At a time when inmates were dying of preventable causes in Tulsa’s jail and medical records were being falsified, owners of a company holding a lucrative medical contract treated former Sheriff Stanley Glanz, Chief Deputy Michelle Robinette and other TCSO supervisors to lavish dinners and wine during conferences, new federal court documents allege.

Motions filed Wednesday in Tulsa’s federal court provide new details surrounding prisoner deaths in the jail under Glanz. The allegations include that the jail’s former physician made entries in a woman’s medical chart the day after she died and that a nurse falsified medical records to cover up the woman’s death.

Former Sheriff Glanz, current Sheriff Vic Regalado, the former medical provider and other defendants face multiple civil rights lawsuits, with one of the highest-profile cases set to begin later this month.

Attorneys for the defendants could not be reached for comment by The Frontier Wednesday. In legal filings, they have denied the defendants have been deliberately indifferent to violations of prisoners’ constitutional rights and have disputed many of the allegations.

Former Tulsa County Sheriff’s Maj. Shannon Clark said in a deposition filed with the plaintiffs’ motion Wednesday that Glanz, Robinette and other top TCSO staff frequently joined the owners of Correctional Healthcare Companies Inc. for dinners and wine at expensive restaurants during American Corrections Association conferences.

Clark details how CHC, the jail's medical provider, hosted "large dinners" with "clients" including then-Sheriff Stanley Glanz, Chief Deputy Michelle Robinette and others.

While there’s nothing illegal about TCSO officials taking part in such dinners, they occurred at a time when prisoners in the jail were dying largely due to the company’s poor medical care, according to jail audits, medical experts, jail video and court records.

CHC, based in Denver at the time, held contracts worth more than $35 million during the years that Clark said owners Chris and Christina Capoot were buying expensive dinners for Glanz, Robinette and other top TCSO officials at American Correctional Association conferences.

Clark said the former sheriff and other TCSO officials “did as much as they possibly could to maintain a relationship with that particular medical provider for consistency because they had been our medical provider for a long time. And they said sometimes it’s easier to maintain consistency than it is to replace a whole new company.”

The motion was filed Wednesday in a federal civil rights lawsuit on behalf of the estate of Lisa Salgado, a 40-year-old woman who died in the jail from a heart attack in 2011.

Salgado’s lawsuit is set to go to trial later this year. Many of the same issues are expected to surface in the upcoming trial over the death of Elliott Williams in the jail four months after Salgado died.

After Williams’ case is tried, Salgado’s lawsuit is one of at least five civil rights suits against the sheriff’s office and other defendants scheduled for this year.

Evidence in the lawsuits will overlap because the deaths all occurred between 2011 and 2013 and the suits name some of the same defendants.

The motion filed by attorneys for Salgado’s estate Wednesday details a history of reports and audits concluding that the jail was providing inadequate health care to prisoners and risking lives in some cases. Meanwhile, some members of the medical staff were directed to falsify medical records after death, it alleges.

“The death of Ms. Salgado was no ‘freak accident.’ On the contrary, her death was as foreseeable as it was preventable,” states the motion by attorney Robert Blakemore, who works for the law firm suing the Tulsa County Sheriff’s Office on behalf of Salgado and numerous other plaintiffs.

“For many years, Defendant Stanley Glanz was repeatedly and continuously put on notice, by multiple credible sources, of serious, grave and systemic deficiencies in the medical treatment provided to inmates at the jail,” the motion states.

However, in a motion filed late last year, attorneys for Glanz and Regalado denied they violated Salgado’s constitutional rights. Salgado “received more than adequate medical care during her stay in the jail,” the motion states.

“There is no evidence that any of the Defendants appreciated that Salgado presented a risk of a fatal medical condition and chose to disregard it,” the motion states.

Tulsa County Sheriff Vic Regalado is among defendants in civil rights lawsuits related to deaths of inmates in the Tulsa jail under former Sheriff Stanley Glanz. Though Regalado was not present at the time of the deaths, he represents TCSO in its official capacity. DYLAN GOFORTH/The Frontier

In a separate motion, CHC said it was also not responsible for Salgado’s death.

“Each of Ms. Salgado’s diagnosed medical conditions was being treated appropriately and reasonably. … There is no sign or symptom that went unassessed or untreated by the jail health care providers,” CHC’s motion states.

