Jail standards commission needs greater healthcare focus

Interested readers should see recommendations for the Texas Commission on Jail Standards submitted to the Sunset Commission from Matt Simpson at the ACLU of Texas, compiled in response to a survey of advocates. Key proposals include stricter evaluation of medical care provided at county jails and improving medical care and services for pregnant inmates.

I agree with most of what Simpson has proposed, but this statement in particular strikes me as only 2/3 correct: "Currently, the statutory authority of TCJS does not allow it to inspect in a meaningful way the quality of medical care, the quality of mental health services, or the conditions of confinement."

While it's accurate TCJS has no capacity for meaningful oversight of jail medical services, they do a pretty good job IMO of identifying problems with "conditions of confinement." The bigger dilemma in that regard, and TCJS' own agency self-evaluation (pdf - p. 13) said the same thing - is that the agency suffers from a "lack of enforcement options available to bring jails into compliance." In other words, TCJS rules need more teeth.

Simpson's right, though,that TCJS presently has no staff qualified to evaluate jails' delivery of medical care. Current TCJS inspections ensure at least that medical grievance procedures exist, but the agency has no way to tell whether appropriate care was given. What's more, TCJS has no authority nor capacity to go in after specific incidents to see whether rules have been broken.

In particular, I'd like to see TCJS perform after-action reviews in certain jail deaths - perhaps along the lines of hospitals' morbidity and mortality conferences - to identify causation and what if any procedural fixes might have prevented what happened. Perhaps that's not necessary in every instance, but we've seen jail deaths recently that cry out for greater oversight by the state.

For more on this subject, see earlier recommendations for the jail commission's sunset review from Bob Libal at Texas Prison Business and from the Texas Jail Project.

Jury awards fat verdict against Dallas County over jail health failures

For the second time in 18 months, a jury has awarded a plaintiff nearly $1 million because of inadequate healthcare provided by the Dallas County Jail. Reports the Dallas News ("Jury orders Dallas County to pay $900,000 over lack of medical care for fomer inmate," Aug. 27):

A federal court jury ordered Dallas County on Tuesday to pay $900,000 to a former Dallas County jail inmate for denying him proper medical care while he was in custody.

The jury found that Stanley Shepherd's constitutional rights were violated when he was denied basic medical care while in the Lew Sterrett Justice Center on burglary and drug charges in late 2003.

Jurors in the weeklong trial issued their verdict Tuesday morning after deliberating since about 1 p.m. Monday, said Don Tittle, the attorney for Mr. Shepherd. If lawyers' fees and interest are granted, the county could have to pay more than $1 million, he said.

Commissioner John Wiley Price, who has spearheaded recent jail improvements and who voted against contracting out jail health in 2002, said he disagreed with the verdict.

"We will appeal the case. We are going to be vindicated on appeal," he said.

Tuesday's verdict is significant for two reasons, Mr. Tittle said. First, it's the largest jury verdict over a jail-neglect suit against Dallas County. And second, the verdict is an indictment of the county's entire jail-health system instead of one or several isolated cases, he said. In legal terms, that means the jail's "general conditions of confinement" led to the damage suffered.

"It's a finding that they failed to meet the basic essential needs of an inmate" because of systemic problems, Mr. Tittle said.

Mr. Shepherd, 51, who testified during the trial, entered the jail in October 2003 on a burglary and drug charge and suffered the stroke in January 2004. In the seven weeks before his stroke, he received little or no treatment or medication despite high blood- pressure readings, Mr. Tittle said. Mr. Shepherd told the jail staff about his blood pressure medication upon being booked into the jail, the suit said.

He was taken to Parkland Memorial Hospital almost an hour after he was found on the floor of his cell, according to the lawsuit.

The charges against Mr. Shepherd were later dismissed.

Mr. Shepherd, who filed his federal lawsuit in 2005, uses a wheelchair and is paralyzed on his left side, Mr. Tittle said. He can only eat soft foods; his speech, hearing and sight are impaired; he is impotent and suffers from depression; and his wife must help him with everyday activities, the suit said.

With what we know about health care at the Dallas jail, I'd bet dollars to donuts Price is wrong the county will be "vindicated" on appeal. A report (pdf) from the feds issued this spring found some improvements, but overall said many of the same problems described in Mr. Shepherd's suit are still happening.

Indeed, given the details of the plaintiff's case and the clear culpability of the county, Mr. Price and the Commissioners Court might be better served spending money to improve jail health care instead of on appellate lawyers. When he makes comments like that it leads me to believe he's not serious about acknowledging or fixing the jail's problems.

To be honest, $1 million sounds like an awfully cheap payout considering what happened to this fellow and the permanent disabilities that resulted. How hard would it have been just to give him his high-blood pressure medicine, which was in the Sheriff's possession?

Plus, it's not like this is the first time this happened. As mentioned, last year Dallas County was ordered to pay damages for failing to provide adequate healthcare to three other plaintiffs; again from the Dallas News:

Tuesday's verdict – if intact after the county's appeal – will be the second six-figure payout in two years related to the jail's well-publicized problems in providing health care to its jail population.

In February 2007, commissioners agreed to pay $950,000 to the families of three mentally ill former inmates, one of whom died, to settle their civil rights lawsuit over jail medical care.

James Monroe Mims didn't get his medication for two months and nearly died after water to his cell was shut off for two weeks. Clarence Lee Grant Jr. died in his jail cell in 2003 after he did not receive any medicine for five days. And Kennedy Nickerson was found lying sick in the street after being released from the jail without medication or notice to his family.

Several scathing reports have criticized medical care in the Dallas County jail system, and the jails haven't met state standards since 2003.

The only reasons jail health won't be more of an issue in the hotly contested Dallas Sheriff's election are that it's unclear what if anything the GOP candidate might do differently, plus so much blame goes to the county commissioners court for failing to adequately fund jail health over the long haul.

