One year before a paralyzed veteran endured a slow death without food or water on the floor of his cell, an assistant district attorney sent an ominous email warning the Tulsa County Sheriff’s Office not to ignore “any and all signs” of trouble with the jail’s health-care system.
The email from Andrea Wyrick, an assistant district attorney for Tulsa County, noted that Oklahoma County had sued the company providing medical care in that county’s jail for falsifying records to cover up understaffing. The same company was paid $5 million per year to provide medical care in Tulsa’s jail, where several prisoners had already died that year under questionable circumstances.
“This is very serious, especially in light of the three cases we have now — what else will be coming?” Wyrick wrote in the email to Josh Turley, risk manager for the Tulsa County Sheriff’s Office.
“It is one thing to say we have a contract .. to cover medical services and they are indemnifying us … It is another issue to ignore any and all signs we receive of possible issues or violations of our agreement with them for services in the jail. The bottom line is, the Sheriff is statutorily … obligated to provide medical services,” she wrote.
Her email was written one year before Elliott Williams, a 37-year-old U.S. Army veteran and businessman, died in the jail after days without food, water or medical attention with a broken neck.
The email is among previously undisclosed documents obtained by The Frontier as part of an investigation into deaths of inmates in Tulsa’s David L. Moss Correctional Center, including Williams’ 2011 death.
The Frontier’s investigation has found:
- Out of more than two dozen medical professionals and TCSO jail staff who crossed Williams’ path before he died, only two employees were held accountable for his treatment in any way. One was a black detention officer who claims in a racial discrimination suit that TCSO fired her after she tried to help Williams.
- Oklahoma licensing board records do not reflect any disciplinary actions against the doctors and nurses due to their involvement in Williams’ case. The psychiatrist, Dr. Stephen Harnish, still works at the jail and the medical director, Dr. Phillip Washburn, works at a family medicine clinic in Sapulpa.
- Williams’ death was investigated by the OSBI while then-Sheriff Stanley Glanz was on the agency’s commission, which hires and fires the director. The agent who conducted the investigation said in a deposition he did not watch the videotape depicting Williams’ treatment and death. The OSBI report, half as long as TCSO’s 82-page internal report, minimizes important factors leading to Williams’ death.
- Audits and investigations in 2007, 2009, 2010, 2011 and 2012 found the jail failed to provide basic medical and mental care to prisoners. A medical expert hired by the county reviewed 52 prisoner medical charts and reported that six prisoners who died in 2009 and 2010 might have lived with adequate mental and medical health care.
- Estimating the number of prisoners whose deaths may have been prevented with better medical care in the jail is difficult. Some staff members had a practice of feigning efforts to resuscitate dead inmates “so that the jail would not become a ‘crime scene,’ “ according to a 2013 affidavit by the jail’s former director of nursing.
The Sheriff’s Office and the company that purchased the jail’s former medical provider declined interview requests for this story.
‘Treated worse than a POW’
Williams, a 37-year-old U.S. Army veteran who ran his own wholesale business, sustained a broken neck in the jail during a mental breakdown. Jail video shows he received no medical care, food or water for several days before he died in 2011.
The jail’s psychiatrist, nurses and detention staff thought Williams was “faking” paralysis and ignored his cries for help. Two jail supervisors laughed at him and asked “who had anally sodomized him,” a former detention officer claims.
The Sheriff’s Office didn’t take Williams’ mugshot and prosecutors didn’t charge him with a crime until two hours after his death. The Tulsa County DA’s office filed a misdemeanor charge of obstructing the police, stemming from Williams’ refusal to sit down on a curb.
Williams’ brother said relatives were not allowed to visit Elliott Williams in the jail. Kevin Williams wept as he spoke to The Frontier about watching video footage of his brother’s last days.
“He’s calling out for help the whole time and nobody helps him. … At the end you can tell he knows nobody’s going to help him and he has given up and he’s thinking, “Lord forgive them, for they know not what they do.’ “
Elliott Williams. one of nine close-knit siblings, planned to retire early so he could realize his dream of becoming a minister. Williams had a history of mental illness, with occasional episodes triggered by stressful events. Williams’ breakdown on the night of his arrest came after his wife said she planned to leave him.
Kevin Williams said he wants an outside agency such as the U.S. Department of Justice to conduct an independent investigation of his brother’s death.
