A North Carolina prison inmate with a history of mental illness died of dehydration in March, according to an Associated Press report. All the details are not yet known, but there are a number of striking similarities to the 1996 of a Vietnam veteran who suffered from post traumatic stress. A subsequent federal audit found a host of problems plaguing medical and mental-health care at Central Prison: inadequate staffing, an out-of-date facility, poor management and overuse of drugs and restraints in the psychiatric hospital.
In March, Anthony Michael Kerr, 53, died of dehydration while in care of Alexander Correctional Institution.
Here is the article on the previous death.
November 2, 1997 Sunday
Case puts prison's hospitals on notice
JOSEPH NEFF AND WADE RAWLINS, STAFF WRITERS
Glen Raeford Mabrey was a Vietnam veteran with a drinking problem and post-traumatic stress disorder. When he got drunk and behind the wheel, as he did repeatedly, the state of North Carolina locked him up. Last year, during his fourth stretch in prison for drunken driving, Mabrey lost touch with reality and drifted into a psychotic haze. He didn't know who or where he was.
Officials at Umstead Correctional Institute shipped him to the medical facilities at Central Prison in Raleigh for his protection.
After eight days in the care of medical staff there, Mabrey, 47, was dead.He died of thirst.
Prison officials say the rapid death of a man in adequate physical health could have been prevented. Locked in a cell without water for days, his kidneys shut down.
And when he was moved to Central's hospital, medical personnel botched his care, according to documents from the Office of the Chief Medical Examiner, the Department of Correction, the Department of Human Resources and the N.C. Board of Nursing, as well as court records.
"Had I been the physician in this case, I would have handled it far differently," said Dr. Barbara Pohlman, who was named the Department of Correction medical director nine months after Mabrey's death.
Said Mabrey's sister, Cheryl Hollowell: "He shouldn't go to prison for a two-year sentence and come back in a body bag."
How Mabrey died provides a snapshot of a troubled medical institution.
Prison officials kept outmoded policies in place for years. Prison guards, in some cases, were able to overrule the medical decisions of doctors and nurses. Correctional officers with no medical training were - and still are - given the task of monitoring mentally ill prisoners.
And there have been repeated warnings that staffing at Central's psychiatric hospital is inadequate in light of a growing prison population.
Central Prison houses the state's most dangerous criminals. Still, its two hospitals are charged by law with providing basic health and nutritional care.
"Inmates are wards of the state, and we have an obligation to provide the best medical care we can," Correction Secretary Mack Jarvis said.
The Department of Correction fell short of its obligation in Mabrey's case, according to official records.
His death brought some changes to Central Prison: Nursing policies have changed. The understaffed medical hospital hired dozens more nurses. Jarvis has asked the National Institute of Corrections to audit his department's health system. The psychiatric hospital has begun video monitoring of some inmates.
But the 144-bed psychiatric hospital operates with a staff as barebones now as in 1993. The chief psychiatrist cannot say that inmates are being adequately checked.
As a result of the Mabrey case, the N.C. Nursing Board has disciplined six nurses. The N.C. Medical Society has taken no action against any doctor involved.
A damaged veteran:
Mabrey grew up in Roanoke Rapids, the oldest of four children. His father was a loom repairman for J.P. Stevens, working in the textile mill featured in the movie "Norma Rae."
Drafted after high school, Mabrey served in Vietnam from 1968 to 1970, escorting convoys, setting up ambushes and protecting an Army base in the Ia Drang Valley.
"It was rough," said Melvin Tharrington, a boyhood friend who recalled the night they spent pinned down under enemy fire for five hours. "Glen was good as gold. He was like a brother to me. He wasn't the same Glen I had known after he got back. I think it just really got to him."
A week after Mabrey's return, his mother heard noises in his bedroom. She found him in his closet crying, banging his head against the wall.
"Momma said he talked about all his friends coming back in body bags and it was too much for him," Hollowell, his sister, said.
He was a welder by trade, but had trouble holding a job. Diagnosed with post-traumatic stress syndrome, Mabrey lived on monthly $ 900 disability checks.
He had numerous run-ins with the law resulting from his abuse of alcohol and cocaine: DWI, driving with a revoked license, larceny, writing bad checks. His first marriage ended. His second marriage was rocky. He was arrested for assaulting his wife, usually while he was drinking.
