IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

)

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HN-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD

)

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, BILLY MITCHEM,

)

Warden of Limestone Correctional Facility,

)

DAVID WISE, Deputy Warden,

)

)

Defendants.

)

------------------------------------)

CIVIL ACTION No. CV-02-BE-2812-W CLASS ACTION

MOTION FOR AN ORDER TO SHOW CAUSE WHY DEFENDANTS SHOULD NOT BE HELD IN CONTEMPT

Plaintiffs, the present and future HIV infected prisoners at the Limestone Correctional

Facility ("Limestone") in Harvest, Alabama, move this Court to enter an Order to Show Cause

why defendants should not be held in civil contempt for their failure to comply with numerous

provisions of the Settlement Agreement (DOC #159) in this case. Ten months since the parties

signed the Settlement Agreement on April 29, 2004, and eight months since the Order adopting

the Settlement Agreement on June 26,2004 (DOC #165), and the defendants' innumerable

assurances to this Court that during the course of this litigation the "DOC was making

1

improvements" in the medical care and housing provided to HIV prisoners, compliance with the
provisions of the Agreement is no more closer than the day the document was signed. I
Defendants' inactions not only threaten the health and endangers the lives of the
I In their Briefin Opposition to Fees/Expenses, defendants assured this Court that the Alabama Department of Corrections was enacting needed changes in the medical care for HIV prisoners at Limestone, or had implemented changes in the contract with the newly contracted medical provider. In their Briefin Opposition to Fees/Expenses, the defendants asserted:
However, as pointed out by the court in Reedy, the desirable settlement was the result, just as importantly, of the circumstances of the case: namely, light opposition from the Commissioner of Corrections, who voluntarily stepped in and drastically changed the housing arrangements, terminated an inadequate health care contractor and hired a competent one, and then agreed to a set of standards, many of which were already included in the new provider's contract, and were in process of implementation, and others which the DOC simply felt ought to be adopted and were perfectly willing to agree to.
See DOC # 173, Alabama Department of Corrections' Brief in Opposition to Fees/Expenses of $866,00, at 4. In their Opposition Brief, defendants' continued to assure this Court that they had hired a new, "competent" medical provider to provide adequate medical care to HIV prisoners:
These defendants do not deny that there were constitutional inadequacies, but, as· hereafter related in more detail, the defendants themselves began a self study which became an important basis for the plaintiffs' lawsuit, the defendants themselves drastically changed the housing arrangements, fired the inadequate health care provider and replaced it with a competent one, and voluntarily entered into a satisfactory settlement of this case.
Id. at 5 (emphasis in original).
Yet, these assurances of change in the medical care for HIV prisoners did not cease there. In fact, the defendants indicated to this Court that most of the. provisions in the Settlement Agreement were going to be "voluntarily followed even without litigation." Id. at 7-8 ("There was simply no reason to subject the taxpayers to the fees and costs of litigating over a set of standards, most of which would be voluntarily followed even without litigation."). Nevertheless, since the inception of the Settlement Agreement, the defendants have woefully failed to comply with the terms of the Settlement Agreement. Defendants have misled this Court and they have misled us.
2

plaintiffs, but breaches their commitment to this Court who has expended considerable time,
attention, and effort to attempt to ensure that HIV infected prisoners are provided minimal medical care and housing guaranteed by the Eighth Amendment of the United States Constitution.
In support of this Motion, plaintiffs submit the Quarterly Reports from the neutral
medical consultant -- Dr. Joseph Bick2, the letters of Dr. Valda M. Chijide, M.D., the former HIV
Specialist at Limestone3, and declarations from individual HIV prisoners at Limestone4• In
addition, plaintiffs state the following:
1. This civil rights case addresses the medical treatment and living conditions provided to the HIV prisoners confined at Limestone. On April 29, 2004, both parties in this case signed a comprehensive Settlement Agreement. On June 24,2004, this Court approved and entered an Order adopting the Settlement Agreement (DOC #165).
2. The Settlement Agreement provides a comprehensive process to informally resolve acts of noncompliance. The steps·include:
(1) first, upon any report or observation of noncompliance, the plaintiffs will submit a written description to the defendants addressing the noncompliant act;
(2) second, upon receiving the written complaint from the plaintiffs, the defendants will
2Dr. Joseph Bick's, the neutral medical consultant, Quarterly Reports are contained in Exhibits 5 and 6 to this Motion. Dr. Bick's appointment as the neutral medical consultant stems from section 26.1, page 15 of the Settlement Agreement and was endorsed and approved by this Court in an Order on June 24, 2004 (DOC #165). Among his court approved duties, Dr. Bick authors a written quarterly report following a one week on-site inspection and examination of all facets of the delivery of medical care to HIV and AIDS prisoners -- Plaintiffs -- at Limestone.
3Dr. Valda Chijide's letters are contained in Exhibits 8, 9, 10, and 11 to this Motion. 4HIV prisoner declarations are all contained in Exhibit 12 to this Motion.
3

have fifteen days to resolve the dispute; (3) thir~, !f after fifte~n days, the dispute has not been adequately resolved, the plaintiffs may petItIon the SpecIal Master for a finding of fact addressing noncompliance.5 See §§ 28.1,28.3, and 28.5 of Settlement Agreement, at 18 (DOC #159). Plaintiffs have pursued the informal resolution process described in the Agreement. Nevertheless, defendants have chosen not to participate in the process. 3. On December 20, 2004, plaintiffs notified defendants that they were in violation of numerous provisions of the Settlement Agreement including: gaps and delays in medication distribution (Id., § 7.1, at 6); waiting several months for routine checkups with the HIV Specialist (ld., § 5.1, at 5); not able to see the doctor for urgent medical needs (ld., § 3.4, at 3); newly arrived HIV prisoners are not being seen by the HIV Specialist when urgent medical needs are identified at intake (ld., § 11.2, at 8); broken windows in the HIV dorms (ld., § 19.1, at 12); inadequate responses to medical emergencies arising in the Health Care Unit (Id., § 3.4, at 3); and no treatment for HIV prisoners co-infected with Hepatitis C (Id., § 8.3, at 7).6 Defendants have never responded to these noncompliance issues. 4. On January 12, 2005, plaintiffs again notified defendants that they were in violation of
the Settlement Agreement.7 In the beginning of January 2005, Dr. Wyndol Hamer, the pnmary
physician at Limestone, left the facility. Plaintiffs notified defendants that Dr. Hamer's absence violated section 3.1 of the Settlement Agreement. See § 3.1 of Settlement Agreement (DOC
5See §§ 28.1-28.5 of Settlement Agreement. 6See Exhibit 1, letter from plaintiffs to defendants, dated December 20, 2004. 7See Exhibit 2, letter from plaintiffs to defendants, dated January 12,2005.
4

#159) ("An HIV Specialist and a medical doctor shall provide medical treatment at Limestone Correctional Facility.") (emphasis added). Defendants have never responded to these noncompliance issues.
5. On January 27, 2005, plaintiffs again notified defendants that they were violating numerous provision of the Settlement Agreement. Plaintiffs' notification was attached to a letter written by Dr. Valda Chijide, M.D., the HIV Specialist at Limestone. 8 Dr. Chijide's letter provided a detailed description of numerous acts of noncompliance by the defendants. Defendants have never responded to these noncompliance issues.
6. On February 1, 2005, plaintiffs yet again notified defendants that they were violating the provisions of the Settlement Agreement.9 Plaintiffs notified defendants that Dr. Chijide's placement on administrative leave without an adequately trained replacement, violated section 3.1 of the Agreement. See § 3.1 of Settlement Agreement, at 2-3 ("An HIV Specialist and a medical doctor shall provide medical treatment at Limestone Correctional Facility."). Defendants did not respond to this letter. In fact, defendants have never responded to any of the plaintiffs' noncompliant written complaints:
(1) letter of December 20,2004. See Exhibit 1; (2) letter of January 12, 2005. See Exhibit 2; (3) letter of January 27, 2005. See Exhibit 3; (4) letter of February 1, 2005. See Exhibit 4. 7. Some limited progress has been made at Limestone. Nevertheless, substantial and very
8See Exhibit 3, letter from plaintiffs to defendants, dated January 27,2005. 9See Exhibit 4, letter from plaintiffs to defendants, dated February 1, 2005.
5

serious medical care and housing problems exist which endanger the health, safety and lives of the HIV prisoners at Limestone. These problems include: (l) the absence of an HIV Specialist (§ 3.1 of Settlement Agreement, at 2-3); the absence ofa full time physician (§§ 3.1 and 3.7 of Settlement Agreement, at 3); the failure to treat HIV prisoners co-infected with Hepatitis C (§ 8.3 of Settlement Agreement, at 7); gaps in the provision of medication (§ 7.1 of Settlement Agreement, at 6); inadequate HIV prisoner access to outside specialist medical care (§ 4.4 of Settlement Agreement, at 4); and a shortage of nursing staff(§ 3.7 of Settlement Agreement, at 4). In each of these areas, defendants are violating the provisions of the Settlement Agreement. I. AREAS OF NONCOMPLIANCE
A. Healthcare Staff. 8. Section 3.1 of the Settlement Agreement states that "[A]n HIV Specialist and a medical doctor shall provide treatment at Limestone Correctional Facility ('Limestone')." The Defendants are in violation of section 3.1, one of the core provisions of the Agreement. Dr. Valda Chijide, the HIV Specialist at Limestone, was placed on administrative leave and subsequently resigned on February 8, 2005 as the HIV Specialist at Limestone stating: Pursuant to previous memos you have received and due to lack of organizational and administrative support from Prison Health Services as well as personal abuses I have received, I resign effectively immediately.lo Her position has not been replaced. Because Dr. Chijide was placed on administrative leave and then resigned, most HIV prisoners have not seen the HIV Specialist for two weeks or longer. In fact, the lengthy delays in not being examined by the HIV Specialist have caused many HIV
IOSee Exhibit 11, letter from Dr. Chijide dated January 31,2005. 6

prisoners to not be seen in confonnance with section 5.1 of the Settlement Agreement. II The physician positions at Limestone are understaffed which violates numerous provisions of the Agreement: section 3.1, pp. 2-3; section 3.7, p. 4.
9. Section 3.4 states that "[P]risoners shall not provide emergency medical treatment to other prisoners." Medical emergencies that arise in the Limestone Health Care Unit ("HCU"), are often first responded too by prisoner runners. The prisoner runners ask the HIV prisoner in need of medical treatment for a description of their symptoms. The prisoner runner then decides if the HIV prisoner needs to see a nurse. Prisoner runners do not have the necessary training to make these medical decisions. In his November 2004 report, Dr. Bick describes the system:
To call a nurse, the patients use the call system. Because the nurse is not actually in the infinnary, an officer or inmate must be relied upon to go get the nurse. In effect, inmates and correctional staff control access to nurses in the infinnary. See Exhibit 6, Dr. Joseph Bick November Report 2004, at the Information Concerning the Infirmary section. Such actions jeopardize the health, safety, and lives of HIV prisoners and violates the Settlement Agreement. 10. Section 4.2 states that all registered nurses and licensed practical nurses shall not make medical decisions outside the scope of their license. Decisions made outside the scope of a person's medical license threatens the health and lives of HIV prisoners at Limestone. 11. Section 3.7 requires that all staffing levels confonn to NCCHC P-C-07 (2003).

II

Section 5.1 states:

The HIV Specialist shall see all HIV infected prisoner at least quarterly, or more frequently as medically necessary, which will include: a history, physical examination, and evaluation of current CD4+ levels and viral load. All prisoners with AIDS shall be seen every sixty (60) days.

7

According to Dr. Bick's November report, medical staff at Limestone is understaffed and fails to comply with the provisions of the Settlement Agreement. See Exhibit 6, Dr. Joseph Bick November Report 2004, at section 3.7. ("Because of the intensity of the medical mission at Limestone, I do not believe that the existing physician and RNP staffing conforms to NCCHC p_ C-07.").
12. Section 4.4 of the Seftlement Agreement states that "[I]f Limestone lacks adequate resources for the medical treatment of an HN infected prisoner, then the prisoner shall be sent to an outside specialist in a timely manner." Defendants are in violation of section 4.4. For example, HN prisoners have not received physician ordered eye exams and EKG'S.12 Such inadequate access to outside medical specialists and emergency medical care jeopardizes the lives of the HN prisoners at Limestone.
B. HIV Medical Treatment at Limestone. 13. Section 5.1 of the Settlement Agreement requires the H1V Specialist to see all HIV prisoners at least quarterly, and sometimes more often if needed, and all AIDS prisoners every sixty days. Defendants continue to violate this provision of the Settlement Agreement. Dr. Bick's November 2004 report· indicates that HIV and AIDS prisoners are not seen by the HN Specialist within these time frames. See Exhibit 6, Dr. Bick's November 2004 report, at section 5.1. 14. Section 6.2 of the Settlement Agreement provides that: "All prisoners who have, or are suspected to have, contagious tuberculosis, shall be placed in respiratory isolation until they
12See Exhibit 12, Declaration of Paul Edwards, at 2 (received an order for an eye exam and EKG on December 5, 2004 and has not received either an eye exam or EKG as of February 10,2005)
8

[have] sic no longer pose a risk to the public health, especially to other HIV infected prisoners." Since this Settlement Agreement has gone into effect, defendants have never been in compliance with this provision. Not only does this violate the provisions of the Settlement Agreement, but it also threatens the health, safety, and lives of all of the HIV prisoners at Limestone, the medical staff, and correctional staff.
15. Section 6.3 of the Settlement Agreement requires defendants to implement treatment guidelines and minimize the spread of Methicillin Resistant Staphylococcus Aureus ("MRSA") among HIV prisoners at Limestone.13 HIV prisoners continue to receive inadequate treatment for MRSA infections. Moreover, HIV prisoners with MRSA have not been adequately isolated from the rest of the HIV popUlation to prevent or minimize a MRSA outbreak among the HIV prison popUlation at Limestone. 14
c. Medication Administration.
16. Defendants continue to violate section 7.1 of the Settlement Agreement. HIV prisoners are not provided their medication at the proper times or in the proper dosages as prescribed by the Food and Drug Administration ("FDA"). Many HIV prisoners have

13

Section 6.3 states:

Protocols shall be adopted to minimize the spread of Methicillin Resistant Staphylococcus Aureus ('MRSA') among the HIV infected prisoner popUlation at Limestone. The MRSA guidelines will address: (1) prevention, (2) examining and interviewing prisoners at intake and listing MRSA on a prisoner's "problem list" in their medical chart, (3) diagnosis and treatment, and (4) MRSA outbreak and control protocols.
14See Exhibit 12, Declaration of Terry Shelby (he has not received medical treatment for boils on his body), at 1-2; Declaration of Ronald Evans, at 1-3 (he experienced a delay in receiving medication to treat his infection and was taken off medical wash).

9

experienced dangerous gaps in receiving their antiretroviral medication and other life saving medication. IS In his February 2005 report, Dr. Bick provides an exhaustive list demonstrating dangerous gaps in the provision of life saving medication for 192 HN patients at Limestone. 16 Inadequate staffing to appropriately dispense medication is not an adequate explanation and violates section 3.7 of the Agreement.
17. Section 7.5 of the Settlement Agreement requires defendants to administer medication "to HIV prisoners in strict accordance with the prescriptions -- including directions relating to the timing ofHN medication administration in relation to food and water intake." As stated previously, defendants continue to violate this provision and fail to ensure that medication is properly dispensed to HN prisoners. 17
18. Section 7.3 of the Settlement Agreement states that defendants shall provide HIV prisoners with "clear written instructions for medication administration." Additionally, "[A]ll HIV medications shall be administered, and dispensing documented, consistent with FDA regulations." Several HN prisoners have not been provided clear, written instructions addressing their medication administration.
19. Section 7.8 of the Settlement Agreement requires defendants to keep medications on their medication formulary that are typically used to treat HIV infection, co-occuring illnesses,
15See Exhibit 12, Declaration of Terry Shelby, at 2 (every month, he has to wait one to two weeks to receive his medication); Declaration of David Keith, at 1-4 (has received his HIV medication, anti-seizure medication, or diarrhea medication inconsistently); Declaration of Richard Berry, at 1 (upon arriving at Limestone, he did not receive his HN medication for three days)
16See Exhibit 7, Dr. Joseph Bick February 2005 report, at Attachment C.
17Id.
10

and opportunistic infections. Defendants have violated this provision. An inability to timely receive essential HIV and other life saving medications threatens the health and lives of the HIV prisoners.
D. Hepatitis C Treatment. 20. Since the adoption of this Settlement Agreement, defendants have never been in compliance with section 8.3. 18 In his November 2004 report, Dr. Bick identified several HIV prisoners who may qualify for Hepatitis C treatment. In his February 2005 report, Dr. Bick identified thirty-four additional HIV prisoners who would qualify for Hepatitis C treatment. 19 Several HIV prisoners have been informed that there is no medical treatment being provided to prisoners co-infected with HIV and Hepatitis C.20 Since the adoption of the Settlement Agreement, no HIV patients at Limestone have received Hepatitis C treatment. E. Food. 21. Section 9.5 of the Settlement Agreement requires defendants to provide dietary supplementation and medications for HIV prisoners experiencing wasting. Defendants have failed to comply with this provision. Numerous HIV prisoners experience difficulties receiving

18

Section 8.3 states:

Treatment of HIV infected prisoners with Hepatitis C shall conform to Baker, et. aI. v. Campbell. et. aI., settlement agreement dated _, 2004. HIV infected prisoners with symptoms of liver dysfunction and who have a negative HCV antibody test, shall be administered an HCV PCR test, as medically indicated.
19See Exhibit 7, Dr. Joseph Bick February 2005 report, at Attachment A.
20See Exhibit 12, Declaration of Paul Edwards, at 1-2 (has been informed that no one is receiving Hepatitis C treatment).

11

Resource and other dietary supplementation needed to prevent wasting. 21 F. Medical Emereencies. 22. Section 10.4 of the Settlement Agreement states that during medical emergencies, all
medical decisions will be made by an on-site, on-duty medical person. Recently, medical emergency decisions have been made by an off-site physician, Dr. Willard Mosier, located in Montgomery, Alabama. While in Montgomery, Dr. Mosier has overruled emergent medical care ordered by the on-site HIV Specialist at Limestone. Such actions by an off-site physician violate section 10.4 of the Settlement Agreement and threaten the lives of HIV prisoners at Limestone.
G. Intake at Limestone. 23. Section 11.2 of the Settlement Agreement states: "Within two weeks of arriving at Limestone, the HIV infected prisoners shall be seen by the HIV Specialist or mid-level provider." Newly arriving HIV prisoners have not been seen by the HIV Specialist or mid-level provider within two weeks, several weeks, or even several months. 22 24. Section 11.3 states that if a newly arriving HIV prisoner can identify their medication upon entering Limestone, that patient will be provided their medication and there shall not be any unnecessary interruptions in the continuity of their medication. As indicated in Dr. Bick's November 2004 report, numerous, newly arriving HIV prisoners have experienced lengthy gaps
21See Exhibit 12, Declaration of earl Smith, at 1-2 (has inconsistent access to Resource and has lost a lot of weight).
22See Exhibit 6, Dr. Joseph Bick November 2004 report, at section 11.2 ("Often HIV infected arrivals in September, 4/1 0 were not seen by an MD as of 11/16/04. An additional 111 0 September arrival was not seen until 10/20/04. In total 50% were not seen within two weeks o[ f] arrival.") ; see also Declaration of Richard Berry, at 2 (after entering Limestone, he did not see a physician for approximately three months.)
12

in their medication.23 H. Dental Services. 25. Section 14.2 of the Settlement Agreement states: "All HIV infected patients shall
have access to prophylactic dental hygiene; which include dental cleanings, at least annually." HIV prisoners in need of outside dental specialist care, not available at Limestone, have been unable to access the necessary care.24 The inability to access necessary outside specialist dental care causes unnecessary pain and suffering.
I. Complaint and Grievance Process. 26. Section 17.3 of the Settlement Agreement requires that defendants shall respond to informal grievances within seventy-two (72) hours, and formal grievances within five (5) days. Defendants fail to respond to complaint and grievance forms in accordance with the Agreement. J. Housioe. 27. Section 19.1 of the Settlement Agreement provides in part that the physical condition of the buildings used to house HIV prisoners shall be maintained in good working order. The housing used to confine HIV prisoners is not maintained in good working order. Windows remain broken and are not replaced. Instead, staff covers the windows with tape and plastic. Though a temporary solution, the tape and the plastic fall off. Such temporary measures to cover broken windows does not comply with the "good working order" provisions of section 19.1.
23See Exhibit 6, Dr. Joseph Bick November 2004 report, at section 11.3 ("Of 5 new arrivals on 11/16/04, four were on medications at the time of transfer. These inmates all arrived from Kilby at -- 10:30 am. 4/5 missed at least one dose of meds upon arrival at Limestone."); see also Declaration of Richard Berry, at 1 (upon arriving at Limestone, he did not receive his HIV medication for three days.)
24See Exhibit 12, Declaration of Jonathan Sexton, at 1-3. 13

28. Section 19.3 of the Settlement Agreement requires defendants to conduct rodent and pest control on a monthly basis, or as needed. Rats in examination rooms and housing units unnecessarily expose HIV prisoners to potentially dangerous diseases and infections. See Exhibit 8, letter from Dr. Valda Chijide dated January 26, 2005, page 10 ("One day while evaluating an inmate in dorm 7, a rat ran across the exam room floor...[R]ats can carry diseases which can sometimes spread to humans.").
K. Release From the Department of Corrections. 29. Section 22.3 of the Settlement Agreement states that prior to being released into the community, HIV prisoners will be provided appropriate discharge planning. Defendants have failed to provide appropriate discharge planning for HIV prisoners being released from Limestone. L. Dr. Dick's February 2005 Quarterly Report. 30. In his February 2005 audit, Dr. Bick found continued noncompliance with core provisions of the Settlement Agreement. Indeed, the defendants remain in violation of the core provisions of the Agreement including: sections 2.1. and 2.2 (the standard of care shall be consistent with National Commission on Correctional Healthcare and Centers for Disease Control guidelines); section 2.3 (the provision of treatment that is "medically necessary"); and section 3.4 (an HIV Specialist). II. RELIEF REQUESTED For all of the reasons stated above, plaintiffs request that this Court issue an Order to Show Cause Why Defendants Should Not Be Held in Contempt. A proposed Order is attached to this Motion. If defendants dispute any factual matters set forth in this Motion, plaintiffs request
14

that the Court order defendants to identify such disputed items and set an evidentiary hearing for their resolution.
Upon a finding that defendants are in contempt for their violations of the Settlement Agreement, plaintiffs will seek the following relief:
(1) an Order by this Court requiring defendants to comply immediately with all terms of the Settlement Agreement;
(2) a schedule of per diem monetary sanctions for future violations of the Settlement Agreement;
(3) toll the two (2) year statute of limitations until defendants are in substantial compliance with the Settlement Agreement while Dr. Joseph Bick's quarterly visits continue, or in the alternative, issue an Order nunc pro tunc tolling the two year statute of limitations from the date of the Order adopting the Settlement Agreement since the defendants have never complied with the Agreement;
(4) an award of reasonable attorney's fees and costs to plaintiffs; and (5) such additional relief as the Court may deem just and necessary.
Respectfully submitted this _ day February, 2005.
Southern Center for Human Rights Miss. Bar. No.: 101399 83 Poplar Street, N.W. Atlanta, Georgia 30303 Telephone: 404/688-1202
15

Facsimile: 404/688-9440
GRETCHEN N. ROHR Holland & Knight, LLP GA Bar No: 613518 1201 West Peachtree St NW Atlanta, GA 30309 Telephone: 404/898-8177 Facsimile: 404/881-0470
DAVID M. LIPMAN David M. Lipman, PA FLBarNo: 280054 5901 S.W. 74 Street Suite: 304 Miami, Florida 33143-5186 Telephone: 305/662-2600 Facsimile: 305/6673361
FRANCIS A. ANANIA FL Bar No: 160256 Anania, Bandklayder, Blackwell, Baumgarten Nations Bank Tower Suite: 4300 100 S.E. 2nd Street Miami, Florida 33131-2144 Telephone: 305/373-4900 Facsimile: 305/373-6914
STEPHEN HANLON FL Bar No: 209430 Holland & Knight LLP 2099 Pennsylvania Ave, N.W. Suite 100 Washington, D.C. 20006-6801 Telephone: 202/828-1871 Facsimile: 202/955-5564
Attorneys for Plaintiffs
16

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

)

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HIV-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD

)

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, BILLY MITCHEM,

)

Warden of Limestone Correctional Facility,

)

DAVID WISE, Deputy Warden,

)

)

Defendants.

)

----------------------------------)

CIVIL ACTION No. CV-02-BE-2812-W CLASS ACTION

CERTIFICATE OF SERVICE

I hereby certifthat on February 17, 2005, I electronically filed the foregoing with the

Clerk of Court using the CM/ECF system which will send notification of such filing to the

following: Albert Butler, Esq., Attorney for the Defendants Donal Campbell, Ronald

Cavanaugh, Billy Mitchem, 101 South Union Street, P.O. Box 301501, Montgomery, Alabama 36130-1501.

Respectfully submitted,
s/Joshua R. Lipman Joshua R. Lipman

The Southern Center for Human Rights Miss. Bar No.: 101399 83 Poplar Street, N.W. Atlanta, Georgia 30303-2122 Telephone: 404/688-1202 Facsimile: 404/688-9440 E-mail: ilipman@schr.org

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

)

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HIV-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD

)

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, BILLY MITCHEM,

)

Warden of Limestone Correctional Facility,

)

DAVID WISE, Deputy Warden,

)

)

Defendants.

)

------------------------------~--)

CIVIL ACTION No. CV-02-BE-2812-W CLASS ACTION

MEMORANDUM OF LAW IN SUPPORT OF PLAINTIFFS' MOTION FOR AN ORDER TO HOW CAUSE WHY
DEFENDANTS SHOULD NOT BE HELD IN CONTEMPT

Plaintiffs, by counsel, submit this Memorandum of Law in support of their Motion for an

Order to Show Cause Why Defendants Should Not Be Held in Contempt. Plaintiffs request that

this Court order Defendants to show cause, why they should not be held in civil contempt for their

failure to comply with numerous provisions of the Settlement Agreement. I. PURPOSE

Federal courts have the inherent power to enforce their lawful orders through civil

1

contempt proceedings. Spallone v. United States, 493 U.S. 265, 276 (1990); Young v. United States, 481 U.S. 787, 793 (1987); Michaelson v. United States, 266 U.S. 42,65-66 (1924); see also Reynolds v. McInnes, 338 F.3d 1201, 1208 (11 th Cir. 2003) ("In Reynolds II, we emphasized that consent decrees, like all injunctions, are to be enforced through the trial court's civil contempt power."). This Court retains jurisdiction to impose contempt sanctions against defendants because defendants are parties of record to the Settlement Agreement, and because contempt proceedings are a continuation of the original proceedings. Leman v. Krentler-Amold Hinge Last Co., 284 U.S. 448, 452 (1932).
Contempt proceedings are convened to determine whether obligations established by a court order are being discharged by those responsible for doing so. Newman v. Graddick, 740 F.2d 1513,1524 (11th Cir. 1984). The question presented therefore is not whether the present conditions arise to a constitutional violation -- indeed plaintiffs submit that they do -- but rather, this Court need only determine whether Defendants are complying with the specific terms of the Settlement Agr.eement.l "Whatever may have been the understanding for proving a constitutional violation at the time of the decree, they all agreed on a course of conduct. .." Sarabia v. Toledo Police Patrolman's Ass'n, 601 F.2d 914,919 (6th Cir. 1979).
By filing a Motion for an Order to Show Cause, Plaintiffs seek civil contempt sanctions with the goal of coercing Defendants into full compliance with the Settlement Agreement, or else
l"A consent decree or order is to be construed for enforcement purposes basically as a contract. .." United States v. ITT Continental Baking Co. 420 U.S. 223, 238 (1 ~75); see also Reynolds v. McInnes, supra, at 1211 ("We apply the same rules that govern contract interpretation when we interpret a consent decree, because a consent decree is essentially a form of contract."). Therefore, this Court should address defendants' compliance within the four corners of the Settlement Agreement. Id.
2

remedying Plaintiffs' injuries caused by their noncompliance. See Blalock v. United States, 844
F.2d 1546, 1550 (11 th Cir. 1988). "It is well-settled that sanctions in civil contempt proceedings
may be employed to coerce a contemnor into compliance with the court's order, and/or to
compensate a complainant for losses sustained." Martin v. Guillot, 875 F.2d 839, 845 (11 th Cir.
1986); see also Bush Ranch v. E.!. DuPont de Nemoyrs R. Co., 99 F.3d 363,368 (11th Cir.
1996)(same). As the Supreme Court recognized, civil contempt sanctions are "designed to
compel future compliance with a court order, are considered to be coercive and avoidable
through obedience, and thus may be imposed in an ordinary civil proceeding upon notice and an
opportunity to be heard." International Union, United Mine Workers of America v. Bagwell, 512
U.S. 821, 827 (1994).
II. PROCESS
In Mercer v. Mitchell, 908 F.2d 763 (11 th Cir. 1990), the Eleventh Circuit outlined a
model proceeding to be followed in civil contempt actions:
Every civil contempt proceeding is brought to enforce a court order that requires the defendant to act in some defined manner. The defendant then allegedly acts, or refuses to act, in violation of the order. The plaintiff would like the defendant to obey the court order and requests the court to order the defendant to show cause why he should not be held in contempt and sanctioned until he complies. If the court finds that the conduct as alleged ~ould violate the prior order, it enters an order requiring the defendant to show cause why he should not be held in contempt and conducts a hearing on the matter.
At the hearing, the defendant is allowed to show either that he did not violate the court order or that he was excused from complying. Typically, a defendant will argue . that he should not be held in contempt because changed circumstances would make strict enforcement of the order unjust. In such a case, the defendant should move the court to modify the order, and the hearing on the show-cause order would take on the appearance of a hearing on a motion to modify the injunction. If the court determines that the order should be modified and that the defendant's conduct did not violate the order as modified, then ordinarily it would be unjust to hold the defendant in contempt. If, however, the court concludes that the order should not be modified and that the defendant did not
3

comply with the order, then the court may hold him in contempt and impose sanctions designed to ensure compliance. Thus, the typical proceeding satisfies the two essential requirements of due process: notice and hearing. Id. at 768 (citations omitted); see also Chairs v. Burgess, 143 F.3d 1432, 1436 (11 th Cir. 1998). In their Motion to Show Cause, Plaintiffs have provided Defendants with ample notice of their alleged non-compliance with the Settlement Agreement. Plaintiffs allege that Defendants have violated section 3.1 (HIV Specialist and general physician staffing), section 3.4 (prisoners providing emergency medical treatment), section 4.2 (nurses making medical decisions outside the copse of their license), section 3.7 (medial staffing), section 4.4 (referral to outside medical specialists), section 5.1 (periodic evaluations of HIV and AIDS prisoners by the HIV Specialist), section 6.2 (treatment ofHIV prisoners with tuberculosis), section 6.3 (protocols for treatment of Methicillin Resistant Staphylococcus Aureus ("MRSA"), section 7.1 (proper provision of medication), section 7.5 (administer medication with food and water as prescribed), section 7.3 (clear instructions provided to HIV prisoners addressing medication provision), section 7.8 (medication formulary), section 8.3 (hepatitis C treatment), section 9.5 (dietary supplementation), section lOA (medical emergencies), section 11.2 (newly arrived HIV prisoners seeing the HIV Specialist), section 11.3 (medication provision to newly arrived HIV prisoners), section 14.2 (prophylactic dental hygiene), section 17.1 (complaint and grievance process), section 19.1 (physical condition of housing for HIV prisoners), section 19.2 (rodent and pest control), and section 22.3 (discharge planning). Following the Eleventh Circuit's analysis in Mercer, supra, defendants are entitled to an opportunity to show why they are not in violation of the Consent Order. See Chairs v. Burgess, 143 F.3d 1432,1436 (11th Cir. 1998) (Once the prima facie showing ofa violation is made, the
4

burden then shifts to the alleged contemnor 'to produce evidence explaining noncompliance' at a 'show cause' hearing.") (quoting Citronelle-Mobile Gathering, Inc. v. Watkins, 943 F.2d 1297, 1301 (11 th Cir. 1991). If the defendants dispute any of the factual allegations made in plaintiffs' Motion for an Order to Show Cause, the Court may order an evidentiary hearing on those factual matters. Plaintiffs are prepared to prove the above-listed violations of the Consent Order by clear and convincing evidence at a show cause hearing. See United States v. Hayes, 722 F.2d 723,725 (11th Cir. 1984). If the defendants do not dispute plaintiffs' factual allegations, the Court may properly dispense with a hearing prior to finding defendants in contempt. Mercer, 908 F.2d at 769 n. 11.
At a show cause hearing, defendants will not be able to rely on their subjective beliefs or intent as defenses to noncompliance. See Howard Johnson Co. v. Khimani, 892 F.2d 1512, 1516 (11 th Cir. 1990); Doe v.Bush, 261 F.3d 1037, 1047 (11 th Cir. 2001); Newman v. Graddick, 740 F.2d 1513,1524 (11th Cir. 1984). As the Supreme Court has explained:
The absence of willfulness does not relieve from civil contempt. Civil as distinguished from criminal contempt is a sanction to enforce compliance with an order of the court or to compensate for losses or damages sustained by reason of non-compliance....Since the purpose is remedial, it matters not with what intent the defendant did the prohibited act. McComb v. Jacksonville Paper Co., 336 U.S. 187, 191 (1949) (citations omitted); see also Wright & Miller, Federal Practice and Procedure CriminaI3rd., § 705 ("Willfulness is not a necessary element of civil contempt."). III. RELIEF Upon a finding that defendants are in contempt, plaintiffs will seek injunctive relief and monetary sanctions that are narrowly tailored to each violation of the Settlement Agreement but
5

nevertheless sufficient to coerce defendants into full compliance. This Court has substantial equitable power to address and remedy defendants' present non-compliance.
When considering the type of injunctive relief to coerce the defendants into full compliance, this Court "must consider the character and magnitude of the harm threatened by the continued contumacy, and the probable effectiveness of any suggested sanction in bringing about the result desired." United States v. United Mine Workers of America, 330 U.S. 358, 304 (1947); see also Reynolds v. Alabama Department of Transportation, 10 F.Supp. 2d 1263, 1278 (M.D. Ala. 1998) (same). In this case, the "magnitude of the harm" caused by continued noncompliance by the defendants with this Court's Order, is the persistent, unabated violation of the plaintiffs' Constitutional rights and the continued threatening of the health and lives of the plaintiffs. Plaintiffs therefore request that this Court suspend the two year time period of the Settlement Agreement pending substantial compliance by the defendants, or in the alternative, Order nunc pro tunc the tolling of the two year time period to the date of the Order adopting the 8..ettlement Agreement. Since the signing of the Agreement, nine months ago, defendants have not been in compliance with the terms of the Agreement. The injunctive relief requested is warranted to prevent the defendants from remaining noncompliant throughout the two year term of the Agreement without ever complying with the Agreement's terms. Indeed, plaintiffs have yet to realize the provisions of the Agreement or their Constitutional rights.
Finally, upon a finding that defendants are in civil contempt of the Settlement Agreement, plaintiffs will seek reasonable attorney's fees and costs. Federal courts have discretion to award such fees and costs in contempt proceedings, even where the contemptuous conduct was not willful. Sizzler Family Steak House v. Western Sizzlin Steak. Inc., 793 F.2d 1529, 1535-36 (lIth
6

Cir. 1986). IV. CONCLUSION
In conclusion, defendants continue to violate some of the most important and fundamental aspects of the Settlement Agreement in this case. Defendants have been put on notice of their non-compliance by plaintiffs' counsel. Their defiance of this Court's Settlement Agreement is endangering the health and lives of the HIV prisoners at Limestone. Plaintiffs
therefore respectfully request that the Court order defendants to show cause why they should not be held in civil contempt.
A,
Respectfully submitted this r1 'day February, 2005.

y -"~''''"~'

," ,"' \

I

t1

"-

1I"'r----- BY: JOSH,U',,A--/R\Jy:xhRl~f~( ~

Southern Center for Human Rights

Miss. Bar. No.: 101399

83 Poplar Street, N.W.

Atlanta, Georgia 30303

Telephone: 404/688-1202

Facsimile: 404/688-9440

GRETCHEN N. ROHR Holland & Knight, LLP GA Bar No: 613518 1201 West Peachtree St NW Atlanta, GA 30309 Telephone: 404/898-8177 Facsimile: 404/881-0470

DAVID M. LIPMAN David M. Lipman, PA FL Bar No: 280054 5901 S.W. 74 Street

7

Suite: 304 Miami, Florida 33143-5186 Telephone: 305/662-2600 Facsimile: 305/6673361 FRANCIS A. ANANIA FL BarNo: 160256 Anania, Bandklayder, Blackwell, Baumgarten Nations Bank Tower Suite: 4300 100 S.E. 2nd Street Miami, Florida 33131-2144 Telephone: 305/373-4900 Facsimile: 305/373-6914 STEPHEN HANLON FL Bar No: 209430 Holland & Knight LLP 2099 Pennsylvania Ave, N.W. Suite 100 Washington, D.C. 20006-6801 Telephone: 202/828-1871 Facsimile: 202/955-5564 Attorneys for Plaintiffs
8

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

future HIV-positive inmates in the Limestone

Correctional Facility in Capshaw, Alabama,

Plaintiffs,

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD

)

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, BILLY MITCHEM,

)

Warden of Limestone Correctional Facility,

)

DAVID WISE, Deputy Warden,

)

)

Defendants.

)

-----------------------------------)

CIVIL ACTION No. CV-02-BE-2812-W CLASS ACTION

CERTIFICATE OF SERVICE

I hereby certifthat on February 17, 2005, I electronically filed the foregoing with the

Clerk of Court using the CM/ECF system which will send notification of such filing to the

following: Albert Butler, Esq., Attorney for the Defendants Donal Campbell, Ronald

Cavanaugh, Billy Mitchem, 101 South Union Street, P.O. Box 301501, Montgomery, Alabama

36130-1501.

Respectfully submitted,
s/Joshua R. Lipman Joshua R. Lipman

The Southern Center for Human Rights Miss. Bar No.: 101399 83 Poplar Street, N. W. Atlanta, Georgia 30303-2122 Telephone: 404/688-1202 Facsimile: 404/688-9440 E-mail: iliptnan@schr.org

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

)

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HIV-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD

)

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, BILLY MITCHEM,

)

Warden of Limest~ne Correctional Facility,

)

DAVID WISE, Deputy Warden,

)

)

Defendants.

)

----------------------------------)

CIVIL ACTION No. CV-02-BE-2812-W CLASS ACTION

ORDER TO SHOW CAUSE WHY DEFENDANTS SHOULD NOT BE HELD IN CONTEMPT

THIS CAUSE has come before the Court on Plaintiffs' Motionfor an Order to Show

Cause Why Defendants Should Not Be Held in Contempt. The Court having reviewed and

considered Plaintiffs' motion, it is hereby GRANTED.

ORDERED AND ADJUDGED

(1) The Defendants in this case will SHOW CAUSE, if there be any, WHY THEY

SHOULD NOT BE HELD IN CONTEMPT OF COURT for their failure to comply with the

1

Settlement Agreement approved and entered by this Court. If defendants dispute plaintiffs' factual assertions, they are ORDERED to appear in person at a hearing in front of the Special Master, Magistrate Judge John Ott, to be set by separate order. This process is contemplated by the Settlement Agreement (DOC#159), section 28.5, page 16 ("If after 15 days, the dispute has not been adequately resolved, then the Plaintiffs may petition the Special Master to make findings of fact addressing noncompliance, in accordance with 18 U.S.C. § 3626(f)(l)(A).")
DONE AND ORDERED in Birmingham, Alabama this _ day of _ _ _ _ __ 2005.

cc:counselofrecord

JOHNE. OTT UNITED STATES MAGISTRATE JUDGE

2

 
 Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 1 of 43

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALAB~~PR -2 PH 3: 31

WESTERN DIVISION

", _i. GIS f f\lCi" COURT

)

N.D. OF ALABAHA

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HIV-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

CIVIL ACTION

v.

)

)

No. CV-02-BE-2812-W

)

DONAL CAMPBELL, Commissioner of the

)

CLASS ACTION

Alabama Department of Corrections, RONALD )

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, NAPHCARE, INC, )

healthcare provider for the Alabama Department )

of Corrections, JAMES FRANCIS DELONG,

)

Medical Director of NaphCare, Inc., BILLY

)

MITCHEM, Warden of Limestone Correctional )

Facility, DAVID WISE, Deputy Warden,

)

)

Defendants.

)

--------------------------------- )

SECOND AMENDED COMPLAINT

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 2 of 43
I. INTRODUCTION 1. In this civil rights action, plaintiffs consist of a class oflllV-positive male inmates, who are now or will be incarcerated in the future at Limestone Correctional Facility ("Limestone") in Capshaw, Alabama. Plaintiffs challenge the inhumane and unconstitutional medical treatment and inhumane living conditions. Due to inadequate medical treatment and deplorable living conditions, the Limestone lllV-positive inmates are exposed and are more susceptible to various illnesses and infections. These illnesses and infections cause needless pain and suffering. Indeed, these illnesses and infections are potentially life threatening to an lllVpositive person. 2. The Defendants - the Commissioner of the Alabama Department of Corrections, the Director of Treatment for the Alabama Department of Corrections, the Limestone Security and Medical Staff, and NaphCare, Inc. - have demonstrated deliberate indifference toward the medical care of lllV-positive inmates at Limestone. In fact, the Defendants have failed to provide even a minimal level of acceptable medical treatment and living conditions that would limit exposure to serious illnesses and infections, including: (1) failing to provide a safe medical and living environment which has fostered a disproportionate number of deaths; (2) failing to adequately document the causes of deaths among the lllV-positive inmate population; (3) failing to provide adequate medical treatment in chronic care situations; (4) failing to properly dispense medication; (5) failing to provide a competent nursing staff that monitors and can provide a prompt response to address and treat lllV-related emergencies; and (6) failing to provide a
2

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 3 of 43
reasonably safe and healthy living environment for mv-positive inmates. I
3. Since the filing of the original complaint, Roger Childers, Jacqueline Moore and Larry Mendel -- representing a private company called Moore and Associates -- conducted an audit addressing the HIVIAIDS medical treatment at Limestone. Pursuant to the contract between the Alabama Department of Corrections and NaphCare, Inc., the audit assessed the performance of NaphCare. See Attachment 1, § 7.6, pg. 51. ("To evaluate and assess that all standards are being met and that Contractor is in full compliance with the contract, DOC may employ, at its own expense, the services of a Contract Monitor.") Consistent with the Department of Corrections and NaphCare contract, Moore and Associates act under the auspices of and are "accountable" to the Alabama Department of Corrections. Id. Therefore, Moore and Associates acts independently of NaphCare. See Attachment 1, § 7.6(1); pg. 52. ("Contract Monitor shall operate independently of Contractor and shall be directly accountable to DOC.") Upon completion of the audit, Moore and Mendel issued a written audit evaluating NaphCare's provision of medical treatment to lllV-positive inmates at Limestone. The audit report confirmed the factual allegations expressed in the initial complaint and concluded that: "The failure, or perceived failure to provide access to sufficient care for this population will invite further controversy and potential litigation." See Attachment 2, Audit Report II, pg. 3.
4. The denial of adequate medical treatment and adequate living conditions violates the rights of Limestone lllV-positive inmates under the Eighth and Fourteenth Amendments to the United States Constitution. On behalf of themselves and all other lllV-positive inmates confined
IAll HIV-positive male inmates confined in the Alabama Department of Corrections, have been segregated to Dorm 16, specified cells in Dorm 7, and specific areas of the Health Care Unit at Limestone.
3

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 4 of 43
to Limestone in the future, the Plaintiffs seek preliminary and permanent injunctive relief and declaratory relief.
II. JURISDICTION 5. This Court has jurisdiction over plaintiffs' claims pursuant to 28 U.S.C. §1331 and §1343(a)(3), and the United States Constitution. 6. This court is authorized to grant declaratory and injunctive relief under 28 U.S.c. § 2201 and § 2202.
III. VENUE 7. The Northern District of Alabama is an appropriate venue for this action under 28 U.S.c. § 1391 (b)(1) because the defendants in their official capacity reside in the district. The Northern District of Alabama is also an appropriate venue under 28 U.S.C. § 1391(b)(2) because the events giving rise to plaintiffs' claims have occurred and are occurring in the District.
IV. PARTIES A. Plaintiffs
8. Plaintiff Antonio Leatherwood is HIV-positive. Currently, Leatherwood is incarcerated at Limestone. During his incarceration at Limestone, Leatherwood has not received adequate medical treatment and has been denied adequate living conditions.
9. Plaintiff Eric Howard is HIV-positive. Currently, Howard is incarcerated at Limestone. During his incarceration at Limestone, Howard has not received adequate medical treatment and has been denied adequate living conditions.
10. Plaintiff Jerry Sanford is HIV-positive. Currently, Sanford is incarcerated at Limestone. During his incarceration at Limestone, Sanford has not received adequate medical
4

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 5 of 43
treatment and has been denied adequate living conditions. 11. Plaintiff John Levins is HIV-positive. Currently, Levins is incarcerated at Limestone.
During his incarceration at Limestone, Levins has not received adequate medical treatment and has been denied adequate living conditions.
12. Plaintiff Michael Patrick is HIV-positive. Currently, Patrick is incarcerated at Limestone. During his incarceration at Limestone, Patrick has not received adequate medical treatment and has been denied adequate living conditions. B. Defendants
13. Defendant Donal Campbell is the Commissioner of the Alabama Department of Corrections. As Commissioner, Campbell is responsible for the daily functioning and administration of the entire Alabama Department of Corrections. Campbell is being sued in his official capacity as the Commissioner of the Alabama Department of Corrections.
14. Defendant Ronald Cavanaugh is the Director of Treatment for the Alabama Department of Corrections. As Director of Treatment, Cavanaugh is responsible for administering health and safety inspections of correctional facilities in the Alabama Department of Corrections and addressing health and safety issues that arise in the Department of Corrections. Cavanaugh is being sued in his official capacity as Director of Treatment for the Alabama Department of Corrections.
15. Defendant NaphCare, Inc. is a private company. NaphCare, Inc. has contracted with the State of Alabama to provide all necessary medical and mental health care services for all persons incarcerated in the Alabama Department of Corrections.
16. Defendant James Francis DeLong is the Medical Director for NaphCare, Inc. As
5

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 6 of 43

Medical Director of NaphCare, Inc., DeLong is responsible for establishing medical procedures

and policies for NaphCare, ensuring the quality of the services provided by NaphCare and its

employees, and overseeing the day-to-day administration of NaphCare.

