Should we fix the jails or get addicts out of them?

What went wrong, Part 2

by Jordan Green

The first installment of this story, published on Sept. 30, introduced Jen McCormack, a high-spirited 31-year-old who became addicted to a prescription painkiller and suffered a heart attack while awaiting trial in the Forsyth County jail. She was 18 weeks pregnant at the time. A disclosure here: I knew Jen through a circle of friends, mainly UNCG alumni, who gathered at parties held at our mutual friend, LaToya Winslow’s apartment on Mendenhall Street in Greensboro. Like most of her friends, I had no idea that Jen had developed a dependency on opiates and was shocked to hear about first her arrest and then her death.

Episodes of incontinence and falling, as detailed in jail incident reports, raised troubling questions about the quality of Jen’s treatment under the care of medical staff employed by Correct Care Solutions.

What remained unanswered in the first installment was what level of culpability the Forsyth County Sheriff’s Office and Correct Care Solutions hold in Jen’s death, and more importantly whether addicted persons, particularly pregnant women, should be locked up instead of receiving treatment while they face criminal charges.

What happened to Jen McCormack in the Forsyth County jail sometime before 10:33 a.m. on Sept. 13, 2014 is described in an official report by a county medical examiner as the “onset of injury or illness” — more specifically, cardiac arrest.

Once she arrived by ambulance at the emergency department at Winston-Salem’s Baptist Hospital, staff intubated her and induced hypothermia to lower the temperature of her brain and prevent it from shutting down due to lack of oxygen and blood flow, according to a report by Dr. Patrick Lantz, a pathologist at Baptist. The procedures appear to have made little difference considering that Dr. Lantz’s postmortem report next indicates that Jen was transferred to the intensive care unit, where she developed hypoxic ischemic brain injury and was mechanically ventilated until Sept. 18, when she died after her family made the decision to remove her from life support.

Jen’s father and brother, respectively John Sr. and John Jr., received the news in Pennsylvania, where they live.

“She had already gone to the hospital when we found out, me and my father,” John Jr. recalled. “I’ve never seen my dad cry except when he had to pass me or my sister off because our parents are divorced. He cried when he called and said, ‘We have to go down to North Carolina; your sister is in critical condition.’ We made a mad dash, and made it there in six hours.”

Working backwards from the cardiac arrest, Dr. Lantz’s postmortem external examination lists the probable cause of Jen’s death as hypoxic ischemic brain injury — the two terms refer to depletion of oxygen and blood flow, respectively. That primary cause of death, Dr. Lantz determined, was triggered by a cascading sequence of crises. From most proximate, they include complications of acute renal failure — another way of saying kidney failure; hyponatremic dehydration — a deficit of body water accompanied by low sodium; and finally, decreased fluid intake.

Put aside for a moment that one physician I contacted — Dr. Robert Newman — challenged the probable cause of death findings; maybe they don’t tell us all that much about what went wrong for Jen while she was awaiting trial in the Forsyth County lockup on charges of prescription drug fraud.

“Pathologists are very limited,” Dr. Jacquelyn Starer, a consulting physician in Massachusetts with extensive experience in addiction treatment, told me. “The cause of death can’t tell you whether someone received adequate medical care. You can’t rely on an autopsy for that. The end cause of death is often very similar in very different types of cases because your information is so limited. You need all the medical records to determine what happened.”

There are a lot of important details that we still don’t know:

• Janis, Jen’s mother, said that she was treated with Suboxone — an opioid medication that contains the drug buprenorphine and is used to treat narcotic addiction — when she underwent a drug-treatment program at Forsyth Medical Center in the eight days prior to her incarceration. Janis reported that she turned over the Suboxone to the jail authorities so Jen could continue treatment, but Correct Care Solutions has declined to address whether they continued Jen’s Suboxone or any other kind of medication-assisted therapy.

• Janis also said that Jen had a prescription for Xanax, an anti-anxiety medication, but that jail officials refused to allow her to bring the medication into the jail. We don’t know if Jen had access to Xanax or any other benzodiazepines — the active ingredient in the drug — while she was in jail.

• We don’t know why Jen was transferred out of the jail for off-site medical treatment on Sept. 3, 4 and 8.

• The jail logged an unexplained incident on Sept. 9, but the county declined to release the report on that basis of it being a “medical record” and “not within the purview” of North Carolina public records law. So we don’t know what happened on that date.