Dallas County is presently in the midst of a self-manufactured budget crisis. The Commissioners Court has declared it won't raise taxes, then used the resulting projected shortfall to justify draconian cuts, mostly affecting services provided to the poorest among us. So unfortunately, in that context, major civil verdicts against the county may be the only way to get the Commissioners Court's attention and focus more resources on jail health on the front end.

UPDATE: Robert Guest adds that this is why Dallas should not be "using their jail to incarcerate those with outstanding traffic fines," noting that "To fill the coffers, Dallas launched the ill conceived "Operation Pay or Stay" program. The result is that one of the most dangerous jails in Texas, is now being used a debtor's prison." "Tarrant County has already had a traffic ticket arrest turn into a death sentence, wrote Guest. "It is only a matter of time before Dallas experiences a similar tragedy."

Feds: Dallas jail healthcare still not up to snuff

I'm not sure how I missed a new report (pdf) from the feds last month about improvements and deficiencies at the Dallas County jail, but the story by Kevin Krause at the Dallas News ("New report finds Dallas jail improved but still falling short on health care," July 22) contains a good analysis of what's been accomplished at the jail and the mainly healthcare related shortcomings USDOJ says they still need to address. Perhaps most disturbingly:

Mentally ill inmates are inappropriately locked in their cells for 23 hours a day, because of staffing shortages and lack of space for "out-of-cell time," according to the report.

In the mental health category, other problems reported were a difficulty in tracking patients, lack of privacy, inadequate staffing and a lack of adequate space to conduct mental health evaluations.

That said,

The report highlighted several areas of improvement, including jail maintenance response times, the cleanliness of laundry, and a training program to help jail guards recognize and respond to health emergencies.

In addition, there is now excellent leadership of health operations, the jails are on a "steady foundation of funding," and clinical staffs are of high quality, the report said.

However quite a few areas still needed upgrading; here's Krause's summary:

• Difficulty tracking patients' medical needs.

• Lack of privacy during medical screening.

• Lack of follow-up for inmates returning from the hospital.

• Inadequate fire safety systems in all five jails, including broken or inadequate alarm systems in four jails.

• Slow response to inmate sick calls.

• Use of dirty mattresses that can no longer be cleaned and should be thrown out.

• Improper use of chemical cleaning agents by inmates.

• Lack of dedicated sanitation officers.

Inevitably these criticisms of the jail will be thrown into the political fire this fall, and rightly so, though I'm not sure Republican Lowell Cannady would do any better - he's a former Dallas police supervisor and Irving police chief who's never worked in a jail and brings no experience in correctional health to the table.

It's little secret that Dallas County Republicans view Sheriff Lupe Valdez as the weakest down-ballot candidate they have a chance to unseat; if she's vulnerable, it's because of how she's managed the jail. She's been there a full term and it's time to own the problems; after four years she can no longer blame them on her predecessor, even if they did exist before she got there.

In such a high-turnout election with a popular Democratic presidential candidate above her on the ballot, I personally think Valdez's vulnerability may be overstated. But the stakes are high on many levels and if more voters split tickets locally because of the Sheriff's race, GOP leaders hope they can stifle Democratic gains among Dallas judgeships from the 2006 election, possibly even creating an electoral roadmap for challenging popular District Attorney Craig Watkins in 2010.

One problem with this blame game in the Sheriff's race is that funding from the county commissioners court - not any decision the Sheriff makes - remains the primary barrier to fixing problems like inadequate staffing to manage mentally ill inmates.

Dallas isn't the only Texas jail facing similar problems managing mentally ill or sick offenders in the face of staffing shortages, but they're the only one with the USDOJ looking over their shoulder waiting to force them to fix things with a court order. The Supreme Court has long declared counties are constitutionally required to provide healthcare to those in their jails. If Dallas won't pony up for adequate carceral health care services, I wouldn't be surprised when one day soon a federal judge steps in and takes the decision, not to mention control of the cost, entirely out of their hands.

Dumping Debra and Donna: Counties should reduce pretrial incarceration if they can't afford health costs

Over the last decade or so, even as crime has declined, most Texas jails have gotten fuller mostly because of a dramatic expansion in pretrial detention - in particular requiring bail instead of releasing offenders on personal recognizance bonds. Indeed, for reasons I cannot explain, this pattern constitutes a statewide trend even though the decisions behind it are all made by local judges. According to Dr. Tony Fabelo, overall jail populations in Texas increased 18.6% between 2000-2007, while the number of pretrial detainees increased 49.2% over the same period.

With this decision, though, comes all the costs resulting from jail overcrowding - particularly health care for inmates.

In two ugly cases this year in Henderson County, a judge refused to offer a female defendant a personal bond, then while incarcerated they became sick unto death. Reports the Athens Review ("Second inmate dies after jail release," Aug. 1):

Like Debra Lee Newton, Donna Carroll, 49, of Mabank was released from jail on a personal recognizance bond a few days before she died earlier this month.

The cases of the two women are similar in some respects.

Both were handled by area police on drug charges. Both became ill while in the Henderson County Jail. And both were released on $5,000 personal recognizance bonds once it was determined they needed major medical attention.

Both also died within several days of being released from Henderson County Sheriff’s Department custody.

While Newton’s body was disposed of without an autopsy being performed, Carroll’s body was autopsied.

The difference?

Carrol’s death was “unattended” at her home in Mabank. State law requires that all such deaths undergo autopsy.

Newton died at ETMC as a patient of the hospital.

The article goes on to speculate that health problems related to meth abuse may have caused these women's deaths, but there are policy concerns that won't be satisfied with that explanation.

In the case of Debra Newton, she'd been in the jail two months before a judge released her on a personal bond and deputies took her to the local hospital where she later died. So even if drug abuse caused her problem, she'd presumably been off drugs and under the jail's care for two full months. If either a) she was able to get drugs in the jail or b) the Sheriff did not provide adequate health care, the county may still be at fault.

Finding another, similar case makes me think the county simply has too many people in its jail to provide adequate health care. These women had not been sentenced, they were being held pretrial on drug charges because they could not make bail and a judge denied them personal bonds. Then, when healthcare costs became too dear, probably the same judge decided they were safe to release on their own recognizance, conveniently eliminating the county's obligation to pick up the tab for their health care.

