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Omar Paisley
Final Report of the Miami-Dade
County Grand Jury
http://www.miamisao.com/publications/grand_jury/2000s/gj2003s.pdf
IN THE CIRCUIT COURT OF THE ELEVENTH
JUDICIAL CIRCUIT
OF FLORIDA IN AND FOR THE COUNTY OF
MIAMI-DADE
FINAL REPORT
OF THE
MIAMI-DADE COUNTY GRAND JURY
SPRING TERM A.D. 2003
*******
State Attorney
KATHERINE FERNANDEZ RUNDLE
Chief Assistant State Attorney
DON L. HORN
Assistant State Attorney
BRONWYN C. MILLER
CONCEPCION PORTELA SHIRLEY BOYER
FOREPERSON CLERK
FILED
January 27, 2004
Circuit Judge Presiding
JUDITH L. KREEGER
Officers and Members of the Grand Jury
CONCEPCION PORTELA
Foreperson
DANIEL CALIXTE
Vice Foreperson
DONNIE K. JOHNSON
Treasurer
SHIRLEY BOYER
Clerk
JAIRO ABREU JOSE L. MARCOS
LANA M. ANGEL DOROTHY MILLER
JOSE BELETTE DARQUITA ROBINSON
JULIAN BOWEN JUAN F. RODRIGUEZ
HUMBERTO DURAN GLORIA M. SARDUY
LUIS C. GUIA SANDRA M. SEGURA
MILDRED M. KAVALIR ROYCE E. SMITH
LIBBY KLEIN MARTIN SUAREZ
FELIX M. LORENZO
* * * * * * *
Clerk of the Circuit Court
HARVEY RUVIN
* * * * * * *
Administrative Assistant
ROSE ANNE DARE
* * * * * * *
Bailiff
NELIDO GIL, JR.
I N D E X
INVESTIGATION INTO THE
DEATH OF OMAR PAISLEY
AND THE DEPARTMENTOF
JUVENILE JUSTICE MIAMI-DADE REGIONAL
JUVENILE DETENTION CENTER
Pages 1 - 50
I. INTRODUCTION
..
... 1
II. BACKGROUND REGARDING THE DEPARTMENT OF
JUVENILE
JUSTICE AND THE MDRJDC
.
.
..
.
. 2
III. BACKGROUND REGARDING OMAR PAISLEY
..
... 5
IV. ISSUES REGARDING EMERGENCY PROCEDURES
IN THE
MIAMI-DADE REGIONAL JUVENILE DETENTION
CENTER
.
....... 12
V. OVERCROWDING IN THE FACILITY
.
...
..
...
. 15
A. MODULE STAFFING ISSUES IN THE FACILITY
.
.
.... 17
B. CENTRAL CONTROL STAFFING IN THE
FACILITY
..
. 18
VI. LACK OF A FUNCTIONING SURVEILLANCE
SYSTEM IN
THE FACILITY
..
..
..
....
..
19
VII. PROVISION OF MEDICAL CARE IN THE
FACILITY
..
..
...
....
21
A. MEDICAL REQUEST FORM RESPONSE TIME
..
... 21
B. LACK OF FACILITY OPERATING PROCEDURES
GOVERNING HEALTH CARE REQUESTS
.
..
.. 23
C. ISSUES RELATING TO MEDICAL STAFF IN THE
FACILITY
.
23
1. Lack of a Health Services In-House
Delivery System
.
..
23
2. Failure By Medical Staff to Respond to
Requests for
Assistance and Failure by Medical Staff to
Coordinate
Emergency Efforts
.
.
..
.. 25
3. Failure by Nursing Staff to Contact a
Physician and Failure
by Medical Staff to Follow Standing Orders
.
.
26
4. Failure by Medical Staff to Document
Medical Records in a
Comprehensive & Timely Manner
.
..
.. 27
5. Assigning an Officer Permanently to the
Medical Station /
Requiring That All Patients be Examined in
the Medical
Station of the Facility
...
.. 30
6. Lack of Availability of 24-Hour On-Site
Medical Care
in the Facility
...... 30
VIII. RELATIONSHIP BETWEEN THE DEPARTMENT
OF
JUVENILE JUSTICE AND THE OFFICE OF THE
INSPECTOR GENERAL
..
.
. 31
IX. ISSUES RELATING TO STAFFING AND SUPERVISION
..
..... 32
A. Failure to Conduct Preliminary National
Background Screenings
On Privately Contracted Providers
.
.
.
32
B. Issues Regarding Department of Juvenile
Justice Employees
With Criminal Backgrounds and Pending
Criminal Cases
.. 34
C. Non-Compliance With Quality Assurance
Standards in the
Facility
.
.
..
..
36
D. Issues Regarding Lack of Communication
Between Administration
And Staff in the Facility
...
...
. 39
E. Staff Failure to Comply With OSHA
Requirements and Facility
Operating Procedures Regarding Disposal of
Biohazardous Waste
In the Facility
..
.. 41
F. Staff Failure to Comply with Facility
Operating Procedures
Governing Infectious Disease
.
..... 42
X. CONCLUSION
..
...
