Sudden death behind bars

Investigators find questionable judgment in some Travis County inmate deaths

Sudden death behind bars

Investigators find questionable judgment in some Travis County inmate deaths

Story by Katie Hall
Published on July 12, 2019

Jail isn't supposed to be a death sentence, but for a few in the Travis County Correctional Complex at Del Valle's medical unit awaiting trial or sentenced to jail in 2018, it was. While in-custody deaths are rare at the correctional facility, experts say some recent deaths deserve extra scrutiny.

In one case, no one noticed 55-year-old Ronald Hall hurting himself and falling until an investigator watched the cell surveillance video after he died.

Hall had banged his head against the thinly padded wall of his jail cell almost 30 times one summer night in July 2018 and into the morning. Shortly before 7 a.m., a corrections officer saw Hall — a man who'd been diagnosed with bipolar disorder and was in jail for multiple DWI offenses — shaking on the floor.

“Hey, this guy is not going to die on me, is he?” the officer asked a nurse on the phone, according to the officer’s statement given later to investigators.

The nurse chuckled and said that’s the reason Hall was being housed in a padded cell, the officer told investigators. The officer said he then asked when he should call back to report on Hall’s status, and the nurse responded, “If he starts bleeding.”

By 10:20 a.m., Hall was dead.

They should’ve said, "This man keeps falling. Let’s check his blood levels, let’s see what’s going on. Let’s take him off these meds, let’s do something." Instead, they just said, "Oh, he's fine."

Tara Hall, daughter of inmate Ronald Hall who died July 2018

A Travis County medical examiner determined Hall's death was natural and the cause was heart failure because of high blood pressure — not his injuries. But Hall’s daughter said the jail staff should’ve noticed sooner that her father was acting strangely and should've noticed something was wrong.

“They should’ve said, ‘This man keeps falling. Let’s check his blood levels. Let’s see what’s going on. Let’s take him off these meds. Let’s do something,’” Tara Hall said. “Instead, they just said, ‘Oh, he’s fine.’”

Hall was being held in the Health Services Building of the jail, where physically and mentally ill inmates are placed. He was among five inmates to die in the correctional facility last year, four of whom were health services inmates.

Four is the highest number of deaths the Health Services Building has seen in at least a decade.

The American-Statesman reviewed 2018 investigation reports produced by Travis County Internal Affairs unit, and found that investigators flagged a few instances of questionable judgment by jail personnel in the days or moments that led up to some inmates' deaths.

The Travis County sheriff's office declined to discuss the jail death investigation reports obtained by the Statesman or the performance of the jail staff involved. While the reports concluded that the jail staff’s actions were not directly responsible for any of the deaths, investigators did raise questions about the level of supervision and care that inmates received in the Del Valle correctional facility's medical unit.


Six people died last year in the custody of the Travis County sheriff’s office. Five of those deaths happened in the Travis County Correctional Complex, and four of the six deaths happened in the jail’s Health Services Building.


One corrections officer, G.W. Williams, was suspended for a day earlier this year and received additional training over the incident involving Hall's death. His disciplinary records show he did not complete one of his required visual checks on Hall.

In another case, an officer told a nurse she had given the wrong medication to a 24-year-old inmate who later died, and she responded, "Am I supposed to f---ing care?" according to an internal memo. The nurse denied making the comment.

And in another report, an investigator wrote he was concerned that an officer did not immediately get help when an inmate was unresponsive.

Experts also raised serious concerns that two men younger than 25 died in the jail last year, with medical examiners determining that they both died of cardiovascular disease.

A nurse makes notes at the clinic in the Travis County Correctional Complex. Photo courtesy of Travis County sheriff's office

Isolation

Obviously, criminal justice experts said, jails are not hospitals.

“The tools we have are not the tools that a mental health hospital has, even though we have the same kinds of people who are in a mental health hospital,” said Daniel Smith, the mental health services director for the Travis County sheriff’s office.

The staffing level is the most drastic difference between these two, Smith said. The Travis County Correctional Complex in Del Valle has roughly 48 inmates for every officer.

Ronald Hall, right, with his daughter, Tara Hall. Ronald Hall was an inmate in the Travis County Correctional Complex when he died on July 8, 2018. Photo courtesy of Tara Hall

“In a hospital — it depends on the units — but you’re looking at (a ratio of) 1-to-12,” he said. “It’s a completely different setup. A suicidal patient is a one-on-one in a hospital. Literally, you sit here next to me while I watch you. Until that suicide risk is over, you’ve got a person with you.”

