The Los Angeles County Jail system lacks enough doctors, nurses and other medical workers to meet the most basic needs of inmates, resulting in long delays in treatment for conditions ranging from hernias to heart disease.
Breakdowns in medical care, including treatment errors by physicians and nurses, have contributed to the deaths of at least 14 inmates since 1999, a Times investigation found.
Understaffing has contributed to an array of medical problems in the nation's largest jail system, a review of court files, autopsy reports, jail records and other documents shows.
Broken bones have gone untreated. Illnesses have been overlooked. Inmates have waited days, or weeks, for exams they're supposed to receive within 24 hours of making a request. Twenty percent of inmates who ask to see a doctor are released from jail without ever being examined, officials acknowledge.
In a confidential report, a consultant said an additional 720 jail medical workers were needed to meet minimum state treatment standards. At the time, the work force stood at about 980.
"The county incurs significant liability for continuing a system of care that clearly is not working," the consultant said in the 2004 report to the Los Angeles County Board of Supervisors.
Spurred by those findings, officials began to bolster the ranks of doctors and nurses. But the system remains several hundred medical workers short.
Jody Kent, a court-sanctioned monitor who for three years walked the county's cellblocks documenting complaints for the American Civil Liberties Union, said she frequently saw inmates suffering.
She said inmates showed her what seemed to be gaping wounds from staph infections, broken bones and bulging hernias.
"I basically saw grown men crying because they were in such pain," Kent said.
Sheriff's Lt. Stephen Smith, who oversees the jail system's medical services bureau, said tending to sick prisoners is fraught with complications. He said some inmates conceal medical problems from their jailers, while others feign illness. Thousands are mentally ill.
"We face unique challenges, and we do the best we can," Smith said. "These are difficult, angry, messed-up people. We try to treat people with the respect, not that they necessarily deserve, but that human decency demands."
Smith cited recent improvements in the quality of care: Medical records have been computerized, allowing for better tracking of doctors' orders, and distribution of prescription drugs has been automated, reducing medication errors. He said the department plans to launch a "telemedicine" program that will expand the reach of doctors by allowing them to remotely diagnose and treat inmates via computer and teleconference.
Smith acknowledged, however, that staffing shortages still exist and "bad outcomes" occur.
Pamela Wimberley was serving a 30-day sentence for forging a prescription. On the morning of Feb. 10, 2003, she awoke in her cell in the Twin Towers jail downtown with a headache and fever. A nurse who examined her noted that Wimberley's blood pressure was up and her pulse was racing.
A doctor was informed over the phone, and he noted that Wimberley was diabetic and at risk of developing a respiratory infection. He ordered blood and urine tests to determine if that's what she had.
The order was never put in writing, however, and the tests were never done.
Instead, Wimberley was given a pain reliever and sent back to her cell.
The next morning, she saw a doctor -- the same one who had ordered the blood and urine tests. But the doctor did not check to see if the tests had been done. Rather, the physician concluded that Wimberley was suffering from a viral infection of the nose, throat and sinuses. She was given cough medicine and sent back to her cell.
Three days later Wimberley was seen by the medical staff again. Now she was experiencing chills, had a sore throat and had laryngitis. Though these symptoms can be signs of a bacterial infection, she was not placed on antibiotics. She was merely encouraged to drink lots of fluids.
On Feb. 15, five days after she initially complained, Wimberley's condition deteriorated. She had chest pains and difficulty breathing. Her pulse rate was high, her blood pressure low.
She was taken by ambulance to County-USC Medical Center in septic shock from bacterial pneumonia that had been ravaging her lungs. It was too late: Wimberley, 38, died two days later.
In response to a wrongful death lawsuit filed by her husband, county lawyers concluded that the treatment errors, including the failure to conduct blood and urine tests, "resulted in a missed opportunity to diagnose and treat Ms. Wimberley's condition, and are directly responsible for the results observed here."
The county settled the case for $150,000. The unidentified doctor who failed to follow up on the tests was suspended for three days.
Alan Wimberley said he felt frustrated and helpless as his wife tried to deal with her illness behind bars. He said she would call home in tears, complaining that no one would help.
"I was like, 'Honey, you're in jail,' " said Wimberley, an electrician from the Antelope Valley. " 'What can I do?' "
'I need my medicine'
An average of about 200,000 people enter the county jails each year. On most nights, the population hovers around 18,000, with more than a third requiring medical care. Many are in fragile health because of drug abuse, homelessness or chronic illness. For some, the only time they see a doctor is when they're behind bars.
The county Sheriff's Department, which runs the jails, is required by state law to provide basic medical care to all inmates -- 90% of whom have not been convicted of the charges against them.
It is a constant struggle.
