Coroner: As SF jail inmate was dying, nurses ignored moaning from cell

California WatchBlog

October 8, 2010 | Ryan Gabrielson


Issiah Downes died in a padded room at the San Francisco County Jail after sheriff’s deputies worked to restrain him. And now, questions about what caused the inmate’s death have focused on the conduct of those at the scene.

Those questions gained greater attention in September when the San Francisco Medical Examiner ruled the death a homicide. Last week, Downes’ mother, Esther, filed a wrongful death lawsuit [PDF] against the city seeking $50 million in damages.

But records from the death investigation [PDF] also shine a spotlight on those not present: medical staff.

On Sept. 7, 2009, Downes got into a loud argument with a deputy who had shut off television sets in the cells. Downes, a 31-year-old black man, had been incarcerated six months on battery charges. Diagnosed with schizophrenia, Downes was being treated with multiple medications.

As a result of the verbal altercation, deputies decided to transfer Downes to segregate him from the other inmates, according to medical examiner records. Deputies first told him he was being moved to a more desirable area in the jail, and Downes cooperated.

Upon realizing that he was instead headed to “administrative segregation,” Downes began to resist.

Four or five officers moved in, reports state. They brought Downes to the ground, handcuffed his wrists, shackled his legs and carried him to a padded safety cell.

Deputies then placed him into a hold.  Two nurses working at the jail reported to investigators that they heard Downes “moaning” from the safety cell as deputies restrained him.

One of them, Paula Avery, left her station to find out what was taking place, but never checked on Downes. In a summary of an interview with Avery, Dr. Judy Melinek, an assistant medical examiner, wrote of the situation:

The moaning was going on for ‘quite some time,’ enough for her [Avery] to be concerned, but she couldn’t further quantify the amount of time. After she crossed back toward her office, she passed the cell a second time but did not look in. The moaning had stopped so she thought things were better.

Downes became unresponsive as deputies removed handcuffs and undressed him.

Nurses at the jails are supposed to be directly involved in precisely these situations.

Lt. John Garcia, a trainer with the sheriff’s office, told Melinek that nurses “need to evaluate every person placed in the safety cell,” according to the medical examiner’s report. “They are automatically notified when a safety cell placement is occurring.”

Geri Green, the attorney representing Downes’ mother, is more emphatic about the role nurses should play when an inmate is restrained.

“The only way you’re supposed to do that is if there’s somebody, preferably a medical person, asking, ‘Are you OK? Talk to me,’” Green said. “Because the risk of asphyxiation is so great in a normal person.”

Downes was significantly larger than most; he stood more than six feet tall and weighed 307 pounds, autopsy records show.

Eileen Hirst, a spokeswoman for the sheriff’s department, told the San Francisco Chronicle last month that the agency believes “all department procedures were followed properly.”

Green cites inaction by the two nurses as transgressions against Downes’ civil rights in the wrongful death lawsuit.

The San Francisco Police Department and District Attorney’s Office have open investigations into Downes’ death. The sheriff’s office declined to comment on its own inquiry, citing the lawsuit, and referred questions to the city attorney’s office.

Melinek’s ruling of homicide means only that Downes died at the hands of another, not that the actions that caused his death were criminal offenses.

“The manner of death, homicide, indicates that the volitional actions of others caused or contributed to this death,” Melinek wrote in her opinion. “Were it not for the physiological stresses imposed by the struggle and restraint, there is no reasonable medical certainty that Mr. Downes would have died at the moment he did.”

The number of nurse positions in the county’s jails has decreased from 114 in 2002 to 84 today, said Frank Patt, deputy director of San Francisco jail medical services. Six of the remaining nurse positions are being held vacant.



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