Dying for Care

Robert Foster did not budge when a Gregg County jailer slid open the bean hole to deliver his lunch one day last August. The obese inmate was sprawled on the floor, his breakfast untouched. When the jailer opened the door, a stench wafted out of the cell. Foster’s flesh was cold. He had no pulse.

Foster, 57, who had diabetes and a heart condition, was one of more than 280 Texas county jail inmates who died from illnesses while in custody over a four-and-a-half-year period, according to data provided by the Texas attorney general and analyzed by The Texas Tribune. The number of illness-related deaths in county jails comes close to the number of deaths in state penitentiaries — despite the fact that county lockups house half as many inmates, on average, and keep them for much shorter periods.

Sheriffs say they are doing everything they can to care for people who come to them with a multitude of physical and mental illnesses that are exacerbated by drug and alcohol addiction. And, they say, they are struggling to meet the health care needs of more inmates at a time when budgets are dwindling.

There are no state standards for health care in county jails, but criminal justice advocates and correctional facility experts say the large number of illness-related deaths prove they are needed. “People aren’t dying of old age in jails,” said Michele Deitch, a jail conditions expert and professor at the University of Texas at Austin’s Lyndon B. Johnson School of Public Affairs. “Those numbers are more likely to be reflective of medical care concerns.”

The data analyzed by the Tribune related to more than 1,500 deaths that occurred in law enforcement custody statewide from January 2005 through September 2009. Nearly 500 of those deaths were inmates who were in the custody of the state’s 254 sheriff’s departments. Some were the result of high-intensity pursuits or suicides that occurred before an offender was arrested. Some happened during the course of the arrest, when a person was shot, Tased or restrained by officers.

But more than half of the deaths reported by county law enforcement — 282 — happened as a result of an illness contracted before or during incarceration. Many inmates died of heart conditions, some of cancer or liver and kidney problems, and others of afflictions ranging from AIDS to seizure disorders and pneumonia.

Like Foster — who when he died had been in jail for about 10 weeks on deadly conduct charges — many inmates come into county lockups with conditions that have been neglected for years because of poverty, substance abuse or mental illness, said Gregg County Sheriff Maxey Cerliano. From 2005 to 2009 there were six deaths in his 916-bed jail, where the average daily population is about 790. Most of those deaths resulted from health problems the inmates had before they got to jail.

“While those are treated in the jail,” Cerliano said, “sometimes they’re just unable to sustain life.”

Gregg County, in rural East Texas, spends about $1 million a year — out of a total annual public safety budget of about $15 million — to employ eight medical staff members and pay for medication and health care equipment and supplies. The county doctor, Cerliano said, is always on call and visits the jail once a week.

While illness-related deaths were fairly steady among county jails during the nearly five years analyzed — an average of 70 per year statewide — health care costs rose significantly. In counties with populations of 1 million or more, like Harris, Dallas, Bexar and Tarrant counties, average jail health care expenditures tripled from about $5 million in 2005 to nearly $15 million in 2009, according to a survey by the Texas Association of Counties. “They’re not costs the county can avoid in any way,” said Tim Brown, the association’s senior analyst.

In small counties, Brown said, one seriously ill inmate can cause health care costs to skyrocket. That’s the situation in rural Ector County, where, according to published reports, one inmate with terminal cancer is awaiting trial on murder charges and has accumulated more than $140,000 in treatment costs. “Not just well people get arrested,” said Ector County Sheriff Mark Donaldson. “Some people are in bad shape.” He added that it is “our responsibility to take care of them.”

The Texas Commission on Jail Standards, which regulates county lockups across the state, is charged with ensuring that the facilities meet basic life and structural safety standards. When it comes to health care, though, county jails are only required to have a plan to provide medical attention to inmates. No standards dictate how that care ought to be provided.

“Everybody has an ethical obligation to do the right thing,” said the commission’s director, Adan Muñoz, who was formerly sheriff of Kleberg County. “How they do it is up to them.”

That is not good enough, Deitch said. Without uniform standards, she said, jails find themselves strapped for resources and staff, choosing the cheapest forms of medication and treatment. Because inmates in county facilities typically get released quickly on bond or are sent to a state prison, local officials tend to think of inmate health care as a problem that someone else will deal with. They try to push the cost and the responsibility down the line.

“Jails have never felt that compunction unless they’re sued,” she said.

Dallas County got sued by the family of an inmate with bipolar disorder who died of pneumonia in jail because she never had a health check-up during the 18 months she was incarcerated while awaiting trial. On the night she died, said the family’s lawyer Scott Medlock, director of the prisoners’ rights program at the Texas Civil Rights Project, there was one nurse on duty to care for 3,000 inmates. And in 2005, the United States Department of Justice threatened to take over the Dallas County jail facilities when serious health and safety violations were discovered. But then Lupe Valdez, a former jailer, took over that year as Dallas County sheriff, and there have been significant changes at what is the sixth-largest lockup in the nation.

The county partners with Parkland Hospital to provide medical care, there is a dialysis facility and a staffed infirmary on site, and medical attention is available at all times. Finally this year — after spending at least $138 million on improvements — the jail passed its state inspection for the first time in nearly seven years. “A lot of times they get better care here than they do out on the streets or at home,” said Kim Leach, the sheriff’s spokeswoman.

Diana Claitor, director of the Texas Jail Project, said that is rare. Inadequate health care complaints are the ones she hears most often from county jail inmates and their families. “A whole lot of these people would not have died in the outside world,” she said.

The problem is the perception that inmates come into county jails with health conditions that result from their own bad behavior. “There is an attitude that they don’t deserve good health care,” Claitor said.

Claitor and Medlock agree that state jail health care standards would be laudable. But they question how effective such rules would be because the Commission on Jail Standards has little enforcement power.

The only true sanction that can be applied against a failing facility is to close it down — a drastic result that rarely occurs. Claitor proposes an independent ombudsman for county jails to help inmates and their families get medical attention. Medlock said what is needed is a wholesale change in local law enforcement’s approach to inmate care. Counties, he said, should find ways to keep fewer people behind bars, releasing those awaiting trial who are nonviolent and finding appropriate treatment for the mentally ill. They should also invest more in preventive health care, implementing national incarceration standards not only to save inmates’ lives but also to save their own pocketbooks from the costs of serious illness and litigation.

“These people have broken the law,” Medlock said, “but they certainly haven’t earned the death penalty, which is what some of them are getting.”