One inmate committed suicide in August. Two more followed on a single day in September. All three were believed to be in withdrawal from opioid addiction.
In October, two inmates died within eight days of each other. One was a diabetic man whose glucose levels were spiking. The other was a woman who complained of trouble breathing and died soon after, naked on the floor of her cell.
The five deaths at the Fulton County Jail came within 75 days of each other. Officials are placing the blame on the Morehouse School of Medicine and Tennessee-based Correct Care Solutions, who were together awarded a multi-million dollar contract to provide health care for the jail’s 2,800 inmates.
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Fulton County has notified Correct Care Solutions and subcontractor Morehouse that their contract would end on Dec. 31. The county commission is scheduled to vote on the issue at a meeting Wednesday.
But officials have made clear who they think is responsible.
In an Oct. 30 termination letter, Fulton purchasing director Felicia Strong-Whitaker wrote that the only connections between the five deaths was each inmate “being medically treated by CCS/MSM.”
In the meantime, the Georgia Bureau of Investigation is already investigating one of the deaths — Ligwenda Renee Metts, 53. But the GBI has received medical records for the other four deaths as well, so the investigation could expand.
Was Morehouse the right choice?
Fulton County’s Chief Jailer, Mark Adger, said Atlanta-based Morehouse has been in over its head since coming aboard.
“Morehouse is not qualified to do any of this. They have no correctional health care experience,” Adger told The Atlanta Journal-Constitution.
But Ronna Charles, a spokeswoman for Morehouse, said in a statement that Fulton County had “mischaracterized” the quality and care of services. Despite what Fulton County claimed in the notice to terminate, jail employees were regularly trained in inmate management and medical care, and inmates were receiving “the highest quality of services,” Charles said.
And in a Nov. 3 letter, Morehouse School of Medicine President and Dean Valerie Montgomery Rice said she strongly disagreed “with any inference that the medical care provided by our two institutions can be tied to the unfortunate loss of life at the Fulton County Jail.” She implored county officials to “not engage in any further discussions about these events outside of and prior to the conclusion of appropriate medical review.”
The Fulton County Jail has been troubled from the day it opened in 1989, and has a long history of problems providing health care for its inmates.
Federal court oversight of the facility ended in 2015, 11 years after the Southern Center for Human Rights filed a lawsuit alleging crowded, dirty and dangerous conditions. That suit followed one the Southern Center brought in 1999 that claimed the jail provided inmates with inadequate health care.
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In 2015, the Fulton Sheriff’s Office wanted to get rid of Corizon, the then-jail health provider, which they blamed for the jail’s loss of accreditation.
Last year, the jail medical contract was awarded to Correct Care, which subcontracted with Morehouse to provide doctors and nurses. The contract came after an unusual search process.
Another company, NaphCare, scored higher than Correct Care in the first round of scoring. But the county then changed its criteria and Correct Care's score rose. NaphCare, based in Birmingham, Ala., will take over the medical care at the jail Jan. 1 if commissioners approve the move to terminate the existing contract.
“Who are they to sentence my mom to death?”
The spate of deaths began Aug. 12 when Shannon Thompson killed herself. On. Sept. 17, Bobby Fields and Vincent Williams also committed suicide at the jail. Authorities believe all three were recovering from opioid addictions. Medical intake officials should have been prepared in case the inmates could became a danger to themselves.
Adger said egregious mistakes led to the two other deaths within eight days — Metts on Oct. 18 and Willie Green, 41, on Oct. 26.
Metts had been in the jail for 200 days after violating probation for a drug conviction when she complained of pain and trouble breathing at 6:36 a.m. Oct. 18, documents show. A nurse was alerted and she said Metts should be scheduled for “sick call.”
Two minutes later, an officer making rounds saw Metts lying on the floor, naked.
The nurse was called again. Metts didn’t respond to the nurse’s questions. After checking Metts’ pulse, the nurse “walked out and indicated that there were no medical concerns.” The nurse said she would refer Metts for a mental health examination, according to reports.
At 7:14 a.m. Metts’ cellmate told officers Metts was dead.
The cause of her death has not been determined, but Adger said he suspects a blood clot developed after she had dental work.
“It’s disgusting what they did to my mom,” said Akiyoshi Metts. “They neglected to give her help.”
Metts said her mother suffered from schizophrenia and, as a result, medical staff blamed all her ailments on her poor mental health.
“Who are they to sentence my mom to death? Because someone is mental they can’t have physical problems?” Akiyoshi Metts said.
A little more than a week after Metts’ death, Green died.
Green was a diabetic with exceptionally high glucose, yet he was still booked into the jail.
“They usually have to go to the hospital and get clearance,” Adger said. “They (Morehouse medical staff) knew what his blood sugar was and they accepted him. The medical director said they thought they could manage.”
The first doctor who saw Green, according to records, prescribed insulin, which he never got. A second doctor said the next day that the first physician had prescribed the wrong insulin. So Green’s prescription was changed. But he didn’t get that injection either.
After that, Green refused to cooperate.
“My question is, why didn’t you all (the doctors) get the medication prescription correct first off?” Adger said. “If he was not going to be compliant with what we needed him to do as far as managing his blood sugar, why didn’t we get him shipped off to Grady (Memorial Hospital)? We could have got him committed to a mental health unit.”
Green was hospitalized Oct. 22 and died four days later.
Sarah Geraghty, managing attorney at the Southern Center for Human Rights, called the recent spate of preventable deaths “alarming.”
“An urgent investigation is needed to determine the source of the breakdowns and to prevent future loss of life,” she said.
Inadequate supervision and not enough staff
While the deaths have attracted increased scrutiny, problems with the health care at the jail had already been emerging.
County officials noted the providers had been unable to adequately staff the jail since the contract went into effect.
“The Fulton County Jail continues to have weekends without provider coverage, placing both the inmates and the Fulton County Sheriff’s Office at risk,” the termination letter said. “If the facility was faced with an emergency, it would be inadequately covered.”
Fulton County first contacted Correct Care and Morehouse about terminating their contract in August, when Fulton County wrote to Correct Care with a number of issues, including the company’s “failure to meet minimum staffing levels.”
The county also said unsigned medical orders indicated “inadequate supervision” on behalf of Correct Care staff.
The company’s September response said that it was committed to providing “the appropriate level of care” to meet or exceed national standards, and had recently added nurses and other providers after the departures of both the site medical director and the health services administrator. Those positions were filled in mid-September.
Correct Care, in its response, also said there had been “no delay in care.”
Inmate, Date of death
Shannon Thompson, Aug. 12
Vincent Williams, Sept. 17
Bobby Fields, Sept. 17
Ligwenda Renee Metts, Oct. 18
Willie Green, Oct. 26