When judges require bail for low-level offenses, they're undertaking costs to the taxpayers that can easily rise if the person gets sick or must stay in jail many months awaiting trial. Counties unwilling to meet their obligation to provide health care to inmates shouldn't incarcerate so many of them prior to sentencing. But once they do, they're the county's responsibility when they get sick; jailers and judges can't just dump sick inmates at home or in the local E.R. and wash their hands of the matter.

Dallas court identifies "deadly weapon" that can't kill you

According to the Center for Disease Control, reported The New York Times ("Prison for man with HIV who spit on police officer," May 16), "Although there have been rare cases of transmission through severe bites, 'contact with saliva, tears or sweat has never been shown to result in transmission of H.I.V..'”

Even so, a homeless man was sentenced to 35 years in prison in Dallas for "harassing a public servant with a deadly weapon: his saliva." What's more, "Because of the deadly weapon finding, the man, Willie Campbell, 42, of Dallas, will not be eligible for parole until he has served half his sentence."

So to flesh out the logic, you can't contract HIV from spit, but spit is a deadly weapon because it might transmit HIV? Huh? I'm amazed Dallas DA Craig Watkins' office pursued that line of argument, and more amazed still that a judge bought into it.

According to Chapter 22.05 of the penal code, an offender engages in "deadly conduct" if "he recklessly engages in conduct that places another in imminent danger of serious bodily injury." So if the Center for Disease Control says saliva "has never been shown to result in transmission of H.I.V.,” where, exactly, is the "imminent threat of serious bodily injury"?

Mr. Campbell sounds like a seriously disturbed person, a homeless alcoholic and possibly mentally ill to boot, to judge by his screaming outbursts in the courtroom." Even so, although spitting at an officer was both obnoxious and assaultive, on its face the act doesn't seem to meet the definition of "deadly conduct."

In any event, unless some appellate court decides differently, add "spit" to the list of bizarre items deemed deadly weapons under Texas' statute.

MORE: From Simple Justice.

On the sunny side of the street: Is it time for an independent evaluation of 'telemedicine'?

Since I've posted quite a bit of critical material about healthcare in Texas prisons over the years, I thought it only fair to share what Correctional Managed Health Care E.D. Alan Hightower told the Senate Criminal Justice Committee yesterday are the three most important improvements at TDCJ healthcare since UTMB and Texas Tech took over the system. I personally learned quite a bit from the discussion.

First, the main benefit from operating the prison health system through UTMB appears to be reduced drug pricing. Because UTMB is a state hospital that does indigent healthcare, it qualifies for "340B drug pricing," which dramatically lowers its pharmacy costs. As mentioned earlier, 48% of TDCJ's pharmacy costs go for inmates with HIV. (As an aside, the committee was informed that "Big Pharma" is lobbying Congress right now to end reduced 340B pricing, so it's not inevitable those reduced prices will continue.)

Except for emergencies, all prescriptions in TDCJ are filled in Huntsville at a state of the art, UTMB-run pharmacy using entirely electronic prescription and medical records. Shifting to the cheaper drug prices saved UTMB about $1 million per month. In addition, because all medication is delivered to units in blister packs, unused medication is recycled, saving the state an additional $8 million per year.

In the past, drugs were delivered from Huntsville to outlying units in TDCJ trucks driven by prison trusties, but in recent years it's become more cost effective to simply ship them via UPS, said Dr. Raimer.

Hightower said the second important change for inmate healthcare delivery under the two university systems (UTMB and Texas Tech) was a shift to entirely electronic medical records integration of medical records (upgrading from paper files) into a central system accessible from any unit by medical personnel.

The third big improvement, said Hightower, has been the expansion of "telemedicine," which he said has been invaluable for providing additional consultations at rural units. He and other speakers cited Fort Stockton, in particular, as a spot where the state can't find nurses and doctors, and said that facility was particularly reliant on telemedicine.

In past hearings on this topic, senators had questioned the short amount of time spent per patient in a telemedicine setting - about seven minutes per patient, on average. This time Dr. Ben Raimer came prepared with better answers to such questions. He pointed out that TDCJ and UTMB operated chronic care clinics for a variety of specialized ailments, including HIV, mental health, liver and heart disease, and diabetes.

For those chronic ailments, he said, inmates are housed closer to medical facilities and specialists who can help them on an ongoing basis. Raimer said telemedicine was used more as a triage tool (though that seems to contradict past hearings where we learned they prescribe medications in a telemedicine setting), and that more serious cases received more extended attention.

That certainly makes me feel a little better about "telemedicine," which UTMB pioneered and is now marketing in a spin-off company, of all things. To the extent telemedicine really is just a triage tool, it could be extremely useful. As a substitute for on-site medical personnel, though, which appears to frequently be how it's used, seven minutes per patient is just not an adequate consultation for anyone with a serious problem.

I'd still like to see some medical school or other independent academic (not a Texas institution) evaluate the quality of care being delivered via telemedicine to Texas inmates compared to face to face doctor interactions. Is the quality of care at least close to the same? Maybe such studies exist, but I've never seen them, and if Texas prisons have become so reliant on a basically untested methodology, I think it's high time for an independent evaluation.

AIDS drugs, healthcare for elderly inmates driving TDCJ medical costs

Here's a mind blowing statistic about health care costs in Texas prisons that came out at yesterday's Senate Criminal Justice Committee hearing: A whopping 48% of TDCJ's total pharmacy budget goes to pay for drugs for inmates with HIV.

Chairman Whitmire asked the Correctional Managed Health Care Committee executive director Alan Hightower to compile for him a list of the top ten most expensive inmates in terms of medical costs and their parole status. The assumption is that the state is eating high medical costs for inmates who could be released and treated safely in the free world. According to Sen. Whitmire, TDCJ recommends about 70 or more inmates per month for medical-based parole, but the parole board on average releases just 10% of them.