43
XI. SUMMARY OF RECOMMENDATIONS
..... 44
INDICTMENTS
.
.
..... 48
- 49
ACKNOWLEDGEMENTS
.
..
.. 50
1
INVESTIGATION INTO THE DEATH OF OMAR
PAISLEY AND THE
DEPARTMENT OF JUVENILE JUSTICE MIAMI-DADE
REGIONAL JUVENILE
DETENTION CENTER
I. INTRODUCTION
Seventeen-year old Omar Paisley spent the
last three days of his life, which ended
June 9, 2003, in agony, lying on a
concrete bed in Room 13 of Module Three in the
Department of Juvenile Justice Miami-Dade
Regional Juvenile Detention Center
(hereinafter MDRJDC). Despite his
repeated requests for help, Omar was denied that
which many of us take for granted,
appropriate and timely medical care.
As grand jurors, we came from different
backgrounds, perspectives, and beliefs.
However, in the course of our service, we
discovered that we were united in our outrage
over the death of Omar Paisley. All of us
shared common values in our belief that
juvenile detainees are entitled to live in
safe, habitable, clean and secure surroundings.
As parents, we knew that we were required
to provide our children with medical attention
or face the consequences. We felt strongly
that when a facility assumes care for the
children of our community, the facility
should be held to this same standard.
We were sensitive to the implementation of
severe budgetary cuts in our State
following September 11, 2001. However,
each of us arrived independently at the same
conclusion: one can never measure the cost
of human life in taxpayer money.
Over the past nine months, we listened
closely and critically to testimony from
various people involved in the
investigation into the death of Omar Paisley, we labored
over a multitude of statewide reports, we
studied statistics and budgets, we toured both
the MDRJDC and the Broward Regional
Juvenile Detention Center and we asked
questions at every step along the way. We
were, above all, determined to make
recommendations, which, if implemented,
would prevent another unnecessary death in
the MDRJDC.
We were appalled at the utter lack of
humanity demonstrated by many of the
detention workers charged with the safety
and care of our youth. Our mission,
constrained by our legally set time limit,
included ascertaining the underlying causes that
2
led to this tragically preventable death
in order to demand reforms, and if appropriate,
concurrently identifying criminal acts
that may have been committed, either by
individuals or the facility administration
or both. At every turn in our investigation, we
were confronted with incompetence,
ambivalence and negligence on the part of the
administration and the staff of the MDRJDC
as well as the nurses employed by Miami
Childrens Hospital. We discovered in the
course of our investigation that numerous
individuals played roles in the death of
Omar Paisley. However, in determining which
individuals should be charged with crimes,
we are compelled to isolate only the most
egregious conduct. In our estimation, the
conduct of two of the nurses was so outrageous
as to rise to the level of criminal
negligence and we have felt compelled to issue
indictments for these acts.
In the process, we became frustrated by
the numerous legal and factual obstacles
we were confronted with, especially with
regard to pursuing criminal charges against the
State, its facility and its direct
employees.
The issues we confronted in this case were
unique. We do not intend that our
decision to issue indictments in this
instance will open the floodgates to consideration of
criminal charges in other cases that are
purely civil in nature, i.e. medical malpractice.
We are hopeful that the present state of
the law regarding public entities, including
administrative rules concerning government
employees, does not diminish in any way the
significance of our findings. Our findings
clearly expose a lack of supervision, a lack of
resources, and above all, a lack of
benevolence in the MDRJDC.
Following are the conclusions we have thus
far reached and the recommendations
we most respectfully request be
implemented. 1
II. BACKGROUND REGARDING THE DEPARTMENT OF
JUVENILE
JUSTICE AND THE MDRJDC
In 1994, the Juvenile Justice Reform Act
created a new state agency designed to
oversee juvenile justice issues, the
Department of Juvenile Justice.2
The Secretary of the
1
We recognize that, as in all cases, the facts and the evidence
essential to the truth of a case surface as the
case unfolds in the
system over time. The law does not permit us to sit as a grand jury
beyond nine months.
We know this case will
remain visible in the system for years to come. Those reforms that
can occur today,
must; however, those
needs that become self-evident over time must also be addressed in
the future.
3
Department of Juvenile Justice was charged
with planning for and managing all programs
and services in the juvenile justice
system, including detention care.3
In addition to
creating the Department of Juvenile
Justice, the Florida Legislature established the
Florida Department of Juvenile Justice
Quality Assurance System.4
The purpose of the
Quality Assurance System was to establish
minimum thresholds for each component of
programs operated by the Department of
Juvenile Justice.5
In the State of Florida, there are a total
of 25 juvenile detention centers with a
total of 2,042 beds.6 These centers serve three
primary purposes: to detain and monitor
juveniles prior to adjudicatory hearings;
to maintain custody of all adjudicated juveniles
awaiting placement in a commitment
program; and to impose sanctions for mandatory
sentences implemented pursuant to state
law.7
The MDRJDC is, by far, the largest in the
State. The funded operating capacity of
the center is 226 beds on any given day.8
Between January 1, 2001 and December 31,
2002, 6,808 juveniles were booked into this
facility, often exceeding the funded
operating capacity.9
The facility is spread out over a large
area of land and is comprised of fourteen
modules intended to house the detainee
population, a public school facility, a cafeteria, a
medical center, a gymnasium and
administrative areas. As with every juvenile detention
facility in the State of Florida, the
MDRJDC has a statutory duty to provide each juvenile
detainee with food, clothing, shelter,
education, and medical care. Historically, the
Miami-Dade County Public Schools have
provided education for the detainees and the
facility has chosen to outsource medical
care.10
In 2001, the MDRJDC entered into a
contract with Jackson Memorial Hospital for
the provision of medical services for all
detainees. This contract was not renewed in
2002. Instead, on July 1, 2002, the
facility opted to enter into a contract with Miami
2
Florida Corrections
Commission, 2001 Annual Report at 5.