17. Defendant Billy Mitchem is the Warden of Limestone Correctional Facility. As

Warden, Mitchem is responsible for the daily operations of the Limestone Correctional Facility.

Mitchem is also responsible for establishing policies and procedures and ensuring that the

Limestone correctional staff adheres to such policies and procedures. Mitchem is being sued in

his official capacity as Warden of Limestone Correctional Facility.

18. Defendant David Wise is the Deputy Warden of Limestone Correctional Facility. As

Deputy Warden, Wise is responsible for the daily operations of Limestone Correctional Facility.

Wise is being sued in his official capacity as Deputy Warden of Limestone Correctional Facility.

19. Since the filing of the original complaint, Plaintiff's medical expert has toured

Limestone and reviewed numerous HIV-positive inmate medical files. Through this process,

Collette Simon -- the Medical Director at the Limestone Correctional Facility -- has been deemed

a well-qualified physician for the treatment of HIV-positive and AIDS patients. This

determination was later confirmed in Audit Report II of the Limestone Correctional Facility

conducted on November 8,2002 by Jacqueline Moore and Larry Mendel of Moore and

Associates. See Attachment 2, Audit Report II, pg. 4. ("Dr. Simon is very well qualified to fill

this position [the site medical director].") Therefore, the Plaintiffs have dismissed Dr. Simon as

a defendant in this lawsuit.

v. CLASS ALLEGATIONS

20. The Plaintiffs bring this class action on behalf of themselves and others similarly

6

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 7 of 43
situated pursuant to Rule 23(a) and 23(b)(2) of the Federal Rules of Civil Procedure. The members of the class will consist of mv-positive inmates who are or will be incarcerated at Limestone and have been or will be denied adequate medical treatment and confined in deplorable living conditions.
21. At any given time, there are approximately 240 mv-positive inmates confined in Dorm 16, the Health Care Unit ("HCU"), and Dorm 7 at Limestone. This large group of inmates is constantly changing in size, composition, and location in Limestone. Thus, joinder of all Limestone mv-positive inmates is impracticable.
22. In addition, there are questions of law and fact that are common to the class members, including but not limited to: (1) first, a lack of minimal end-of-life treatment to dying mv-positive inmates; (2) second, the inadequate and untimely response to HIV medical emergencies that arise in Dorm 16; (3) third, inadequate and inhumane living conditions; and (4) fourth, the failure to provide Limestone mv-positive inmates with access to competent medical specialists. A detailed discussion of these and other unconstitutional conditions at Limestone will follow.
23. The claims of the Plaintiff representatives are typical of the claims of the class as a whole.
24. Plaintiffs can and will fairly and adequately protect the interests of the class members.
25. Plaintiffs are represented by counsel who are familiar with the applicable law and are experienced in class action litigation addressing prison conditions.
26. Pursuant to Federal Rules of Civil Procedure 23(a) and 23(b)(2), class certification is
7

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 8 of 43
warranted because the Defendants have acted or failed to act in a manner applicable to the class as a whole. Thus, final injunctive relief addressing the class as a whole is appropriate.
VI. FACTUAL ALLEGATIONS A. Audit Report II of Limestone Correctional Facility Conducted by Roger
Childers, Jacqueline Moore and Larry Mendel of Moore and Associates Confirms the Factual Allegations of Plaintiffs' Claims. 27. On November 8, 2002, an audit inspection was conducted by Moore and Associates addressing the medical treatment provided to HIV-positive inmates confined at Limestone. The audit report was completed consistent with "[t]he Department of Health and Human Services guidelines were used to judge the appropriateness of care. Outcomes were compared with the values developed by the Infectious Disease Society of America." See Attachment 2, Audit
Report n, pg. 3-4. In addition, the auditors consulted the standards devised by the National
Commission of Correctional Healthcare and other well-accepted community healthcare standards.
28. After the inspection was performed, a written audit report was prepared. This audit report was a striking confirmation of the factual allegations detailed in the original complaint.
B. The Complexity of the HIV Virus Requires Complex Medical Treatment and Care.
29. HIV is a retro-virus. The virus debilitates a person's immune system. A person with a compromised immune system becomes much more susceptible to various illnesses, infections and diseases, particularly when confined in an unsanitary living environment. These illnesses and diseases are referred to as opportunistic infections, which ordinarily do not cause illnesses in
8

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 9 of 43
someone with a healthy immune system. Frequently, illnesses and diseases - opportunistic infections - are life-threatening to an HIV-positive person. Thus, survival of an HIV-positive person is dependent upon the careful medical monitoring and effective treatment of opportunistic infections.
30. The complexity of care, monitoring, and dispensing of medication requires the attention of competent medical specialists. In addition, an adequate and quick response mechanism must be in place to effectively address and treat HIV-related medical emergencies. During medical emergencies, the failure to provide prompt access to medical treatment can cause death.
31. The US Department of Health and Human Services ("DHHS"), the Henry J. Kaiser Family Foundation, the United States Public Health Services ("USPHS"), the Infectious Diseases Society of America ("IDSA"), the Centers for Disease Control ("CDC"), and the National Commission on Correctional Health Care ("NCCHC") have developed guidelines for the treatment and prevention of opportunistic infections in persons with HIV. These guidelines are frequently updated and are generally recognized by the medical community as a standard for providing a minimum level of medical care for HIV-positive patients. Both NaphCare, Inc. and the Limestone correctional staff have failed to meet these guidelines or otherwise provide an acceptable, minimum level of medical care and living conditions for the HIV-positive inmates confined at Limestone.
C. NaphCare, Inc. has Failed to Provide a Minimal Level of Medical Treatment for HIV-positive Inmates at Limestone.
32. The State of Alabama has contracted with NaphCare, Inc. to provide medical care at
9

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 10 of 43
Limestone. NaphCare's medical treatment of lllV-positive inmates at Limestone is grossly inadequate. Indeed, the medical treatment provided to lllV-positive inmates at Limestone fails to satisfy the constitutionally minimal and accepted medical community standards for the treatment of such patients. A discussion of each of the areas of non-conformity with minimum
standards of mv medical treatment follows.
33. Due to the inadequate medical treatment and deplorable living conditions, an extremely high and constitutionally unacceptable number of AIDS-related inmate deaths occur at Limestone. The November 8, 2002 audit report stated:
Based on the information available, it appears that six deaths this year are attributable to AIDS and three were caused by liver disease. This calculates to a rate of .23 deaths per thousand. This rate is more than twice the AIDS death rate from the 2001 ACA ("American Correctional Association") statistics and is also about twice the expected number using statistics from "The Correctional Yearbook".
The number of AIDS deaths is remarkably high when one compares averages reported by other DOC systems. The Medical Advisory Committee provides only a cursory mortality review. It is recommended that mortality reviews be conducted as a part of the monitoring process and that the results of these reviews be reported to the Medical Advisory Committee.
(emphasis added) See Attachment 2, Audit Report n, pg. 9. NaphCare is responsible for
reporting inmate deaths at Limestone -- including lllV and AIDS-related deaths -- to the Medical Advisory Committee. However, "[I]t should be noted that the Medical Advisory Committee is a year behind in reviewing mortalities that have occurred at the DOC facilities." Id. Thus, any census addressing the number of lllV and AIDS-related deaths at Limestone is inaccurate.
34. In addition, some of the narrative summaries addressing cause of death of lllV and AIDS-related inmate deaths contradict the entries on a listing of inmate deaths at Limestone. The November 8, 2002 audit report describes:
10

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 11 of 43
A listing of deaths for 2002 through November 5 was provided along with very brief summaries of ten of the fourteen deaths...Two of the ten narrative summaries reveal a cause of death that contradicts the entry in the list. These include J.C. who was listed as a cardiac arrest, while the summary shows that he had pneumonia and diabetic ketoacidosis. The other case was also listed as a cardiac arrest, while the direct cause was gastrointestinal bleeding because of end stage liver disease.
See Attachment 2, Audit Report IT, pg. 9.
35. The Defendants fail to conduct timely reviews of IllY-positive and AIDS inmate
deaths. This failure prevents the gleaning of valuable information concerning causes of death,
failure of medical treatment and the failure of the medical system to prevent a death which could
be used to prevent similar inmate deaths. The November 8,2002 audit report recommended:
Statistics should accurately reflect the cause of death and provide a useful source of statistical information. The reviews also provide a window into multiple aspects of the delivery system. Charts should be reviewed to see whether appropriate preventive measures such as vaccinations and TB testing are working properly. Records should also be evaluated from the time that symptoms first began and to track diagnostic and therapeutic interventions.
See Attachment 2, Audit Report IT, pg. 10. The audit report continues:
It is strongly recommended that the DOC review all deaths that occur at Limestone. One fifth of the summaries provided showed a cause of death that contradicted the listed cause on the facility roster. Statistics should accurately reflect the cause of death and provide a useful source of statistical information.
(emphasis added) See Attachment 2, Audit Report IT, pg. 10.
36. Many IllY-positive inmates have filed "sick-call" slips to receive medical treatment.
A sick IllY-positive inmate can be forced to wait from several days to several weeks to see a
nurse or a doctor. Some sick-call slips are not answered at all. The November 8,2002 audit
report addressed this issue:
The HSA and other nurses reported that sick call request are triaged only 5 days a week instead of "daily screening" that is required by the NCCHC standards.
11

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 12 of 43
See Attachment 2, Audit Report II, pg. 5. 37. Dying HIV-positive and AIDS inmates fail to receive adequate end-of-life medical
treatment. Bed sores and other manifestations of inadequate end-of-life medical treatment are endured by dying HIV-positive and AIDS inmates. This failure to provide adequate end-of-life treatment causes needless pain and suffering.
38. When responding to medical emergencies in Dorm 16, NaphCare's medical staff response has been extremely slow and completely inadequate. No medical emergency buttons exist in Dorm 16. In the HCU, which houses inmates with very serious illnesses, the emergency buttons are often turned off. In addition, the nurse's station in Dorm 16 is only occupied by a nurse during pill call - three times per day. During all other times of the day, the nurse station in the Dorm 16 is unattended. Thus, when a medical emergency arises, HIV-positive inmates must pursue a dangerously slow emergency response system. This system includes: (1) first, HIVpositive inmates report the medical emergency to the correctional staff; (2) second, the correctional staff person relays the emergency to the "shift officer;" (3) third, the shift officer - a member of the correctional staff, not a medical person - decides if the emergency warrants transferring the HIV-positive inmate with the medical emergency to the Limestone ReU; (4) fourth, if the shift officer decides that the inmate should be brought to the RCU, the prison must be locked-down2; (5) fifth, once the prison is locked-down, then the HIV-positive inmate with the medical emergency can be transferred from Dorm 16 to the RCU. Dorm 16 is located on the
2"Locked-down" refers to when general population inmates are moved out of the common yard areas of the correctional facility. The general population inmates are then locked inside their Dorms so that the HIV-positive inmates can be moved through the common yards without coming in contact with general population inmates.
12

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 13 of 43
opposite side of the prison complex from the HCU. (6) Sixth, the inmate, assisted by other mvpositive inmates, is transported through three security gates to the HCU; (7) seventh, if the NaphCare doctor is not present at the HCU when the emergency is occurring, then the nursing staff must contact the doctor by telephone to receive the doctor's permission to call "911" or an ambulance. This slow and needlessly burdensome system is dangerously deficient for addressing and treating medical emergencies experienced by HIV-positive inmates. The slow response to medical emergencies has contributed to the death of several HIV-positive inmates. More deaths will occur in the future if the process is not addressed and changed.
39. NaphCare medical staff fail to provide basic medical assistance to HIV-positive inmates. Often, mY-positive inmates are responsible for providing medical treatment to each other. HIV-positive inmates provide medication to each other, carry each other to the HCU on stretchers, provide end-of-life treatment to dying mY-positive inmates, and provide CPR to each other. In fact, the November 8,2002 audit report described a similar instance that occurred in the infirmary:
One inmate runner was observed providing nourishment/fluid to one inmate that was admitted to the health care unit. Holding a cup while another inmate consumes nourishment or medication should only be performed by licensed health care providers and inmate "runners" should provide only custodial services. (emphasis added) See Attachment 2, Audit Report IT, pg. 6-7. The audit report also addressed the inadequate training of the Limestone nursing staff:
Current licensure was on file for all staff. CPR training for all health providers was not current. Twenty-three per cent of Naphcare employees had no documentation of current CPR training. The HSA reported that "training for these employees including herself would be done soon". The Deputy warden reported that notification of CPR training, on site, for these employees had been provided to Naphcare, on numerous
13

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 14 of 43
occasions, however, Naphcare employees did not attend. There was documented in-service training for only 14% of the health staff health
care staff. Eighty-six per cent of the health acre staff did not have proper documentation of continuing education on file. A planned agenda for training for the next several months was undeveloped [sic] but was unavailable for review. (emphasis added) See Attachment 2, Audit Report II, pg. 8. 40. NaphCare also fails to meet the basic medical needs of amputee mv-positive inmates. Upon entering Limestone, some amputee mv-positive inmates experience weight changes - either a loss or gain in weight. These weight changes affect the fitting of prosthetic limbs. Often, a re-fitting and new prosthesis are necessary. However, NaphCare has refused to address this problem. Instead, the amputee mv-positive inmates must endure their confinement without the assistance of their prosthesis. One amputee mv-positive inmate, Eric Stephens, does not have a leg. Stephens gained weight when he entered Limestone and his prosthetic leg no longer fits properly. Therefore, he could no longer use his prosthetic leg. Stephens has been confined to a wheelchair, in an environment that is not equipped to address the needs of the handicapped. Without the use of his prosthetic leg, Stephens must wheel the chair to the shower area and hop - with the use of his good leg - into the shower. On two occasions, he tripped in the shower area, fell, and was injured. Because Dorm 16 is located on the opposite side of the prison complex from the Health Care Unit, Stephens did not receive timely medical treatment. 41. Many mv-positive inmates have co-occurring chronic diseases. For example, some mY-positive inmates suffer from seizure disorders. Dilantin sometimes is prescribed to treat the seizures. Often, the NaphCare medical staff fails to adequately monitor Dilantin levels in the inmates. For example, Plaintiff Michael Patrick was informed by the medical staff that he was
14

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 15 of 43
being administered dangerous levels of Dilantin. While receiving the high doses of Dilantin,
Patrick experienced severe side-effects and extreme pain. In addition, some mv-positive
inmates who have experienced seizures are assigned to top bunks. Being assigned a top bunk
creates a serious risk of personal injury for seizure-prone inmates. If the inmate experiences a
seizure while on the top bunk, he can fall from the bunk and be injured. While lying on his top
bunk, Patrick experienced a seizure. The seizure caused him to fall out of the top bunk and hit
his head on the floor. He has been told by the NaphCare medical staff that the fall caused him
serious head injuries. The serious medical situation endured by Mr. Patrick is consistent with the
November 8,2002 audit report findings:
A review of chronic care charts indicated that problem lists were inconsistently completed. Out of twenty records reviewed eight lacked an updated problem list. Therapeutic blood levels were present for seizure patients. Two of the four levels reviewed were subtheapetic [sic] yet there was no change in the medication prescribed. Documentation on the Medication Administration Record showed inconsistent documentation of medication.
(emphasis added) See Attachment 2, Audit Report IT, pg. 2-3.
42. The chronic care treatment is extremely dire for mv-positive diabetic inmates. Larry Talley - an mv-positive diabetic inmate confined at Limestone - endures various health
complications caused by the failed medical management of his diabetic condition. The
November 8, 2002 audit report confirmed consistent mismanagement by medical staff of mv-
positive diabetic inmate conditions:
The facility [Limestone] has recently stated to perform Hemoglobin AIC's on diabetics but does not provide routine testing of blood sugars daily on insulin dependent diabetics. Staff indicate that Naph Care's policy is to only perform monthly accuchecks. This policy is contrary to community standards of care and since at least one death at his facility during the past year was due to ketoacidosis, it is recommended that the facility review clinical guidelines published by the American Diabetic Association and the
15

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National Commission on Correctional Health Care and adjust their policy accordingly.
(changes to original) See Attachment 2, Audit Report n, pg. 3. Failure to adequately manage
illV-positive inmates' diabetic conditions causes needless pain and suffering and possible death. 43. Similarly, some illV-positive inmates need dialysis. Limestone is equipped with
only one dialysis machine. Often, the dialysis machine is malfunctioning or inoperative. The dialysis machine mechanic is not located near the prison. If the dialysis machine breaks down and the mechanic is unable to travel to the prison, then the NaphCare staff may try to transport the inmate to an outside hospital for dialysis treatment. However, if the medical staff cannot transport the inmate to an outside hospital, then the NaphCare medical staff informs the inmate that he will have to wait an extra day before receiving his dialysis. Carl Simmons - an illVpositive inmate on dialysis - has been told on numerous occasions that he must wait an extra day to receive his dialysis treatment, because the dialysis machine is broken and cannot be repaired until the next day. Waiting an extra day to receive dialysis causes Simmons needless pain and suffering.
44. Numerous illV-positive inmates, in need of surgery or other specialized care and treatment, have endured excessive delays in receiving treatment. For example, since arriving at Limestone in 1997, Johnnie Creech - an illV-positive inmate - has developed genital warts. The genital warts have become extremely painful and bleed. For months, Creech has been asking Dr. Simon about surgery to treat his genital warts. Creech has not received surgery for the genital warts. Creech continues to endure needless pain and suffering.
45. The NaphCare pill dispensing nurses fail to dispense necessary antiretroviral medication - medication for the treatment of illV - at proper times. Immediately before meals,
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Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 17 of 43
medication is dispensed. Upon being provided antiretroviral medication, IDV-positive inmates are instructed by personnel to immediately take the medication. If the IDV-positive inmate refuses to immediately take the medication, he is denied the medication. Some antiretroviral medication must be taken at specific times - before or after meals. These specified times have been adopted and approved by the Federal Drug Administration ("FDA"). Failure to take the medication at prescribed times can decrease the effectiveness of the medication or increase the toxicity of the medication. Thus, NaphCare's failure to provide antiretroviral medication at proper times exposes the IDV-positive inmate to possible IDV medication failure and premature death.
46. In addition, NaphCare nurses dispense medication outside Dorm 16. Because the medication is dispensed outside Dorm 16, HIV-positive inmates are required to stand in intense heat, cold, or rain in the outdoors for long periods of time to receive their medication. In fact, one of these "pill lines" is conducted at 3: 15 a.m. If sick IDV-positive inmates are physically able to stand outside in the "pill line", then the inmate is exposed to conditions which threaten their health, safety and lives. Yet, if the IDV-positive inmate is too sick to stand outside, they do not receive their medication.
47. Some IDV-positive inmates experience gaps in their medication administration. The November 8,2002 audit report described numerous medication administration gaps:
Medication records showed gaps in the medication administration process on consecutive days in several patients. Most of the gaps corresponded to weekends. In response to an inquiry, I was advised that the facility had a very high turnover rate in its nursing staff and a persistent problem with position vacancies. (emphasis added) See Attachment 2, Audit Report II, pg. 4. In fact, medication gaps of several
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weeks occur when an HIV-positive inmate is first transferred from Kilby Correctional Facility to Limestone.3 Constant gaps in medication administration exposes an lllV-positive inmate to
possible medication failure and premature death.
48. In addition, medication and immunization distribution to lllV-positive inmates has
been erratic. Since the filing of the original complaint, proper distribution of medication and
immunizations could have prevented several HIV-positive inmate deaths. In fact, several
inmates -- including Michael Headon and Russell Batiste -- contracted pneumocystis carinii
pneumonia ("PCP) and died. PCP can easily be prevented by providing an HIV-positive person
with a single, inexpensive pill every day. The November 8,2002 audit report recommended that
mv Bactrim be administered to -positive inmates:
The cost to the system of opportunistic infections [HIV and AIDS-related illnesses] can be prohibitive, while the expense of preventive medications is minimal. Bactrim therapy for pneumocystis pneumonia (PCP) prevention is an excellent example. This infection is highly lethal and extremely incapacitating. Hospitalization costs usually exceed $10,000, while the cost of prevention runs about $2 a week. PCP prevention should be strongly encouraged even if patients refuse other treatment.
(changes to original) See Attachment 2, Audit Report n, pg. 10. The November 8,2002 audit
report also addressed the medical staffs' failure of providing necessary medication and
immunizations to HIV-positive inmates:
Although some charts showed evidence of immunizations, less than a third of the records had evidence of flu vaccinations and only one fifth had documentation of a pneumonia vaccine. None of these records showed that prevention for hepatitis A or B was given even though many of the patients reviewed had been diagnosed with hepatitis C, and three of the deaths this year were because of liver disease, including acute hepatitis.
3Kilby Correctional Facility is the receiving institution for all inmates processed in the Alabama Department of Corrections.
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See Attachment 2, Audit Report n, pg. 4. In fact, the medical staff provides inadequate diagnosis
and medical treatment addressing Hepatitis C. Proper medication and immunization distribution can prevent needless pain, suffering, and death.
49. HIV-positive inmates are assessed medical treatment fees an excessive number of times. To receive medical treatment, HIV-positive inmates must pay $3.00. No HIV-positive inmate has been denied medical treatment because they have been unable to pay $3.00. However, often HIV-positive inmates must pay $3.00 for any type of encounter with medical staff. Some inmates are even charged $3.00 for follow-up visits addressing the same, unresolved medical condition. Recently, Antonio Leatherwood - an HIV-positive inmate - has requested to visit the doctor to receive medical treatment for various ailments. Before visiting the doctor, Leatherwood is required to arrange th doctor appointment with a nurse. Since raising his medical condition with the nurse, Leatherwood has not been brought to see the doctor. However, each time that he visits the nurse to inquire about the scheduling of his doctor appointment, Leatherwood has been charged $3.00. Therefore, despite not visiting the doctor and receiving medical treatment, Leatherwood has still been charged $3.00 each time he sees the nurse. The excessive charging of a $3.00 payment for medical services, which are often not even provided, discourages many inmates from seeking essential medical treatment.
50. HIV-positive inmates are not provided special food diets. Some HIV-positive inmates - for example, diabetic inmates - are not provided special food diets to address their medical conditions. Not providing special food diets exposes an HIV-positive inmate to needless pain and suffering.
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D. The State of Alabama has Failed to Provide Adequate and Safe Housing for HIV-positive Inmates at Limestone.
51. Dorm 16 - euphemistically labeled an "infirmary" - is completely inadequate to house mY-positive inmates. In fact, Dorm 16 is nothing more than an open warehouse formerly used to store prison supplies. The November 8,2002 audit report describes the living conditions for mY-positive inmates confined in Dorm 16:
The building was an old warehouse that was converted to a dorm that was initially used to house the chain gang and later converted to an AIDS dorm. The ceilings are high and the close proximity of the beds fosters infections among this population. Interviews with officers and inmates indicated that extremes in temperatures are prevalent as the dorm leaks in the winter and is extremely hot in the summer. See Attachment 2, Audit Report IT, pg. 1. The inadequacy of the conditions in the Dorm threatens the safety and welfare of the IllY-positive inmates. Indeed, the Dorm is inadequate to house any human-being. It is crucial to assess the effect of specific living conditions on the health, safety and lives of IllY-positive inmates. 52. Numerous brown spiders, rats, and birds infest Dorm 16. Many HIV-positive inmates have been bitten by brown spiders that live in the Dorm. Often, while the inmates are eating, rats take the inmates' food. At night, rats climb into the inmates' beds. Also, birds have entered Dorm 16. Exposure to bird droppings can cause opportunistic infections in mY-positive patients. For example, exposure to bird droppings can cause cryptococcal meningitis. While incarcerated in Dorm 16 at Limestone, Emmitt Robinson, an HIV-positive inmate, developed cryptococcal meningitis, likely due to his exposure to pigeon droppings in the poorly ventilated dormitory. Meningitis is a crippling illness that can cause death if untreated. The numerous insects and vermin inside Dorm 16 pose a substantial threat to the health and Iives of the HIV-
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positive inmates. 53. In addition, Dorm 16 is structurally unsound. During rainstorms, rain leaks through
the Dorm's roof and soaks the inside of the Dorm. Standing water can provide a breeding ground for disease, mosquitos, and mold. In the ceiling, exposed pipes and electrical wiring pose a substantial danger of fire and electrocution to the prisoners.
54. Dorm 16 is inadequately ventilated, heated, and air conditioned. Without adequate heat, the Dorm is very cold in the winter. Without adequate air conditioning, the Dorm is very hot in the summer. During the summer, the HIV-positive inmates are provided some fans. These fans do not circulate enough air to cool the Dorm in the summer. These fans often blow dust, dirt and airborne contaminants around the Dorm.
55. Despite being labeled an "infirmary", Dorm 16 does not make adequate provisions for disabled HIV-positive inmates. No facilities for the disabled are provided in the shower and bathroom area of the Dorm. The lack of handicapped facilities in the Dorm caused one handicapped HIV-positive inmate, Eric Stephens, to trip on two occasions while trying to access the shower. The falls caused Stephens to injure his back and foot. Yet, because Dorm 16 is located on the opposite side of the prison complex from the HCU, Stephens did not receive medical treatment for approximately thirty minutes.
56. During medical emergencies, Limestone correctional staff do not provide assistance to HIV-positive inmates. HIV-positive inmates must carry each other on stretchers. In fact, some HIV-positive inmates have been forced to provide CPR to each other. This practice is unsafe. Indeed, this practice violates well-established standards for correctional medicine and well-accepted public health guidelines.
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57. When IllV-positive inmates file Medical Complaint Forms or Medical Grievance Forms, correctional staff read the forms, question the inmates about their medical treatment and sometimes berate the inmates for filing the medical complaints and grievances. This practice discourages mY-positive inmates from filing necessary medical complaint and grievance forms. Indeed, questioning by correctional staff addressing inmate medical care issues discourages inmates from seeking essential medical treatment.
58. Some specific conditions in the Dorm 16 kitchen and eating area threaten the health of the mY-positive inmates. As the November 8,2002 audit report describes:
Tables where the inmates consume nourishment were noted to be rusty. Seventeen half-gallon jugs with ice were found on the floor of one freezer. These containers were reported to be used as ice for the work squads. These should be stored off the floor. Cabbage, peanut butter and mayonnaise were found to be uncovered. The DOC officer in the IllV dorm reported that the kitchen area in that sector had a leak in the roof. Annual inspections by the health department would be prudent. See Attachment 2, Audit Report II, pg. 8. These conditions contribute to mY-positive inmates' needless pain and suffering. 59. There is no classification system for the IllV-positive inmates confined at Limestone. The Alabama Department of Corrections IllVIAIDS inmate segregation policy confines all IllVpositive and AIDS inmates primarily in one housing facility - Dorm 16 at Limestone. Because all of the IllV-positive inmates are confined in one Dorm, classifying serious crime and less serious crime inmates does not exist. Instead, regardless of the crime committed by the inmate, all of the my-positive inmates are forced to co-exist in an open-dorm type environment. This environment fosters dangerous and hostile living conditions which threaten the health, safety and lives ofHIV-positive inmates.
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60. Many dying lllV-positive and AIDS inmates have been unable to receive timely "compassionate release" prior to their deaths. Thus, many HIV-positive and AIDS inmates die at Limestone absent the presence of family members.
61. lllV-positive inmates are denied access to Supervised Intensive Restitution programs ("SIR"), work release programs, and vocational programs. HIV-positive inmates are segregated from the Limestone general population. This segregation policy prevents contact between the HIV-positive inmates and general population inmates at Limestone. mY-positive inmates are prevented from participating in the same or similar supervised release, education and training programs that are provided to general population inmates. In fact, HIV-positive inmates are only permitted access to a very limited number of facility programs that are provided to general population inmates. Thus, lllV-positive inmates - unlike general population inmates - are forced to endure the full duration of their sentences, with no ability to obtain an early release, in an extraordinary environment of idleness, without access to job or other training programs which are provided to non-HIV-positive inmates. This environment of extraordinary idleness, threatens the health and safety of mY-positive inmates.
E. Defendants Have Acted and Continue to Act with Deliberate Indifference Toward the Medical and Housing Needs of HIV-positive Inmates at Limestone.
62. The Southern Center for Human Rights contacted Ronald Cavanaugh, the Medical Director of the Alabama Department of Corrections about the egregious medical and living conditions detailed above. See Attachment 3. In addition, the Southern Center for Human Rights informed Francis Henderson, the former Medical Director of NaphCare, Inc., about the outbreak of boils infecting the lllV-positive inmates at Limestone only to be told that the boils
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were simply mosquito bites and there was nothing to worry about. The Alabama Department of Corrections and NaphCare, Inc. have not responded.
63. Numerous complaints by HIV-positive inmates, both formal and informal, written and oral, have not been addressed or have been inadequately addressed. The continued pursuit of the present policies of the Alabama Department of Corrections and NaphCare, Inc's are causing and will continue to cause unnecessary suffering to the HIV-positive inmates at Limestone. Absent intervention by the Court, unnecessary and preventable deaths are inevitable.
64. Plaintiffs have exhausted all administrative remedies available. NaphCare has adopted a procedure for inmates to file grievances concerning medical treatment. See Attachment 4. The procedure provides: (1) the inmate must obtain and file a NaphCare Medical Complaint Form ("complaint"); and (2) if the complaint is not resolved, then the inmate may file a NaphCare Medical Grievance Form ("grievance"). (Id.) Plaintiffs have exhausted the NaphCare grievance procedure. Many HIV-positive inmates at Limestone have actively asked and sought
mv- complaint and grievance forms. Often, the NaphCare medical staff refuses to provide any
positive inmates with complaint forms. The NaphCare medical staff has never provided HIVpositive inmates at Limestone with grievance forms. Because NaphCare's medical staff has refused to provide complaint and grievance forms to inmates upon request, plaintiff's counsel has had to provide such forms to HIV-positive inmates. HIV-positive inmates rarely receive copies of the grievances they file.
65. Responses from NaphCare, Inc. - either written or oral - to complaints are rare. Responses to grievances have been even rarer. The grievance process has failed to address and resolve the continued egregious practices of the NaphCare medical staff.
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66. The Alabama Department of Corrections does not provide a grievance process. Thus, Plaintiffs have been unable to resolve problems relating to their living conditions through a grievance process.
67. Despite the attempts of prisoners to resolve problems through NaphCare and the Alabama Department of Corrections, an environment of needless suffering and premature death for the HIV-positive inmates at Limestone persists.
VII. CLAIMS FOR RELIEF 68. Plaintiffs support the following claims by reference to the previous paragraphs in the Complaint:
Count I 69. The Defendants have been deliberately indifferent to the serious medical needs of HIV-positive inmates at Limestone, which rises to the level of cruel and unusual punishment in violation of the Plaintiffs' rights under the Eighth Amendment and Fourteenth Amendments to the United States Constitution, as enforced through 42 U.S.C. § 1983.
Count II 70. The conditions of confinement for HIV-positive inmates at Limestone and the Defendants' deliberate indifference to those conditions, as well as their policies and practices in administering and overseeing Limestone, considered both discretely and in their totality, constitute cruel and unusual punishment in violation of the Plaintiffs' rights under the Eighth Amendment and Fourteenth Amendments to the United States Constitution, as enforced through 42 U.S.C. § 1983.
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Prayer for Relief 1. Plaintiffs respectfully pray that this Court: 2. Assume jurisdiction of this case. 3. Order that this case may be maintained as a class action pursuant to Rule 23(a) and 23(b)(2) of the Federal Rules of Civil Procedure. 4. Declare unconstitutional and unlawful the medical treatment and living conditions of HIV-positive inmates incarcerated at the Limestone Correctional Facility. 5. Enter preliminary and permanent injunctions ordering defendants, their successors, agents, employees, and all other persons acting in concert with them to immediately provide HIV-positive inmates at Limestone Correctional Facility with access to competent medical specialists, adequate and appropriate emergency care, adequate end-of-life treatment, and adequate diagnosis, culturing and medical treatment for opportunistic infections. 6. Enter preliminary and permanent injunctions ordering defendants to permit an thirdparty infectious disease specialist to enter to the prison, culture, diagnose, and treat the opportunistic infections that continue to plague the HIV-positive inmates at Limestone incarcerated in Dorm 16. 7. Grant Plaintiffs a full trial and discovery addressing the issues raised in this Complaint. 8. Rule that the acts and inactions of the Defendants violate the HIV-positive inmates' rights under the Eighth and Fourteenth Amendments of the United States Constitution and 42 U.S.c. § 1983. 9. Order that the Defendants comply with the Constitution and 42 U.S.C. § 1983 and
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enjoin the Defendants from continued violations of the Plaintiffs rights.
10. Award plaintiffs the costs of this lawsuit and reasonable attorneys' fees.
11. Order such additional relief as the Court deems just and proper.
/"
t.V] Respectfully submitted, this day of March, 2003.
{JAmc1v--
DAVID M. LIPMAN David M. Lipman, PA FL Bar No: 280054 5901 S.W. 74 Street Suite: 304 Miami, Florida 33143-5186 Telephone: 305/662-2600 Facsimile: 305/6673361
FRANCIS A. ANANIA FL Bar No: 160256 Anania, Bandklayder, Blackwell, Baumgarten Nations Bank Tower Suite: 4300 100 S.B. 2nd Street Miami, Florida 33131-2144 Telephone: 305/373-4900 Facsimile: 305/373-6914
STEPHEN HANLON FL Bar No: 209430 Holland & Knight LLP 2099 Pennsylvania Ave, N.W. Suite 100 Washington, D.C. 20006-6801 Telephone: 202/828-1871 Facsimile: 202/955-5564
Attorneys for Plaintiffs
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EXHIBIT 1

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 29 of 43
HEALTHCARE SERVICES AG~REEMENT BY AND BETWEEN
THE ALABAMA DEPARTMENT OF CORRECTIONS
AND
NAPHCARE, INC.
FEBRUARY 13, 2001

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 30 of 43
7.4 Exi~ting Re,~. DOC shall make available tel Contractor all available Inmate medical records as provided in 3.8 above.
7.5 Orientation 1:.m.inin.g. DOC shall provide sixteen (16) hours oforientation training for Contractor's new employees. with emphasis on Adrninistrative Regulations and Institutional Security. The c)ntent, scheduling, and methodology of said training shall be detennined by the DOC and ,~easonably acceptable to Contractor.
7.6 Contract Monl!2I. To evaluate and assess that all standards are being met and that Contractor is in full complian:e with the contract, DOC may employ, at its expense, the services of a ContraCt Monitor. To the extent permitted by law. Contractor shall provide the Contract Monitor ongoing, comprehensive, and expeditious access to all chnical files and all corporate files (to the extent such corporate files are related to the provision of healthcare services to inmates in Alabama) to include but not limited to personnel records of Alabama employees, payroll records, licensure certification records, employee evaluations, physiCian billing, hospital or other outside service invoic~. or any other contract entered into by Contractor for the purposes of carrying out the requirements of the contract. The Contract Monitor shall perform. but not be limited to, the following tasks:
(a) Review of service levels, quality ofcare, and administrative practice.~ as specifie~ , in the contract;
(b). Meet on a regular basis with Department representatives ofContractor and the DOC to address contract issues.
(c) Assist in the develo.,ment of future cbange requests as needed.
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(d) Review of Contractor documentation to ensure compliance with contractual obligations.
(e) Review ofcl)ntract personnel work schedules, time sheets, personnel records, and wage fanTIs to ensure compliance with staffing levels and contractual obligations.
to (f) Review of files, records, and reports pertinent the provisi~n ofinmate
healthcare services. (g) Review of medical billings to detennine appropriateness to contract specifications
and cost effectiveness to DOC. (h)· Review the collection of third party reimbursement ofcertain expenses. (i) Conduct site visitations, interviews, and inspections as required to perfonn an on-
going health services program. Contract Monitor shall operate independently of Contractor and shall be directly accountable to DOC. Contract Monitor shall subrnit a monthly report of provider services and fulfillment of contractual obligations to the DOC contact person. Upon review of said report the DOC contact person shall notify ContracWr's authorized representative of the monthly findings. Discrepancies and/or deficiencies in contracted services shall be assessed and penalized accordingly. Contractor shall submit a writtt~n response within fifteen (15) calendar days to the DOC C(lntact person detailing corrective actions. Failure to perform corrective action or meet contractual obligations within thirty (30) calendar days shall place the Contractor in default ofthe contract.
7.7 Security, The parti ~ hereto understand that adequate s:ecurity services are necessary for the safety of the agents, employees and/or subcontracton~ ofContractor~ as well as for the security ofInmates. DOC agrees to provide security services mutually satisfactoty to the
S2

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EXHIBIT 2

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 33 of 43

Limestone Correcl:ional Facility
Roger Childers ofMoorc and Associates conducted an audit ofthe LRnestone Correctional Facility, on October lSI, 2002 on behalfofthe Al1Ilhama Depanment of Corrections. The audit closisted ofa tOUf of the health C8fC: unit, HlV donn, and dietary Oepartment. C)truc:rured "lterviews were conducted with the site HSA. dietary manager, day shift RN, ~liDic LPN, rune uunates,Ueputy \\'aroen and 'Warden. informal uuel"\tiews were conducted with the J'egional HSA, correctional officers kIC8ted in the heaJrh care unit and HIV donn. and other DOC penonnel On November 8, 2002 Jacqueline Moore RN Ph.D. CCHP·A and Lan)' Mendel DO, CCHP, fonner medical director orObic conducted a subsequent revi£w ofthis facility.
An exit conference was cC)nducted with the Warden" site HSA, Regional Manger, two Naphcare corporate admiilistrators, day shift RN, and the Department ofCorrections' Director ofTreatment.

Facility Information

This facility was constructed in 1983, and during the audit, bad a census, of2130 male

inmates. There is one satellite facility. the Decatur work release that contains a population
of430 inmates. The mv donn was noted to be crowded, but generally clean. New

screens had been placed (In the windows tms housing area, anc! it was reported that this

dor- had recently been fiDnigated bv '"c.ooks" pest ~ontrol oc:!' contract with the DOC. _

The mcility bas a 21 bCCf ;nfirmary. There are two SIX bed dorms, three C:amelll ceUs and

tbe others are single OT double man teDs. All ofthe AIDS patients are only admitted to

the infirmuy donn. The medical unit consisted of an exam rolJm which was shared by

both the PA and the: physician, an emergency room, dialysis rclQlD,. There are nine housing
dorms throughout the COJ1lplex. There is one dorm that is designated for mv positive

patients. Inmates that are assigned to this unit have aU activitic:s performed on the unit.

Meals are ~d on the unit from the main kitchen, a substanc:e abuse program is available

as weD as a small bbrary. Inmates are aDowed access to the Itain law blnry on a weekly

basis- There is a OED prugram ava.ilab~ however inmates m: the student teachers. The

AIDS dorms ~ donn style aU bunks are double. The buiJding was aD old warehouse that

was converted to a dorm that was initiaUy used to house the cbam gang and later

converted to an AIDS dClrm. The ceilings are high and the cklsc proldmity oftbe beds

fosters infection among (lis population. Interviews with of!ioers and imnatcs iodicated

that extremes in temperatures are prevalent as the donn has leaks in the winter and is

extremely hot in the SUJJlJDCr. There is a small medical exam :room located in the AIDS

dorm

-'

Transition

The ~cdicaJ services han transitioned from Correctional Mecl.ical Systems to Naphcare effectlvc March 2002. The new contractor has been providing service for approJcimately

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 34 of 43
Out of twenty records reviewed eight lacked an updated probltMl list. Therapeutic blood levels were present for seizure patients. Two of the four levehi reviewed wert subtheapetic yet there W3!~ no change in the medication prescribed. Documentation OD the Medication Admillistration Record showed inconsistent documentation ofmedication. BUN and creatine levels were not consistently found 00 the charts ofhypenensive inmates reviewed. The &cility hali recently stated to perform Hemoglobin Ales 00 diabetics but does not provided routine testing ofblood sugars daily on insulin dependent diabetics. Statlindicate that Napn Care's Policy is to only pcrionn mODLo1y a.c::~~hccks. Iius puiJ",y is contrary to community standards ofcare and since at least one death at this facility during the last year was due to ketoacidosisis, it is recommeod.cd that the tBcilty review clinical guidelines publisb=d by the American Diabetic: Assoeiation and the National Commission on Correctional Health Care and adjust their polM:y ac:cordingiy.
HIV AIDS CaN
Because oftlle high cost I)fcare for inmates infected with mv, contract vendors roay be
tempted to cut comers. Medication costs alone run between Si8,OOO and S12,OOO annually, and labwork adlls to the expense. Because oftbe c;omplexity aDI'severity of the illness, poor care or gaps in the deJivery system wiD tend to be quite evident.
The quality armv care has added significance for Alabama b:cause ofscrutiny from
outside organizations tbf: take issue with the department's policy of segregating mv
infected inmates from the general population. Disagreement with the policy bas already resulted in expensive, protracted litigation. The failure. or perceived fBilure to provide access to sufficient care bl this population will invite further ,:omroversy and potential litigation.
In view oftbe substantial value of the contract for medical services, it is prudent to closely monitor the performance of the vendor. Monitoring activities should include the tjJ)leliness ofaccess to care, vacancy rates, credentialing, and 1:rairUDg activities. Clinical evaJuations to assure that services are pcrfunned consistent with community standards arc also warranted. Monitor.lIlg activities are needed not just for fiscal concerns, but also to decrease the risk of6ability. In addition to the potential cost ()fUtigation, poor care can produce other costs, such as increased hospitalization rates.
Audit Process
charts were randomly selected from the list ofHlV positive ira:oates. Additional records
were pulled from the roster of diabe& inmates and from inmates who entered the system
during the past year. The: records were reviewed to track medication rcgimcm, both antiretroviral therapy. and preventive treatment fbr opportuni!;tic infection. when indicated. LabworJc to measure CD4 helper ceO levels and vir.alload was recorded sequentially. Screening br TB and protective immunizations were also noted.
The Department ofHeaJth and Human Services guideliDes wen: used to judge appropriateness ofcare. Outcomes data were compared with values developed by the

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 35 of 43
19...I1'OJ1Ih$. .~e was a DeW health administrator 1hat had been in her position for
approximately one-month. The medical director indicated that ~ere ~ ~ tre~ous tumoYCt oftbe nursing staff. It was reported to Mr. Childers liunna his inteMeW WIth the prior HSA that 1-10 new bW'SCS had recently been hired duriog tbe last seven months.
Staffing Vacancies al,d Hours of SelVice
(.;UtTent full time staffing consists of • 1 site HSAIRN • 1 pbYfician • I PA
• 5 RN's
• 12 LI-N's • 2 medical record clerks • 1 secr.9ary
• J fun !:ime dental assistant
• 1 medical technician
In addition there are two part time dialysis RN's that work 24· hours a week. and two dentists that provide 40 tlOurs ofdental coverage each week. Nursing vacancies consist of 1 RN and 2 LPN vacancies.
Both dentists has recently begun work in this facility The current dental staff reported that the dental backlog has be en reduced to only 30 inmates on a waiting list for non-urgent
care
History and Physical Exams
By policy, inmates are to receive a health assessment, by a qu:1lified provider no later than
run 7 days after admission, tel the DOC, with annual TB updates t:very year; and a physical
every three years. It was reported that some inmates continue to have delays in the initiation ofmedication when identified as HIV positive prior to transport from the Kilby mcility. Historically, in the last six montbs, delays in mcdicatkln therapy have been four. five, six and seven weeks.
ChlOnic c.,.
Naphcare statrreported tbat cbroruc care clinics are consistenrly conducted in thic; facility. However inmate number 145983 that is HIV positive stated" (have DOt seen the doctor in
7 to 8 months". lrunate 1#133445 that ~ mv positive reportc:d "1 have not seen the
doctor in three months", [mnate # 198466 that is HlV positivt: stated " I have not seen the doctor in 7 months... Inrr.ate 1# 461886 reported that he had nOI seen the doctor in 6 months. lrunate # 174131 that he had turned in S sick call slips since February 2002 and "bas yet to seen by the dnctor'".
A review ofchronic care charts indica.ted that problem lists Wl:rC inconsistently completed.

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 36 of 43

Infectious Disease Society of America. Brief summaries of the 2002 deaths of HIV
positive inmates were provided, but only one chart was available for review..

AuditResuhs

Several components comprise the delivery system for HIV caR! at Limestone. Directing clinical care is Dr. Simon, the site medical director. Dr. Simon is very weD qualified to till this position. She i.s traincu Ul inf'.:c.tious di~~ anJ ui1n~~ p.,;:vivu:> h~~ G.nJ correctional experience. Her initial correctional experience OC(:um:d at Rikers Island in
New York. a location with many complex HIV cases and a IUgll prevalence ofTB and
other infectious diseases.

Dr. SimoD·S expcricoce lid qualifications were readily apparent in the review oCher

charts. Her documentation is exceptional and sk.ill as a pnctitioner is apparent in

promptly and decisively addressing medical problems as they are presented. Most of the

patients in the charts reviewed are responding with optimal1evels ofviral suppression.

Those with poor response all have completed resistance testinf: and the regimens have

been adjusted to COlTespo:!ld with the test results. All patients who meet the DHHS

guidelines for antiretroviral therapy 8{"e either receiving medication or have been oJfered

treatment.

'

Six of the charts audited were for patients who met criteria for preventive treatment for opportunistic. Although Hll six bad been offered preventive mc:dications, only one had agreed to treatment. Twc, ofthe inmates declining medication bad a history ofmental illness, but it is not clear f~rn the chart whether their condition was severe enough to impair their ability to comprebend the consequences of their refusal.
The f8cility staffbas paid close attention to screening for tuberculosis. AD ofthe charts reviewed had current TB ~kin test results completed and the readings were charted. In every case where further action was wammted, the appropriate: tests were ordered. Completion of INH therapy when indicated was also documented.. The results were
placed in the same location in each chan and were easy to find.
Medication ~rds shoWl~ gaps in the medication administration process on consecutive days in several patients. Most ofthc gaps corresponded to weekeods. In response to an inquiIy, [was advised tJ.~ the 13cility had a very high tumoVCt rate in its nursing staff and a persistent problem with position vacancies.