He was sent to prison in December 1994, after his fourth conviction for DWI.
Cutting off the water:
In prison, Mabrey was a frequent client of mental health services, receiving treatment for depression and other illnesses.
When he became incoherent and disoriented, officials at Umstead involuntarily committed him to Central Prison's psychiatric hospital. That was Feb. 21, 1996.
He was put in a cell with a mattress, a blanket, a toilet and a sink.
Dr. James Smith, medical director of the psychiatric hospital, noted that Mabrey was "acutely psychotic."
Mabrey repeated the word "raisins" over and over. At night, he yelled and banged his head on a door, as he did when first home from Vietnam. He piled up his mattress and clothes and poured food on them.
Smith ordered that Mabrey be put in restraints and given Thorazine, an anti-psychotic medicine sometimes referred to as a "pharmaceutical straitjacket." The Thorazine continued daily while he was in the mental health ward.
Two days after admission, Mabrey flooded his cell at 5 a.m. by stopping up his toilet and repeatedly flushing it. He said he smelled smoke.
Someone turned off the water to his cell. Prison officials don't know who. But cutting the water off is standard practice, Smith said. "If an inmate is flooding his cell, we'll cut the water off so other patients aren't disrupted."
With the water off for nearly five days, Mabrey's health depended on the meals delivered three times a day. His medications increased his body's need for fluids.
Mabrey was uncooperative and paranoid, according to the medical staff. At times he refused to come to the door, telling one nurse, "You just want me to come over there so you can push medicine and kill me!"
Although Mabrey was locked in a cell without water, his charts show no evidence that the staff monitored his eating or drinking. There are just two notes mentioning food or water: He ate one dinner and drank 18 ounces of water while the cell's water was turned off.
Mabrey was checked hourly by the staff, but the checks often were done by correctional officers with no medical training. Officers also delivered his food and picked up his trays, a policy changed after Mabrey's death. Officers aren't trained to monitor an inmate's intake of fluids and food or to look for signs of dehydration.
According to the National Commission on Correctional Health Care, inmates in psychiatric seclusion should be monitored constantly.
"There should be documented 15-minute checks by health-trained personnel or qualified health care professionals," the commission's standards say.
According to a deposition given by Smith in a case unrelated to Mabrey, there is not enough staff to make 30-minute checks, whether by nurses or correctional officers.
"It has never been," Smith said in September.
Could more frequent checks be made? he was asked.
"If somebody wrote me a check for some more staff, we might could," Smith said. "We always submit requests to everybody for more staff."
The 76-member staff at the psychiatric hospital has not been increased over the past five years. During that time, the prison population has risen 50 percent and has become more assaultive. Auditors from the state Department of Human Resources repeatedly have recommended substantial and specific increases in staff: 44 positions in a 1993 audit and 34 in a 1995 audit.
When preparing the psychiatric hospital's budget in 1994, hospital administrator Steve Berry requested 12 of the 44 recommended positions.
"I am submitting only the bare minimum that we feel is necessary to continue to provide the necessary services," Berry wrote.
Al Harrop, Correction's director of mental health services, cut that request to two when preparing the Division of Prisons budget. That request was cut when Gov. Jim Hunt prepared his 1995 budget.
After Mabrey's death, Harrop acknowledged that low staffing levels limited the attention given to Mabrey.
"Due to staffing limitations, the frequency of observation by nursing staff was reduced," Harrop wrote in May 1996 to Bert Rosefield, the director of medical services. "Custody staff present[s] meals and conducts hourly security checks. Observation of meal or fluid consumption is not done on a routine basis."
Harrop made three recommendations: use more correctional officers to free nurses for medical care, monitor inmates with videos and increase staff training. He did not recommend hiring more staff.
In the 1997 budget, Harrop requested 16 new positions for the psychiatric hospital. When the department submitted its proposed budget to the governor in 1997, all medical and mental health requests were dropped. Correction officials say the omission was inadvertent.
After Mabrey's water was off for three days, the nursing staff wrote in his medical log that he was confused and afraid in the early morning. He was yelling "like someone was after him." During the day, he was disoriented.
Early on the fifth day after the water was cut off, Smith saw Mabrey in his cell.
"He was still confused, and I felt comfortable enough with him to have his water turned back on," Smith wrote later.