3
Id.
4
Florida Department of Juvenile Justice, Introduction to Quality
Assurance revised
March 24, 2003, 2.
5
Id.
6
www.djj.state.fl.us/detention/index.html
at 1.
7
Department of Juvenile Justice, 2003 Outcome Evaluation Report at
29.
8
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated October 27,
2003.
9
Id.
10
Outsourcing refers to a process by which a State agency enters into
a contract with a private entity to
provide services required
by statute.
4
Childrens Hospital (hereinafter MCH).
The Medical Services contract provided that
the services of five MCH employees (two
licensed practical nurses, one registered nurse,
one physician and one file clerk) would be
used to fulfill the medical needs of the
detainees at the MDRJDC. The contract
specified both hours and shifts: the registered
nurse was to work forty hours per week
(from 8:00 a.m. until 5:00 p.m. Monday through
Friday); each licensed practical nurse was
to work forty hours per week (with one
working from 1:30 p.m. until 10:00 p.m.
Sunday, Wednesday, Thursday, Friday and
Saturday and the other working from 9:30
a.m. until 6:00 p.m. on Sunday, from 1:30 p.m.
until 10:00 p.m., Monday and Tuesday and
from 7:00 a.m. until 3:30 p.m. Friday and
Saturday); the physician was to work nine
hours per week; the file clerk was to work
forty hours per week (from 8:30 a.m. to
5:00 p.m., Monday through Friday).
During the same month that MCH entered
into the contract to provide medical
services with the MDRJDC, the State of
Florida Bureau of Quality Assurance conducted
its 2002 annual inspection.11 Findings issued in the
2002 Bureau of Quality Assurance
Report indicated that the MDRJDC was
non-compliant with statewide facility standards
and rated its overall program performance
as minimal.12
Specifically, the report found
that the facility was non-compliant with
required substance abuse assessment and
evaluation for detainees, screening for
health-related conditions, appropriate inventories
of controlled substances, implementation
of a required system for control of infectious,
communicable diseases, and implementation
of a required system for the provision of
sick call care.13
As reported, surveyed detainees indicated
that they did not see the doctor or
dentist in a timely manner.14 The inspection also
revealed a persistent failure to obtain
consent from parents prior to
administering mind-altering medications to the detainees
and failure to educate staff as to the
side effects of those medications. Detainees
complained of not being provided with
clean towels, clean underwear or clean clothing as
required pursuant to departmental policy.
11
The report itself was issued in September, 2002.
12
The contract between
MCH and the Department of
Juvenile Justice began on July 1, 2002.
13
See Department of Juvenile Justice, Bureau of Quality Assurance
Report (2002).
14
Id. at 7.15 (page 21). It
should be noted that a timely manner was not defined in the body
of the report.
5
III. BACKGROUND REGARDING OMAR PAISLEY
Over eight months after the release of the
abysmal 2002 Bureau of Quality
Assurance Report, seventeen-year old Omar
Paisley was arrested by the Miami-Dade
Police Department on charges of aggravated
battery. Omar was evaluated pursuant to a
Department of Juvenile Justice Detention
Risk Assessment form to determine whether or
not he should be detained in the MDRJDC
pending the resolution of his case. A
Department of Juvenile Justice Risk
Assessment Tool recommended commitment in
secure detention and the presiding judge
ordered Omar Paisley detained in the
Department of Juvenile Justice MDRJDC.
On March 26, 2003, the State subsequently
filed an announcement of its intent to
review the case for direct file pursuant
to section 985.21(4)(d)5, Florida Statutes (2003).
Following this filing, Omars defense
counsel contacted the State in an effort to convince
the State to retain the case in the
juvenile system. Omar Paisley wrote a letter to the State
Attorneys Office stating: I am sorry for
what I have done. I made a stupid mistake. I
was wrong. I should not have had a fight
with that man. On June 6, 2003, Omar Paisley
entered into a written plea agreement
wherein he admitted to committing the offense of
aggravated battery and agreed to enter
into Bay Point Schools, a moderate risk
residential program, where he would also
receive individual counseling. Omar was to
remain in secure detention at the MDRJDC
pending his placement in the residential
program.15
Day One: Saturday
On Saturday morning, June 7, 2003, less
than twenty-four hours after he entered
into his plea, Omar Paisley began to
complain of illness to both staff members and his
fellow detainees. Omar filled out a Youth
Request for Sick Call form. These forms
were in use in the facility for detainees
to communicate medical complaints to the
Department of Juvenile Justice staff
members.16
Once the form is submitted to a
Department of Juvenile Justice Staff
member, notification of the Request is sent to the
Medical Station. Omar wrote on his form:
My stomach hurts really bad. I dont know
15
The Plea Agreement was filed on
June 6, 2003. The plea
agreement specified that a psychiatric
examination was a
prerequisite for program placement.
