Category: Medical Care

The Wichita County Jail, in Wichita Falls, Texas, recently failed an inspection by the Texas Commission on Jail Standards (TCJS). As a result, the Wichita County Jail is now listed as being non-compliant by the TCJS. The TCJS notified Wichita County Judge Gossom and Wichita County Sheriff Duke.

The TCJS inspector found, when reviewing restraint logs, that observation checks were conducted beyond the required 15-minute maximum interval by as few as one minute and by as many as nine minutes on multiple occasions. The TCJS inspector required that the Wichita County jail administration conduct documented training with staff on the use of restraints.

The TCJS inspector also found, when reviewing inmate medical files, that Wichita County jail staff, on multiple occasions, failed to complete the Screening Form for Suicide and Medical/Mental/Developmental Impairments in its entirety. Missing information included the times the form was completed, comments for affirmative answers, and continuity of care query return information. Thus, Wichita County jail staff had to conduct documented training regarding these issues.

The Galveston County Sheriff’s Department, in Texas, filed a report regarding the custodial death of Broderick Demoures Davis. Mr. Davis was only 40 years old at the time of his death. We provide in this post information we obtained from that report, and we make no allegation of any wrongdoing against anyone.

The report indicates that the time of the incident was 4:25 a.m. on September 4, 2022. The report also indicates that Mr. Davis passed away at 5:11 a.m. on September 4, 2022. Finally, the report indicates that Mr. Davis entered the jail at 12:04 a.m. on September 4, 2022. The report does not provide the medical cause of death, pending an autopsy. The summary portion of the reports reads in its entirety:

“In an attempt to place hand restraints on the inmate, he was placed on the ground by deputies. After the restraints were applied, the inmate continued to resist and deputies attempted to control him on the ground. While on the ground, deputies noticed that the inmate became unresponsive and on-scene jail medical staff responded. Additional jail medical staff were called, along with EMS/first responders. The inmate was transported to an area hospital were he was later pronounced to be deceased.”

While we do not have sufficient information to comment on the cause of Mr. Davis’s death, we are currently handling another case in which an arrestee died in a jail from positional asphyxiation. Positional asphyxiation can occur if a person is placed face down and pressure is put at certain points on the person’s body.

The United States Constitution guarantees the right of inmates and others not to have unreasonable force used against them by law enforcement officers and jailers. Moreover, inmates have the right to receive reasonable medical care. If a person’s constitutional rights are violated, and the person dies as a result, then certain surviving family members may be able to file a federal civil right lawsuit regarding the death.

The Travis County Sheriff’s Department, in Austin, Texas, filed a report regarding the custodial death of Victor Rene Gonzales. Mr. Gonzales was only 37 years old at the time of his death. We provide information we obtained from that report, and we make no allegation of any wrongdoing against anyone.

The summary portion of the reports reads in its entirety:

“On 9/3/2022 at about 1000 hrs, the post officer observed Inmate Victor Gonzales laying naked on the floor of his single man cell. Gonzales was alert, conscious, and was scratching his body. Gonzales pushed the intercom button in his cell shortly after and told the post officer that he had difficulty breathing. Gonzales could not advise what was the cause, only that he could not breath. Medical staff was advised and Gonzales was told to get dressed so he could be taken to be seen by medical staff. At about 1020 hrs, Gonzales started to gasp for breath and went unresponsive when another officer attempted to move him to medical. CPR was initiated on Gonzales by TCSO staff until relieved by EMS & FD. EMS transported Gonzales to Dell Seton Medical Center where he was later pronounced deceased on 9/4/2022 at 0343 hrs.”

The report also indicates that Mr. Gonzales, as the most serious offense for which he was incarcerated, was incarcerated for a prohibited substance in a correctional facility. The report also indicates that he originally entered the jail on September 1, 2022 at 3:06 p.m. Unfortunately, the report provides no information regarding Mr. Gonzales’s previous medical issues, how often he had been observed in the jail, or anything else leading up to the incident.

People who are incarcerated in Texas county jails have the right, under the United States Constitution, to receive medical care for serious issues. If jailers and/or medical personnel in a jail fail to provide such care, and they are unreasonable and/or deliberately indifferent in doing so, then they could be liable to certain surviving family members of a person who dies as a result. Also, if a jail’s policies, practices and/or customs result in suffering and/or death of a person incarcerated in a Texas county jail, the county likewise could be liable to certain surviving family members.

The Harris County Jail, in Houston, Texas, is now listed as being non-compliant with the Texas Commission on Jail Standards (TCJS). The TCJS made this determination after investigation of a complaint regarding inmate Helen Subeka.

