After more than five days on the concrete floor of his jail cell, Elliott Williams died naked, cold and alone, unable to move.
Hungry and thirsty, Williams screamed for help but couldn’t convince anyone at Tulsa’s David L. Moss Detention Center to help him.
Detention officers at the Tulsa Jail tossed three styrofoam trays of jail food at his feet, but Williams could not retrieve them. Though Williams begged for something to drink, he couldn’t pick up the styrofoam cups of water they placed near him.
One day turned to two, three and four days. On the fifth day, none of the jail’s staff bothered to enter Williams’ cell, Medical Cell #1.
The jail’s medical staff began to wonder if Williams might actually be paralyzed from a broken neck, as he claimed. But those in charge did nothing to find out whether his claims were true.
Instead, they watched him slowly dying on a video camera.
WARNING: GRAPHIC CONTENT. May not be suitable for all viewers. This video is a compilation of the events between Elliott Williams’ arrest by Owasso police Oct. 21, 2011 to his death in a Tulsa jail cell Oct. 27, 2011.
On the morning of the sixth day, the 37-year-old veteran who faced no formal charge died on the floor of his cell. The jail’s medical staff performed CPR on his lifeless body but it was too late to save Williams, pronounced dead Oct. 27, 2011.
In a key ruling Wednesday, a federal judge found that a federal civil rights lawsuit by Williams’ family against the county can go forward.
“A reasonable jury could find that Mr. Williams’ needs were obvious to any layperson,” states the ruling by U.S. District Judge John Dowdell.
“They could also find that the medical unit-wide attitude of inhumanity and indifference shown to him, which resulted in the delay and denial of medical care in the face of his symptoms that were obviously indicative of a serious medical condition or medical emergency, amounted to deliberate indifference.”
Dowdell’s order denied motions by the defendants — Sheriff Vic Regalado and former Sheriff Stanley Glanz — to dismiss the suit. The judge also ruled that jail videos depicting Williams are admissible in the case, as are prior reviews or audits that found problems in the jail.
Dowdell’s 55 page ruling includes a blunt condemnation of the Tulsa County Sheriff’s Office jail staff for failing to help Williams. (An autopsy found he died from complications of a broken neck and noted he was seriously dehydrated.)
“A significant number of jail staff were aware that Mr. Williams did not walk, stand, sit up, eat, or drink on his own for days,” Dowdell’s ruling states.
Attorney Dan Smolen, who represents Williams’ family, said Dowdell’s ruling Wednesday was powerful but not surprising, given the facts of the case.
“It’s rare that you have a set of facts that would dictate such a an emotional response. … It’s one of the very few cases that shows what I would consider to be complete inhumanity,” Smolen said.
“I don’t think anyone can objectively look at the facts — no matter what your religion, what your race — and argue that the way that this guy was treated was appropriate.”
Smolen noted that no one has been held accountable for Williams’ death, despite an OSBI investigation and some interest by the U.S. Department of Justice. He hopes Wednesday’s ruling prompts a federal investigation of Williams’ death.
Clark Brewster, the county’s attorney in this case and numerous similar cases, said in an email to The Frontier that Dowdell “at this stage, as a legal standard must assume the facts alleged by the plaintiff as true.”
“The ruling is solely based on legal sufficiency and it is rare that any court will dismiss a case, even those that are clearly frivolous. … We trust that a jury in this case will carefully exercise their duty after a trial where the county will be zealously defended.”
The Williams case is one of at least a dozen civil rights lawsuits against the county for deaths and serious injuries in the jail. Verdicts against the county in the Williams case, or any of the other suits, could cost county taxpayers millions.
Earlier this year, a jury found against the county, ruling that the Sheriff’s Office deliberately indifferent, in the first of these cases to reach trial stage.
Smolen noted Wednesday that Tulsa County commissioners and Regalado are ultimately responsible for the outcome in Williams’ case and the other jail lawsuits. The commissioners have said little publicly about their role in overseeing the quality of medical care at the jail.
“You can refuse to acknowledge what’s happening and people are going to die but it’s going to catch up with you,” he said.
Glanz and the county have denied liability in Williams’ case, saying if failures existed, they did not rise to the level of “deliberate indifference” that the plaintiffs are required to prove.
Though Glanz is no longer sheriff, Dowdell’s ruling leaves him as an individual defendant in the lawsuit. Regalado, and by extension the county, is the “official capacity” defendant.
The plaintiffs have already settled with the jail’s former medical provider, Correctional Healthcare Companies Inc., based in Nashville, for an undisclosed amount.
CHC was sold to Correct Care Solutions Inc., of Nashville, in 2014. Correct Care Solutions is one of several companies bidding on a new jail medical contract, worth about $5 million per year.