The Tulsa law firm of Smolen, Smolen & Roytman represents Salgado’s estate as well as the estates of Williams, Gregory Brown and Gwendolyn Young, who all died in the jail between October 2011 and February 2013 from what the plaintiffs’ medical experts say appear to be preventable causes.

Williams’ death from a broken neck and dehydration was videotaped over five days in a medical cell, as jailers tossed trays of food at his feet and medical staff did not treat him or send him to the hospital. Records indicate the jail’s medical and detention staff thought he was “faking” paralysis.

In an order allowing Williams’ case to proceed to trial, U.S. District Judge John Dowdell said Williams’ cell became his “burial crypt.”

“A reasonable jury could find that Mr. Williams’ needs were obvious to any layperson,” Dowdell’s ruling states.

“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.”

The trial is currently scheduled for Feb. 21 in Dowdell’s courtroom in U.S. District Court, 333 W. 4th St.

Another plaintiff whose case is awaiting trial against the sheriff’s office is Bridget Revilla, who tried to commit suicide twice after the jail allegedly gave her an overdose of medication and failed to treat her mental illness, according to court records.

Last year, a civil rights case filed by the law firm resulted in a jury verdict against Glanz and the county. The jury found the sheriff was “deliberately indifferent” to the civil rights of a teenage girl who was repeatedly sexually assaulted by a detention officer while being held in the jail on an adult charge.

Chief Deputy Michelle Robinette has supervised the jail during a period when about 20 inmates died, some of preventable causes like dehydration and sepsis. DYLAN GOFORTH/The Frontier

Robinette was overseeing jail operations when Williams, Brown, Young and Salgado died and when the jail failed several audits and reviews, records show. She remains in a supervisory role at the jail today under Regalado, elected to a four-year term last year.

The lawsuit brought by Salgado’s estate alleges she had previously been diagnosed with heart disease, had been recently discharged from the hospital after complaining of chest pain and repeatedly complained of chest pain and related symptoms at the jail.

The suit says despite the obvious warning signs, jail detention officers and medical staff ignored and failed to treat her complaints and she died three days after being booked into jail.

Smolen said Salgado, Young and Brown are just a few of many inmates who have died due to lack of medical care in the jail and a prevailing attitude of indifference.

“We are not talking about people who died because it was their time … I get that people die from natural causes. … The cases that our firm is currently litigating with the Tulsa jail involve inmates whose deaths were imminently preventable.”

He said the longstanding problems at the jail — as documented beginning with a 1995 Department of Justice oversight order — can’t be remedied by building expansions. County voters approved a  0.041 percent sales tax in 2014 to expand the jail and build “mental health pods.” 

However, with those pods set to begin filling up with prisoners, it’s unclear whether the overall number of trained mental health professionals will increase and if so, by how much. (The new pods will hold adult men, not women or juveniles, TCSO says.)

“You can build the biggest jail but you have to eliminate this attitude of indifference to the inmates’ safety and well-being,” Smolen said.

“This culture has existed and been allowed to exist for decades at the sheriff’s office and it takes a person coming in and stomping that out to its core.”

Smolen said he believes the new sheriff is not fully committed to addressing violations of prisoners’ rights and improving medical care.

Regalado engineered a key change in the county’s $5 million annual medical contract process, which actually decreased the level of experience required. That change benefitted Turn Key Health Clinics, an Oklahoma City company operated by a state lawmaker who donated to Regalado’s campaign.

The Frontier filed suit against Regalado after he refused to release all video related to a prisoner whose neck was broken, claiming jail video isn’t subject to the Open Records Act. Sheriff’s employees later transported the prisoner to a hospital in a patrol car without following medical protocols to stabilize his neck, records show.

Smolen dismisses the notion that the jail’s new mental health pods are going to help inmates with mental illness unless they come with additional trained staff.

“What would a brand new mental health pod have done to save Elliott Williams’ life? Nothing.”

‘Warning signs’ ignored?

Salgaldo was arrested by Broken Arrow police on a DUI on June 24, 2011 and brought to St. John Medical Center the following day due to medical concerns. She had been hospitalized shortly before her arrest and medical records noted she had a history of serious heart issues that required previous operations and hospital treatment.

She was discharged from the hospital to the Tulsa jail, with instructions to watch for “warning signs” that signal a heart attack. At the jail, her symptoms continued. An EKG showed abnormal results but wasn’t reviewed by the jail’s medical director, Phillip Washburn, Salgado’s jail medical records show.