Although some charts shclwed evidence of immunizations, less than a third ofthe records had evidence of flu vaccinations and only one tifth had dOCUIIX:ntation ofa pneumonia
vaccine. None oftile rec(lrds showed that prevention for hepatitis A or B was given even
though many ofthe patients reviewed bad been diagnosed witll hepatitis C, and three of the deaths this year were because ofliver disease, including one from acute hepatitis.
None ofthe inmates who were newly diagnosed with mv infettion at intake wefe started
on medication before arriving at Limestone. Although none oftbese cases resulted in any apparent compljc:ation, patients diagnosed with HIV infection Itt intake. or arriving with

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 37 of 43

known infection should be screened for the need for inunediatc therapy, especially to

prevent opportunistic: ~:tioQ when indicated.

.

Screening for metabolic cl)mplications of HlV and medication side effects was done on a consistent basis and in each case where action was warranted. :medication changes or treatment adjustmeots wert made.

Sick C.U

, .

The HSA and other Durses reported that sick can request are triaged onIy 5 days a week
instead oC"daiIy screeninf:" tbat is required by the NeCHe standard. Until recently the PA and physi<:ian shared tbe same exam room. Under tWs syst:em confidentiality and privacy of care are sorely compromised. While Cl new exam room bas been established for the PA , she was observed conducting sick call in the same eDlDl room as the phySician.

Chart review indicated that inmates were generally triaged by the nurse within two to three days of their requesl. and were seen by a physician/PA within 7-10 da)'5-

Inmate interviews indkat(1Ci that they bad not received health educational material on the medication that they were taking. 1'hcre was however a large variety ofbcaltb educational, material in the health care unit where chronic care clinics were being conducted.

There is a co-payment program for sick call services in etfec:t. Awureness of co-pay progmn was evident among the inmates interviewed and lO~{) of tile inmates interviewed reported that they underS1 ood that ifthey did not have sufficient funds, health care would still be pro\'ided.

Consu/flltlons
Oifsite consults continue to be approve~ in a timely manner, by the contractor. Recent consults, requiring physician refenals for specialists were approved by Napbcare's utilization n:view process within, 24 to 48 hours, ofthc facility's request. A review ofthc medical record indicated that oftentimes consuhs were delayed for several months before approval was sought. For example inmate 164568 had a berni1L for four months the size of a grapeftuit before he wa:l finaUy sent for a surgical appointment. Inmate 169383 complained ofstomach puin for foW' months before a barium swallow was performed.

Infection Control
There ~ two inmates that were on prophylactic lNH therapy housed at the facility.
These patlCntS had beeD Illonitored for medication compliance.
Documented infection control efforts were not weU documentc~. There was DO documentatjon ofa quality improvement meeting held within fhe last 7 months. The site

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 38 of 43

HSA reported "We have not bad one ofthosc, something always comes up, but we will

have one s()()D. In a facility oftbis size that houses the majority ofthe HIV inmates, in a

system of27,000 inmates, a QI program is "essential" to meet. NeCHe standards. A lack

ofadequate monitoringJreportiug of infection control efforts and vital statistics in regards

to infectious/communicable disease is dangerous and extremely poor quality health care. A

. .

physician chaired, muhidrlciplinary Ql meeting should be held immediately. More recently, the new H:iA indicated that nurses we~ startin& to audit nve cha.rtS each

month. As oCtbe audit there bad been no physician involvement in the program and there

were no CQI or infection toutrol meetings available.

Dental Servieu
The facility bas a four chair dental unit. Sbalps and spore counts were current and weU
documented. There was a backJog, or30 inmates. No routine dental cleanings are
provided to inmates. The toothpaste provided by the DOC does not contain fluoride. No oral screening is completed when an inmate enters the facwty.. It was reported that inmates receive dental bYUiene instruction on admission to the system. A cOpy ohhis sheet was reviewed and it included the importllDCe ofbrushing and flossing instructions, however dental floss is nc,t provided to inmatcs as per DOC policy. A more comprehensive dental program is recommended. The Director of treatment for the DOC has begun a review of the contract requirements for dental services. Omission of routine dental cJeaning, and the b.ck of availability of fluoride does ncr.: meet any approved community standards ofcares.

Mental Health SeNko.
Mental Health services are under the direction ofa court monitor and wiD not be reviewed as a part of this contract.

Infinnaty
There is a total capacity of21 beds in the "infirmary" including 4 isolation ceUs. The unit included multiple admiss~ms dwing the audit that consisted cases involving HIV, pulmoDal)' complications. fi'actures and ceUulitis.. The infirmary area contained an
operational "ca.lllight" syrtem in tIDs area.
1bere were no admission sheets found for patients admitted to the infirmaJy nor were there separate chans as required by the NCCHe standards.
There was no documental ion ofinmate "in.firmary" runners had training on bloodbome pathogens, however it was reported that they processed an of the dirty "infirmary" linen, meal trays and soiled clothing on a regular basis. A lalUldry foT the health care unit inmates is maintained in the healtll care unit. One inmate runner was ohserved pro~ding

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 39 of 43
nourishmeotlfluid to one inmate that was admined to the health cafe Wlit. Holding a cup while another inmate consumes nowisbmtnt or medications sht,u]d only be pelformed by }jcensed heahh care provic.ers and inmate "runners" should pro'vide only custodial services.
Environmental Condhions in the InfimHIf)'
All sharr'S were flOt properly accounted for in the infirmary. ~rnere was at least 6 metallic restraint cuff keys that were not routinely counted. In addition there were 7 to 9 metallic spoons and knives that were being held in a plastic bag but the,-e was no docwnentation that they were ever inventoried. Failure to contmue to account for bUves, spoons and box
stae: cutters by hcahh care is a major security risk for the DOC prison facilities. This issue
has been addressed before and an example ofthis security problem is weD docwnented in the Tutwiler report months ago.
Phal"lJtfllCy
It may be prudent to revit~ the accountability oftbe pharmaceutical Ooor stock in this fuci1ity and the procedw-e for psychotropic medications. Zypre:d, Elavil. Thorazine and artane, were not counted ·)n a regular basis. The DOC securi~f reported that in the recent
past, mane was found in abundance in the protective custody dorm during security
sweeps. Narcotic counts were correct at the time ofthe audit. Pharmacy inspection reports wc:re not available during this site visit. The site HSA stated" I saw one oftbose things last Tuesday but I just can not find it or the other ones a.t this tiJ::ne". Two pharmacy repons wcxe located and :sent to the DOC in the next couple of days after the audit. Documentation of timely .M:countability for medications. including narcotics. by a pharmacist is esseDtial to 'meet DEA requirements and cOlDDlUllity standards. The pharmacy reports that we're &xed seemed accurate but should be stored on site and it is reasonable fot them to be retrievable. Three vials of opened in:sulin was not dat~ in the lUV dorm and pill caD f(] am. Sterile water in the main pill call. room was expired. Naphcare nurses reported thal they coJrtinue to use "individually ordeml" inmate medication as floor stock because "sometimes we run out due to delivery delays" This is not the first report ofdelays or lack of medication to facilities iin the Alabama system. lmnate #215180 bad an. e;ulier order for sul& but it was found being administered IS flOOT stock to '"Who ewr needc~ it". An order fur tlagyl for a disc:burged inmate was also found in the floor stock for "ge-ocral administndion" to anybody tba1 needs it. Inmate # 127819
bad an expired order for ~l psychotropic medication, Zyprexa, but it was also fO\Uld in fioor stock for generallfu,tn"bution. Nurses were administering Loritab, Phenobarbital,
Morphine and Tylrenol #~I also as floor stock. This practice is illegal and should ce_
iJnmP.niately. The administration ofprescnbed med1Cation that 'were oruered ana aispense<l
severa. - - - - - - ror other inmates or the administration ofnarcotics from stock containers is in violat;o!;"r
tliC DEA regwatlOos. Thi!; same problem was idenuned at me St'- Clur liCilit)' weeks ago.
A review and observation of the medication system during pill call indicated that the nurses that poured the medication were frequently not the nun;es who dispensed the medication. This is a violation of the Nurse Practice Act.

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 40 of 43
profesSional RegulaltiOns
Current licensw'e was on file for all staff . CPR training for aU health providers was not current. Twenty-three p:r cent ofNapbcare employees bad no documentation of current
CPR training. The HSA ;~eportcd that ~g for these employees including herself would be done soon". 1lle Deputy warden reponed that notification of CPR training. on site. for these employees had been provided to Naphcare. ott t1ume~u!' occao;k,"~, " however Napbcarc empl')yees did not attend.
There was documented ill-service training for oniy14% ofthe health staffhealth care statr.
Eighty -six per cent of the beahb care staffdid not have prolX~r documentation of continuing education on file. A planned agenda for training for the next several months was undeveloped but was unavailabJc for review.
StaR Administrative and StaffMeetings, CQI
Administrative meetings were held weekly with the warden mid minutes w~re available for
review. Health care meetings were not weD documented in de last year. A comprehensive CQ[ and infection control effort was not documented in this filcility. There bas been no disastl~r drills conducted at this mcility in the last twelve months. The HSA reported thai there was "8 problem" and it was ''Dever done".
Grievances and COmplaiJJt5 couJd not be tracked because as mentioned above there was no documentation ofQI act.vity. National aod comaltmity staod;ard~ require that OI
docnm:ntatiQD should list c:omp~tSt disease statistics, the~],ies, ~ many otbet' ~C¢a topics, to monitor and improve heaith care deUverv. .Review ofpossible agenda topics are wen outlined by the NecHe standards to assist health providen jn monitoring esseotw
health activities in the a:iIity.
#(itchen Inspection and Food Service.
The food service area WclS found fo he dean and orderly. A m'S't-aid kit was present but
poorly stocked. There \\ ere signs in the inmate bathrooms to remiJXi inmates of band
mr washing. Internal thenno meters the cooler m1 freezers wt:re opcratioaaJ and appeared
to be accurate. The last inspection report by the Alabama Department of Public Health on August IS'" 200J yielded a rating of98%. A sample tray ofe.ach meal is leept (or 24 hours. Tables where the inmates consume nourishnJent were D:Oted to be rusty. Seventeen half.gaUoajugs with ice were fuund on the Ooor ofone fieezer. These containers were reported to be used as icc! for the work squads. These should be stored otrthe floor. CBbbage, peanut butter aod mayonnaise were found to be uncovered. The DOC officer in the HIV dorm reported that the kitchen area in that sector hadl a leak in the roof. Annual inspectiolJS by the health department would be prudent.
Critical Incidents anc' Moltillity Reviews

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 41 of 43
Death reviews were not provided during this audit. Naphcare I"eported that deaths in this facility would come under review ofthe medical ad.~ry co~ttee. It ~~uld be noted that the Medical Advisor), Committee is a year behind mrcvJeWUlg moralities that have occWTed at the DOC facilities. Current standards require an on-site mortality review within 30 days of the death. This site has reported 14 deaths within the last year.
A listing ofdeaths fur 20Cl2 tbroughNove~~r S was provided along With very bnef
summaries of ten of the fhurteen cases. However, only the chart for the most recent death was at the tacility available for review. Two ofthe ten narrative swnmaries reveal a cause
of death that contradicts 1:hc entry in the list. These include J.C. who WiLt; listed as a
cardiac anest. while the S\lJDJJJ8[)' shows that he had pnetl1M11ja and diab:tic ketpacidos§.
The( other case was also listed as a cardiac arrest. wbjJ, the: direct causc was
..,&astrointc:stioal b1crding hecause ofend stage liver disease.
Based on the information available, it appears that six deaths this year ate attributable to AIDS and three were callsed by liver disease. This ca1culates to a rate of .23 deaths per thousand. This ratc is mure than twice the AIDS death fatc fJ om the 2001 ACA stA~ics and is also about twice tlle expectectnumber using statistics from ''The Com:ctions Yearbook' ....
The number ofAIDS deaths is remarkably high when one compares averages reported by other DOC systems. 11K: Medical Advisory Committee provides only a cursoIY morality review. It is recouunendcd that mortality reviews be conducted as a pan of the monitoring
process and that the resu'its ofthese reviews be reported to tb~ Medical Advisory
Committee.
Summtlty
Efforts to provide comprehensive chronic care evaluation, in this t3cility, have yet to be weD documented. Areas ,ieCommeDded for improvement include the development of policies and procedures that are site specific, to assist staffin specific facility operations. Staffparticipation in mardatory disaster drills, and site physica involvement in autopsy reviews should enhance QI efforts. The pbarmaty practices ~;bou1d be fWly reviewed.
Delays in the provision 0 fmPred pharmaceutical intervention for HlV inmates identified
wen at the Kilby fucilily should be resolved. Pharmaceutical prac:tic:es have been
documented as problems in other facilities, including administering medications to inmates
thaI were dispensed and. .)rdercd for other individuals contmu.:. This practice: L~ i1ltul and
could create liability for lbe nurses. the ooc ~ the contractQf. All re.gulatioM by the Drug Entorcement Agen••, sbouJa be adbaed to UnrncUunCJvA tQ ~ the safety of the
prison and help enhso;-' !m:ctive health care deJjy~n'. Removal of medICation that was l)iOereQ anu aispeD:.to!t1 to inmates thar are no longer in tbe system, rh.,. to death or end of
sentence~. shoU1d c.~ and des~t ~iate1y. V'QiJa~;s 8l~ clfmii.c..W-;unauUIOnzed, and UJega). pharmaceutlCa.l practwes derived by the fitcility staffshould become unnecessary. It would be prudent to document comprehensive CQl meetings as soon as possible and cont:inue meetings monthly to get a base line on facility activities.

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 42 of 43
Oral screenings, routine dental cleanings and fluoride should be provided. Regular inmate and employee educatio~ dforts in this facility are inadequate. Special educatiOnal etrorts should be documented for imnates, with chronic care issues ard for runners that may be involved in bandline material that is contaminated.. When the warden report·s that the site HSA displays "poor cobununication skiDs and is "a security risk for the facility" bealth care management ad,;ustnlent'slreplacements are usually prudent. Staff with less than • tni07JT1ttm. f!'3.inhlg in C~R. omission of r;w'datory disaster: drills. lack ofa curren: fa~ilitv evacuation experience, 0<1 current practlce of review oftnage, and obsolete contmumg health education docwrlelltation, rarely delivery healtb care th.'1t meets the community or national standards.
Recommendations
It is strongly recoll'll1leDCi.~ thai the DOC review all deaths th."t occur at Limestone. One fifth ofthe summaries P,ruvidcd showed a cause of death that ,;ontradicted tl1e listed cause on the fucility roster. Statistics should accurately reflect the cause of death and provide a
useful source of statist~l information. The reviews also provide a window mto multiple aspects of the detiveI)' bstem. Charts should be reviewed to 'see whether ~ppropriate preventive measures subh as vaccinations and TB testing arc working properly. Records should also be ew1uate~ from the time that .symptoms first began and to trac;k diagnostic
and therapeutic intervebt'ions. I
Three of the deaths ~\rTed as the resuh oftiver disease. The charts should be reviewed to determine whether these patients were evaluated for 'medic~ intervention including
therapy for hepatitis C Itt.d other measures to reduce the cotllpljcations ofliver disease.
A disproportionate number ofHJV infected inmates were nott~ to refuse medication.
Better docUIDe1ltation is needed to verify that these jodividual'i are fully aware of the
consequences of their aClions and able to panicipate in an informed refusal. Mental health evaluations are probablY warranted in each pa1ient who is reft:lSing treatment. At a minim~ ifthere is a tiistory of mental illness., the mental beahb naifshould complete an evaluation.
The cost to the system ofopportunistic infections can be probibitive, while the expense of preventive medicationsj ~ very minimal. Bactrim therapy for l)Qeumocystis pneumonia (PCP) prevention is lID ~n"DeDt example. This infection is hiJ~ lethal and extremely incapacitating. Hospitalization costs usually exceed S10,000, while the cost of prevention runs aroWld S2 a weelc~ PCP prevention should be strongly eJ)(:ouraged even ifpatients refuse other treatment..
The presence ofindividuals with badly impaired irrunune function who have become infected with oppommistk infection may pul others at risk, staffand inmates. The Alabama Department o'f:folealth should be consulted regardin@ deconwninatiop and other protective measures to n:duce the risk ofinfection. Toilet de<:ontamination procedures for Toxoplasmosis and other parasites should be evaluated in addition to testing the ventilation system to aSsure that it is adequate for TB prevent.ion. The installation of ultr3violet lighting is a w"rthwhiJe consideration for the main housing unit and the

Case 7:02-cv-02812-KOB Document 55 Filed 04/02/2003 Page 43 of 43
.. ,
The DOC should monitor staff vatallCies and medicuioD admiJ:Ustnrtian.. {ntenuptiorliR treatment programs can lead to drug resistance. Higb rates of drug resistance will tend to increase the cost ofoff-sil e care.

 
 Case 7:02-cv-02812-KOB Document 152 Filed 05/07/2004 Page 1 of 22

IN THE UNlTBD3TES DIS11UCI COURT

POll THE NOR

DISTR.ICT 0' ALABAMA

WBS DIVISION

O~ HAY -7 PH 3: 50

)

ANTONIO LBATHBRWOOD. BRIC

)

HOWARD. JERRY SANFORD. JOHN

)

LEVINS, MIaJABL PA1RICK, md,

)

iDdMduaIly IDd OIl behalfofaD pract IIId

)

future mv-poIi1ivo iDmatea in the Limeltone

)

CorrectiODll FacUity in CIpIbaw. AIabIma,

)

)

PJaiIdifti.

)

)

Y.

)

)

)

DONAL CAMPBELL. QmmriAioaer oldie

)

AJabIma DepIdmcat ofComlctioDa, RONALD )

CAVANAUOB. DiJCCtor ofTreatmcat AlabICIa )

DepII1meDt ofCcrrectioDl, BILLY Ml'I'CHEM. )

Wilden ofLimeltone Correctional

)

Facility, DAVJD WISE. Deputy Waniea,

)

)

)

----------------------~--)

CIVD..ACl'ION No. CV-02-BB-2812-W CLASSACl10N

IOINT M<P'ION TO ADOP1' SI1TLIMINT AGPPMJNT AND PRoyIDI lOB SlIW', MAmB

The Parties jointly IDOYO tbiJ Court to. .tho IitIIcbod order IdoptiDa IDd incolJlOlatiug

the Parties' Settlenumt Aareemeat (Bxbibit A Meta) ID4 providiq for • Special Muter.

this.:t- ReIpectfuJ1y aubmittod,

day ofMay, 2004.

Case 7:02-cv-02812-KOB Document 152 Filed 05/07/2004 Page 2 of 22
M.LlPMAN. F!.. Bar No. 280054 David M. LipmIa, PA 5901 S.W. 74 S1reet Suite 304
Miami. Florida 33143-5186
Telephcae: 305/662-2600 FlCIimile: 3051667-3361
FRANCIS A. ANANIA, PI. Bar No. 1602S6
IaDiI. BIDdIdayder, BIIckweIl, Baum.prtea,
Torricella &: Stein 8Imk ofAmorica Tower, Suite 4300 100 SA ~ S1net Miami, Florida 33131-2144 Tekphono: 3051313-4900 FlCIimile: 3051373-6914
STBPHBN HANLON. PI. Bm' No. 209430
BoUlDd" KDiaht UP
2\l99 PeaaaylVIDia Avo, N.W~ Suite 100 W-.lJinaton, D.C. 2()OO6..68()l Telephone: 2021828-1871 FICIimiIe: 20219S5-5S64
GUTamN ltOHR. GA Bar No. 613518 HoDlDd A JCniabt, u.P 1201 Welt P.:htnIe StNB, Suite 2000 Atlanta, GA 30309 Tclephaar. 400fJ898-8117 FIcaImilo: -4041881-0470
2

Case 7:02-cv-02812-KOB Document 152 Filed 05/07/2004 Page 3 of 22
~4~ Kim'l'bolDll. BIq. AIIbaa~ofComlcCioDl Lopl DiviJioa 101 South umoa. StnIeC MoIqcJmIry, AIabIma 36130 Co1IDIOl fbr l)eftmdanta
3

Case 7:02-cv-02812-KOB
85/85/2884 13:82 334353.:. ... ~1
.......
- - ...,...',"

Document 152 Filed 05/07/2004
DEPT OF CORRECTIl.JI~S

Page 4 of 22
PAGE 82/2a

IN nm UNrrEo stATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF /J...!JJAMA WESTERN PMSION'

)

ANI'ONIO LEAlHERWOOD, ElUC

)

HOWARD, reUY SANFOlU>, JOHN

)

LEVlNS, MICYAEL PATlUCK., and, ,

)

individually and on bebal! of aU p.resen1l1ld

)

future HlV-politivc inmates in the Limestone )

Coxrcctional,facility in Capshaw. Alabama.

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner otthe )

Alabaml Department of Coneetiom, RONAlD )

CAVANAUGli, Director of'Ireaanent Alabama )

DepUttctnt ofCorrections, BILLY MITCHeM, )

Warden of Limeatone CoucctioZlsl '

)

Faeilityl DAVID WISE, DeputY Warden.

)

)

Defendants.

)

--------------------------)

CIVa ACfION CLASSACTlON

SEmlMlNT AGB!'M!NI

The Ptaintitrs have filed euit ehalleqins me coDJtiNaional adequacy orth. medical &;arc

and conditions relating to HIV infcc;ted prisonm incarcerated 11 the Limestone Correctional

Facility ("Limestone',.

DefendAnu have denied, and continue to deny, allegations oIPbiiLti1fs' complaint and the connrussion of the conarltutional vi.olatio~.

The pllrtics have agreed that it is in 'their best interests to resolve this UtipIlOD.

'l'hetefore. the parties stipulalc and agree to the following provisions to resolve this

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lawS\rlt. L IutrocluctioD
1.1.' During the tenn of the Agreement, the l:1Dited States District CoUIt for the
Normem District of Alabama, Westeni Division. shall retain jurisdiction to enforce the terms of the S.l,iellle7tt Agrame1tt. This Settleme1't Azreement and tho Defendants' stipulation that their conduct Shall be governed by the standards set forth berein, shall automaticallytmninate two yean after the COUl't has grantect final approval ofita terms. Th. parties a p that this provision shall not limit Ol divest the Court ofjurisdiction over claims ofcumnt and Ollgoing violations of . the United Stales Constitution.
n. The StADdard of Care
2.1. The standard ofmedical care sball be consistCDt with ~ guidelines adopted by
the National Commission Oil COlICCtional Hea1th.care ('NeCHe', and the Centert for Disease
Control and Prevention ("CDC"). 2.2. This stmdard of medical care applies to antin=troviral treatment oCHIV infection
as well as the treatmCDt and prevention ofopportuJlisdc infections and other illnesses
experienced by HIV infeoted prisonm confined it Limestone.
2.3. Medically necessary services shal1 be provided in a timely mamlec. "Medically necessBl)'" refers to that which is required Cor the tl1cviation of''Pai~ p~ventioD ofdiseases, prevention ofdeterioration of t\mcticri or orptlI. or reduction ofmorulity. In Healthcare Stir!
3.1. An HIV Specialist and a medical doctor shall provide medical treatment at Limestone Correctional Facility ("Limestone"). The HIV Specialist will provide medical
.~
2

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treatment to HIV and AIDS infected priaonCII at Limestone. The HIV Specialist shall have mOlC

than three years experience in inpatient and outpatient management ofpatienu infected with
HIV. The: HIV Specialist shall devote at least thirty (30) hours per week to 1l'eatment 0.£lilV

infected prisonen. The medical doctor will provide medical hUtment to non-HIV infected

prisoners.
3.2,

The Medical Diro;tor shall be de.lsoate4 ~ the health authority confonning to

NCCHe P-A-02 (2003). The Medical Director should be, 'but not limited to, (1) ~eountable for

ac<;eSl to care ancl quality orcars. (2) cllilical 8upcni.Jo:o oflice:nacd health profc:as1oDals, (3)

penonnance MeUIU'tIDent, (4) utiU:zation management, and (5) quality management.

3.3. An additional full timo registered nUl''' shall be hired to work at Limestone. The

registered nurse shall sem: 3S an "HIV,Coordi.'l2tot' tnd coordinate the .infection control

program. 1bc HIV Coordinator shall be reaponBlole for coordinating care to HlV i~ed

prisoners includilla: eoordintrulg and supervising ,appoina;ncnts with both Limntone and with .

outside specialists; ensuring that follow-up care ordered by 0. medical provider OCCUl'l in a timely manner~ monitoring the progr~ and treatment of all known H1V infected prisoners at I.i.mestone; and organizing education on the trwmissiOll and ~tment ofHIV and other

infectious and sexually tranamitted diseuet. The HIV Coordinator shall alao serve IS a tria..

person for HIV infected prisODm needing to vitit the HIV Speciali8L

3.4. PrisooCfl 8hall not provide ~cy D\~cal treatment to other prisoners. This includes prisoners placing deceased prisoner bodies ~to'body bags. .

3.5. A registcmi nurse sball be on duty twenty (Olll' (24) hours per day, seven days per

week: in the Health Care Unit. A licensed practical nurse &ball be on duty sixteen (16) hours per 3

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day, seven days I weel\ in the HIV Domu.

3.6. C01'1'eCtional officcn shall not make medical decisions or medical judgments.

3.7. All staffing levels shall conform to NCCHe P-C-07 (2003).

IV. H..ltbcan SWf Trabaiilg

.

.

4.1. All medical and correctionalstafl' sh.a.lJ. ~ve current cardiopulmonary

resuscitation ("CPR") training. Train~ medical and conectional staff&hall be available to

perfonn CPR and other emergency aid when needed.. CPR. training shall be consistent witb the

recommendations of the American Heart Association or the American Red Cross.

Documentation addreui.ng CPR. trainJng for medical and comctiooal staffsball be maintained at

Limestone. App~ate prot=etive gear and adequate training for the use of the protective gear

shall be made availabJe to heaIthcaro and comctionaI 3ta1fto safely perfmm CPR.

4.2. All ~~tcred nurses (14RN'') and licenacd practical nmes ('"U'Nj shall Dot make

medical decisions outside the scope of their Ucenie:

4.3. All medical stail'must attend continuing medical edu.cmonal programs ..

!

or recommended by the state of Alabama and provided h1 the AleblXllI Rul~ ofRegWations the

I ; .

I

Board ofMedical Examinm. Attendance ofhealthcare sWrat continuing medical education

!

i programs shall be documented.

4.4. IfLimestone lacks adequate resources for the medical treatment ofAD HIV

infected priSOl'ler, then the prisoner .ha.lJ. be sent to an outside .tpccfali.tt in • timely mazmCl'.

Diagnostic reports. cODIultation reports, and hospital discharge summaries shall be incolpOrated

into the HIV infected prisoners' Limestono medical record.

4.5. Copies ofan HN infected prisoner's Kilby Correctional Facility medical record 4

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mv shall Collow the infcef,cd pritOna' it Limestone.

V. Periodic EvaluatioDs 5.1. The HIV Specialist shall see all HIV infected prisoner at least qUll1Q'IY, or more
frequently as mediea1ly ntceuU}'. which wi~l include: a history. pbysical examination, Dlld

evaluation of current CD4.... levels and Vinlload. All prisoners with AIDS shall be seec every

sixty (60) days.

5.2. Any HIV infec:rtod prisoner taking medications wmc:h can damage the livCl',

'including bu~ not limited to Isooia:tid ("lNH"). or w'bD dem.onttrate sip ofliver dysfimetion

shall bave their en%YJnes moni~red periodically.

I
!

i

VI. IDrec:tioD Coutrol

I

6.1. The registered nurse referenced in seetlon mhereofshall impltment the infection

I

I

control progam aod doeummt che activities of the Limestone intectiOD control program. The

i

J
:

, inftction CODtrol program shall include: airborne mel blood bomepathogen control pl8DI that

I
, i

follow CDC.

I

6.2. All pr150ne:s who have, or are suspected to have, contagious tuberculosis. ,shall be

i·

placed in respiratOry isolation until they bave no longer pose a rilk to the public health,

I

especially to other HIV infected prisoners.

6.3. Protocols ahall be adopted to minimize the spread ofMetb,ieillin Resistant

Staphylococcus Au.rc:ul ("MRSA'') amona the my infected prisol1er population at Limestone.

The MRSA guidelines will address: (1) prevention, (2) examining:md inteniewing pri$ODf:rI at intake and lis1ins MRSA 011 .. prilonert , '~roblem ~at" in. tbeir medical chart,,(3) diagnosis and
treatment. and (4) MRSA outbreak and control protocols.
5

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YD. Mc:dicatiOD AdministratioD

1.1. Medication shall be provided withlD forty·eight (48) hours ofbeing prescribed by the liIV specialist. Medicazions shalll?e provided iu appropriate doses and times in a~cor4ance

with Food and Drug Admizmtration ("FDA") approval.

7.2. IfHIV iofcctcd prisoners refuse the dose, c:ounselina sb.a11 be provided and the

record shall document this eoW\se1ins. HIV infected prisonexs who m.i.. doses on three consecutive clays shall be seen by the ptescri'bing physician aDd counseled. A ~ord ofsUGh

counseling shall be maintained.

7.3. Criteria shall be established for a "selfmedication"prosram. Each HIV infcc:ted

prisoner that keeps JJ\edication on their puson shall be provided C'lcar written instrUctions Cor
medication ~atio.n, including doling timina and pote:ntiallide eft'ccts for each

medication. All HlV medicationl shall be admj;nist~ and dispensinl documalted, consistent

wilh FDA reoommcodaticma.

7,4. No medication prescribed to ODe prisoner shall be given to another prisoner in

accordance with the rules and regulations adopted. by the 'DIu, Enforcement Aleney r'DEAj.
7.5. Medication shall be hand Gl;livareci to aUlcutoly u,. mv.infected prisoners.

Medication shall be administered to HIV infected. prito'ClIIl'I in striot accoxdance with the

prescriptions •• including di.rccti.ons relating to the timing ofHIV medicatiOD adminiJtratjon in

relation to food and water intake.

7.6. When medically appropriate, a snack sball be provided With the distribution of medication.

7.7. All HIV infected prisoners shall have access to frub drinJdng water twenty.four

.

6

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hours per daYJ seven da~ PC[ week.

7.8. The medication formulary shaU include mcdication5 typically uaed to lTelt mY

infection, oo-oc:currlng illnesses, and opportUnistic infections. Ala minimum, the fo~u1ary

shall be updated quarterly. The fomnslary shalllM published armuaDy.
vm. Chronic Car~ ofHIV·Po.Jdve PrhoDcrs

A. lDV..posltlVe diabetic: prllOnen.

8.1, Treatment fot' HIV infected prisoners with diabetes mellitus shaU confonn to

Gaddis et. At. v Campbell etc at.. uttlement a.Srecaent dated October. 2004.

B. Hepatitis A. B, alld C IcretDblg ud treatmeat.

8.2. HIV-positive prlaoners ahall be vaccinated agamlt Hepttitis A and B.

8.D. Treatment oCHIV infected prlso~en with Hepatitis C shall conform to Baker. et.

at. v. Campbell. et. a].. scttlcmcmt agreement dated ---.J 2004. HlV lnfcc:tcd prisoners with

symptoms oCliver dysfunction and who have a ne28tive HCV antibody test, 8ball be

i
!

admwS1ered In Hev PeR test, as medically Inlficased.

i'

IX. Food

I·

9,1. All HN infected prisoners shall receive three meals per day, six days per week.

On Sundays a%Id holidays. all HIV in:fected priscmers shall receive two meals per day and a

medication food sack consisting of one sandwich and eight ounces of milk.

9,2. Mca:1s shall be served to HlV inf~ prilODers after 5:00 a.m.

9.3. HIV infected prisoners prescribed special diets ~ be provided a special diet.

9,4. HIV infectod prisoners shall bave,medical diets addrcsalng their individual

medical needs for calories, carbohydrates and fRt. A record ofthose prisoners receiving special 7

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diets IlWl be maintaiJ::led ~ Limestone. 9.5. Patients with wuting shall have dietary suppll:JIlentation and mtdicatioIl5 as
medically nccessary. X. Emerleneie.s
in 10.1. A wireless intercom system Iball be placed five cells per dorm used to house
HIV infecled prisoners. The wuelcss intercom .in these ccUs lhaU be li%Jlced to the dormitory officer station. These cdls shall be available for acutely ill HIV infected prisoners.
10.2. Bmeraency drills shall be conducted one time per yev involving both medical and comctiou1 staff. The medical cmergerioyplan shall conf'Olm with NCCHC P-A-07.
10.3. An emcrgencymedical plan shall be developed in conformity with NCCHC standards and shall be active twenty-four hours per day, seven days per week.
10.4. DuriD, emergencies, all medical d=isions .hall be made by an on·sitc, ·0000000ry
medical penon. 10.5. All emergency medical equipment shall bo kept in good working condition.
XL llIta1ce at Limestone 11.1. Within twenty-four (24) bours ofaniviIlg at Limtstone, tho HIV infected prisoner
shall have an iniake assessment or screenina by a nune. This assessment shall include, but not be limited to, inquiry into communic~lo mseiiell, includin, tubc:roulosi. and sexually transmitted. diseases, and urgent conditiOns; review and CODtinuation of any medications; and timely referral for HIV infected prisoners .in urgent need otphysician teYiew.
11.2. Within two weeks of arriving at Limestone, the HIV infected prisoner shall be seen by tile HlV Specialist or a mid-level provider.
8

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1J.3. Ifan HlV infected prison.. can jd~t:ift his mcdi,.tion ,upon entry at Limcatone.

then the medication shall be continued provided the prescription for such medioation can be

vo:ified by a physician or plwmacist. There Shall be no UDDCCesaary l1isrupnol1 in the ~ontinuity

ofmedication. The, intake provider shali ask each known HIV infected prisoner 'to sign a release ofinformation fOlm 30 that confinnation otanytreatment ~gimen and exchange ofrelevant

, information can taU plac~ u soon as possible.

11.4. Within {orty..eigbt hours ofamving at Limestone, in HlV infected prisoner sholl

be referred to the ijIV Specialist
11.5. .All HlV infected prisoners shall be te6tcd tor syphilis and screened for ch.Iamydia,

and gonorrhea. Testing for chlamydia and JOllOnhea shJll be performed if aymptoms are

present.
xn. Eucl-o!-6fe Treatmeat

12.1. Appropriate palliative eare shall be provided to all end-of-life HIV' and AIDS

j,

infec:ted prisoneR.

12.2. ''Temrinally ill" is de.tmed as aphysical condition that his deteriorated to tho

pointwbere 1he patient has been given )cssthan I yqrto live. S,eNCCHC P-G·12 (2003). At

the poilU that an BIV infected prisoner becomes terminaUy ill. the prisoner shoUld be counseled

regarding end ofliIe care.

12.3. Ono option for end of life treatment may be to continue vigolOUI tteatment. The

HIV infected patient may also opt to or may also choose to refUse certain Ute prolonging
mv measures which could include: iotraYenous ~ mechanical ventilation, Ot' CPR. The
Wccted prisoner may then sign an Advanced ~edical Directive, consistent with state law, 9

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regarding th~r choice regarding cmd onife: care. At least two witnc!lcs al,o .hall sign an
Advanced Medical Directive. l'n no case sball aD HIV infected prisoner be denied appropriate comfort, sut:h as medication for pain. A copy ofthe end of life treatment requC$1 shall be maintained in the HIV infected. prisoner's modical record.
xm. mv Pbya!caUy Dfaabted Infected Prisoaen
13.1. Celli used to confine physically disabled HIV in:f.ccted prisoners shall ha-..e adeqUJte hand-railing.
13.2. One shower in each HIV dorm shall have adequate hand-railing. raa1p Imtry, and
seating. 13.3. If medically indicated. an HIV i:D!eaed prlsoncr shall have a ptOSthesis re-fined
for a rmsed or new pros~is within ninety (90) daya. XIV. Deatal Services
14.1. HIY infected prisoners who require dcnturea &hall have timely.dental treatment, including the making ofdenture imprcsalons, to prepare for proper use ofdCllt\U'CS. Dentures shall be delivered and fined within sixty (60) days ofimpreuioDJ.
14.2. All HlV infected patients shalJ have access to prophylactic dental bygiene, Which include dental cleanings. at least annwalG'. XV. Trlaee System
IS.1. All sick call slips shan be triaaed daily for degree ofurgc:ncy. All medical
informal grievance rorms and medical Connll gricvlIlCe fonns shall be triagee! r-Jety five days for degree oiUJ'gency. The triage system for'aiclc·call slips, medical complaint fotms, and medical grievance Coons shall conform with NCCHC guideline P-E-07.
10

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XVI. C~paym.DtI 16.1. Co-paymec.ts shall aot be assessed Cor cbroW.c: care clinic appointments.
emergency care, care ofconunuruoabJo diseases, or aDy foUow.up appointments. 16.2. All co-payment fees shill be accurately documented. 16.3. A document describing the Limestone co-payment system shall be postal in the
mv hliceted living quarters.
XVlL Complaint l1ld Grievance PrOcell 17.1. All HIV infected prisoners &ball have reedy aceen to COIQplaint and gricvanco
f01'1lU; be informed of the location ofthc complaint and grievaaco forme; and be provided documentation describing the comptamt and grievance proc...
17.2. All complaint and grievance forms shall be accurately trac.ked by the Continuing Quality Improvement C'CQI") program.
17.3. All informal srievanus Jubulitted by HlV infected prisoners 1hal113e answered
within sovmty-two (72) hours. .All formal grievances submitted by H1V fntected prisoners shall be answered within in :five (5) days.
17.4. All HlV infected. prisoners sball be provided duplica1c copies of the medical grievance f'oxms tbAt are submitted.
17.5. A log sball be kept documClltinB all medical grievance forms submitted. 17.6. A medical staffperson shall prepare a monthly report Idd.rcsIing tbc number,
substanCe, and resolution to medical gricvIDCe forms. nm report shall be maintained at
Limestone.

11

.

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xvm. TJ'aDlJaton
18.1. When Spamsh speaklDg HIV int'ected prisoncrB visit the mY-specialist or physician assistant for sick caU, a translator shall be located. XIX. Hauug
19.1. Housing facilities will be clWlcc:l on a daily buis; the housing areas shaD be disinfected between prisoDer placement: and the physical conditions of the hoUsing areas be
m.aintain~ tn 'good womng order. The Department ofCorrec:1ions sball conduct weekly checks
on these housing areas to eIlSUl'C (bal sani~tion and physical conditions comply with these standards, and shall respond promptly to any deficiencies id~fied during these checks. Sanitary supplies sucb 31 soap. clesn towel" bleach and disinfectaDtllhIU be made Available to prisoners and staff as needed. Gloves and other safety equipment .recommended dw:ing uagc of certain disinfeetanta shall Dc provided to my prisoner or staff usi;nJ the product. The Department of Corrections shaU maintabl an 'axposure control plm far blood-borne pathogens consistent with the tenns ofthis Agrvemen.r.
19.2. There shall be no donnitory or open-bay houaing or triple celling ormY infcoted prisoners.
19.3. Rodent and pest control !han be COJ2duded OD • moo1hly basis, or as needed.
xx. mv CouDleJor
20.1. H1V infected prisonet1l shall be intonned. that they may visit an HlV cou:nae1or. HIV oounseling at Limestone can be provided by'outside &gQcies incJudin, representatives from
Public Health J:UV Division or AJabama AIDS Outreach. HIV cOW1lcling ahall be provided at
Limestone one day per week. 12
'J "

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20.2. The HIV cOUDlclor shall have relevant training or experience in the area ofHIV. 20.3. HN infected prisoners shall be able to request a visit with the HIV cOWlSelor through the Limestone tick-call procedure. XXI. BlV Edllc.adoD 21.1. Outside HIV educatcrs, pamphlets, newsletters, and up-to-date periodicals addressing HIV disease education shall be accessible 10 HlV infected prisoners. 21.2. Periodically, a persoll with knowledge oflUV disease sha.ll conduct group edue:l.tion sessions with HIV infected pl'isdnera.
of XXII. Rel.... fro~ tlae Department ContetioDI ("DOC")
22.1. Upon release from the DOC. all HIV infected priloncn shall baTe TCaaonably expeditious access to their Limestone medical records upon submission of a signed medical release of information.
22.2. Upon the aubmisaion of a signcci mcdiw1'01cuc. an outside medical provider shall have acccu to an HlV infcetcd prisoner'l LimalOl1e medical rceonfl.
22.3. Prior 10 being released into ~ community, an HN infected prisoner shaU be provided adequate and appropriate discharge planning.
22.4. UpOll ~leas~ HIV infected prisollO:r1 shall be provided at least a thirty (30) day supply ofmedication.
22.5 The DOC shall invite l~c:u Social Security Administration ("'SSA'~ represeatatives to visit Limestone IUld register the faciJily for the SSA Prerelease .Program for the
~tutionalized.
.13 .

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xxm. COllftcleatiaUty
23.1. Confidentiality :lddressing the HIV status ofprisoners aha1l be maintained. XXIV. Mortality
24.1. All DOC mortality reviews shall be candueted by the Depar1ment ofCorrections, its agents or coatrators within thirty d4ys ofan HIV positive prisoner's death.
24.2. Documentation shall be maintAined ~dreui:as the number of HIV infected prisoner deaths :per year.
24.3. The Department of Con8orious shall provide Plaintiffs' counsel with a copy of all DOC mortality mriews or MAC reports within fifteen daY' of completion.
24.4. Full intemalllld exttmal a\rtopt)' reviews shalt b- ~D.duetocl after an mv
infected prisoner's death, as long IS the cost ofeach individual review docs DOt exceed SlSOO. XXV. Quality Improvl':lQent Program (lfCQr')
25.1. The De.P~tI1l: of Correetioos Ihall perfoxm an on-JOmg Quality lmpravement
Program at Lbnatone•
.25.2. Copies oftbo Qualitative lmprovement findings.. concluaioM, coxrcctiveplms. and any other reports anC! outcomes ofthe corrective plans shall ~ maintained at Limestone.
25.3. Staff!hall also perform qualitative aulyaj. to identify problems. and sluD implement timely re~~dies.
25.4. A multi-ctisciplinary QualityllllDlFMalt Committee shall meet quarterly, ODd sball perform at least quarterly reviews of all upectl ofhealthearo. The Committee shall involve
of . the participation qualified professional. with appropriate specialties and representatives from
all clinical departments at Limestone.
14

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XXVI. Medical Consultant 26.1. Subject to CoUl1 approval. the Plaintiff's and Defendants ,shall identify a ntUtral
medical consultant, independent of both Plaintiffi and Defe:udan~ to facillitate the implClllcntation ofthis Settlement Agreem~. The medical consultant shall be experienced in correctional htaltbcare and HIV infectioD. The parti., asree'that _ _ shal14erve as the

medical consultant. 26.2. ,The fees and expenses oftbe mcclical cousultant shall be bome equally by the
DOC and. sam.. 26.3. UPOD' entry of this agreement, and for a period of two years, the medical
consultant will tour I..imc.stolle four times pc year, far a total of'eiSht visits. for the four ytal'ly visits, the medical consultant shalt notify the DOC at lew one week prior: to the visit. 1'hc medical consultant's vilte shall Jast no 10000000than five days.
26.4. During each viSit. the medical consultant sball meet with any medical ltaff or other Limestone ataft', shall toUt Limest.cme. and mayre\'iew all recorda relating to the mQ(lical

condition, living conditiotUllDld food servic.e provided'to thc class. '

26.5. At the conclusion of the medical COIlSultant's toar. an exit conference shall be conducted with Limestont medical ,~ oorreotioDIl stlft't plaintlHa' COUDael and defendants' counscl'ac1dressing positive ch8l1ges~ failures to conform witb this Agreement, md sugaested

remedies.

XXVlt Draiijty Eutorcemot

27.1. Mental health cvaluations, trea1ment, and ~at.fing shall conform with the ~

,

'

~ settlement agreemonl

IS ,'.,<

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",

XXVIU. CODcNlloD 28.1. Upon any report or observation ofp088ible noncompliance with the Settlement
Agr,emetlt, tho plainti1l's shall submit I written dcacription to tho Defeudant. addressing tho noncompliant acts.
28.2. The parties agpc that the re:mcdial pbasc ofthis case ia sufficiently ~mplcx to warrant the appointment of a special master pU1'l\Wlt to 18 U.S.C. 63626 (1)(l)(A). Magistrate Judge John Ott shAll serve as special muter. The parties also agree to waive their right to an interlocutory appeal chaUc~g the District Court'. ~ent ofMa,istrate Judge John Ott as special masterpunuant to 18 U.S.C. §36l6 (~3).
28.3, Upon receipt of the complaint, tho Defendmta shall have 1S days to re:so~ the dispute.
28.4. Prior to applying to the Special Muter tor such reli~ Plaintiff~' counsel will tty to resolve the issues infomtally with fbe Defendanta and the Monitor.
28.5. It after 15 days, the dispute h.u not be aaequately molved, then the Plaintiffs may petition the Special Mast=- to make lindings offact addressing noncompliance, ill accordance with 18 U.S.C. § 3626(t)(1)(A).
28.6. Upon entty of the Special Muter. findinga ofnoDcompliucc. Plainti1fs may petition the District Court for an order enforcing specific provisions 'oftho StJtl'1IIl11lt Agtwmenl and providing other tppl'Ol)riate relic!.
28.7. The parties agree and stipulate, that the prospective nlie! set forth in this Settlement Agreement is narrowly ~. extenda no h1hcr than necessary to c;:~ the alleged violations of plaintiffs' fedeml rights set forth in the Second Amended Complaint, and is the
16 .~. 'k

Case 7:02-cv-02812-KOB Document 152 Filed 05/07/2004 Page 20 of 22

05/05/2004 13:02

DEPT OF CORREC1. _. ~S

PAGE 18/2e1

least in1Iuaive means necesa&ry to comet these alleged violations. 28.8. The parties agree and atipulate. that this SdtlBM1lt AgrumenJ win not have an
adverse impact on the public :!Iafety or the operation of the operation of the criminal justice system.
mar 28.9. AccordiIlily, the parties agree and stipulate. this Sutitme11t Agreemenr
complies in all respects with the provisions of18 U.S.C. § 3626(a). 28.10. Prior to tbe Court's.approval oftlle Settlement Agreement, Plaintiffs' counseJ
shall·be afforded the opportunity EO meet with all ellli membeR - in groups of It least fifteen t~ inform them ofthe provisions of th~ SoltlemCll1& Agreement Class mClllbcrs shall bo informed that they have the right to accept or object U) the remu of'thc Scttleutent .\eremumt, and how they may express their acceptance or objcdioos to the terma thereof: pursuant to Rule 23(e)(4)(A) ofthe Fed.~ Rules ofdie Ci'Yil ProceduR. Consistent with R.wtl23(c), notice of the Settlement Agreement shall be posted in aU areas wed to house HIV infected prisOncrs- at Limestone.
28.11. In the event the parties are 1mable to hereafter resolve by agreement issues relating to.Plaintifl"s' claim for attorneys' fees, Plaintiifs may petition the Court within sixty days
ofthe date 00 which the Court.men itS cnd.er srantinc th~ parties' Joi1tt Motion to Adopt
SerrlemelU Agreement Qnd Pr01lidsfor Special MtU'''',for a~lutlcm thereof.