It’s unclear why the contract is being put out for bids now, because the county commissioners voted to renew the current contract with Armor Correctional Health Services Inc. just last month.
Mental breakdown, then arrest
Dowdell’s ruling recounts the history of Williams’ case and many points along the way his death might have been prevented.
On Oct. 21, 2011, Williams’ relatives took him to an Owasso hotel “because Elliott had not slept in days and was having psychological issues,” the ruling states. A breakup with his wife had left Williams despondent and he caused a disturbance in the hotel lobby.
Owasso police responded and the situation escalated. Williams, who relatives said had been diagnosed as bipolar in the military, said he wanted to die and did not comply with officers’ commands to sit down.
Rather than wait for a mobile mental health unit to arrive, Owasso police pepper sprayed Williams and took him to the city jail. Once there, Williams descended further into psychosis, hiding under a bench, taking off his clothes and barking like a dog.
Though inpatient beds are often scarce, Owasso police did not attempt to find a mental health facility that would take Williams. Instead, they decided they couldn’t handle Williams and took him to the Tulsa Jail, booking him in at 1:50 a.m. Oct. 22, 2011.
When Williams failed to cooperate at the jail, Owasso officers threw him to the floor, with one officer landing on top of him. After that takedown, Williams had difficulty walking, though wasn’t yet saying he was paralyzed.
Despite his threats of suicide, Williams was not placed on suicide watch. Instead, he was placed in a holding cell, where 45 minutes later, he allegedly rammed his head into the steel door of his cell and fell to the ground, not moving.
He told detention officers and jail medical staff he had broken his neck. However, for more than 10 hours, Williams was left in the holding cell without attention.
WARNING: GRAPHIC CONTENT. This video may not be suitable for all viewers. This video is a compressed version of about 50 hours that Elliott Williams spent on the floor of a jail medical cell, with little food or water, before he died in 2011.
During that time, detention supervisors knew about Williams’ claims his neck was broken, including “Watch Commander Captain Wood, booking supervisors Corporal (Arthur) Jackson and Sergeant (Carla) Housley, and the Housing Supervisor, Sergeant (Jack) Reusser,” Dowdell’s order states.
Early the next morning, when Williams was still unable to move, the jail staff declared a “medical emergency.” However, the “head nurse” for the jail “cussed at and berated Williams, telling him that he should be ‘ashamed’ of himself, to get his ‘nasty ass’ in the shower, and to ‘quit fucking faking.’”
Capt. Tommy Fike and Sgt. Doug Hinshaw placed Williams on a gurney and “dumped Mr. Williams off the gurney into the shower,” Dowdell’s ruling states, “where Wiliams hit his head with a ‘smack.’”
Williams was left in the shower for up to three hours, unable to move.
“Throughout the first day at the jail, Mr. Williams continued to tell his captors that he was paralyzed and unable to move or walk,” Dowdell’s ruling notes.
A detention officer had to “pour water into his mouth” and feed him a bologna sandwich by holding his head up. However an LPN, Raymond Stiles, appeared to doubt Williams’ claims of paralysis.
“Wants to be waited on,” Stiles’ wrote in a “progress note.”
Cell became ‘burial crypt’
For the next three days — Oct. 23 through 25 — some jail medical staff and detention officers expressed concerns about Williams’ condition but did not provide medical treatment or call 911.
John Bell, a member of the jail’s mental health staff, visited briefly with Williams on the evening of Oct. 24. During the visit, Williams told Bell he was paralyzed and said, “I want water.”
“Williams still received no medical care. Instead, Bell recorded in notes that he provided Williams ‘education’ regarding ‘coping skills,’” the judge’s order states.
Dr. Stephen Harnish, a psychiatrist employed by the jail’s medical provider, failed to visit Williams until Oct. 25, three days after Williams claimed he had a broken neck. Though jail staff thought Williams was pretending to be paralyzed, Harnish ordered no neurological exam or “any type of medical examination” during the 12 minute visit to rule out paralysis, the order says.
In a footnote, Dowdell notes that even if Williams was faking paralysis, “that would not have eliminated the obligation to provide him adequate nutrition and hydration” as well as medical care.
“Instead of providing or ordering medical care, Harnish ordered jail staff to place Mr. Williams in Medical Cell number 1, which would be his burial crypt. … The remainder of Williams’ life was recorded by a video camera.”
Detention officers placed Williams, who was naked, on a blanket and dragged him into the cell.
That day, jail staff tossed two trays of food into Williams’ cell, where they remained for two days because he was unable to reach them or feed himself. He was also unable to reach a cup of water placed nearby.
On day five, Oct. 26, no jail staff entered Williams’ cell. Though LPN Kimberly Hughes expressed concern, Detention Officers Steven Smith and Crystal Rich refused to open Williams’ cell door, “claiming they could not do so for safety reasons.”