Attorney Dan Smolen, who filed a civil rights lawsuit on behalf of Williams’ estate, said his firm, Smolen, Smolen & Roytman, and Williams’ family “have been fighting for years to get this case to trial and to reveal its gruesome facts to the public-at-large.”
“Elliott Williams was a black veteran who was willing to fight for our country, but he was treated worse than a POW — in a U.S. jail in the Bible Belt,” Smolen said.
Williams’ death drew national attention earlier this month after a story by The Frontier recounted details of his death and how he was deprived of food, water and medical attention for days. The story was shared thousands of times on social media nationwide.
Of the two employees fired after Williams’ death, one is a detention officer who claims she begged her supervisors to send Williams to a hospital. The former detention officer, Tammy Hanley, has filed a racial discrimination lawsuit against the Sheriff’s Office, saying she was accused of falsifying logbooks but “adamantly disputes” that allegation.
Sheriff Vic Regalado declined to comment on Williams’ case and issued a written statement.
“Since the events of the Elliot Williams’ matter, the office has undergone a change in leadership including the election of a new sheriff, Vic Regalado. Sheriff Regalado is committed to administering the Tulsa County Sheriff’s Office with positive leadership, accountability and compassion … and will strive to make any necessary improvements at the jail.”
Turley, still TCSO’s risk manager, is now running for Tulsa County Commissioner against incumbent Karen Keith. In an interview with The Frontier, Turley said he couldn’t discuss the case but called Williams’ treatment in the jail “unacceptable.”
Jail doctor gave placebo shots
Harnish, the jail’s psychiatrist, is among the medical professionals who could have sought an X-ray and other tests to rule out physical causes of the paralysis. But they never ordered Williams to be examined at a hospital.
The jail’s physician, Washburn, claimed he had “assessed” Williams before his death.
“The assessment consisted of him looking through bean hole at the inmate and stating he was okay,” states a log kept by Tammy Herrington, the former director of nursing for CHMO. “This was 2 hrs prior to death. There was no actual hands on assessment of the inmate.”
Doctors in the jail remained on duty for months after alarming reports from medical staff about their alleged incompetence. One jail doctor allegedly gave inmates “placebo” shots of salt water because he thought they were faking illnesses.
Many of the problems occurred under Correctional Healthcare Companies Inc., which changed ownership in 2014. A spokesman for the new parent company, Correct Care Solutions Group Holdings, LLC, declined to comment for this story, saying Williams’ death occurred before the purchase.
The county faces at least a dozen federal lawsuits over deaths and serious injuries in the jail. In March, a jury found the Sheriff’s Office “deliberately indifferent” to the rights of a woman who was sexually assaulted by a detention officer while she was a juvenile held in the jail.
The new records analyzed by The Frontier show that the Tulsa County Sheriff’s Office has received numerous clear warnings since at least 2007 that its medical and mental health care of inmates failed to meet the most basic standards. Those warnings came from within the Sheriff’s Office and county government as well as from outside entities: paid consultants, accrediting agencies and the federal government.
Audits and reviews in 2007, 2009, 2010, 2011 and 2012 documented the failure of TCSO and its private medical provider, CHMO, to abide by the state jail standards law and accrediting agency standards governing inmate mental and medical care. TCSO was placed on probation by accrediting agencies and cited with deficiencies by state and federal government agencies but little substantive changes have been made.
In some cases, the treatment of sick, injured and dying prisoners appeared inhumane.
- One inmate with advanced-stage cancer was using an oxygen tank to assist with breathing while in the jail. Before the prisoner was to be released in 2008, a nurse asked that he be allowed to continue using the medical provider’s oxygen tank during the release process. The request was denied, possibly leading to the inmate’s death.
“The inmate became short of breath, was placed on a ventilator within 24 hours and died several weeks later,” according to a former nursing director’s affidavit.
In another case, the jail’s medical director, Dr. Andrew Adusei, refused to examine a mentally ill inmate with stitches in his wrists from a prior suicide attempt.
“I won’t see him unless he’s septic,” Adusei reportedly told the jail’s director of nursing, Tammy Harrington.
Records show Adusei was publicly reprimanded by the Oklahoma State Medical Board in 2013 and ordered to complete 100 hours of community service and complete a course on prescribing medicine. He retained his medical license and is listed as practicing with a physician’s group in Florida.