The Travis County jail system typically has about 20 people on suicide watch at any given time, Smith said. While state laws and jail policy require officers to check on these inmates regularly, laws do not require inmates on suicide watch be under constant surveillance.

When Hall banged his head and fell repeatedly, he was in a minimally padded room. Another inmate who died, 24-year-old Eric Taylor, "was on lockdown 24 hours a day and had no physical contact with anyone," according to a jail sergeant cited in a report by the Texas Rangers, who have been tasked with investigating inmate deaths.

Diana Claitor, director of the Texas Jail Project, a nonprofit that advocates for inmates and their families, said solitary confinement needs to be significantly reduced in jails across the country.

“I’m very concerned about the use of seclusion cells for mentally ill people. ... I’ve seen what isolation does to people who are already quite ill,” Claitor said. “And I recognize that there is no easy answer on this if a person is acting out. ... I recognize why some people may be put in those seclusion cells. But it is a terrible way of dealing with that, because it makes people sicker.”

The Del Valle correctional facility, like most jails, puts people in these cells a little too readily when it should be a last resort, she said. If a person is at risk for falls, Claitor said, a padded cell is not the answer.

Observation

In jails across America, quick visual checks are not enough to adequately assess how an inmate is doing, said Michele Deitch, an attorney who lectures on prison and jail conditions at the University of Texas.

“All the research around the world shows there’s no single factor that affects an inmate’s success more than the way the staff interacts with an inmate,” Deitch said. “A superficial passing through, laying eyes on an inmate — that’s at best a missed opportunity. As opposed to really engaging with them, finding out what’s going on with this person, finding out what problems they’re having, how they can help them — that’s the sort of thing that could actually go a long way.”

Naquan Carter, a 23-year-old who died at the correctional facility on July 24, 2018, was brought to Del Valle last summer from a mental health treatment facility outside Houston so he could attend his competency hearing on a charge of assault on a public servant.

On the morning of his death, jail surveillance footage captured something than an investigator flagged as strange. An officer seemed to linger in front of Carter's cell while checking on inmates and “kept going back and forth to inmate Carter’s cell between 9:30 and 9:38 a.m. while trays were delivered," the internal investigator wrote.

The officer twice went looking for another officer and passed in front of Carter’s cell, and when he returned to his desk, he didn’t sit down, the investigator said.

“I asked Officer Chidsey what was going through his mind at that time," the investigator wrote.

Chidsey — whose full name is not given in the report — told the investigator that he did not think that anything was wrong until 9:56 a.m., when he sounded the alarm about an unresponsive inmate.

Carter was pronounced dead at 10:39 a.m. The medical examiner ruled his death natural and, like in Hall's case, said that he died of heart failure due to high blood pressure.

Carter grew up in foster care and also spent some time in mental health treatment facilities, according to his sister, Mercy Mills, who was also raised by foster parents. Mills said she and the rest of Carter's family were saddened and in disbelief to learn of his death.

"It was a shock to everyone," Mills said.

The investigator recommended that the officer's supervisors look into the incident, but no disciplinary records about an investigation have been made available to the public. Travis County jail officials said the lack of documentation does not mean the incident was not reviewed, but the sheriff's office declined to confirm whether an investigation took place.

Jail officials declined to answer questions about specific inmate deaths, citing advice from county lawyers who say they shouldn’t comment while the two-year statute of limitations allows family members to file lawsuits.

A counselor speaks to an inmate at the Travis County Correctional Complex on May 29, 2019. Photo courtesy of Travis County sheriff's office

'Am I supposed to care?'

Jail death investigators in reports last year also noted other allegations that correctional facility nurses were dismissive — or in one case, outright disdainful — with patient care.

Taylor, the 24-year-old on lockdown, was given a different inmate’s medication instead of his own, according to a memo issued on the date of his death, March 31, 2018.

According to an officer’s recounting, nurse Susan Conway incorrectly called Taylor by the name “Jennings” before giving him medication.

The officer told an investigator that he “did a double-take and looked at the med pack tag, and it stated, ‘Larry Jennings.’ I told Nurse Conway, ‘That’s not Jennings. It’s Taylor,’ as she was giving Taylor the meds.’”

The report says the officer repeated this statement again until Conway finally said, “Am I supposed to f---ing care?”

The officer then checked the log, told Conway which cell Jennings was in and informed a supervisor nurse about what had happened. The supervisor nurse said she would check to ensure Taylor hadn’t taken anything that could cause him dangerous side effects.

It was later determined that Taylor, who had been found incompetent to stand trial after deputies accused him of chasing a child with a knife, was given medication that was not life-threatening, the memo says. Further details about his medication were redacted in the memo.