6
what to do. I cand (sic) sleep. He signed
the bottom of the form and gave it to a
Juvenile Detention Officer (hereinafter
JDO). Logbook entries reveal that the Medical
Station was notified at 12:10 p.m.17
Omar refused to eat lunch on
Saturday.
At approximately 2:15 p.m., according to
an entry in the Module Three logbook, a
Licensed Practical Nurse (hereinafter
LPN) by the name of Gaile Loperfido saw
Omar.18
This is the first contemporaneously
documented visit of LPN Loperfido.19
LPN
Loperfido filed an addendum to Omar
Paisleys medical records the day after he died.
Her addendum indicates that she first saw
Omar at 9:00 a.m. on Saturday morning.
However, we found no evidence to
corroborate the 9 oclock morning visit.20 LPN
Loperfidos addendum also indicates that
she conducted a physical examination of Omar
on Saturday. Detention staff members
contend that they never saw LPN Loperfido
conduct a physical examination of Omar
that day.21
In fact, these staff members did not
observe LPN Loperfido carrying any
equipment with which to conduct a physical
examination, i.e. a blood pressure cuff or
a thermometer.22
After seeing Omar at approximately 2:15
p.m., LPN Loperfido filled out a
twenty-four hour medical alert form,
specifying that Omars medical alert would end on
Sunday, June 8, 2003. She placed Omar on a
twenty-four hour liquid diet and ordered
him on bed rest.23 LPN Loperfidos addendum
further indicates that she saw Omar at
7:00 p.m. on Saturday. However, this visit
is not corroborated by logbook entries, nor is
it consistent with the testimony of the
Department of Juvenile Justice staff.24
16Miami Childrens Hospital, Sick Call and Injury Response
Procedures.
17
A logbook is maintained in each of the modules at the facility and
is used to record all entries into the
module and any action
taken as to any detainee. According to a June 7, 2003 entry in the
Module Three
logbook: Detainee
Paisley, Omar complaining about being sick. He refused to eat lunch.
Nurses station
notified. (12:10 p.m.)
18
It should be noted that LPN Loperfido has twenty-five years
experience as a medical professional.
19
Her addendum further sets forth that she first saw Omar at
9:00 a.m. on Saturday
morning and documents
a series of visits over
Saturday and Sunday, totaling 5 visits. The logbooks do not reveal
prior documented
visits.
20
See Sworn Statements of JDO Keith North and JDO Nesby Rodriguez.
21
Id.
22
Id.
23
The twenty-four hour liquid diet was in direct contravention with
the Miami Childrens Hospital Sick
Call and Emergency
Response Procedures. These procedures reflect the following for
Abdominal
Discomfort: (i) give
nothing by mouth; (ii) consult with on-call medical provider; (iii)
refer to E.R. if
acute abdomen is
suspected.
24
See Sworn Statements of JDO Johnny Byrd and JDO Kavin Walton.
7
At 3:45 p.m. on the same day, Dr. Lloyd
Miller arrived to perform Omars
psychiatric examination pursuant to the
plea agreement. Dr. Miller noted that Omar was
an average sized young man who was under
the sheets of his bed suffering from
gastroenteritis. He discovered that Omar
was on bed rest which is why Dr. Miller made a
house call to the bedside of this young
man who appeared not to be in one hundred
percent perfect health.25 He further observed that Omar
was sick with a stomach virus
and his physical condition may have
affected his mental outlook during the interview.26
The MCH physician did not work on
Saturday, June 7, 2003, and he was not contacted by
LPN Loperfido regarding Omars condition
on that day.
On Friday, the day before these events
transpired in Module Three, another
detainee was complaining of similar
symptoms in Module Seven. He submitted a Youth
Request for Sick Call Form and the Medical
Station was notified. According to the
medical records of that detainee and the
June 6, 2003 logbook entries, that detainee was
seen by LPN Dianne Demeritte. After
meeting with that detainee, LPN Demeritte
referred the detainee to the physician.
The detainee was indeed physically examined by
the physician and later transferred to the
emergency room.27
Day Two: Sunday
On Sunday, June 8, 2003, witnesses
reported that Omar continued to complain of
abdominal pain, and continued to have
vomiting and diarrhea.28
LPN Loperfido saw
Omar at approximately 9:00 a.m. on Sunday.29
LPN Loperfido continued to order a
liquid diet and bed rest, as she had the
preceding day. As LPNs are traditionally charged
with patient assessment, a major issue in
this case is whether or not LPN Loperfido
conducted a physical examination of Omar
during the Sunday morning visit.30
Detention
25
Dr. Miller received information from the detention staff on duty
and Omar regarding Omars condition.