The order notes Williams had not been violent or aggressive toward officers there appeared to be no basis for that warning.
Another mental health team member, Patricia Benoit, noted that Williams was “still refusing to move” on the morning of Oct. 26. An LPN, Carmen Luca, also noted that Williams had said he couldn’t move.
By that evening, LPN Devorsha Stewart reported that Williams was “partially covered by a blanket, shaking” and unresponsive.
Still, the jail’s nurses, doctors, mental health professionals and detention officers did nothing to assist Williams.
Dowdell’s order states: “Although Williams had repeatedly announced, for over four days, to numerous jail staff, that he was paralyzed, could not move, could not get up, and was thirsty, and while he had not eaten, had water, or moved from the position to which he was dragged more than 36 hours before, Stewart recorded that she ‘encouraged (Williams) to inform staff of needs or concerns.’”
On the last day of Williams’ life, Oct. 27, jail staff threw a third tray of food into his cell, this time pushing it through a hole in the door.
John Bell, identified as a mental health team member, noted Williams was laying on the floor with spit on his cheek, mumbling. A visiting medical resident, Dr. Khadga Limbu, saw Williams and expressed concern about his condition, conducting a reflex test on his feet with little response. (The reflex test was the only documented medical attention Williams received before his death.)
Limbu told the jail’s medical director, Dr. Phillip Washburn, that Williams needed medical attention. Washburn would later say he didn’t check on Williams and didn’t recall being asked to do so.
“Washburn testified that, ‘If it happened, it was my bad. Because if a resident Doctor would have said that he needed to be sent out (to the hospital) I would have sent him right out.’”
Under the jail’s $5 million annual contract, Washburn was responsible for treating inmates with illnesses and injuries. Under state law, the Tulsa County sheriff (Glanz at the time) is responsible for overseeing all jail operations, including the medical contract.
Just after 11 a.m. on Oct. 27, 2011, Williams was found unresponsive, “more than five days after being detained for a misdemeanor for which he was never even arraigned and reporting a broken neck and paralysis,” Dowdell’s order states.
“After unhurried attempts at CPR, it was clear that Williams, who was lifeless and had blood coming from his mouth, was dead.”
An autopsy found that Williams died of complications from a broken neck and that he was also dehydrated.
Khan, an expert for the plaintiffs in the case, “has opined that the jail’s failure to stabilize William’s cervical spine resulted in a hematoma traveling up the spine, shutting down the spinal cord, which caused Williams’ respiratory muscles to stop working, thereby causing his death.”
The death would have been avoidable if Williams received adequate medical treatment, Khan states.
Asked in a deposition about Williams’ death, Washburn said he believed Williams received “appropriate care,” adding: “people just die sometimes.”
Washburn is currently a licensed physician in good standing, according to the state Medical Board, which states he works at a Sapulpa family medical clinic. Harnish’s practice is listed as the David L. Moss Detention Center his employer is listed as the jail’s current medical contractor, Armor, records show.
Neither Washburn nor Harnish have disciplinary actions on their record. It’s unclear whether the state Medical Board ever considered complaints against either doctor as a result of Williams’ case.
During a previous interview with Regalado, The Frontier asked if he had read the lawsuits against the sheriff’s office alleging civil rights violations for deaths and injuries in the jail. Regalado replied that he had not.
The Frontier has filed an Open Records Act lawsuit against Regalado after he refused to release jail video of an inmate, David Fulps, whose neck was broken in the jail
Staff made ‘dummy charts’
Dowdell’s order notes that in order to prevail, the plaintiffs must prove that the Sheriff’s Office was deliberately indifferent to the risk that Williams would receive inadequate medical care.
His order finds that Glanz had been placed on notice by three prior audits of the jail’s medical care: audits by the National Commission on Correctional Health Care in 2007 and 2010 and an audit in 2011 by the U.S. Immigrations, Customs and Enforcement agency.
All three audits found serious lapses in medical care of inmates at the jail, yet Glanz refused to replace the medical provider, Correctional Healthcare Companies Inc., and little changed in the way of policy and procedure, the order states.
Instead, Glanz and then-Undersheriff Tim Albin directed nurses and other jail personnel to hide inmate medical files that were considered problematic from the auditors. An employee of the jail’s medical provider, Pam Hoisington, also directed staff to create “dummy charts” for the auditors, the order states.
Regardless of the subterfuge, all three audits identified widespread failures by the jail to provide adequate medical care to inmates. Though Glanz received the audit reports, he took no action to address the findings.
“Mr. Glanz testified … that, with respect to such reports, he would ‘read the first two or three pages and then … file them.’”
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