- Adusei refused to send another prisoner with a history of bowel obstructions to the hospital for days. The man, Gregory Brown, had black urine and was in respiratory distress by the time Adusei agreed to send him to the hospital, where doctors said it was too late to save Brown’s life and he died.
Adusei was the subject of a 2012 memo from Maj. John Bowman to then-Chief Deputy Michelle Robinette. The letter states that the jail’s psychiatrist, Harnish, “disapproves of some of Dr. Adusei’s actions.”
Adusei was giving inmates injections of a saltwater “placebo” — apparently because he thought they were faking illness — and giving inmates injections in their jugular veins. Adusei had also been “asked to leave the surgical residency program at OU,” Bowman’s letter states.
Bowman discussed concerns about Adusei with a CHMO administrator, who assured him the doctor “would never purposely harm a patient. .. If the matter needs to be addressed, CHC will do so.”
Adusei wasn’t terminated by the company until seven months later, records show.
During that time Adusei remained as medical director, one mentally ill inmate who wasn’t monitored, Bridget Revilla, tried to kill herself twice in the jail. After both suicide attempts, she was treated at a hospital and brought back to jail instead of being taken to an inpatient mental facility.
Another inmate with a history of heart problems, Lisa Salgado, was denied medication, suffered a heart attack in the jail’s medical unit and died. Salgado’s body wasn’t discovered by a nurse in the medical unit for six hours, when rigor mortis had begun to set in.
Medical staff falsified her records to make it appear as if she died after being taken by ambulance from the jail, according to a lawsuit filed by her estate.
‘Not all inmates are trying to con you’
The notion that inmates were pretending to be sick or injured was not unusual among the jail’s medical providers and detention staff.
Three months after Williams’ death, TCSO held several meetings with CHC’s medical staff. Then-Chief Deputy Rick Weigel reminded the medical staff that inmates are entitled to medical care, are innocent until proven guilty, are away from their families and should be treated with kindness.
“Not all inmates are trying to con you,” Weigel told the medical staff.
CHMO’s contract was suspended in October 2013 and the county signed a contract with Armor Correctional Services, of Florida. Armor is currently paid $5 million per year to hire and supervise the full-time equivalent of about 40 employees including doctors, nurses and nurse aides.
Though the jail changed medical providers, some of the key personnel from the past remain in place.
Harnish, the psychiatrist who thought Williams was faking paralysis in 2011, still works at the jail, now as an Armor contract employee.
Robinette, chief deputy in charge of the jail since 2008, is still involved in jail operations today, supervising construction of four new pods. During her tenure the jail repeatedly failed inspections by accrediting agencies and the county has been named in dozens of tort claims, state lawsuits and federal civil rights lawsuits related to jail operations.
While those suits were filed during Glanz’s tenure, Regalado’s office has also struggled with the issue of inmate medical care. TCSO is currently under investigation by the state Health Department’s jail inspections unit for failing to report prisoner injuries and transporting injured inmates in patrol cars.
Under Regalado’s watch, TCSO has transported critically injured and ill inmates to hospitals in patrol cars, including one inmate with a broken neck, although the contract requires Armor to pay for ambulance transports. Regalado has also refused to release jail videos and The Frontier has filed an Open Records Act lawsuit against his office.
TCSO and its medical provider actually have a financial incentive to deny hospital treatment to inmates. The contract caps the annual amount the contractor must spend on outside medical care for prisoners at $500,000. At the end of the year, the company must rebate 100 percent of the unspent amount back to the sheriff’s office.
County officials said during the past three years, however, the cap has been exceeded.
Judgments and costs from the lawsuits would be paid through the county’s sinking fund, which is funded by property taxes.
A spokeswoman for Armor said the company “is honored to be the current healthcare provider to the TCSO; however, we were not the provider at TCSO in 2011. Regarding matters that predate Armor’s service as health care provider, it is our policy to stay focused on delivering quality patient care and not get involved in pre-Armor matters.”
In a 2011, the U.S. Department of Homeland Security’s Office of Civil Rights and Civil Liberties investigated multiple complaints about treatment of undocumented immigrants held in the jail under a federal contract.
The agency had received complaints about treatment of undocumented immigrants held in the jail under a contract with the federal government. The investigation found “a prevailing attitude among clinic staff of indifference” to the rights and needs of prisoners.