26
Id.
27
See Medical Records of D.H. (it should be noted that juvenile
detainees are referred to by initials only).
28
See Sworn Statement of JDO Michael Johnson at page 25 (Omar told
LPN Loperfido his stomach was
so sore).
29
The Logbook reflects a
9:05 a.m. visit by LPN
Loperfido. Nurse on mod to see Paisley, Omar. Youth
has a virus and
complaining of serious abdominal pain. Staff advised to give plenty
of liquid and not to
allow youth to leave
room. Again, LPN Loperfidos addendum to Omars medical records
indicates that
she first saw Omar at
9:00 a.m.
on Saturday morning and documents a series of five visits over
Saturday
and Sunday. We do not
have any evidence to corroborate these five visits.
30
It should be noted that a medical diagnosis (as opposed to a
nursing diagnosis) is typically done by a
physician.
8
staff contend that they did not observe
her perform a physical examination.31
Per her
addendum, LPN Loperfido states that she
again saw Omar on Sunday night at
approximately 8:00 p.m. However, detention
staff members contend that she went to
Module Three to see another detainee,
A.W., but did not see Omar.32
The MCH
physician was not working on Sunday, June
8, 2003, and LPN Loperfido did not contact
him regarding Omars condition on that
day.
Day Three: Monday
According to sworn statements of JDOs and
an entry in the Module Three
Logbook, on Monday, June 9, 2003, Omar
woke up at 5:30 a.m. urgently requesting
medical care. The on-duty JDO observed:
Paisley is not looking real well.33
Per JDOs
Burney and Morgan, this message was
conveyed to the Department of Juvenile Justice
LPN at breakfast. However, there was no
apparent follow-up.34
By most accounts, Omar spent Monday in
excruciating pain.35
He was unable to
get out of the bed and continued vomiting
and excreting on himself.36
Payroll records
indicate that at least four of the five
contracted MCH medical personnel were working in
some capacity at the facility on that day.
However, by all accounts, it appears that only
LPN Dianne Demeritte saw Omar on Monday.37
At approximately 1:32 p.m., Indigo38
JDO Alfreda Mitchell picked up
detainee
K.R. on Module Three. Upon arrival on
Module Three, Officer Mitchell was informed of
Omars chronic illness by a JDO. Officer
Mitchell returned to the Medical Station with
K.R. and believes she informed LPN
Demeritte at that time of Omars worsening
condition.39
31
See Sworn Statements of JDO Shana Jerry and JDO Michael Johnson.
32
See Sworn Statements of JDO Johnny Byrd and JDO Kavin Walton.
33
Entry in Module Three Logbook at
9:05 a.m.
34
The Department of Juvenile Justice LPN was in a training during the
day on June 9,
2003.
35
See Sworn Statement of JDO Johnny Byrd at 21; Sworn Statement of
JDO Michael Johnson at 30.
36
See Sworn Statement of A.W. at 22; See Sworn Statement of Terry
Mixon.
37
Detainee S.S. stated that LPN Demeritte saw Omar once before dinner
and once after dinner. LPN
Demeritte indicated to
the Department of Juvenile Justice LPN that she had seen Omar twice
on the date of
his death. See Sworn
Statement of LPN Jeffrey Coachman to Office of the Inspector General
at 20.
38
An Indigo JDO is an officer who is assigned to escort medical
personnel throughout the facility.
39
See Sworn Statement of Alfreda Mitchell to the Office of the
Inspector General at 7.
9
Detention Officer Terry Mixon was alone on
Module Three with over twenty
detainees for much of the afternoon and
early evening hours of June 9, 2003.40
At dinner,
between 5:30 p.m. and 5:50 p.m., Officer
Mixon saw LPN Demeritte in person and asked
her to check on Omar.41 Officer Mixon appeared worried
and told LPN Demeritte that
Omar was real sick, already on a liquid
diet and could not keep anything in his
stomach.42
He told LPN Demeritte that someone
needed to look at Omar.43
Sworn
statements reveal that during the early
evening hours, Officer Mixon contacted Indigo
Officer Talmecia Minnis two times over the
radio in an effort to summon LPN
Demeritte.44
Officer Minnis conveyed these
requests to LPN Demeritte.45
Immediately after dinner, and upon Mixons
return to Module Three, numerous
officers heard Officer Mixon frantically
requesting assistance over the radio from a nurse
or a supervisor.46 These calls continued for an
hour and a half, but there was no
immediate response.47 Although Officer Mixon could
see Omars worsening condition,
he could not leave the module to get
assistance nor could he call 911 to summon help for
Omar. As to the former, he was the only
JDO in the module and he could not leave more
than twenty detainees unattended. As to
the latter, the design of the telephone system
within the facility prevents anyone from
being able to make 911 emergency phone calls
from inside the modules. Further, to do so
without first contacting a supervisor or
making the request through Central Control48
with approval of a supervisor could
constitute a violation of procedure and
could subject Officer Mixon to disciplinary action.
Officer Mixon made radio contact with LPN
Demeritte via Indigo JDO Minnis
sometime prior to 7:00 p.m.49
According to Officer Mixon, LPN
Demeritte asked what
40
Entry in Module Three Logbook at 181.