What is clear is that more and more women who are pregnant and addicted to opioids are likely to wind up in local jails in North Carolina and across the country, often without access to adequate medical care, not only endangering their health but also jeopardizing their pregnancies.

Rates of “opioid-exposed pregnancies have risen sharply across the state,” according to the NC Pregnancy & Opioid Exposure Project, a collaboration between the UNC-Chapel Hill School of Social Work and the state Division of Mental Health. As an indication of the number of pregnant women struggling with addiction — who by virtue of their substance use are likely to wind up in the criminal justice system — the rate of hospitalization associated with drug withdrawal in newborns multiplied fivefold from 2004 to 2012, according to the State Center for Health Statistics.

“The incarceration of addicted pregnant women is one of the major crises of our times,” Dr. Starer told me in an email, “and immediate criminal justice reform is needed. But, even with the status quo, incarcerated persons should receive appropriate and humane medical care, which is certainly not my impression of the care given in this account.”

‘Torture or a lingering death’

To make a successful claim for legal redress, prisoners must prove that prison or jail officials acted with deliberate indifference.

The standard was established the 1976 Estelle v. Gamble case, in which the US Supreme Court ruled that deliberate indifference to an inmate’s serious illness constitutes cruel and unusual punishment, in violation of the Eighth Amendment. Writing for the majority, Justice Thurgood Marshall cited “the government’s obligation to provide medical care for those whom it is punishing through incarceration.”

The definition of “cruel and unusual punishment” goes back to the re Kemmler case, decided in 1890, in which the court articulated that “punishments are cruel when they involve torture or a lingering death.”

“In the worst cases, such a failure may actually produce physical ‘torture or a lingering death,’ the evils of most immediate concern to the drafters of the Amendment,” Marshall wrote. “In less serious cases, denial of medical care may result in pain and suffering which no one suggests would serve any penological purpose. The infliction of such unnecessary suffering is inconsistent with contemporary standards of decency as manifested in modern legislation codifying the common law view that ‘it is but just that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.’”

Deliberate indifference might play out with jail or prison guards “intentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed,” Marshall added.

John McCormack Jr., Jen’s brother, declined to comment on whether the family is planning to file a lawsuit.

Whether or not the Forsyth County Sheriff’s Office and Correct Care Solutions demonstrated deliberate indifference in failing to adequately respond to Jen’s medical problems would be up to a court to determine should Jen’s family decide to pursue a claim. The more important question might be why we’re locking up people who are sick and in need of treatment.

To recite some of the information previously published in the first installment, Jen was booked in the Forsyth County jail at 12:46 p.m. on Aug. 28, 2014. Her intake report indicated that she was “experiencing withdrawal,” and another booking document noted, “Pregnant!”

“I would speculate that a lot of what should have happened, didn’t happen,” Dr. Starer said. “The standard management for a pregnant woman with opioid dependence would be for her to be treated throughout the pregnancy with either methadone or buprenorphine.

“When she went into jail she would have been continued on that medication or transitioned to methadone if buprenorphine was unavailable, but if she had a prescription she should have been able to receive buprenorphine,” Starer continued. “Unfortunately, a lot of jails and prisons don’t allow opioid agonist treatment in jail.”

As reported previously here, a National Institutes of Health consensus panel recommended methadone maintenance as the standard of care for pregnant women addicted to opiates in 1998, according to a protocol published by the US Department of Health and Human Services. And a committee opinion reaffirmed by the American College of Obstetrics and Gynecologists warns: “Abrupt discontinuation of opioids in opioid-dependent pregnant women can result in preterm labor, fetal distress or fetal demise.”

There is no state law or regulation in North Carolina requiring local jails to continue medication-assisted therapy for individuals who are prescribed buprenorphine or methadone to treat opioid addiction. Drug treatment is a hodgepodge of different practices across the state’s 100 counties. Each county jail maintains its own medical plan, which is approved by the county public health director, said Alexandra Lefebvre, a spokesperson for the state Department of Health and Human Services.

The Durham County Detention Center is a rare example of a local jail where inmates who come in with a prescription for methadone continue to receive treatment, said Melissa Godwin, a clinical instructor at the UNC-Chapel Hill School of Social Work.

“It is not seen by and large that county jails are set up to provide substance abuse services,” Godwin said. “The norm is to not have any medication-assisted treatment for opioid use disorder.”

