At least seven prisoners have died since the Tulsa County Sheriff’s Office hired a nurse to serve as a watchdog overseeing jail medical care two years ago.
However the nurse has generated no reports about the prisoners’ deaths and has submitted just one report to TCSO about the company’s medical care in the past two years, an investigation by The Frontier has found.
That report in February 2015 by nurse Angela Mariani focused on widespread failures by Armor Correctional Health Services Inc. to abide by its $5 million annual contract with the county. Mariani also wrote three memos notifying TCSO that Armor failed to staff various positions in the jail and recommending that the county withhold more than $35,000 in payments, records show.
The Florida-based company is paid about $450,000 per month to oversee doctors, nurses and other employees providing medical and mental health care for prisoners in the 1,700-bed jail.
Her report shows that jail medical staff often failed to respond to inmates’ medical needs, the company failed to employ enough nurses and left top administrative positions unfilled for months. Meanwhile, medical staff did not report serious incidents including inmates receiving the wrong medication and a staff member showing up “under the influence.”
The new records obtained by The Frontier could shed light on why three prisoners have died in the jail so far this year. The latest to die, 59-year-old veteran Mitchell Godsey, was found unresponsive in his cell late Sunday.
In a statement, Godsey’s family members said they have received few answers about how and why Godsey died.
“With all the problems the Tulsa County Jail has had with inmate deaths related to poor medical care, we fear the worst,” the statement says. “Was his death preventable? What were the specific circumstances of his death? So far, TCSO has provided us with very little information.”
In a statement, a spokeswoman for Armor said: “Armor’s team of caregivers is committed to delivering quality patient care. Due to federal HIPAA regulations, we cannot comment further on the patient’s health.”
The Frontier also requested an interview with Regalado’s office. A spokeswoman, Casey Roebuck, said questions should be submitted in writing.
The Frontier submitted questions in writing Thursday, but received no answers from Regalado.
Regalado has previously said his office follows Armor’s advice in the care provided to prisoners. However state law makes the sheriff, not the company, ultimately responsible for prisoners’ welfare.
Court records in 2013 stated Godsey was a diabetic who took several medications to control his condition. He told investigators he was a carpenter and was injured when he was hit by a forklift on the job.
The statement by Godsey’s family said he was “a veteran of the US Army. He was a man of diverse interests. He was a music lover and skilled musician. Most of all, he was a loving father and grandfather.”
He is survived by three adult children.
“We are still mourning his sudden and unexpected death. We are in shock. We are also searching for answers,” the statement says.
Records show he was convicted in 1993 for concealing stolen property in Rogers County and given a five-year suspended sentence.
Godsey was convicted in 2013 for using a telephone during a drug transaction and given a five-year suspended sentence. In that case, he offered to trade $60 cash and some pain medication for methamphetamine, court records state.
He failed to pay $1,400 in court costs from that case and was arrested Friday on an outstanding failure to pay warrant.
Just before midnight Sunday, a detention officer found Godsey unresponsive in his cell, according to an incident report to the state Jail Inspector’s office. He was pronounced dead about 1 a.m. Monday.
Though TCSO has refused to release details about Godsey’s death, Roebuck told a reporter his death appeared to be from “natural” causes.
Records show the Sheriff’s Office and its medical contractors have a long history of failure to provide adequate medical care to prisoners, sometimes with fatal consequences.
A doctor hired by the Sheriff’s Office to review prisoners’ medical care criticized the jail’s treatment of five inmates who died in 2010 and one inmate who died in 2009. Dr. Howard Roemer’s report questions whether the six inmates’ lives could have been saved with better medical and mental health care.
In 2011, a federal investigation found “a prevailing attitude among clinic staff of indifference” and stated that “adequate medical care is not being provided.”
That report came about a month before another veteran, Elliott Williams, died in his cell after more than 50 hours without food, water or medical care. Williams, who had a history of mental illness, suffered a broken neck in the jail and was paralyzed.
The jail’s psychiatrist, Dr. Steven Harnish, thought Williams could be faking paralysis and did not order medical treatment. Williams’ pleas for help and water were ignored and he was taunted by some jail staff, according to an internal investigation.
Watchdog worked for contractor
In 2013, the Sheriff’s Office created a new position to monitor Armor and report on the company’s performance. The monitor “documents recommendations and ensures recommendations are followed” regarding medical care in the jail, the job description states.
The position was created four years after a consultant urged TCSO to create an oversight position. Many of the jail’s problems stemmed from a lack of oversight by a trained observer, said the report by consultant Betty Gondles.
“It is not enough for a correctional administrator to have good intentions or trust that a private provider is carrying out the administrative and clinical mandate to provide adequate health care to inmates,” Gondles’ 2009 report states.
“The correctional administrator must have the expertise in his or her executive staff to judge the competency of the health staff … and the quality of health services being provided,” her report states.
