$50M lawsuit regarding death of diabetic Ill. inmate may go to trial

The lawsuit says Michael A. Carter died because medical staff at the jail refused to give him prescription medicine and appropriate attention as his condition worsened


By Clay Jackson
Herald & Review

DECATUR, Ill. — Attorneys are readying for trial later this year in the $50 million wrongful death lawsuit involving 35-year-old Decatur inmate Michael A. Carter, who died of diabetes complications in the Macon County Jail.

The suit, filed in September 2016 in U.S. District Court, names as defendants the sheriff’s office, which runs the jail, as well as several correctional officers who were on duty; Decatur Memorial Hospital, which was contracted to provide care; Robert Braco, the physician who saw Carter in the jail; and Jo Bates, the licensed practical nurse who was on duty. All have denied wrongdoing.

Michael A. Carter, 35, died of diabetes complications in the Macon County Jail. (Photo/Macon County Sheriff)
Michael A. Carter, 35, died of diabetes complications in the Macon County Jail. (Photo/Macon County Sheriff)

While stressing that improvements were not motivated by litigation, Macon County officials have made major changes to the jail’s medical operations since Carter died on July 18, 2015. Those include a new medical provider, Crossing Healthcare, and a number of other upgrades.

Carter died days after he was booked into the jail while he awaited federal court proceedings on drug and weapons charges. The lawsuit says that Carter died because medical staff working at the jail refused to give him prescription medicine for diabetes and appropriate attention as his condition worsened.

A trial date has been set for September, though there are outstanding motions seeking an earlier ruling.

Court documents obtained by the Herald & Review show that less than a year after that lawsuit was filed, nurse Bates was named in a similar wrongful death lawsuit concerning a Champaign County Jail inmate who also died as a result of alleged medical neglect. Bates, 51, was dismissed in October 2019 from that case, but is still involved in the Macon County lawsuit.

Circumstances and medical details vary between the two death cases. In both, however, the veteran correctional nurse was among those accused of failing to provide adequate care and showing negligent indifference to the fate of grievously ill inmates. Bates has vehemently denied those claims, various court filings show.

Bates said in a March 2018 deposition in the Macon County case that she had been a correctional nurse for over 15 years, including two separate four-year stints working for the Logan Correctional Center in Lincoln. A licensed practical nurse provides basic medical care, working under the direction of doctors and registered nurses.

The Champaign County Jail case concerns the death of Paul E. Clifton, 59, who was diagnosed with severe asthma and chronic pulmonary obstructive disease and died March 27, 2016, after his condition worsened dramatically while in custody.

Both sheriff’s offices that run the respective jails, their staff and all the medical providers involved have denied all liability in both cases. Regan Lewis, an attorney for Decatur Memorial Hospital, said they do not comment on ongoing litigation. Attorneys representing the county on Friday did not respond to an email from the Herald & Review seeking comment. William Kurnik, a Rosemont attorney representing the sheriff’s office and its personnel, had previously declined to comment on the case.

Reached by phone, Bates said she did not want to comment for this story and referred all questions to her lawyer.

Peoria attorney Peter R. Jennetten represents Bates in the Macon County case. In an email, he said legal rules prevent him from commenting in detail on her case at this stage in the court process.

Talking generally, however, he described delivering health care to inmates as an “actively evolving area of medical practice.” He said nurses find themselves placed in the forefront of providing inmate health care services.

"The correctional environment is challenging for health care providers for many reasons, and specialties in correctional medicine are developing to address those challenges," Jennetten said.

“... Nurses are on the front lines of medical care in jails, often providing care to detainees who did not seek, or did not have access to care outside the jail,” Jennetten added. “Nurses, of course, act under the supervision and direction of higher level providers.”

A second lawsuit

Chicago attorney Rahsaan A. Gordon, who represents Carter’s estate in the Macon County lawsuit, obtained Bates’ DMH personnel file as part of the case. The hospital was sanctioned by a U.S. District Court judge in April for taking more than a year to hand that file over to Gordon.

When the attorney re-deposed Bates in May after reviewing the file, he made repeated attempts to ask her about the Champaign case but was blocked by Jennetten, who instructed her not to answer. Gordon, who clearly thought her being named in a second wrongful death suit was pertinent background information, kept circling back to the subject.

