The family of a man who died from an asthma attack at the Forsyth County jail has filed a wrongful death lawsuit against the medical provider at the jail.
DeShawn Coley died at the jail on May 2, 2017, one of two men who died in the jail that month. Stephen Patterson was found unresponsive in his cell on May 26, 2017 and was later found to have died from “probable cardiac dysrhythmia due to hypertensive cardiovascular disease,” according to his autopsy. Patterson’s son filed suit against the medical provider in December 2018.
The suit filed by Coley’s mother as administrator of his estate names Correct Care Solutions, which held the contract at the time of Coley’s death, along with WellPath, a successor company, as defendants. WellPath was formed in 2018 through a merger between Correct Care Solutions and Correctional Medical Group Companies, according to the company website. Coley’s suit also names as defendants six employees working as nurse practitioners, registered nurses and licensed practical nurses.
The suit contends that medical staff at the jail was aware that Coley, who had made at least nine emergency-room visits in Winston-Salem in the previous six months, was being treated for asthma and using inhalers when he was admitted to the jail on April 20, 2017 to serve a sentence for traffic violations. The information was documented in a “receiving screening” document e-signed by two nurses; on the same day nurses approved a referral form allowing Coley to be seen by a physician for his asthma, then faxed requests for Walgreens and CVS for his medication history.
The lawsuit alleges that staff repeatedly failed to provide Coley with his medication and inhaler over the next several days.
The complaint includes an inmate grievance statement handwritten by Coley two days before his death, stating, “I feel that my life is in jeopardy because I have severe asthma and I can’t get my inhaler when needed. I have asked over and over that something be done to no response. My next step is to bring someone of a higher power into it.” Coley continued, “Call my doctor so he can explain. I take steroids but I didn’t have any. Please someone respond.” The lawsuit alleges that Walgreens and CVS had returned Coley’s prescription records to Correct Care Solutions, confirming that he had been receiving prescriptions for Prednisone, described as “an oral steroid commonly prescribed for the treatment of asthma.”
The suit cites a report by an Officer Inman that he observed Coley as exhibiting labored breathing and being unable to speak in complete sentences on May 1, when Nurse Carol Surratt — named as one of the defendants — administered his albuterol nebulizer treatment. The lawsuit said Inman observed Coley “request several times to be taken to the emergency room,” and alleges Surratt “stated that was not going to happen.”
The lawsuit says about two and a half hours later an Officer Haynes called Nurse Kristen L. Johnson — also named as a defendant — and told her Coley was having difficulty breathing and requesting his inhaler again. Johnson allegedly told Haynes it was “not time” for Coley to use his inhaler. In response to attempts by multiple officers to get Johnson to come to Coley to administer the inhaler, the lawsuit alleges that Johnson insisted the officers bring Coley to the medical unit. While officers were wheeling Coley to the medical unit, he went into respiratory arrest and was confirmed dead at 2:43 a.m. after unsuccessful resuscitation efforts by detentions officers, along with personnel from Forsyth County EMS and the Winston-Salem Fire Department.
Judy Lilley, the vice president for communications and public affairs for WellPath, said the company has not been served with the lawsuit and as a matter of policy does not comment on pending litigation.
“This case is truly a tragedy that could have been avoided,” Lonnie Albright, an assistant county attorney assigned to the sheriff’s office, said in an email. “So very sad. My heart broke for this man’s mother.”
Albright said he listened to Coley’s phone calls to his mother and common-law wife from the jail’s phone recording system in an effort to understand what transpired.
“This young man, like so many, stumbled and fell, was paying his debt to society via his incarceration, getting lectured by his mom on cleaning up his act, doing something with his life and such,” Albright said. “A week later and he’s gone.”
A second death in the jail
Stephen Patterson was admitted to the jail 16 days after Coley’s death. According to a suit filed by his family, Patterson answered “yes” to the medical screening question, “Have you ever or are you currently being treated for asthma, diabetes, seizure disorder, thyroid disorder, heart condition, high blood pressure, bleeding disorder or kidney disease?” The lawsuit states that Patterson told his medical screener that he was “supposed to be on [a] HTCZ/lisinopril combination pill and has not taken it for over six months because he does not have a provider.”
