Citing "protocols," a nurse turned away an ambulance despite multiple seizures.
An inmate with a history of seizures was denied emergency care by a prison nurse who overrode a doctor's orders for an ambulance, and within an hour the man suffered irreversible brain damage that led to his death, according to documents obtained by the Star Tribune.
Although prisoner Xavius Scullark-Johnson had suffered multiple seizures over a period of hours, a nurse at the state prison in Rush City cited "protocols" in turning away an ambulance team sent to take him to a nearby hospital, crew reports show.
Johnson's 2010 death is expected to produce a federal lawsuit against the Minnesota Department of Corrections (DOC), with a filing likely early this week.
The agency said Friday that it would not allow Dr. David Paulson, its medical director, to be interviewed about the death, "due to potential litigation." Officials said the department has investigated Johnson's death, but would not provide details or describe the protocols cited by the nurse.
Yet events in the hours before Johnson was found "pulseless" in his cell raise questions about denial of care because of the rationed-care philosophy of the for-profit contractor Minnesota has hired to care for the state's 9,400 prisoners. Corizon Inc., formerly known as Correctional Medical Services, has had a contract with the state since 1998, worth $28 million this year.
One of the contract's major cost-saving provisions says that Corizon is not required to provide overnight medical staff in the state's prisons, except Oak Park Heights and Faribault, where medically complicated, elderly and terminally ill prisoners are held.
No doctors, who are all Corizon employees, work in the state's prisons after 4 p.m. or on weekends. Corrections nurses, who are state employees, work seven days a week, but their last shifts end at 10:30 p.m. The last time the Rush City prison had 24-hour medical coverage was in 2002.
Additionally, services such as ambulance runs are strictly monitored by Corizon and the department in an effort to cut costs, according to department medical staff. An average ambulance run costs about $3,000 plus mileage, the department says.
Corizon declined to comment for this story, or to allow a reporter to interview the Corizon physician who was on call the night of the incident.
'Something is not right'
Johnson's last hours are a series of scenes that show prison medical staff acting with indifference as well as compassion, corrections officers caught in the middle as communications break down, and guards left to evaluate a prisoner spiraling downward, according to DOC documents and ambulance reports.
The incident started on the evening of June 28, just as the health services unit was closing for the night.
Johnson, 27, a St. Paul native who suffered from schizophrenia and a seizure disorder, was found soaked in urine on the floor of his cell. He was coiled in a fetal position and in an altered state of consciousness that suggested he had suffered a seizure, according to notes taken by nurse Linda L. Andrews, who was on duty at that hour. He was somewhat combative when a nurse tried to take his vitals and wipe him with a cool washcloth, but his breathing was normal.
Andrews wrote that she covered the prisoner, then issued orders to a lieutenant to let Johnson sleep and to check on him during rounds. Andrews did not contact the system's on-call doctor, according to her last chart, written at 10:55 p.m.
About four hours later, Dr. Sharyn Barney, a longtime employee of Corizon, picked up her telephone at home. A corrections officer told her that Johnson had had a seizure the previous evening that was evaluated by the health staff, but that now his cellmate was having "trouble waking" him, according to the doctor's notes.
Barney, who works primarily out of the prison in Moose Lake, told the officer that Johnson was probably "exceptionally sleepy from the seizure the previous evening."
She advised officers to monitor him carefully and alert the medical staff when they arrived for the morning shift.
Under the department's contract with Corizon, there is just one on-call doctor to serve the entire prison system across Minnesota, and who is then left to assess a prisoner's case without the benefit of a written file because health service units are shut down overnight.
Prison medical staff interviewed in recent weeks say the practice often leaves the doctor "flying blind'' and leaves prison officers with no on-site medical staff to evaluate a patient's distress.
An hour or two later, the officer called Barney back. "He was uncomfortable and felt something just was not right and we agreed to call for an ambulance," the doctor wrote. It was a 911 call.
A two-person ambulance team arrived at the Rush City prison at 5:39 a.m. While they evaluated Johnson, noting he was "slow to respond,'' nurse Denise L. Garin arrived. She did not want Johnson transported, the ambulance crew wrote.
"They say the patient has had three seizures through the night," a crew member wrote in her June 29, 2010, report. "They believe that he has a seizure [history] but do not know because health services is closed at night. They did not want patient transported.
"They have protocols to deal with the patient,'' her notes continue, "and say this is because patient has recently gotten his Dilantin cut in half.''
Dilantin is a drug used to control seizures. An autopsy later showed that Johnson's Dilantin was "below therapeutic level,'' but there is no mention in Garin's charting why she refused to let the ambulance crew take him to the hospital to have his Dilantin level checked immediately.
Garin's own report makes no mention of protocols or drug dosages.
In fact, Garin wrote that Johnson was "alert, his vital signs were stable and he responded appropriately" -- the opposite of what the crew observed.
Garin did not apprise the on-call doctor about her decision to cancel the ambulance order, according to her entries in Johnson's medical file. Garin, who continues to work at the prison, could not be reached for comment.
The ambulance crew packed up and left. It was 6:07 a.m.
About 35 minutes later, an emergency alarm called staff to Johnson's cell. Garin wrote that she found Johnson face-down in his bunk. She turned his head and noted a heartbeat. She asked an officer to stay with Johnson while she tried to reach a doctor. While waiting, she was called back to the cell. She pressed Johnson's neck to find the cartoid artery and found that he was "pulseless."
About 20 minutes later, a new ambulance crew arrived while prison staff administered chest compressions on Johnson. He could not be revived.
Johnson was transported to the Fairview Lakes Regional Hospital in Wyoming, Minn., and then later to Regions Hospital in St. Paul. He was pronounced dead at 7:37 a.m. on June 30. "Scans had shown herniated brain stem. Administration notified," a nurse's last entry stated.
At the time, Johnson was expected to be released from prison in less than three months.
Paul McEnroe • 612-673-1745