The TCJS determined that 64 inmates had remained in holding cells for over 48 hours. As a result, Harris County had to submit a plan to the TCJS demonstrating how inmates would be processed, classifies, and assigned to appropriate housing within 48 hours. The Harris County Sheriff’s Department had to do so within 14 days of receipt of the notice of the TCJS requiring such corrective action. Harris County also had to develop a corrective plan of action to ensure that inmates held over 48 hours are provided the opportunity to purchase personal hygiene supplies, or in the alternative, providing such personal hygiene supplies if an inmate is unable to do so due to being indigent. Harris County Jail problems continue.

The Moore County jail, in Dumas, Texas, is now listed as being non-compliant with minimum standards promulgated by the Texas Commission on Jail Standards (TCJS). This occurred as a result of a death in the Moore County jail.

A TCJS inspector, after reviewing videos submitted by the Moore County Sheriff’s Department after the death of an inmate who was in a holding cell, noted that the inmate had not been observed multiple times over several hours before the inmate’s death. This is inexcusable. The most basic function for any jailer in a Texas county jail is to make appropriate periodic observations of detainees. Without observation, jailers are unable to contact mental health professionals and/or medical personnel in the event an inmate is having a mental health or medical crisis.

The TCJS inspector determined, with regard to the Moore County jail in Dumas, that observations were not conducted of the deceased inmate as required by minimum jail standards. The inspector determined that there were multiple hours when face-to-face observation simply did not occur.

The TCJS thus required the Moore County jail to submit a corrective plan of action to the inspector. The plan of action had to also “include some type of training for jail staff.”

The inspector also determined that inmates in the Moore County jail are “moved” in the jail’s computer system to show the inmate in a different location or cell than where the inmate is actually being held. Thus, with regard to the deceased inmate, the inmate was “moved” in the Moore County jail’s computer system to a different cell, while the cell he was actually housed in was noted in the computer system to be “empty.” The inspector wrote, “This practice will cease immediately.”

The Webb County Jail, in Laredo, Texas, failed to comply with Texas Commission of Jail Standards (TCJS) minimum standards.

The Webb County Jail was thus listed as being non-compliant by the TCJS at its website.

The TCJS inspector found, when reviewing videos submitted by the Webb County, Texas Jail after a custodial death, that observation rounds were not conducted in accordance with minimum jail standards. There is no excuse for not conducting appropriate observation rounds. Inmates, by the nature of incarceration, cannot obtain medical and/or other care for themselves. They rely on jailers. Thus, jailers must make periodic observations to assure that inmates are not in medical or serious mental health distress. One cannot determine from the TCJS report for the Webb County Jail whether the failure to make observation rounds led to the death. Regardless, hopefully, the Webb County Jail has cured its deficiencies and will avoid the potential for serious injury or death.

The Runnels County jail, in Ballinger, Texas, recently failed an inspection by the Texas Commission on Jail Standards (TCJS). The Runnels County jail is now listed as being non-compliant by the TCJS.

The TCJS inspector determined when reviewing life safety documentation that multiple Runnels County jail staff had failed to complete required quarterly training for the second quarter of 2022 and fourth quarter of 2021. The inspector also found that, at the time of inspection, the facility generator was unable to be tested due to a faulty transfer switch. Surprisingly, jail administration advised that the transfer switch had been inoperable since April 2021. Runnels County jail staff also advised that there was no maintenance contract in place to keep the generator maintained.

The TCJS inspector also determined, on perhaps a more serious note, that a log of positive returns identifying prisoners who were veterans had not been maintained for the previous 5 months. The law requires our jail staff across Texas to appropriately identify and treat veterans who happen to be arrested and incarcerated.

On a note that could have led to serious injury and/or death, the TCJS inspector determined, when reviewing restraint logs, that staff had exceeded the 15-minute observation checks by as little as one minute, and by as many as 25 minutes on multiple occasions. The TCJS inspector required Runnels County jail administration to conduct documented training with staff regarding the use of restraints and the importance of conducting rounds within the mandated 15-minute time frame. That training had to be conducted within the following 30 days.

On yet another very serious note, with the potential for serious injury or death resulting, when reviewing observation logs, the TCJS inspector determined that Runnels County jail staff exceeded the 30-minute observations in areas in which inmates who were known to be assaultive, potentially suicidal, or mentally ill, were kept. Those checks were exceeded by as little as one minute, and by as many as 45 minutes on multiple occasions. Runnels County administration advised that such likely occurred due to staffing levels. This was no excuse. Interestingly, when reviewing records, the TCJS inspector found that jail staff were sufficient to meet the required ratio of 1 officer to 48 inmates but were insufficient to perform other required functions within the facility. Areas which the inspector found to be affected by staffing during the inspection included food preparation in the kitchen, restraint checks, and observation checks. The TCJS inspector also determined that, when the facility was staffed with two members, staff could not keep up with required functions within the facility. Hopefully, no serious injury or death resulted in the Runnels County jail as a result of these deficiencies.

