Report finds fault with jail nurse in death of inmate

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Frank Schultz
Monday, January 4, 2016

JANESVILLE—The nurse attending a Rock County Jail inmate who died of a heart ailment last August at first suspected he was suffering from indigestion and gave him antacid tablets, according to investigative documents obtained by The Gazette.

The nurse was later fired. No jail personnel were disciplined, Sheriff Robert Spoden said Monday.

Dante T. Wilson, 38, of Beloit, had complained of chest pains before seeing the nurse late Aug. 17.

Wilson took the antacids and was held for observation in the jail medical unit.

About 55 minutes after he first told jailers of his chest pains, he was found unconscious in his medical cell and never recovered, despite attention from the nurse and CPR administered by the jailers, reports indicate.

A review by Dane County investigators lists “concerns,” most prominently with the conduct of the nurse, but also jailers, and with Wilson himself.

Wilson had previous episodes of chest pain, and if he had seen a doctor while not in custody, doctors might have identified the condition that caused his death, the Dane County report states.

Wilson also could have given the nurse more information about his health history and the symptoms he was having the night of his death, the report states.

Wilson died of “natural causes due to hypertensive and atherosclerotic heart disease,” according to the county medical examiner's office, one of the reports indicates.

The Dane County report also raises concern about the maintenance of an AED unit that malfunctioned the night of Aug. 17-18, but much of the blame seems focused on nurse Kim Beede.

Beede, a licensed practical nurse and former CPR instructor, had worked for Advance Correctional Healthcare since May 2013. The company is under contract to provide medical care for inmates at the jail and the nearby juvenile detention facility.

A spokesman for the company said it can't comment on care provided to an individual because of health-care privacy rules, and “the company does not generally discuss employment matters or litigated claims.”

Spoden said he has not heard indications of a lawsuit arising from the incident.

Wilson was booked into the jail Aug. 12 on warrants charging non-payment of child support and a probation violation, records indicate.

Wilson, who was 5 feet, 8 inches tall and 256 pounds, had a history of chest pain, possibly gastrointestinal related, and was taking Lisinopril, a blood-pressure drug, according to a form completed when he entered the jail Aug. 12. It was not clear whether nurse Beede had accessed that information.

Wilson told jailers at about 11:42 p.m. that he had chest pains and needed to see the nurse, jailers told investigators. They took him to the medical unit.

Wilson had to lean against a wall to catch his breath on his way to the unit and appeared to be in pain, but jailers did not report these details to Beede, the Dane County report states.

Jailers did a good job of responding to Wilson and of giving CPR, the Dane County report states. One of the jailers had known Wilson in school and was upset when recounting what happened to investigators.

Spoden said all the jailers involved were similarly upset about the incident.

Beede interviewed Wilson and found him agitated and difficult to talk to, according to reports. She decided his symptoms were consistent with gastro-esophageal reflux disease.

Beede sent Wilson to an observation cell in the jail's medical unit after giving him the antacids, observed him via video and visited his cell once, the reports indicate. She did not contact a doctor.

Wilson never told her he was having a heart attack or that he wanted to go to the hospital, Beede told a detective.

During the interview, Wilson was agitated and cut off the nurse asking questions to say that his chest hurt, a jailer assigned to the medical unit told a detective.

On his way to the medical cell, Wilson said, “My chest hurts. It's killing me,” the jailer said.

But the jailer assumed that Beede's assessment of heartburn was correct, and he noted inmates often complain of chest pain.

Beede should have noted that Wilson did not improve within 10 minutes of taking the tablets and should have seen that as a clue that something else was wrong, nurse Brandi Malcook told investigators.

Malcook supervises the jail medical staff.

Beede was the only member of the medical staff working that night.

An analysis of jail video appears to show Beede saw, via video, Wilson possibly vomiting in his cell at 12:11 a.m. and holding his chest at 12:17 a.m.

“At one point, Wilson pushed the monitor button inside (Medical Cell 5) and told (the jailer) that his chest still hurts,” a detective's report states. (The jailer) relayed this to the nurse, who checked the monitor and said that he needs to relax.”

At 12:37 p.m., the jailer heard Wilson snoring loudly and oddly. The jailer entered the cell, called out, got no response, and then approached, finding Wilson vomiting with eyes blinking.

The jailer rolled Wilson onto his side. He thought Wilson was having a seizure, the report states.

Beede arrived quickly and administered smelling salts, which got a reaction, reports indicate. They lowered Wilson, who was breathing, to the floor.