A past analysis showed the most expensive inmates cost the state more than $1 million per year in healthcare costs, so it'll be interesting to learn whether it's still true that TDCJ's most expensive inmates are mostly eligible for parole.

The Committee expressed concern that inmates who could be released into a hospice or nursing home facility (where the feds through Medicaid would pay 2/3 of the cost), are being held in TDCJ even though they're bedridden and immobile. Dee Wilson of the Office on Offenders with Medical or Mental Impairments told senators that "many" offenders recommended for medical release pass away before the parole board gets around to their case. Around 40 inmates per month die in Texas prisons.

Blackburn succeeds in Amarillo with medical necessity defense for marijuana defendant

Reason's Hit and Run blog brings the news that our buddy Jeff Blackburn - the civil rights attorney who runs the Texas Tech law school Innocence Project and was the main lawyer representing defendants in the Tulia drug sting case - has just won a major victory in an Amarillo courtroom, convincing jurors that his client used marijuana out of medical necessity. The argument earned him an acquittal! Congrats, Jeff! According to a press release from the Marijuana Policy Project I received via email:

Though such a defense - which requires the defendant to establish that an otherwise illegal act was necessary to avoid imminent harm more serious than the harm prevented by the law he or she broke - has rarely been successful in Texas, the jury took just 11 minutes to acquit Tim Stevens, 53. The trial was hotly contested.

Outstanding news! More from the Marijuana Policy Project and from AP. MORE: See coverage from an Amarillo TV station and the Amarillo Globe News. AND MORE: See a legal analysis from Defending People.

UPDATE: Robert Guest points me to this hilariously misguided thread on the topic at the prosecutors' user forum. Given that a) a judge allowed the medical necessity defense, and b) a jury acquitted on it, you've gotta like Williamson DA John Bradley's legal assessment that "The government has already decided, as a matter of law, that the drug is not available for such a purpose. No defense permitted." Further evidence that Mr. Bradley's legal advice and $2 will get you a cup of coffee at the Starbucks and little else.

Half of TX prison doctor positions currently vacant

Dr. Ben Raimer from UTMB says more than 50% of physician slots at UTMB are vacant!!

CORRECTION: Apparently I (and every reporter and senator in the room) misheard Dr. Raimer; the UTMB PR director contacted me to say that Raimer said 15%, not 50%, of doctor positions are vacant. I apologize for the error.

I've been listening on and off this morning online to the Senate Criminal Justice Committee's hearing on medical care at TDCJ, which has mostly been a laboriously detailed questioning of officials involved with the inmate described in this Houston Chronicle article ("Injured inmate spent two days on cell floor," Jan. 24). (NOTE: The hearing is over; archived video will be available here soon.)

In addition, said Raimer 18% of registered nurses slots and 18% of mid-level practitioners positions are currently unfilled. Raimer said the Lege increased salaries for nurses and pharmacists, therapeutic staff, and as of Jan. 1 increased pay for physicians, who make between $140K to $160K per year.

Sen. Robert Deuell, who is a medical doctor, was particularly concerned that L.V.N.s were making "medical assessments" of seriously ill or injured people, or at least in the case described in the Chronicle. UTMB claimed the LVN may have called a physicians assistant working at another unit, but Deuell walked through the documentation to show that such a conversation was never recorded in the file.

The state is still suffering, Raimer said, from the 2003 budget cuts, and also higher cost related to the increase in the number of older and elderly inmates. Every year 1.5% more people come into TDCJ, he said, but 14% more every year turn 55 years old, after which they have 5-6 times more medical visits than younger offenders.

Related MSM coverage:

• Statesman: Staff shortages get blame in inmate death
• Star-Telegram: Inmates death is focus of hearing
• Chronicle: Inmate's death called 'highly complex'
• AP: Panel mulls neglected inmate's death

Prison healthcare on Senate committee agenda

The quality of prison healthcare will be back in the spotlight this week when the Senate Criminal Justice Committee takes up the topic. Here are the time and place details of Thursday's hearing in Austin (invited testimony only).

According to the Austin Statesman editorial board (Jan. 19), "nearly 2,000 inmates died over a recent four-year span, the most in any state in the country - even California, with its larger prison population." Mike Ward supplied an overview piece in preparation for the meeting last week ("Texas medical neglect cases stir concern about prison healthcare," Jan. 16):

From 2001 to 2005, federal statistics show, 1,933 convicts died in Texas prisons, more than in any other state including California, which had 1,672 deaths and has a larger prison system than Texas. California had 175,115 prisoners and Texas 172,889 as of June 30, 2006, according to the federal Bureau of Statistics.

Whitmire, D-Houston, has scheduled a Jan. 24 hearing of the Criminal Justice Committee to examine prison health care, which is provided by the University of Texas Medical Branch in Galveston and Texas Tech University. Both universities declined to comment Tuesday.

At nearly 500 deaths per year, that breaks down to about one annual mortality for every 350 prisoners or so.

The point to make here isn't just to blame the UTMB, Texas Tech and the prison system for failing to provide adequate healthcare, though we know they do not. For taxpayers, though, each of those deaths represent an abnormally high set of medical costs leading to the prisoner's final demise. Even though prisoners with HIV/AIDS make up a small portion of the inmate population, for example, their prescriptions make up about 40% of TDCJ's pharmacy costs. The lifetime cost of treating an HIV positive prisoner easily heads into the range of six figures per person.

Just like in the free world, prevention and better front end healthcare leads to fewer overall costs. Every staph infection prevented, for example, saves thousands of dollars in unnecessary followup care.

One looming problem that will make prison health MUCH more expensive over the next decades: Elderly inmates tend to cost much more than younger ones, so super-long prison sentences inevitably set up taxpayers to foot those seniors' medical bills.

I'll be looking forward to hearing testimony at next week's meeting, but we've heard a lot about the problems before. The question becomes, are there solutions besides throwing massive amounts of new money at the system? That's all they could come up with in California, where court-ordered inmate health spending is now twice that in Texas, and it's the only solution I've ever heard besides living with the status quo until the court makes Texas do something. We'll see what Whitmire and the Lege come up with, though, for 2009.