As its watchdog over Armor, TCSO hired Mariani, who worked for Armor at the time she was hired in 2014. Though the job required someone with five years of nursing experience, Mariani received her nursing degree two years before she became the contract monitor, records show.
Mariani was also married to Capt. Scott Dean, a shift captain in the jail supervising more than 100 detention officers, according to his LinkedIn profile.
In May, Scott Dean was involved in TCSO’s investigation after an inmate sustained a broken neck and pelvis in the jail. The inmate, David Fulps, was transported to the hospital in a patrol car, records show.
Mariani wrote no reports about Fulps’ case. The Sheriff’s Office has refused to release video of Fulps and another inmate, Nathan Bradshaw, who died in the jail.
Regalado has said jail video is not public record unless related to an arrest. The Frontier has filed an Open Records Act lawsuit against the sheriff.
In June, The Frontier and its media partner, NewsOn6, reported that TCSO was under investigation by the state for failure to report three serious prisoner injuries and using patrol cars to transporting injured prisoners.
On June 20, The Frontier requested all reports submitted by Mariani during the past two years.
TCSO supplied eight pages of records Wednesday, more than a month after the reports were requested. Two of the documents were memos dated several days after The Frontier’s request.
The only comprehensive report Mariani wrote reviewing Armor’s performance was dated Feb. 6, 2015. In the report, she cites numerous instances in which the company failed to live up to its lucrative contract, including:
- Medical staff did not respond to “many of the requests” by prisoners for medical care within the required time frame. Nurses had from one to three days to respond to prisoners’ requests unless the issue was deemed urgent or involved mental health.
- Armor failed to report multiple “adverse events” to the sheriff’s office as required, including a member of its medical staff who “appeared to be under the influence” at work. The company also did not report three incidents in which inmates received the wrong medication.
- Armor did not employ a director of nursing, as agreed to in the contract.
- The infirmary was not staffed with at least one registered nurse, as agreed to in the contract.
- The company had a “shortage of RNs on all shifts.” For several months, “there was only 1 charge nurse and LPNs were in charge on each shift.” Armor’s contract required the company to provide eight registered nurses and 15 licensed practical nurses.
- Armor agreed to provide regular reports to the Sheriff’s Office about staffing levels and prisoners’ care but rarely provided them.
The remaining records supplied by TCSO are memos in which Mariani reports various Armor positions were vacant. Under the contract, TCSO can withhold funds in certain cases for staffing shortages.
Mariani recommended withholding more than $24,000 because the jail had no health services administrator from August 2015 through February 2016. She also recommended that the county withhold more than $12,000 from Armor’s payments because the jail had no director of nursing for three months this year.
The records do not state whether the funds were actually withheld from Armor’s monthly payments.
Another memo, dated June 23, discussed the planned departure of Harnish, the jail’s psychiatrist.
“Per our MAC meeting yesterday, Dr. Harnish’s last day will be on 7/9/16,” Mariani states in a memo to Maj. Eric Kitch.
“They (Armor) are discussing with Dr. Harnish about potentially utilizing him for tele-medicine 2 days a week until they can fill the position. I explained to them that the contract requires a full-time psychiatrist to be on site 8 hours a day during the work week.”
In its statement, Armor said that its current contract requires its health services administrator to be a registered nurse, “therefore the position is now covered by an RN HSA during the coverage overlaps.”
“The psychiatrist’s contract ended on Friday 7/29/16 and was quickly replaced by a full- time psychiatrist on Monday 8/1/16,” the company said.
A video of Williams’ last days shows Harnish walking into the dying man’s cell, looking at him briefly and leaving. Due to his paralysis, Williams could not reach the food and water placed on his cell floor and the video shows Harnish did nothing to help him.
No medical provider, including Harnish, was disciplined by a state licensure board following Williams’ death.
His death was investigated by the Oklahoma State Bureau of Investigation while then-Sheriff Stanley Glanz served on OSBI’s commission. No charges were filed.
While Mariani’s memo states Harnish’s “last day” would be July 9, a spokesman for Regalado stated in an email last week that Harnish remained employed at the jail.
Attorney Dan Smolen, who represents Godsey’s family, said in a statement that Mariani’s 2015 report “raises many of the same concerns we have seen at the Jail since 2006.”
“Most troubling are the delays in treatment and lack of qualified medical staff. These are chronic, long-standing and dangerous deficiencies that TCSO has failed to alleviate. The recent string of deaths at the Jail suggests that little has changed under the new administration. …. Our leaders at the County must make improving and overhauling the Jail’s medical program their top priority.”
The county currently faces a dozen federal civil rights lawsuits over deaths and injuries of prisoners in the jail, possibly costing taxpayers millions in increased property taxes to resolve.
In court filings, TCSO and its current and former medical providers have denied that their actions amounted to deliberate indifference to prisoners’ rights. Records show Armor has settled several of the lawsuits for undisclosed amounts.