Shortly after noon, a licensed practical nurse became concerned about Mabrey's lethargy. She suspected he was dehydrated. He had a high pulse and extremely low blood pressure. The staff paged Smith, and he referred Mabrey to the emergency room at Central Prison's medical hospital.
To the emergency room:
Nursing board and prison records offer this account of Mabrey's hospital care:
Mabrey arrived on a stretcher about 1 p.m. Amy Ortiz, an emergency room registered nurse, noted that Mabrey was curled up, emaciated and unconscious. He had green crust around his eyes and cracked skin around his mouth. His tongue was so dry it had furrows in it.
Ortiz immediately started treating him for dehydration, starting an IV line and putting him on oxygen.
Dr. Mohammad Zaman, a staff physician, managed the emergency room care. Prison and nursing board records show that Zaman made no written orders and put no written documentation on Mabrey's charts. Someone ordered lab tests.
The absence of orders was crucial for nurses, who cannot carry out specific treatment or medical procedures on a given patient without a signed order by the physician. The N.C. Nursing Board later disciplined Ortiz for exceeding her scope of practice by giving the IV fluids without a doctor's orders.At 3 p.m., Dr. Terry Rees, another staff physician, took over from Zaman, and registered nurse Hal Farthing took over from Ortiz.
Rees ordered a third liter of IV fluids and a transfer of Mabrey to a regular hospital room in Central.
The third IV was never given. And according to the chart, Farthing, the only nurse in the emergency room on his shift, provided no more care over the next six hours.
Since Mabrey's death, Central Prison has added 49 nursing positions in the hospital and emergency room. The level of nursing care per patient has increased between 36 and 50 percent, depending on which floor a patient is on.
And the emergency room now is staffed by two nurses during the second shift, the shift when Mabrey was in Farthing's care.
Farthing received two lab reports by telephone that showed significant abnormalities, nursing board and prison records show. The reports indicated Mabrey was suffering kidney failure and had life-threatening levels of sodium in his bloodstream.
Farthing never reported the results to Rees or to the doctor who came on at 7 p.m., the records show. When questioned by the nursing board, Farthing said that because the reports were consistent with the diagnosis of dehydration and Mabrey had been given fluids, he didn't see any need to call the doctor.
No doctor inquired about the lab results.
Pohlman, correction's current medical director, said that given the seriousness of the lab report, she would have sent Mabrey immediately to an emergency room at WakeMed or Durham Regional.
"I have two expectations," Pohlman said. "My first expectation is that the physician who ordered the lab test will want to see it. My second is that the person who receives the call will notify the doctor."
About 4 p.m., after receiving two liters of fluid, Mabrey awakened. He was confused and agitated. Sometime about 8 p.m., he walked to the elevator and was taken to Room 333, a poorly lighted cell.
Room 333 has two locked doors, one solid and one made of heavy steel screen. The room is isolated from nurses and was used to seclude disruptive patients.
Rees had ordered Mabrey sent to an acute care ward on the fourth floor, where it would be easy for nurses to monitor him and administer fluids intravenously.
Someone, presumably a correctional officer, changed Rees' order.
"Someone crossed out fourth floor, and 333 is written in," Pohlman said. "I do not know who wrote 333."
Central Prison has changed this policy. Correctional officers no longer make room assignments based on custody concerns. Nursing supervisors assign beds based on the level of care needed.
After Mabrey was admitted to the third floor, nursing supervisor Rosa Settle did not assess him or check his vital signs, according to prison and nursing board records. Prison documents show she ordered a licensed practical nurse to omit the nursing assessment and vital sign check. She didn't review Mabrey's charts or reports, nor verify that Mabrey had been given the third liter of fluid, the documents show.
At 11 p.m, licensed practical nurse Lizzie Simpson took over. She checked Mabrey every 30 minutes by kicking his door, shining her flashlight on his eyes through the door and seeing if he moved, according to prison and nursing board records. The same records show that Simpson did not enter the cell or read his records.
The next morning, Rees found Mabrey unconscious in his cell. The doctor sent him to the prison emergency room. An hour and a half later, an ambulance took Mabrey to WakeMed's emergency room.
Prison regulations require that an inmate's medical file accompany him to an outside hospital. Mabrey's file either was missing or of no help because of the lack of written documentation.
