Lockup found lax in teen’s death
June 9, 2005
An internal investigation has found that a supervisor at the Alexander Youth Services Center did not "adequately" address the medical complaints of a 17-yearold female inmate who died in April.
The Youth Services Division investigator also found that nurses did not notify a doctor when LaKeisha "Keisha" Brown complained of chest pains, shortness of breath and dizziness more than twice during a 24-hour period before she died, even though emergency nursing protocols required them to do so.
The internal investigation report was given to the Arkansas Democrat-Gazette on Wednesday afternoon by Keisha’s mother, Juana Michelle Brown. The newspaper had requested a copy of the report last week from the state Department of Human Services, which oversees the Youth Services Division. The report had not yet been provided.
Julie Munsell, a Human Services Department spokesman, said Wednesday that the agency had not yet provided the report because significant portions would have to be redacted before it could be released to the newspaper. State youthful-offender laws and federal patient privacy laws prevent the agency from releasing inmate records.
However, Munsell said, agency attorneys were in the process Wednesday of getting a court order so that the department could release the unedited report to the newspaper and a legislative committee that discussed Keisha’s death Wednesday afternoon.
Michelle Brown said she cried when she read the report, specifically a section about the center’s treatment supervisor Joy Cole. "Ms. Cole violated the basic rights of a juvenile.... Client Brown’s medical complaints were not adequately addressed. When Ms. [Latoya] Hicks informed Ms. Cole that client Brown was obviously sick, to call an ambulance, Ms. Cole dismissed that as attention seeking behavior," investigator Barbara Ausbrooks wrote in her findings. "She failed to follow up on client Brown’s condition."
Michelle Brown said, "How can she make that call? How can you make that call that this person isn’t sick enough when everybody else notices it?"
Keisha, who had been at the state’s largest youthful-offender lockup for nearly two years, died the morning of April 9 at Southwest Regional Medical Center in Little Rock. During the three hours before her death, Keisha complained of exhaustion and difficulty breathing. She had complained about the same symptoms in January and February. At that time, nurses and a doctor working for the Alexander facility did not believe that Keisha was really ill, according to medical records provided to the newspaper by Michelle Brown.
On the day she died, several employees noticed that her lips were pale and that she was cold. A nurse examined Keisha but again found nothing wrong.
A preliminary autopsy report showed that Keisha likely died from a blood clot that went to her lungs, possibly caused by blood clots in her legs. She was to be released May 1.
The Youth Services Division investigator also found: Credible evidence that Cole violated policies when she instructed another employee not to file an incident report about Keisha’s worsening condition at breakfast the morning she died. Credible evidence that Cole violated policy because she "had a duty to ensure [that] the severity" of Keisha’s medical condition was conveyed to the Alexander center administrators. "The information was poorly documented," and incident reports that would have alerted others to Keisha’s symptoms were never completed. Credible evidence that Joann McCoy, another supervisor, violated student-supervisor policy and basic youthful-offender rights when she ordered Keisha to walk to the cafeteria even though Keisha had been placed on bed rest. "Ms. McCoy knew that client Brown was sick," the investigator wrote. "Not only did client Brown [walk] to the canteen, she was in the gym for over an hour before her demise." Credible evidence that nursing staff members violated medical policy. At least five medical employees responded to Keisha’s complaints of being lethargic and "debilitated" in the days and hours before her death. However, they documented only one visit. All nurse-patient encounters are to be documented.
Neither Cole nor McCoy could be reached Wednesday night for comment.
Keisha’s mother and other family members contend that Keisha did not get the care she needed from the Alexander facility, which is run for the state by a private company called Cornell Cos. Inc.
Munsell acknowledged Wednesday that some medical protocols and policies were not followed by the staff at Alexander. No employees have been disciplined or fired in connection with Keisha’s death, and Arkansas State Police investigators found no criminal wrongdoing on the part of her caretakers. "I think it was clear that the process for addressing those concerns was not being met. It’s not within our expertise, frankly, to be able to determine whether or not it would have altered the outcome," she said Wednesday evening. "It is not for us to say, nor do we have the expertise to be able to say, whether or not the medical care they provided was adequate."
Instead, she said, the agency is responsible for making sure its contractors, including Cornell, follow all policies and procedures that have been put in place to ensure that proper medical care is given.
Youth Services Division Director Kenneth Hales told the Joint Performance Review Committee on Wednesday that he has asked Cornell to quickly address the problems found during the internal investigation.
Specifically, the Human Services Department wants Cornell to improve documentation of medical conditions and treatments; offer additional medical training for both medical and administrative employees; and ensure that all medical policies and procedures are being followed.
The Human Services Department will provide additional supervision such as auditing medical files, Hales said, to ensure that those procedures are being followed. He said he believes that policies that are in place are adequate.
Hales declined to answer legislators’ specific questions about Keisha’s death and medical care, citing federal patient-privacy laws. He did not provide legislators with a copy of the internal investigation detailing the problems with Keisha’s care.
When asked about Cornell’s overall performance since it took over the Alexander center in 2001, Hales responded, "I believe we’re getting good service."
Keisha’s death was brought to the attention of the committee by state Rep. Kevin Goss, D-Wilson, after he read about it in the newspaper. "She complained of various health problems, which ultimately fell on deaf ears," Goss said. "I find this whole ordeal very troublesome."
He and fellow legislators noted that the Alexander center historically has been plagued with problems from abuse to neglect and suicide.
The U.S. Department of Justice criticized the Alexander unit in a November 2002 report for violations of several civil rights, including the right to religious freedom, mental health treatment, educational services and a safe environment. State officials signed a settlement with the Justice Department in March 2003 agreeing to correct problems found. Almost all have been corrected.
In addition, the Youth Services Division conducted an internal review Oct. 4 that found several problems, including a delay in responding to medical needs. A March audit shows that that problem had been corrected.
Committee Chairman state Sen. Terry Smith, D-Hot Springs, told Hales and others that he was concerned about what happened to Keisha and about the Alexander center. "We continue to have problems with the Youth Services Center," Smith said. "It will get straightened out."