Lonnie Albright, an assistant county attorney with Forsyth County, said the jail does not have a policy on whether to provide medication-assisted therapy to addicted individuals who come into the system with a prescription, referring questions to Correct Care Solutions, which he said holds responsibility for such decisions. Karla West, a spokesperson for Correct Care Solutions, declined to comment for this story.

“I think it was straight cold turkey when they took her in jail,” said John Jr., who is about 18 months younger than his sister. “From what my mom told me, she had nothing.”

The first sign of trouble for Jen came on Sept. 4, her ninth day in jail, when Pfc. McBride discovered through the camera monitoring system that she was on the floor, while observing “a large puddle of water on the floor and the cell was not sanitary,” as noted in the incident report. Jen reported that she had fallen, and the detention officer “moved the bed that appeared to have trapped her against the wall.”

“If she was allowed to go into withdrawal, that could lead to a number of problems,” Dr. Starer told me. “Additionally, if she wasn’t allowed to take her Xanax, that would have also caused a lot of problems — if she had been consistently taking Xanax prior to coming into jail. The largest risk of Xanax withdrawal is seizures.

“If you see someone who has fallen down and become incontinent of urine and trapped against the bed, my first thought was that this person had a seizure,” she added.

Three different physicians across the country who reviewed for this story Jen’s postmortem and jail incident reports expressed concern about the possibility of withdrawal from benzodiazepine, the active agent in Xanax.

But Dr. Spencer Greene, the director of medical toxicology at Baylor College of Medicine in Houston, said in his opinion the symptoms Jen presented are not consistent with benzodiazepine withdrawal.

“Her findings as well as her lab results are more consistent with a combination of starvation and dehydration and under resuscitation prior to arrival at the hospital,” he said. “The timing is also not typical for benzodiazepine withdrawal.”

Dr. Greene’s opinion dovetails with the analysis of Dr. Lantz, the Baptist Hospital toxicologist who performed Jen’s postmortem exam.

“Looking at her laboratory values, when she came in being dehydrated, with her kidney function test it indicates that she was dehydrated,” Lantz told me. “She had kidney failure and all the complications thereof. It matches fairly well unless there was something else going on.”

Lantz’s postmortem exam, reported on a standard form issued by the state Department of Health and Human Services, checked off manner of death as “natural.” As a matter of course, reports by county medical examiners are reviewed by the state Office of the Chief Medical Examiner, which holds the authority to override the local examiner’s findings. On Jen’s postmortem, Dr. Nabila Haikal, an associate chief medical examiner at the state office changed the manner of death finding from “natural causes” to “undetermined.”

State officials determined that a hunger strike allegedly undertaken by Jen “contributed to her death, and although not strong enough to determine her death as a suicide, a natural classification was also not appropriate,” said Alexandra Lefebvre, the spokesperson with the state Department of Health and Human Services. Lefebvre said state officials based their conclusions that Jen was engaging in a hunger strike on information in Lantz’s report, which in turn comes from detention officers at the jail. Janis, Jen’s mom, has said in the past that she disagrees with the characterization.

An incomplete picture

“History received from detention officers: She had been incarcerated 2.5 weeks prior, and while in detention center she was placed on suicide precautions,” Lantz wrote in his postmortem report. “She had been on hunger strikes attempting to starve herself, spitting out food and liquids for a number of days. She refused to drink or eat most of the time.”

Incident reports filed by detention officers in some ways contradict the accounts staff provided to Dr. Lantz, and include critical details omitted from Lantz’s report. Those details would have put events in a different light.

Four incident reports authored by detention officers make no mention of Jen “spitting out food and liquids,” as Lantz wrote, although the reports indicate she was experiencing a loss of appetite and refusing to eat.

The postmortem report completed by Dr. Lantz makes no mention of multiple incidents of Jen falling and urinating on herself, which are documented in the jail incident reports.

Lantz told me he doesn’t recall seeing any reference to those incidents in any of the reports he reviewed, but he added that had he seen the information he doubted that it would have changed his conclusions.

Dr. Robert Newman, a former assistant commissioner for addiction programs for the New York City Health Department who was responsible for implementing the city’s methadone program in the early 1970s, challenged Dr. Lantz’s conclusions about the likely causes of Jen’s death after reviewing the report.

“The medical examiner’s entries under the heading ‘probable cause of death’ seem to me to be totally unsupported — and, indeed, refuted by the limited information available,” Newman said. “Nothing confirms the cause of death: ‘hypoxic ischemic brain injury’ — what brain injury? When did it ostensibly occur? Examined by what medical facility? Treated how? Observation period after the ‘injury’?”