See prior, related Grits posts:

• Texas underspends on prison healthcare
• Elderly inmates health costs rising
• Thirty percent of Texas inmates former MHMR clients
• Faculty blog fears healthcare for TX prisoners gives UTMB a black eye
• UTMB should make telemedicine work better at Texas prisons before exporting it
• I guess if it's possible to have "phone sex" you can have "telepsychiatry"
• Why Texas per-inmate healthcare costs are (relatively) low and why it's an illusion
• Death sentence for stealing a Playstation: Texas prison healthcare problems not unusual
• Sex crimes and elderly prisoners' health costs
• Prison health is a budget buster
• Lack of accountability explains why counties dropping UTMB healthcare
• Healthcare poor for kids in TYC, committee told
• UTMB mental healthcare quality declining at TYC
• Harris County kids in TYC don't receive prescribed medications, treatment

Dallas jail gets surprise inspection

The Texas Commission on Jail Standards decided to conduct a surprise visit to the Dallas County Jail rather than wait for their regularly scheduled inspection in March, reports the Dallas News ("Jail gets surprise inspection," Jan. 14). Despite tons of county resources poured into the jail in recent months, the core problems remain the same: Chronic understaffing and intolerably poor inmate healthcare.

County commissioners approved millions of dollars worth of new jail guard positions during the past year. The jails will have to meet the state's minimum staffing requirement of one guard for every 48 inmates.

Mr. Munoz said he understands that the county is working to complete its south jail tower and other large projects but that he expects to see improvements in jail staffing and other things "we've asked them to improve."

County commissioners will be debriefed by the team on Friday morning; the meeting will be open to the public. The final inspection report could be released by the end of next week.

At last year's inspection, healthcare documentation was so poor inspectors couldn't determine whether the jail was in compliance with state regulations. Since that time the US Justice Department has filed suit over poor healthcare at the jail. Reported the News:

Inspectors also noted in last year's report a lack of "sufficient documentation" to ensure that sick inmates were receiving prompt care. And they reported crowded cells and day rooms in the north and west towers.

Jail administrators expect TCJS to cite staffing, again, as one of the jail's major shortcomings.

So here's my question: How does Dallas expect to open new jail wings to eliminate overcrowding when they've experienced a chronic guard shortage that makes them unable to staff the jails they've got? That's essentially the problem we're facing at state prisons, too, and at some point it's absurd to keep pretending that guard understaffing will take care of itself.

In terms of new jail and prison construction, the old adage, "If you build it, they will come" is certainly true of inmates, but empirically speaking, it doesn't necessarily apply to prison and jail guards any longer, at least at current wage levels.

Magic Johnson Goes to Texas Prison for "Wall Talk"

Here's one sports star I never expected to see in prison, even with all the professional athletes out there in trouble with the law: Basketball legend Earvin "Magic" Johnson. Fortunately, he was just visiting the Darrington Unit to participate in TDCJ's "peer education program, 'Wall Talk,'" filming a video that will be shown to "at risk" offenders. The prisoners Johnson met with are "trained to 'spread the word,' ... [to] help educate fellow offenders about preventive health care as it relates to HIV/AIDS, tuberculosis, hepatitis A, B and C, as well as diabetes and staph infections." Good for him! Also, good for TDCJ for using peer education to supplement top-down approaches to its longstanding healthcare failings; they have to try something! Johnson and TDCJ "filmed a discussion he had with a group of offenders. The resultant DVD will be used to disseminate his message further into at-risk communities"

Lack of accountability explains why Texas counties dropping UTMB jail healthcare

The UTMB-Galveston Faculty Association blog identifies the common reasoning between Jefferson County's recent decision not to hire UTMB for its jail healthcare (discussed on Grits here) and Dallas County's decision to end its contract with the Galveston medical school: UTMB wants "to make mistakes and have the contracting county eat the resulting lawsuits."

Bingo!

UTMB recently obtained a contract to provide healthcare at the Galveston County Jail, and supplies health services for inmates at the Texas Youth Commission and for most Texas prison inmates, much of it via "telemedicine.

Media criticisms unfair about Dallas jail good time policy

Because criminals and jail inmates aren't very popular with average folks, it's easy to spin stories in the MSM to imply to the public that the government is being too soft on criminals, and I'm afraid that's what happened with a story Kevin Krause reported in the Dallas News, mentioned earlier on Grits in this roundup.

An unsigned Dallas News editorial followed up Krause's story chastising the Sheriff's Department for an 11 year old policy on good time that gives offenders three days "good time" credit for every one served in the Dallas county jail, whether or not they participate in work programs. Tarrant and some other counties give two for one credit, Krause reports, and allow offenders to earn the third day by performing volunteer work, including on crews picking up trash and performing other work outside the jail.

Really, it's as though the Dallas News editorialists don't read their own newspaper. "If you plan to get arrested and/or sentenced to jail time for a misdemeanor offense," they write, "and you could choose where – wouldn't you pick Dallas County?"

Hmmm ... Duh ... I don't know, why wouldn't you pick Dallas County?

Maybe because for every month you spend in jail there you're more likely to acquire a staph infection than you would be to roll "snake eyes" shooting dice? After a scathing report last year, the feds finally sued Dallas County over poor healtchare for inmates last month.

Or perhaps because, once you go in, they might just lose your ass for a year or so?

Possibly because many jailers are young and untrained, making it among the more dangerous and overcrowded urban jails?

So why do Dallas News editorial writers think the Dallas jail is such a great place to be? Because offenders don't participate in work crews. But they've reported the reasons why before--not enough work-crew eligible inmates due to initiatives that reduce overcrowding by diverting low level offenders. State regulators ordered them to release low-level offenders by the hundreds earlier this year - precisely the category of offenders who might be eligible to work outside the jailhouse - and yet, the jail is still overcrowded.

Even so, you know what? Labor from jail inmates on road and bridge crews is nice to have, but it's not the purpose of the jail to provide the county free labor. Reported Krause:

Sheriff's spokesman Michael Ortiz said the department has always had trouble filling the trusty positions.