By:

DavidM.L

.David M. I.J m

5901 S.W.7

Swte 304

Miami, Florida 33143

Date: ~il{O~
Esq. FranCis A. Anania,
Anaoia, BmdkIayder, ct &1. Ste. 4300.100 s:e.Second St. Miami, Florida 33131
17

Case 7:02-cv-02812-KOB
e5/e5/2ee4 13:e2

Document 152 Filed 05/07/2004
DEPT OF' CORREC1._.~5

Page 21 of 22
PAGE 19/2e1

~tcbCJl RoM. Esq.
Holland .t Knight. LLP.
Suito2000
1201 West Peacbtree St
AJlan1A,' Gcoraia30309

Stephen H8Dl~ Esq. HoUaad. &: Knight. LLP. Suite 100 2099 PemwylveniaAve, N.W.
Washington, D.C. 20006-6801

Cok1Uelfo,. Platllti.ffi

~,w. ~L mA.j~,. ~tDt> By: ca ClOOk. Esq.

Dote: ~ I

Jf

William F. Addison, ~q.

Kim Thomas, Esq.

Alabama Dcparancnt of Ccmectiona

Lep1 Divisicm

101 SoUCh Uni01l Street

Montgomery, Alabama 36130

eowu,1for D'iDUla17u, Alabama Dept ofCorrections;
DoDal Campbelli Ronald Cavanaugh;
Billy Mitchem. Warden of Limestone ComctionaJ Facility, David Wise, Deputy WardeD

18

..:.'

":

Case 7:02-cv-02812-KOB Document 152 Filed 05/07/2004 Page 22 of 22

05/05/2004 13:02 33435 31

DEPT OF CORR~C1. S

PAGE 20/20

..,.~
19

 
 Case 7:02-cv-02812-KOB Document 165 Filed 06/24/2004 Page 1 of 3
F-IL.ED

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

04 JUN 24 PH 3: 07

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HIV-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD )

CAVANAUGH, Director of Treatment, Alabama )

Department of Corrections, BILLY MITCHEM, )

Warden of Limestone Correctional Facility, and )

DAVID WISE, Deputy Warden,

)

)

Defendants.

)

U
EN1EREO
JUN 2 ~ 2OO't
CV 02-BE-2812-W

MEMORANDUM OPINION AND ORDER

This matter is before the court following a hearing before the magistrate judge to

determine the fairness, reasonableness, and the adequacy of the proposed settlement and the joint

motion of the parties for preliminary approval of the settlement agreement (hereinafter "Joint

Motion") (doc. 148) filed by the parties to this action. The court has carefully considered de

novo the "Joint Motion;" the court's orders of May 7,2004, granting the joint motion ofthe

parties to adopt the Settlement Agreement and provide for a Special Master (doc. 153) and

directing that notice of the proposed settlement be given to members of the certified class (doc.

156); 1 the submissions concerning the fairness hearing; the report and recommendation of the

1 This notice provided the class members with the terms of the proposed settlement agreement of the parties; notice of their right to object to the same; and the date, time, and place of the fairness hearing.

Case 7:02-cv-02812-KOB Document 165 Filed 06/24/2004 Page 2 of 3
magistrate judge concerning the fairness hearing; the defendants' limited objection to the report
and recommendation of the magistrate judge; the actual notice to the class members (doc. 154);2
a document captioned "A Cry For Help From the H.I.V. Inmates at the Limestone Corr.
Facility;,,3 and the parties agreement to entry ofthis order (doc. 152). Having reviewed and
considered these items, along with the remainder of the file, the court is of the opinion that the
magistrate judge's findings are due to be and are hereby adopted. Moreover, his conclusions of
law and his recommendation that the proposed settlement should be adopted are accepted.
Accordingly, it is hereby ORDERED:
1. The Order of May 7, 2004, granting the joint motion of the parties to adopt the Settlement Agreement and provide for a Special Master (doc. 153) is reaffirmed and incorporated herein and
a. The Joint Motion for Adoption of the Settlement Agreement (doc. 161) is GRANTED and the terms thereof are hereby adopted and incorporated herein;
b. In accordance with the Settlement Agreement, during the terms of the Agreement, the court shall retain jurisdiction to enforce the terms thereof;
c. The Settlement Agreement shall automatically terminate two years after this court has granted final approval of its terms; and,
d. The court hereby APPOINTS Magistrate Judge John E. Ott as Special Master under the Settlement Agreement.
2. The court has considered the "limited" objection of the defendants and the submission of the "H.lV. inmates" in this matter and finds that they do not alter the court's determination that the proposed settlement should be adopted.
3. The terms and provisions of this court's order of May 7,2004, have been carried out and satisfied by the parties to this action.
4. The Settlement Agreement previously filed in this action and the terms set forth therein are found and determined to be fair, reasonable, and adequate, and are hereby
2 The court notes that the objections of certain class members were addressed by the magistrate judge in the report and recommendation that was filed after the fairness hearing. (Doc. 163 at pp. 23-25).
3 This document was received June 16, 2004, and it chronicles the struggles of certain inmates at the Limestone facility.
2

Case 7:02-cv-02812-KOB Document 165 Filed 06/24/2004 Page 3 of 3
APPROVED. 5. The court finds that the manner and method used to provide notice to the class
members were fair and reasonably calculated to provide actual notice to the class members and complied with all the requirements of FEDERAL RULE OF CIVIL PROCEDURE 23(e) and due process. The Clerk is DIRECTED to serve a copy of this memorandum opinion and order upon counsel of record and the objecting plaintiffs. The objecting plaintiffs are to be served by posting this "Memorandum Opinion and Order" in accordance with the notification process previously issued in this case. (See Doc. 156).4 The defendants are hereby DIRECTED to post the "Memorandum Opinion and Order" in the same manner as was done regarding the Settlement Notice.
DONE, this t h * J u n e , 2004.
4 The "Memorandum Opinion and Order" shall be posted in Dorm 6, Dorm 7, the Health Care Unit, and all other facilities used to house HIV prisoners at Limestone Correctional Facility within twenty-four hours from the date it is entered.
3

 
 Case 7:02-cv-02812-KOB

r:"'n ~~

4

,, _ _ _ _

~

Document 174

Filed 11/30/2004

Page 1 of 4

FILED

2004 Dec-01 PM 02:50 U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT

o. ~R THE NORTHERN DISTRICT OF ALABAMA

:;.

WESTERN DIVISION

,';

)

ANTONIO LEATHERWOOD, ERIC

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRICK, and,

)

individually and on behalf of all present and

)

future HN-positive inmates in the Limestone

)

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of Corrections, RONALD )

CAVANAUGH, Director of Treatment Alabama )

Department of Corrections, BILLY MITCHEM, )

Warden of Limestone Correctional

)

Facility, DAVID WISE, Deputy Warden,

)

)

Defendants.

)

--------------------------------- )

CNILACTION No. CV-02-BE-2812-W CLASS ACTION

PARTIES' JOINT MODIFICATION OF SETTLEMENT AGREEMENT

Joshua R. Lipman Southern Center for Human Rights 83 Poplar Street, N.W. Atlanta, Georgia, 30303
David M. Lipman 5901 S.W. 74 Street, Suite: 304 Miami, Florida, 33143
1

Charles Crook William F. Addison Kim Thomas Alabama Department of Corrections Legal Division 101 South Union Street Montgomery, Alabama 36130

Case 7:02-cv-02812-KOB Document 174 Filed 11/30/2004 Page 2 of 4

Stephen Hanlon Holland & Knight, LLP Suite: 100 209 Pennsylvania Aven, N.E. Washington, D.C. 20006-6801
Francis A. Anania Anania, Bandklayder, et. al. Ste. 4300, 100 S.E. Second Street Miami, Florida 33131
Gretchen Rohr Holland & Knight, LLP Suite: 2000 1201 West Peachtree St. Atlanta, Georgia 30309
Counsel for Plaintiffs
Dated: November 29, 2004

Counsel for Defendants, Alabama Department of Corrections; Donal Campbell; Ronald Cavanaugh; Billy Mitchem, Warden of Limestone Correctional Facility, David Wise, Deputy Warden

2

11/23/2C00a4se 174:0:529-cv-03238431523-3K8O91B

Document 174 Filed 11/30/2004
DEPT OF CORRECTIONS

Page 3 of 4
PAGE 02

SOUTHERN CENTER/or HUMANRIGHTS
83 Poplar Street, N.W., Atlanta, Georgia 30303-2122
(404)688-1202 F4lX (404) 688-9440 E1llIlil: rigbt8@80br.org Wab site: htip:/lwww.scbr.arg
November 23, 2004
Charles Crook Alabama Department ofCorrections Legal Counsel 301 South Ripley Montgomery, Alabama 36130
RE; Leatherwood. et. al. v. Campbell, et. al.
Dear Charles:
I believe the following letter memorial.izes our conversation on November 22, 2004. Pursuant to our conversation, the following provisions ofthe Leatherwood, et. al. v. Campbell, et. al. Consent Decree have been modified. These provisions include:
7.2. Ifmv infected prisoners refuse the dose. counseling shall be provided and the record shall document this counseling. mv infected prisoners who miss doses on three consecutive days
shall be seen by the prescribing physician and counseled except those patients on Keep On Penon medication. A record of such counseling shall be maintained.
15.1. All sick call slips shall be triaged daily for degree ofurgency. The triage system for sick-call slips, medical complaint forms, and medical grievance forms shall conform with NeCHe guideline P-E-07.
Once I receive a signed copy from you, I will forward a copy ofthese agreed upon changes to Dr. Joseph Bick and Magistrate Judge John Ott. Please feel free to contact me at: (404) 688-1202, should you have any further questions or concerns. You can fax the signed copy ofthe letter to: (404) 688-9440. Have a nice Thanksgiving holiday.

1

11/23/20C04ase147::5092-cv-303248351323-8K9O1 B

Document 17D4EPT FOiFleCdO1RR1E/3CT0I/O2N0S04

Page 4 of 4
PAGE 03

BY:

Date: n \ 1.. '1) 0'1

Francis A. Anania., Esq.

Southern Center for Hwnan Rights Anania, Bandklayder, et. al.

83 Poplar Street, N.W.

Ste.4300, 100 S.B. Second Street.

Atlanta, Georgia, 30303

Miami, Florida 33131

David M. Lipman, Esq. David M. Lipman, P.A. 5901 S.W. 74 Street, Suite 304 Miami, Florida 33143

Stephen Hanlon, Esq. Holland &. Knight, LLP. Suite: 100 209 Pennsylvania Ave, N.E.
WaWU~n,D.C.Z~6801

Gretchen Rohr, Esq. Ho1laod & Knight, LLP.
Suite: 2000 1201 West Peachtree St. Atlanta, Georgia 30309

CounselIt»' Plaintiffs
By: ~.'1JL. £.iP"; Charles Crook, ESq. WilUamF. Addison, Esq. Kim Thomas, Esq. Alabama Department of Corrections Legal Division 101 South Union Street Montgomery, Alabama 36130

CounselIt»' De.lend4nis. Alabama Department ofCorrections;
Donal Campbell; Ronald Cavanaugh; Billy Mitchem, Warden ofLimestone Correctional Facility; David Wille; Deputy Warden

cc:
Dr. Joseph Bick Magistrate Judge John Ott

2

 
 Case 7:02-cv-02812-KOB

Document 182

Filed 01/03/2005

Page 1 of 2

FILED

2005 Jan-03 PM 02:48 U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION

ANTONIO LEATHERWOOD, ERIC

]

HOWARD, JERRY SANFORD, JOHN ]

LEVINS, MICHAEL PATRICK, and,

]

individually and on behalf of all present ]

and future HIV-positive inmates in the

]

Limestone Correctional Facility in

]

Capshaw, Alabama,

]

]

Plaintiffs,

]

]

v.

]

]

DONAL CAMPBELL, Commissioner of ]

the Alabama Department of Corrections, ]

RONALD CAVANAUGH, Director of

]

Treatment Alabama Department of

]

Corrections, BILLY MITCHEM,

]

Warden of Limestone Correctional

]

Facility, DAVID WISE, Deputy Warden, ]

]

Defendants.

]

CV-02-BE-2812-W

ORDER THIS CAUSE having come before this court on Joint Motion for Modification of Consent Decree. ORDERED AND ADJUDGED: 1. The Consent Decree in the above-styled case shall be modified as follows: (1) Section 7.2. If HIV infected prisoners refuse the dose, counseling shall be provided and the record shall document this counseling. HIV infected prisoners who miss doses on three consecutive days shall be seen by the prescribing physician and counseled except

1

Case 7:02-cv-02812-KOB Document 182 Filed 01/03/2005 Page 2 of 2
those patients on Keep On Person medication. A record of such counseling shall be maintained. (2) Section 15.1. All sick call slips shall be triaged daily for degree of urgency. The triage system for sick-call slips, medical complaint forms, and medical grievance forms shall conform with NCCHC guideline P-E-07. 2. The parties agree that the above modifications do not constitute a substantive change to the Consent Decree and the court expressly finds that the above cited modifications do not change the Consent Decree substantively. Rather, the above cited modifications resolve clerical mistakes that existed in the Consent Decree and, as reported by the Medical Consultant, resolves conflicting provisions of the Consent Decree. Therefore, the court finds no reason to notify the parties and allow for objections addressing the above modifications. The court expressly finds there are sufficient circumstances to warrant a modification of the Consent Decree.
DONE AND ORDERED in Birmingham, Alabama this 3rd day of January, 2005.
____________________________________ KARON OWEN BOWDRE UNITED STATES DISTRICT JUDGE
2

 
 86/83/2884/18:17 4
".

PAGE 82

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALA8~ JUN -., PII~: I ~

WESTERN DIVISION

.. , ...

ANTONIO LEATHERWOOD, ERIC

)

1.,1 ::'. ~'.< 1;";1::' Cot::-;: r
i·i.';. l;F :"LAG,'iI·j,\

HOWARD, JERRY SANFORD, JOHN

)

L.EVlNS, MICHAEL PATRICK, and,

)

individually 8J1d on behalf of all present and

)

lUture HIV.positive irunales in the Limestone )

Correctional Facility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

) cv 02-BE-2812-W

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Dqlartment ofCorrcctions, RONALD )

CAVANAUGH, Director o{T,eatment, Alabama )

Department of Corrections, BaLY MITCHEM, )

Warden of Limestone Correctional Facility, and )

DAVID WISE, Deputy WardOll,

)

)

Defendant~.

)

MAGISTRATE JUpGE'S RE.PORl AND RECOMMENDATION

This class action is before the court following a "fairness hearing" that was conducted on

May 26, 2004, by the undersigned magistrate judge. Premised on the applicable law, the record,

and the "fairness hcaring~ proceedings, the court finds that the settlement in this case is due 10 be

approved.

I. BACKGROUND

On November 18, 2002, five HIV prisoners filed this action individually and on behalf of

a class of all "present and future HTV-positive inmates confined at Umestone Correctional

Facility rLimestone") in Harvest, Alabama." (Doc. I). J They tiled an amended complaint (doc.

I ReferebCft herein to "Pt)c, ._" an 10 die documenillumben _peli by the: Clerk of tbe Cow,.

05/03/2004 10:17 4

PAGE 03

42) and a second amended complaint (doc. 55).' On January 6,2003, the plaintiffs Hied a motion seeking class certi.licalion. (Doc. 13). On January 27,2004, United States District Judge leMon O. Bowdre entered an order granting the motion. (Doc. 114). Pursuant to Rule 23(e) orthe FEPERAl, RULES OP CIVIL PROCEDURE, "[TJbc court must approve any settlement, voluntary dismissal, ot compromise oCclaims, issues, or defenses of a certified clas5." FED. R. OV. P. 23(e)(I)(A).
The proposed settlement agreement was Hied on May 6,2004. (Doc. 151 8t 152 al Ex. A). On May 6, 2004, the plaintiffs also filed a motion seeking an order concerning publication and notice orlbe settlement a~ement. (Doc. 149). The court approved the notice for publication and ordered the plaintiffs' counsel to publish the same in accordance with the tenns agreed to by the parties and approved by the court. (Doc. 1S6). Because of the fact that the claimants were all inmates at Limestone, the court required that !be settlement notice be published at various locations used to house HIV prisoners. (Jd.). Publication was done and included notice to any claimants ofthe proposed settlement, the date aod time oCthe fairncss hearing, and thai anyobjccticns thereto must be filed in writing within ten (10) days orthe poating ofthe notice, which was required to be done within 24 hours of enlfy or the court's order. (/d.). A fairness hearing was ~onducted as scheduled on May 26.2004.
On May 7, 2004. the court granted the partics' "Joint Motion to Adopt Settlement Agreement and Provide for a Special Master." (Doc. \53). This order provides that "the Settlement Agreement shall automatically tenoinate two years after t.he court has granted 6nal
2The second amended tOtnplaint i. rcf~ced IS ~tlmenI 22 in d,! ""alntlffs' Memorandu", of taw in SupPOrt of
Fina' Entry .rlb. SdtI.....nt Apeement," wIIiok il round .. document 161.
2

06/03/2004 10:17 4

PAGE 04

approval of its terms." (ld. at 13). The court further staled thai a Faimcs~ Hearing, pursuanlto
Rule 23(.) ofthe FEDERAL RULES OF CIVIL PROCEOURE, must occur before final approval of the
Settlemenl Agreement. Therefore, the order granting the motion to adopt the settlement
agreement and 10 provide for a special master does Dot constitute a final adoption oflhe
agreemenl untillhe Rule 23(e) Faimess Hearing resolves any class objections to the agreement.
II. DISCUSSION
In Meyer v, CitiuPIS Southerll Naliona/ Bank, 677 F, Supp. 1196 (M.D. Gil, 1988). tbe
court set furtb tbe applicable slandards tor the present matter. The court stated:
In deciding whether to approve the settlemenl of Ihis class action, this Court is g\lided by established principles set by Ihe appellate courta fur the Fifth and Eleventh Circuits. Bennell Y. Behrinli Corp., 737 F.2d 982 (II" Cir. 1984); In re Corrugated Container Antitrust Wigalion, 643 F.2d 195 (5" CiT. J981), cert. denied, 456 U.S, 998, 102 S, Ct. 2283, 73 L. Ed. 2d 1294 (1982); Calton v. Hinton, 559 F.2d 1326 (Soh Cir, 1977); and Miller Y. Republic National Life Insurance Company, SS9 F.2d 426 (5'" Cir. (977). In order to approve the settlement the Court must determine Ihal tho settlemenl is fait, adequate, and reasonable and that there has been no fraud or collusion between the parties in reaching the settlement. Be"nett Y. Behrillg Corp., supra; Ruiz Y. McKas/c/e, 724
F.2d t 14.9 (5'" Cir, 1984); and Cotton v, Hinton, supra.
In applying the established principles to the preeeni case Ihe Court is mindful that each case musl be decided on its own facts and that the Court's lask is to essentially balance the applicable principles, COllon, 559 F.2d al 1330, The Court is also aware Ihal there is a sttongjudicia( policy favoring settlement, Bennett, 737 F.2d at 986, and that "(p)articularly in class action suits, there i. an overriding public interest in lavor of scitiemenIS." COItOIl, 559 F,2d 8t 1331. "II is often said that litigants should be encouraged to determine their respective rights between themselves." Id. al 1330·31.
In considering whether this settlement is (air, adequate, and reasonable, the Court sbould address the following factors:
(I) The liJcelihood of success al trial and range ofpOlenlial recovery; (2) The terms oilbe setllement; (3) The complexity. expense, and duration of litigation;
3

0&/03/2004 10:17 4

PAGE 05

(4) The pro~edures afforded to notify the class members of the proposed settlement and to allow them to present their views;
(5) The judgment of eJperieneed counsel; (6) The substance and the amount of opposition to the settlement; and (7) The slage of the proceedings at which the settlement was
achieved.
]n re COTnl/fated Co"tainer Alllilrusl LiligtJIion, 643 F.2d 195; Bennell v. Behring Corp., supra; Ruiz ". McKaslde, sllpra; Miller v. Republic Natio"al Life, Sllpra; Peltway v. American Cosliron Pipe Co., 576 F.2d 1157 (Sttl Cir. 1978); COIIO" v. Hi",on, supra; Holmes v. Continental Can Co., 706 F.2d 1144 (11" Cir. 1983); and In,.., Den,.is Greenman Securities Litigation, 622 F. Supp. 1430 (D.C. Fla. 1985), rev'd On other grounds, 829 F.2d 1539 (11,h Cir. 1987).
III considering the foregoing factors, an important function of a district court is il9 consideration ofthe settlement terms is a comparison ofthose terms with Ihe likely rewards the class would bave received following a successful trial. Tn re Corrugated Co",alner Ant/trust Litlgalion, 643 F.2d at 212. In this regard, "[t]he relief sought in the (Clomplaint may be helpful to establish a benchmark by which to compare the settlement terms." Cotton, 559 F.2d at 1330.
Meyer, 677 F. Supp. al 1200-0 I.
The first issue that the court must evaluate is the "likelihood of success on the merits
against the amount and form of reliefof'f'ered in tbe settlement" Carson v. American Brands.
inc., 450 U.S. 79, 88 n.14, 100 S. Ct. 3009, 6S L. Ed. 2d 1111 (1981). There Is astrongjudicial
policy favoring settlemenl premised on the ''realization that compromise is the essence of
settlement." Bennett v. Behring Corp., 737 F.2d 982, 986 (lllh Cir. 1984); see also D.H.
OvermyerCo. v. Loflin, 440 F.2d t213, 1215 (S"Cir. 1971), cen. denIed, 404 U.S. 8SI, 92 S. a.
87,30 L. Ed. 2d 90 (1971) r'Settlement agreements are hig/lly favored in the law and will be
upheld whenever possible because they are a means of amicably resolving debts and preventing
lawillllts."); Austin v. Hopper, 28 F. Supp. 2d ) 231, 1235 (M.D. Ala. '1998) ("Judicial policy
favors voluntary settlement as the means of resolving class-action cases.").
4

06/03/2004 18:17 4

PAGE 06

11Ie second amended complaint in Chis matter asserts Chat Che defendants provided inadequate medical treatment and conditions ofconfinement that violated the plaintiffs' rigbts under the Bighth Amcndmcnt as applied through the Fourteenth Amendment and enforced through 42 U.S.C. § 1983. {Doc. 55). The plaintiffs seek declaratory and injunctive relief. Spe<ifically, they request that the court enjoin the defendant. to adopt new policios and procedures for providing constitutionally adequate medical treatment and conditions of confinement which would prevent the plaintiff class from enduring needless pain, Buffering, and in some instances, death. The likelihood of success On the merit. is app&re/l.t.
A. Claims Related to Excessive Dealb, The plaintiffs claim in their second aft\ended complaint tbat "an e)tttemely high and constitutionally unacceptable number of AIDS-related inmate deaths occur at Limestone." (Doc. 55 at 133). In their independent audit of the medicaltrcatment at Limestone conducted OIl November 8, 2002, Jacqueline Moore and AssociateS> found that "the number of AIDS deaths is remarkably bigh wben one compares averages reported by other DOC systems." (ld. at Ex. 2, p. 9). Additionally, the plaintiffs' expert, Dr. Stephen Tabet, conducted a detailed mortality review of forty-two (42) HIV and AIDS prisoner deaths al Limestone since 1999.· Such detailed

, Jooqucline M.... ond AllO<i..e, woo .. independenl audilins compony thOl .... hired by !he Alabam. Dcpornntn. ofCol1'ecnoftc to review the qUinCy 01 medical "e.tltlmt provided at LimestCITIIC ColTtcfiDfial Fleility.

• TheR inmulc.'i mClludtd the (ollowiDa individlllll:

NAME

I.

Ruu~l1 alliSie

2.

J..uisBluca

3.

lohn Bolron

4.

M.hODYCO'

S.

~ndy er-r.rd

6. E.an. Danill.

7.

!Any DI.e.pon

8.

Howard Dlvl.

AGE AT DEATH 46 44 39
39 41 6G 27
48
s

DATE 0 .. D'A78 12·29-2002 2·22-2001 5.22-2000 2-4-2001 5-22·2000 11·24·2002 1·2<.2000
8·9·10l)fl

06/03/2004 10:17 4

PAGE 07

deceased HIV prisoner monality reviews had not been conducted previously. In faet, the Alabama Depanment of Corrections, NaphCare, Inc. (the former contracted healthcare provider for the plaintiffs' class), Prison Health Services (the CUl'l'CnI contracted healthcare provider for the plaintiffs' class), Dr. Collette Simon, Moore and A.!sociate., nor any other entity or individual had ever conducted detailed deceased HIV prisoner mortality reviews.
The importance of conducting detailed mortality reviews was described in Jacqueline Moo!'e and Associates' Limestone audit repon, which states that "Statistics should accurately reflectlhe cause of death and provide Ii useful source of statistical infonnation. The reviews also

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06/03/2004 10:17 4

PAGE as

provide a window into multiple aspects of the delivery system." (Doc. 55, Ex. 2 at p. 10). Dr. Tabet summari~ed his findings by slating that "[T)he most egregious medical failure at
Limestone is the number ofpreventable deaths." (Doc. 76 at p. 111). More specifically, he
stated as follows: .. " In almost all instances the death was preceded by a failure to provide proper medical care Or !realm.ent. Consistently, patients died of preventable illness. Patients with serious diseases experienced serious delays in medical care or were not treated at all. Chronic care clinics are unheuct of at Limestone. Life-threatening laboratory results were treated routinely instead of urgently. Other tests such as radiographs showing pneumonia were commonly not assessed until many days later. At lcast one patient had such severe pneumonia that be suffocaled in front of the medical staff - despite the patient's requests for treatment, he w.... not sent to a hospital until biB condition was irreversible. CPR was rarely attempled in any critically ill patient. ...
(Id.). In their Petition of Notice of Objections 10 Settlement Agreement, certain members of lhe
Plaintiffclass provide a personal account of the constitutionally inadequate medical treatment
provided to HIV prisoners al Limestolle. They state that "[b).cause ofthes. Eightb Amendmcnt
violations, many male HIV-positive inmates{,} which was (sic) housed in dormitory 16,
warehouse HIV in6nnary, died a horrible death, literally standing all their feel." (Doc. \60, p.
I).
Dr. Tabet's deceased HIV prisoner QIOrlaJity reviews demonstrate thaI the inadequate
medical treatment is IUIGOnstilUtional. It is evident thaI lives were lost due 10 pn:ventable lapses
.in Ihe medical treatment Additionally, the evidence demonstrates an absence ofeflbrts to save
lives by takinlllllleliorative actions such as conducting mortality reviews and ascertaining
obvious problems in the medical system and then resolving these problems. HIV prisoners died
without necessary intervention by the Limestone medical staff or Alabama Department of
7

06/03/2004 10: 17 4

PAGE 0g

Corrections. This Ilok of ameliorative action on the part of the defendants and others demonstrates a sufficient disregard ofhuman life and therefore provides a likelihood that tbe plaintiffs would succeed on the merits at a trial on Ihis aspect or their second amended complaint.
B. EDle/'leney Medicil System In addition, lhe plaintiffs claim thai responses to HIV prisoner medical emergencies have been "extremely slow and completely inadequate." (Doc. SS at p. 12). The difficulty is demonstrated in the mortality review of HIV prisoner Tmell Grey. While Terrell Grey was critically ill on January 25, ZOO3, Ihe Limestone medical staff decided to transport him to a hospital. However, a nurse stated "(T]hc iJUDate was sent to a hospital via Department ofCorreclions van for follow-up C8fe. No indications were present for need of ambulance or emergency van." The cO!Tectiona\ officers assigned to drive Terrell Grey to a hospital questioned the emergency medical decision-making of the nurse, stating as follows: I (Officer Howard] staled to Nurse Smith thai the two officers transporting Inmate Grey do nOI have medical training to be able to tran.qport an inmate with the problem that rrunate Grey was having. Nurse Smith staled, 'He'll be line. I'll pUI some oxygen in the vehicle with him and let lalm fell. He'll be fine. {Doc. 72 at p. 57 (emphasis in original». Despite the con:cxtional officer's concerns, Terrell Grey was placed in a Department of Corrections van and transported to a hospital. However, instead ofbeing transported to nearby Athens Limestone Hospital, Terrell Grey was transported on a two holD' drive to Binningham. While in roule to Birmingham, Terrell Grey died in tbe van. rId.). Dr. Tabet's detailed review ofTerreU Grey's death and numerous other inadequate emergency medical responses, reflects a violation ofth. constitutional rights ofHIV prisoners at
8

136/133/213134 113:17 4

PAGE 113

Limestone. The evidence is sufficient to show that inadequate emergency medical care
contributed to the preventable dealhs ofHIV prisoners. Dr. Tabet's findings IhcrefOl'C
demonstrate a strong liblihood tbat Ihe plaintiffs would succeed on the merits at a trial.
C. Cbroaic Care and Inreellon Control P!'Ogr.1D
The plaintiffs also claim that chronic care for HIV prisoners is extremely dire. (Doc. SS
It pp. 14-16). The plaintiffs assert Ihatlhey experience life Ihreatening lapses in Ihe infection
control program at Limestone. They argue that these lapses have caused the plaintiff class to be
unnecessarily exposed to tuberculosis. The plaintiff class describes the situation as follows:
The wbole male HIV-positive iMlates population. because ora lack or inadequate infection control systern, was exposed to tuberculosis, a disease which is known to be extrernely dangerous and deadly to people who are suffering from HIV infections.
This tuberculosis exposure also poses a future Ihreal to the health of those HIV-positive inmates who may have been exposed to this disease.
(Doc. 160 at p. 2 (emphasis in original». In his supplemental expet1 report, Dr. Tabet confirmed
the life threatening lapse. in the Limestone infection control program when he stated:
Unfortunately, infection control policy and practices are virtually DODexlsl••t at Limestone COITectional Facility. Although some infection control poliCies exist on paper, it teems these practices are not in place at Limestone. In the prior repolt's sununary, a concem about the possibility of an outbreak of tuberculosis was raised. True to Ihe warnings and concerns, because there is no infectious disease prevention protocol in practice, a patient with active tuberculosis WI! housed in the HN population. The result is that virtually all of the HIV-infe<:ted inmates and possibly som" ofthe staff, were directly exposed to tuberculosis.
(Doc. 132 aI p. 47 (ernphasis in original».
The failure in the Limestone infection control policy resulted in Ihe Clqlosureof
practically the whole HIV prisoner population, and some correctional staff, to tuberculosi•.
9

06/03/2004 1B:17 4

PAGE 11

Exposing the HIV prisoner population to tuberculosis under the circumstances in this case is unconstitutional. This cxposure to tuberculosis and other inadequate chronic care treatment therefore demonstrates that the plaintiffs would likely succeed on the merits at a trial.
D. Relief and Enforcement The Senlement Agreement provides relief for the plaintiffs' claims. Under the Agreement, a system for providing constitutionally adequate medical treatment and hOWling for HIV prisoners confined at Limestone 'will be establisbed. Additionally, a renowned HlV prisoner medical consultant -- Or. Joseph Bick -- has been selected by the panies to ascertain any improvements and evaluate compliance with the provisions or the Settlement Agreement.' Magistrate Judge John Ott has been ajlpointed a Special Master to ensure compliance and the United States District Court will relaihjurisdiction to enforce the terms ofthe Senlement Agreement and protect the Constitutii)nal rights of the Plaintiff class. The comprehensive relief provided in this Settlement Agreemerlt would be difficult to schievc at trial. E. Llmltadona Oil Relief at II Trill,lmpoled by the Prison LitigatioD Reform Act Despite the strength ofthe plaintiffs' case, iftbis litigation wen: to go to trial, comprehensive relief similar to this Settlement Agreement would be difficult to achieve. The Prison Litigation Reform Act (''PLRJi'') limits the ability or the court to fashion comprehensive relief in prison conditions cases. Under the PLRA, the court can only grant prospective relief upon a findiDg that "such relief is nutowly drawn, eJ(tends no further than necessary to correct the violation of the Federal right, and is the least intrusive means nece.sary til Cllrrect the
. . ':the ~Uft nolndiM cenain firm 1Imft~IS t'OJIccminl Dr. 8ick ,emAined to be Rsolved, The coun antic::ipatts no
d,m"'''tteS In Ihl. MI dUll Wguld wlIITant ..y~IC in the countslIRumen' ark prumt matters.
10

06/03/2004 10:17 4

PAGE 12

violation ofthe Federal right" 18 U.S.c. § 3626(a)(I)(A). Additionally, the PLRA was intended to l'reventjudieial micro-management ofplisons. See, e.g., Be"jami" v. Fraser. 343 F.3d 3S. S3 (2d Cir. 2003) (the PLRA was intended to prevent the judicial micro-management of JUisons). Thus, at a trial, the court may not have been in as an advantageous position in being able to fashion the comprehensive relief provided for in tho Settlement Agreement.
The undersigned fmds that under the present circumstances, the likelihood ofsuccess on Ihe melits and the range ofpossibJe recovery requirement is satisfied. III. FAIRNESS, ADEQUACY, AND REASONABLENESS REQUIREMENT ARE
SATISFIED BY TAE SETTLEMENT AGREEMENT The criteria for determining the "reasonableness" of a settlement agreement is III\cenain
and imprecise. As the plaintiffs' counsel notes, "it is recognized that there is a I'lUlge of reasonableness, •a range which recognizes the uncertaintica of law and fact in any particular case ond the concomitant risks and costs necessarily inherent in taking any litigation to completion ...." Newma1l v. Stein, 464 F.2d 689, 693 (Zd Cir.). cert. de"ied, 409 U.S. 1039,93 S. Ct. 321,
34 t. Ed, 2d 488 (1972). A, The DetaD.
The Settlement Agreement provides Ihe plaintiffs with substantial benefits which will have a profound impact upon the adequacy ofthe medical treatment and living conditions received. The following details the more significant changes as a consequence of the settlement.
I, A F.Il-Time HIV Spr:claJIJI The parties recognize that the complexity ofthe medical care ~d treatment for HIV prisonen requires the attention of a full-time HIV Specialist. Therefore. the defendants agree to
II

05/03/2004 10:17 4

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have a physician with more tban three yean of experience in inpatient and outpatient management ofHtV patients to provide medical care and treatment to the HIV prisoners confined at Limestone. (Settlement Agreement at §§ 3.1-3.2). In addition, thirty hours per week
have been allocated in which the HIV Specialist will provide medical treatment only to HIV
prisoners at Limestone. (Id.). This will ensure that the complex medical needs of the HIV prisoners at Limestone will be adequately addressod by • qualified physician.
2. Hi....g •• "HIV Coordlntor" The parties also recognize the importance ofbetter organizing timely visits to specialists to address HN prisoners' needs; to wure that follow.up care is being provided in a timely manner; to monitor the progJess ofHIV prisoners to avoid drastic declines in health; and to organize educational sessions and programs for HIV prisoners. (AgJeCTDcot at § 3.3). To satisfy these concerns, the defendants agree to hire an additional nurse at Limestone. This nurse will act as IIl"HIV Coordinator~ and will coordinate the provision ofm.die.1 treahnent to the HIV prisoners at Limestone. Additiohally, in the event ofa medical emergency, a nurse will be stationed in the HIV prisoner housing units sixteen hours per day to implement emergency medical procedures. (Agreement at § 3.S). These provisions will ensure that the medical delivery system for HfV prisoners is coordinated and operates in an efficient manner.
3. Healthure Staff Tralaiag The parties recognize the importance of adequate healthC8le staff training. Therefore, the defendants have Bgreed that all staff -- medical staff and correctional staff -- will receive cum:nt cardiopulmonary resuscitation ("CPR") training; all registered nunes and licensed practical nunes will not make medical decisions outside the scope oftheir license; all medical staffwill
12

06/03/2BB4 1B:17 4

PAGE 14

attend continuing medical educational programs; HIV prisoners will be sent to an outside specialist if Limestone lacks the resource!l to provide for the medical treatment; and that copics of an HIV prisoner's Kilby Correctional Facility medical records will follow the prisoner to Limestone. (Agreement at §§ 4.1-4. S). Such training will ensure that the medical and correctional staff at Limestone will have adequate resources to address medical emergencies that arise in the HIV prisoner population. Importantly, ifLimestone is not equipped with the rcsource,. to adequately address a medical concem, this provision e"&\Ires that the HIV prisoner will be seen in a timely manner by an outside specialist.
4. Periodic Ev.lutlon, for HIV IDd AIDS PrIsoners The parties have agreed that HIV prisoners should be provided a medical history, physical examination. and evaluation orth.ir "CD4+" and viral load at lellSt quarterly. Priloners infected with AIDS will receive periodic evaluations every llixty days. (Agreement at §§ 5.1-5.2). This will ensure that HIV prisoners will be provided physical examinations which will occur more fi'equently based upon the advanced stage of the prisoner's illness.
5. bnplemeDtltioa of an Infection Co"trol P1aD The parties have agn:ed that an infection control program mUllt be implemented addressing airborne and blood borne pathogen control plans. (Agreement at §§ 6.1.6.3). These infection control plans win follow Center for ])jSClISC Control guidelines. Additionally, all prisoners suspected of having contagious tuberculosis will be placed in respiratory isolation until they no longer pose a risk 10 HIV prisoners and the public health. Protocols will also be adOPled to minimize, control, and treat the spread of Methicillin Resistant Staphylococcus Areus ("MR.SA") infections. This infection control plan will ensure the protection oCHIV prisoners
\3

06/03/2004 10:17 4

PAGE 15

from expo~Ufe to airbom~ and blood borne pathogens. MOf~vtf. it will ensure that correctional staff and medical staff are adequately proleclod from exposure to airborne and blood borne path.ogens.
6. Adoptio. of ProtOCOls for tbe Admbllstration of Medieatioa til HJV PrisoDUI
Protocols (Dr the administration of medication to HIV infected prisoners wilt be implemented. (....greement al §§ 7.\-7.8). Medication will be administered fony-eight hour.; after being prescribed by the HIV Specialist. Dosage and times Cot administering medication will be in accDrdance with Food and Drug Administration guidelines. HIV prisoners refusing a dose DfmcdicatiDn will be seen by the prescribing physician and cOIUlsclcd. A "self-medication" program will alSD be developed and written instructions will be provided to liIV prisoners qualifyiDg for the program. This will permit HIV prisoners more flexibility to coordinate doses of medication with meals and consistent with Food and Drug Administration recommendations.
Also. medication will be hand delivered to acutely ill mv infected prisollers. Hand delivery of
medication to acutely ill H1V prisoners will preyen, missed medication. doses caused by a prisoner's inability to stand in the pill line due ID illness.
7. Provldblg Medkal Treatment to HlV Prilonert witt. DI_bete. Mellitu cor Rep.tid. A, D, or C
The parties have fecognized the importance DC providing Ireatment to HIV prisoners with diabetes mellitus or Hepatitis A. B. or C. (Agreement at §§ 8.1-8.3). Because the defendants have recently enten:d settlement agreements addressing chronic care treatment for these illnesses. the Settlement Agreement in tbis ease will conConn. to the stal1dafds adopted in these settlement agreement.. Confonning the medical care to these recently entered settlemenl agreements will
14

06/03/2004 10: 17 4

PAGE 16

ensure that HIV prisoners will not endure wmecessary pain. suffe{ing, and in some instances death caused by the inadequate treatment ofdiabetes and Hepatitis A. B. or C-
8. Food for mv Prlloaen
HIV infected prisoners will receive three meals a day. six days a week. On Sundays and holidays. HN prisoners will receive a food sack. (Agreement §§ 9.1-9.5). The food sack will enable HIV prisoners to take Ibeir medication with meals ralbet than on an empty stomach. This will decrease the severity or prevent H.IV prisoners from e"peri"""ing medication side-effects associated with medication dosage on an empty stomach.
9. ImpleIBeallng.1 ERectlYe Emergeaty PI•• The parties recognize the importance of implementing an effective emergency plan. (Agreement at §§ 10.1-10.S). Thetefore, the defendants agree to provide a wirelass intet'COtII system in five cells used to house acutely ill HN prisonm. This intercom SystCIIII will be linked to the dormitory officet slation enabling an acutely ill HN prisoner 10 have immediate access to correctional and medical assistance in the event of an emergency. Emetgency drills will also he ccnducted periodically to assure Limestone staff readiness in the event of an emergency. In addition, the emetgency medical equipment will be kept in good working order to quickly effectuate Ibe emergency protocols. These provisions will ensure Ibat the medical and correctional staff are well-prepared to effectively respond in the event of an emergency.
to. Implemcatation of New IDtake Protoeoll
The parties agree to new intake protocols that will require that HIV prisoners arriving at Umestonc receive an intake assessment and screening within twenty-four hours of arrival. (Agreement §§ 11.1-II.S). Within forty-eight hours, an HIV prisoner will be seen by the HN
IS

06/03/2004 10:17 4

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Specialist. Within two weeks of arriving at Umestone, an mv prisoner will be seen by the HIV
SpceialiBt or a mid-level practilloller. Thi~ process will ensure that HlV prisoners newly arriving at Limestone will begin receiving medIcal treatment and be: screened for other inrectiou5 diseases or conditions within a reasonable amount of time. l.n Addition, H{V prisoners arriving at Lim.•stone will be permitted 10 continue their prescribed medication, upon verification. This will prevCDt intemlption. in an IllY prisoner's continuity of medical cate whicb could cause resilllRnce to life-saving HIV medications.
11. The ProvitioD of Approp,iate Pamltive Care 10 TermlDIUy IU IDV Prlsone"
The pani.. recognize the importanee o{providing appropriate pallillt:ive care to taminally ill "IV infected plisoncts. (Agreement §§ 12.1-12.3). Terminally ill HIV prisoners will b. provided cowlseling addressing end-of.life trealment which includes: continued vigorous It'ealment or signing on Advanced Medical Directive consistent with Alabama state law describing the H(V ptisoner's choice (If end-of-life b'eatmont. This provision will ensure that terminally ill HJV prisoners will receive important cou.nseling addressing options for end-of-Iifc treatment.
12_ Accommodatloft. (or Physically Disabled HIV l'rI~oners The parties recognize that lome HIV positive prisoners are physically disabled and need accomrnodations addressing their disability. (Agreement §§ 13.1-13.2). The defendants bave .agreed to imtall adequate.band-railing in colis used to confine phYSIcally disabled J:IIV prisoners. Also, a sboWCl' in the HIV prisonor unil will be equipped with adequate hillld-railing, ramp enby, and seating. This will enslIre that physically disabled HIV prisoners will be able to lise basic
16

0&/03/2004 10:17 4

PAGE 18

amenities •• showers, toilets, and beds .. safely and Ihe risk of unnecessarily falling and injuring themselves will be diminished.
13, Adopting Time Frames for the Re-ftttinc of prostbesil and Dentures Cor
HIV Prisoner. The partie. agree 10 adopt time frames addressing the ro-fitting ofHTV prisoner pro.thesis and dentures. (Agroement at §§ 13.3, 14.1). This provision will ensure thai HN prisoners with prosthesis OT dentures will not endure unnecessary pain and suffering.
14. Adoption or. l'lmely l'rlaRt S)'!tern
The pu1ies recognize tho importance ofathnely triage system. (Agreernentat § IS. I.). TherefoTc, the defcnc!ants agree to adopt • triage systerR in which sick call slip. submitted by H1V prisoners will be triaged daily according to dCll:ree of urgency. Additionally, fonnal and infonnal grievance fonns from HIVprisoners will be triaged every .five days according to degree oCurgeney. This timely triage system will ensure that HIV prisoners with urgent medical concerns will be treated in a timely manner.
15. Loc.llaR a Tra.slltor Whell •• mv Prisoner Does Not Speak Eagllsb
The parties recognize the importance 0 r locating 0 translator when an HIV prisoner does
nol speak English, (Agreement at § 18.1). Thill, they agree one will be located in such eases... This will ensure (hat HIV .prisoners will not be prevented iTom receiving adequate medical treubnent beclll1se they do not speak English.
16. HOM.iIll1 The parties recognize the importance ofclean, disinfected. and good working order housing used to confine prisoners wid1 compromised immune systems. (Agreement at §§
17

e5/e3/2e04 10:17 4

PAGE 19

19.1-19.2). Therefore, the Settlement Agreement provides that no dormitory Dr open· bay housing Of triple eellin.g of HIV prisoners will be used. Rodent and pest control will also be conducted monthly. These conditions win CNlure that the HlV prisoners confined at Limcstone will live in housing that does not promote or facilitate the spread of infectious diseases.
17. Acee,. to aD HIV CouDselor The panics recognize the importance of providing HI" prisoners access to an HIV counselor with training and experience in the area ofHIV. (Agreement al §§ 20.1.21,2). Additionally, the Settlement Agreement will permit HIV prisoners to have access to up·to.date educational materials addressing HIV. This will facilitate that any questions Of con,cerns that any
JUV prison.er. have addressing thoir illness will be answered by a knowledgeable mv counselor.
18. AdopdDg New Releas. Protocols ror HJVPmoDers The parties recogni~e the il.nportance ofrelease protocols. Accordingly. the agreement addresses HIV pri80ner access to Limestone medical reconts; 81Tangements Cor appropriate diseharge planning for HJV prisoners upon release; thirty day supplies of medication upon release from Limestone; and tbat L;meslone will be registered in the Social Sccllrily Administration's Prerelease Program for Ir\.gtitution.aJi~ed PersDIIlI. (Agreement at §§ 22.1.22.5). These proviSIOns will cosure a continuity ofmedical treatment for HlVprisonell! between the
time, of being released from Limestone and bcgiMing .mv treatment outside Limestone.
19. Protoeo" Addreulng tile Mortality of KIV PrlsODen The parties recognize the imponance ofconducting timely mortality reviews for deceased HIV infected !,risanml; that documentation be kepI addressing Ihe number of deceased HN priSonc:r3; ami that full internal and external autopsies be performed on deceased HIV infected
18