41
Id. at 8.
42
Id. at 6.
43
Id.
44
Sworn Statement of Talmecia Minnis to Office of the Inspector
General at 8.
45
Id. at 9.
46
See Sworn Statement of JDO Johnny Byrd at 21.
47
Id.
48
Central Control is located directly inside the front entrance of
the facility. All incoming and outgoing
telephone calls,
visitors, employees, mail, and deliveries are directed through
Central Control.
49
See Sworn Statement of JDO Terry Mixon at 9. See Sworn Statement of
Indigo JDO Talmecia Minnis to
Office of the Inspector
General at 8.
10
was wrong with Omar and indicated she was
busy with other things.50
Officer Minnis
recalled that LPN Demeritte indicated
several times via radio she would respond to
Module Three, but did not respond.51
A witness indicates that LPN
Demeritte was not in
a particular hurry that night; rather, she
had time to carry on conversations with staff and
sit down on the various modules for a
period of time.52
LPN Demeritte indicated during
the course of one conversation with
Officer Mixon that she did not wish to examine
Omar due to the fact that she had a sick
child at home.53
Sometime after 8:00 p.m., LPN Demeritte
finally made her way to Module Three
to look at Omar. Per Officer Mixon and the
detainees housed in Module Three, despite
the fact that Omar could barely move, LPN
Demeritte ordered Omar out of his cell.54
Omar dragged himself out of his cell,
clinging to a chair outside the door for support.55
LPN Demeritte stated that she had a child
at home and did not wish to contaminate her
child with Omars virus.56
Cellular telephone records reflect that at
8:08 p.m., LPN Demeritte contacted her
supervisor, Registered Nurse (hereinafter
RN) Stacy Linfors.57
According to detainees,
LPN Demeritte was laughing on the
telephone during the less than two-minute
conversation. At 8:30 p.m., LPN Demeritte
completed the paperwork authorizing Omar
to be transferred to Jackson Memorial
Hospital for emergency treatment. On the transfer
paperwork, LPN Demeritte indicated that
Omar had a 98.5 temperature and a normal
pulse. LPN Demeritte handed the transfer
paperwork to Central Control, told the Central
Control JDO that Omar had a normal
temperature but was delusional, and then left the
facility without coordinating rescue
efforts.58
50
Id.
51
Id.
52
Id. at 33.
53
See Supplemental Sworn Statement of JDO Terry Mixon.
54
Id.
55
Id.
56
Id.
57
The duration of the telephone call was 118 seconds. Based on the
information we received, this was the
first contact anyone made
with the RN regarding Omar. There is no evidence that has been
presented to us
that indicates that the
MCH physician was ever notified of Omars condition before Omars
death.
58
This failure to coordinate emergency efforts is discussed at length
later in this report.
11
As she was leaving the facility, LPN
Demeritte was contacted by JDO Aileru
regarding an ill detainee, I.E., on Module
Eight. LPN Demeritte was told that I.E. was
vomiting, had diarrhea, and needed to be
seen by medical personnel. LPN Demeritte
stated that the detainee should fill out a
Medical Request for Sick Call form and
proceeded to leave the facility.59
Her decision to leave was in direct
contravention of the
Miami Childrens Hospital/Department of
Juvenile Justice Contract for Medical
Services.60
After LPN Demeritte prepared the paperwork
authorizing Omars transfer for
emergency treatment, detention staff
initially made efforts to transport Omar to Jackson
Memorial Hospital with the MDRJDC van and
equipment. However, Facility Operating
Procedures required Omar to be placed in
leg and arm restraints (even though in this
instance the detainee could barely walk).
Because Omar was unmoving and catatonic by
the time rescue efforts were initiated,
lengthy discussion was had regarding the best
means for transport. Omar continued to sit
in the chair outside of his cell on Module
Three. As he remained in the chair, brown
fluid flowed from his nose and mouth.
Eddie Williams, a volunteer for the
Christian Counseling Program, visited the
facility that evening to counsel several
of the juvenile detainees. Mr. Williams proceeded
to Module Three at approximately 9:00 p.m.
He described what he saw when he arrived
as: fear, panic, grief, [and] anger.61
Mr. Williams observed Omar slumped
over in the
chair outside of Room 13. He immediately
checked and noted that Omar had no pulse.
Despite the fact that each detention
worker was trained in First Aid and Cardiopulmonary
Resuscitation, not one of them engaged in
efforts to save Omars life. LPN Demeritte
was nowhere to be found at this time.
59
See Sworn Statement of JDO Ayodele Aileru at 5.
60
The Miami Childrens Hospital/Department of Juvenile Justice
contract specifies that licensed practical
nurses shall provide the
following services: coordinate any emergency medical or dental care
approved by
the facility
superintendent or designee. It further specifies: nursing services
shall provide consultation
and response to medical
crises, by either on-site presence or coordination of care
throughout local
emergency care
facilities. (emphasis added).
61
Sworn Statement of Reverend Eddie Williams at 4.