“The question was ‘Have you been named in another lawsuit other than the one involving Michael Carter Sr?' ” he asked after an extended back and forth with Jennetten on the issue in the deposition. More discussion followed before Jennetten replied: “...(I’m) going to direct her not to answer. If you want to get the Judge involved, that’s up to you.”

At this point Gordon called the chambers of U.S. Magistrate Judge Jonathan E. Hawley, who will preside over the case, but the battling attorneys were told by the judge’s clerk to try and proceed “as best as possible” and to come back to court with legal motions if the dispute continued.

Gordon agreed to carry on and move ahead with the deposition, probing Bates about her actions and the circumstances of Carter’s death, but he appeared frustrated at not being able to to explore what happened in Champaign. Gordon declined to comment about the pending case.

Jennetten repeatedly told him that the rules of the deposition limited questions to Bates’s DMH personnel file only, a position the judge agreed with when Gordon later filed a motion seeking permission to ask about the Clifton death lawsuit.

The judge ruled such questions were outside the scope of the redeposition into the DMH file on Bates, which contained a “termination form” from the hospital that revealed she had been fired after Carter’s death for what the Decatur hospital called “unsatisfactory performance.” A three-page narrative with the termination form, included as part of a court filing, said Debbie Acciavatti, former director of DMH corporate health services, was told by sheriff’s office administrators that the nurse had made inappropriate comments in front of correctional officers.

The narrative said Acciavatti was told the nurse had said, in relation to Carter’s death, “This was God’s way of natural selection, weeding out the riff-raff.” Bates has denied saying that in court depositions, and the file indicates that she denied making inappropriate comments when speaking to a DMH human resources official in 2015. Bates has also said she was fired for medical reasons after becoming injured, and was told she could reapply for her job by DMH officials.

The termination form narrative also says she was told she could reapply. However, the form notes she was not eligible for rehire with the explanation, “Employee made inappropriate actions and comments regarding an inmate’s medical issue.”

More criticism from Macon County Jail officers, claimed in court documents, said Bates had told them Carter was faking his illness and being uncooperative. Central to his death, the lawsuit accuses Bates and Braco, a physician employed by DMH, of failing to react to Carter’s deteriorating condition and of failure to provide essential treatment that could have saved him.

In a motion filed Nov. 1, Bates argued that she had acted at the direction of the physician, Braco, and that jail policy did not authorize her to monitor the glucose levels of Type 2 diabetics unless ordered to do so by the doctor. One of the two diabetes medications that Carter used was not provided to him because it was not available at the jail, according to the motion. Bates gave him doses of the other medication on several dates, and he refused it on one occasion four days before he died, she said.

Bates said in a March 2018 deposition that Carter had been uncooperative at times while in the jail’s medical unit.

On the morning of his death, Carter had been moved to “dead lock,” or a segregated area of the jail. Bates testified that she had checked his glucose level at that point, at Braco’s direction, and found it at 500 milligrams per deciliter, the highest that the machine would register. She had not checked his glucose levels prior to that day, and was not aware of anyone else doing so, according to her deposition.

The American Diabetes Association’s recommended target blood sugar range for a diabetic who is fasting is 80 to 130 mg/dL, and is less than 180 mg/dL for a diabetic two hours after eating.

Braco directed Bates to give Carter insulin and check his glucose level again, which she did. His glucose level registered at the highest level again. Braco then directed that Carter should be taken to Decatur Memorial Hospital by a private vehicle, rather than an ambulance.

Gordon, the attorney for Carter's estate, has said in the initial legal complaint that Braco would not order the ambulance because he did not want the county to incur the $1,000 bill for an ambulance ride.

Braco testified during a deposition that he had asked Carter to provide a urine sample July 17 and Carter had refused. He said that Bates had told him Carter was walking, talking and coherent during two phone calls the morning of July 18, and that “there was no indication of it being an emergency.”

Jail staff ultimately contacted the ambulance, which rushed Carter to DMH, but it was too late. Carter was pronounced dead at 12:35 p.m. July 18. Bates said she helped perform CPR on Carter until the ambulance arrived.

“LPN Bates provided prompt and appropriate care for those conditions of Plaintiff’s which she was made aware,” her attorney argued in the November motion. “The care provided by LPN Bates was up to the maximum scope of care she was authorized to provide as the jail nurse under the circumstances provided.”