66/63/2664 18:17 4

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prisoners. (Agreemenl at §§ 24.1-24.4). This system, addressing deceased mv prisoners, will
reveal any lapses in the medical treatment provided al Umestone. Revealin&lhe lapses in medical care will permit the Limeslone medical slaffto mike changes to CIIsure that adequate medical treatment is provided 10 HIV prisoners confined at Limestone.
20. IlIIplemeDtatioD or. Qallity Improvemea. Progr.m .t Llm_toDe The parties lastly recognize that a quality improvement program al Limestone will ensulC that any inadequacies or lapses in the Limeslone medical system will be assessed, corrective plans addressing the lapse will be implemented, and the outcome of the corrective plan will he monitored. (Agreement at §§ 25.1-2S.4). Therefore, the defendants will implement a quality improvemenl committee which will identify HIV medical treatment problems and implement timely remedies to solve the problems.
B. Enrorcemnt or the Senlemeat Alretmeat
The Settlement Agreement provides relief addressing the claims made by the plaintiffs in the Second Amended Complaint. Consistent with the terms ofth. Agreement, the class members will receive medital treatmenl under a medical system thai is efficient, attends to the needs of HN infected people, and is morc accountable. Indeed. the living conditions for HIV prisoners will also improve. To ensure Ihel Ihe lenns oflhe Agreement are adhered, the parties have agreed to provide three enforcement measures.
1. Neutral Medica. CO••lllt••t The parties have agreed to hire a neutral medical consultant. (Apeement at §§ 26.1.26.5). The medical consultant will conduct periodic visits to Limeatone to assess compliance with the tenns ofthe Agreement. It is the job of the medical consultant to ensure that
19

06/03/2004 10:17 4

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th.e \em\. of the Agr1:cment arc IIIl\ered by the medical staff and correctional staff at J.imcstooe. In addition, the medical consultant will be available to provide suggestions to the Limestone medical or correctional staff addressing any lapses in complying with the tem\. of the Settlement Agreement.
2. Appal_IDIe.t of • Special Muter Because the remedial phase oflhi. litigation is sufficiently complex, the parties have a~ to the appointment of a Special Master. (Agreement at §§ 28.2, 28.4-28.6; see also Prison Litigotion Reform Act, 18 U.s.C. § 3626(f)(I)(B)("Thecourt shall appoint 8 speci" master under this sUbaeetion during the remedial phuc ofIhc action only upon afinding that the remedial phase will be sufficiently complex to warrant the appointment."». They further agree that the undersigned will serve in that capacity. The Spacial Master will administer factual inquiries addressing compliance with provisions or the Agreement See Benjami1l v. FrtlSlr, 343 F.3d 35, 45 (2d Cir. 2003) ("They (the power$ orthe Special Master) include the ability to convene 8I)d to regulate bearings, to rule on the admissibility of evidence, to subpoena and swear witnesses., and to bold non-cooperating witnesses in conlcrnpt.', (chaDges 10 original); .re~ also FEn. R. Clv. P. 53 (same). These inquiries will culminate in a report thai will be submitted to District Court Judge Karon Bowdre. Based upon the Special Master's factual findings, the District Court will fender a decision addressing eompliaDcc with the provisions ofthe Agreement.
J. United State. Dlatrlet Court .JarlldtettoD II RecalDed Throughout the two year remedial pbase of lhis litigation, the parties have agccd that Ibe United States Distric! Court will retain jurisdiction for enforcc:ment oflhe Age.ment provisions.
20

6&163/2664 16:17 4

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(Agreement at § 1.1). The Di.tricI Court will prov;de the class members with an optimal venue to enforce compliance with lb. prov;sions ofthe Agreement that is Jcnowledgeable about the facts and history ofthis civil rights action.
C. Odler Matten The plaintiffs =ogni~. thai the defendlnb have made nwnerous concemons in the settlement ofthis action, including hiring a medical consulWlt, contracting to perform internal autopsies on all dcceased HIV infected prisoners, and birini additional Urnestone medical staff. Th. defendanb also recognize that as a result ofthis process, the plaintiffs have roade numerous concessionl. By WIlY of example, the plaintiffs recognize thai the hiring of additional medical staff c:onstitutea a substantial cos! fur the defendants. Thus, the plaintiffs and the defendants have agreed upon policies and protocols that would effectively address the concerns ofthe HlV prisoners at Limestone witboul the need to bire new medical staff. Th. plainti ffs were also informed of the substantial costs lhal would be incurred if all the donns used to house HIV prisoners were refurbished with ADA accommodations. Therefore, the plaintiffs and defendants agreed that only cells used 10 house physically disabled HIV prisonen would be refurbished fOf ADA complfance. Also, rather lhan installing ADA accommodations in all orthe showers used by HIV prisoners, only one shower win be re-fitted forp/lysically
disabled HIV prisoner use.
mview of the foregoing, the court finds thai the fairness, adequacy. and reasonableness
requiremenll are satisfied by the J\grmnent entered into by the parties.
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IV. THE COMPLEXITY, EXPENSE, AND DUJl4TION UQUJREMENT IS SATISFIED BY THE SETTLEMENt" AGREEMENT The p1aintiffs correctly note that this litigation is extTemely complex. The complexity of
HIll medical treatment is well documented. The medical treatment ofHIV and AIDS infection, opportunistic infections, Hepatitis C co-infection with HIV, and other concerns is doeumCllted in dctail by the Centers for Disease Control, the National !nstiNtes ofHealth, and many other
organitations and committees. The delivery of mv medical treatmet1t requires the expertillC of 8
specialist. HIV Specialists must remain well vmcd on recent changes, addressing the constantly evolving HIV medical treatment standards. Due to the complexity ofMIV medical treatment, the plaintiffs assert that they sought the expertise ofone ofthe leading HIV physicians in the coUlltry -- Dr. Stephen Tabel. His extensive reports have been reviewed and evaluated by the court and have contributed greatly to the court's determination in tbis matter. (Doe. 76 and 132).
A tri.l on the merits ofthi! eose would be a substantial expense. Preparation for trial would also require additional, subatantial expenses. Continued litigation in this case would require the plaintiffs to complete outstanding depositions, prepare thousands ofpages of medical records for presentation at trial, and many olher expensive endeavors in preparation for trial. Absent a settlement agreement, the class ofHIV prisoncn al Limestone may not receive any
assistance for 8 veIY. very long time. During lhis time, more mv prisoners cOllld die and ",any
will endure needless pain and suffering. Expenditure of the additional time and money would riot guarantee any better result than thai proposed by the parties. To the contruy, this Agreement clearly encompasses a full and complete means to address the present situation.
Premised on the foregoing, the complexity, expense, and duration requirements are
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!l8tisfi~d by the Settlemenl AgJeelllent. V. THE SUBSTANCE AND AMOUNT OF OPPOSITION TO THE SEfl"LEMENT
AGREEMENT REQUIREMENT IS SAllSmD IN TMS CASE A. Ge.erally
AJ DOled by counsel tor the plaintiffs, "When considering the obje<:tions ofclass members addressing a proposed settlement I!greement, 'the court must look beyond the numbers to the totality ofthe circumstances presented and from those circumstances attempt 10 extrapolate some picture of the tJUe support for the [.ettlementJ.... (Doc. 162 at p. 24), citing Reynolds v.
Killg, 790 F. Supp. 1101, 1109 (M.D. Ala. 1990) (Thompson, J.». The plaintiffs fwthernote
that the prcsentlitigation involves prison conditions. Therefore, this court must llso collSider if tbe agreement satisfies the Rquirements of 18 U.S.C. § 3626 ofPLRA. See Aus/;" v. Hopper, 28 F. Supp. 2d 1231, 1235 (M.D. Ala. t998)(Thompson, l)("Not only must this court approve the settlement agreement, it must also determine whether the agreement meets the Rquircmcnts of the Pri.on Litigation Reforrn Act, 18 U.S.C. § 3626, as well as whether the putative class to which tbe agreement applies meets the criteria for class certification Wider Rule 23.'').
According to the plaintiffs, "BecaUle the settlement agreement provides a comprehensive fCSolution ofthe claims raised in the complaint and satisfies the strictures ofthe PLRA, this Court sbould approve the SeltlemtJIl Agree"'tJIl." (Id. at 25). The court agrees. Although there arc objcctions signed by a number of inmates, which will be addressed below, at least three inmates wrote the court indictiog th~r 6atisfaction and approval oftbe Agreement. (See Letters Dated May 20-21, 20(4).
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PAGE 25

B. ObjectlODS The objcetolS he.ve two general complaints: First, there is a lack of cooperation. Second. desegregation is not addressed. Specifically, in the "Petition ofNotice of Objections to Set1lement Asrccmenl," onc hundred thirty-silt members of the plaintiff claas object to the Settlement Agreement asserting that: A gummary of plaintiffs' proposed final settlement proposal, dated September 17, 2003, was presented to the roaIe HJV.positive inmate population by their Attomey, and this settlement proposal in its entirety was asreed to by all class membClS as being adequate compensation for their pain and suffering. The crowning jewel of this proposed settlement was provision nineteen (19) on page nine (9), access to institutional programs. (Doc. 160 at p. 4). The plainti./fs' counsel is comcl that one oflheplalntiffs' initial claims i. not addressed in the Settlement Agreement. The segregation ofHtV prisoDm and restricting tflV prisoner acces~ 10 supervised release, education, and training programs, which are provided to general population prisoners, is not resolved by the SeUlcment Agreement. (Doc. 162 at p. 25). Counsel for the plaintiffs' assertion in their response that one of the portions ofthe objection is misplaced is a correct statement. Monetary compensation .....as never sought in this litigation. However, the othet portions oIthe objection require more attention becBWic acceSs to institutional prosrams was a claim in the Second Amended Complaint. It was also an iS8I1o of contention raised in the settlement negotiations. (Doc. 1621126). Acc:otding 10 the plaintiffs' coumel, a summll')' ofthl! plaintiffa' proposed settleruent agreement was presented by their attorneys' to the plaintiffclus in September 1993. This proposed settlement Isreement, dated September 17, 2003, addressed the issue ofpermittinll the
24

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PAGE 25

HIV prisonen acccss to SIR programs, Pre-discretionary Leave programs, eligibility for
Community Conec;tions programs, work release programs, vocational programs, educational
programs, and job or other ttaining programs. (Jd.). However, desegregating institutional
programs remained an issue until March 2004. The plaintiffs' counsel asserts the following:
During the lengthy mediation session on March 23, 2004, the defendants infonned the plaintiffs that desegregating institutional programs could not be a provision of. final reltlernent agreement. Dcfendanll assured the plaintiffs thai Donal Campbell, the ConuniS9ioner oflbe Alabama Department of Corrections, was c\llTelltly working to dcsegregatc the institutional programs at Umcatonc. The defendants insisted that desegregating institutional programs could be resolVed upon the good faith unilateral action of Commissioner Campbell. Plaintiffs' cOUllsel decided to yield on this issue. Plaintiffs counsel did not want to jeopardize the parties' ability to construct a comprebensive SlIlI/e11l"'" Agreemf11lt addressing the constitutionally inadequate medical treatment and housing issues. Thus, one ortbe plaintitT$' claims went unresolved to achieve comprehensive mediCIIltrealment and housing conditions relief. See ~ Hinton, 559 F.2d 1326, \330 (5'~ Cir. 1977) CThe trial coun should not make a proponent ofa prllposed sr;ttlcmcnt 'juslilY each term oC the settlement against a hypothetical or speculative measure ofwbst concessions might have been gained; inherent in compromise is a yielding ofabsolutes and an abandoning ofhiah hopes." (quoting Milstejn y. Werner. S7 F.ltO. SIS, 524·25 (S.D.N.Y. 1972».
(Doc. 162 at pp. 26-27). The plaintiffs' counsel concludes, that "despite the objections by class
membcnI, the Settlement A.greemenl sh(l\lld be approved." (Id.). The defendants agree.
Following an extensive examination orthe reeon! and the serious issues presented by
these proceedings, the court·finds that the failure orthe settlement to address this one aspect of
their initial claims is insufficient 10 wanant a rejection Df the Agreement. To the contruy. the
Agreement is II comprehensive, inclusive means for addressing critical life and death issues in a
complex environment. To reject the Agreement for failillg to deliver on this issue would be
imprudent. Accordingly, the court finds that despite the objections of certain class memben, tile
Agreement should be approved by the court.
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VI. THE STAGE 0 ' 11IE PROCEEDINGS IN WHICH THIS SETrLEMENT WAS ACHIEVED [S SATISnED BY THE SETTLEMENT AGREEMENT The stage oftbc proceedings in wbich the Settlement Asreement was achieved must be
...essed 10 determine if the c11111' members were provided sufficient infonnstion 10 determine the adequacy of a settlement proposal with the strengths and weaknesses of their case. See /11 re: 11re PIwlen/ial Life Insurance Company ofAmerica Sales Practices Litigation, 148 F.3d 283, 319 (3d Cir. 1998), cui. denied, 525 U.S. 1114, 119 S. Ct. 890, 142 L. Ed. 2d 789 (1999) (,70 ensure thaI a proposed settlement is the product of informed negotiations, there should be an inquiry into the type and amount of discovery the panics have undertaken.')' The plaintiffs' cOWlsel argues that the substantial amount of discovery conducted in this case morc than satisfies this reqUirement The court again agrees.
Due to the role that the undCl'$igned phl)'l:d in this matter, it is evident to the court that substantial time, effort, and money was expended in the discovery process. It was more than adequate to test the strengths and wealmes!es of the plaintiffs' case. For instance, there hu been substantial discovery. Many depositions were taken. Several comprehensive expert reports have been issued.' The panics bave filed e~t.nsi.ve witness lists and exhibit lists in prepllfation for biaJ. Since May 2003, the parties have engaged in intensive mediation sessions to lIogotiate the tenns of the Settlement Agreement ill this case. These mediation sessions have atI'ordod the plaintiffs' counsel outstanding insight into whether or not to accept and rcc;ommend the terms of the Agreement to the plaintiffclaas. According to counsel for the plaintiffs, the plaintiffs, through the mediation process, have been aware of the strengths and weak!leeses of their legal
26

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claims and negotialed the lenns of the Agreement. The court i5 thus satisfied Iha! the settlemelll of this matt.. come. at an IIJlIIropriate stage
ofthe proceedings. Additionally, the: court finds a total absemce orlllY allegations, much less any evidence, of tTaud or collision between the panies in reaching the 9enlement in this matter. VII. CONCLUSION
Premised on the requesl ofcounsel for the parties and lhe foregoing analysis, the court
finds that the terms ofthe Settlement Agre,,",enl are due to be adopted.' Any party, including individual plaintiffs, may file specific written objections 10 this
report and recommendation within fifteen (I S) days ftom tile date it is filed in the office oCthe Clerk. Failure to file written objections to the: proposed findings and recommendations contained in this report and recommendation within fifteen (t S) days from the dale il is filed shall bar III aggrieved party from attacking the factual findings on appeal. Writtet1 objeotions shall specifically idc:ntif)' the portions ofthe proposed findings and recommendation to which objection is made and the specific basis for objection. Acopy of tile objections must be sClVed upon all other parties to the action.
The Clerk is DIRECI'ED to serve I copy of this report and recommendarion upon coUllael or record and the objecting plaintiffs. The objecting plaintiffs are to be served by posting the "Magistrate Judge's Report and Recommendation" ill accordance with the notification

.'.so 14".,,,,,,,,, 7 The 1;0un note" u ~d COUlItel (or the pllintift's, tim "(I)doptiOft o'thc ""~"'f

doea not dinll

Ibis cue ft'om the DiJtri!;t Count, junldl~. Itatber, rhe District Coun: loti.1 ~l:Iinjuri.diction to enforce ,omplianee wtdt the

~trll!",e", A".""..nl, Ihil Cau", will N:t III Spetio.l Muttr, and Ihe District COUft will tali" juriedielion to .ddJu, attorney's

no...• (Doc. 16211 p. 28)

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pJOCess previously issued in this ClISC. (See Doc. 156).' Thc dcfendants are hereby DIRECTED to posl the report and recomm.endation in the game marmer as was done with regard to the Settlement Noticc.
DONE. this Ibe ~ay of June, 2004.
~
JORNE.OTr - - - - United States Magistrate Judge

ear. • Th. ' - ' IIICI "",...-.cIllien .hlll be POlled in Donn 6. Dorm 1. dll HQlch Unil. loci .n.lh" r..mrifl u,,",
10 bollK HJV prilonrrs at Limetl:cme Comc:ricm,1 Fat,lity.nthin twenry..tOur houn I'tom the dlte it il entered.
28

 
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U.S. District Court Northern District of Alabama (Western) CIVIL DOCKET FOR CASE #: 7:02-cv-02812-KOB

CLOSED

Leatherwood, et al v. Haley, et al Assigned to: Judge Karon O Bowdre Demand: $0 Cause: 28:1331 Federal Question: Other Civil Rights

Date Filed: 11/18/2002 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: Federal Question

Plaintiff
Antonio Leatherwood individually and on behalf of all present and future HIV-positive inmates in the Limestone Correctional Facility in Capshaw, AL

represented by Stephen F Hanlon HOLLAND & KNIGHT LLP 2099 Pennsylvania Avenue NW, Suite 100 Washington, DC 20006 202-828-1871 Fax: 202-955-5564 Email: shanlon@hklaw.com

David M Lipman DAVID M LIPMAN PA 5901 SW 74 Street, Suite 304 Miami, FL 33143-5186 305-662-2600 Fax: 305-667-3361 Email: dmlipman@aol.com ATTORNEY TO BE NOTICED

Francis A Anania ANANIA BANDKLAYDER BLACKWELL BAUMGARTEN TORICELLA & STEIN 100 SE 2nd Street, Suite 4300 Bank of America Tower Miami, FL 33131-2126 305-373-4900 Fax: 305-373-6914 Email: fanania@anania-law.com ATTORNEY TO BE NOTICED

Gretchen N Rohr HOLLAND & KNIGHT LLP 1201 West Peachtree Street NW One Atlantic Center, Suite 2000 Atlanta, GA 30309-3409 404-898-8177 Fax: 404-881-0470

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Plaintiff Eric Howard individually and on behalf of all present and future HIV-positive inmates in the Limestone Correctional Facility in Capshaw, AL
Plaintiff Jerry Keith Sanford individually and on behalf of all present and future HIV-positive inmates in the Limestone Correctional Facility in Capshaw, AL

Email: gretchen.rohr@hklaw.com TERMINATED: 08/14/2006 ATTORNEY TO BE NOTICED
Joshua R Lipman SOUTHERN CENTER FOR HUMAN RIGHTS 83 Poplar Street NW Atlanta, GA 30303-2122 404-688-1202 Fax: 404-688-9440 Email: jlipman@schr.org ATTORNEY TO BE NOTICED
represented by Stephen F Hanlon (See above for address)
David M Lipman (See above for address) ATTORNEY TO BE NOTICED
Francis A Anania (See above for address) ATTORNEY TO BE NOTICED
Gretchen N Rohr (See above for address) TERMINATED: 08/14/2006 ATTORNEY TO BE NOTICED
Joshua R Lipman (See above for address) ATTORNEY TO BE NOTICED
represented by Stephen F Hanlon (See above for address)
David M Lipman (See above for address) ATTORNEY TO BE NOTICED
Francis A Anania (See above for address) ATTORNEY TO BE NOTICED
Gretchen N Rohr (See above for address) TERMINATED: 08/14/2006

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Plaintiff John . Levins individually and on behalf of all present and future HIV-positive inmates in the Limestone Correctional Facility in Capshaw, AL
Plaintiff Michael . Patrick individually, and on behalf of all present and future HIV-positive inmates in the Limestone Correctional Facility in Capshaw, Alabama
V.

ATTORNEY TO BE NOTICED
Joshua R Lipman (See above for address) ATTORNEY TO BE NOTICED
represented by Stephen F Hanlon (See above for address)
David M Lipman (See above for address) ATTORNEY TO BE NOTICED
Francis A Anania (See above for address) ATTORNEY TO BE NOTICED
Gretchen N Rohr (See above for address) TERMINATED: 08/14/2006 ATTORNEY TO BE NOTICED
Joshua R Lipman (See above for address) ATTORNEY TO BE NOTICED
represented by Stephen F Hanlon (See above for address)
David M Lipman (See above for address) ATTORNEY TO BE NOTICED
Francis A Anania (See above for address) ATTORNEY TO BE NOTICED
Gretchen N Rohr (See above for address) TERMINATED: 08/14/2006 ATTORNEY TO BE NOTICED
Joshua R Lipman (See above for address) ATTORNEY TO BE NOTICED

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Defendant Michael Haley Commissioner of the Alabama Department of Corrections TERMINATED: 02/24/2003
Defendant Ronald Cavanaugh Director of Treatment Alabama Department of Corrections
Defendant NaphCare, Inc.

represented by Andrew W Redd ALABAMA DEPARTMENT OF TRANSPORTATION LEGAL BUREAU 1409 Coliseum Blvd. Montgomery, AL 36110 1-334-242-6965 Fax: 1-334-264-4359 Email: redda@dot.state.al.us TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
represented by Albert S Butler ALABAMA DEPARTMENT OF CORRECTIONS LEGAL DIVISION 301 South Ripley Street PO Box 301501 Montgomery, AL 36130-1501 1-334-353-3886 Fax: 1-334-353-3891 Email: courtorders@doc.state.al.us LEAD ATTORNEY ATTORNEY TO BE NOTICED
Charles M Crook ALABAMA DEPARTMENT OF CORRECTIONS LEGAL DIVISION 101 South Union Street PO Box 301501 Montgomery, AL 36130-1501 1-334-353-3888 Fax: 1-334-353-3891 fax
William H Pryor, Jr OFFICE OF THE ATTORNEY GENERAL Alabama State House 11 South Union Street Montgomery, AL 36130-0152 1-334-242-7300 Fax: 1-334-242-2433 fax
Andrew W Redd (See above for address) ATTORNEY TO BE NOTICED
represented by Giles G Perkins

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NaphCare, Inc., healthcare provider for the Alabama Department of Corrections TERMINATED: 01/30/2004
Defendant Francis Henderson

MILLER HAMILTON SNIDER & ODOM LLC 505 North 20th Street, Suite 1200 Birmingham, AL 35203 205-226-5200 Fax: 205-226-5226 Email: gilesperkins@mhsolaw.com TERMINATED: 01/30/2004 ATTORNEY TO BE NOTICED
J E Murrill, Jr MILLER HAMILTON SNIDER & ODOM LLC 1200 Financial Center 505 20th Street, North Birmingham, AL 35203 226-5200 Fax: 226-5226 fax Email: jaymurrill@mhsolaw.com TERMINATED: 01/30/2004 ATTORNEY TO BE NOTICED
James A Patton, Jr OGLETREE DEAKINS NASH SMOAK & STEWART One Federal Place 1819 Fifth Avenue North, Suite 1000 Birmingham, AL 35203 205-328-1900 Fax: 205-328-6000 Email: jay.patton@ogletreedeakins.com
TERMINATED: 01/30/2004 ATTORNEY TO BE NOTICED
T Scott Kelly OGLETREE DEAKINS NASH SMOAK & STEWART One Federal Place 1819 Fifth Avenue North, Suite 1000 Birmingham, AL 35203 205-328-1900 Fax: 205-328-6000 Email: scott.kelly@ogletreedeakins.com TERMINATED: 01/30/2004 ATTORNEY TO BE NOTICED
represented by Giles G Perkins

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Medical Director of NaphCare, Inc. TERMINATED: 02/24/2003
Defendant Billy Mitchem Warden of Limestone Correctional Facility
Defendant David Wise Deputy Warden

(See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
J E Murrill, Jr (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
James A Patton, Jr (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
T Scott Kelly (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
represented by Albert S Butler (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Charles M Crook (See above for address)
William H Pryor, Jr (See above for address)
Andrew W Redd (See above for address) ATTORNEY TO BE NOTICED
represented by Albert S Butler (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Charles M Crook (See above for address)
William H Pryor, Jr (See above for address)
Andrew W Redd (See above for address) ATTORNEY TO BE NOTICED

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Defendant Collette Simon NaphCare, Inc. physician TERMINATED: 02/24/2003
Defendant Donal Campbell Commissioner of the Alabama Department of Corrections
Defendant James Francis Delong Medical Director of NaphCare, Inc.

represented by Giles G Perkins (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
J E Murrill, Jr (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
James A Patton, Jr (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
T Scott Kelly (See above for address) TERMINATED: 02/24/2003 ATTORNEY TO BE NOTICED
represented by Albert S Butler (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Charles M Crook (See above for address)
Andrew W Redd (See above for address) ATTORNEY TO BE NOTICED
represented by Giles G Perkins (See above for address) ATTORNEY TO BE NOTICED
J E Murrill, Jr (See above for address) ATTORNEY TO BE NOTICED
James A Patton, Jr (See above for address) ATTORNEY TO BE NOTICED
T Scott Kelly (See above for address)

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Date Filed 11/18/2002 11/18/2002 11/18/2002 11/18/2002 11/19/2002 11/26/2002 11/26/2002 11/26/2002
11/26/2002 11/26/2002 11/26/2002
11/29/2002 12/02/2002
12/02/2002 12/02/2002
12/26/2002

ATTORNEY TO BE NOTICED

#

Docket Text

1 COMPLAINT filed, amount paid $ 150.00, receipt # 200 184694 (KWC) (Entered: 11/19/2002)

SUMMONS and complaint issued -ret to pla (KWC) (Entered: 11/19/2002)

2 NOTICE of related case, CV 02-C-1517-W filed by plaintiff (KWC) (Entered: 11/19/2002)

3 MOTION by plaintiff for expedited discovery filed cs (KWC) (Entered: 11/19/2002)

REMARK - sent phv letters (KWC) (Entered: 11/19/2002)

4 MOTION by plas for attorney David M. Lipman to appear pro hac vice (fee pd) filed cs (KWC) (Entered: 11/26/2002)

PRO HAC VICE admission fee for David Lipman paid on 11/26/02 receipt # 200 184945 (KWC) (Entered: 11/26/2002)

5 ORDER granting motion for expedited discovery [3-1] dfts ORDERED to provide plas medical records requested in pla's motion w/i 15 days filed ( by Judge Karon O. Bowdre ) cm (MAA) (Entered: 11/26/2002)

6 MOTION by plas for attorney Stephen F Hanlon to appear pro hac vice (fee pd) filed cs (KWC) (Entered: 11/27/2002)

PRO HAC VICE admission fee $50 for atty Stephen Hanlon paid on 11/26/02 receipt # 200 184974 (KWC) (Entered: 11/27/2002)

7 4- ORDER granting motion for attorney David M. Lipman to appear pro hac vice [4-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 11/27/2002)

9 MOTION by plas for attorney Francis A Anania to appear pro hac vice (fee pd) filed cs (KWC) (Entered: 12/02/2002)

8 6 - ORDER granting motion for attorney Stephen F Hanlon to appear pro hac vice [6-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 12/02/2002)

PRO HAC VICE admission fee $50 for atty Francis A Anania paid on 12/02/02 receipt # 200 185049 (KWC) (Entered: 12/02/2002)

10 9 - ORDER granting motion for attorney Francis A Anania to appear pro hac vice [9-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 12/03/2002)

11 ANSWER by defendant Michael Haley, defendant Ronald Cavanaugh, defendant Billy Mitchem, defendant David Wise w/appear by atty(s)

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12/31/2002 01/06/2003 01/06/2003 01/13/2003 01/13/2003 01/13/2003 01/21/2003 01/21/2003 01/21/2003 01/21/2003 01/22/2003 01/22/2003 01/31/2003 01/31/2003 01/31/2003

Andrew W Redd filed cs (KWC) (Entered: 12/26/2002)
12 Initial ORDER governing proceedings in this action; parties are reminded of their obligations under FRCP 26 filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 12/31/2002)
13 MOTION by plas for class certification filed cs (KWC) (Entered: 01/06/2003)
14 Memorandum of law (BRIEF) by plas in support of plas' motion for class certification filed cs (KWC) (Entered: 01/06/2003)
15 SUMMONS and complaint returned executed: upon defendant David Wise on 11/25/02 w/ affidavit of lost original summons filed (KWC) (Entered: 01/14/2003)
16 SUMMONS and complaint returned executed: upon defendant Collette Simon on 11/25/02 w/attached afdvt of lost original summons filed (KWC) (Entered: 01/14/2003)
17 SUMMONS and complaint returned executed: upon defendant Billy Mitchem on 12/10/02 w/attached afdvt of lost original summons filed (KWC) (Entered: 01/14/2003)
18 SUMMONS and complaint returned executed by pla: upon defendant Michael Haley on 11/22/02 filed (KWC) (Entered: 01/21/2003)
19 SUMMONS and complaint returned executed by pla: upon defendant NaphCare, Inc. on 11/20/02 filed (KWC) Modified on 01/21/2003 (Entered: 01/21/2003)
20 SUMMONS and complaint returned executed by pla: upon defendant Ronald Cavanaugh on 11/22/02 filed (KWC) (Entered: 01/21/2003)
21 SUMMONS and complaint returned executed by pla: upon defendant Francis Henderson on 12/2/02 filed (KWC) (Entered: 01/21/2003)
22 MOTION by plas for order for on-site physical exam of class members by their medical expert filed cs (KWC) (Entered: 01/22/2003)
23 MOTION by plas for order to photograph and video record conditions of confinement and photograph on-site physical exam of class members by their medical expert filed cs (KWC) (Entered: 01/22/2003)
24 MOTION by plas for order to shorten time for dfts to answer discovery and provide medical records to plas' expert during physical exam of class members filed cs (KWC) (Entered: 01/31/2003)
25 MOTION by plas for order to enforce this court's order of Nov. 26, 2002 relating to production of medical records filed cs (KWC) (Entered: 01/31/2003)
26 ANSWER by defendant NaphCare, Inc., defendant Francis Henderson, defendant Collette Simon w/appear by atty(s) Giles G Perkins, James A Patton Jr, J E Murrill Jr filed cs (KWC) (Entered: 02/03/2003)

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02/11/2003
02/13/2003 02/18/2003 02/18/2003 02/18/2003 02/18/2003 02/18/2003 02/18/2003 02/21/2003
02/21/2003 02/21/2003 02/21/2003
02/21/2003 02/21/2003

27 ORDER finding the motion for on-site physical exam of class members by their medical expert [22-1] moot; finding the motion to photograph and video record conditions etc, [23-1] moot; finding the motion to shorten time for dfts to answer discovery etc, [24-1] moot; finding the motion to enforce this court's order of Nov. 26, 2002 relating to production of medical records [25-1] moot; as counsel for plas' notified court that motions have been resolved; filed (by Judge Karon O. Bowdre) cm (KWC) (Entered: 02/11/2003)
28 NOTICE of appearance for defendant NaphCare, Inc., defendant Francis Henderson, defendant Collette Simon by T Scott Kelly filed cs (KWC) (Entered: 02/13/2003)
29 MOTION by plas to drop party Collette Simon filed cs (KWC) (Entered: 02/18/2003)
30 MOTION by plas to substitute parties , and for leave to amend complaint (amd cmp att) filed cs (KWC) (Entered: 02/18/2003)
31 MOTION by plaintiff for release of medical records filed cs (KWC) (Entered: 02/18/2003)
32 MOTION by plas for order to shorten time to responsd to motion for release of medical records filed cs (KWC) (Entered: 02/18/2003)
33 MOTION by plas for order to photograph and video record various conditions at Limestone Corr Fac filed cs (KWC) (Entered: 02/18/2003)
34 MOTION by plas for order to shorten time to respond to motion to photograph and video record various conditions at Limestone Corr Fac filed cs (KWC) (Entered: 02/18/2003)
35 Opposition to plas' motion to photograph and video record various conditions at Limestone Corr Fac and MOTION by defendant NaphCare, Inc., defendant Francis Henderson for protective order filed cs (KWC) (Entered: 02/21/2003)
36 33- ORDER granting motion for order to photograph and video record various conditions at Limestone Corr Fac [33-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 02/21/2003)
37 35- ORDER denying motion for protective order [35-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 02/21/2003)
38 34- ORDER finding the motion for order to shorten time to respond to motion to photograph and video record various conditions at Limestone Corr Fac [34-1] moot ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 02/21/2003)
39 32- ORDER granting motion for order to shorten time to responsd to motion for release of medical records [32-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 02/21/2003)
40 31- ORDER granting motion for release of medical records [31-1] ( by

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02/21/2003
02/24/2003
02/24/2003 02/24/2003 02/24/2003
02/28/2003 02/28/2003 03/05/2003
03/06/2003
03/12/2003 03/24/2003
03/25/2003 03/25/2003 03/26/2003 04/02/2003 04/02/2003

Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 02/21/2003)
41 30- ORDER granting motion to substitute parties [30-1], granting motion for leave to amend complaint [30-2] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 02/24/2003)
42 AMENDED complaint filed by plas [1-1]; terming party Francis Henderson, terming party Michael Haley; adding Donal Campbell and James Francis Delong as dfts filed cs (KWC) (Entered: 02/24/2003)
43 ORDER granting motion to drop party Collette Simon [29-1] filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 02/24/2003)
DOCKET modification (utility event) terminating party Collette Simon per order doc #43 (KWC) (Entered: 02/24/2003)
44 OBJECTIONS by defendant Ronald Cavanaugh, defendant Billy Mitchem, defendant David Wise to plas' motion to photograph and video [33-1] filed cs (KWC) (Entered: 02/24/2003)
45 MOTION by dfts for pre-certification discovery filed cs (KWC) (Entered: 03/03/2003)
46 First amended ANSWER and affirmative defenses by dft NaphCare, Inc., dft James Francis Delong filed cs (KWC) (Entered: 03/03/2003)
47 MOTION by defendant NaphCare, Inc., defendant James Francis Delong to quash subpoenas to Roger Childers, Larry Mendel and Jacqueline Moore filed w/exh attached cs (KSS) (Entered: 03/05/2003)
48 MOTION by defendant NaphCare, Inc., defendant James Francis Delong for court inspection of Limestone Corr Fac filed cs (KWC) (Entered: 03/07/2003)
49 MOTION by plas for order declaring dfts' motion to quash subpoenas as listed moot filed cs (KWC) (Entered: 03/12/2003)
50 MOTION by defendants for scheduling conference or in alternative, for entry of ddls/limitations agreed upon filed cs (KWC) (Entered: 03/24/2003)
51 MOTION by plas to compel production of addt'l deceased inmates' medical records filed cs (KWC) (Entered: 03/25/2003)
52 MOTION by plas to expedite response to plas' motion to produce addt'l inmates' medical records filed cs (KWC) (Entered: 03/25/2003)
53 MOTION by plas for leave to amend complaint (2nd amd cmp attached) filed cs (KWC) (Entered: 03/26/2003)
54 53- ORDER granting motion for leave to amend complaint [53-1] ( by Judge Karon O. Bowdre ) entered cm (KWC) (Entered: 04/02/2003)
55 Second AMENDED complaint filed by plaintiffs [42-1] filed cs (KWC) (Entered: 04/02/2003)

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04/02/2003
04/04/2003
04/04/2003 04/07/2003 04/10/2003 04/11/2003 04/16/2003 04/23/2003 04/23/2003 04/25/2003 04/29/2003 06/02/2003 06/16/2003 06/19/2003 07/09/2003

56 ORDER granting motion to expedite response to plas' motion to produce addt'l inmates' medical records [52-1]i; dft have until 04/10/03 430pm to file a response filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 04/02/2003)
57 Scheduling ORDER that discovery cutoff 11/28/03; pla ddl amd/join 08/04/03; dft ddl amd/join 08/18/03; joint status rpt ddl 09/15/03; dispositive mtn ddl 01/15/04; submissions should comply with attached exh A; by Judge Karon O. Bowdre entered cm (KWC) (Entered: 04/04/2003)
DOCKET modification (utility event) terminating motion for scheduling conference [50-1] per order doc #57 (KWC) (Entered: 04/04/2003)
58 MOTION by plas to amend sched order of 04/04/03 , or in alternative, Motion for scheduling conference pursuant to Rule 16 FRCP filed cs (KWC) (Entered: 04/07/2003)
59 RESPONSE (answers to plas' 5th req for prod) by defendant NaphCare, Inc., defendant James Francis Delong to order [56-1] filed cm (KWC) (Entered: 04/11/2003)
60 RESPONSE by defendant Donal Campbell, defendant Ronald Cavanaugh, defendant Billy Mitchem, defendant David Wise to order [56-1] for fifth req for prod filed cs (KWC) (Entered: 04/11/2003)
61 RESPONSE by defendants in opposition to plas' motion to amend sched order of 04/04/03 [58-1], motion for scheduling conference [58-2] filed cs (KWC) (Entered: 04/16/2003)
62 RESPONSE by Dept of Corrections' defendants to order [56-1] (pla's 3rd req for production of docs) filed cs (KWC) (Entered: 04/23/2003)
63 Second amended ANSWER by defendant NaphCare, Inc., defendant James Francis Delong filed cs (KWC) (Entered: 04/24/2003)
64 ANSWER to plas' second amd cmp by defendant Ronald Cavanaugh, defendant Billy Mitchem, defendant David Wise filed cs (KWC) (Entered: 04/25/2003)
65 RESPONSE by plaintiffs to dft Naphcare, Inc and Delong, interrogatories & request for prod to plas on issue of class cert w/att exhs filed cs (KWC) Modified on 04/29/2003 (Entered: 04/29/2003)
66 Supplemental memorandum (BRIEF) in support of motion for class certification by plas filed cs (KWC) (Entered: 06/02/2003)
67 MOTION by movant Roger Childers to quash or modify subpoena, for protective order or for other relief filed cs (KWC) (Entered: 06/16/2003)
68 MOTION by defendant NaphCare, Inc. for order to enforce subpoena issued to Roger Childers filed cs (KWC) (Entered: 06/20/2003)
69 ORDER Status conference to be held on 10:30 7/14/03 in chambers filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 07/09/2003)

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07/11/2003 07/24/2003 07/31/2003 08/01/2003
08/01/2003
08/01/2003 08/19/2003 08/27/2003 08/27/2003 09/02/2003 09/05/2003

70 ORDER that Status conference reset for 10:00 7/24/03 in chambers filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 07/11/2003)
COURTROOM NOTES: Status/motion hearing held on 7/24/03 BOWDRE - written order to be entered - Teresa Roberson, rptr (PRW) (Entered: 07/24/2003)
71 Unopposed modified and/or supplemental MOTION by plas to produce addt'l deceased inmates medical records (fifth req for prod of docs) filed cs (KWC) (Entered: 07/31/2003)
72 ORDER that parties submit a brief Joint status rpt addressing class certification by (Notice of Compliance) ddl 9/15/03; In-court hearing on moiton to class cert (doc #13) set for 2:00 10/3/03 in Crtrm 5-A briefs on the issue are by by 09/18/03 430pm; reply briefs due by 09/25/03 430pm; submissions should comply with attached exh A to sched order; filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 08/01/2003)
73 ORDER finding the motion to quash subpoenas to Roger Childers, Larry Mendel and Jacqueline Moore [47-1] moot; finding the motion for order declaring dfts' motion to subpoenas as listed moot [49-1]; moot finding the motion to quash or modify subpoena, for protective order or for other relief [67-1] moot; finding the motion for order to enforce subpoena issued to Roger Childers [68-1] moot; finding the motion to compel production of addt'l deceased inmates' medical records [51-1] moot; granting motion for pre-certification discovery [45-1]; granting motion for order declaring dfts' motion to quash subpoenas as listed moot [49-1]; granting motion to amend sched order of 04/04/03 [58-1]; granting motion for scheduling conference [58-2]; granting motion to produce addt'l deceased inmates medical records (fifth req for prod of docs) [711]; filed by Judge Karon O. Bowdre ) cm (KWC) (Entered: 08/01/2003)
74 Amended Scheduling ORDER that discovery cutoff 11/1/03; dispositive mtn ddl 11/15/03; other ddls as set out; by Judge Karon O. Bowdre entered cm (KWC) (Entered: 08/01/2003)
75 ORDER Case referred to Magistrate-Judge John E. Ott for mediation filed ( by Judge Karon O. Bowdre ) cm (KWC) (Entered: 08/19/2003)
76 NOTICE of filing expert report of Dr. Stephen Tabet on behalf of plas filed by plaintiffs [1 vol bound notebook] cs (KWC) (Entered: 08/28/2003)
77 MOTION by plaintiffs for protective order , or in alternative, for order to seal attachment II of expert report of Dr. Stephen Tabet filed on behalf of plas filed cs (KWC) (Entered: 08/28/2003)
78 ORDER In-court hearing set for 10/3/03 is rescheduled to 9:30am 11/21/03 filed ( by Judge Karon O. Bowdre ) cm (BST) (Entered: 09/02/2003)
79 OPPOSITION by defendant NaphCare, Inc., defendant James Francis Delong to plas' motion to compel and for protective order [77-1] filed cs

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09/09/2003
09/10/2003 09/10/2003 09/10/2003 09/18/2003 10/15/2003
10/15/2003 10/15/2003 10/15/2003 10/15/2003 10/21/2003 10/29/2003 11/03/2003 11/03/2003 11/03/2003

(KWC) (Entered: 09/05/2003)
80 ORDER it is hereby ORDERED that this matter is SET for mediation on 9/29/03 at 10:00 a.m., in chambers of the undersigned magistrate judge, Hugo L. Black U.S. Courthouse, Birmingham, Alabama; information parties would like to submit must be submitted by 9/24/03 and marked CONFIDENTIAL filed ( by Magistrate-Judge John E. Ott ) cm (KSS) (Entered: 09/09/2003)
81 MOTION by plaintiff Antonio Leatherwood to compel dft Naphcare to produce request number one of plas' 6th request for production filed cs (KWC) (Entered: 09/10/2003)
82 Memorandum of law (BRIEF) by plaintiffs in support of motion to compel doc #81 filed cs (KWC) (Entered: 09/10/2003)
83 Second supplemental memorandum (BRIEF) by plaintiffs in support of class certification filed cs (KWC) (Entered: 09/10/2003)
84 Joint status rpt in compliance by plaintiff, defendant with order filed cs (KWC) (Entered: 09/18/2003)
85 MOTION by pla Antonio Leatherwood, pla Eric Howard, pla Jerry Keith Sanford, pla John Levins, pla Michael Patrick to compel request six of their third request for production filed cs (Former Employee) (Entered: 10/15/2003)
86 BRIEF by pla Antonio Leatherwood, pla Eric Howard, pla Jerry Keith Sanford, pla John Levins, pla Michael Patrick in support of plas motion to compel (doc #85) filed cs (Former Employee) (Entered: 10/15/2003)
87 NOTICE of deposition of Lee Harrison filed by plas cs (Former Employee) (Entered: 10/15/2003)
88 NOTICE of deposition of Larry Haverland by plas filed cs (Former Employee) (Entered: 10/15/2003)
89 NOTICE of deposition of Dr Collette Simon by plas filed cs (Former Employee) (Entered: 10/15/2003)
90 NOTICE that plas will take the deposition of Bob Malone on 10/28/03 in Bham, AL filed cs (KLL) (Entered: 10/21/2003)
91 MOTION by plas for order for release of Nathan Sullivan's medical records filed cs (KLL) (Entered: 10/29/2003)
92 MOTION by plas for order for an on-site physical reexamination of class members by their medical expert filed cs (KLL) (Entered: 11/03/2003)
93 BRIEF in support of motion for on-site physical reexamination of class members by their medical expert by plas filed cs (KLL) (Entered: 11/03/2003)
94 MOTION by pla for order for release of Alfred Thomas' medical records filed cs (KLL) (Entered: 11/03/2003)

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11/03/2003 11/03/2003 11/12/2003 11/12/2003 11/12/2003 11/13/2003 11/13/2003 11/19/2003 11/19/2003 12/04/2003 12/04/2003 12/05/2003 12/08/2003 12/15/2003 12/22/2003

95 MOTION by pla for order to photograph and video record the conditions of confinement and photograph on-site physical examination of class members by their medical expert filed cs (KLL) (Entered: 11/03/2003)
96 MOTION by plas for standing order to obtain medical records of prisoners who die after 11/1/03 close of discovery filed cs (KLL) (Entered: 11/03/2003)
97 MOTION by pla for order for release of Robert Walker's medical records filed cs (KLL) (Entered: 11/13/2003)
98 MOTION by plas for order to shorten time for dfts to respond to motion for release of Robert Walker's medical records filed cs (KLL) (Entered: 11/13/2003)
99 MOTION by dfts NaphCare, Inc & James Francis Delong to dismiss filed cs (KLL) (Entered: 11/13/2003)
100 MOTION by dfts Ronald Cavanaugh, Billy Mitchem, David Wise, and Donal Campbell to extend ddl for filing dispositive motions filed cs (KLL) (Entered: 11/14/2003)
101 RESPONSE by dfts Ronald Cavanaugh, Billy Mitchem, David Wise, and Donal Campbell to motion for class certification [13-1] filed cs (KLL) (Entered: 11/14/2003)
102 MOTION by plas to compel production of Dr Collette Simon's HIV prisoner death summaries filed w/exhs att cs (KLL) (Entered: 11/19/2003)
103 BRIEF in support of motion to compel Dr Collette Simon's death summaries by plas filed cs (KLL) (Entered: 11/19/2003)
104 RESPONSE in OPPOSITION by plas dft's to motion to dismiss [99-1] filed cs (KLL) (Entered: 12/04/2003)
105 RESPONSE by plas to dfts' motion to extend ddl for filing dispositive motions [100-1] filed cs (KLL) (Entered: 12/04/2003)
106 RESPONSE by defendant NaphCare, Inc., defendant James Francis Delong to motion to compel production of Dr Collette Simon's HIV prisoner death summaries [102-1] filed cs (MAA) (Entered: 12/09/2003)
107 100 - ORDER granting motion to extend ddl for filing dispositive motions [100-1] ( by Judge Karon O. Bowdre ) entered cm (KLL) (Entered: 12/09/2003)
108 RESPONSE by plas to dfts' response to plas' motion to compel production of Dr Collette Simon's HIV prisoner death summaries [102-1] cs (KLL) (Entered: 12/15/2003)
109 RESPONSE by dfts NaphCare, Inc & James Francis Delong to plas' response in opposition to motion to dismiss [99-1] filed cs (KLL) (Entered: 12/23/2003)

