One day after losing a $10 million civil rights lawsuit over Elliott Williams 2011 death in the jail, the Tulsa County Sheriff’s Office said that its reviews of all inmate deaths are exempt from the Open Records Act.
Following a request by The Frontier for copies of all inmate mortality reviews conducted under Sheriff Vic Regalado, a TCSO spokeswoman said Tuesday those reviews “are not open records.”
The Sheriff’s Office claims an obscure state law dealing with the hospital peer review process allows it to withhold the inmate mortality reviews from public disclosure. However, that law does not appear to be related to jails or inmate deaths.
Regalado did not respond to a request for an interview for this story Tuesday.
TCSO’s refusal to release inmate mortality reviews came one day after a jury found Regalado and former Sheriff Stanley Glanz were deliberately indifferent to Williams’ civil rights, ordering the county to pay the plaintiffs $10 million.
In an email March 15, The Frontier requested copies of all reviews conducted by TCSO following deaths of inmates in the jail since April 2016, when Regalado began serving as sheriff.
Last year tied with 2013 for the deadliest year in the jail since 2010. Four inmates died in the jail in 2016, including one death shortly before Regalado took office.
The latest inmate death in the jail occurred Feb. 2, when TCSO said inmate Thomas Willingham III “coded” after being placed on an EMSA gurney.
The Frontier’s request followed testimony in federal court during the civil rights trial over Williams’ death about inmate mortality reviews conducted by the Sheriff’s Office.
During testimony March 13, plaintiff’s attorney Dan Smolen asked County Commissioner Karen Keith about her statutory obligation toward the jail.
“You know what a mortality review is?” Smolen asked Keith.
“The number of souls that have passed in our jail?” she responded.
“There’s supposed to be a mortality review for every one of those people; correct?”
Keith responded that she had not looked at the mortality reviews.
“I would tell you that I am not a medical expert. We rely on the sheriff to run the jail,” she said.
Later, Keith said: “We get reports through the Jail Trust Authority, and certainly I care what happens in there, but we do get reports from the chief in charge of the jail telling us what’s happened.”
As a member of the Tulsa County Criminal Justice Authority, Keith received brief reports about injuries and deaths in the jail each month from TCSO officials, but not copies of the full inmate mortality reviews. The authority oversees sales taxes that fund jail operations.
TCSO and its medical provider are required to conduct the mortality reviews as part of the jail’s accreditation process by the National Commission on Correctional Health Care.
In 2010, the NCCHC placed the jail on probation after a review found numerous serious violations, including failure to conduct adequate death reviews within 30 days. The jail’s medical provider at the time was Correctional Healthcare Companies Inc., of Colorado.
“There have been several inmate deaths in the past year,” the 2010 report states. “In March 2010, deaths were related to pulmonary embolism, suicide, and unknown cause. There was no psychological autopsy for the suicide. The clinical mortality reviews were poorly performed. ln June 2010, there was a death due to natural causes. No death review was conducted. The standard is not met.”
The suicide case referred to in the report involved an inmate named Clinton Labor. Records show Labor submitted a request to jail staff stating “need to talk” but Labor wasn’t seen by mental health staff for six days.
At that time, Labor denied he intended to kill himself but said he was anxious about his upcoming court hearing, jail records state. Labor hanged himself in his cell two days later.
An inmate mortality review, filed with other exhibits in the Williams case, states that the jail’s psychiatrist was not informed about Labor’s suicide on March 28, 2010.
Under “lessons learned,” the jail medical staff wrote: “Contact appropriate people when events of this magnitude occur.”
Another inmate mortality review included in court exhibits details the death of Damien Tucker, who died several weeks before Labor, on March 12, 2010.
The death review states Tucker died from a pulmonary embolus. Under “lessons learned,” the mortality review states: “Proper equipment at the ready.”
The mortality review fails to mention that jail staff waited 42 minutes before calling EMSA. Tucker’s death was among several that an independent expert hired by TCSO identified as possibly preventable.
In an interview with The Frontier, former Tulsa mayor Dewey Bartlett said he asked for mortality reviews when serving on the Tulsa County Criminal Justice Authority.
Bartlett said the Sheriff’s Office would provide basic reports on whether any injuries or deaths occurred in the jail, but normally “not too many people asked questions.”
When someone would ask a question about a jail death, they were told the Sheriff’s Office was waiting on a report or autopsy, Bartlett said. If a board member didn’t ask about the death the following meeting, it wouldn’t be brought up again.
Bartlett said he asked the Sheriff’s Office for copies of reports on deaths about a year ago.
“I got a lot of pushback. … They did not want to give out those reports,” he said.
Bartlett was told the Sheriff’s Office was still waiting on “some things” and had liability or privacy concerns involving HIPAA (which restricts what health information can be released about a patient), he said.