Washburn said during his deposition that “as a matter of practice, he never actually reviews EKG results himself but relies on nurses to read the results to him. According to Dr. Washburn, this practice of not reviewing EKG results is ‘better than nothing.’”

The following day, Salgado “was observed hyperventilating and rubbing her chest,” jail medical records state. She also complained of nausea, shortness of breath and increased chest pain, all signs of a heart attack that were warned about in hospital discharge instructions.

“Medical staff responded by giving her ‘a bag to breathe into’ and Ms. Salgado was returned to her cell,” records state.

“When reviewing this portion of the medical records during his deposition, Dr. Washburn laughed and asserted that Ms. Salgado was exaggerating her symptoms,” the motion filed Wednesday states.

Salgado’s condition continued to deteriorate and she continued to complain of chest pain, dizziness, weakness, shortness of breath and similar symptoms yet the jail’s medical staff did not send her to the hospital, records indicate.

A medical expert for the plaintiff called that decision “reckless” while an expert hired by the defense said in his deposition that the jail’s medical system “failed” Salgado.

Salgado was found dead in a medical cell three days after she entered the jail. The lawsuit alleges Salgado had been dead for up to six hours before a nurse discovered her.

“The time of death is evinced by the fact that rigor mortis had set in,” the lawsuit states.

A nurse on duty at the time of her death, Karen Metcalf, did not take Salgado’s vital signs or monitor her medical condition, the suit alleges.

“Nurse Metcalf failed to recognize that an inmate under her care had been dead for hours. This, in and of itself, is evidence of extreme neglect amounting to deliberate indifference.”

The jail’s former director of nursing, Tammy Harrington, states in an affidavit that after Salgado’s death, CHC’s health services administrator, Chris Rogers, “instructed the nursing staff to doctor her medical records so that it would appear that Ms. Salgado’s vitals had been taken and recorded.”

A medical expert hired by the defendants, Dr. Keith Kassabian, said during his deposition: “Due to Nurse Metcalfe’s documented performance problems, including a history of falsifying medical records, he would not have permitted Metcalf to provide care or treatment to Ms. Salgado at all.”

Washburn also made entries in Salgado’s medical chart after her death, the plaintiff’s motion claims.

For its part, CHC claimed that it lacked “any final decision-making authority as to municipal policies at the jail.” The company said it was required to follow state laws and policies of accrediting organizations and that TCSO could have ended the contract.

In a motion filed in the case, attorneys for Glanz state: “In context of a jail death, plaintiff must produce evidence showing that the Defendants appreciated that Salgado had a risk of a fatal medical condition and chose to disregard that risk.

“It is doubtful that the medical care described even rises to the level of negligence. … Unsuccessful treatment, medical malpractice, and acts of negligence do not constitute deliberate indifference; nor does a prisoner’s disagreement with his medical treatment, absent exceptional circumstances,” states the motion, filed in November.

However, records show Glanz and the county have been on notice for many years that medical care in the jail often 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.

Former Tulsa County Sheriff Stanley Glanz. DYLAN GOFORTH/The Frontier

Audits and reviews in 2007, 2009, 2010, 2011 and 2012 documented the failure of TCSO and its private medical provider, CHC at the time, to abide by the state’s jail standards law and accrediting agency standards governing inmate mental and medical care.

One report — written by a physician hired by the sheriff’s office in 2010 — stated three inmates had died from heart disease that year in what appeared to be preventable deaths.

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. Glanz resigned in September after he was indicted by a grand jury for refusing to turn over public records and for double-dipping on his state car allowance.

Smolen said a new sheriff, new jail pods and even a new medical provider do not guarantee progress. Smolen has been pursuing civil rights lawsuits against the sheriff’s office for nearly a decade, hoping to prevent prisoner deaths and serious injuries from preventable causes. He said he’s frustrated by the lack of progress on the county’s part.

“A change in leadership, a change in the provider doesn’t mean that you’ve remedied the more than two-decade old identification of systemic deficiencies that exist in your jail.

“There are people dying that should not be dying and there are many people in a position to stop it and … no matter how many people they pay to tell them what is so obviously wrong, they don’t make the changes they need to make.”

Records gathered by the plaintiffs’ attorneys in discovery indicate a shocking lack of concern for prisoners’ medical care in some cases.

The jail’s former 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.

Adusei was the subject of a 2012 memo from Maj. John Bowman to Robinette. The letter states that the jail’s psychiatrist, “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 CHC 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.

In 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 Williams’ case during a deposition, Washburn said: “People just die sometimes.”