The state Health Department is investigating the Tulsa County Sheriff’s Office over its failure to report three serious prisoner injuries as required and its use of patrol cars to transporting injured prisoners.
Additionally, records show the sheriff’s office and its medical contractor had concerns about the condition of injured inmates yet they were taken to the hospital in patrol cars instead of ambulances anyway.
The state’s investigation is in response to stories by The Frontier and its media partner, NewsOn6, about problems with medical treatment of prisoners in the jail.
The sister of one of the injured prisoners said she was “stunned and appalled” to learn how her brother, Tohres Busby, was treated in the jail. The 61-year-old man suffered a brain hemorrhage after falling in his cell and striking his head on a bunk. Busby wasn’t taken to the hospital for at least one and possibly three days.
“It’s amazing that we have a correctional facility that is building onto its current facility at this time but cannot even follow policy and procedures to oversee a third-party medical company,” said Trini Brown, Busby’s sister.
In an email to The Frontier late Thursday, a state Health Department official said: “We identified that 3 of the 7 incident reports submitted in May and June were not submitted within the required ‘next working day’ timeframe.”
State law requires sheriffs to notify the Health Department’s jail inspections unit of all deaths, “serious suicide attempts,” and “serious injury to staff or prisoner defined as life threatening or requiring transfer to outside medical facility.”
Deaths require immediate notification while other categories only require jails to submit a report to the state by the next working day. An earlier statement that TCSO did not report one inmate’s death was not accurate, an OSDH spokesman said.
An email to The Frontier from James Joslin, service director of the OSDH Health Resources Development Service, states: “Your report on the transportation of the inmate will generate an investigation to determine whether the means used were not consistent with the policies adopted by the jail and accepted medical standards.
“Where violations of the rule are identified, a notice of violation is issued which includes a list of deficiencies in the operation of the jail and specific proposals for their solution. A jail has 60 days to correct any violations.”
In an interview, Joslin said “most jails are familiar with the requirements for next day reporting.” He said when jails fail to report incidents, “it’s not surprising that it’s with a change in administration.”
Regalado could not be reached for comment late Thursday on the state’s investigation.
In an earlier email to The Frontier, Regalado’s spokeswoman, Casey Roebuck, said TCSO was not aware of the severity of the inmates’ injuries but reported the incidents when it became aware. However that contention is not supported by TCSO’s own records.
After repeated requests from The Frontier, the sheriff’s office released 54 pages of records Wednesday on a recent prisoner death as well as injuries and suicides. The Health Department also released incident reports sent by the Tulsa jail.
Regalado continues to withhold other records, such as jail videos and incident reports filled out by detention officers, claiming they aren’t public records. The Frontier has filed a lawsuit against Regalado, alleging he is violating the Oklahoma Open Records Act.
Among the findings in the newly released records:
- The sheriff’s office did report the death of inmate Leo Horn to the state jail inspector’s office as required. The state Health Department told The Frontier last week Horn’s death had not been reported. The department now says the report was submitted on time and was overlooked because an employee was out of the office.
- Reports to the state about prisoner David Fulps, a mentally ill man whose neck and pelvis were broken in the jail, were incomplete and not filed by TCSO for six weeks. In an internal email, a TCSO captain states: “There was a disagreement … about moving this inmate and the inmate was moved anyway.”
- The sheriff’s policies and state law require inmates with life-threatening conditions to be transported by ambulance. Records show jail medical staff suspected Busby had a brain hemorrhage after falling and striking his head on a bunk. Medical staff recommended he be sent to the emergency room, yet he was taken to two hospitals in a patrol car.
- TCSO apparently did not file a report with the state about a female prisoner treated at a hospital June 8 and 10. The prisoner ingested the street drug PCP, which another inmate smuggled into the jail. No such report exists in documents released to The Frontier.
‘Why take that chance?’
Fulps was jailed April 8 after he stole two cars from Tulsa auto dealerships, leaving one parked in front of his apartment. His mother, Lynn Grimes, said her 38-year-old son has struggled with mental illness since he was in his 20s and lives on Social Security disability.
Grimes said Fulps told her he purposely caused a disturbance at the jail so he would be segregated from other inmates, fearing he would be attacked due to his behavior. She said he claims he was beaten in the jail but she has not pressed for details because of his mental and physical state.
TCSO said Fulps fell down a staircase backwards at the jail while being escorted in handcuffs by a detention officer on April 29. Several days later, the sheriff’s office took Fulps to OSU Medical Center in a patrol car, records show.
