Report: Inadequate medical and mental health care contributed to 2020 deaths in Oregon jails

Disability Rights Oregon released an investigative report on Monday, examining ten deaths in eight Oregon jails over the course of 2020.

Posted: Feb 8, 2021 1:15 PM
Updated: Feb 8, 2021 1:27 PM

PORTLAND, Ore. — Inadequate medical and mental health care, among other factors, contributed to the deaths of ten inmates at eight local jail facilities throughout Oregon over the course of 2020, according to an investigative report by Disability Rights Oregon released on Monday.

The report looked at ten deaths between the beginning of January and the end of October, 2020, in Clatsop, Deschutes, Jackson, Klamath, Marion, and Polk counties, as well as the Springfield Municipal Jail and the NORCOR detention center in The Dalles.

"As the jail population plummeted last year in response to the threat of COVID-19, the number of deaths in Oregon jails rose," DRO said in a statement. "Jails are shielded from public scrutiny like few other places in society. DRO’s investigation documents the systemic failures — by both hospitals and jails — that led to this tragic loss of human life, and makes clear that many, if not most, of deaths that occurred in Oregon jails were preventable."

According to the DRO report, nine out of the ten inmates who died had a disability. Five had documented mental health conditions, and six of them died by suicide. Eight had documented substance use disorder, and six of those were in custody on drug-related charges. At least four were homeless, or had a history of housing insecurity.

The ten deaths examined were unrelated to COVID-19, and did not include deaths in the state prison system.

The organization concluded that the deaths resulted from a combination of restraint practices that are banned in clinical settings, inadequate assessment of medical conditions, an inability of the jails to provide necessary treatment, and a failure to take adequate measures to prevent suicide — in addition to a lack of meaningful transparency or oversight, and a revolving door of detainees with a lack of community treatment options.

Though including them in the report, DRO did not explicitly cite details from the cases that occurred in Jackson and Klamath counties. The Jackson County Jail reported the death of 46-year-old Carl Sullivant in February of 2020 after he died following an apparent medical emergency. 22-year-old Randall Holmes, the suspect in a 2019 drive-by shooting, reportedly died in the Klamath County Jail in April.

"While this report does not tell the entire story of each person’s death, each individual case is its own tragedy and speaks to the urgent need for action," DRO said. "Use of force, inadequate medical and mental healthcare, insufficient screening, and failure to follow safety protocols contributed to the deaths analyzed in this report. Criminalization of mental health conditions, lack of substantive healthcare standards, and lack of jail oversight were systemic issues uncovered through this investigation."

The report examined two cases in particular. Alex Jimenez, an Army veteran, struggled with mental illness and addiction. According to DRO, officers approached Jimenez in Warrenton, Clatsop County, for jaywalking. He was tased and forcibly taken into custody when he did not respond to commands. He was taken to a local hospital for an assessment prior to booking.

"A doctor’s medical assessment consisted of looking at Alex as he sat in the back of a police car yelling and moving around," DRO said. "The hospital did not measure Alex’s vitals, examine the area where he was tased, or assess his mental health needs. Based on a cursory observation, the doctor cleared him for jail, saying 'I guess you’re ready to go to jail.'"

Outside of the Clatsop County Jail, Jimenez struggled with officers as they tried to steer him toward the facility. He was forced to the ground and held down to the pavement with "as many as six people holding him down" until he stopped moving and one of the officers found that he wasn't breathing.

While Jimenez was briefly revived at the hospital, he died later that day. The medical examiner's report concluded that his death was caused by methamphetamine toxicity, with "recent application of conductive electrical devices" and fatty liver cited as contributing factors.

The DRO report also cited the case of 26-year-old Jennifer McLaren, a woman with a history of drug possession charges, who died from a severe case of undiagnosed pneumonia at a jail in The Dalles. Though McLaren complained of rib pain and her cellmate asked to be moved because "she seemed sick," she was not taken to a hospital for eight days — instead, she was moved to a booking cell for closer observation.