The Leon County jail, in Centerville, Texas, recently failed an inspection by the Texas Commission on Jail Standards (TCJS). The TCJS notified Leon County Judge Byron Ryder and Sheriff Kevin Ellis in writing of the jail’s non-compliance.

The inspection occurred on or about July 12, 2022. The TCJS inspector found during an investigation of a compliant related to overcrowding, that Leon County had 9 inmates housed in area H which is a multiple occupancy cell which could not exceed 8 inmates. The inspector also found that the Leon County jail housed females in areas E and F in close proximity to male inmates. Finally, the TCJS inspector found, when reviewing a complaint related to overcrowding that Leon County did not meet the 1 to 48 ratio of staff to inmates. Hopefully, the Leon County jail will bring itself into compliance with minimum jail standards.

The Gregg County jail, in Longview, Texas, recently failed an inspection by the Texas Commission on Jail Standards (TCJS). The Gregg County, Texas jail is now listed as being non-compliant by the TCJS.

The TCJS inspection occurred from August 29 through 31, 2022. The TCJS inspector found that the fire alarm panel at a certain facility was inspected by a fire alarm company on March 17, 2022. However, the alarm company failed to properly tag the alarm panel following the annual inspection.

Further, and more seriously, when the TCJS inspector reviewed medication administration records at the Gregg County jail, multiple records were found to be missing documentation that medication was administered in accordance with instructions from a physician. Multiple days were seen on multiple medication administration records to be missing signatures and initials indicating that medications were administered. The TCJS inspector required that, within the next 30 days, Gregg County jail staff administration had to develop a plan of action to ensure that medications were administered in accordance with written instructions from a physician and moreover address missing documentation seen on medication administration records. Hopefully, the Gregg County jail’s failure to properly administer medications, or at least document saying, did not lead to serious injury and or death.

The Gray County jail, in Pampa, Texas, failed an inspection by the Texas Commission on Jail Standards (TCJS). The Gray County jail was thus listed as being non-compliant by the TCJS. Gray County Judge Chris Porter and Sheriff Michael Ryan were provided written notice of the jail’s failure to comply.

The TCJS inspector found, when reviewing training records, that Gray County jail staff did not document training during the second quarter of calendar year 2022 for fire drills and SCBA. The TCJS inspector instructed staff to ensure that training was completed once per calendar quarter in accordance with minimum jail standards.

Further, the TCJS inspector determined, when reviewing life safety documentation, that quarterly fire prevention training was not completed during the prior 12 months. The TCJS inspector instructed staff to complete a fire hazard inspection checklist, which would be evaluated no less than each calendar quarter. The inspector also found, when reviewing the ANSUL Hood system, that there was not inspection documentation showing an inspection since October 15, 2021.

Turning to potentially more serious issues, the inspector determined, when reviewing medication administration records for inmates, that medication apparently had not been distributed to one or more inmates as required by prescribing physician on several occasions. The TCJS inspector determined that Gray County jail’s documentation was not consistently broken down to list when an inmate received or refused each individual prescribed medication. The TCJS inspector prescribed remedial measures.

The TCJS inspector also found, when reviewing Gray County jail restraint logs, that jail staff exceeded the 15-minute observation checks required by Texas jail standards by as little as one minute and by as many as 10 minutes on multiple occasions. This could lead to serious injury or death.

Finally, the TCJS inspector received an investigative report for a custodial death that had occurred at the Gray County jail in June 2021. The TCJS determined that the intake jailer told a Texas Ranger that the deceased inmate was under the influence of methamphetamine upon booking. However, this was not noted on the Screening Form for Suicide and Medical/Mental/Developmental Impairments. Additionally, the Rangers report indicated that the jailer supposedly believed that he had marked “yes” to the question “Does the inmate appear to be under the influence of drugs or alcohol?,” but the form was marked “no.” Finally, the jailer stated he did not ask the inmate all the questions on the Screening Form for Suicide and Medical/Mental/Developmental Impairments. The TCJS inspector required follow up of Gray County jail administration, specifically training with staff on proper completion of the screening form for Suicide and Medical/Mental/Developmental Impairments and to provide documentation of such training to the inspector within the following 30 days.