Medical records and interviews with Fulps’ parents raise questions about when and how he sustained his most serious injuries and how long he waited for treatment.
Regalado initially said Fulps was injured when he jumped from a sink to a bed.
However the hospital’s report states: “The patient is apparently isolated in his jail, so when he dove off the top bunk onto the floor, he experienced a brief loss of consciousness.”
The sheriff said officers checked on Fulps every 30 minutes as he lay on the floor. However, TCSO policy requires more frequent checks for inmates who are violent or mentally impaired. (Fulps’ mother said she called the jail to tell them her son was mentally ill.)
Grimes said when Fulps told detention officers he couldn’t move, “they were walking around him going, ‘Come on, you can move your toes.’ He said when they got to his back side, he could tell by their faces that it was bad.’’
Fulps was transferred in a wheelchair to a patrol car and then taken to a hospital. Records have not been released that would show how long Fulps’ waited to go to the hospital.
Sick or injured inmates can be taken to the hospital in patrol cars “as long as the transportation will not aggravate the injury,” Regalado has said. Asked how the sheriff’s office determines the severity of an inmate’s injuries, Regalado said detention officers allow the jail’s medical contractor to decide that.
“I think it’s more of if we can transport safely without calling EMSA and tying them up,” he said in a previous interview.
However the jail’s medical contract with Armor makes the company responsible for paying for inmates’ emergency transports, up to a $500,000 total cap each year on certain medical costs. Both Armor and TCSO have a financial incentive to limit costs under the contract, which rebates any savings under the cap to TCSO.
The contract states: “To the extent any Inmate, visitor or TCSO staff requires off-site health care treatment (e.g., hospitalization, specialty services, etc.), TCSO will notify appropriate routine transportation services. ARMOR will be responsible for ambulance services for inmates requiring emergency transportation.”
The company is paid about $500,000 per month to provide medical staff and services to prisoners at the jail.
Brown said she understands detention officers have a difficult job but said the medical provider, not jailers, should be arranging emergency transports.
“He (Busby) was taken first to one hospital and then by a patrol car to another hospital and the second hospital was the one that said, ‘No more. We are taking him by ambulance.’ Why take that liability and that chance and put it on the county?”
Medical records show Fulps was diagnosed with a fractured vertebrae in his neck, a fractured pelvis, fracture of a bone in the lower spine and a fractured rib. Fulps also had a “large abrasion” on his forehead. OSU Medical Center records state he needed immediate surgery for his “serious cervical spine injury” and fractured pelvis.
In videos captured by his parents shortly after he was hospitalized, Fulps sobs and tells his parents “don’t worry about anything.”
Fulps also discusses how jail medical personnel told him to sign a medical form “in case you fall off the top bunk and your head splits in half. … That way we can take care of you.”
TCSO claims Fulps jumped off of his bunk, breaking his neck.
After spending about a month in the hospital, Fulps was sent to a Tulsa mental health treatment facility by court order. Grimes said the facility kept her son just a few days and did not adjust his medication as she pleaded with doctors to do.
“He was in such severe pain and traumatized. … They just put him in a cab home. I told them not to do that because he couldn’t even get up the stairs.”
Grimes said she was trying to help Fulps get into specialists for physical therapy. But he was afraid charges would be refiled and he’d end up in the Tulsa jail again, she said.
“The night before he ran, he said, ‘They can come get me any time they want to.’ I knew he was afraid. I knew he had been through so much there. I told him, ‘Keep your door locked. It’s going to be OK.’”
The next day, June 14, Fulps packed a bag, jumped from his balcony and fled. He stole a neighbor’s car, ditched the car at a QuikTrip and stole a truck someone left running, Grimes said.
Fulps led law enforcement officials on a 17-mile chase in Washington County, where he was arrested.
Grimes said her son was taken to a Bartlesville hospital but is now in the Washington County Jail and she is not allowed to visit him. She said she talked to him recently on the phone and he said he was in severe pain and receiving no medication.
“He thought they were going to come get him. … The mental health system didn’t protect him from himself. He was running for his life.”
Busby’s medical records show he also had a serious injury when transported to a hospital via patrol car. After he passed out in his cell June 6, striking his head on a metal bunk, Busby was taken to the jail infirmary.
The next day, June 7, the jail’s doctor recommended that Busby be evaluated in the emergency room with a CT scan “to eliminate intracranial bleed.”