"The day before her death, Jennifer became very dehydrated. This concerned medical staff, so they ordered her to drink a gallon of juice but did not attempt to have her hospitalized," the report said.

Emergency medical staff were not called until just before McLaren fell unconscious, and she died at the jail before she could receive treatment. The medical examiner listed her cause of death as pneumonia in both lungs, with blood-borne bacteria that had spread throughout her body.

The majority of the ten deaths investigated by DRO were caused by suicide, but the organization found that none of the individuals had been placed on suicide watch, even where there were indications of elevated risk.

"All of those who committed suicide died by hanging: Each person was left unsupervised in cells with unmitigated ligature risks," DRO said. "Unlike hospital licensing which requires eliminating all furnishings or fixtures that a patient could use to hang themselves, there is no oversight or licensing body in Oregon that proactively requires jails to address ligature risks."

Though Oregon law requires hourly welfare checks in correctional facilities, the investigation found that — in at least two of the cases — jail staff failed to conduct adequate checks, resulting in the inmates laying "dead for hours" before being discovered.

In cases where deaths were caused by medical emergencies, the report also placed some of the responsibility on hospitals, which had cleared the inmates for booking.

"Over the course of this investigation, Oregon sheriffs and jail commanders reported that local hospitals regularly clear patients for jail transport, regardless of the severity of their medical or mental health condition," DRO said. "In two cases reviewed for this report, hospital staff quickly released the individuals with conditions that ultimately contributed to their death."

DRO did say that jail commanders and sheriffs from the investigated facilities provided them with "extensive records in a forthcoming and timely manner." Oregon does not have a centralized source for data on jail deaths, the organization said.

A DRO investigation into the death of a Medford man at the Oregon State Penitentiary resulted in his family suing the state for wrongful death. The state Department of Corrections agreed to a record $2.75 million settlement in October.

Oregon Coronavirus Cases

Data is updated nightly.

Cases: 176157

Reported Deaths: 2461
CountyCasesDeaths
Multnomah35145568
Washington23569229
Marion20282299
Clackamas15499204
Lane11722144
Jackson9984127
Umatilla798483
Deschutes721472
Linn418763
Yamhill412575
Klamath353759
Polk346452
Malheur343058
Josephine307862
Douglas305765
Benton275418
Jefferson207432
Coos198431
Columbia155426
Union141824
Lincoln130520
Wasco130228
Hood River113029
Morrow108115
Clatsop9008
Crook89119
Baker86114
Curry5999
Tillamook5833
Grant4204
Lake4147
Harney3136
Wallowa1575
Gilliam571
Sherman571
Wheeler261
Unassigned00

California Coronavirus Cases

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Cases: 3723446

Reported Deaths: 61122
CountyCasesDeaths
Los Angeles122964123668
Riverside2976204547
San Bernardino2949734561
San Diego2753683674
Orange2691764900
Santa Clara1173172017
Kern1080131331
Sacramento1016651647
Fresno1007021646
Alameda855831477
Ventura803321002
San Joaquin717351334
Contra Costa67157782
Stanislaus605831032
Tulare49443831
Monterey43301364
San Mateo41226560
San Francisco36094529
Santa Barbara33926446
Solano32047239
Merced31289453
Sonoma29720311
Imperial27995719
Kings22781245
Placer21908283
San Luis Obispo20991257
Madera16289240
Santa Cruz15666204
Marin13868226
Yolo13572200
Shasta11747219
Butte11601196
El Dorado9797109
Napa971579
Sutter9299109
Yuba612744
San Benito598963
Lassen567924
Tehama544556
Nevada448975
Tuolumne408664
Mendocino399347
Humboldt363138
Amador362946
Lake341643
Glenn235825
Colusa220416
Calaveras206252
Siskiyou196521
Inyo141838
Del Norte12907
Mono12744
Plumas6936
Modoc4904
Mariposa4287
Trinity3985
Sierra1100
Alpine880
Unassigned440
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