Lantz’s postmortem report alluded to the fact that Jen’s suicide watch required that jail staff conduct observation checks on her every 15 minutes. The contrast between the check reported at 10:15 a.m. and the one at about 10:30 on the morning of her sudden failure of health is jarring.

“At her 10:15 check, she was alert and mentation was appropriate,” Lantz wrote. “Around 10:30 she was found to be slightly discolored, a nurse was called and she was determined to have a weak pulse. Shortly after no pulse found, CPR initiated.”

Lantz told me in a recent interview: “It does seem a little odd that she would be found unresponsive just 15 minutes after being checked and found alert. I’m not sure what the check entailed. They may have thought she was sleeping.”

If Jen had been sleeping during the reported 10:15 a.m. check, it’s hard to understand how she would have been “alert.”

Newman told me that the implication that Jen “died as a result of lack of fluid intake seems to me preposterous. She was under constant supervision — every 15 minutes. At 10:15 she is said to be ‘alert and mentation appropriate.’ Eighteen minutes later she was ‘discolored’ and unresponsive and without a pulse. The timing itself would have demanded a full autopsy.”

Under state guidelines, the decision of whether to perform an autopsy, as opposed to a more limited external exam, is up to the county medical examiner.

“Based on her period of hospitalization she was here [at the hospital] for six days,” Lantz told me, explaining his decision not to perform an autopsy. “There wouldn’t have been much to learn from an autopsy. If she had come directly from the jail and died, it would have been a different matter.”

The theory that Jen was carrying out a hunger strike and suffering from dehydration is confounded by reports that on at least two occasions she experienced significant urinary incontinence, suggesting that she was taking in at least some water.

Going back to Jen’s ninth day in jail — also nine days before she was found unresponsive — when she was discovered trapped against the wall by her bed with a large amount of urine on the floor, Nurse Carol Surratt advised Jen “to eat her meals and slow down drinking water,” according to the report filed by Pfc. McBride.

“They probably told her to slow down on drinking water because of the incontinence episode,” Dr. Starer told me, “because there is no medical reason for that advice.”

Starer’s theory that Jen had suffered a seizure puts the official story that she was on hunger strike in a different light.

“When you have a seizure you go into a fugue,” Starer said. “You wouldn’t really be inclined to eat.”

A theme of the jail incident reports is the suggestion that Jen was faking her symptoms.

“Inmate McCormackschuler has been refusing to walk or use the toilet on her own,” Pfc. McBride wrote again on Sept. 13, using a compound of Jen’s last name and a name from her previous marriage. “Medical has stated that Inmate McCormackschuler is capable and there is no medical reason at this time that she cannot walk on her own.”

The report was made scarcely eight hours before she was found unresponsive in her cell.

Dr. Jody Rich, director of the Center for Prisoner Health and Human Rights at Brown University in Rhode Island, said there could be some truth to staff’s characterizations about Jen’s behavior.

“The truth is, they probably often do have patients who malinger, act out, deliberately pee all over themselves and worse,” he said. “And who knows, I am sure she felt miserable — maybe some of her behavior was deliberate.”

Pfc. McBride’s reference to Jen’s urinary incontinence on the eve of her collapse adds a curious twist to the theory that dehydration contributed to her death.

“The active suicide gown that had been issued to Inmate McCormackschuler was underneath her and soaked with urine,” McBride wrote. “We could not mop up the mess around her with her in the cell without producing a hazard.”

Dr. Starer said in her opinion the episode is “not consistent with dehydration.”

While maintaining that he hadn’t been aware of the urinary incontinence episodes, Dr. Lantz made a statement that seems to cut against his position.

“Toward the very end if she was dehydrated you wouldn’t expect her to urinate because the kidneys have a mechanism to hold on to as much water as possible and the urine will be concentrated,” he said.

After Jen was relocated to a new cell, McBride reported that she “refused to respond to directives and just stared at officers.” The report goes on to say: “Medical assisted by placing an ammonia capsule under her nose. At that time Inmate McCormackschuler held her breath and medical administered a chest rub to get her to respond.”

The report struck Dr. Starer as odd when she read it.

“You do a chest rub to see if somebody’s conscious, but if she’s staring at officers then she’s conscious,” she said. “None of that makes sense.”