Bartlett insisted HIPAA didn’t apply to mortality reviews of jail deaths.
“Finally they did say they would put it all together and I could see it, and that was toward the end of my term,” he said.
Officials with the Sheriff’s Office told Bartlett they would assemble the reports and let him know when he could see them, but Bartlett said he doesn’t recall that happening. His term as mayor ended a couple of months later in December 2016.
“They were very concerned,” Bartlett said. “They didn’t want to give those reports out.”
In a response to The Frontier’s initial request for mortality reviews given to members of the Criminal Justice Authority, spokeswoman Casey Roebuck said: “The sheriff’s briefings were given verbally during TCCJA Meetings, not through documents.”
The Frontier responded by requesting copies of all inmate mortality reviews.
Roebuck stated: “The Oklahoma Open Records Act … does not apply to records specifically required by law to be kept confidential including records protected by a state evidentiary privilege.”
Her email cites a state law that does not mention deaths in jails or prisons. The law deals with peer review committees established by hospitals and other medical facilities to track patterns in patient mortality.
It states that hospitals, nursing homes and other authorized entities may provide information intended to reduce morbidity and mortality to the state Board of Health, the Oklahoma State Medical Association, the American Medical Association, hospital committees or the city-county health department.
The Frontier has challenged TCSO’s legal basis for withholding the mortality reviews, noting that the law Roebuck cited does not appear to apply.
In addition to claiming that mortality reviews are exempt from the Open Records Act, Regalado has also asserted that nearly all videos recorded by cameras installed in the jail are off limits to public disclosure. (He has acknowledged the Sheriff’s Office must provide videos of inmates engaged in conduct that results in criminal charges.)
The Frontier has sued Regalado and the Sheriff’s Office over his refusal to release jail videos. The suit is pending in Tulsa County District Court.
TCSO has a troubled history when it comes to transparency and the Open Records Act. Glanz was forced to resign after being indicted on two misdemeanors, including refusing to release a report about former Reserve Deputy Robert Bates.
Tulsa attorney Spencer Bryan, who represents the family of Nathan Bradshaw, who died in the jail last year, said the statute cited by TCSO to withhold inmate mortality reviews “wasn’t passed to shield reports about operations of a public jail. I believe it was part of the tort reform package spearheaded by the medical lobby.”
“Even assuming it did apply, the privilege appears limited. It prohibits evidence in civil cases, which has nothing to do with an open records request. But more fundamentally, records are public unless an ORA exemption applies, and TCSO did not cite an ORA exemption.”
Bryan said the jury’s decision in the Williams case “is certainly a bellwether for jail operations in Tulsa County.”
“It clearly establishes that by 2011, every person subjected to the medical and mental health practices at the jail experienced a system that was so poorly managed that it failed to satisfy basic constitutional standards.
“Other victims like Nathan Bradshaw’s family can use this verdict to establish a baseline of unconstitutional conduct to help prove their cases, but that is secondary to what is truly an appalling indictment on the sheriff, and the community as a whole. We all failed Elliot Williams.”
Regalado and other county officials have refused repeated requests for comment about the verdict.
Attorney Clark Brewster, who represented the Sheriff’s Office in the Williams case, he has a “high confidence” that the verdict “will not stand on appeal.” Brewster took issue with evidentiary rulings during the trial as well as the jury instructions.
Smolen said Keith’s testimony during the trial showed she “doesn’t even know that she has a statutory obligation to look at these issues that are being identified.” He said Keith protested that there are 1,700 inmates in the jail and county commissioners can’t possibly review the treatment of all of them.
“I’d start by looking at the files of the ones who died and how they died. To sit there and say that the sheriff operates autonomously from the county is a very dangerous position to take,” Smolen said.
The county still faces lawsuits stemming from deaths of four inmates in the jail, in addition to a lawsuit over the rape of a mentally disabled woman in the medical unit.
An investigation by The Frontier found that one out of three inmate deaths in the jail since 2006 were identified by experts as possibly or likely preventable.
Audits and reviews from 2007, 2009, 2010, 2011 and 2012 concluded that the Sheriff’s Office and its private medical provider, CHC, were failing to abide by the state’s jail standards law and accrediting agency standards governing inmate mental and medical care.
Meanwhile, TCSO left Michelle Robinette in charge of the jail and county commissioners approved multiple contract renewals with CHC until 2013, which paid the Colorado-based company about $5 million per year. Robinette has recently been promoted to a newly created civilian job coordinating inmate mental health care programs.
It’s unlikely the jail could have prevented all or even most of the deaths since 2006. Some inmates come into the county’s 1,700-bed jail with serious medical and mental health issues that are difficult to treat in a jail.
The Sheriff’s Office also failed to take important steps its own consultants said must be taken to reduce the risk of additional deaths and injuries.