Each of the five jails has its own assignments and labor pool, he said. Some days, there are plenty of trusties. But because the jail population is always in flux, there are shortages, he said.

"Sometimes we'll have a good number, and the next day we'll be short," Deputy Ortiz said.

Some inmates realize it's too much work and would rather watch TV, he said.

"They apply for trusty status and get it and then realize they don't want to do it anymore," he said. "There's a high turnover rate."

Terry Grisham, a Tarrant sheriff's spokesman, said his agency has not had difficulty finding work volunteers. Those who work receive three days credit while everyone else gets 2-for-1, he said.

"It's the pre-eminent factor," he said. "They want to make that time as short as possible."

If that's the case, I've got a suggestion: Let them keep their 3-1, since changing it would worsen overcrowding and risk a federal court's wrath, and give jail inmates an extra day off their time if they participate in work crews. If they inmates used the new program, it would solve Mr. Mayfield's problem and help cycle more low-level offenders out of the jail more quickly. For that matter, I think participating in work crews probably contributes more to rehabilitation than sitting around the jail doing nothing, so it's really a win-win all around.

The Dallas jail is woefully overcrowded, with private and federal lawyers, not to mention state regulators, already breathing down their necks. Even if they build more jail beds the county can't find enough guards to staff them. So to cavalierly claim they're giving inmates living in squalor such a great deal ignores the obvious question: What would you do instead, Dallas News? On that difficult question, I guarantee, they'll have no snarky reply like their mocking editorial on the work program.

The Dallas jail doesn't have very many options at this point, and none of them include keeping low-level offenders in the jail longer so they can clean up roads in Commissioner Mayfield's precinct.

(Image via Proximo)

Arrests for pain, anxiety drugs worrisome for legitimate patients

I get a little edgy when police start making arrests for a legal pharmaceutical that I've been prescribed recently by my personal physician: It makes me wonder under what circumstances I could become a target?

Over the last year or so I've struggled with some health problems that caused my doctor to prescribe one of the medicines now named by drug enforcers as a primary target, according to the Houston Chronicle ("Southeast Texas called 'mecca' for pill pushers," Oct. 22). So if I'm driving or out in the world and have my medication with me (as I've been advised to), if a cop sees me with it will I be arrested?

I wonder: How much documentation must I carry with me to imbibe prescribed medication? Under what circumstances would possession be illegal and when would it be okay?

I was also disturbed to learn about a bill signed by Governor Perry that I'd missed during the 80th Legislature, expanding DPS regulatory authority to include most medicines. That's just wrong: I want doctors regulating my prescriptions, not cops! Reported the Chronicle:

The DEA classifies drugs in "schedules" or levels, based on the risk of abuse. Drugs such as lysergic acid diethylamide (LSD) and heroin are considered level 1 and have no accepted medical use in treatment in the U.S.

The level 2 drugs, such as the painkiller OxyContin, are available by prescription but are regulated at the federal level by the DEA and at the state level. Pharmacies electronically transmit prescription information to the Department of Public Safety, which works with licensing boards to identify doctors and pharmacists who may be inappropriately prescribing or dispensing drugs.

This summer, Gov. Rick Perry signed a bill that would expand monitoring by DPS to include level 3 through level 5 drugs, which would include Xanax and drugs combined with hydrocodone, which are levels 4 and 3, respectively.

State Sen. Tommy Williams, R-The Woodlands, said he sponsored the bill to give Texas law enforcement agencies the tools to investigate drugs that are classified as less prone to abuse by requiring all prescriptions for controlled substances to be sent electronically to DPS. The official enforcement date for the law is September 2008.

Still, some law enforcement officials in Texas argue that hydrocodone and Xanax should be grouped with more addictive drugs and targeted separately — not with other schedule 3, 4 and 5 drugs. They are pushing for the Legislature to reclassify hydrocodone and Xanax as level 2 drugs, which would make them subject to far greater scrutiny, similar to OxyContin, officials said.

"We have to change the overall approach that the state has in regards to regulation, " said Houston Police Lt. Gray Smith, with the narcotics division.

Honestly, I don't want my prescription information transferred to DPS, and I don't think most Texans know that that happens. Did you? I'm fairly shocked by it. I wonder what they do with all that data?

What do you think? Why should state troopers have access to Texans' prescription information? And should criminal law enforcement focus its limited resources on tracking what drugs your doctor gave you or how often you renew your prescription? Does that make you feel safer, or less safe?

ADDENDUM: This story from KHOU gives a fuller picture of the real problem: If the real source of crime is stolen or black market drugs, how does it help to gather information on legal prescription holders?

Feds sue over Dallas jail healthcare: 'If people treated animals this way, they would be prosecuted'

Who couldn't see this coming a mile away? The feds have sued Dallas County over poor health conditions in the jail, reported AP yesterday:

Federal prosecutors allege in a lawsuit that inmates at the Dallas County Jail are at risk of harm because of unsafe jail conditions and a lack of proper health care.

The U.S. Attorney's Office asked the court to require Dallas County to take actions to correct deficiencies at the jail, among the largest complexes in the country. In a lawsuit filed Wednesday, the federal government contends Dallas County and Sheriff Lupe Valdez have known about problems at the jail for some time but have failed to address them adequately.

By failing to fix the inadequacies, the rights of the inmates were violated, the suit said.

"Through the acts and omissions...Defendants have exhibited deliberate indifference to the health and safety of Dallas County Jail inmates," the suit said. The federal government says court action is necessary to effect change. ...

Federal officials contend the jail hasn't provided adequate medical and mental health care to inmates and hasn't ensured a safe and sanitary environment for detainees, the lawsuit contends.

"This problem has been simmering and festering for at least 10 years," said David Finn, a Dallas attorney and former judge.

Earlier this year, county officials approved a nearly $1 million settlement with the families of three mentally ill inmates who were denied medication while in the jail. A little more than half of the award went to James Mims, a jail inmate whose psychiatric medications were withheld for two months in 2004. Mims nearly died when water was shut off in his cell for two weeks, said Finn, who represented the inmate.

