State jail inspector not notified of Tulsa Jail death until after questions by The Frontier

Sheriff Vic Regalado’s office failed to follow a state law requiring it to immediately report inmate deaths and serious injuries to the state jail inspector, a law that Regalado said he was not aware of, an investigation by The Frontier has found.

State law requires the sheriff to immediately report all deaths of prisoners and follow up with a written report within 24 hours. Additionally, the sheriff is required to report “serious injury to staff or prisoner defined as life threatening or requiring transfer to outside medical facility” within the next working day.

However, the death of prisoner Leo Horn early Saturday wasn’t reported until Monday night, after Regalado was informed by The Frontier about the law. A serious injury to prisoner David Fulps II, hospitalized with a broken neck, back and pelvis, wasn’t reported at all, according to the state Health Department.

Asked why his office had not reported Horn’s death to the state jail inspector as required, Regalado indicated he was not familiar with that law.

“I don’t know if we did that or not. I guess I gotta’ say that I am not aware of that,” he said.

Horn’s death from what the sheriff’s office says is natural causes came during a week of serious incidents, security lapses and injuries in the jail.

• Horn was found dead in his cell in the jail’s medical unit early Saturday reportedly after experiencing problems with a tracheotomy tube. His death wasn’t reported to the state as required until late Monday, after The Frontier asked Regalado about the matter;
• Two female prisoners were treated Wednesday after overdosing on PCP that a prisoner had smuggled inside the jail in her vagina, officials said;
• A prisoner tried to hang himself twice in the same day, the second time while on suicide watch using a blanket that was thought to be impossible to tear.
• A 61-year-old prisoner who suffered a serious head injury was transported to the hospital in a patrol car, despite a policy saying such transports shouldn’t happen if they could worsen the injury. His relatives have called on the sheriff’s office to release video showing how he was injured;
• The sheriff says he has been told video of a handcuffed prisoner falling down stairs in a hallway of the jail does not exist. The Frontier requested the video after the prisoner, David Fulps II, was hospitalized with a broken neck May 2.

The Frontier requested video and reports related to all of the incidents but has received no records. Regalado said he will check into providing incident reports but indicated he is withholding videos on the advice of Tulsa County District Attorney Steve Kunzweiler’s office.

The sister of the injured 61-year-old inmate told The Frontier and NewsOn6 that her family has received no information from the Tulsa County Sheriff’s Office about what happened to her brother, Torhres Busby (listed in jail records as Torhes). She said she believes TCSO should release video showing how her brother sustained a head injury that left him unable to walk without assistance.

Busby was about to be released from a Tulsa halfway house with an ankle monitor when officials discovered an outstanding 16-year-old warrant for bogus check charges. His sister, Trini Brown, said he was walking fine when he went into the jail.

“At least tell us how he fell. If he slipped on a banana peel, OK. If he fell off of a bunk, tripped on his own shoelace, whatever the case may be, that’s fine. Just tell us.”

Brown said she doesn’t know the date of the injury or what happened but learned Friday that Busby had been taken to a hospital. His 35-year-old son came from Dallas to see him but deputies would not allow a visit, she said.

The county often drops charges against prisoners who are hospitalized with injuries or illnesses that require expensive medical care. However that apparently hasn’t happened yet with Busby’s 16-year-old bogus check charge.

Brown said Busby has tribal healthcare that should cover her brother’s medical expenses.

“Family is family at this point in life,” said Trini Brown, wiping away tears. “And, you know, you may not agree with things, but you certainly would like to know if they’re in danger medically.

In an interview with The Frontier late Monday, Regalado described the jail as “a small country” where people sometimes become ill, get injured, try to harm themselves or die.

“You have mental illness and then you have those that make poor choices in David L. Moss. Although we do our best … things are going to happen. I wish we could prevent every single incident in the jail.”

It’s difficult to know whether the recent incidents represent a spike in medical problems and security lapses at the jail or just a string of bad luck for the new sheriff. Regalado said his staff is “certainly are looking at the quality of medical care from our provider,” Armor Correctional Health Services Inc.

“If we decide that they are not providing top-notch medical care then we would certainly seek it elsewhere,” he said.

When asked what the minimum staffing level was that Armor Correctional Health Care was required to maintain in the jail. Regalado said he didn’t know but would find out.