Conway declined to comment for this article. In disciplinary records, she denies she said what the officer alleged and, when asked why that officer would say that, she added that she had reported him to his supervisor not too long ago.

Nonetheless, a supervisor coached her on how to properly document medication errors and on the use of appropriate professional language and compassionate nursing care, disciplinary records say. The supervisor told her that the incident would be further investigated and could lead to possible disciplinary action if the accusation was verified. There is no record of further disciplinary action.

In 2007, Conway was reported as having an attitude of indifference during an emergency, and in 2017, she swore and got angry with a staff member, according to disciplinary records. In 2015, she reportedly forwarded an email containing a photo of the postmortem liver of a patient who had died in custody to sources not related to the incident, the records say.

Records from 2018 also show that an inmate thanked Conway for exemplary nursing care at the jail.

Travis County Correctional Complex on Wednesday June 19, 2019. [JAY JANNER/AMERICAN-STATESMAN]

Cardiovascular disease

The five inmates who died in the Del Valle correctional facility last year were as young as 23 and as old as 55. The Travis County medical examiner’s office determined that all five of their deaths were natural. Their causes of death were listed as follows:

Naquan Carter

Eric Michael Taylor

Arthur Westly

Donald Coor

Ronald Hall

● Naquan Carter, 23: hypertensive cardiovascular disease

● Eric Taylor, 24: atherosclerotic cardiovascular disease

● Arthur Westley, 48: cardiovascular disease

● Donald Coor, 50: heart attack

● Ronald Hall, 55: hypertensive cardiovascular disease

All but Coor were being housed in the Health Services section of the jail when they died.

Some of the men’s autopsies show they had previous health issues. Carter, for example, was overweight, and his body showed signs of hypertensive cardiovascular disease. After Taylor's death, doctors removed a "large piece of calcium" from one of his arteries, according to a Texas Rangers report that, citing autopsy doctors, says Taylor died of a specific form of heart disease in which his artery walls thickened and plaque began to build up.

Hall had a bevy of health issues. He had been a chronic alcoholic and had a history of cardiovascular disease as well as bipolar disorder with hallucinations, his autopsy says. He also had pneumonia at the time of his death.

Still, it is incredibly rare for men in their 20s to die of cardiovascular disease, said Dr. Kirsten Bibbins-Domingo, a medical doctor and professor at the University of California San Francisco who wrote a paper about cardiovascular disease in inmates.

“While one can find high blood pressure in younger people for sure, having your heart already exhibit the consequences of high blood pressure to such an extent that you end up dying of hypertensive disease would be highly unusual at age 23,” said Bibbins-Domingo, who chairs the university’s department of epidemiology and biostatistics.

Any case that involves a person in their 20s dying of cardiovascular disease should trigger increased scrutiny, she said. “You just don’t see that. If you heard that somebody you knew was 20 and this happened, they would definitely be doing autopsies. They’d be definitely calling in family members to figure out if there was some genetic risk.”

Taylor’s autopsy acknowledges this.

“Having severe atherosclerotic disease at such a young age would be indicative of a genetic component, and immediate family members should inform their doctors of the decedent’s cause of death,” the autopsy says.

Additionally, some of the Travis County inmates’ autopsies document head injuries.

There was a superficial cut on Taylor’s head, and he had swelling in the brain, but his autopsy does not say why. A corrections cadet described seeing blood on the back of Taylor's head, the Texas Rangers report says.

Hall’s autopsy found that he had a subdural hemorrhage but said that head injury was not related to his cause of death. Bruises and abrasions were scattered over his body.

Nurses and officers were aware that Hall had received a head wound. Two days before he died, he was taken to the emergency room for a fall that had happened a day prior, as well as for an “altered mental status” and hallucinations, according to his autopsy. However, a CT scan of his head during that ER visit “revealed no acute intracranial abnormality.”

“The altered mental status and hallucinations were attributed to his bipolar disorder and a recent change in his medications,” the autopsy says.

An officer walks through the Travis County Correctional Complex. Photo courtesy of Travis County sheriff's office

Investigations

The deaths of Hall, Carter and Westley are still being investigated by the Texas Rangers. The Texas Rangers found no evidence of a criminal offense in their death investigations for Coor and Taylor. In the past, the Travis County sheriff’s office investigated these deaths internally, but according to rules outlined in the 2017 Sandra Bland Act — named after the woman who investigators say killed herself in a Waller County jail in 2015 — outside entities must now investigate all county jail deaths in Texas.

