 3.43 0.82 Orange 42 3.00 0.63 Monterey 6 0.43 0.45

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* California Forensic Medical Group began providing medical care for Ventura County inmates in 1987.

** Based on jail populations in 2000

Source: California Department of Justice

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Ventura County Jail Deaths

Inmate deaths when Ventura County hospital and mental health agency provided health and psychiatric care:

*--*

Total Year deaths Natural Suicide Homicide 1980 2 1 1 0 1981 0 0 0 0 1982 1 1 0 0 1983 1 0 1 0 1984 1 1 0 0 1985 1 0 1 0 1986 0 0 0 0

*--*

Deaths per year: 0.86

Inmate deaths when California Forensic Medical Group provided health and psychiatric care:

*--*

Total Year deaths Natural Suicide Homicide 1987 2 1 1 0 1988 3 2 1 0 1989 0 0 0 0 1990 1 1 0 0 1991 0 0 0 0 1992 1 1 0 0 1993 0 0 0 0 1994 2 1 1 0 1995 3 1 1 1 1996 5 3 2 0 1997 6 5 1 0 1998 0 0 0 0 1999 4 3 1 0 2000 1 1 0 0 2001 2 2 0 0

*--*

Deaths per year: 2.00

Source: California Department of Justice