The audit found that doctors were using standing orders, nurses weren’t trained and at least two ICE detainees had not been seen by a doctor for mental health and medical problems.
Williams’ death came one month after the critical federal audit. When asked about his case during a deposition, Washburn said: “People just die sometimes.”
Conflicts of interest
Since Glanz took control of the jail from a private operator in 2005, no death in the jail has resulted in criminal charges against an employee of the sheriff’s office or its medical contractor.
Investigations into inmate deaths, when they were done at all, are usually done by the Sheriff’s Office.
After Williams’ death in 2011 however, TCSO asked the Oklahoma State Bureau of Investigation to investigate due to the involvement of Owasso police in Williams’ case.
However that presented a clear conflict of interest, as Glanz was on the seven-member commission overseeing the OSBI at the time. The commission of hires and fires the agency’s director.
During a press conference last year, Glanz said it would be a conflict of interest for the OSBI to investigate his office. The DA’s office had asked the OSBI to investigate issues surrounding the April 2015 shooting of Eric Harris by Reserve Deputy Robert Bates, a wealthy friend of the sheriff’s.
“I’m on the commission that appoints, that hires and fires the director” of OSBI, Glanz told reporters. “He’s not an outside guy. He’s someone that I have direct control and influence over.”
Glanz had no qualms asking the OSBI to review his jailers’ actions in 2011 to determine whether any state laws were violated in Williams’ death.
The Tulsa County DA’s office received the 42 page report and former DA Tim Harris, decided not to pursue criminal action. However the DA’s office also serves as the sheriff’s legal counsel in all civil lawsuits over prisoner deaths, including the suit filed by Williams’ family.
In a statement to The Frontier, District Attorney Steve Kunzweiler said neither OSBI nor TCSO presented criminal charges to the DA’s office. In fact, both OSBI’s report and TCSO’s internal report are silent on the issue of whether the investigators believed criminal conduct occurred in the jail’s treatment of Williams.
Kunzweiler said no conflict of interest existed in the case because “just like in the Bates case, there is a separation in my office regarding criminal and civil issues. We provide advice to county officers as required by statute — not to individual employees.”
His statement noted that “horrific things happen that do not always result in criminal charges but there are civil remedies available.”
“My sympathies are with Mr. Williams’ family for their loss.”
If the DA’s office relied on the OSBI’s report, prosecutors may not have seen all of the facts when they decided not to file charges.
OSBI’s investigation didn’t include the most powerful piece of evidence in Williams’ case: jail video showing the last 52 hours of his life.
The agent who conducted the investigation, Chuck Jeffries, was normally assigned to investigate oilfield crimes. Jeffries never mentions viewing the video from William’s medical cell, which a federal judge has called Williams’ “burial crypt,” and the video isn’t listed as evidence in the report.
The video shows that Harnish failed to examine Williams, that jail staff placed food and water just out of his reach and that Williams never moved the lower half of his body.
The OSBI report — which is half as long as TCSO’s report on its internal investigation — omits many details leading up to Williams’ death. It also minimizes his treatment by some jail employees and medical personnel.
For example OSBI omits the fact that Williams was dumped off of a gurney by two TCSO supervisors, striking his head on a shower floor and possibly exacerbating his injury. That anecdote is included in TCSO’s internal report.
It also fails to note statements by some nurses and detention officers that Williams had begged for water at the end of his life but was not given any he could reach. Harnish says Williams asked him for water but doesn’t say that Williams couldn’t reach it.
Another discrepancy between the two investigations: The OSBI report doesn’t state that Williams was left on the floor of the running shower screaming for help for at least an hour and possibly three hours, according to TCSO’s internal investigation.
Some claims by some witnesses, such as whether Washburn was told to help Williams, are in conflict with each other.
A visiting physician making rounds in the jail and a therapist on the CHMO staff both state Washburn was told to help Williams just hours before Williams died.
“Washburn never saw Williams, it was a system screw up,” therapist John Bell told the OSBI.
Washburn told investigators that details of the day Williams died were hazy.
“Was it Monday he died? … Thursday? It’s all a blur to me,” Washburn said. “And (the doctor) said he needs to be sent out of here and they said they told me. …. I do not remember that! If it happened, it was my bad.”