At WakeMed, doctors inserted a tube in Mabrey's nose and put charcoal in his stomach, a standard treatment for a drug or poison overdose, not for dehydration.
"Nobody quite knew what was going on," said Dr. Dewey Pate, the pathologist who performed Mabrey's autopsy. "The doctors were unsure of what they were dealing with, and he might have had a drug overdose."
While the charcoal was inappropriate treatment, it was harmless. The Department of Correction didn't know what treatment WakeMed delivered. Prison officials did not request Mabrey's WakeMed records until this past Wednesday.
At 5 a.m. Feb. 29, after eight days of care, Mabrey died of organ failure. The autopsy found that the sole cause of death was dehydration.
Nurses are disciplined:
Discipline came relatively swiftly for the nurses involved. In April, John Brown, the department's director of nursing, wrote that the incident must be reported to the N.C. Board of Nursing.
Since then, the board has suspended the licenses of four nurses and put permanent letters of reprimand in the files of two others. One nurse is contesting his suspension.
As the Board of Nursing investigated, prison officials conducted their own investigation.
Two registered nurses quit, and one was fired. The department placed the remaining three on nonclinical duty. One has returned to clinical care.
Although two of Mabrey's doctors have been terminated for other reasons since his death, none was reprimanded in his case.
Rosefield, the director of medical services for the Department of Correction, has a Ph.D. in education and oversees all prison medical services.
Rosefield said he didn't refer the case to the N.C. Medical Society because he is not a medical doctor. Instead, he let the doctor in charge of Mabrey's care make the call.
"I referred that decision to the senior medical doctor on the staff, who was Doctor Baloch," Rosefield said. "That was the best clinical guidance I could get."
Dr. Mohammad Baloch was medical director at Central Prison at the time and supervised Zaman and Rees. Although Baloch did not treat Mabrey, he was listed as his attending physician when Mabrey was admitted to Room 333 from the emergency room.
"It should have been reported to the medical board," said Jarvis, the state correction secretary.
Baloch declined to discuss Mabrey's case, as did Zaman and Rees and five of the six nurses disciplined by the Nursing Board.
In November 1996, Pohlman joined the Department of Correction as medical director, the system's top clinical post. After reviewing Mabrey's case, she referred it to the N.C. Medical Board in January 1997.
The board subpoenaed Mabrey's medical files Jan. 13 but has taken no action.
In the months after Mabrey's death, his family tried unsuccessfully to find out what had happened. They had no idea how he died until contacted by a reporter.
"I called the prison hospital and asked what happened," said his sister Judy Mabrey. "They said we cannot release that information. I got a stone wall at Central Prison."
FEB. 21, 1996
Mabrey admitted to Central Prison's mental health facility. Described as "acutely psychotic." Repeating word "raisins."
Described as out of control and put in restraints for four hours. Forced to take anti-psychotic medication.
Floods cell. Water cut off to cell about 5 a.m. Starts banging head against door; put in restraints for four hours.
Rambling and screaming throughout the night that staff would kill him.
Asks for water at 6 a.m. and then refuses it. Drinks three six-ounce glasses of water an hour later.
Very unstable. Involuntary medication continued. Taken out of cell, given shower. Water remains off in cell.
- 9 a.m.: Doctor examines Mabrey and orders water back on in cell.
- 1 p.m.: Sent to Central Prison hospital emergency room unconscious.
- 3 p.m.: Nurse gets lab report that indicates significant abnormalities with blood tests but doesn't inform doctor.
- 4 p.m.: Awakens after two liters of IV fluid. Third liter of IV fluid never started, despite doctor's orders.
- 7 p.m.: Second lab report phoned in, indicating kidney failure and life-threatening levels of sodium in bloodstream. Nurse does not inform doctor.
- 9 p.m.: Moved back to isolation cell instead of hospital ward. Nurse supervisor does not read chart or take vital signs.
- Overnight: Licensed practical nurse checks on Mabrey by kicking door and shining flashlight through door every 30 minutes but never enters cell or checks vital signs.
- 8:15 a.m.: Doctor finds Mabrey unconscious and orders him moved to prison hospital emergency room.
- 10 a.m.: Transferred by ambulance to WakeMed. Acting on little information, emergency room doctors treat him for possible drug overdose, among other things.
- 5 a.m. Pronounced dead