When inmates are booked, they are questioned to determine if they are physically or mentally ill. About half require additional screening or treatment before being assigned to a cell. If inmates develop medical problems later, there are daily "sick calls" in which they can sign up to see a nurse in clinics throughout the sprawling system.
Inmates requiring constant attention, such as kidney dialysis patients, are housed in a 200-bed mini-hospital known as the Correctional Treatment Center in Twin Towers. Urgent cases are transferred to a jail ward at County-USC or to other area hospitals.
"Today's jail population is older and sicker than it was a decade ago," Smith said. "The healthcare system is broken on the outside, and we see that in here."
The volume of inmates, coupled with a shortage of doctors and nurses, has resulted in a backlog of hundreds of inmates waiting to be examined.
"I could have every doctor in the county of Los Angeles here, and it still wouldn't be enough," said Sander Peck, chief physician in the jail system. "I don't know what 'enough' would be."
A terminally ill inmate, Cynthia Barella, 48, was so desperate to see a doctor that she bashed her head against her cell wall, inflicting a bloody injury that could not be ignored, records show. Barella, who suffered from hepatitis, cirrhosis and other ailments, was then taken to a hospital, where she died the next day.
The difficulty getting medical care is illustrated in more than 10,000 confidential complaints filed by inmates from 2000 to 2005.
The records, reviewed by The Times, portray an overwhelmed system in which inmates literally beg to be seen for problems ranging from rashes to life-threatening illnesses. "I feel myself becoming unglued, anxiety attacks, unstable," wrote one woman who said her medication had run out two weeks earlier.
"Please," her hand-scrawled note read, "I need my medicine. Please."
Another woman complained that she had gone 11 days without her medication for Huntington's disease, a neurological disorder characterized by involuntary muscle movement.
"My motor control is going; my speech and memory are disintegrating daily," she wrote in September 2001. "Help me!"
The complaint form indicates that the woman told medical workers about her condition at the Inmate Reception Center in the Twin Towers complex on Sept. 7 and was prescribed Motrin. For the two weeks that she remained in custody, she was given no follow-up care, sheriff's documents show.
In another case, a male inmate complained that he had been vomiting bile and traces of blood, and losing weight for weeks, but that his requests to see a doctor had been ignored.
"This is well known by staff and inmates," he wrote. "I don't know what it's going to take to get proper medical attention, short of expiring." Several days after complaining, the inmate was prescribed ulcer medication.
Scores of female inmates complained of being unable to get medication for vaginal infections.
"I have a yeast infection or some kind of female infection, and I would like some medical attention," wrote one woman, who said she'd been complaining about the problem for weeks. "The discharge is getting worse, and I feel nasty and unclean. Please help me."
'No street criminal'
The case of Jerone Woods illustrates how errors, oversights and inaction have contributed to inmate deaths.
Woods, 55, entered the jail in September 1999 to serve time for drunk driving. He had told authorities he had diabetes, high cholesterol and hypertension, for which he was taking Pindolol. The drug controls high blood pressure by decreasing the force and rate of heart contractions. He brought his medications with him. But in keeping with jail policy, they were taken away to be stored and returned upon his release -- medications for inmates are supplied by the jail pharmacy.
Policy requires that inmates 55 or older be given an enhanced medical screening, including chest X-rays, lab tests and an electrocardiogram. When Woods was seen by a nurse at the Inmate Reception Center, the nurse erred by indicating on a form that he was not 55 or older.
Then came a second mistake: The nurse did not document that Woods had been taking Pindolol. Suddenly stopping the drug can trigger a heart attack. When the doctor briefly examined Woods a couple of hours later, jail records note, the inmate's blood pressure was "dangerously high." The doctor ordered that it be checked daily.
Because the doctor was relying on the nurse's form, he failed to order Pindolol.
Woods was transferred to a cell in Men's Central Jail. When he awoke the next morning, no one checked his blood pressure. He was assigned latrine duty, mopping bathroom floors, wiping toilets and cleaning sinks. At about 1:15 p.m., Woods had a heart attack. He was taken to a hospital, where he died an hour later.
A doctor and two nurses, whom sheriff's officials declined to identify, were punished for their treatment of Woods. The doctor was suspended for 10 days; one nurse received a five-day suspension, the other a one-day punishment.
County lawyers found that the failure to prescribe Pindolol and to monitor Woods' blood pressure "fell below the standard of care and may have directly contributed to Jerone Woods' ... death." The county settled a wrongful death suit by his widow, Joyce, agreeing to pay her $850,000.
In a recent interview, she said her husband worked more than two decades in the aircraft parts business, didn't miss church on Sundays and raised a nephew as his own when the boy's mother died.