The problems aren't just in dealing with mentally ill inmates, but also extend to people who require medication, such as diabetics, said Finn.

"We're talking about basic health care. If people treated animals this way, they would be ... prosecuted," he said.

A federal report sent to Dallas officials in December said the jail violated the constitutional rights of inmates by failing to provide adequate medical and mental health care.

A separate report from February 2005 found that lapses in medical care in the Dallas County jail system resulted in undetected illnesses, excess costs and risks to the public.

The only thing I find puzzling is why it took the feds this long to sue? A year and a half ago we already knew that "For every month spent in the Dallas County Jail, you're more likely to get a staph infection (~3.4% chance) than you are to hit 'snake eyes' when playing craps in a Vegas casino (~2.77%)." As I asked then, "Wanna roll the dice?"

Well, roll the dice is exactly what the Sheriff and Dallas County Commissioners Court chose to do. The result was worsening problems that caused a tax increase. And it's not just health care, but overcrowding and overall management. They occasionally just lose people in the jail. The feds issued their own criticisms jail healthcare in December, and already have monitors at the Dallas jail.

Incidentally, last year as complaints mounted, the Sheriff transferred responsibility for Dallas jail healthcare from UTMB-Galveston to a local provider, Parkland hospital. But even today, similar problems exist in other facilities where UTMB operates, particularly Texas' adult and youth prison systems (TDCJ and TYC). While the feds are at it, they should investigate healthcare in other carceral settings where UTMB operates, and I'll bet they'd find similar results.

RELATED: See Part One and Part Two of the 47 page report by the feds from December '06.

ACA report on TYC health care available

The impact of understaffing problems on health care for kids incarcerated in Texas youth prisons was described to agency officials and the Texas Legislature this spring in a detailed spot-analysis by the American Correctional Association.

I just received a copy of the report evaluating Texas Youth Commission health services by the ACA on April 30, 2007, in response to an open record request. I'll go through it more thoroughly soon, but I thought I'd go ahead and post it for those interested.

Recent indications make me wonder if anyone followed up on these recommendations after receiving the ACA report?

In August, Dr. Ben Raimer told the Lege that UTMB was still "having a difficult time recruiting healthcare workers to staff Texas Youth Commission facilities because of deteriorating safety conditions at TYC units." Raimer also told legislators that mental healthcare is "probably worse" than it was one year ago.

The ACA report praised the quality of TYC mental health care, particularly at Corsicana, though even that facility requires more nursing support, they said. But concurring with Raimer, regular, acute healthcare for the general TYC population appears to be spotty, irregular, and most of all understaffed with qualified health personnel. Though only three units' records were examined, I don't imagine these issues were isolated to just those facilities.

Given Dr. Raimer's comments last month, how many of these issues do you suppose have been solved yet?

UTMB should make telemedicine work better in Texas prisons before exporting it

"Telemedicine" is the physicians' version of fast food, a cheap, industrial, low-quality product that promotes dehumanized social relations for both health workers and customers. And to judge by the results UTMB has had in Texas, health outcomes under telemedicine are quite poor.

But that won't stop UTMB from subsidizing a private start-up firm to market the idea to other prison systems and the private sector. The Houston Chronicle reported over the weekend ("Virtual care, real profit," Aug. 25):

The group that helped pioneer remote medical treatment of prison inmates in Texas hopes to commercialize that technology and market it beyond government contracts.

The University of Texas Medical Branch in Galveston is expanding part of its telemedicine group as a for-profit startup, dubbed NuPhysicia, with $5 million in funding from Houston-based private equity group Sanders Morris Harris.

Being Texas, it's not enough that we develop some of the worst corrections policies on the planet, our taxpayers subsidize the export of those bad ideas to other places and the private sector.

That's what's happening here. UTMB is responsible for most inmates' care, but rather than adequately staff prison medical facilities, they've relied on this gimmick they've dubbed "telemedicine" to give medical care through video conferencing systems.

The result: UTMB's Ben Raimer testified to the Texas Legislature last year that they were "very close" to providing unconstitutionally poor levels of health care. Legislative hearings on the subject pinned blame on the telemedicine system, as Grits reported in November:

Prison doctors see 60 patients in eight hours using telemedicine systems, sometimes from 4 a.m. to noon, witnesses told the commission.

So let's think about that. At most, assuming docs take no bathroom or meal breaks, and with zero time between prisoners, that would mean prison docs using telemedicine systems spend 8 minutes per patient. Since all that is unrealistic, with 15 minutes per hour for restroom breaks, meal breaks, and time transferring from one to another prisoner, medical visits are likely to be more like 7 minutes long. And your workday, for the doc, starts at 4 a.m.?! Who would want that job?

Sen. Bob Deuell from East Texas, who is a medical doctor, sounded skeptical of the telemedicine system. He questioned during the Sunset hearing how high the quality of care could be for patients who only saw their doctor that short a time and only over a video feed.

UTMB hasn't fixed problems with Texas prisoner health systems, but they're now planning to export those systems to other locales for profit. How much sense does that make? Ironically, UTMB cited low spending on Texas prisoner healthcare in the article as a selling point for its program, but the writer doesn't mention that the state suffers poor health outcomes to go with its low spending. The Chronicle reported:

Half of UTMB's telemedicine patients are prison inmates.

Texas spends 46 percent of what California does per prisoner for health care, in part because telemedicine has driven down costs.

Texas spent $7.66 per inmate per day for health-related expenses in 2006 while California spent $16.60 per inmate per day, according to figures compiled by the Texas State Auditor's Office.

Electronic Health Network will continue to exist and treat Texas inmates.

NuPhysicia will pay UTMB to use its technology and some of its staff for governmental and private telemedicine contracts outside of Texas.

Texas' low spending on healthcare should be no selling point when UTMB publicly admits to being "very close" to providing care so poor it violates patients rights! In fact, it's odd to see UTMB citing that $7.66 figure as a positive - they told the Legislature that number needed to increase substantially, and said it could go as high as California's costs if the courts ever required UTMB to provide similar levels of care.