Starer added that in her opinion Jen should have been transferred off site long before the episode on the eve of her collapse.

Dr. Lantz suggested that any judgments about whether Jen should have been transferred to a hospital earlier can’t help but be colored by the knowledge that the worst ultimately transpired.

“That would be in hindsight,” he said. “It looks like if she transferred earlier it may have made a difference. Then again, it’s going to depend on protocols and everything else as far as what all the factors were.”

John Jr.’s perspective on the relative quality of care Jen received at Forsyth County jail is informed by his family’s history of involvement in the detention industry. His parents worked together in the profession, and John Sr. has continued to operate detention centers while Janis has spent much of her career working in dispatch for police departments. As a child, John Jr. spent time hanging around detention centers and developed a familiarity with their processes.

“I don’t know if she was having a hunger strike,” he said. “I know for a fact with my family if it becomes a danger to the person they’re going to force them to go to the infirmary to get IV. That’s what’s always done in a jail. It’s amazing to me that not only as an addict, but also as a pregnant woman she had to be their priority. She’s a pregnant woman going cold turkey off opiates, which is going to make her sick.”

Along with being unaware that Jen had been falling and urinating on herself, Lantz was also not informed that Jen was released from custody a day prior to her death. He marked on her postmortem report that she Jen’s “death occurred while in custody.”

“I didn’t know that,” Lantz said. “That never got passed down to me. Technically when someone comes from the jail I would assume they were in custody. If a district attorney did give an order to lift the bond I had no knowledge of that.”

As a bizarre coda to the story, John Jr. said when he arrived at Baptist Hospital, the sheriff’s office was limiting the family to 20 minutes with Jen per day, so that each person was allowed to spend five minutes with her. A sheriff’s deputy was posted in Jen’s hospital room throughout, until the family worked one of Janis’ law enforcement connections to get Jen released from custody so they could have full access to her before they took her off life support and allowed her to pass.

John Jr. couldn’t handle the hospital room scene, and left two days prior to Jen’s death to spend time with his grandfather in Kernersville.

“To have a sheriff looking over her and to hear my last words to my sister felt degrading,” he said. “And a needless use of force. There was no reason why they needed to waste resources to watch her.”

‘She needed a higher level of care’

Dr. Jacquelyn Starer, the physician from Massachusetts, said that overall it sounds like Jen was “horribly mistreated,” adding that the tragedy could have been avoided if the authorities had looked for alternatives to incarceration.

“She needed a higher level of care,” Starer said, “and it sounds like whatever level of care she received made her problems worse.”

Considering his family’s background in law enforcement, John Jr. said he appreciates that his sister needed to be held accountable for her crimes, of which she was evidently guilty. But he also believes there’s a right and wrong way to run a jail.

“I believe that what happened with my sister was that nobody was paying attention, and once they found her in cardiac arrest it was too late,” he said. “People were careless. You’re going to have people walk away from their post. They’re not owning up to anything that went wrong.”

Dr. Jody Rich, the director of the Center for Prisoner Health and Human Rights at Brown University, suggested Jen’s death should raise questions about the decision to hold her in jail as much as about the quality of care she received there.

“Jen’s death should prompt people to ask themselves if society did right by her in processing her through the criminal justice system,” Dr. Rich said. “Apparently, she did break the law,” he said, “and yet, the blind enforcement of the law in this instance resulted in the most tragic outcome of all.”

Melissa Godwin, the clinical instructor at the UNC-Chapel Hill School of Social Work, said she would like to see individuals in jail have better access to buprenorphine and other medications approved to treat opioid addiction — both for the health of the women who are incarcerated and their pregnancies.

“That does jeopardize the pregnancy, and that is what frequently happens in the jail: Pregnant women are forced to go into withdrawal, which does create potential complications for the pregnancy,” she said.

“I think it would be terrific if that issue were looked at in all 100 counties in how those services are provided to not just pregnant women, but all people who are coming in and having that aspect of health addressed, as well as high blood pressure and other conditions,” Godwin added.

In broad strokes, there’s a growing cry for more treatment and less incarceration.

“The take-home for me is, we need more treatment of addiction, we need more alternatives to incarceration, we certainly need more services for pregnant women with addiction, and we need more examination of what actually works,” Dr. Rich said. “Even if she had not been pregnant and had not died, it is unlikely that her time incarcerated would have stopped her from relapsing to drug use — in fact, it likely would have made things much worse than if she had gotten good quality addiction treatment and support.”