12
At 9:01 p.m., approximately forty-five
minutes after LPN Demerittes
conversation with RN Linfors, a call was
finally placed to 911.62
At 9:12 p.m., almost an
hour after LPN Demeritte ordered emergency
transport and left the facility, paramedics
arrived on Module Three and found Omar
unresponsive. Omar was transported to
Jackson Memorial Hospital, where he was
declared dead on arrival at 9:43 p.m.
Sometime that evening, JDO Terry Mixon was
instructed by his supervisor to
make delayed entries in the Module Three
logbook detailing LPN Demerittes interaction
with Omar Paisley. He made an entry in the
logbook documenting LPN Demerittes
appearance on Module Three.
The MCH physician was contacted for the
first time regarding Omar Paisley
between 10:30 p.m. and 11:00 p.m. on
Monday, June 9, 2003.
On Tuesday, June 10, 2003, LPN Loperfido
submitted a detailed Addendum to
Medical Records, documenting her
treatment of Omar Paisley on Sunday, June 8, 2003.
That same day, LPN Demeritte told the
Department of Juvenile Justice LPN that she did
not want to go in Omars room the
preceding day because she didnt want to catch his
virus and take it home.63 She further indicated that she
had seen Omar twice the
preceding day.64 She indicated that during her
second visit to Module Three, Omar had
been delusional.65
IV. ISSUES REGARDING EMERGENCY PROCEDURES
IN THE MIAMIDADE
REGIONAL JUVENILE DETENTION CENTER
When we first immersed ourselves into the
facts surrounding the death of Omar
Paisley, each of us listened to the
recording of the call placed by Department of Juvenile
Justice staff to 911 on the evening of
June 9, 2003, with feelings of anger, sorrow, and
confusion. Over forty-five minutes elapsed
between the time LPN Demeritte issued
orders for Omar to be transported to the
hospital and the time a call was placed to 911.
62
We were unable to determine why such a long period of time passed
before a call was made to 911. It
should be noted that
Central Control initially contacted 911 at 9:01 p.m., but the call
was disconnected
prior to any
conversation. Several seconds later, a second call was placed. In
the communications with the
911 operator, the caller
indicated that: the nurse has left the compound.
63
See Sworn Statement of LPN Jeffrey Coachman to Office of the
Inspector General at 17.
64
Id.
65
Id.
13
We listened as a caller told a 911
operator that Omar had a normal pulse and normal
breathing pattern at 9:06 p.m., consistent
with the paperwork filled out by LPN
Demeritte. We knew, based on testimony,
that by this time, Omar had no pulse, was not
breathing, and had brown fluid seeping
from his nose and mouth.
Armed with this information, we carefully
watched the first round of Legislative
Hearings pertaining to the death of Omar
Paisley. In the course of these hearings, we
scrutinized the testimony of Larry Lumpee,
Assistant Secretary of the Department of
Juvenile Justice. Mr. Lumpee stated that
each detention officer was capable of dialing
911 directly from any given facility in
the event of an emergency. The Facility Operating
Procedures in place in the MDRJDC indicate
to the contrary.66
We were further dismayed when we toured
the MDRJDC and visited the
modules. We discovered that when we
attempted to dial 911 ourselves, the telephones
located in each module did not permit
direct access to 911. Instead, workers are required
to contact a shift supervisor and then 911
calls are approved and routed through Central
Control. We further learned that secure
detention workers are not permitted to utilize
personal cellular telephones in the
facility.
Finally, we heard compelling testimony
regarding the fear of detention workers to
defy their chain of command and to reach
out to outside agencies. We learned of specific
instructions communicated by the
Superintendent of the Facility to staff members
prohibiting them from contacting external
agencies without specific prior Superintendent
approval.67
Thus, we concluded that the
legislative testimony of Mr. Lumpee failed to
accurately portray the reality of the
situation at the MDRJDC.
For comparison purposes, we decided to
visit the Broward Regional Juvenile
Detention Center (hereinafter BRJDC).
When we toured the BRJDC, we noted that a
different system for contacting 911 was in
use. Specifically, each room populated by
detainees, staff, or both, had an intercom
on the wall that could be pressed to instantly
connect with Central Control. Engaging the
intercom in this manner instantly allowed
66
We were aware that Miami-Dade Regional Juvenile Detention Center
Facility Operating Procedure 7.13
requires that 911 be .
. .called by the shift supervisor as needed.
14
Central Control to view the room via a
surveillance camera and to assess the situation. It
also permitted verbal contact via the
intercom.
We were disturbed at the looming potential
for both staff and detainee
emergencies in MDRJDC. We firmly believe
that emergency situations require
emergency measures. We observed first-hand
the efficiency of the system implemented
in the BRJDC. We tested it and determined
it was the best means of insuring direct,
immediate contact with Central Control,
and thus with 911. We further believe that each
staff member should have direct
access to 911 from all areas of the facility populated by
detainees or staff.
We recommend that the MDRJDC immediately
install an intercom system
comparable to the system currently in
place in the BRJDC. As an immediate
alternative during the installation
process of the intercom system, we recommend that
the current Facility Operating Procedures
be modified immediately to provide for any
employee noting an emergency situation to
have unimpeded direct access to 911. This
would require Facility Operating
Procedures to reflect that any employee who
perceives an emergency situation, must, as
a matter of responsibility, call 911. This
responsibility should, in our opinion,
exist separate and apart from the mandates
assigned to any medical personnel.