Though the jail is building two new pods intended to hold mentally ill prisoners, Regalado was unclear about whether more trained mental health professionals would be available to treat them.

“All DOs are trained in crisis intervention but there will be DOs” to staff the mental health pods, he said.

As far as more trained mental health professionals, Regalado said, ‘that’s the partnership with the mental health community.” He said he didn’t know how such a partnership would work or what organizations would be involved.

“I don’t know. I am going to have to talk to Chief Robinette.”

Regalado said he has also considered hiring a public information officer specifically assigned to respond to questions about the jail, which usually holds about 1,700 prisoners. The sheriff’s office currently has two public information officers, though neither is assigned full time to the jail.

Horn’s death

Horn, 58, was found unresponsive in his cell Friday and detention officers tried to resuscitate him. He has been in the jail since August 2015 on rape and kidnapping charges, to which he pleaded not guilty.

“At this point it appears that he died from natural causes but that’s certainly for the medical examiner’s office to determine,” the sheriff said.

Horn was pronounced dead at the jail about 1:30 a.m. Saturday morning. His tracheotomy tube is visible in his jail mugshot. Sources who requested anonymity told The Frontier Horn may have died after pulling out the tube, which often became clogged.

Asked by The Frontier late Monday whether his office had reported Horn’s death to any agency, Regalado replied: “Yeah the Tulsa County Sheriff’s Office, then of course to the medical examiner.”

Regalado said he assumed his employees in the jail were “doing their jobs.” However, the state Health Department said it had no reports from TCSO about a prisoner death.

State law requires sheriffs and other agencies to notify the state jail inspector’s office, part of the state Health Department, immediately about all deaths and submit an incident report within 24 hours.

Corey Robertson, public information officer for the Oklahoma State Department of Health, said in an email to The Frontier on Monday afternoon that the department had received no reports, either verbal or written, on any inmate deaths in the Tulsa Jail.

Robertson said someone from the sheriff’s office notified the jail inspector’s office overnight on Monday. That notification occurred after the Frontier informed Regalado about the law.

“There have been 3 incidents reported since April of this year,” Robertson said. “All happened last week and were reported on time.”

But Fulps was hospitalized May 2, which means his case was not reported to the state.

Robertson said agencies that do not report incidents or deaths on time would be issued a notice of violation. The jail inspector’s office can also order jails to make certain improvements when it finds officials have failed to abide by state law.

In apparently unrelated incidents, Busby sustained a head injury on or before Friday when he allegedly fell at the jail and another inmate tried to hang himself twice on Friday.

In both cases, Regalado refused to provide details, saying he believes he is prevented by HIPAA from doing so.

Regalado said Busby had been transported in a patrol car to a hospital and then taken via ambulance to a second hospital. At Saint Francis, Busby is being treated by a neurosurgeon, his family said.

“This is going to go into HIPAA stuff. He’s got some health related stuff that I’m not sure I can talk about. … If they are diagnosed and it’s medical related, we are not authorized to do that.”

Asked to provide the name of the suicidal inmate, Regalado said: “I don’t know if that crosses into HIPAA.”

However, according to the U.S. Department of Health and Human Services, law enforcement agencies are not required to comply with the federal rules protecting patient privacy. The rules define “law enforcement agency” as any agency that investigates or prosecutes crime.

It defines “covered entities” as healthcare providers such as hospitals and doctors that bill electronically for medical services.

It’s unclear exactly when Busby was injured but Brown said she found out on Friday, when she called the jail to check on him. The Sheriff’s Office initially said only that Busby wasn’t at the jail but eventually, a chaplain told her Busby was in the hospital.

They later discovered by calling hospitals that he was a patient at Saint Francis Hospital. After talking to a nurse, Brown said the family learned that he had fallen “and he has a brain bleed.”

“He has to be assisted in walking; he cannot get up and use a walker alone. He has to have help doing that. And then she said they would be watching that and monitoring the brain bleed before they will be sending him to a long-term rehabilitation center. And we still have no clue what has happened.

“Did he have a stroke, and fall? Did he slip on something?”

Busby, a retired electrical lineman and ironworker, didn’t have any health issues his sister and adult children are aware of, other than a sore knee. He had been living in a DOC-contracted halfway house and was preparing to be released on a GPS ankle monitor.