The suit contends that at the time of his screening Patterson’s blood pressure was recorded at 210/140, a range that “constitutes a hypertensive crisis that could result in death, serious injury, target end organ damage and/or neurological changes manifesting as altered mental status, confusion and anxiety.”
Despite an order from Dr. Alan Rhodes that Patterson’s blood pressure be taken and recorded every day for three days, the lawsuit alleges that the procedure was conducted only once, on May 19, and then discontinued. The lawsuit alleges that caregivers also failed to perform simple diagnostic work such as blood work, EKG or urinalysis or even ask Patterson how he was doing over the next seven days.
The lawsuit alleges that “the medical and nursing staff of CCS failed to adhere to the applicable standard of care and failed to properly treat, manage, assess and/or monitor decedent, directly and proximately causing him to suffer sudden cardiac death on May 26, 2017.”
The day Patterson died the lawsuit alleges that he told a detention officer that “he had received a visit from Jesus” and that “everything was going to be alright.” Later that day, a mental-health caregiver allegedly found Patterson sitting on his bunk, rocking and tapping his fingers on the mattress while counting, and observed feces smeared on the cell floor and vomit in his toilet.
In January 2018, Forsyth County District Attorney Jim O’Neill determined there was no basis for criminal charges against anyone involved in the deaths of Patterson and Coley.
‘Vendor did not have a full complement of staff’
Lonnie Albright, the assistant county attorney assigned to the sheriff’s office, said in an email today that Sheriff Bobby Kimbrough has met several times with WellPath management to discuss “appropriate staffing concerns.” Kimbrough defeated Bill Schatzman, who served as sheriff at the time of Coley and Patterson’s deaths, in the 2018 election. Kimbrough took office in December.
“Assurances have been made to Sheriff Kimbrough the jail will be adequately staffed and financial penalties are in place for the vendor if they do not hold up their end of the bargain,” Albright said. “The sheriff is very concerned over health care for all inmates and detainees in his detention center.”
Albright said he “was unaware until recently that the vendor did not have a full complement of healthcare staff.” He added that a meeting between the vendor and county officials “drove home the point that the county demand the benefit of its bargain and credit for services the vendor contracted to provide, but did not.” As an example, Albright said Correct Care Solutions billed the county for a pharmacy tech position that was vacant. Albright said that to the best of his knowledge “the breach has been corrected.”
“Sheriff Kimbrough is on top of this issue and did not mince words with the vendor’s management,” Albright said. “He was very plain spoken when he told them he wanted everything that he is paying for.”
The county commission last voted to extend Correct Care Solutions contract for medical services in the jail in July 2017. At the time, the company was the sole bidder.
In June 2017, Correct Care Solutions agreed to add staff to handle prescription medications at the Greensboro and High Point jails as a result of discussions with the family of a woman who died from “prolonged seizure activity,” after she was allegedly denied access to her prescribed anti-seizure medication.
“Correct Care’s direct phone contact with the outside pharmacy or provider, coupled with the facsimile request that proceeds it, are designed to further reduce any potential delay in the inmate care,” the Guilford County Sheriff’s Office said in a press release at the time. “These procedures are followed on weekdays and weekends.”
The Patterson lawsuit contends that Correct Care Solutions’ (now WellPath) policies “are largely motivated by CCS’s commitment to its overall goal of cost-cutting/saving.”
The suit alleges that “misconduct” by medical and nursing staff at the Forsyth County jail and other detention facilities under contract with Correct Care Solutions was “widespread,” and contends that at least seven inmates died at the Forsyth County jail from 2011 to 2014 “due to inadequate or improper care from nursing and/or medical staff.”
The Forsyth County Commission approved a $180,000 settlement to the family of Dino Vann Nixon, who died in the jail in 2013 as a result of what the medical examiner described as withdrawal from benzodiazepine, an anti-anxiety medication marketed as Xanax. And the family of Jennifer McCormack Schuler, who died from a heart attack suffered at the jail in 2014, agreed to settle for unspecified financial damages. The settlement ended a lawsuit in which McCormack’s family alleged that nursing staff’s failure to provide her with Zofran, an anti-nausea medication, prevented her from taking other needed medications.