Bates was fired from DMH in August 2015. She testified in her deposition that she was let go because she had broken her arm in a boating accident and could no longer perform her job duties.

Licensing nurses

All nurses in Illinois are licensed by the state Department of Financial and Professional Regulation. Discussing the general rules governing license infractions, DFPR spokesman Chris Slaby provided a written copy of issues nurses must “self-report” to the licensing authority. The list includes “any adverse final action” taken against them by any law enforcement agency or any court.

Citing another example, Slaby said the license of a nurse who gets fired by a hospital would not necessarily be exposed to any penalty. But he said a nurse who fails to report her termination to the department would be breaking the licensing rules. “Yes, that can be a cause for discipline,” he added.

The DFPR does not discuss individual cases and it’s not known whether or not Bates reported her termination from Decatur Memorial Hospital; the department did confirm, however, that she retains her nursing license and she has never been subject to any discipline.

At the time of inmate Paul Clifton’s death in the Champaign County Jail, Bates was working for a company called Correct Care Solutions, LLC (now called Wellpath after a 2018 merger) which had the contract for inmate medical care.

A lawsuit filed over his death cited Bates, another doctor and various other medical and jail professionals for failing to assess, treat or respond to Clifton’s worsening health and being negligent in their approach to his care.

“By means of the negligence of the Defendant Bates and as a direct and proximate result of the breach of the applicable standard of medical care, the decedent, Paul Clifton, suffered conscious pain and suffering, incurred future lost wages, suffered mental anguish, incurred medical expenses; suffered death and other damages,” said the lawsuit, filed by attorney Shayla Maatuka.

Court documents filed Oct. 30 show that Bates, along with a doctor, was dismissed from that lawsuit after Correct Care Solutions reached a settlement with the representative of the estate of Paul Clifton. That dismissal was confirmed by Chicago attorney Robert P. Vogt, who acted for Correct Care Solutions.

Issues with healthcare behind bars

The wider issue of health care standards for prisoners has become a growing legal battleground in Illinois. In January 2019, the American Civil Liberties Union of Illinois announced a major settlement of a lawsuit against the state that will lead to a vast overhaul of the system providing physical health care to some 40,000 inmates in the state’s prison system. The settlement calls for employing physicians with specific qualifications and mandates improvements in health care facilities and equipment, installing an electronic records system and maintaining a stringent quality assurance program.

Court-appointed reviews of the state’s prison health care system took a sampling of 33 inmate deaths and concluded 12 were “clearly preventable,” according to the ACLU. The reviews went on to claim that another seven deaths “may have been preventable” and in five other cases the record-keeping was so poor that medical experts were unable to determine what had happened.

The John Howard Association in Illinois is an independent monitor of correctional facilities and agitates for a more humane criminal justice system. It led an effort to end a $5 medical co-pay which it said was too steep for prisoners to pay and kept many of them from seeking medical help. Gov. J.B. Pritzker signed a law eliminating prison medical co-pays in July that took effect Jan. 1.

JHA Executive Director Jennifer Vollen-Katz told the Herald & Review that much remains to be done for prison health care, while the scope of problem medical issues in the county jail system can only be guessed at. She said her organization was created to monitor health care in prisons, not jails.

“And it’s not because we don’t think jails need to be monitored,” she said. “It’s just not the work we do.”

Vollen-Katz said she doesn’t know details about the individual cases cited in either the Macon and Champaign lawsuits, but neither of them particularly surprises her. “It gels with what we’ve seen in the prison system,” she added.

Reforms within that prison system, at least, are on the way. Yet Vollen-Katz remains concerned about a society that doesn’t seem to worry too much — unless pushed through legal action — about what happens to an increasingly large segment of its population, often poor to begin with, who find themselves behind bars and suffering from medical conditions that don’t get treated properly.

She says it would be better for us all if those incarcerated experience humane conditions while they are there.

“You can’t think that you are going to send somebody into prison (or jail) and treat them horribly, keep them locked in what essentially looks like a cage, deny them adequate medical care and mental health treatment, and think they are going to leave incarceration better off and able to enter society successfully,” she said.

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©2020 the Herald & Review (Decatur, Ill.)

McClatchy-Tribune News Service

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