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01/15/2004 01/22/2004 01/23/2004 01/23/2004 01/27/2004 01/28/2004 01/28/2004 01/30/2004 01/30/2004
01/30/2004 01/30/2004 01/30/2004
01/30/2004

110 MOTION by Dept of Corrections dfts for order for trial to be scheduled after 5/1/04 filed cs (KLL) (Entered: 01/16/2004)
111 ORDER Status conf to be held at 2:00 pm on 2/5/04 in Bham, AL , and joint status report due by 2/3/04 filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/22/2004)
112 MOTION by plaintiff for order to shorten time to respond to motion for release of Robert Strikland's medical record filed cs (MAA) (Entered: 01/23/2004)
113 MOTION by plaintiff for order for release of Robert Strickland's medical records filed cs (MAA) (Entered: 01/23/2004)
114 ORDER granting motion for class certification [13-1] filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/27/2004)
115 RESPONSE by plas to dft NaphCare, Inc's reply to plas' response in opposition to motion to dismiss [99-1] filed cs (KLL) (Entered: 01/28/2004)
116 RESPONSE by plas to motion for order for trial to be scheduled after 5/1/04 [110-1] filed cs (KLL) (Entered: 01/28/2004)
117 ORDER case set for mediation on 2/4/04 at 1:30 pm in Bham, AL filed ( by Magistrate-Judge John E. Ott ) cm (KLL) (Entered: 01/30/2004)
118 ORDER granting motion to compel request six of their third request for production [85-1], granting motion to compel dft Naphcare to produce request number one of plas' 6th request for production [81-1], dft Naphcare is ordered to produce materials by 2/17/04 filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/30/2004)
119 ORDER granting motion to compel production of Dr Collette Simon's HIV prisoner death summaries [102-1]; dfts shall produce docs b 2/17/04 filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/30/2004)
120 ORDER granting motion for standing order to obtain medical records of prisoners who die after 11/1/03 close of discovery [96-1] filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/30/2004)
121 ORDER granting motion for order for release of Robert Strickland's medical records [113-1], granting motion for order to shorten time to respond to motion for release of Robert Strikland's medical record [1121], granting motion for order to shorten time for dfts to respond to motion for release of Robert Walker's medical records [98-1], granting motion for order for release of Robert Walker's medical records [97-1], granting motion for order for release of Alfred Thomas' medical records [94-1], granting motion for order for release of Nathan Sullivan's medical records [91-1] filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/30/2004)
122 ORDER denying motion for protective order [77-1], granting motion for order to seal attachment II of expert report of Dr. Stephen Tabet filed on

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01/30/2004
01/30/2004 01/30/2004 02/03/2004 02/04/2004 02/04/2004
02/04/2004 02/05/2004 02/05/2004 02/05/2004 02/06/2004
03/03/2004 03/11/2004 03/11/2004

behalf of plas [77-2]; clerk is directed to file attachment II under seal filed ( Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/30/2004)
123 ORDER granting motion to dismiss all claims against dft Naphcare w/out prej [99-1] contingent upon its compliance with all standing disc orders in this case filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 01/30/2004)
DOCKET modification (utility event) terminating party NaphCare, Inc pursuant to doc #123 (KLL) (Entered: 01/30/2004)
124 NOTICE of Att II of expert report of Dr Stephen Tabet filed UNDER SEAL pursuant to doc #122 by plas (deemed filed 8/27/03) cs (KLL) (Entered: 02/02/2004)
125 NOTICE of compliance (joint status report) by parties, with court's order [111-3] filed (KLL) (Entered: 02/03/2004)
126 MOTION by dfts Ronald Cavanaugh, Billy Mitchem, David Wise, and Donal Campbell to extend ddls for expert reports, discovery, witness exchange, and dispositive motions filed cs (KLL) (Entered: 02/04/2004)
127 SUPPLEMENTAL & AMENDED ANSWER by dfts Ronald Cavanaugh, Billy Mitchem, David Wise, and Donal Campbell w/appear by atty(s) Charles M Crook filed w/in motion to dismiss or for sumjgm cs (KLL) (Entered: 02/04/2004)
127 MOTION by dfts Billy Mitchem, David Wise, Donal Campbell, and Ronald Cavanaugh to dismiss , or for summary judgment filed w/in supplemental and amended answer cs (KLL) (Entered: 02/04/2004)
128 MOTION by pla for attorney Gretchen N Rohr to appear pro hac vice filed w/notice of appearance att thereto cs (KLL) Modified on 02/05/2004 (Entered: 02/05/2004)
PRO HAC VICE admission fee paid on 2/5/04 receipt # 200 199925 (KLL) (Entered: 02/05/2004)
129 128 - ORDER granting motion for attorney Gretchen N Rohr to appear pro hac vice [128-1] ( by Judge Karon O. Bowdre ) entered cm (KLL) (Entered: 02/05/2004)
130 ORDER (Amended Scheduling) that ddls are amended as further set out: trial will be conducted on 5/17/04, proposed findings of fact and conclusions of law due 6/1/04 by Judge Karon O. Bowdre entered cm (KLL) (Entered: 02/06/2004)
131 ORDER denying motion for court inspection of Limestone Corr Fac [481] w/leave to refile filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 03/03/2004)
132 NOTICE of filing supplemental expert report of Dr Stephen Tabet filed in independently bound binder by plas cs (KLL) (Entered: 03/11/2004)
133 MOTION by plas for protective order , or in the alternative, to seal

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03/11/2004
03/18/2004
04/01/2004 04/01/2004 04/01/2004 04/01/2004 04/01/2004 04/01/2004 04/08/2004
04/08/2004
04/19/2004 04/28/2004 04/28/2004 05/05/2004
05/06/2004 05/06/2004
05/06/2004

photograph 10 of plas' supplemental expert report of Dr Stephen Tabet filed w/att cs (KLL) (Entered: 03/11/2004)
134 MOTION by plas for protective order , or in the alternative, to seal att II of plas' supplemental expert report of Dr Stephen Tabet filed w/att cs (KLL) (Entered: 03/11/2004)
135 ORDER matter set for mediation on 3/23/04 at 9:00 am in Bham, AL filed ( by Magistrate-Judge John E. Ott ) cm (KLL) (Entered: 03/18/2004)
136 WITNESS list by plas filed cs (KLL) (Entered: 04/01/2004)
137 EXHIBIT list by plaintiffs filed cs (KLL) (Entered: 04/01/2004)
138 WITNESS list by defendants filed cs (KLL) (Entered: 04/01/2004)
139 EXHIBIT list by defendants filed cs (KLL) (Entered: 04/01/2004)
140 MOTION by dfts for protective order re plas' 9th rfp filed cs (KLL) (Entered: 04/01/2004)
141 NOTICE of filing report of Steven A Jenison, MD filed by dfts cs (KLL) (Entered: 04/01/2004)
142 BRIEF in opposition to dfts' motion for protective order by plaintiffs filed w/atts and w/in motion to compel 9th rfp (see expandable folder) cs (KLL) Modified on 07/12/2004 (Entered: 04/08/2004)
142 MOTION by plas to compel ninth rfp filed w/atts and w/in brief in opposition to motion for protective order cs (see expandable folder) (KLL) Modified on 07/12/2004 (Entered: 04/08/2004)
143 BRIEF in opposition to motion to dismiss or for sumjgm by plas filed cs (KLL) (Entered: 04/19/2004)
144 MOTION by plas for attorney Joshua R Lipman to appear pro hac vice filed cs (KLL) (Entered: 04/28/2004)
PRO HAC VICE admission fee paid on 4/28/04 receipt # 200 202771 re Joshua R Lipman (KLL) (Entered: 04/28/2004)
145 144 - ORDER granting motion for attorney Joshua R Lipman to appear pro hac vice [144-1] ( by Judge Karon O. Bowdre ) entered cm (KLL) (Entered: 05/05/2004)
146 NOTICE of appearance for pla class by Joshua Lipman filed cs (KLL) (Entered: 05/06/2004)
147 MOTION by plas for fairness hearing , and for order designating Magistrate Judge Ott to conduct hearing filed cs (KLL) (Entered: 05/06/2004)
148 MOTION by plas for order preliminarily approving settlement agreement filed cs (KLL) (Entered: 05/06/2004)

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05/06/2004 05/06/2004 05/06/2004 05/07/2004 05/07/2004
05/07/2004
05/07/2004 05/07/2004
05/07/2004
05/07/2004 05/14/2004 05/17/2004

149 MOTION by plas for order to provide notice of class action settlement filed cs (KLL) (Entered: 05/06/2004)
150 BRIEF in support of motion to provide notice of class action settlement by plas filed cs (KLL) (Entered: 05/06/2004)
151 NOTICE of proposed class action settlement filed by plaintiff cs (KLL) (Entered: 05/06/2004)
152 JOINT MOTION by parties for order to adopt settlement agreement , and to appoint special master filed cs (KLL) (Entered: 05/07/2004)
153 ORDER granting motion for order to adopt settlement agreement [1521], and terms thereof are adopted and incorporated, granting motion to appoint special master [152-2], court appoints Magistrate Judge John Ott as Special Master filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 05/07/2004)
154 NOTICE to all class members of proposed class action settlement w/terms as further set out in notice; if any party wishes to object to the settlement agreement, objections must be filed in writing with clerk's office w/in 10 days of date of notice filed cm (KLL) (Entered: 05/07/2004)
155 ORDER granting motion for fairness hearing [147-1], granting motion for order designating Magistrate Judge Ott to conduct hearing [147-2] ; fairness hearing set for 5/26/04 at 10:00 am filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 05/07/2004)
156 ORDER granting motion for order to provide notice of class action settlement [149-1]; dfts shall post copies of signed settlement notice in dorm 6, dorm 7, the Health Care Unit, and all other facilities used to house HIV prisoners at Limestone Correctional Facility w/in 24 hours from the entry date of this order filed (by Judge Karon O. Bowdre ) cm (KLL) (Entered: 05/07/2004)
157 ORDER establishing notice procedure and scheduling fairness hearing: w/in 24 hours of receipt of this order, dfts shall post copies of attached notice, at dorm 6, dorm 7, the health care unit, and all other facilities used to house HIV prisoners at Limestone Correctional Facility, court shall conduct fairness hearing at 10:00 am on 5/26/04 in Bham, AL; any class member may object to final settlement agreement by filing a written objection w/clerk of court filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 05/07/2004)
158 148 - ORDER that motion for order preliminarily approving settlement agreement [148-1] is withdrawn (by John E. Ott ) entered cm (KLL) (Entered: 05/07/2004)
160 OBJECTIONS by class plas to settlement agreement [159-1] filed no cs (KLL) (Entered: 05/17/2004)
159 NOTICE of settlement agreement filed by parties (deemed filed 5/7/04 per doc #153) (KLL) (Entered: 05/17/2004)

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Page 20 of 27

05/21/2004 05/21/2004 05/26/2004 06/02/2004
06/17/2004 06/24/2004
06/24/2004
06/28/2004 06/29/2004 10/15/2004 10/15/2004

161 MOTION by plas for final approval of settlement agreement filed cs (KLL) (Entered: 05/21/2004)
162 BRIEF in support of final entry of settlement agreement by plas filed cs (KLL) (Entered: 05/21/2004)
COURTROOM NOTES: Fairness hrg before the Honorable John E. Ott, USMJ - arguments - ORDER (oral) that a report and recommendation adopting the settlement agreement will be entered by the Court- hrg adj (Julie Martin, Rpr) (DDR) (Entered: 05/26/2004)
163 Report and Recommendation that court is satisfied w/settlement agreement and agreement is adopted ; written objections to this report may be filed w/in 15 days from filed date of report; objecting plas are to be served by posting the report and recommendation in accordance w/the notification process previously issed in this case; dfts are directed to post the report in the same manner as was done with regard to the settlement notice filed ( by Magistrate-Judge John E. Ott ) cm (KLL) (Entered: 06/02/2004)
164 OBJECTIONS by dft to certain limited aspects of magistrate judge's report & recommendation [163-1] filed cs (KLL) (Entered: 06/17/2004)
165 MEMORANDUM, opinion, and order: filed ( by Judge Karon O. Bowdre ) granting motion for final approval of settlement agreement [161-1]; settlement agreement shall automatically terminate two years after court has granted final approval of its terms; court appoints Magistrate Judge Ott as Special Master under the settlement agreement; settlement agreement previously filed are found and determined to be fair, reasonable, and adequate, and are APPROVED cm (KLL) (Entered: 06/24/2004)
166 ORDER finding the motion for order for an on-site physical reexamination of class members by their medical expert [92-1] moot, finding the motion for order to photograph and video record the conditions of confinement and photograph on-site physical examination of class members by their medical expert [95-1] moot, finding the motion for order for trial to be scheduled after 5/1/04 [110-1] moot, finding the motion to extend ddls for expert reports, discovery, witness exchange, and dispositive motions moot, finding the motion for summary judgment [127-2]/motion to dismiss [127-1] moot filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 06/24/2004)
167 MOTION by plas for attorney fees and costs filed cs (KLL) (Entered: 06/30/2004)
168 NOTICE of clerical error re plas' motion for attorney fees and costs filed by plas cs (KLL) (Entered: 06/30/2004)
169 MOTION (Supplemental) by plas for attorney fees filed cs (KLL) (Entered: 10/18/2004)
170 BRIEF in support of supplemental motion for attorney fees by plas filed

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10/15/2004 10/22/2004
10/29/2004 11/30/2004 11/30/2004 12/06/2004
12/06/2004 12/06/2004
12/13/2004 12/16/2004 12/29/2004

cs (KLL) (Entered: 10/18/2004)
171 SUBMISSION of evidence in support of supplemental motion for attorney fees by plas filed no cs in expandable folder (KLL) Modified on 10/18/2004 (Entered: 10/18/2004)
DOCKET modification (utility event) terminating case referral to Magistrate-Judge John E. Ott motion for attorney fees, motion for attorney fees and costs, motion to compel ninth rfp, motion for protective order re plas' 9th rfp, motion for protective order, motion to seal att II of plas' supplemental expert report of Dr Stephen Tabet, motion for protective order, motion to seal photograph 10 of plas' supplemental expert report of Dr Stephen Tabet (SNH) (Entered: 10/22/2004)
172 ORDER oral argument re motion for attorney's fees set for 9:30 am on 12/6/05 in Bham, AL filed ( by Judge Karon O. Bowdre ) cm (KLL) (Entered: 10/29/2004)
173 Brief in opposition to fees/expenses of $866,000 filed by Department of Corrections (Attachments: # 1 Exhibit # 2 Exhibit # 3 Exhibit)(KLL, ) (Entered: 12/01/2004)
174 JOINT MODIFICATION to SETTLEMENT AGREEMENT by Parties (KLL, ) (Entered: 12/01/2004)
Minute Entry for proceedings held before Judge Karon O Bowdre : Motion Hearing held on 12/6/2004 re 169 Motion for Attorney Fees filed by Jerry Keith Sanford, Antonio Leatherwood, Eric Howard, John Levins, Michael Patrick, 167 and Supplemental Motion for Attorney Fees filed by Jerry Keith Sanford, Antonio Leatherwood, Eric Howard, John Levins, Michael Patrick. Parties announced that an agreement has been reached regarding attorney fees. (Court Reporter Teresa Roberson.) (PRW) (Entered: 12/06/2004)
175 ORDER finding as moot 167 Motion for Attorney Fees, finding as moot 169 Supplemental Motion for Attorney Fees . Signed by Judge Karon O Bowdre on 12/6/2004. (KLL, ) (Entered: 12/06/2004)
176 ORDER denying 133 Motion for Protective Order, granting 133 Motion to Seal photograph 10 of plas' supplemental expert report of Dr. Tabet, denying 134 Motion for Protective Order, granting 134 Motion to Seal attachment of plas' supplemental expert report of Dr. Tabet. Signed by Judge Karon O Bowdre on 12/6/2004. (KLL, ) (Entered: 12/06/2004)
179 JOINT MOTION for modification of consent decree by Parties(KLL, ) (Entered: 12/14/2004)
180 JOINT MOTION for modification of consent decree by parties (KLL, ) (Entered: 12/17/2004)
181 NOTICE of Appearance by Albert S Butler on behalf of ADOC dfts Billy Mitchem, David Wise, Donal Campbell, Ronald Cavanaugh (KLL, ) (Entered: 01/03/2005)

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01/03/2005 01/03/2005 01/07/2005 01/21/2005 01/21/2005 01/28/2005
01/28/2005 01/31/2005 02/18/2005
02/22/2005 02/22/2005
02/25/2005

182 ORDER granting 179 and 180 Joint Motions to modify the consent decree; consent decree modified as further set out in order. Signed by Judge Karon O Bowdre on 1/3/2005. (KLL, ) (Entered: 01/03/2005)
183 ORDER denying as moot [140] Motion for Protective Order, denying as moot 142 Motion to Compel the ninth rfp . Signed by Judge Karon O Bowdre on 1/3/05. (KLL, ) (Entered: 01/03/2005)
184 JOINT MOTION to approve fees and costs of David M. Lipman (Attachments: # 1 Exhibit proposed order)(KLL, ) (Entered: 01/12/2005)
ORDER granting 184 Joint Motion in Support of Fee Agreement. The Order requested by the parties will be entered separately. Signed by Judge Karon O Bowdre on 1/21/2005. (KOBLC1) (Entered: 01/21/2005)
185 ORDER: pursuant to agreement of the parties re fees and costs, ADOC shall pay David Lipman $410,000.00. Signed by Judge Karon O Bowdre on 1/21/2005. (KLL, ) (Entered: 01/21/2005)
186 MOTION for Protective Order, or in the alternative, MOTION to Seal patient medical record reviews of the Nov 2004 neutral medical consultant report by plas Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John Levins, Michael Patrick. (Attachments: # (1) Exhibit) (KLL, ) (Entered: 01/28/2005)
187 NOTICE of filing Nov 2004 Neutral Medical Consultant Report by Plas Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John Levins, Michael Patrick (Attachments: # 1 Exhibit)(KLL, ) (Entered: 01/28/2005)
188 ORDER denying 186 Motion for Protective Order, granting 186 Motion to Seal Patient Medical Reviews. Signed by Judge Karon O Bowdre on 1/31/05. (KLL, ) (Entered: 01/31/2005)
190 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt by Antonio Leatherwood, Eric Howard, John. Levins. (Attachments: # 1 Exhibit Show Cause Motion Appendix for Exhibits# (2) Exhibit Show Cause Motion Exhibits 1-6# (3) Exhibit Show Cause Exhibits 7-12)(Lipman, Joshua) (Entered: 02/18/2005)
191 ORDER re: 190 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt, the court orders that the motion is referred to Magistrate Judge John E. Ott. Signed by Judge Karon O Bowdre on 2/22/2005. (KSS, ) (Entered: 02/22/2005)
192 MOTION to Seal exhibit 1 and exhibit 7 filed in support of motion for order to show cause why defendants should not be held in contempt (with sealed envelope attached) by Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John. Levins, Michael. Patrick. (MAA, ) (Entered: 02/22/2005)
193 ORDER that Telephone Status Conference is set for 3/1/2005 at 02:00 PM re 190 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt and 192 MOTION to Seal; call will be initiated by undersigned judge's staff . Signed by Judge John E Ott on

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03/01/2005
03/11/2005 03/11/2005 03/11/2005 03/14/2005 03/21/2005

2/25/05. (KLL, ) (Entered: 02/25/2005)
ORDER. This matter is set for a telephone status conference on March 11, 2005, at 10:00 a.m. It is further set for an evidentiary hearing on the plaintiffs' motion for the court to hold the defendants in contempt on March 29, 2005, at 9:30 a.m. in Courtroom 2C at the Hugo L. Black Federal Courthouse, Birmingham, Alabama. Additionally, the plaintiffs' motion to seal exhibits 1 and 7 is hereby granted. The Clerk of the Court is directed to place the exhibits under seal, pending further order of this court. Signed by Judge John E. Ott on 3/1/2005. (Ott, John) (Entered: 03/01/2005)
ORDER. This matter is SET for a telephone status conference on March 29, 2005, at 9:30 a.m. It is further SET for an evidentiary hearing, if necessary, on April 12, 2005, at 10:00 a.m. in Courtroom 2C, Hugo L. Black Federal Courthouse, 1729 5th Avenue North, Birmingham, Alabama. Signed by Judge John E. Ott on 03/11/05. (DSS) (Entered: 03/11/2005)
194 NOTICE by Antonio Leatherwood, Eric Howard, John. Levins of Filing February 2005 Neutral Medical Consultant Report (Attachments: # 1 Appendix Appendix for Notice of Filing February 2005 Neutral Medical Consultant Report# 2 Exhibit Exhibit A to Notice of Filing February 2005 Neutral Medical Consultant Report)(Lipman, Joshua) (Entered: 03/11/2005)
195 First MOTION to Seal Attachments A, B, C, D, and E of the February 2005 Neutral Medical Consultant Report by Antonio Leatherwood, Eric Howard, John. Levins. (Attachments: # 1 Appendix for Motion for an Order to Seal Attachments A, B, C, D and E of February 2005 Neutral Medical Consultant Report# 2 Exhibit A, Motion for an Order to Seal Attachments A, B, C,, D, and E of the February 2005 Neutral Medical Consultant Report)(Lipman, Joshua) (Entered: 03/11/2005)
ORDER. The motion to seal exhibits 195 is hereby GRANTED. The Clerk is DIRECTED to seal the requested items. Signed by Judge John E. Ott on 3/14/2005. (Ott, John) (Entered: 03/14/2005)
ORDER. Following a telephone conference in this matter, it is hereby ordered that the status conference set for March 29, 2005, and the hearing set for April 12, 2005, are continued. This matter will be set for a conference on April 26, 2005, or some other mutually agreed time, to determine the status of compliance. If necessary, an evidentiary hearing will be set for a later date. Counsel are to inform the court of the agreed upon time. The plaintiff's statement enumerating the issues will be due April 22, 2005, and the defendants' response or responses will be due April 25, 2005, as agreed. Other mutually agreed upon dates will be considered, if necessary, depending on the availability of the expert. It is also understood that the expert's report will be presented on May 27, 2005. The Clerk of the Court is to see that this order is served, electronically or otherwise, on all counsel of record, including counsel for PHS. Signed by Judge John E. Ott on 3/21/2005. (Ott, John) (Entered:

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04/22/2005
04/22/2005 04/22/2005 04/22/2005 04/25/2005 05/09/2005 07/07/2005
07/07/2005
07/11/2005 07/13/2005
07/21/2005

03/21/2005)
197 STATUS REPORT Plaintiffs' Statement Enumerating the Issues for Court's Status Conference Scheduled for April 26, 2005 Addressing Contempt by Antonio Leatherwood, Eric Howard, John. Levins. (Attachments: # 1 Exhibit Dr. Joseph Bick February 2005 Quarterly Report)(Lipman, Joshua) (Entered: 04/22/2005)
198 MOTION for Modification of the Settlement Agreement by Antonio Leatherwood, Eric Howard, John. Levins. (Lipman, Joshua) Additional attachment(s) added on 4/22/2005 (KLL, ). (Entered: 04/22/2005)
199 MOTION Plaintiffs' Motion for Modification of the Settlement Agreement Plaintiffs' Motion for Modification of the Settlement Agreement by Antonio Leatherwood, Eric Howard, John. Levins. (Lipman, Joshua) (Entered: 04/22/2005)
200 Brief re199 MOTION Plaintiffs' Motion for Modification of the Settlement Agreement Plaintiffs' Motion for Modification of the Settlement Agreement filed by Antonio Leatherwood, Eric Howard, John. Levins. (Lipman, Joshua) (Entered: 04/22/2005)
201 RESPONSE to re 197 filed by Billy Mitchem, David Wise, Donal Campbell, Prison Health Services, Inc., Ronald Cavanaugh. (Attachments: # 1)(Lunsford, William) (Entered: 04/25/2005)
202 MOTION for removal from Limestone Correctional Facility and MOTION to Appoint Counsel, by Michael Patrick. (Attachments: # 1 Exhibit)(KLL, ) (Entered: 05/11/2005)
203 NOTICE by Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John. Levins, Michael. Patrick re 190 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt (Attachments: # 1 Exhibit May 2005 Neutral Medical Consultant Report)(Lipman, Joshua) (Entered: 07/07/2005)
204 MOTION to Seal Document 203 Notice (Other), Notice (Other) the NonRedacted Pages 7, 12, and 14 of the May 2005 Neutral Medical Consultant Report and Attachments 1, 2, 3, 4, and 5 of the Report by Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John. Levins, Michael. Patrick. (Lipman, Joshua) (Entered: 07/07/2005)
ORDER granting 204 Motion to Seal Document. Signed by Judge Karon O Bowdre on 7/11/2005. (KOBLC1) (Entered: 07/11/2005)
206 ORDER REGARDING ELECTRONIC FILING: ALL attorneys are REQUIRED to provide the clerk of court with their email addresses by 7/20/05 by accessing the court's website; failure to do so will result in counsel being deleted from the docket and their pro hac vice admission revoked. Signed by Judge Karon O Bowdre on 7/13/05. (KLL, ) (Entered: 07/13/2005)
ORDER. The State of Alabama Department of Corrections is hereby ordered to pay Dr. Joseph Bick $1,700.00 for services rendered in this

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08/17/2005 12/19/2005 12/21/2005 01/13/2006 01/21/2006
01/27/2006
01/27/2006 02/09/2006
02/10/2006

matter as the neutral medical consultant. Signed by Judge John E. Ott on 7/21/2005. (Ott, John) (Entered: 07/21/2005)
207 NOTICE of "Amended Settlement Agreement Complaint" by Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John. Levins, Michael. Patrick (Attachments: # 1 Exhibit A)(KLL, ) (Entered: 08/19/2005)
208 MOTION for cease and desist order by Gregory Reaser. (KLL, ) (Entered: 12/20/2005)
209 ORDER denying 208 Motion for cease and desist order; any filing must be made by counsel. Signed by Judge Karon O Bowdre on 12/21/05. (KLL, ) (Entered: 12/21/2005)
210 AFFIDAVIT re medical mistreatment and abuse of Jerry Terry. (KLL, ) (Entered: 01/18/2006)
ORDER. The undersigned has received an "Affidavit" from Jerry Terry regarding certain circumstances at Limestone Correctional Facility. 210. Counsel for the parties are to review the same and counsel for the defendants' shall forward a copy of it to Dr. Bick as the medical monitor. Any issues appropriate for discussion should be addressed at the next quarterly conference. Signed by Judge John E. Ott on 1/21/2006. (Ott, John) (Entered: 01/21/2006)
211 ORDER finding as moot 190 Motion for Order to Show Cause why dfts should not be held in contempt, finding as moot 198 Motion for modification of settlement agreement; Dr. Bick shall conduct an audit at Limestone in November 2006, participate in an exit conference, and issue his written report on his findings; the Special Master, representatives of the parties, and counsel shall attend the November 2006 exit conference; any motions to terminate or extend the Settlement Agreement shall be filed within 30 days of the termination date of the Settlement Agreement, June 26, 2006. Signed by Judge Karon O Bowdre on 1/27/06. (KLL, ) (Entered: 01/27/2006)
212 ORDER denying 202 Motion to Appoint Counsel, denying 202 Motion for release from Limestone. Signed by Judge Karon O Bowdre on 1/27/06. (KLL, ) (Entered: 01/27/2006)
ORDER. The court has received a February 6, 2006 letter from Michael Patrick (inmate number 182436) regarding certain occurrences at Limestone. The Clerk of the Court is directed to serve a copy of this letter upon counsel of record. The Clerk is further directed to serve a copy of this order on counsel of record and upon Michael Patrick at the Limestone Correctional Facility, 28779 Nick Davis Road, Harvest, Alabama 35749-7009. Signed by Judge John E. Ott on 2/9/2006. (Ott, John) (Entered: 02/09/2006)
213 Letter from Michael Anthony Patrick regarding prison conditions & medical practices at Limestone Correctional Facility (deemed filed 2/7/06 & per judge's instructions) (Attachments: # 1 Exhibit Grievance and Medical Complaint Forms) (KLL, ) (Entered: 02/10/2006)

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03/03/2006 03/08/2006 03/15/2006
03/17/2006 03/17/2006
03/17/2006 04/05/2006
08/08/2006 08/14/2006 08/14/2006

ORDER. The court has received another letter from Michael Anthony Patrick. The Clerk is directed to file the same and send a copy to counsel of record. Defendants' counsel is to forward a copy of the same to Dr. Bick for his review and comment at the next exit conference. Signed by Judge John E. Ott on 3/3/2006. (Ott, John) (Entered: 03/03/2006)
214 Letter from Michael Anthony Patrick, deemed filed 3/3/06 per judge's instructions. (Attachments: # 1 Exhibit) (KLL, ) (Entered: 03/08/2006)
ORDER. The court has received a letter from Mr. Michael Anthony Patrick, Inmate # 182436. The Clerk of the Court is directed to file the same in the record. In the letter, he requests that the Court contact the Alabama Pardon and Parole Board on his behalf. The court declines to do so. The Clerk of the Court is directed to serve a copy of this order upon Mr. Patrick at the Limestone Correctional Facility and upon counsel of record. Signed by Judge John E. Ott on 3/15/2006. (Ott, John) (Entered: 03/15/2006)
215 Letter from Michael Anthony Patrick, deemed filed per instructions from Magistrate Judge Ott. (KLL, ) (Entered: 03/17/2006)
216 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt by Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John. Levins, Michael. Patrick. (Attachments: # 1 Appendix Appendix to Attachments# 2 Exhibit letter dated November 17, 2005# 3 Exhibit letter dated February 13, 2006# 4 Exhibit letter dated March 15, 2006# 5 Exhibit letter dated March 16, 2006)(Lipman, Joshua) (Entered: 03/17/2006)
217 Brief re216 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt. (Lipman, Joshua) (Entered: 03/17/2006)
218 PROTECTIVE ORDER GOVERNING THE DISCLOSURE OF MORTALITY REVIEWS BY NON-PARTY PRISON HEALTH SERVICES, INC.: Parties are to adhere to the provisions of the protective order as further set out in order. Motions terminated: 216 First MOTION for Order to Show Cause Why Defendants Should Not Be Held in Contempt deemed MOOT. Signed by Judge John E Ott on 4/4/06. (KLL, ) (Entered: 04/05/2006)
219 MOTION to Withdraw Gretchen Rohr as Attorney by Antonio Leatherwood, Eric Howard, Jerry Keith Sanford, John. Levins, Michael. Patrick. (Hanlon, Stephen) (Entered: 08/08/2006)
ORDER. The "Motion to Withdraw as Counsel" 219 filed by Gretchen N. Rohr is GRANTED. Signed by Judge John E. Ott on 08/14/06. (DSS) (Entered: 08/14/2006)
ORDER. Attorney Gretchen N. Rohr is terminated from further representation in this case. Signed by Judge John E. Ott on 08/14/06. (DSS) (Entered: 08/14/2006)

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04/26/2007

ORDER. The State of Alabama is hereby ordered to pay Dr. Joseph Bick $4,000.00 for the last quarter evaluation. Signed by Judge John E. Ott on 4/26/2007. (Ott, John) (Entered: 04/26/2007)

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 135/135/213134 13:132 3343533891
"-' .

DEPT OF CORRECTIONS

PAGE 132/213

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DIS'l'RlCT OF ALABAMA
WESTERN PMSION·

)

ANTONIO LEArnERWOOD, ElUe

)

HOWARD, JERRY SANFORD, JOHN

)

LEVINS, MICHAEL PATRl~ and,

)

individually and on behalf of all present and

)

future ElY-positive inmates in the Limestone )

CorrcctionalFacility in Capshaw, Alabama,

)

)

Plaintiffs,

)

)

v.

)

)

)

DONAL CAMPBELL, Commissioner of the

)

Alabama Department of ConectiOllS, RONALD )

CAVANAUGH, Director of Treaanent Alabama )

Depax1mt:nt of Corrections, BILLY MITCHEM, )

Warden of Limestone Correctional.

)

Facility, DAVID WISE, Deputy Warden,

)

)

Defendants.

)

----------------------------)

CIVIL ACTION CLASS ACTION

SETILEMENI AGREEMENT

The Plaintiffs have filed suit challengins the constitutional adequacy ofthe medical C;IU'C

and conditions relating to HN infected prisoners incarcerated at the Limestone Correctional Facility ("Lim~stonc").

Defendants have denied, and continue to deny, allegations of Plaintiffs' complaint and

the connIussion ofthc constitutional violations.

The parties have agreed that it is in 'their best interests to resolve this litigation.

. !herefore, the parties stipulalc and agree to the following provisions to resolve this

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DEPT OF CORRECTIONS

PAGE 03/20

lawsuit. 1. IDn-oductioD
1.1.' During the term of the Agreement, the United States District Court for the
Northem District ofAlabama, Western Division, shall retain jurisdiction to enforce the tenns of
the Settlement Agreeme1lt. This Settlement Agreement and tho Defendants' stipulation that their conduct shaH be governed by the :standards set forth herein, shall automatically terminate two years after the Coun bas granted final approval ofits terms. The parties agree that this provision shall not limit or divest the Court ofjurisdiction over claims of currant and ongoing violations of . the United States COllStitutiOn. II. The Stllndard of Care
2.1. The standard ofmedical care shall be consistent with the guidelines adopted by the National Commission on Correctional Healthcare (~CCHC'~ and the Center! for Disease Control and Prevention (,'CDC").
2.2. This standm:d of medical care applies to antire1roviral treatment olHN infectioll as well as the treatment and prevention ofopportunistic infections and other illnesses experienced by HIV infected prisoners confuled at Limestone.
2.3. Medically necessary services shall be provided in a timely manner. "Medically necessary" refers to that which is required for the alleviation ofpain, prevention ofdiseases, prevention of deterioration of function or organs, or reduction ofmortslity.
In Heslthc.are starr
3.1. An HN Specialist and a medical doctor shall provide medical treatment at Limestone Correctional Facility (,'Limestone''). The HIV Specialist will provide medical

'.:.,

2

. ~.

05/05/2004 13:02 .......
,'" '

3343533891

DEPT OF CORRECTIONS

PAGE 04/20

treatment to HIV and AIDS infected prisoncn at Limestone. The HIV Specialist shall have more

than three years experience in inpatient BIld outpatient mana.gement of patients infected with

. I

aN. The HlV Specialist shall devote at least thirty (30) hours per week to treatment 0.£ HIV

infected prisoners. The medical doctor will provide medical treatment to non-HlV infected

prisoners. 3.2. The Medical Director shall be designated ~ the health authority confonning to

NCCHe P·A-02 (2003). The Medical Director should be, but not limited to, (1) accountable for

access to care mel quality of care, (2) clinical supervision oflicensed bealth professionals, (3)

performance measurement, (4) utilizntion management, and (5) quality management.

3.3. An additional full timo rogistered nune sholl be hired to work at Limestone. The

r~gistered nurse shall serve ~ all "HIV Coordi"llitoz" and coordinate the infection control

program. The HN Coordinator shall be respo1lSlo1e for coordinating care to HJV infected

prisoners including: coordinating and supervising .appointments with both Limestone and with .

outside specialists; ensuring that follow-up care ordered by 11 medical provider oocurs 'in a timely

manner; monitoring the progl'ess and treatment of all known HlV infected prisoners at

Limestone; and organizing education on the t:ransmission and treatment ofHlV and other

infectious and sexually transmitted diseues. The HIV Coordinator shall also serve as a triage

person for HN infected prisoom needing to viBit the my Specialist.

3.4. Prisoncsrs shall not provide emergc:ncy medical treatment to other prisoners. This

includes prisoners placing deceased prisoner bodies into body bags.

3.5. A registered nurse shall be on duty twenty four (24) hours per day, seven days per

week in the Health Care Unit. A licensed practical nurse shall be on duty sixteen (16) hours per
3
.,

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DEPT OF CORRECTIONS

PAGE 135/213

day, seven days a weel\ in the HIV DOrI119.

3.6. Correctional officers shall not make medical decisions or medical judgments.

, I

3.7. All staffi.ng levels shall confoIID to NeCHC P-C-07 (2003).

I

I

!

\

IV. Reslthcare Staft Training

!

4.1. All medical and correctional staff shall receive current cardiopulmonary

resuscitation CUCPR") training. Trained medical and. correctional staff &hall be available to

perfonn CPR and other emergency aid when needed. CPR training shall be consistent with the

recommends.tions of the Amerioan Heart Association or the American Red Cross.

Documentation addressing CPR training for medical and correctional staff'sball be maintained at

Limestone. Appropriate protective geat and ~equate1:r9.lning for the use of the protective gear

shall be made available to healthcare and correctional 3taff to safely perform CPR.

4.2. AJI ~gist~d nurses C'RN") and licensed practical nl1l'scs ('"LPN") shall not make

medical decisions outside the scope of their licenSe.

4.3. All medical staff must attend continuing medical educational programs as

reconunended by the state of Alabama and provided iii. the Alnbam8 ~ules ofRegulations of the

Board ofMedical Examiners. Attendance ofhealthcare staff at continuing medicnl education

programs shall be documented.

4.4. If Limestone lacks adequate resources for the medical treatment ofan HIV

infected prisoner', then the prisoner shall be sent to an outside .specialist in a timely manner'.

Diagnostic reports, consultation reports, and hospital discharge summaries shall be incorporated

into the HIV infected prisoners' Limestone medical record.

4.5. Copies of an HN infected. prisoner's Kilby Correctional Facility medical record
4
,~.

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shall follow the HIV infected prisoner at Limestone.

V. Periodic Evaluations 5.1. The H1V Specialist shall see all HIV infected prisoner at least qU1lrterly, or more
frequently as medicallY necess~. which will iJJ.clude: a history, physical examination, and evaJuatlon of current CD4-1" levels and Viral load. All prisoners with AIDS shall be seen every

sixty (60) days. S.2. Any HlV infected prisoner taking mcdication6 which can damage the liver,
.including but not limited to Isoni3Xid ("lNH"), or who demoll8trate gigas of liver dysfunction shall have their erttymes moni~ored periodically.

VI. Infection Control
6.1. The regjstercd nurse referenced in section mhereof shall implement the infection

control program and document the activities of the Limestone infection control progr.ml. The

. infection control program shall include: aitbome and blood home pathogen control pl8ll3 that

i
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follow C.DC.

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6.2. All prisoners who have, or are suspected to have, contagious tuberculosis. shall be

i·

placed in respiratory isolation until they have no longer pose a risk: to the public health,

i

especially to other HIV infected prisoners.

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I

1

6.3. Protocols shall be adopted to minimize the spread ofMethjcillin Resistant

i

Staphylococcus AW'cus ("MRSA'') among the HIV infected prisoner population at Limestone.

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I

The MRSA guidelines will address: (1) prevention, (2) examining and interviewing prisoners at

!
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intake and listing MRSA on a prisoner's "problem list" ~ their medical chart, (3) diagnosis 8lld

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treatment, and (4) MRSA outbreak and control protocols.

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VII. Medication Administration 7.1. Medication shall be provided within forty-eight (48) hours ofbeing presQribed by
the mv Specialist. Medications shall be provided in appropriate doses and times in a~cordance

with Food and Drug Administration (''FDAn) approval. 7.2. IfHIV infected prisonm refuse the doso, counseling shall be provided and the

record shall document this counseling. HIV infected prisoners who miss doses on three

consecutive days shall be seen by the prescribing physician and counseled. A record ofsucll

counseling shall be maintained. 7.3. Critain shall be established for a "selfmerucation" program. Each HIV infected

prisoner that keeps medication on their person .shall be provided clear written instrUctions fot

medication administration. includiIlg dosing timing and potential aide effects for each medi~ation. All HIY medications shall be adnrini&tered, and dispensing documented., consistent

with FDA reconunendationi.

7.4. No medication prescribed to one prisoner shall be given to another prisoner in

I

i

accordance with the rules and regulations adopted by the Drug Enforcement Agency ("DEA'').

\.

7:.5. Medication shall be hand dclivored. to all acutoly ill HN.infected prisoners.

Medication shall be administered to HIV infected priconcra in strict accotdance with the

prescriptions _. including directions relating to the timing ofHIV medication adrn.in.iBtratjon in

relation to food and water intake.

7.6. 'When medically appropriate, a snack shall be provided with the distribution of

medication.

7.7. All HIV infected prisoners shall have access to fresh drinking water twenty-four

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hours per day) seven days per week. 7.S. The medication formulary shall iDclude medication$ typically used to treat mY

infectioll, oo--occurring illnesses, and opponunistic infections. At a minimum, the fom:ulary

shall be updated quarterly. The foonulary shall be published annually.
vm. Chronic Care' ofHIV·Positive Prhoners

A. IUV-posftlve diabetic prisoners.

8.1 , Treatment for HIV infected prisoners with diabetes mellitus shall confonn to

Gaddis. et. at. v. CampbelL etc at, settlement Ilgreement dated October, 2004.

B. Hepatitis A. B, and C streenlDg and treatment.

S.2. HN-posirive prisoners shall be vaccinated against Hepatitis A and B.

8.3. Treatment ofHIV infected prisonen with Hepatitis C shall conform to Balcer. et.

al. v. CampbelL et. 81.. settlement agreement dated _-,,2004. HIV infected prisoners with

i

symptoms of liver dysfunction and who have a negative HCV antibody test, slWl be

I,I

administered an Hev PCR test, as medically Indicated.

I

IX. Food

i·

9.1. AU EN infected prisoners shall receive three meals pcr day, six days per week.

On Sundays and hoHdays, all roY infected priSOllClS shall receiYe two meals per day and a

medication food sack consisting of one sandwich and eight ounces of mille.

9.2. Meals shall be served to H1V infe~ prisoners after 5:00 a.m. 9.3. HN infetted prisoners prescribed spedal diets sh~ be provided a special diet.

9.4. HN infected prisoners shall havemedical diets addressing their individ.ual

medical needs for calories, carbohydrates and fat. A record ofthose prisoners receiving special
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diets shall be maintained :1t Lixnestone. 9.5. Patients with wuting shall have dietary supplr:mentation and medicatiolLS as

medically necessary.

X. Emergencies 10.1. A wireless intercom system shall be placed in five cells per donn used to house
mv infected prisone~. The wireless intercom .in these cells &hall be linked to the donnhory
officer station. These cells shall be available for acutely ill HN infected prisoners.

10.2. Emergency drills shall be conducted one time per year involving both medical and

correctional staff. The medical emergency plan shall conform with NCCHC P-A-07. 10.3. An emergency medical plan shall be developed in conformity with NCCHC

standards and shall be active twenty-four hOUlS per day, seven days per week.

10.4. Puring emc:l'gencies, all medical decisions shall be made by an on-sitc,on-duty

medical person.

10.S. All emergency medical equipment shall be kept in good working condition.

XI. IntAke at Limestone

I.

11.1. Within twenty-four (24) hours ofaniving at Limestone, the HIV infected prisoner

I

shall have an intake assessment or screening by a nurse. This assessment shall include, but not

I

be limited to, inquiry into communicable diseases, including tuberoulosis and sexually

I

tr~mitted diseases, and urgent conditiOns; review and continuation of any medications; and

timely referral for HN infected prisoners in urgent need ofphysician review.

J1.2. Within two weeks of arrivingo.t Limestone, the HIV infected prisoner shall be

seen by tlle HIV Specialist or a mid-level provider.

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11.3. If an HlV infected prisoner can id~tify his mcdicationupoll entry at Limestone,

then the medication shall be continued provided the prescription for such medioation can be

vel'ified by a physician or phannacist. There shall be no UDIlecessary disruption in the ~ontinuity

of medication. The, intake provider shali SBk. each known HIV infected prisoner "to sign a release
of information fOIm so that confirmation of any treatment regimen and exchange of relevant

. information can take place as soon as possible.

11.4. Within forty-eight hours of amving at Limestone, an HlV infected prisoner shall

be refeo:ed to the ~rv Specialist.

11.5. All HIV infected prisooers shall be tested for syphilis and screened for chlamydia,

and gonorrhea. Testing for chlamydia and gonorrhea shall be performed if symptoms are

present.

xn. End-of-life Treatmellt

12.1. Appropriate palliative care shall be provided to all end-of-life mv and AIDS

i

infected prisoners.

I

12.2. ''Tenninally ill" is defmed as a physical condition that has deteriorated to tIlo

I·

point where the patient has been given less than a year to live. See NCCHe P-G·12 (2003). At

the poirtt that an HIV infected prisoner becomes terminally ill. the prisoner should be counseled

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regarding end oflife care.