A background check turned up the 16-year-old warrant for bogus checks and he was arrested and taken to jail. It’s unclear how Busby could have served an entire prison sentence without anyone discovering the old, outstanding warrant. Records show Busby was convicted of a drug charge in Okmulgee County and sent to prison in October 2014.

Brown said Busby should not have been taken to the hospital in a patrol car with a serious injury. The Frontier first reported the practice in a story about Fulps, who was taken to the hospital in a patrol car with a broken neck, back and pelvis.

When discussing Fulps’ case Monday, Regalado said he has learned no video exists that showed the inmate allegedly assaulting a detention officer while handcuffed April 29. The Sheriff’s Office said Fulps was being taken back from the shower to his segregation cell when he began to struggle with the officer and fell backward down the stairs.

The agency has claimed he wasn’t seriously injured at that time but said he was injured later when he repeatedly dove off of his bunk onto a concrete floor. The description of how Fulps broke his neck, back and pelvis has changed, with Regalado initially saying Fulps had jumped from a sink to a chair.

Sick or injured inmates can be taken to the hospital in patrol cars “as long as the transportation will not aggravate the injury,” the sheriff 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.”

Brown said the family deserves to see jail video and records showing what happened to Busby. The Frontier has filed suit against Regalado and the Tulsa County Criminal Justice Authority over the sheriff’s refusal to release video and other records related to a death and a serious injury in the jail.

“Definitely, they have a right to see those videos,” Brown said. “Here’s my take on this: If this is a detention center, a public jail, a county jail, whatever the case may be, why is it not transparent? I totally understand where there are circumstances that records may not be transparent to the public. But why are these videos, why are these accident reports, not transparent? Why are they hiding those? I don’t understand that.”

In addition to Horn’s death and Busby’s injury, detention officers were faced with an inmate who tried to kill himself twice on Friday.

The male inmate was found unconscious after hanging himself with his T-shirt in a general population cell. Regalado said detention officers intervened and “once he regained consciousness, he was moved to medical for suicide watch.”

The inmate then “secreted a battery that he had lodged (in his body) and swallowed it,” the sheriff said.

The man was transported to OSU medical center, treated and returned to the jail, where he was again placed on suicide watch. Regalado said the inmate again attempted to hang himself, this time by ripping up the “indestructible” suicide blanket.

Inmates on suicide watch are generally not allowed to wear clothing and are given a blanket that is supposed to be impossible to tear.

Regalado said the sheriff’s office is investigating how to prevent such incidents in the future.

“We are certainly looking into it…. I don’t know how on earth he could have ripped that thing. …
We are looking at checks being made the way they were supposed to.”

In an unrelated incident, at least two women were treated Wednesday after taking the liquid form of PCP, a powerful hallucinogenic street drug, in the jail.

A spokesman for EMSA confirmed that two women were transported from the jail to a hospital Wednesday and one was transported Friday.

“According to the investigation, there was a female inmate that smuggled in a portion of PCP in her vagina and at some point in time distributed that out,” Regalado said.

One of the prisoners was “found comatose” in the jail and taken to the hospital Wednesday. He said that woman returned to the jail but was taken back to the hospital on Friday for additional treatment.

Regalado said he didn’t have reports showing the inmates’ names but that one woman’s last name was Neal.

Jail records show that Kimberly Nicole Neal, 21, has a court date this week on complaints of possession of controlled drug within a jail and possession of controlled drug with intent to deliver. Neal has been in jail for more than a year on child neglect charges.

The deaths and injuries in the jail in recent days have raised questions about what the new sheriff is doing to improve operations there.

During public appearances and forums for his campaign, Regalado has not specifically detailed how he plans to improve or change jail operations. Jail medical care is currently overseen by the same company that former Sheriff Stanley Glanz contracted with, Armor Correctional Services Inc.

Under Glanz, the jail was named in more than 20 civil rights lawsuits, many over deaths and injuries in the jail. Most of the cases remain pending in federal court and could cost taxpayers millions.

Those suits include one filed by the estate of Elliott Williams, a mentally ill man who suffered a broken neck in the jail. Jail medical personnel and detention officers thought Williams was faking paralysis and he died after languishing on the floor without food, water or medical attention for days.