The Sixth Circuit Court of Appeals has overturned a case involving private inmate medical contractor Southern Health Partners (SHP), finding the company was recklessly indifferent to the medical needs of a 25-year-old at the Hopkins County Detention Center (HCDC) in Madisonville, Kentucky.

The lawsuit [PDF], brought by the administratrix of the inmate’s estate Cindy Shadrick against SHP and Hopkins County, alleges SHP failed to adequately train and supervise its nurses at the facility. The case has been remanded to district court.

The decision is potentially significant, as it affirms governmental immunity from lawsuits does not extend to private contractors working in jobs typically performed by government employees.

SHP contracts to provide care in 198 jail facilities, thirty of which are located in Kentucky. The company no longer holds a contract with HCDC.

Tyler Butler died from an antibiotic resistant MRSA infection at the jail in April 2010, just three days after arriving for a short sentence for a misdemeanor.

A district court previously granted summary judgement in favor of SHP, but the appeals court rejected that finding for the company’s “failure to train or supervise its LPN nurses.” The appeals court also found SHP was not entitled to governmental immunity on the negligence claim.

Shadrick’s medical expert, Madeleine LaMarre, told the court SHP “failed to establish an adequate health care system to meet the serious medical needs of the inmate population at HCDC.”  SHP’s nurses, she testified, “violated generally accepted standards of nursing practice,” and failed to hire enough qualified staff for the job, relying instead on Licensed Practical Nurses (LPN), who are not licensed to make independent nursing assessments or diagnoseses.”

SHP’s president and Chief of Operations, Jennifer Hairsine, told the court she believes SHP nurses are “trained by virtue of being licensed in Kentucky.” She stated nurses may receive additional training from SHP administrators, all of whom are nurses themselves. Hairsine did not know the difference between Registered Nurses (RN) and LPN’s, except she knew LPN’s could not diagnose medical conditions. Her testimony indicated she was not familiar with HCDC’s policies, which state only medical staff may determine if an inmate cannot be admitted to the jail for health reasons.

LaMarre testified the situation at HCDC was “illegal and dangerous,” and felt the “lack of training and supervision of LPN nurses directly contributed to Butler not receiving appropriate medical treatment, ultimately leading to his death.”

“I don’t need to be here”

Butler was late to his intake appointment at HCDC on April 8, 2010. While waiting to be admitted to the jail, a control tower operator noticed him put something in his mouth and ingest it.

Butler vomited twice as he changed into his jail uniform and the deputy noted he appeared to be under the influence. He was sweating profusely and struggling to answer the deputy’s questions.

Butler informed the deputy he had a MRSA infection and was under care for high blood pressure, rheumatoid arthritis, gout and osteoporosis. He said he was taking a variety of medications for these ailments and denied drug or alcohol addiction.

The deputies did not want to admit Butler into the jail in his condition but knew only medical staff had the authority to refuse an inmate on those grounds.

As the shift wound down, SHP LPN Candace Moss (the only medical staffer on duty at the jail at that time) met Butler and was told about his infection and vomiting. He told nurse Moss he had infections and rashes his doctor had not yet diagnosed. He showed her his open wounds. Deputies noticed Butler’s skin was grey and clammy, and he was bloated. They heard Butler say, “I have staph infection all over me… it’s in my groin… I don’t need to be here.”

Moss never worked in a correctional setting prior to her employment at HCDC. She did not report receiving any training prior to beginning work. She could not recall if she ever read SHP’s policies or if she signed a form acknowledging she had. Despite working there for 18 months, she never received a performance evaluation by SHP.

In her opinion, federal appeals court judge Jane Stranch wrote that “as an LPN, [Moss] knew she lacked the credentials to diagnose any illness, but she was aware that MRSA infection could lead to sepsis and death if not treated.”

Moss told the deputies to admit Butler to the jail. He was placed on 72-hour detoxification unspecified “suspected drug use” and medical watch for his staph infection.

Butler’s cell consisted of “a mat placed on a concrete slab three to four inches off the floor.” This was because he was placed on suicide watch, even though there was no evidence he was suicidal. Records show his blood pressure was falling, but the LPN who came on after Moss, Andy Johnson, said he “did not recall ever touching Butler.”

There is no evidence Butler was given medication or treated by nurses in response to his falling blood pressure. A “Medication Administration Records” shows Butler was given medications on the 9th, but SHP stated, under oath, that “Butler’s medical record does not reflect that he was given any medications during his incarceration beginning on April 8, 2010.”

Johnson, like Moss, told the court he never received training before beginning work at HCDC, aside from “limited on-the-job training during his first two days of employment, such as learning where supplies were kept.” He did not recall ever reading SHP’s policies, either.

It comes as no surprise, then, that none of the nurses followed SHP’s policies for treating MRSA, which can spread quickly.

Too much pain to move

During a medication pass late in the afternoon on April 9, a deputy overheard Butler tell nurse Moss about his infection, but the nurse did not conduct an assessment.

The following day, on April 10, Butler filled out a slip for sick-call, and the deputies tried to persuade the SHP nurse on duty to see Butler, but there is no record a medical assessment ever took place. Butler stated he could not get up to walk to the door and get his medication. Again, there is no indication he was assessed, or received his medication on that day.