The Texas Rangers investigated all Travis County correctional facility deaths in 2018, but the Travis County sheriff’s office has arranged for Round Rock police to investigate in-custody deaths in 2019 if Texas Rangers are not immediately available. The people who Round Rock police arrest end up in the Williamson County Jail, so the Round Rock Police Department could serve as an appropriate outside entity, officials said.

This decision was made after the Texas Rangers told Travis County sheriff’s officials that their resources were stretched thin, so the investigations could take a while, said Travis County sheriff’s Maj. Wes Priddy, who oversees the administration and support bureau of the sheriff’s office.

An inmate's death will still trigger a concurrent, internal investigation within the Travis County sheriff's office, Priddy said.

Better resources, better care

Deitch, Claitor and several other experts emphasized in interviews that the Del Valle correctional facility takes far better care of its inmates than the average Texas jail.

“Looking at the amount of complaints we get from the Travis County correctional complex, they’re definitely lower than the number of complaints we get from other jails of that size,” said Claitor, the Texas Jail Project director. "It’s a large jail — it’s one of the six largest jails in the state — so that tells us they’re doing some things right in terms of medical care and mental health care."

The jail has a lot of helpful programs for inmates because the sheriff's office has more resources and funding than most counties, she said.

"I believe they have a fairly decent rate of pay. I’ve had officers tell me how much they’d love to come and work there. So you get a higher quality and a better choice of staff," she said. "That being said, that doesn’t mean they’re doing everything they could.”

In 2018, 11 inmates died in the Harris County Jail, six inmates died in the Bexar County Jail, four inmates died in the El Paso County Jail and five inmates died in the Dallas County Jail.

The people who come into our facility, most of them are in our facility because they can't afford a bond. If they can't afford a bond, they often can't afford health care.

Travis County Sheriff Sally Hernandez

The officers who work in the Health Services Building are assigned there and do not typically rotate into other sections of the jail, officials said. They have regular briefings to address concerns about any inmates in the Health Services Building. They do not earn special pay. Special training is not required — all corrections officers receive training regarding mental health impairments, suicide detection and negotiating with people who are mentally ill — but additional mental health training is offered.

"When we're hiring, anybody who has prior experience working with this population, they're bumped to the top to be suited to this assignment," said Major Sally Peña, who oversees the corrections bureau of the sheriff’s office. "We're definitely working with people who generally want to serve this type of population. You have to have that in you, because it takes a certain skill set and patience."

In the past, jail officials proposed that the officers in the Health Services Building could occasionally rotate into shifts among the jail’s general populace to relieve those officers from one of the most challenging jobs in the jail, Peña said.

"The health building staff elected not to do that,” she said. “They didn’t want to divide their attention. They’ve formed good, positive relationships with the clients here. And they did not want to divide that attention. That spoke volumes to me, for staff to say that. They said, ‘We appreciate it, but no thank you.’”

Sheriff’s officials, on the advice of Travis County’s attorneys, said they could not talk about individual cases. However, they said each inmate death is treated seriously and investigated carefully.

"We take all of these matters very seriously," Sheriff Sally Hernandez said. "It's our duty to address them, and we do."

Officials emphasized that deaths are rare in the jail.

“It’s important to pay attention to the fact that we have over 40,000 people who are booked into our facility every year,” said Kristen Dark, sheriff’s spokeswoman. “Our average daily population sits around 2,300 to 2,400 inmates. A death in custody is shocking every time it happens — every time — and I don’t want to make light of it. I just want to make sure we’re clear that it’s a rarity … and we feel it every time."

Officials also acknowledged inherent risks with detaining people who are coping with some of society’s toughest problems, including poverty, addiction, homelessness or mental illness. At least two-thirds of the population in the Travis County Correctional Complex have substance use disorders, Travis County sheriff’s officials said. About one-third of the population is mentally ill.

Well over a thousand people a year are put on suicide watch in Travis County jails, sheriff's office spokeswoman Kristen Dark said. Last year, 36 inmates attempted suicide, but none died.

"The people who come into our facility — most of them are in our facility because they can't afford a bond," Travis County Sheriff Sally Hernandez said. "If they can't afford a bond, they often can't afford health care."

People are often already entering the jail “in a compromised state of health,” said Mary Gallo, the medical director for the sheriff’s office.

“We see a lot of folks where their health hasn’t been their priority,” she said. “Other things have been their priority — their money may go toward taking care of their family or groceries, and they just put themselves last. Oftentimes, people come in who are just in bad physical condition, and their pain tolerance is so high.”