They checked for a pulse, and got none. Another jailer began administering chest compressions, and jailers continued to do so until the paramedics arrived to take over, around 12:50 a.m., reports state.

An automated external defibrillator, or AED, was brought in and attached to Wilson, and the unit asked for the “analyze” button to be pushed, but the jailers and nurse could not find the button. They pushed every button except the one marked “shock,” reports state.

Beede wanted to push the “shock” button, but jailers kept her from doing so, worried it could harm Wilson. Another AED was brought in quickly, and it worked. It called for CPR and did not ask for a shock to be administered, reports said.

The Janesville ambulance left the jail at 1:20 a.m. and took Wilson to Mercy Hospital, reports indicate.

A Mercy doctor pronounced Wilson dead at 1:35 a.m., and resuscitation efforts were stopped, a report states.

Wilson did not have a pulse when leaving the jail and did not have one at the hospital, reports state.

The medical unit jailer told a detective the he believed Beede was a good nurse and that she had not hesitated to send inmates to the hospital in the past.

Beede relied too heavily on her initial assessment of Wilson's condition and should have asked him more questions about his chest pain, the Dane County report states.

Beede also should have checked on Wilson more frequently, the Dane County report states.

Both Beede and the medical unit jailer saw Wilson on his hands and knees near the toilet and apparently thought he was vomiting, but he was likely trying to get fresh air from an air duct near the toilet, the Dane County report states.

Beede did not call one of the three on-call doctors available to her until about 1:04 a.m., reports state.

“She did not believe Wilson was having a cardiac-related event and did not want to wake the doctor up in the middle of the night for a case of heartburn,” according to a Rock County detective who interviewed Beede.

Policies required Beede to get a doctor's permission before administering any medication, but a supervisor had told her that in the case of over-the-counter meds, a doctor's permission could be obtained later, which was common practice, Beede told investigators.

Dr. Karen Butler and Malcook, both employees of Advanced Correctional Healthcare, however, told a detective giving any medication without a doctor's approval is a violation of company policy.

The Dane County investigators said jailers could have better communicated their observations of Wilson to the nurse, but Jail Cmdr. Erik Chellevold noted that the nurse knew even before Wilson was brought in that he had complained of chest pains.

Still, the Dane County report notes a concern over communications between jailers and the nurse, Chellevold acknowledged.

Spoden said the incident was traumatic for all the jailers involved, “but you're dealing with human beings, and unfortunately, human beings are not always perfect.”

As for the AED malfunction, the Dane County report calls for better maintenance.

Chellevold said all safety equipment is checked monthly. However, the check of the AED does not include turning it on, Chellevold said.

Spoden added that it's not clear when the button got stuck; it could have happened when they tried to use it that night.

Spoden and Chellevold said jail medical policies and procedures are under review over the next six to eight months, not because of Wilson's death, but because changes in state rules require it.

Chellevold said it's hard to say whether this incident would lead to any procedure or policy changes.

Spoden said his staff will do “a very objective review” of Wilson's death, and if changes need to be made, they will take action.

Spoden said the jail tradition is to err on the side of caution and send an inmate to the hospital. A jail sergeant can overrule a nurse and send an inmate to the hospital, Spoden added.

A jailer interviewed for the investigation said that “chest pains” are “magic words” for jailers, who always bring someone with that complaint to the nurse.

 A relative told investigators Wilson had sought medical treatment for chest pains in the past, but five or six months before his death, he had pain and could not move a leg but refused to get treatment.

Some jail inmates interviewed said Wilson had told them he had high blood pressure and complained that after four or five days in jail, he had not yet received his medication.

The Dane County report, however, states Wilson received some kind of medication on Aug. 15, 16 and 17. The name of the medication was blacked out, apparently by the Rock County Corporation Counsel's office, which blacked out some but not all medically-related information in the reports before they were released to The Gazette, apparently out of concern for laws about medical confidentiality.

Wilson was hot and sweaty while playing poker the night of Aug. 17 and blamed it on not having his med, one inmate said.

Advanced Correctional Healthcare has provided services to the jail for the past five years, and its contract is up at the end of this year, officials said.

Jail medical service will be offered up for bids on a new contract, to begin a year from now, Chellevold said.

Spoden said he is “very satisfied” with the company, which he said does “an outstanding job.”

The company will do its own review of the incident, Spoden said.

Wilson's mother has received a copy of the investigation reports, Spoden said

Spoden said he and his staff have been in contact with Wilson's family over the months since his death.

“They've been very understanding, and our sympathies are still with them. It's a terrible thing,” Spoden said.

Last updated: 7:56 pm Monday, January 4, 2016

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