Further, as a practical measure, we believe that a
telephone system must be implemented in
the facility in which each area populated by
detainees is equipped with direct access
to 911. Finally, we recommend that current
Facility Operating Procedures be
re-written to require detention workers to first
contact 911 in an emergency situation, and
only then to contact Central Control.
We recommend that procedures be
implemented requiring that on those
occasions when medical personnel order
emergency transport, either Central Control
or detention workers are required to
contact 911 within one minute. This should not
be problematic, given either the
implementation of direct access to 911 from each
module or the installation of an intercom
allowing for direct contact with Central
Control. Together, we believe that when a
human being is suffering and a life hangs
67
We learned of an altercation that occurred between two detention
workers. An external law enforcement
agency was contacted by
staff following the altercation. The Superintendent of the facility
became angry
and notified the staff
members that all incidents should be handled within the facility.
15
in the balance, the decision to call 911
should be immediate and without
contemplation.
V. OVERCROWDING IN THE FACILITY
We were amazed to learn that many
Department of Juvenile Justice secure
detention facilities in the State of
Florida are populated beyond the recommended
capacity. Statewide, ten of twenty-five
detention centers operated above one hundred
percent capacity during 2001-2002.68
In Miami-Dade County, the Regional
Juvenile
Detention Center had an average
utilization rate of one hundred and thirty-five percent in
2001-2002.69
Thus, despite the fact that the
operating capacity of the facility was 226
detainees, the average daily population
was 304 detainees.70
The obvious result of this overpopulation
is overcrowding and shared quarters.
The less obvious result is the staffing
shortages we observed firsthand. Overcrowding
renders detention difficult to manage and
not as safe for residents and staff as a facility
operating at recommended capacity.71
Residents spend more time in
lockdown. When
staff members must focus primarily on
safety and security, effective intervention and
treatment are compromised.72 Staffing shortages may
result in suicidal detainees being
left unattended for significant time
periods and may increase escape attempts. In the
MDRJDC, specifically, the overcrowding has
resulted in such problems as the failure to
provide one operable shower for every nine
youths, as required pursuant to Quality
Assurance Standards.73
While we heard testimony, provided during
the Legislative Public Hearings that
overcrowding could be attributed to
increased stays in secure detention, we were aware of
68
Detention Services, 2003 Outcome Evaluation Report at 31.
69
Id. We did note that in Department of Juvenile Justice, Response to
Subpoena Duces Tecum dated
October 23, 2003, the average population was stated to be 251 during 2002-2003.
70
Id.
71
JAIBG Bulletin at 3. In the course of our investigation, we learned
of an incident that occurred on
February 11, 2003 in which a Guardian Ad Litem attorney visited a detainee at the
MDRJDC. When the
attorney arrived at the
facility, the JDO on the detainees module did not have a key to
open the detainees
cell. It took approximately ten minutes for the JDO to retrieve
the key that matched that cell from
elsewhere in the
facility. The attorney, rightfully, was deeply concerned regarding
the ability of the staff to
release the inmate in an
expeditious manner in a fire or emergency situation.
72
Id.
73
Department of Juvenile Justice, Bureau of Quality Assurance Report
(2002), 3.03 (page 9).
16
the fact that statewide, the average stay
in secure detention in 2001-2002 was 13.04 days.
This number reflected a decrease
from the average length of stay in 2000-2001 of 13.27
days. In Miami-Dade County, the decrease
was greater. The average length of stay in
secure detention from 2001-2002 was 15.04
days, while from 2002-2003, it was 14.91
days.74
Despite the persistent issue of
overcrowding in the facility, the MDRJDC does not
have a contingency plan for
overcrowding/group arrest. In facilities in which such a plan
exists, operating procedures define
critical population levels and set forth counteractive
measures. Further, allowances may be made
for detainees to be transported to a nearby
facility in situations of severe
overcrowding.75
In the BRJDC, a Contingency Plan
for
Overcrowding/Group Arrest is carefully
delineated within the Facility Operating
Procedures.76
Specifically, the plan sets forth
that whenever the population in the facility
exceeds the available bed space, the
superintendent or designee will perform, at a
minimum, the following actions: (1) notify
the Southern Regional Office, Human
Service program administrator, juvenile
court judges, court unit, Office of the Public
Defender, and Office of the State
Attorney; (2) if the population issue persists, notify the
Regional Director, Assistant Secretary of
Programs, and the Deputy Secretary of
Operations; (3) call in staff to work
overtime at a ratio of one staff per ten detainees
exceeding the recommended number of
detainees; (4) review the capacity of home
detention; and (5) request expedited
placement from commitment managers.77
While we are aware of the waiting periods
associated with entry into many
residential programs, we are confident
that increased efficiency regarding the
performance by medical staff of physicals,
mental health assessments, and the
coordination of transportation efforts
will decrease the length of time that detainees spend
awaiting entry into these programs.
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