TCSO submitted an incident report on Busby’s injury June 16, after The Frontier asked Regalado about the matter.
The report to the state on Busby’s injury states he was transported to the hospital on June 7. However the jail’s medical records call that into question. The doctor’s notes, dated June 9, state Busby is in the jail infirmary, “having trouble standing” and is “not fully oriented.”
Brown said because her brother is still in custody, her family has been unable to get any medical records or much information about his condition from the hospital. Deputies have allowed short visits with family, which Brown said she appreciated.
“He is in their care, custody and control. They neglected to get him medical help and it’s on them. The doctor said he had a massive stroke.”
Regalado told NewsOn6 that jail personnel followed protocol from the moment Busby told them about his symptoms.
“There’s really not anything else we could have done,” Regalado said. “From a jail staff standpoint, we’re not medical professionals, so we depend on the medical provider to dictate when someone should go to the hospital.”
Regalado said medical personnel also decide if the inmate needs an ambulance or if a patrol car will suffice.
“They followed protocol,” Regalado explained, “including transportation of him. He’s receiving medical care.”
‘Inmate was moved anyway’
Roebuck said the sheriff’s office was unaware of the severity of injuries to Fulps and Busby “until after thorough medical exams were conducted at the hospital. Once TCSO was notified of the extent of both men’s injuries, notifications were made.”
But records conflict with that claim.
Fulps sustained a broken neck, vertebrae and pelvis on or just before May 2. The Sheriff’s Office did not send an incident report to the Health Department until June 16, two days after The Frontier raised the issue with Regalado.
Roebuck’s email also states that per TCSO policy: “Transportation of the inmate to the hospital will be the responsibility of those deputies assigned to hospital guard duty at DLM, (David L. Moss) unless exigent circumstances exist.”
That policy may conflict with state law, which requires sheriffs to provide certain medical services to prisoners, including an emergency plan that involves “use of an emergency vehicle” and “twenty-four hour (24) emergency medical care.”
The Armor contract also requires the medical provider to arrange for ambulance transports.
Roebuck said jail staff was “unaware of the extent of Fulps’ injuries at the time he was transported.” However emails appear to contradict that.
“Inmate Fults (sic) in the hospital,” states an email from Capt. Scott Dean to another TCSO official.
“We discovered it and sent him to the hospital. We believe it was inadvertently self-inflicted while acting out in his cell. … I’m told there was a disagreement between officer and supervision about moving this inmate and the inmate was moved anyway.”
Roebuck said that Dean did not learn about Fulps’ broken neck and pelvis until he visited the hospital. TCSO has refused to release detention officers’ incident reports to confirm that.
Dean is a shift captain over the jail, supervising more than 100 detention officers, according to his LinkedIn profile. His wife, Angela Mariani, is a nurse who was hired to monitor the jail’s medical contract with Armor Correctional Health Services, in 2014.
Mariani was employed by the jail’s former medical contractor from 2005 through 2013, Correctional Healthcare Companies Inc. The county sought other bids on that contract after a series of incidents including the 2011 death of Elliott Williams, an inmate who suffered a broken neck in the jail.
The county faces a lawsuit by the estate of Williams, a mentally ill man who went 51 hours without food or water before dying naked on the floor of his cell.
Records show detention officers and jail medical personnel thought Williams was faking paralysis. He was dumped off of a gurney to the floor and placed in a cold shower for two hours. A 10 minute jail video released as part of the lawsuit shows Williams lying naked on a blanket in a cell, unable to feed himself the food that detention officers throw beside him.
In a deposition, then-Chief Deputy Michelle Robinette described Williams’ treatment in the jail as lacking “human decency.”
The Williams lawsuit is one of about 20 civil rights suits filed against the sheriff’s office for injuries and deaths in the jail.
The issue of how to deal with mentally ill inmates has come up repeatedly in the current race for sheriff.
Challenger Luke Sherman, a Tulsa police sergeant, has made mental health in the jail a central issue of his campaign. He appeared at a press conference this week with Cathy Costello, the widow of late Labor Commissioner Mark Costello, who was stabbed to death by his mentally ill son.
Regalado won a special election to complete the term of indicted former Sheriff Stanley Glanz. Regalado faces Sherman in the primary election Tuesday.
The winner moves on to face either Democrat Rex Berry or Arthur Jackson in the November general election. For more information on Tuesday’s election, including sample ballots and polling places, visit the Tulsa County Election Board site.