Teen’s death inquiry finds widespread lockup flaws
Posted on Thursday, August 11, 2005
URL: http://www.nwanews.com/adg/News/124589/
An official with the state Department of Human Services told state lawmakers Wednesday that an investigation into the death of 17-year-old LaKeisha Brown at the Alexander Youth Services Center uncovered widespread problems at the state’s largest lockup for youthful offenders. "The things we learned in looking at the ways things were done relative to LaKeisha’s death displayed systematic weaknesses," said Kenneth Hales, director of youth services, which oversees the Alexander facility. "It was not just with LaKeisha."
In the days and hours before her death on April 7, Brown collapsed repeatedly and complained to staff members of shortness of breath and exhaus- tion. Subsequent investigations have found that the staff violated the policies of the facility and state law. Brown later died from a blood clot in her lungs.
Hales said the state has investigated and has asked for similar investigations from the state Board of Nursing, and the Arkansas Medical Society. Cornell Companies Inc., a Houstonbased company that operates the Alexander center, also has investigated the circumstances of Brown’s death.
Cornell has a six-year contract to run the center, according to the department. That contract pays $9.5 million annually. It expires in 2008.
Before Brown’s death, the Department of Human Services had regularly audited the Alexander center to confirm that Cornell was meeting its contractual obligations in operating the facility, said Julie Munsell, a spokesman for the agency.
But those auditors were not trained to evaluate the medical procedures and policies being used by the company, she said. "That is something that we have had to ask for some additional assistance to evaluate because our auditors are not clinicians," Munsell said. "The audit is just not designed to do that."
Brown’s death revealed that the state’s audit wasn’t suited for medical aspects of care for inmates at the Alexander center, she said.
Auditors will in the future be joined by staff members from the Department of Health, who will evaluate medical procedures at facilities like the one in Alexander, Munsell said.
The additional auditors are in response to Brown’s death, Munsell said.
The investigations found a variety of problems, including how nurses documented inmates’ complaints and policies that were inconsistently enforced at the center. "When sick call was made, it was difficult to tell what the response to that sick call was," Hales told the Legislature’s Joint Performance Review Committee. "When the nurses examined a youth, you couldn’t tell what they saw or what they concluded to do following that examination."
The investigations also found that nurses at the facility lacked supervision, were poorly trained and "weren’t given good instruction on what expectations were upon them," he said.
A detailed report from Cornell on how it will improve the Alexander facility in reaction to Brown’s death is due Oct. 9, Hales said. He said he expects to get the report as early as late September.
Brown’s medical records show that nurses did not believe she was ill and called a doctor only after she was unconscious.
Since then, two contract nurses have been fired as have the center’s nurse manager and its program supervisor, the secondin-command at the Alexander center, said Jane Miller, director of behavioral health services for Cornell.
Three other employees were disciplined, Miller told the committee. "We have some resignations, we’ve had some terminations," Miller said. "And we’ve had some disciplinary action that stopped just short of termination. "’
Miller also said that between 10 and 20 other employees quit working" due to what morale had come to between the death and the time when we came in to investigate and to try to get the program back on track. "
Rep. Kevin Goss, D-Wilson, asked whether these problems would have been found if Brown hadn’t died.
Hales said no.
" Without this critical incident causing this thorough review, we would not have known all these things were not being done well, "Hales said.
Miller said she" would choose to believe" that the center’s problems would have been discovered by supervisors if Brown had not died.
Despite the employees who have either resigned or were fired and the flaws uncovered by the investigations, Miller insisted that Cornell was not at fault for Brown’s death. "I’m not saying that we did nothing wrong," Miller said. "I’m saying that our actions did not directly cause her death."
Hales said he could not say if Brown’s death could be blamed on Cornell’s management of the facility. "I’m unable to say that those things had a direct contribution to LaKeisha’s death or did not," Hales said. "I simply don’t know."
Goss questioned how the company could claim it wasn’t responsible for Brown’s death but still fire people because of that death. Brown was from Osceola. Goss said she was one of his constituents. "If they didn’t do anything to cause her death, why did they fire people?" Goss asked. "I’m just not very pleased."
Miller said the death was "unusual" and that it wasn’t caused by problems in how the company documented the medical complaints of inmates or communication to nurses. "Our series of miscommunication and lack of documentation, et cetera, our inadequate service to her has not been identified as a direct cause of her death," Miller said.
Miller said the company is learning from Brown’s death and that the case has sent "ripples" to other facilities operated by the company.
Cornell describes itself as a provider of "correctional, treatment and educational services outsourced by federal, state and local government agencies," according to the company’s quarterly report to shareholders June 30.
That report, issued Tuesday, did not address Brown’s death.
According to the report, the company operated 79 facilities with a capacity to serve 17,752 inmates in 17 states and the District of Columbia. The company’s stock trades on the New York Stock Exchange under the ticker symbol CRN. The stock closed Wednesday up 24 cents at $13.40 per share.
Brown had spent almost two years in the Alexander center before her death. When she died, she was serving time for raping another inmate.
The Alexander facility houses roughly 140 inmates and has 178 employees.