"He was no street criminal," she said. "They took away a good man."
Artemio Barcenas-Jimenez was jailed in 2003 after suffering a skull fracture in a drunk-driving accident. A passenger in his car was killed in the crash, and Barcenas-Jimenez was charged with murder.
He complained of head discomfort and nausea.
"My head feels big," he told a nurse.
The nurse ignored the complaint, sheriff's disciplinary records show. After learning that Barcenas-Jimenez was having difficulty breathing, a doctor also failed to exam him.
He died two days later from blunt-force trauma complicated by diabetes, the coroner said. He was 34.
The nurse was suspended for seven days, the doctor for four, for ignoring the inmate's complaints.
In 2005, Louis Laskey was in a communal shower in Men's Central when he collapsed and began convulsing in view of 40 other inmates. As his face turned red, then blue, fellow inmates frantically shouted, "Man down!" in an attempt to get help. It took deputies up to 20 minutes to respond, the inmates said. Laskey, it turned out, had suffered a heart attack. He died later that day at age 49.
Two deputies were suspended 15 days for being slow to come to the inmate's aid.
Available records indicate that no disciplinary action was taken after the death of Henry Torres, a 32-year-old drug offender. Moments before his arrest in 2000, he tried to hide some evidence by swallowing it. Over the next two months, he complained to jail officials that something felt stuck in his throat.
Torres' mother, Yvonne Benavides, said her son would call from jail and complain that he couldn't breathe. He told her nurses gave him aspirin and cough syrup but wouldn't let him see a doctor.
Four times the inmate appeared before a judge as his drug case moved through the courts; four times the judges ordered that medical workers take care of his problem.
They X-rayed Torres' neck and found nothing. They X-rayed his chest and found nothing.
The fourth order, signed Dec. 26 by Superior Court Judge Michael Cowell, ordered an "endoscopy to observe obstruction in throat & any other appropriate testing and/or treatment."
None was conducted. On Jan. 1, 2001, Torres was found dead in his cell. The coroner concluded that he choked to death on a plastic syringe cap lodged in his throat.
The county settled a wrongful death suit for $250,000.
County supervisors and sheriff's officials have known for years that there were not enough doctors and nurses in the jails. In 2001, a deputy described the shortages in a memo submitted to the supervisors. A San Francisco consultant, Rebecca Craig, was hired to study the problem.
Craig's conclusions -- submitted to the county's top lawyer in April 2004 -- called for significant increases. More than 520 new doctors, nurses and pharmacists were needed, she wrote. An additional 200 clerks and other support staff were also necessary so nurses and doctors could spend more time treating patients and less doing paperwork.
County supervisors did not respond to inquiries from The Times about medical conditions within the jails or about the consultant's report.
Since 2005, the county has allocated about $20 million to hire 280 more nurses and 13 more doctors, officials said. The Sheriff's Department, however, has been unable to fill nearly 100 of those positions, in part because of competition from private hospitals and clinics.
Nearly 100 other nursing jobs have candidates but won't be filled until background checks are completed, a process that can take months. More than 150 clerical and other support positions remain unfilled.
Smith, the sheriff's lieutenant, said officials have made healthcare in the jails their top priority in budget requests and have secured steady but modest increases in funding in the last two years. That is the best that can be hoped for, he said, since inmates are not a political constituency.
"This is an underserved population for a reason," he said.
Gustavo Ortega, a 50-year-old insulin-dependent diabetic, was arrested March 1, 2004, for drinking in public.
After complications arose from his diabetes, he was taken to County-USC, where part of his right foot was amputated.
When he completed his sentence eight days later, he was given a pair of crutches and escorted to the lobby of the Inmate Reception Center in downtown Los Angeles.
But jailers failed to give Ortega his diabetes medication. Instead of going home, he curled up on a bench in the lobby-- and stayed there, apparently unnoticed, for three days.
Ortega's family learned that he was no longer in custody when his brother tried to visit him a day after his release. The family spent the next two days searching skid row and homeless shelters for him.
When deputies finally noticed Ortega in the jail lobby, he was pale, disoriented and bleeding from his mouth. Yet deputies waited nearly four hours before calling paramedics, county claim records show. Ortega died a short time later of coronary artery disease, with diabetes, chronic renal failure and hypertension listed as contributing factors.
Ortega's family sued the county. Going to trial, county lawyers said, would be risky.
"Experts will be critical of the jail personnel's failure to provide Mr. Ortega with diabetic medications ... and [their] delay to summon medical assistance," county lawyers wrote in a settlement memo.
County lawyers are seeking approval to settle the case for $700,000.
Times staff writer Jack Leonard and researcher Maloy Moore contributed to this report.