I must admit, part of me doesn't like the idea of a public university subsidizing for profit private investments. I don't see why UTMB should get legislative appropriations if they're going to spend millions to start private businesses. Hell, I'd like a few million in legislative appropriations to start a small business, if you don't mind!

But beyond those public policy concerns, UTMB shouldn't be selling its telemedicine program to the public as some big, cost saving success when the truth is, judging from prisoner outcomes, it produces a poor product.

Texas jail news

Several recent jail related items deserve Grits readers attention:

Val Verde jail deaths, illnesses not related?
Kathleen at Texas Prison Bidness has an update on the unexplained jail deaths at the Val Verde detention facility operated by the Geo Group, a private prison company. It turns out the main reason they don't know what's going on yet is that the Bexar County Medical Examiner declined to perform an autopsy on the Honduran inmate who was first to die. "Has anyone asked why the medical examiner's office declined to perform an autopsy?" wrote Kathleen. I think someone just did. It's a damn good question. Meanwhile at the Texas Observer blog Forrest Wilder suggests that Geo's efforts to keep profits up may cause them to neglect expensive medical care. See prior Grits coverage.

Cameron tent jail: Second time's a charm, nearly
After he was forced to tear down Cameron County's first tent jail because he built it without approval from state regulators, Cameron County Sheriff Omar Lucio may begin moving inmates into another version of his tent jail next week. His new tent failed state and local inspections Thursday, but apparently there's only a short checklist of items to be completed before they can open the facility. Counties are allowed to operate tent jails on an emergency basis for up to three years, but Cameron is the only county right now doing so. The Sheriff says he hopes the Lege will change the law in 2009 to let him go longer - personally, I wouldn't count on that.

So who will fill this tent jail? Perhaps predictably, nonviolent misdemeanor defendants awaiting trial. Reported the McAllen Monitor (8/23), "Nearly three dozen nonviolent inmates facing misdemeanor charges are expected to be housed in the tent facility." My question: Wouldn't it be cheaper and smarter to let nonviolent misdemeanor defendants out on personal bonds awaiting trial? I've been considering instituting annual Grits "Smart on Crime" and "Dumb on Crime" awards, and Sheriff Lucio would definitely be a candidate for the latter prize.

Family to police: Tell us what happened
After police told the family of a Pasadena man who died in custody that he may have died of an heart attack or a stroke, an autopsy revealed bruising, abrasions, blood splatters and two knocked out teeth that the defendant still had when taken into custody. Now the family wants the officers to explain what happened in court, reports the Houston Chronicle. Here's an example of how stronger open records laws might prevent civil litigation: Current law puts families in such cases in the position of having zero information, being asked to trust officials who've already misled them, and the only way they can find out what really happened is to sue. Opening records in closed investigations would solve that dilemma once and for all, and probably reduce litigation against police departments.

Munoz to Howard County: Build a new jail
Howard County's jail is old and fundamentally out of compliance with current jail architecture and safety standards. For years the Texas Commission on Jail Standards gave the facility variances, but now the Big Spring Herald reports ("Munoz to Howard County: Build a new jail," Aug. 24) that a letter from TCJS chief Adan Munoz raised the specter of closing the jail if voters do not approve a bond election in November. Howard voters rejected a new jail last year, but as in Tyler, commissioners plan to place it on the ballot again. The Howard County Judge said closure of the jail would bankrupt the county "within a year."

Rangers search Bexar sheriff's home over commissary bribe scandal
Texas Rangers yesterday searched the home of Bexar County Sheriff Ralph Lopez and his wife Nancy (both were named in the warrant as search targets) hoping to find more information regarding alleged bribes and improper gifts and trips relating to Bexar's jail commissary contract. Rangers also executed a search warrant at the home of the Sheriff's campaign manager John Reynolds, a central actor in the bribery allegations. I'm glad to learn DA Susan Reed has outsourced the investigation to the Texas Rangers. It enhances her credibility to have the investigation performed by an outside party. Which is precisely why she should have outsourced the investigation in the Ruben Cantu case when her own office's credibility was in question.

Is "mysterious illness" in Del Rio private prison TB?

“The presence of tuberculosis is almost expected in any correctional facility,” said Dr. Sandra Guerra-Cantu, Region 8 Health Director of the Texas Department of State Health Services.

Really? Okay. Move along folks. Nothing to see here. ...

Rumors in Del Rio have spread that two recent deaths and other reported inmate illnesses were caused by tuberculosis, reports the Del Rio News Herald, but no cause of death has yet been officially confirmed. The facility functions both as the Val Verde county jail and also houses inmates from other counties and even out of state.

It's certainly true that TB is more common in prison, and prisoners are less likely to complete treatment, which takes 6-9 months, encouraging antibiotic-resistant strains to evolve. Because of its method of transmission, prisons and jails are a prime breeding ground for TB.

But for exactly those reasons health officials should be scurrying to prevent it. If TB was the cause of not one but two inmate deaths in Del Rio, that's a much bigger deal than Guerra-Cantu makes it out to be.

The Texas prison system operates a 24-bed TB quarantine facility in San Antonio, described in this excellent article from the Austin Statesman recently by Brad Buccholz. Unit 14, as it's called, is the last of Texas' TB sanatoriums. Before antibiotics, those plagued with tuberculosis, or "consumption," as it was commonly known, were quarantined en masse in these prison-like facilities, says Wikipedia, and 50% who went in did not come out. The last of these institutions apparently was handed over to the state prison system at some point, which continues to operate it to this day.

I don't blame public health officials for trying to avoid a panic, but neither should these unexplained deaths and illnesses be swept under the rug. If this outbreak does turn out to be TB, maybe somebody ought to let the Idaho Department of Corrections know what's going on - they just moved a bunch of their inmates into the Del Rio facility after their director toured and called it a "pleasant surprise." Perhaps they found a way to mute the sounds of hacking and coughing during the director's tour.