LAWRENCEVILLE - An internal investigation released Wednesday by the Gwinnett County Sheriff's Department substantiates the complaints of several inmates who alleged a female inmate died of leukemia after being neglected by the jail's contracted medical provider.
While the three-month investigation clears Gwinnett County deputies of any wrongdoing, it exposes multiple failures by Prison Health Services, the Nashville, Tenn., based company that provides jail health care. The investigation reinforces allegations by numerous inmates who came forward as a result of Harriett Washington's death on Oct. 17 - accusations that painted a disturbing portrait of botched record-keeping, patient neglect and staff indifference by PHS.
The file noted there was "a clear lack of documentation through the medical emergency treatment" performed by PHS staff that day. The report also states there were "some inconsistencies" in the number of times Washington had been seen in the medical unit and what type of treatment was provided to her during the two previous days.
In a memo requesting further investigation of the incident, jail commander Lt. Col. G. Lancaster said "a staff nurse may have overlooked or misdiagnosed Ms. Washington's condition."
Washington's two cellmates claim her requests to be hospitalized were rebuffed on multiple occasions. In the course of the internal investigation, several deputies also harshly criticized PHS staff for failing to send Washington to the hospital and sending her back to her cell sick, dizzy, vomiting and in pain.
"If the medical staff had ordered outside treatment at Gwinnett Medical Center, as the sworn staff had urged, instead of allowing the inmate to remain in the housing unit, the end result very well may have been the same," the conclusion says.
"Had the inmate been transferred to the hospital, however, it would have eliminated the doubt surrounding the appropriateness of the treatment provided."
In a prepared statement released on Wednesday afternoon, Sheriff Butch Conway did not indicate what action, if any, would be taken against Prison Health Services.
"I am in the process of determining what my options are regarding Prison Health Services," Conway said. "When I do, I will make a decision that is in the best interest of the Gwinnett County Sheriff's Department, the inmates and our personnel."
Susan Morgenstern, spokeswoman for Prison Health Services, said she was not aware that any discussions about the company's contract with Gwinnett had arisen as a result of the internal investigation. She declined to discuss Washington's treatment.
"We can't discuss details of an individual case because of patient confidentiality, but I can tell you that our goal is to provide quality health care to all our patients every day," Morgenstern said.
Falling through the cracks
Before she died, 43-year-old Harriett Washington was known affectionately as "Sparkles" among her fellow female inmates. In and out of prison several times for cocaine possession, theft and forgery, friends said Washington was nonetheless an extremely likable woman who had been diagnosed with myeloid leukemia, a rapidly progressing cancer of the blood.
At least one deputy who worked in the housing unit said Washington knew she was getting sicker. Washington told Deputy W. Gowdy she wanted to see her own doctor, and that she had already missed two appointments, according to the documents. When asked by the deputy whether she had spoken to medical staff about this, Washington said the medical unit was aware of her need to make appointments.
The nurse who saw Washington at least twice the day before her death, Brian Woodard, resigned just a week later in the midst of an unrelated internal investigation into some missing medication.
When questioned about why he didn't call a doctor for Washington on Oct. 16, Woodard told authorities she didn't appear to be in any distress. Woodard said he made a doctor's appointment for her the following morning. However, Washington's cellmates and deputies who were in the housing unit witnessed Washington vomiting repeatedly all over the cell, experiencing dizziness, acting delirious and having difficulty breathing.
When asked by his own supervisor about why he didn't document his treatment of Washington, he said it was because he didn't do anything for her. He told the supervisor he knew he should have documented even a lack of treatment, and said "I know I (expletive deleted) up," according to the supervisor's notes.
Gowdy told internal investigators that Woodard seemed indifferent when she tried to get the inmate help. Gowdy said Woodard told her "she has leukemia and there is nothing we can do for her." When symptoms of fever and difficulty breathing were discussed, the nurse told Gowdy "we don't treat more than one condition at a time," the file says.
Woodard wasn't the only PHS staff member who came under questioning after the death. According to the internal investigation, paramedic Sheila Martin should have been a first responder when Washington finally collapsed in her cell in the predawn hours of Oct. 17. Instead, she sent a nurse and a medical assistant. The staff who responded did not immediately start CPR in the cell, according to established protocol. Instead, they chose to place her on a gurney and wheel her to the medical unit first, the report said.
When asked by her supervisor about why she didn't respond to Washington's collapse, Martin agreed that she should have but couldn't provide an explanation as to why she did not. None of the five staff members who reportedly were on duty the night Washington died documented her condition or the treatment she was given.
Washington's sister, Brenda McKibben, has custody of Washington's 12-year-old son. Reached by phone on Wednesday, McKibben said the family is still trying to sort out details of what happened.
"We've only been told what we've read in the newspaper. We're very upset, very," McKibben said. "We want to handle this in a manner for this not to happen to anybody else. That should never happen to anybody."
Prison Health Services, the largest private provider of its kind in the nation, says it founded the private managed correctional health care field in 1978. The company employs more than 4,700 health care professionals and support staff across the country.