Report faults jail care

County memo says two in-custody deaths will not be charged as homicides

By Nick Budnick

The Portland Tribune, Mar 14, 2008, Updated Oct 30, 2009 (62 Reader comments)

CASEY

A 43-year-old man told nurses he had chest pain. He received anti-anxiety medication, only to die of a heart attack.

A 36-year-old woman told nurses she had pneumonia – and that her spleen had been removed, making the disease particularly dangerous to her. Already coughing, she was given an inhaler, which did not stop her from asphyxiating on her own lung fluid early the next morning.

Both were inmates at the Multnomah County Detention Center, and both told the admitting nurses not just of their current symptoms but of red flags in their medical history. And in both cases the nurses did not consult with doctors before administering medications which, in the end, did not work.

These, at least, were the findings of criminal investigations into the deaths of Jody Gilbert Norman and Holly Jean Casey, released Thursday by the Multnomah County district attorney’s office.

Despite the findings, the March 10 memo detailed why no one would be prosecuted for the inmates’ deaths, although it raised questions about the quality of care received in jails.

In the memo, Senior Deputy District Attorney Don Rees wrote that “after reviewing the facts and circumstances surrounding the deaths of inmates Holly Jean Casey and Jody Gilbert Norman I conclude that no single person or persons can be held liable for any degree of criminal homicide as defined in (state law).”

Reese added, “To the investigators who worked on these cases and I, the deaths of inmates Casey and Norman seem to raise serious questions about inmate management and health care practices within the Multnomah County corrections system and the level of health services.”

While prosecutors will not charge anyone with homicide, they are pursuing charges against two nurses who worked in Multnomah County jails. One, William Lee James, is alleged to have altered patient records to falsely suggest he consulted with a doctor prior to prescribing anti-anxiety medication to Norman. Another, Kimberly Joers, is accused of falsifying drug records.

Moreover, Casey’s ex-husband has retained two local attorneys, Hala Gores and Matt Kaplan, to sue the county.

One nurse still on leave

Asked about the jail deaths, county health Director Lillian Shirley, who oversees the corrections health division, said, “This is something that we take extremely seriously and put a lot of planning time around analyzing what went wrong.”

Shirley added, “Now that the criminal complaint is done we can proceed with our personnel investigation, and I promise you it will be completed within a week.”

The first of the two deaths investigated occurred in 2005, after Norman, a petty thief, was admitted to jail while complaining of chest pain and a history of angina. The nurse, James, gave him Ativan and indicated in records that he’d spoken with a doctor before administering the drug.

Contacted in December, James told the Portland Tribune he was following an unofficial policy at the corrections health division and said he felt terrible about Norman’s death.

Shirley denied that her department had tolerated the practice described by James.

The second death, that of Casey, occurred Jan. 4 of this year.

Casey, with a history of drug abuse, was booked for failing to appear in court on a second-degree theft charge. She was given an inhaler after reporting difficulty breathing at 11 p.m. She “reportedly” showed some improvement, but then continued to complain about stomach and breathing problems, the Rees memo said.

At about 5 a.m., the deputy on duty advised a jail nurse that Casey was continuing to ask for medical care, but the nurse “declined to contact or treat Casey,” Rees wrote.

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