Early in the morning of April 11, a deputy observed Butler “sitting on the floor of his cell, leaning against the wall. His elbows were red and swollen, and he was in obvious pain.” The deputy asked if Butler was okay and he replied, “I’m fine.” He was cleared from detoxification status by SHP LPN Renee Keller, but she did not examine or medically assess his condition. He was to remain in isolation due to his infection.

Like the others, Keller testified she never received training from SHP, aside from meetings every other month “to go over policy changes or to explain something the nurses were not doing correctly.” She recalled being told to read SHP’s policies and signing a form stating she had, but conceded she “did not actually read all of the policies and could not discuss any specifics of them during her testimony.” The judge wrote that “a large part of her job involved referring to protocol books without consulting the doctor.”

Butler later asked a passing deputy for a clean uniform because he had defected on himself and was in “too much pain to move.” His joints were swollen and “hot to the touch.” He was placed in a restraint chair and pushed to the shower, where he was transferred to a plastic chair and helped to undress and bathe. He was returned to his cell after showering.

A deputy then went to speak with the nurse about what happened, and the nurse responded “she was aware of Butler’s situation and otherwise expressed no concern.” The deputy indicated his colleagues “commonly received similar responses from SHP medical staff.”

Butler defecated on himself again within an hour and declined a shower, but took a new uniform. The deputy returned to the medical office because his condition was now a “real issue.” The deputy asked if he could move Butler to a cell with a higher bunk so he could more easily reach the toilet. The nurse “showed no inclination to check on Butler.” He was put in a restraint chair and moved to a segregation cell with a bed. The deputy stated he had “never seen an inmate with such limited mobility.”

Later that afternoon, deputies checked on Butler, but there is no documentation of his medical status — they “looked through the cell window only to confirm that he was breathing.” Butler asked for water because he couldn’t get up, and a deputy told him to get it from his cell faucet. She later agreed to get him water but never did so. She returned a few minutes later to find him lying awkwardly and unresponsive on his bunk.

The deputy entered and shook him but he did not respond. He had no pulse and felt cold.

“Everything Looks Fine”

The deputy who found Butler unresponsive called a nurse. Butler was “blue-gray in color and without a pulse” but the nurse not begin CPR. She paged SHP’s Medical Director for HCDC, Dr. Henry Davis, who did not respond. She then called EMS, who arrived and pronounced him dead.

SHP’s doctor denied any responsibility for training medical staff, describing himself as “a consultant who is available to answer questions.” He denied providing “any treatment protocols to SHP, although he probably did give some advice about administering insulin.” Dr. Davis said he did not know about Butler until he heard about his death.

An autopsy found Butler died of “sudden cardiac arrhythmia due to sepsis, a complication of MRSA infection. Significant coexisting conditions were obesity with hypertension, rheumatoid arthritis, and coronary atherosclerosis. ”

After Butler’s death, SHP executives visiting HCDC told Jailer Joe Blue “‘everything looks fine’ and demonstrated no concern SHP medical personnel had acted improperly. ”

Unbeknownst to them, SHP’s medical team administrator and nurse manager for HCDC Andrea Pleasant fired LPN Johnson that day. (Johnson contends he was “terminated for making a mistake in mailing an inmate drug screen sample and not for conduct relating to Butler’s death.”)

Despite claims by SHP president Hairsine that nurses could rely on their administrators for additional training and guidance, Pleasant testified SHP didn’t require her to have a “working knowledge” of SHP’s policies either. She consulted the policies only as problems arose:

Although [Pleasant] was responsible for supervising other nurses, she could not recall the policies on MRSA infection, segregation, or alcohol and drug detoxification. The nurses at HCDC followed an undocumented custom and practice of providing medical assistance only if an inmate asked for it or if there was an emergency. If an inmate reported a staph infection and vomiting, Pleasant would advise him to put in a sick-call slip and ask for help. If he did not do so within a few days, Pleasant would place him on suicide watch. She reasoned that, if the inmate does not seek help, he must have suicidal ideations. She would follow this course of conduct even though she knows that the inmate’s MRSA infection could rapidly deteriorate into sepsis and spread to other inmates and staff in the jail. After Butler died, SHP did not reprimand her or any other nurse for failing to follow any SHP policy.

Nurse Keller maintained she had, in fact, checked on Butler while he was showering, and claimed to have helped him put on his shirt. She stated it was her idea to move him to a new cell with a bunk and asked him if he needed anything—to which he said he did not.

She testified she did not check his vital signs, document their visit or give him any medication because she was not sure if SHP’s policies required her to do so. She echoed Pleasant’s statements, saying it was “customary for SHP medical staff to examine an inmate only if he submitted a sick call request. ”

Jailer Blue admitted he had not read SHP’s policies and procedures “completely,” and said he and his team had relied on SHP to “make all medical decisions concerning the inmates.” He conceded, “Under Kentucky corrections policy, Butler was entitled to receive health care comparable to that available to free citizens in the surrounding community.”