I

12.3. One aption for end of life treatment may be to continue vigorous treatment. The

HIV infected patient may also opt to or may also choose to refuse certain life prolonging

"'

measures which could include: intravenous fceding, mechanical ventilation, or CPR. The HN

infected prisoner may then sign an Advanced Medical Directive, consistent with state law. 9

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regardiIlg their choic~ regarding end ofHfe care. At least two witnesses also shaJlsign an Advanced Medical Directive. In no case shall an HIV infected prisoner be denied appropriate comfort, such as medication for pain. A copy ofthe end of life treatment request shall be
maintained in the HN infected prisoner's medical record.
XIn. PbyslcaUy Disabled mv Infected Prisoners
13.1. Cells used to cOMne physically disabled HIV in:f.ected prisoners shan have adeqUQte hand-railing.
13.2. One shower in ench HIV dorm shall have adequate hand-railing. ramp entry, and seating.
13.3. IfmedicaJly indicated. an HlV infected prisoner shall have a prosthesis .re--fined for a revised or new prosthesis within ninety (90) days. XIV. Dental Services
14.1. HN infected prisoners who require dentuns shall have timely dental treatment, including the making of denture iJnpressions, 10 prepare for proper use of dentures. Dentures shall be delivered and fitted witlrin sixty (60) days ofimpressions.
14.2. All HN infected patients shall have access to prophylactic dental bygiene, which include dental cleanings. at least annually. XV. Triage System
15.1. All sick call slips &hall be triaged daily for degree ofurgcncy. All medical
informal grievance forms and medical fonnal grievance {OImS shall be tria,ged every five days for degree of urgency. The triage system forslclc·cal) slips, medical complaint fonns, and medical grievance forms shall conform with NCCHC guideline P-E-07.
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XVI. C~paymeDts 16.1. Co-payment! shall Dot be assessed for chronic care clinic appointments,
emergency care, care of cormnuruoabJc diseases, oX' any follow-up appointments. 16.2. All co-payment fees shall be accurately documented. 16.3. A document describing the Limestone co-paYlllent system shall be posted in the
H1V inf~ted living quarters.
XVII. Complatnt and Grievance Process
read,. 17.1. All HIV infected prisoners sh:1l1 have access to complaint and grievance
formg; be informed of the location of the complaint and grievance fonns; and be provided documentation describing the complaint and grievance process.
17.2. All complaint and grievance forms shall be accurately tracked by the Continuing Quality Improvement C'CQr') program.
17.3. All infonnal grievances submitted by HlV infected prisoners shall be answered within seventy-two (72) hours. All fonnal grievances submitted by HIV infected prisoners shall be answered within. in five (5) days.
17.4. All HN infected prisoners shall be provided duplicate copies of the medical grievance foms that are submitted,
17.5. A log shall be kept documenting all medical grievance forms submitted. 17.6. A medical sta.ffperson shall prepare a monthly report addre3,ing tl)c number, substance, and resolution to medical grievance forms. This report shall be maintained at Limestone.
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XVDL Translators
18.1. When Spanish speaking HlV infected prisoners visit the IDV-speciaJist or physician assistant for sick call, a tnnslator shall be located.
'XIx. Hausmg
19.1. Housing facilities will be clcaocd on a daily basis; the housing areas shall be disinfected between prisoner placement and the physical conditions of the housing areas be m.aintain~ in good womng ordet'. The Department of Corrections s.bal1 conduct weekly checks on these housing areas to ensure rhat saruro.tion and physical cOAditioDS comply with these standards, and shall respond promptly to any deficiencies identified during these checks. Sanitary supplies such as soap, clean toweJs, bleach and disinfectants alaU be made available to prisoners and staff as needed. Gloves and other safety equipment .recommended during usage of certain diainfeetants shall be provided to any prisoner or staff using the product. The Department of Corrections shaU maintain an exPosure control plan far blood-borne pathogens consistent with the terms ofthis Agreemen.t.
19.2. There shall be no dormitory or open-bay housing or triple ceIling ofHIV inf~ted prisoners.
19.3. Rodent and pest control shall be conducted OD a monthly basis, or as needed.
xx. HIV CouDselor
20.1. HN infected priaonettl shall be informed that they may visit an HlV counselor.
HIV counseling at Limestone can be provided by outside agencies including representatives from Public Health HN Division or Alabama AIDS Outreach. HIV counseling shall be provided at Limestone one day per week.
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20.2. The HIV COUllsclar shall have relevant training or expertence in the area ofHN. 20.3. HN infected prisoners shall be able to request a visit with the HIV counselor through the Limestone sick-call procedure.
XXI. mv Educadon
,
21.1. Outside HIV educators, pamphlets, newsletters, and up-to-date periodicals addressing HIV disease education shall be accessible to HlV infected prisoners.
21.2. Periodically, n person with knowledge oflUV disease shall conduct group eduC:l.tion sessions with HIV infected prisoners.
of XXII. Release from the Department CorrectJODS ("DOC")
22.1. Upon release from thc DOC, all HIV infected priBone.r.s shall have reasonably expeditious access to their Limestone medical records upon submission of a signed medical release of information.
22.2. Upon the submission of a signed medical rcleue~ an outside medical provider shall have access to an HIV infected prisoner's Limestone medical records.
22.3. Prior to being released into the community, an HIV infected prisoner shall be provided adeqWl.te and appropriate discharge planning.
22.4. Upon release, HIV infected prisoners shall be provided at least a thirty (30) day supply ofmedication.
22.5 The DOC shall invite local Social Security Administration ("SSA") representatives to visit Limestone and register the facility for the SSA Prerelease Program for the Institutionalized.

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xxm. Confidentiality
23.1. Confidentiality addressing the HIV status ofprisoners sha.1l be maintained.
XXIV. Mortality
24.1. All DOC mortality reviews shall be conducted by the Department of Corrections, its agents or contrators within thirty days of an HN positive prisoner's death.
24.2. Documentation shall be maintained 2ddressing the number oiRlV infected prisoner deaths :per year.
24.3. The Department of Corrections shall provide Plaintiffs' counsel with a copy of all
DOC mortality reviews or MAC reports within fifteen days of completion.
24.4. Full internal and exte:mal autopsy reviews shalt be conducted after an Hrv infected prisoner's death, as long as the cost of each individual review does not exceed SlSOO.
xxv. Quality Improvement Program ("CQI,,)
25.1. The Department of Corrections shall perform an on-going Quality Improvement Program at Limestone•
.25.2. Copies oftbe Qualitative Improvement findings, conclusions, aorrecriveplans, and any other reports anCi outcomes of the correctiye plans shall be maintained at Limestone.
25.3. Staff shall alsoperfonn qualitative alUllyais to identify problem5, and shall implement timely rerq,ecijes.
25.4. A lDulti-disciplinary Qualitymane.gement Committee shall meet quarterly, md shall perform at least quarterly reviews of all aspects ofhealthcare. The COmmittee shall involve
of . the participation qualified professionals with appropriate specialties and representatives itom
all clinical departments at Limestone.
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XXVI. Medical Consultant 26.1. Subject to Court approval. the Plaintiffs and Defendants .shall identify a neutral
medical consultant, independent of both Plaintiffs and Defendants, to facilitate the implementation of this Settlement Agreemen~. The medical consultant shall be experienced in correctional healthcare and HIV infection. The parties agree that _ _ shall serve as the meclical consultant.
26.2. .The fees and expenses ofthe medical consultant shall be borne equally by the
DOCandSCHR.
26.3. Upon entry ofmis agreement, and for a period of two years, the medical consultant will tour Limestone four times per year, for a total of ei.ght visits. For the four yearly visits, the medical coDSUltant shall notify the DOC at least one week prior: to the visit. The medical consultant's visit shall last no longer than five days.
26.4. During each visit, the medical consultant shall meet with any medical staff or other Limestone staff', shall toUr Limestone, and mayre1J'iew all recordsreiating to the m«lical condition, living conditions and food service provided to the class.
26.5. At the conclusion of the medical consultant's to~. an exit conference shall be conducted with Limestone medical staff, correotional staff, plaintiffs' counsel and defendants'
. counsel addressing positive changes~ failures to confonn with this Agreement, and suggested
remedies.
XXVIL Bradle! Enforcement 27.1. Mental health evaluations, treanuent, and staffing shall confonn with the BradWi
v.Haley settlement agreement.
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XXVlII. ConclulfoD 28.1. Upon any report or observation ofpossible noncompliance with the Settlement
Agr6!emem, tho plaintiffs shall submit a Wl,itten description to the Defendants addressing tho noncompliant acts.
28.2. The pruties agree that the remcciial pbase oftbis case is sufficiently complex to warrant tbe appointment ofa special master pursuant to 18 U.S.C. §3626 (f)(l)(A). Ma.gistrate
JUdge John Ott shall serve as special master. The parties also agree to waive thdr right to an
interlocutory appeal challt:ngiilg the District Court's appointme:nt of Magistrate Judge 10hn Ott as special master pursuant to 18 U.S.C. §3626 (f)(3).
28.3. Upo.n receipt of the complaint, the Defendants shall have 15 days to resolve the dispute.
28.4. Prior to applying to the Special Master for such reliof. Plaintiff~' counsel will try to resolve the issues informaUy with the DefendantS and the Monitor.
28.5. Ifafter 1Sdays, the dispute b.a.3 not be adequately resolved, then the Plaintiffs may petition the Special Master to make findings of fact addressing noncompliance, in accordance with 18 U.S.C. § 3626(1)(1)(A).
28.6. Upon entry of the Special Masters findings of~oiJcompliau.ce, Plaintiffs may petition the DIstrict Court for an order enforcing specific provisions of the Settlement Agreement and providing other appropriate relie!
28.7. The parties agree and stipulate, that the prospective relief set forth in this Settlement Agreement is narrowly drawn, extends no further than neces8ary to correct the alleged violations of plaintiffs' federal rights set forth in the Second Amended Complaint, and is the
16

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least intrusive means necessary to correct theee alleged violations. 28.8. The parties agree and stipulate, that this Settleme"t Agreement will not have an
adverse impact on the public safety or the operation of the operation of the criminal justice system.
28.9. Accordingly, the parties agree and stipulate, that this SerrJemrmt Agreement complies in all resp~ts with the provisions of 18 U.S.C. §3626(a).
28.10. Prior to the Court's approvoJ. ofthe Settlement Agreement, Plaintiffs' counsel shall be afforded the opportunity to meet with all daS! members - in groups of III least fifteen to inform them ofthe provisions of the Settlement Agreement. Class members shall be iDfonned that they have the right to accept or object 10 the temu ofthe Settlement Agreement, and how they may express their acceptance or objections to the terms thereof: pumlant to Rule
23(e)(4)(A) of the Federal Rules of the Civil Pl'oc:edurc. Consistent with Rule 23(c), notice of the Settkment Agreement shall be posted in all areas used to house HIV infected prisoners at
Limestone. 28.11. In the event the parties are unable to hereafter resolve by agreement issues
relating to Plaintiffs' claim for attorneys' fees, Plaintiffs may petition the Court within sixty days of the date on which the Court enters its order granting the parties' Joint Motion to Adopt Serrlernelll Agreement an d Provide for Special Master, for a resolution thereof.

By:
DavidM. L' .David M. Li m 5901 S:W. 7 . ct, Suite 304 Miami, Florida 33143

Date: ~);l (O~ .
Francis A Anania, Esq. Anania, Bandklayder, et al. Ste. 4300. 100 S.E.StcOnd St. Miami, Florida 33131
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Gretchen Rom. Esq. Holland &. Knight. LLP.
Suite 2000 1201 West Peachtree St Atlanta. Georgia 30309

Stephen Hanlo~. Esq. Holland & Knight. LLP.
Suite 100 2099 Pennsylvania Ave, N.W. Washlngton, D.C. 20006-6801

Counsel for Platmi.ff$

~.w. ~ ~C!l/!) By: lea Crook, Esq.

Date: ~ /f}/l.:JIJ".

,}
,.

William F. Addison, El'iq.

Kim Thomas, Esq.

Alabama Department of Corrections

Legal Division

lOl South Union Street

Montgomery, Alabama 36130

Counselfor Defendants, Alabama Dept. of Corrections; Donal Campbellj Ronald Cavanaugh; Billy Mitchem. Warden of Limestone Correctional Facility; David Wise, DcputyWarden

18

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t !II 1ft $'

1 S ' '1

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DEPT OF CORRECTIONS

..

BY:~~::J£:-J.4-J-J.~~­
Bob ltiley Governor, StalO ofAl

~. By: A 0 ~, State of~ama

By: ~C~.•.+~\

DOnal Campbell

"

Commissioner ofDep8I"tmem ofCorreaions

State ofAlabama

PAGE 213/213

19
, I

 
 EXPERT REPORT OF STEPHEN TABET, M.D., MPH
Leatherwood v. Campbell Case No. CV-02-BE-2812-W In The United States District Court Northern District of Alabama Western Division Dated: August 26, 2003

TABLE OF CONTENTS
TAB A. QUALIFICATIONS
B. BASIC SCIENCE OF HIV
C. STANDARDS OF CARE
D. FACILITY TOUR AND OBSERVATIONS PHOTOGRAHS 1 AND 2
E. PATIENT EXAMINATIONS 1. PATIENT 1 (PHOTOGRAPH 3) 2. PATIENT 2 (PHOTOGRAPH 4) 3. PATIENT 3 4. PATIENT 4 5. PATIENT 5 (PHOTOGRAPHS 5 AND 6) 6. PATIENT 6 7. PATIENT 7 8. PATIENT 8 9. PATIENT 9 10. PATIENT 10 11. PATIENT 11 12. PATIENT 12 (PHOTOGRAPH 7) 13. PATIENT 13 (PHOTOGRAPHS 8 AND 9) 14. PATIENT 14 15. PATIENT 15 16. PATIENT 16 (PHOTOGRAPH 10) 17. PATIENT 17 18. PATIENT 18 19. PATIENT 19 (PHOTOGRAPHS 11 AND 12)
F. MORTALITY REVIEWS 1. RUSSELL BATTISTE 2. LUIS BLANCO 3. JOHN BOLTON 4. ANTHONY COX 5. ANDY CRAWFORD 6. EZELLE DANIELS 7. LARRY DAVENPORT 8. HOWARD DAVIS 9. ANDREA EDWARDS 10. MICHAEL ELLIOT 11. TERRELL GREY

PAGES 4-5
6-7
8
9-10
11 12 13 14-15 16-17 18 19 20 21 22 23 24 25 26 27 28 29 30-31 32 33
34 35-36 37-38 39-40 41-43 44 45-47 48-49 50-51 52-53 54-55 56-58
2

12. CHELSEA HAMMAC 13. EDDIE HARRIS 14. KELVIN HARRIS 15. MICHAEL HEADON 16. DENNIS HEARNS 17. CLETIS JOHNSON 18. LESLIE JOHNSON 19. MORRIS JOHNSON 20. STANLEY LILLIE 21. WILFORD LOCKETT 22. JOSEPH McCLURE 23. GEORGE McHEARD 24. JAMES PRYOR 25. WILLIE ROBINSON 26. TONY ROWLAND 27. DIONICIO SALAZAR 28. MILTON SMILEY 29. LAMAR SMITH 30. TIMOTHY SUMMERS 31. RICKEY THOMPSON 32. HENRY TURNER 33. FREDDIE WHITE 34. DEWAYNE WILDER 35. IVERSON WILLIAMS 36. JOHN WILLIS 37. EARNEST WYNN 38. MARVIN YOUNGBLOOD
G. SUMMARY
H. RECOMMENDATIONS
ATTACHMENTS I. CIRRICULUM VITAE

59 60 61-62 63-64 65-66 67-68 69-70 71-72 73-75 76-77 78-79 80 81 82-83 84-85 86-87 88-89 90-91 92-94 95-96 97-98 99-100 101-102 103-104 105-106 107-108 109-110
111-113
114-116
117-124

3

QUALIFICATIONS Stephen Tabet, MD, MPH
See my attached abbreviated Curriculum Vitae for additional information regarding my training and qualifications to serve as an expert witness and provide expert commentary on this case.
In 1991, I received my Doctorate in Medicine (M.D.) with high honors (Junior Year Alpha Omega Alpha National Honor Society) from the University of New Mexico (UNM). My doctoral dissertation focused on assessing health care workers’ attitudes and fears regarding HIV-infected patients. While in medical school, I started providing medical care for HIV-infected patients at the UNM Hospital AIDS Clinic. During medical school, I undertook independent research projects in the area of HIV/AIDS including a study assessing HIV and hepatitis among street-based prostitutes, presented at the World AIDS Conference and published articles in peer-reviewed journals. I have since published dozens of articles, manuscripts, and abstracts and have presented literally several hundred lectures in the area of HIV/AIDS.
In 1993, I completed my Master of Public Health (MPH) in epidemiology at the University of Washington (UW) School of Public Health and undertook residency training in Preventive Medicine. For my Master’s thesis, we were one of the first groups in the world to develop and use molecular epidemiologic methods to track and prevent the spread of tuberculosis among HIV-infected persons. My research resulted in the publication of manuscripts in peer-reviewed medical journals and presentations at national and international medical conferences. I then helped lead public health efforts to decrease the transmission of tuberculosis among HIV-positive persons in Seattle.
In 1994, I completed internship and residency at the UW School of Medicine specializing in Internal Medicine. I went on to further sub-specialize in Infectious Diseases with a concentration in HIV/AIDS at the UW from 1994-97. Upon completion of my Infectious Disease fellowship, I was recruited to become a faculty member at the UW where I am currently Assistant Professor of Medicine in the division of Infectious Diseases. I am double Board Certified in Internal Medicine and Infectious Diseases. I am also Attending Physician in Internal Medicine and Infectious Diseases at the public hospital - Harborview Medical Center (HMC) – in Seattle. One of my main responsibilities at HMC is to provide medical care to patients at Madison AIDS Clinic where we follow over 1200 HIV-infected patients. The majority of these HIV-infected patients suffer from drug and/or alcohol addiction and almost all are homeless, uninsured, mentally ill, or were recently incarcerated. I also serve as one of the main HIV consultants in the community for particularly challenging patients. I teach clinical HIV to medical students, residents, post-doctoral fellows, and practicing physicians. I do a substantial amount of research in the area of HIV/AIDS prevention and treatment both locally and internationally and have been a co-investigator on several National Institutes of Health-funded research grants – the most recent of which is a grant to assess antiretroviral treatment regimens for patients in Lima, Peru – where access to these medications is virtually non-existent. I truly understand the barriers that
4

exist in providing medical care to HIV-infected patients in resource-poor settings both in the U.S. and abroad. I hold numerous local and national appointments. I was appointed by former President Clinton and Secretary Shalala to serve as a member of the Department of Health and Human Service’s Health Resources and Service Administration’s HIV/AIDS Bureau Advisory Committee; the HIV/AIDS Bureau is the largest single provider of care to persons living with AIDS in the US and provides HIV services to the vast majority of our nation’s underserved HIV-infected patients. I am currently a member of the CDC/HRSA Advisory Committee on HIV and STD Prevention and Treatment and advise the current administration on these concerns. I also serve as Senior Advisor to Brown University’s HIV Education Prison Project, the largest HIV education program for correctional providers in the U.S. I have over 7 years providing care to incarcerated HIV-infected patients and working in correctional facilities throughout the State of Washington. I lead a group of physicians that has provided medical care to several thousand incarcerated patients. I have worked in prison settings where we were under federal court decrees because of medical problems that occurred in the past. I am Director of the Northwest Correctional Medicine Education Project where I teach other physicians and providers HIV medicine. As part of this project, I operate an electronic mail consultation service and newsletter. This service is provided free of charge to over 450 providers caring for incarcerated patients. I lecture widely both regionally and nationally on the subject.
5

BASIC SCIENCE OF HIV Stephen Tabet, MD, MPH
Basic Science of HIV
It is important to first briefly describe the biology of HIV disease and to define terms I will be using in order to make this report more understandable to the reader. There are literally tens of thousands of medical articles published each year on the subject of HIV/AIDS. It has been said that to understand AIDS is to understand all of medicine.
AIDS and HIV The Acquired Immune Deficiency Syndrome (AIDS) is the end-result of usually long-term infection with the Human Immunodeficiency Virus (HIV). In 1981, the New England Journal of Medicine published the first articles describing young men with devastating diseases only previously seen in patients with severely suppressed immune systems. Few people were to realize that these men had a disease (eventually termed AIDS) that was already circulating in many parts of the world and that, by year 2001, was to infect 60 million human beings and be the cause of so much suffering and death throughout the world. Only three short years later, in 1984, a virus, later to be called HIV, was found to be the cause of AIDS. What really sets HIV apart from the many viruses that cause illness in humans is that HIV targets and destroys CD4 lymphocytes (or T-cells), a type of white blood cell that is at the center of the immune system. Without T-cells, the immune system defenses cannot work properly thus allowing a number of infectious diseases and cancers to take over the body.
The immune system and T-cells The immune system is remarkable in that it works intricately to ward off foreign invaders if there is no disruption in this system. The average healthy persons has about 800-1,000 Tcells, but this number is variable. When a person first becomes infected with HIV the Tcells can drop dramatically, but then increase to an average of about 600, but again, as in all of medicine, this is variable. In untreated HIV infection, T-cells decrease by an average of 50 cells per year. Persons with HIV infection and higher T-cells are initially at higher risk for skin infections such as rashes, boils/abscesses caused by bacteria, or herpes infection than persons with normal immune systems. HIV-infected persons with low Tcells are also at risk for these same diseases, but the clinical manifestations are often more severe. It is not until T-cells drop below 200 or even 100 that most clinical illnesses associated with HIV occur.
Opportunistic Infections and other illness affecting HIV-infected patients Opportunistic infections (OIs) denote infections capable of causing disease only in a person whose immune defenses is lowered. The majority of diseases that affect patients with AIDS are “opportunistic”. For instance, pneumocystis carinii (PCP) is an organism that can cause a deadly pneumonia in HIV-infected patients, but is harmless to persons with normal immune systems. Some diseases, such as tuberculosis, can manifest in both HIVinfected persons and persons with normal immune systems, but affect HIV-infected persons much more commonly and much more severely and are also sometimes termed “opportunistic”. Persons with HIV infection are also at risk for getting cancers, especially cancers caused by viruses, such as Kaposi’s sarcoma and cervical cancer.
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Treatment and combination therapy In 1995, the number of persons dying from HIV/AIDS dropped precipitously in the developed world because of the advent of combination antiretroviral therapy (also called “the cocktails” or highly active antiretroviral therapy – HAART). Prior to that time, antiretroviral medications were typically being used one drug at a time which disrupted HIV’s life cycle, but then eventually failed because HIV became resistant to the single drug and began replicating again. Currently, a minimum of 3 drugs (and sometimes more) in combination are needed to interrupt life cycle of HIV and the virus becomes “undetectable” (undetectable viral load). Thus, the goal of antiretroviral combination therapy is to suppress viral replication to “undetectable” levels and stop the destruction of T-cells. Because HIV replicates rapidly (billions of time each day), antiretroviral medications must be taken by the patient appropriately and continuously or HIV becomes resistant to the medications, they stop working, and the virus in the blood (or viral load) rebounds and Tcells decrease setting up the patient to contract Opportunistic Infections or other HIVassociated illnesses. Prisons, in particular, have been found to be ideal settings to administer patient’s combination therapy. Studies conducted by Dr. Margaret Fischl in Florida and others have clearly shown that nearly 100% compliance can be achieved when treating incarcerated patients. Years before combination therapy, the use of preventive antibiotics to prevent some infections became the standard of care of therapy when T-cells decreased below certain levels. Preventive antibiotics, with combination therapy, are still the mainstay of therapy. Because these antibiotics are so effective, inexpensive and cost-effective, even many very poor counties in the world have for many years provided these life-saving medications to patients. For example, PCP is nearly 100% preventable when a patient takes one antibiotic once per day. Preventive antibiotics are only a temporizing measure and don’t prevent all disease so combination antiretroviral therapy must also be used to decrease the replication of HIV and increase T-cells.
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STANDARDS OF CARE This report draws upon the minimal standards of care utilized in order to adequately care for HIV-infected individuals. These standards include: The US Department of Health and Human Services and Kaiser Foundation, the Infectious Disease Society of America (IDSA), the Center for Disease Control and Prevention (CDC), and the National Commission on Correctional Health Care (NCCHC) have developed guidelines for the treatment of HIV-infected persons. The Mortality Reviews section of this report draws upon a standard of care that is less than those utilized to adequately treat HIV-infected individuals.
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LIMESTONE CORRECTIONAL FACILITY
On February 13 and February 14, 2003, I toured and observed the Limestone Correctional Facility as a medical expert on behalf of the plaintiffs, Antonio Leatherwood, and the plaintiff class. The review of the facility mainly consisted of observing the following:
- Dorm 16 where the majority of HIV-infected inmates are housed (approx 250); - Substance Abuse Program (SAP) where inmates undergo drug rehabilitation
(approx 50); - The Health Care Unit (HCU) consisting of both an inpatient and outpatient unit; - Dorm 7, The Isolation Unit [I did not see enough of the Isolation Unit (Solitary
Confinement) to be able to provide an informed opinion]
I was not permitted to conduct any formal medical and correctional staff interviews, but did briefly talk to both medical and correctional staff.
I will not go into much detail regarding the Limestone Correctional Facility’s history, as this has been previously documented, but what was most striking about this facility is that there is total segregation of the HIV positive and HIV negative inmates - something that has been almost totally abolished around the world. The HIV positive inmates are segregated into an HIV Dorm (Dorm 16) which is severely crowded. The population of HIV-infected inmates in February, 2003 incarcerated in Dorm 16 was 250. Dorm 16 is an old converted warehouse. The warehouse had previously housed the infamous “chain gangs.” In addition, the inmates’ beds were lined up head-to-toe and very close to each other, as well as side-by-side within a few short feet of each other. The layout of Dorm 16 is documented in photograph 1.
In addition to this severe over-crowding, the facility itself was in poor condition with many of the windows in poor condition, as well as the doors, which clearly allowed cold air to circulate into the facility, creating a health risk to these immunosuppressed individuals. Numerous inmates have reported that Dorm 16 is infested with insects, spiders, and vermin. This is consistent with the condition and physical structure of Dorm 16.
It was reported that the facility had been minimally repaired prior to the February 13-14, 2003 tour. Apparently the Limestone Correctional Facility staff and inmates had painted some of the areas of the unit, as well as had only recently placed screens on the windows. The Department of Corrections had also fumigated the unit given the pest problem.
Of note is that one of the major complaints arising from this unit initially was that of a staphylococcus infection in 2002 where numerous patients had evidence of severe skin infections including pus-filled boils. It is clearly evident that this happened due to overcrowding and the probable influx of stinging and biting insects to the unit. Such conditions would cause infections among HIV-infected patients. An example of this infection is documented in an inmate patient in photograph 2.
There was a lack of adequate facilities or assistance in Dorm 16 and the Health Care Unit for the disabled, as set forth by the Americans with Disabilities Act.
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I also toured the Substance Abuse Program housing unit where inmates undergo drug rehabilitation. This unit is also segregated and housed only HIV-infected individuals. Of note again is the lack of facilities for the disabled. This unit, although crowded, was less crowded than the HIV Dorm, and appeared to have slightly better amenities, but still far below standard.
I spent a considerable amount of time observing the Pill Line in Dorm 16. Patients at the Limestone Correctional Facility are administered medications at 3 a.m., 10 a.m., and 3 p.m. The patients are made to wait outside for their medications, often in very severe weather conditions according to many of the patients. The Pill Line I observed did seem to take a very long period of time, making it very difficult for the weaker patients to stand in line for their medications. The nursing staff administers medications directly into the patient's hands. This practice is not hygienic and unacceptable. Patients were given cups that were placed on a very dirty window sill that had mildew and obvious dirt on the surface which obviously contaminates the cups.
The outpatient facility located in the HCU is a considerable walking distance from Dorm 16 and SAP; it takes approximately 20-30 minutes to walk between the units which creates a potential hazard during an emergency. The outpatient unit seemed small for a facility of this size; apparently, the physician and P.A. at one time even had to share examination rooms at the expense of privacy for the patients.
I was also able to observe the Inpatient Unit at the Limestone Correctional Facility. After talking with several of the patients, they reported that the emergency call buttons were repaired just prior to our visit, and had not been working in the past. The inpatients are often too sick to leave their beds and find a nurse, and must use some sort of remote call device that is within reach of their beds. This practice violates accepted minimal standards that govern inpatient units and hospitals.
A compounding problem in the Inpatient Unit is that inmates called “runners” are often used to assist in the Inpatient Unit. This is not a problem in itself, but patients noted that the runners are performing such duties as nourishment administration which is outside of the scope of their training and inappropriate. This practice needs to be stopped immediately - Nourishment should be administered only by professional nursing staff.
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PATIENT MEDICAL CHART REVIEWS AND INTERVIEWS ON-SITE AT LIMESTONE CORRECTIONAL FACILITY
February 13 and 14, 2003
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 1
Patient’s medical records were reviewed in detail and patient was interviewed and examined on 2/14/03.
The patient is a 35 year old HIV-infected male also co-infected with chronic hepatitis C. He is on combination therapy (HAART) consisting of nevirapine, saquinavir, and Kaletra. The doses of these medications are correct. The patient has had a good response to HAART in that the CD4+ T-cell count is 700 and HIV RNA (viral load) is undetectable when last assessed October 2, 2002. It is noted in the medication records that the patient has missed some doses of medications; he reported that the HIV medications are sometimes not available. He also had rectal warts which were removed by laser surgery on 12/2/02. Like many other patients, this patient has apparently had outbreaks of skin infections which seem to resolve, but then reoccur. According to the patient, he was treated on 1/28/03 apparently by nurse Hawkins with Amoxicillin prior to her calling the physician. On examination, the patient had evidence of a healing scar from a probable bacterial skin infection. This scar is documented in photograph 3.
IMPRESSIONS: 1. This case demonstrates that medications are apparently not always available. This is potentially very significant for the patient insofar as his viral resistance. If the virus in his body becomes resistant to HIV then the medications will become useless and the patient may become untreatable.
2. This case demonstrates the severe understaffing of medical personnel. There are too many patients with compromised immune systems for one physician and one physician’s assistant. This patient is not monitored appropriately especially given his underlying hepatitis C. The last time his liver enzymes were assessed was 3 months previous to the interview and they were elevated and need to be followed more closely. The patient is also overdue for assessment of T-cells and viral load and needs his lipid panel assessed.
3. Patients with chronic hepatitis C are at risk for fulminant liver failure if they acquire hepatitis A or B. This patient apparently has not received a hepatitis A vaccination. This vaccine is the standard of care for patients with Hepatitis C.
4. Nurses are not prescribers of medications; this is illegal and needs to cease.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 2
Chart reviewed and patient interviewed and examined February 13, 2003. His condition is documented in photograph 4.
This patient is a 38 year old male with Class A2 HIV infection (CD4+ T-cells 386/20% and HIV RNA 614 on 7/17/2002). He is not on any medications for HIV (which is appropriate). The patient also has a right leg above the knee amputation and had worn a poorly fitted prosthesis. He is now wheel chair-bound because the prosthesis does not fit; he has been denied an appropriately fitted prosthesis by Naphcare on 3/2/02. Mr. Stephens has reported several falls in which he sustained injury. On 8/23/02, Mr. Stephens was seen by Dr. Simon after having fallen 8/22/02; he was noted to have left ankle swelling and was given analgesics. In her medical note, Dr. Simon wrote: “Needs for handicap accessible shower discussed with Warden Mitchem.” He was seen in follow-up on 8/27/02 with mild swelling of the left foot. The patient also apparently fell in March and was not evaluated until 2 days later.
I was informed by this patient and by others that, in preparation for our visit, Limestone Prison officials had handicapped railing installed 2/10/03 – 3 days prior.
IMPRESSIONS: 1. This patient demonstrates delay in evaluation and care of a disabled person. When this disabled patient fell on 8/22/02, he should have been seen on an emergency basis in the clinic – not a day later. The patient fell again in March and this time was not seen by Dr. Simon until two days later. This is not timely and is inappropriate care.
2. This case displays total disregard by Limestone Correctional Facility for the patient and for the Americans with Disabilities Act (“ADA”). Not having a shower that is accessible to a disabled person is a medical issue and violates the ADA. Limestone Prison officials ignore the ADA; this is a problem and Mr. Stephens has suffered because of this violation.
3. Not providing adequately fitted prostheses for amputees is inappropriate on the part of Naphcare. It will result in his becoming wheel chair-bound, fall, and further injure himself.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 3
Chart reviewed and patient interviewed and examined on 2/14/03.
This patient is a 31 year old male with Class C3 AIDS and chronic cryptococcal meningitis, a severe life-threatening fungal brain infection. He has advanced AIDS, but had a very good response to HAART (CD4+ T-cell count went from 54 3/6/01 to 330 8/23/02 despite having missed doses of HAART). It is mentioned in his chart that he has had issues of noncompliance. The patient informed me that he misses doses because he sometimes does not hear the 3 a.m. pill line call or sleeps through it. Patients with chronic meningitis can have decreased hearing and can be quite sleepy and can have altered mental status. Therefore, the patient’s medication lapses can be a result of his disease progression. He also states that he is given his protease inhibitor before meals which causes him to have nausea and occasional vomiting. He informed me that he finds it difficult to wait in the pill line (some times up to 45 minutes or an hour) given his chronic illness. The patient is on another medication (ddI – brand name Videx) that must be taken on an empty stomach and 2 hours away from a meal, but it is not being administered in that manner. This is in violation of Food and Drug Administration (FDA) protocol for administering this medication. Apparently in August, 2002, the patient did not receive treatment (Diflucan) for his cryptococcal meningitis for two full weeks. According to Dr. Simon’s note dated 8/29/02, “…it was not available”. At that time, the patient reports back pain and shows laboratory evidence of a recurrence of worsening cryptococcal disease as evidenced by an elevated serum cryptococcal titer of 1:128. He is placed in the infirmary and administered appropriate medications and then slowly gets better and is discharged. As a result of the meningitis, the patient has developed a seizure disorder and is on an anti-seizure medication (Dilantin). However, Dilantin is a medication that has to be regularly monitored. This patient’s Dilantin levels are not being obtained as is the standard of care.
IMPRESSIONS: 1. This patient’s case represents many of the severe problems with the administration of
medication administration disaster at Limestone and how patients’ needlessly suffer as a result of the medication problems. Limestone simply ran out of medication for the patient’s life-threatening meningitis. As expected, the patient’s condition got worse. This gap in medication could have caused the patient to die. Running out of medication for a serious infection is not acceptable.
2. The patient is not receiving his life-saving combination HIV therapy appropriately. Food requirements and restrictions for these medications are being ignored with total disregard for the FDA. The patient is on an anti-seizure medication yet levels are not being obtained. This represents inappropriate medical care.
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3. One of the side effects of the HIV medications is high cholesterol and triglycerides. These levels have never been assessed and should be.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 4
The following information was obtained from an extensive medical record review, interview, and examination of the patient on February 14, 2003.
This patient is a 28 year old male with HIV infection who was admitted to Limestone on a HAART regimen consisting of AZT/3TC (called Combivir) and Viracept. On 5/16/01, this patient had a T-cell count of 563 and viral load <50 (undetectable) indicating good compliance which resulted in an excellent response. At some point, the patient started getting severely nauseated and was even vomiting the medications. The medications were stopped. In particular, the patient informed me that the HIV medications he was being administered were given prior to meals at 3 a.m. and 3 p.m. (as opposed to with meals or right after meals) and he associates the nausea and vomiting with taking the HIV medications on an empty stomach. This is very common in other HIVinfected patients. He further tells me that he would take the HIV medications if he were allowed to take them with meals. According to medical records, the patient pleads to be given food with his medications. However, this is not done. Instead, the patient becomes noncompliant and the HIV medications are stopped.
On 12/31/01, the patient is seen by Dr. Simon and diagnosed with Shingles (Herpes Zoster infection). Shingles is the reactivation disease of chicken pox (primary varicella) and can spread to others who have not had chicken pox. Seven months later (3/6/02), the patient declined immunologically and his T-cell count dropped precipitously to 260. According to his medical records, no antivirals were prescribed for the shingles. Shingles is a potentially severe viral infection.
IMPRESSIONS: 1. This case demonstrates the recurrent problems at Limestone with food and medication
administration at Limestone. Note that Viracept is FDA approved to be taken with food for adequate absorption and taking it on an empty stomach can cause greater gastrointestinal side effects. Some HIV medications, such as Norvir and Mepron, must be taken with a large amount of fat in order to be appropriately absorbed. Many Limestone patients, like this one, are being administered medications on an empty stomach in the middle of the night (3 a.m.) which inappropriately leads to noncompliance. The medications are stopped and the patient is blamed; this practice is inappropriate and needs to cease.
2. This case further demonstrates the problem with inadequate medical care and inadequate infection control practices at Limestone. This patient was diagnosed with Shingles – an infection which results in blistering of the skin and severe pain. The standard treatment
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for shingles, especially in an immunocompromised patient, is to use an antiviral agent such as Acyclovir. Acyclovir is often the drug of choice because it is effectual and inexpensive. The standard of care would be for this patient to be prescribed Acyclovir or some similar antiviral and pain medication. Shingles is potentially infectious and could present a problem in a setting (such as Limestone) where immune suppressed individuals are housed in close quarters. The standard of care would be to isolate the patient. An outbreak of any one of a host of potentially serious infectious diseases is possible (and well documented) in an open ward setting and potentially very dangerous. This incident indicates that Limestone does not follow an adequate infection control plan for shingles/chickenpox. I am concerned that they likewise do not have adequate infection control for TB, influenza, and staph infections. (Note that Staph outbreaks have occurred at Limestone in the past.)
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 5
This patient is a 29 year old HIV+ male. His last documented CD4+ T-cell count was 253 with viral load of 15,500 on 12/3/2. He has chosen not to be on HAART. On 1/29/02, the patient reported a rash which progressed into a disseminated pus-filled rash around the hair follicles (called folliculitis) and one large abscess on his thigh. He was given therapy (Keflex and warm compresses) on 5/9/02 by Dr. Simon, but not seen again until 2 months later (7/3/02) after having failed three full courses of Keflex by a physicians’ assistant and Dr. Simon. He was then given a month’s course of doxycline, which is no better for treating this kind of infection than Keflex in this setting. He was then administered a series of other antibiotics (including additional Keflex, doxycycline, penicillin, and amoxicillin). No cultures of the pus were performed, but eventually – 10 months later – the skin infection seems to resolve itself. This patient reports that the dormitory is infested with flying insects and spiders. The patient also reported to me that he was never informed of his blood test results which were obtained two months prior to the on site visit. Upon examination, this patient has numerous scars and healing ulcerations riddling his body, particularly the lower extremities. At the least, these scars and ulcerations are disfiguring. His condition is documented in photographs 5 and 6.
IMPRESSIONS:
1. This case represents what happens when a health care facility with closely housed patients has an outbreak of an infection and does not have infection control practices in place. This patient suffered the consequences of an outbreak of (most likely) methicillinresistant staphylococcus aureus (MRSA) infection that went rampant among the closely housed immune suppressed patients. This is one of the problems with housing these types of patients so close together. The medical records do not reflect an outbreak investigation. Numerous other patients had these same severe skin infections leading me to believe this was, indeed, an outbreak of MRSA. When outbreaks such as this are not properly contained, more infections will occur. This will lead to the deterioration of the patients’ health. The standard of care to control infections in this setting includes: an investigation of this outbreak, infection control practices, and cultures of the patients’ nares to assess for MRSA carriage and attempt to eliminate it.
2. The patient’s care was suboptimal. The causative agent of his infections was not assessed.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 6 The patient was interviewed and examined on February 13, 2003 at Limestone Correctional Facility. His medical chart was reviewed. This is a patient with HIV infection, shingles, and diabetes mellitus. When I saw the patient, he had been complaining of having chronic nausea and vomiting, and he had not been evaluated for quite some time. The patient had a medical order for a diabetic diet, but reports not receiving any diabetic meals. This was confirmed by a Limestone medical staff member who told me that “all the meals were ok for diabetics.” The patient reports that his sack lunch consists of one cheese sandwich. The patient is appropriately on antiretrovirals. However, he informed me that the prison nurses often run out of these antiretroviral medications. The patient often shows up to the early morning or late afternoon pill line, only to discover that his medications are not there. IMPRESSION: This patient represents another HIV-infected inmate at Limestone who also has other illnesses and is being denied adequate medical attention through the pill line system. He reports that they run out of his medications, as many of the other patients have concurred. Inconsistent administration of antiretroviral medication can lead to the patient becoming resistant to the medication. Resistant HIV can often become untreatable.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 7
This patient is a 43-year-old male with HIV infection who apparently had a heart attack (myocardial infarction) in the past. The patient was seen on September 17, 2002. At that time, he reported chest pain, left shoulder numbness, shortness of breath, sweatiness, and nausea. Unfortunately, the EKG machine at Limestone was not working. This was documented by a Limestone nurse. The patient was given nitroglycerin and aspirin and was sent back to his unit. Despite the patient being at high risk for having a heart attack, no attempt was made to get the patient to a local facility where a simple test (and EKG) could be done and labs could be obtained. I was unable to find whether the patient was ever evaluated again. According to the patient, he is currently experiencing chest pain at rest, which is characteristic of possible angina.
Review of his medical records does not show that the patient has been seen by a cardiologist, and in fact, has not received a basic cardiac evaluation. He is on multiple medications. However, these medications are treating angina. The patient also has kidney dysfunction as evidenced by a rising creatinine level. His medical record shows that he has not been evaluated for this condition.
IMPRESSION: This patient is experiencing worrisome symptoms and is clearly at high risk for having a myocardial infarction. The EKG machine at Limestone did not work, and the patient was inappropriately sent back to his room. He may have had a myocardial infarction, and is really not sure whether he did at that time, but fortunately the patient did not die. Yet, he continues to experience chest pain.
A working EKG should be a mandatory minimal component of a health care unit.
Again, this represents a patient who is not being followed in a chronic care clinic and is not being appropriately followed-up on because the medical providers are overwhelmed and Limestone is severely understaffed in terms of medical providers.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 8 The patient was seen and examined on February 13, 2003. His medical records were also reviewed. This patient is HIV infected. His last T cells were drawn on 12/3/2002, when they were 271. The patient is currently off antiretroviral treatment. The patient reports that he had previously been on HAART at Limestone, but the medications were being given inappropriately, including on an empty stomach. As a result, he experienced severe nausea and some vomiting. Thus, this patient discontinued the medication. In addition, the patient was also given a nonsteroidal antiinflammatory drug. This medication was also administered on an empty stomach which caused him to experience many symptoms. According to the patient's medical records, he was last seen in clinic on 8/15/2002. IMPRESSIONS: This patient, similar to many of the other patients, is a justified frustration with the prison’s medication delivery system. As a result, the patient is unable to take his medications. He was prescribed antiretrovirals on an empty stomach which can cause very severe side effects. Unfortunately the patient has a fairly advanced HIV infection and should be on antiretroviral medications. But, he is unable to take them under these circumstances. This also represents a patient who is not being seen on a regular basis by the medical staff. Six months is too long for the patient to go without being seen. He should be seen on a regular basis. Unfortunately, like many of the other Limestone patients, this patient is not seen on a regular basis and is not seen in a chronic care clinic.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 9 The patient was seen and examined on February 14, 2003 in the Limestone inpatient unit. This patient is a paraplegic who has multiple medical problems, including HIV infection, history of a stroke, diabetes mellitus, asthma, hypertension, and hepatitis C. The patient was evaluated in the inpatient unit on 2/14/2003 at the Limestone Prison. The patient informed me that up until this week, he did not have an emergency buzzer in case he needed to contact the nursing staff. Prior to this week, he would have to “holler for a runner” if he had an emergency. The patient also reports that he is not receiving any physical therapy. This was also confirmed in his medical chart. Additionally, the patient did not appear to be receiving intensive management of his diabetes. Physical examination: On examination, the patient clearly has difficulty with movement and has a dense, heavy paralysis. In any kind of an emergency, the patient would have great difficulty moving. IMPRESSION: This patient is paraplegic and is not able to get out of bed without assistance. He has no access to staff in an emergency, unless one of the other inmates, who serve as runners, comes to his aid. Fortunately, emergency medical buttons were installed. However, this only occurred one week prior to our visit. The lack of appropriate facilities for immobile or other very ill patients, represents a potential medical disaster for the Limestone Correctional Facility.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 10 This patient is a 36-year-old male who has stable HIV infection. His last T cell count was in October 2002 when it was 358. He should have had a blood test since that time. The acceptable medical standard is for HIV infected patients to have blood drawn every three months. The patient was seen by me because he was complaining of shortness of breath as well as a cough. He has a history of asthma. The patient reports that he has been trying to be seen by a medical provider, but has not been seen. Unfortunately, I did not have access to his medical records. Physical Examination: On examination, the patient was clearly having some bronchospasm. This was consistent with an asthma attack. IMPRESSIONS: 1. This patient, like every other patient I examined, reported having difficulty accessing the
prison’s medical system. This patient was clearly having an asthma attack. We reported this as an urgent matter to Dr. Simon. She saw the patient and treated him for his asthma attack. 2. The patient also has HIV infection and is not receiving regular chronic care. Overall, Limestone Correctional Facility’s care of the chronically ill is poor.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 11 This is a 34-year-old patient with AIDS, toxoplasmosis of the brain, and a seizure disorder. Currently, the patient is taking medications to treat the toxoplasmosis, (clindamycin and Daraprim). In addition, the patient takes antiretroviral therapy. Unfortunately, like the other patients, this patient is given these medications on an empty stomach, and then is told to eat his meal. As a result, he experiences severe nausea associated with these medications. Also, the patient reports that he often has difficulty standing in line to obtain his medications, especially in the winter. Toxoplasmosis is a parasite which causes abscesses of the brain, as well as inflammation, and can render the patient seriously disabled and quite ill. When not treated appropriately, this is infection often leads to death. IMPRESSIONS: Again, like many of the other patients, this is a patient who is frustrated with the medication distribution system, as well as the medical system at Limestone. As a result, he has great difficulty taking his medications which are administered on an empty stomach. Giving these medications in this manner is not medically appropriate and is not recommended by the FDA. Standing in line to receive medications is intolerable for gravely ill patients such as this one. The medical system, as well as the system of pill distribution at Limestone sets the patients up for medication failure. As so many others, this patient will likely be labeled (or has been labeled) “noncompliant” despite the difficulties and near impossible environment created that do not allow him and others to take their medications appropriately.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 12 This 55 year old patient was examined on February 14, 2003. He has AIDS. He is on an appropriate HAART regimen. Most remarkable about this patient is that he informed me that he has had a nonhealing ulcer on his right forearm for five years. I examined this and noted that he also has multiple skin actinic keratoses. Upon my review of his record, he was not being treated for these conditions. His condition is documented in photograph 7. IMPRESSION: The major issue for this patient is that he has a possible malignancy and is not being followed closely enough. He, like all of the Limestone patients, needs to be followed more closely.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 13
This patient is a 41-year-old male who has AIDS, hypertension, and insulin-dependent diabetes mellitus. The patient is on an appropriate antiretroviral regimen.
This patient had been in prolonged severe pain due to an advanced untreated condition. Since November, 2002, the patient had been reporting anorectal pain to the medical staff. He was seen by a licensed practical nurse (LPN) on November 11, and was given Motrin. On November 20, the patient continued to experience severe anorectal pain and was encouraged by the same LPN, “to stop sexual activity, if he is sexually active.” It is medically inappropriate for the nurse to make this statement instead of providing appropriate care.
The patient continued to have very severe anorectal pain, and continued to submit medical requests to the medical providers. The patient was seen on 1/8/2003 by a surgeon. By that time, it was found that he had a large, cauliflower-like anal wart and was given a mild pain reliever Tylenol No. 3 plus a stool softener.
When I saw the patient, the patient was unable to sit down because of severe pain. He also informed me that he was unable to have a bowel movement.
On examination-- which is documented in photographs 8 and 9, the patient had a huge, fungating, cauliflower-like mass which was the approximate size of a baseball in his anal area. It was eating into the skin of his buttock area. This area was clearly very tender, and was bloody and malodorous due to the probable underlying infection. This mass could be cancerous.
IMPRESSIONS: This case represents yet another patient at Limestone Correctional Facility whom the medical system has failed to treat. The patient has experienced prolonged severe pain. He is clearly not able to understand the seriousness of his underlying disease. An untreated anal wart could be cancerous. The virus that causes these warts is the leading cause of cancer in women (cervical cancer) and can also cause anal cancer. He is having such severe pain that the patient is unable to sit down or have a bowel movement. This lesion is clearly out of control, and it should have been surgically removed at a much earlier date. However, this did not happen. This situation illustrates an extreme case of negligence and inadequate medical care where the patient’s condition is far advanced.
Because this patient’s medical condition was so severe, I sent an emergency letter to the medical staff at Limestone Correctional Facility requesting that the patient be seen by a surgeon and have this mass surgically removed.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 14 This patient is an AIDS patient with a T cell count of 86. He is currently not taking antiretroviral medications. He states that he had great difficulty taking his medications because of the early hours the medications are administered. This patient does not understand any of the consequences of not taking the medications or the importance of medication adherence. Medication is especially important in a patient with a T-cell count this low. This indicates that the patient has very advanced AIDS and that he should be on some form of antiretroviral therapy. The patient has also not been seen by medical staff since August 2002. This delay in medical attention shows that he is someone who has fallen through the cracks. This patient should be seen in a chronic care clinic on a regular basis. IMPRESSION: This patient does not understand the consequences of not taking his antiretroviral therapy. From the record, it appears that no one at Limestone Prison has discussed these consequences with him. Therefore, I do not believe that he has made an informed decision to come off of his antiretroviral therapy.
27

Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 15 The patient was examined on 2/13/2003, and his chart was reviewed. This patient is a 36-year-old male who has HIV and hepatitis C co-infection. He reports that he did not learn of his hepatitis C infection until his legs had swollen to the size of watermelons. This indicates he has advanced hepatitis C and cirrhosis which is causing this swelling (edema). Currently, the patient is on an HIV treatment regimen which is adequately dosed. Similar to other Limestone patients, this patient reports having difficulty standing in line to wait for his medications at 3:00 in the morning.
IMPRESSION: The patient reports that he has worked in the Limestone Inpatient Unit. He informed me that he has provided medical assistance to other patients in the Inpatient Unit. By all accepted medical standards, it is completely inappropriate medical care for inmates to provide medical assistance to other patients. Additionally, the patient is not being treated for hepatitis C. Treatment for this virus is not offered to patients at Limestone, although it is becoming more and more available at most correctional institutions around the country. I was unable to locate in this patient’s records (as in many of the others) documentation that he had been administered vaccinations against hepatitis A and B. These vaccines must be given to all hepatitis C infected patients.
28

Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 16
This patient is a 46-year-old male who has advanced AIDS, chronic hepatitis C and hepatitis B, diabetes mellitus, hypertension, and acute renal failure. When I examined this patient on 2/13/2003, the patient informed me that he is so weak that he is unable to stand in line to obtain his medications. The patient is currently on several medications, including antiretrovirals. Unfortunately, there are no provisions for patients who are too weak to wait approximately one hour for their medication. Photograph 10 documents this patient attempting to wait in line for his medications.
The patient also informed me that he has been experiencing abdominal pain and groin pain. However, he was told by nursing staff that he could not see a physician for two to three weeks.
The patient has acute renal failure. This condition was detected in blood work on 1/29/2003, when the patient had a BUN of 38 and a creatinine of 2.8. Unfortunately, the patient has not had any further evaluation of his acute renal failure.
IMPRESSIONS: 1. This case represents a patient with multiple chronic illnesses and weakness so severe that
he is unable to stand for 30 seconds. However, he is forced to stand in line for his medications. This will often result in the patient not being able to obtain his medications. Unfortunately, the long pill line at Limestone is a problem for many patients.
2. A patient who is this ill and who has acute groin and abdominal pain needs to be seen more quickly than two to three weeks. Because of the large number of patients and the low number of medical providers, many Limestone patients are not seen in a timely fashion.
3. This patient also has serious kidney failure. This patient is not being evaluated in a timely fashion-- again demonstrating the lack of sufficient medical providers at this prison.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 17
I examined this patient on February 13, 2003, in the Inpatient Unit at Limestone Correctional Facility. The patient has HIV infection, end-stage renal disease, and has had recent MRSA (resistant Staph) bacteremia.
Most worrisome in this patient's history is that he initially started contacting the clinic in midSeptember when he was experiencing some skin infections. At approximately the same time, many other HIV infected inmates at Limestone were experiencing similar infections. The patient was not seen by Dr. Simon or the P.A. Instead, in early September, he was given a prescription for amoxicillin as well as Motrin. The patient continues to experience these skin infections which appear to be Staph folliculitis, as well as pus-filled furuncles and boils.
Most concerning, is that the patient reported urinary problems. In particular, he has had polyuria as well as associated dizziness, nausea, and vomiting, which started in early November. According to the patient's medical records and a written message to the clinic, on November 12 and 15, the patient had urinary symptoms. At that time, the patient said that he was told that he could not see the doctor. In fact, he did not see any medical providers. He saw only the nurses. The patient said he was not offered a urinalysis at that time, but according to the nursing notes, did not return to the clinic to have it performed.
Despite persisting symptoms and medical requests, the patient was not evaluated for another month. Finally, on December 18, 2002, the patient was seen by the Physician Assistant. He was experiencing the same symptoms. Again, the patient was taking Motrin. Not until two weeks later was the patient seen by Dr. Simon. He again complained of polyuria and other associated symptoms.
The next day, on 12/31/2002 (nearly 2 months after his initial symptoms), the patient had a basic evaluation which showed that he had protein in his urine. His BUN was 91, creatinine of 11.4, with a bicarbonate of 14, all signifying that the patient had far advanced, irreversible kidney failure.
Currently, the patient is in the Inpatient Unit, reporting that he has had increasing weakness as well as anorexia and weight loss. He is on antiretrovirals at the appropriate doses, but unfortunately he is hemodialysis-dependent.
Physical Examination: On examination, the patient appeared very depressed. He did have multiple healing abscesses, as well as healed scars that appeared to be caused by skin infections.
IMPRESSION:
30

This represents a very severe problem at Limestone Correctional Facility. Patients, such as this one are not seen in a timely manner. It is clearly documented in the patient's chart that he was asking to be seen by a physician or by a physician’s assistant, but was not seen and not evaluated by them. He was not evaluated appropriately or in a timely manner. He had some early signs of kidney failure, but again was not seen until at least 1-1/2 months after his initial symptoms. By that time, he was in end-stage renal disease. This is an irreversible medical condition.
31

Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 18
The patient was examined on February 13, 2003, and his chart was reviewed on that date.
This is a patient who has class C3 AIDS and toxoplasmosis of the brain. Toxoplasmosis is a parasite which causes abscesses and inflammation of the brain tissue. It is uniformly fatal without treatment. The patient carried this diagnosis for quite some time, but a review of his chart shows that the patient had been missing many of his medications for treating the toxoplasmosis. Upon discussing this with the patient, the patient informed me that he had been quite frustrated with the prison’s medical delivery system. On many occasions, the medications had not been available, or he was unable to stand in the pill line. The patient uses a walker because of the neurologic damage and sequela that have been created by the toxoplasmosis of the brain.
The patient had stopped taking his HIV medications (Combivir and Viracept). The patient reports that he had taken these exact medications for many years in the past, but is currently unable to take these medications because of his concern that he may harbor resistant HIV rendering the medications useless. It is not mentioned in the chart whether medication resistance has been discussed with the patient. Resistance testing has not been performed. The patient was also taking Dilantin because toxoplasmosis can cause a seizure disorder, but the patient reports that the dose of the medications is sometimes increased or changed by the nurses. These medication changes are not discussed with him and he does not know if the doctor is consulted about these changes.
Review of the patient's medical records shows that he currently is on a regimen of tenofovir, abacavir, and efavirenz. The patient has a T cell count of 39 which was drawn in January. He is on Bactrim, but the patient reports he does not get azithromycin for Mycobacterium avium complex (MAC) prophylaxis on a regular basis.
IMPRESSION: This patient is an advanced AIDS patient who has a severe brain infection with neurologic sequela of this infection and is unable to walk or stand for more than a few minutes. He uses a walker. But, the patient is forced to stand in the pill line for his medications. As a result, he becomes tired and frustrated. This is probably what contributes to his not taking his medications. Medications for severe diseases such as toxoplasmosis, need to be available to the patients every single day. If a patient is unable or is unwilling to take a medication, this needs to be discussed with the patient in detail. Patients may not understand why they are taking the medication, or there may be some misunderstanding. Therefore, any noncompliance to a life-saving medication needs to be discussed and documented in the patient's chart. This was not done in the case of this patient. This is a huge problem. If the patient continues to not take these medications, it will likely result in the patient's untimely death.
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Patient Medical Chart Reviews and Interviews on-site at Limestone Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 19
The patient was examined on February 13, 2003. His medical chart was also reviewed.
This patient has advanced AIDS, hypertension, and psoriasis. I examined him in the Inpatient Unit. The patient had been admitted to the Inpatient Unit approximately one month earlier. He was found to have fever, headaches, and fatigue. According to the patient, he continues to experience these symptoms. A review of the patient's medical record reveals that the patient rarely had a temperature obtained, and I was unable to find any comprehensive nursing notes.
The patient was on Dapsone as a prophylaxis medication for Pneumocystis carinii pneumonia (PCP). However, it appears that he was not receiving prophylaxis for Mycobacterium avium complex (MAC). The patient had not received the medically appropriate tests and blood work for all his symptoms. In particular he had not been evaluated for causes of fever, wasting, and MAC. He had also not been evaluated for Cryptococcal meningitis.
Upon examination, the patient appeared rather ill. He looked fatigued. Significant exam findings indicated that the patient had thrush. His condition is documented in photographs 11 and 12.
The patient also told me that some of the other inmates had been administering oral nutritional supplementation to him. In addition, the emergency call system used by the patients to contact a nurse had only recently been fixed. This was confirmed by other patients.
IMPRESSIONS: 1. This patient is an advanced AIDS patient who has not been appropriately evaluated for
his symptoms. He should be followed more closely by the physician at Limestone. One physician who treats close to 3,000 patients does not have enough time to give chronically ill patients the medical care they need. In addition, the patient's inpatient notes, including the nursing notes, were inadequate for a patient who is this ill. Nursing is understaffed.
2. Another issue which has come up before is that other inmates are performing duties that should be done by the nursing staff, such as administering nutritional support, as well as possible other physician-prescribed treatments. This is not acceptable and needs to be stopped immediately. This represents one of the problems with the lack of adequate nursing care that these inmates are receiving in the inpatient unit.
3. Because of the patient's profound immunosuppression (T cells 31), and because the patient reported fevers, fatigue, diarrhea and headaches, it was felt that the patient needed further evaluation for opportunistic infections. As a result, I put this patient’s condition in writing to the Limestone Correctional Facility medical officials as an emergency order.
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SUMMARIES OF HIV INFECTED PATIENTS’ DEATHS AT LIMESTONE CORRECTIONAL FACILITY JANUARY, 1999 TO FEBRUARY, 2003

TAB NO. NAME

AGE AT DEATH DATE OF DEATH PAGES

1. RUSSELL BATTISTE

46

2. LUIS BLANCO

44

3. JOHN BOLTON

39

4. ANTHONY COX

39

5. ANDY CRAWFORD

41

6. EZELLE DANIELS

60

7. LARRY DAVENPORT

27

8. HOWARD DAVIS

48

9. ANDREA EDWARDS

39

10. MICHAEL ELLIOT

36

11. TERRELL GREY

41

12. CHELSEA HAMMAC

34

13. EDDIE HARRIS

44

14. KELVIN HARRIS

44

15. MICHAEL HEADON

29

16. DENNIS HEARNS

32

17. CLETIS JOHNSON

36

18. LESLIE JOHNSON

45

19. MORRIS JOHNSON

30

20. STANLEY LILLIE

47

21. WILFORD LOCKETT

68

22. JOSEPH McCLURE

71

23. GEORGE McHEARD

48

24. JAMES PRYOR

36

25. WILLIE ROBINSON

48

26. TONY ROWLAND

30

27. DIONICIO SALAZAR

41

28. MILTON SMILEY

43

29. LAMAR SMITH

49

30. TIMOTHY SUMMERS

32

31. RICKEY THOMPSON

30

32. HENRY TURNER

35

33. FREDDIE WHITE

51

34. DEWAYNE WILDER

37

35. IVERSON WILLIAMS

36

36. JOHN WILLIS

35

37. EARNEST WYNN

39

38. MARVIN YOUNGBLOOD 39

12-29-2002 2-22-2001 5-22-2000 2-4-2001 5-22-2000 11-24-2002 1-24-2000 8-9-2000 10-16-2001 3-27-2001 1-25-2003 11-14-2002 5-28-2000 9-11-2001 9-19-2002 6-14-1999 5-24-2002 12-14-1999 7-24-1999 12-24-2001 3-15-2000 5-6-2002 11-12-2001 10-13-2001 11-5-2002 1-22-1999 9-16-1999 2-12-2003 1-21-2002 3-11-2002 9-2-2002 8-3-2002 6-8-1999 4-17-1999 11-15-2000 3-29-2002 2-16-2002 9-5-2000

35-36 37-38 39-40 41-43 44 45-47 48-49 50-51 52-53 54-55 56-58 59 60 61-62 63-64 65-66 67-68 69-70 71-72 73-75 76-77 78-79 80 81 82-83 84-85 86-87 88-89 90-91 92-94 95-96 97-98 99-100 101-102 103-104 105-106 107-108 109-110

34

DEATH SUMMARY Russell Battiste
Russell Battiste is a 46-year-old male with AIDS and presumptive Pneumocystis carinii pneumonia who died on 12/29/2002 at the Limestone Correctional Facility.
The patient was initially seen at intake by Dr. Simon on 8/7/2002. The first two notations in the chart are “new man, poor historian.” Dr. Simon lists the patient’s medical problems as obtained from the patient. Yet, the patient is again listed as being “a poor historian”.
After the initial intake, the patient is not seen for approximately one month until 8/7/2002. On 8/7/2002, the patient informs Dr. Simon that he is “legally blind”. In her assessment and plan, Dr. Simon did not elaborate further regarding this condition. The patient was found to have highly resistant HIV with a low T cell count of 81 (approximately 1000 T cells is normal). His viral load was greater than 500,000, indicating that he had a large amount of HIV virus. He was placed on antiretroviral therapy.
He developed an allergic reaction. This reaction was managed appropriately and the patient recovered. Yet, on 10/17/2002, approximately three months after his admission to Limestone, the patient was noted to have “AIDS wasting.” He was noted to be an “ill-looking male.” The patient was diagnosed with pneumonia and started on an antibacterial agent.
On 10/22/2002 the patient worsened and was sent to an outlying hospital. At the outlying hospital (Huntsville Hospital), the patient was quickly diagnosed with blindness in one eye from cytomegalovirus (CMV) retinitis. He was placed on treatment for CMV so that he would not lose the vision in his other eye. The patient was also diagnosed with presumptive Pneumocystis carinii pneumonia and started on clindamycin and Primaquine.
The patient was returned to the Limestone Correctional Facility and on 10/27/2002, the focus of his appointment with the physician assistant was the following: “Discharge note that the patient wishes to be DNR, but no signed statement in chart.” At that time, Dr. McClain was called and Decadron, which is a corticosteroid, was started. The patient deteriorated as confirmed in multiple notes, and the shortness of breath worsened. On 11/11/2002, the physician noted that the patient was critically ill, and a critically ill referral was filled out to be sent to Naphcare. There is no response in the chart from Naphcare. On 11/18/2002, the patient was visited by the “hospice team.” An advanced directive and DNR form were signed by the patient.
The patient continued to progress to worsening respiratory distress, severe respiratory failure, and died at the Limestone Correctional Facility approximately six weeks later on 12/29/2002.
IMPRESSION:
1. The presumptive diagnosis was Pneumocystis carinii pneumonia. The patient was only diagnosed presumptively with PCP. When he deteriorated, even though he did not want
35

to be placed on a ventilator, it is still incumbent upon the medical staff to evaluate the patient for other causes. However, this was not done. The patient was not sent to an outlying hospital to evaluate for other potential diagnoses, including such treatable illnesses as tuberculosis. The patient progressed to worsening respiratory failure and died. This is especially concerning, given that the patient appeared to have a history of tuberculosis. 2. Wasting syndrome. There seems to be a common pattern at the Limestone Correctional Facility. Patients are not receiving adequate nutrition and are wasting. They also are not being evaluated appropriately for causes of wasting, such as infections, and are not given appropriate supplements or medications that can increase the patient's appetite or help the patient put on critical weight gain. This was true in this patient. The external autopsy of this patient indicates that he weighed a mere 89 pounds at a height of 6 feet. 3. Also concerning in these patients is the notation that he was a “poor historian.” Yet, there is no indication that any attempts were made to obtain outside medical records for this patient or any of the patients in which charts have been reviewed. This is concerning for some of these patients who are ‘poor historians.’ This patient had a history of CMV retinitis and blindness. These conditions were missed at his admission. 4. The patient was started on an antiretroviral regimen. Yet, when Dr. Simon asked him whether he had received one of the medications, he reported not even recognizing it. He was not receiving a medication that had been ordered. This is an example of a pattern at Limestone where patients either do not receive their medications, or they receive them only sporadically.
This patient had highly resistant AIDS virus. It was likely that he would not survive a long time. Yet, Limestone’s failure to provide adequate medical treatment contributed to his quick demise.
36

DEATH SUMMARY Luis Blanco
Luis Blanco is a patient with chronic hepatitis B, HIV infection, and insulin-dependent diabetes mellitus, who died at the age of 44 on 02/22/2001, at the Huntsville Hospital.
The patient unfortunately, suffered from both HIV infection and chronic active hepatitis B and insulin-dependent diabetes mellitus. The patient was treated for his HIV infection with combination therapy consisting of D4T, DDI, and nevirapine. The patient apparently had a good response to these medications. He apparently had done well in managing HIV-related medical issues, as well as from the hepatitis B, but had difficulties with his insulin-dependent diabetes mellitus for quite some time. At one point the patient even refused to take his insulin because the insulin was being administered, according to the patient, at times of the day that did not seem accurate to him.
The start of the patient's demise appears to have begun on 02/11/2001 when he was seen in bed in the Infirmary or inpatient facility. He was found to have remarkable abdominal distention. He was given a bottle of magnesium citrate which is for severe constipation. No further evaluation was done, but the patient was seen the following day when again the patient was noted to have abdominal distention. Even though the patient was in the inpatient unit, he sent a medical request form on 02/13/2001, stating that “my stomach is swollen up. I can’t eat or hold food down. I can’t take any insulin due to me not being able to eat. Please see me as soon as possible.”
Apparently, the patient was not seen in the inpatient unit. Instead, he was scheduled to be examined at the clinic on 02/15/2001. According to Dr. Simon’s notations, the patient was in fact a ‘no show.’ There was no follow-up with the patient that day, until apparently the patient was sent to the emergency room on 02/16/2001 with abdominal distention.
The notes from the emergency room were not made available, but the patient was seen and examined, and was sent back to the Limestone Correctional Facility. At that time, the patient was housed in the inpatient facility when he was returned on 02/16/2001. I can find progress notes that state that this is so. Starting on 02/16/2001, the patient appeared to have continued abdominal distention, abdominal pain and difficulty eating because the pain and distention were so severe. He was even short of breath because of abdominal distention pressing against his diaphragm.
On 02/20/2001, one of the nurses noted that the patient had generalized tenderness of the abdomen. On 02/21/2001, the patient appeared to have severe respiratory distress and labored breathing. He complained of some chest pain at that time. He was placed on oxygen, and actually sent to the emergency room. He apparently died of an infection the following day. There are no liver function tests present in the patient’s medical chart, even though the patient was on antiretroviral therapy that was potentially toxic to the liver. There was also no assessment for metabolic abnormalities such as lactic acidosis.
IMPRESSION:
37

The main issue with this patient is that he had chronic active hepatitis B and was not being treated, despite his worsening condition. One could assume that if liver enzymes and other appropriate lab studies had been periodically monitored, that this would have been diagnosed much earlier than it was. The patient was on medications potentially toxic to the liver, and these should have been monitored more closely. The lack of any inpatient physician documentation is a serious problem.
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DEATH SUMMARY John Bolton
John Bolton was a 39-year-old HIV positive male who died on 5/22/2000 at 7:47 p.m. at the Limestone Correctional Facility. An external autopsy report from the Alabama Department of Forensic Science stated that the patient died of cachexia (wasting) and was marked emaciated. The patient weighed a mere 74 pounds at the time of his death.
On 4/5/200, the Mr. Bolton's health drastically deteriorated. A Health Service Request form indicates that the patient stated that “have no problem being hungry. It’s after I eat, I have problem keeping my food down.” The nurses noted in his chart that the patient had been vomiting 50% of his food and that he likely had electrolyte imbalances. Despite these observations, there were no laboratory tests obtained and no further evaluation was done other than this cursory examination by the nurses. The patient was not referred to a medical doctor until 4/11/2000.
The patient continued to plea for help. Yet, the medical staff did not provide assistance. The patient submitted another health service request form several days later, reporting that he was thinking of sugar and had no energy. He was seen by a Limestone nurse who administered a cursory evaluation of the patient. She did not provide an adequate evaluation and did not call a medical provider. She wrote down “no discomfort or distress observed and no plan at this time.”
Four weeks later, on 5/7/2000, the patient was admitted to the health care unit with a significant body weight loss of more than 20%. He continued to report not being able to keep food down. By this time, the patient was already end stage and supplementation and Megace (a medication used to increase the appetite) was initiated. At no point was it even discussed with the patient, nor were any medications started, to increase the patient's muscle mass. This treatment -medications to increase muscle mass -- is the standard of care for patients with wasting. Such medications could include Deca-Durabolin or testosterone.
The patient continued to decline in the inpatient unit. End-of-life issues were never discussed with him, or at least never documented. There was no Do Not Attempt to Resuscitate form. He did not receive any adequate hospice care. He expired from starvation on 5/22/2000 in the inpatient unit.
The patient also had some concomitant illnesses including bipolar affective disorder. He had been seen by Psychiatry on 2/12/2000 because of his refusal of HIV medications. The patient reported that he did not want the HIV medications “until he was back on the streets” which he said would be very soon.
39

There were numerous instances in the chart where the patient presented earlier in the year, on 1/11/2000, complaining of vomiting and of not being hungry with a poor appetite. He presented on 1/11/2000 to the physician complaining of these symptoms. Nothing was done at that time. On 1/12/2000 he presented with probable Pneumocystis carinii pneumonia. On 1/13/2000 he was started on a subtherapeutic dose of Bactrim (double strength two times a day). His Bactrim dose was later increased to three times a day. This was started because the patient had fever, shortness of breath, and a disease process in his lungs. However, the patient never received a diagnosis during this time. According to records, he stabilized on the subtherapeutic dose of Bactrim.
No definitive diagnosis of this patient was ever made.
IMPRESSION: The focus of this review has been directed to the events that led to the patient's death. The focus has not been diffuse. There are many other issues in this patient's medical records signifying lack of care or inadequate care.
The most concerning part of this patient's care was that he clearly presented early in the year 2000 with difficulty eating and lack of appetite. This was not addressed adequately, even though in February 2000 the patient had a T cell count of 15. It was not until several months later, in May 2000, when the patient was admitted to the inpatient unit and was provided appetite stimulants. By this time, the patient was already dying and had lost such an extreme amount of weight that no course of therapy could reverse his course of wasting.
There have been multiple patients who have died of wasting at the Limestone Correctional Facility. This addresses the issue of inadequate nutrition, inadequate diagnoses, work-up and treatment of wasting at the Limestone Correctional Facility. There are simple medications that can be used to treat wasting and increase the patient's body mass. While it is true that patients still die of wasting in the free world, it is concerning that there are such a large number of patients at Limestone rapidly dying of this ailment.
In addition, the patient's treatment in December, when he presented with a febrile illness and a lung process, is concerning in that the patient was not appropriately evaluated, nor was he treated appropriately. Patients with a low T cell counts presented with a lung process, need a diagnosis. Instead, this patient was presumptively diagnosed with Pneumocystis carinii pneumonia. He was started on a subtherapeutic dose of Bactrim. He apparently showed some improvement. But this is inappropriate medical care. This patient’s demise was premature.
Finally, this is another patient whose end-of-life care and DNR issues or Advanced Directive was not addressed.
40

DEATH SUMMARY ANTHONY COX
Anthony Cox was a 39-year-old male with AIDS who died at the Huntsville Hospital on 2/4/2001.
The patient had AIDS with a very low T cell count (less than 50), and multiple complications of HIV, including AIDS wasting, esophageal candidiasis, thrush, cytomegalovirus (CMV) retinitis, end-stage renal disease (kidney failure) on hemodialysis, and Staphylococcus bacteremia. The focus of this summary will be on the patient's last few months of care.
As noted by multiple health service request forms, the patient pled for assistance from the health services personnel multiple times. Beginning on 9/13/2000, the patient sent a request to the staff stating “my vision in both eyes are blurry, especially in the left eye and needs to be seen by the doctor.” He was evaluated by an LPN and was noted to have 20/20 vision in both eyes. This result is highly suspect given that the patient ultimately was diagnosed with CMV retinitis – a blinding disease of the eye caused by a virus.
Just four days later, on 9/17/2000, the patient continued to have problems and in an additional health services request form the patient stated, “I am having bad blurry vision in both my eyes. I believe it is CMV and I want my medicines changed…” The LPN did not see the patient, but wrote a note to see the prior health services request form. The patient was not even evaluated.
The patient continued to plea for help. On 10/16/2000, the patient again reported, “I’ve stated I’ve got CMV which my eyesight is getting worse. I see this as neglect. I must be seen by Dr. Simon about my problem. It’s urgent.”
On 10/25/2000, the patient again reported, “My eyesight is worser than before. I’ve been having this problem since early September 2000 and something must be done about it. Needs to see the doctor.” The LPN reports that the patient was ready “to see the eye doctor. Doctor unable to see everyone on first visit. To return in November.” This statement demonstrates a lack of caring, neglect and a lack of understanding on the part of the nurse of the seriousness of this patient's complaints, who clearly understood that he might have sight-threatening CMV (and who ultimately was diagnosed as having CMV retinitis).
The patient was finally seen by Dr. Simon on 11/25/2000, which was more than three months after his initial request. At that time, he was reporting decreased vision and he reported only being able to see shadows. He was scheduled to be seen by an optometrist, but the optometrist canceled due to “bad weather” as listed in the note. Appropriately, late in the course of the disease, the patient was sent to the hospital. However, the patient was still not diagnosed with CMV retinitis or initiated on therapy until five days later on 12/30/2000, even though the patient clearly had loss of vision and was at risk for losing total vision.
41

On multiple occasions in this patient’s medical record (as in the medical records of other patients), there are notes regarding noncompliance. It is evident that patients had difficulty being compliant at the Limestone Correctional Facility. On 6/28/2000, this patient was counseled about noncompliance. His response was “he can’t hear sick call and sleeps through it.” The nurse who evaluated him at this time did not address his noncompliance any further. It is very difficult to evaluate the medication administration record forms in this patient’s medical chart, but it appears that indeed the patient was not fully adherent to his medication regimens. This is similar to many other patients at Limestone.
On 10/4/2000, the patient complained of diarrhea. He was seen by the physician. As has been indicated, he was not given any work-up, but was instead treated symptomatically. At that time, he had also been complaining of decreased vision. A cursory exam was done by the physician who reported no lesions, even though this was a suboptimal way to diagnose CMV disease. She did not work-up the patient's complaints.
On 1/11/2001, the patient complained of shortness of breath and became ill. He was started empirically on Bactrim, as many of these patients were. He did not receive a diagnosis. Unfortunately, at the Limestone Correctional Facility, IV Bactrim was not available that day so he was put on oral Bactrim. He went on to decompensate and on 1/12/2001, his shortness of breath worsened. He went into respiratory failure and was taken by ambulance to the local hospital where he died on 2/4/2001.
There is no external autopsy and no information available from the patient's hospitalization at Huntsville Hospital.
IMPRESSION: This patient represents a well established pattern of patients who presented with either critical laboratory values or very serious symptoms such as decreased vision, who were not appropriately evaluated at Limestone Correctional Facility. Unfortunately, the nursing staff and medical staff were unable to recognize the seriousness of an advanced AIDS patient who complained of decreased vision. This was indeed a medical emergency, and these patients needed to be evaluated emergently.
This patient's loss of vision could have been saved had he been treated earlier. However, this did not occur. His pleas for help, written on the health services request forms, were ignored, even though the patient was able to self-diagnose his own CMV retinitis. Unfortunately, the medical staff was incapable of making this diagnosis until late in the course of the disease. This, combined with the lack of an organized health care system, leads to a pattern of deadly diseases being diagnosed late or not at all, being treated inappropriately and ultimately to higher morbidity and mortality in this population.
This patient was noncompliant. This is a common theme at the Limestone Correctional Facility. High instances of patient noncompliance question the therapeutic relationship or lack thereof, that exists between the patient, the medical system and the staff at Limestone Correctional Facility. There was an extraordinary attempt to document noncompliance. Yet, little or no
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attempt was made to remedy noncompliance or try to help the patients have access to their medications. Instead, patients are warned against noncompliance, and ultimately medications are withheld and discontinued and the patient is blamed. This, despite the fact that the situation the patients are in makes compliance difficult, if not impossible in the long-term. In reviewing some of the older notes, this case also brings up the issue of poor medical records and the lack of transcription services at the Limestone Correctional Facility. I have not seen one note transcribed, which causes many difficulties in interpreting the notes. This creates a medical file which is difficult or impossible to read. In addition, problem lists are not filled out regularly. Medication lists are not regularly filled out or updated. Such basic prevention measures as vaccinations are rarely documented in any of these patients. It is clear from the medical records at the Limestone Correctional Facility that the medical facility is highly disorganized and many patients are falling through the cracks. The patients that are being seen, are not being adequately evaluated because of a substandard and antiquated system.
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DEATH SUMMARY Andy Crawford
Andy Crawford was a 41-year-old male who died on 5/22/2000 from complications of AIDS. He was only at the Limestone Correctional Facility for one night. His history was obtained from scant medical records. It is important to review his medical care prior to arriving at Limestone.
The patient was originally sentenced on 3/13/2000 and held at the Montgomery County Jail until 5/1/2000. He was then transferred to the intake center at the Kilby Correctional Facility. At Kilby, he was held for one week until 5/9/2000. It was clearly documented that he was seen by a physician and noted to have a decreased level of consciousness. It was also noted by the physician that the patient was lethargic prior to his transfer and was urinating on himself (incontinent of urine). However, he was transferred to the Limestone Correctional Facility where he was held overnight. He was then transferred to the Cooper Green Hospital. Mr. Crawford expired two weeks later.
Although there are few medical notes addressing this patient, because of his short stay at Limestone, the notes that can be reviewed are revealing and problematic.
Upon intake, the patient was seen at the Limestone Correctional Facility and was noted to be lethargic and nearly unresponsive. He was also incontinent of urine. Upon reviewing his condition prior to transfer from the Kilby facility, his medical status was similar. At Kilby he was noted to have a decreased level of consciousness. Despite the patient appearing very ill and experiencing decreased levels of consciousness, he was still transferred to Limestone.
The patient received an external autopsy examination. The autopsy noted that the patient had a history of toxoplasmosis of the brain. However, the records do not indicate that he was transferred to Limestone on any anti-toxoplasmosis medications.
Upon being received in this condition at the Limestone Correctional Facility, the patient was sent to the hospital. He died shortly thereafter.
IMPRESSIONS: This patient's case clearly demonstrates the systemic problems in the Alabama correctional facilities. These two facilities are transferring and accepting patients inappropriately. This patient should not have been transferred from the Kilby facility, and should not have been accepted in transfer by the Limestone Correctional Facility. He was transferred without nursing or any other kind of skilled medical care. He was transferred by correctional officers and it was surprising that this patient did not become even more ill during his transfer and require an emergency stop at a hospital.
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DEATH SUMMARY Ezelle Daniels
Ezelle Daniels was a 60-year-old male who died of AIDS on approximately 11/24/2002. An external autopsy or summary of his death was not available in his medical records.
The patient was received at the Limestone Correctional Facility on 6/19/2002. Although this patient had advanced AIDS with a T cell count of 23, hepatitis C and multiple medical issues and complaints, he was not seen until a full month later on 7/18/2002 by Dr. Simon. On 7/18/2002, it was recorded in Dr. Simon’s note that the patient had multiple medical problems. Dr. Simon indicated in her physical examination that he was a thin male and that he was edentulous (he had no teeth).
There was no referral for the patient to be fitted for teeth and no provision made to alter his diet so that he could receive food that he would be able to eat. His extremely thin body habitus was also not addressed.
The patient was not seen again until almost one month later. At that time, the patient had been in the Limestone Correctional Facility for two months. As stated above, his T cell count had been obtained and was found to be quite low at 23 with a viral load of 73,000. The patient was started on Pneumocystis carinii pneumonia prophylaxis, Mycobacterium avium complex prophylaxis and an antiretroviral regimen.
There is no documentation in the chart that there was any attempt made to obtain the patient's outside laboratory results. In addition, there was no attempt made to determine the patient's prior antiretroviral regimen. The patient spent a full two months at the Limestone Corrections facility without HIV medications and at risk of acquiring deadly, yet preventable, opportunistic infections such as Pneumocystis carinii pneumonia or Mycobacterium avium complex.
The patient submitted a health service request form on 7/18/2002 requesting double portions of food because of his profound weight loss. However, Dr. Simon did not address this request and did not increase his food portions.
On 8/30/2002, the patient reported fever. Dr. Simon noted “the patient is shaking under his covers...but is in no apparent distress.” This is a contradictory statement. A chest x-ray from 10 days earlier reflected what was believed to be a pneumonia. There is no documentation in the chart that the suspected pneumonia was addressed at that time. Therefore, there was a 10-day gap between radiographic documentation and the prescribing of treatment. Despite the 10-day gap, the patient was started on treatment for pneumonia and he subsequently improved.
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Finally on 9/05/2002 he was diagnosed with AIDS wasting and started on oral supplementation with Resource. Resource is a protein drink. On 9/13/2002 the patient continued to experience wasting and diarrhea. The diarrhea was not evaluated for parasites or bacterial infection which can cause devastating illness in AIDS patients. Instead, the patient was placed on anti-diarrheal medications which treat the symptom, but not the cause of the diarrhea.
In a physician’s note on 10/07/2002, there is a notation that the patient was observed returning his tray with almost all the food still on the tray. The patient was questioned about this. The patient noted that the food was too hard and he could not chew it. It was again noted that he was edentulous and therefore had no teeth with which to chew his food. The patient was referred to a dentist for dentures. This referral for dentures occurred almost three months after the patient was noted to be edentulous on his first physician visit.
On 10/07/2002 there is a request for an Ensure form. According to the records, Ensure is something that needs to be specially requested from Naphcare. This note describes in vivid detail how emaciated and how sick the patient was at this time. It states that the patient was wasting, that he had prominent cheekbones with no visible fat and decreasing muscle. In parentheses it states “wasting.” The records indicate “rib cage very visible.” He apparently was 5 feet 8 inches and weighed 98 pounds. His ideal weight was 160 pounds. This indicates the patient had lost approximately 30 percent of his ideal body weight. Such weight loss has profound medical complications for an AIDS patient.
The emaciated patient declined in health. He never received his dentures. Consistent with many Limestone patients, he did not receive any end-of-life care. He did not receive any life-saving medications to increase his muscle mass. He expired on 11/24/2002, from AIDS wasting syndrome.
IMPRESSION: This is a disturbing but common event at the Limestone Correctional Facility where patients are admitted with AIDS and decline rapidly. This is not the norm in the developed world. Patients with AIDS typically do not deteriorate this aggressively and rapidly, at least, not in the United States where modern medications are available.
This patient did indeed have advanced HIV, but he went without treatment for one month at the Limestone Correctional Facility before he was seen by a doctor. He was at the facility for two months without receiving any medications. He was at the facility for almost four months before he was even referred to a dentist for dentures because he was unable to chew the food he was provided.
The patient’s Limestone records indicate that his outside medical records were not requested or obtained when he first arrived at Limestone Correctional Facility. Indeed, there is no indication whether there is adequate support at the Limestone Correctional Facility for the physicians and staff to even request outside medical records. If not, that is a serious flaw in a working medical system of care.
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As early as July, Dr. Simon did not address this patient’s request for double portions of food. Dr. Simon ignored this request. Yet, in her medical records she clearly described the patient as being thin. As the treating physician, it was incumbent upon her, to address this request at the time it was made. Dr. Simon also should have addressed his lack of teeth and made the referral to obtain the patient dentures, especially when Mr. Daniels was seen by her and questioned and was informed by him that he was unable to chew his food. This patient died most likely of AIDS wasting which was exacerbated by the lack of adequate medical and nursing care, lack of treatment, lack of adequate nutrition and the lack of life-saving medications to increase his body mass. In this patient, a lack of teeth made the situation only worse.
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DEATH SUMMARY Larry Davenport
Larry Davenport was a 27-year-old male with AIDS who died of septicemia (commonly called bacteria in the blood or blood poisoning) on 01/24/2000 at the Huntsville Hospital. He had only been incarcerated at Limestone since 12/10/1999.
Mr. Davenport had a history of AIDS and a recent hospitalization for Pneumocystis carinii pneumonia. He also had pancytopenia which means that his blood counts were all very low, and a history of hypertension. Upon intake, the patient was seen and only given a cursory evaluation. He had a laboratory blood draw on 12/15/1999. There is no documentation of medical staff or patient follow-up.
None of the medical records show that the patient was placed on medications during this time period. There was also no documented attempt by the Limestone Correctional Facility to obtain medical records from the outside hospital, even though the patient was transferred directly from the hospital into the Limestone Correctional Facility, bypassing the Kilby Correctional Facility.
On 1/12/2000, the patient presented with high fevers. He was put in the inpatient infirmary and was quickly started on an antiretroviral regimen, as well as prophylaxis for Pneumocystis carinii pneumonia and Mycobacterium avium complex. It is important to note that this antiretroviral regimen was started a full month after his laboratory results were drawn which showed an extremely low T cell count of 24.
Throughout the patient's stay in the infirmary, and in fact on 1/12/2000, Dr. Khouri’s notes questioned whether the patient had Mycobacterium avium complex (MAC). Given the low T-cell count, the patient could have had MAC. At some point, an additional antibiotic was started.
However, the patient continued to decline. He continued to experience extremely high, spiking fevers, but according to the medical record, the patient had not been given an adequate work-up. In fact, only one blood test was drawn. No additional blood cultures were obtained, which is the standard of care. The single laboratory test was drawn on 01/18/2000 that showed the patient had bacteria in his blood. The patient was transferred to a local hospital where he died of sepsis six days later.
IMPRESSION: This is an example of another patient at Limestone Correctional Facility who had an incredibly rapid and fatal decline. Despite being transferred directly from a hospital, it is clear that the medical staff at Limestone Correctional Facility did not attempt or did not receive an adequate history regarding this patient’s recent hospitalization. In addition, the medical staff was grossly negligent in that the patient was not followed closely, even though he was presented to the infirmary with such high fevers and in such extremis, to die so rapidly. This was a very young patient, only 27 years old, and he died a very rapid death and preventable death.
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There is one indication in the medical records of the patient hoarding his medications toward the end, which more than anything, signifies the patient's mistrust in the medical system, given that when he was questioned about this, the patient reports no problems with his medications. The patient was critically ill on 1/21/2000. Yet, the nurse was not making sure that this patient was being administered his medications. The patient died only three days later.
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DEATH SUMMARY Howard Davis
Howard Davis was a 48-year-old male with AIDS who died on 8/9/2000. An external autopsy is not available in the records that have been reviewed.
The patient was HIV positive with a very low T cell count (less than 50), as well as presumptive toxoplasmosis of the brain. The patient also suffered from chronic obstructive pulmonary disease (COPD), significant psychiatric illness and had a long history of noncompliance.
A thorough review of the patient's chart clearly demonstrates that the patient had a long history of noncompliance with medications. In addition, the patient had a rather extensive psychiatric illness which was not well delineated in the medical records. However, at one time in 1996 and 1997, he was on Mellaril and amitriptyline and thioridazine which are administered to patients with significant psychiatric illnesses. The patient had been prescribed medications to prevent Pneumocystis carinii pneumonia and medications to prevent Mycobacterium avium complex. He had also been on multiple antiretroviral regimens.
A note in the chart on 8/3/1999 is representative of the patient's history. It states “noncompliance with Septra” and states he did not need Septra. This medical advice was made when the patient had a low CD4 and high viral load. Septra was needed to prevent Pneumocystis carinii pneumonia. “He stated he understood and he would not take it because he did not need it.” This note was written by an LPN.
This note is concerning because the LPN was not really sure whether the patient understood the ramifications of not taking his medications. In addition, the patient did not undergo psychiatric assessment. At any rate, three months later in 11/1999, a note written by a physician reported a discussion with the patient regarding antiretrovirals. The patient said he understood and will “pass again”. From this note, the physician is unsure of whether the patient understands the medical advice being provided, or whether the patient had confidentiality concerns or other issues.
IMPRESSION: This is a patient at the Limestone Correctional Facility who has an extensive history of noncompliance with his medication regimen. He had been provided opportunities to take his medications. What is unclear is why the patient was unwilling or unable to take his medications. This patient may have been distrustful of the system and as a result, decided not to take any of his medications throughout his stay at the Limestone Correctional Facility.
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Confidentiality could have been another issue caused by pill line. At any rate, these issues were in fact not discussed with the patient. Over the course of several years, medications were initiated and then later discontinued because the patient was noncompliant. The patient is partially responsible for his noncompliance and patients must take their own medications, but this patient clearly had a history of psychiatric disease and ultimately died of a history of toxoplasmosis of the brain which affects neurocognitive functioning, the effects of toxoplasmosis could have compromised his judgment.
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DEATH SUMMARY Andrea Edwards
Andrea Edwards was a 39-year-old male who died at the Limestone Correctional Facility on 10/16/2001.
The patient was HIV positive. He died of AIDS wasting syndrome. The patient's illness was complicated by AIDS dementia, severe thrombocytopenia (which is low platelet count), anemia, and liver dysfunction.
The patient had a rather long previous incarceration. His most recent incarceration started on 3/12/2001, when the patient had a blood draw. At that time the patient was found to have a very low T cell count and a high viral load. The patient was seen in follow-up by the physician on 4/5/2001 and was found to have a urethral infection. His T cell count was 10 and his viral load was over half a million. The patient at that time did not want to start antiretrovirals, agreed to start Pneumocystis carinii pneumonia and Mycobacterium avium complex prophylaxis. There was no indication as to why the patient did not want to start antiretrovirals.
The patient was seen again in follow-up on 5/31/2001. It was reported that the patient was not coming to the pill line. Again, the physician’s note does not discuss why the patient was not coming to the pill line, nor was there a psychiatric assessment for depression or for his mental status. Yet, a licensed practical nurse (LPN) discussed Do Not Resuscitate (DNR) issues, and reports that the patient just wanted to think about it at that point, and specifically did not want to be placed on Do Not Attempt to Resuscitate (DNAR) status. This is problematic because it is not the role of a LPN to discuss such an important issue with a patient.
On 6/3/2001, the patient was seen by the physician and diagnosed with AIDS wasting syndrome. At that time, he had not been receiving any therapy. He was housed in the infirmary until his death. Even though the patient was diagnosed with AIDS wasting until his death, he was not started on any oral supplementation or any medications to increase his lean muscle mass.
On 8/8/2001 he was seen by the physician who described the patient as “an emaciated male, looking pale and weak.” He was diagnosed with AIDS wasting and anemia. A few days prior he was started on Ensure which is a protein supplementation. The patient was followed again on the inpatient unit. He continued to decline.
The issue of DNAR was again discussed with the patient. The patient declined DNAR status.
On 10/3/2001 the patient was found to have a critically low platelet count of 11,000. The following day, the patient was started on prednisone to help increase his platelet count. On 10/5/2001, the physician reported that she had ordered some labs that were not sent and that she had to reorder those labs. The patient continued to decline. He received minimal nursing care and no hospice care. He expired on 10/16/2001.
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As a final note, the physician noted that considering the clinical picture and prognosis, cardiopulmonary resuscitation (CPR) was not attempted. The patient was pronounced dead. IMPRESSION: Mr. Edwards was a very advanced AIDS patient who, like many other patients at Limestone, had a rapidly progressive decline in health. His most bothersome symptom was his AIDS wasting. Many other patients at Limestone have also demonstrated symptoms of AIDS wasting. He was not treated appropriately or aggressively. The patient received some minimal protein supplementation, but no medications were provided to increase his appetite or increase his muscle mass. These medications can be life saving. The patient was clearly noncompliant, yet there was no indication in the medical record of discussing the patient's noncompliance and whether he understood why he was on these medications. In addition, this is a pattern at Limestone Correctional Facility where many patients appeared to be unable to stand in line for their medications, and appeared to not receive their medications as a result. Medical orders from doctors (such as laboratories) are often missed at Limestone as was the case with this critically ill patient. As is the pattern at Limestone, while the issue of DNR was discussed with this patient and documented, the patient’s wishes to not be DNAR were not respected.
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DEATH SUMMARY Michael Elliot
Michael Elliot was a 36-year-old male who died at the Huntsville Hospital on 03/27/2001 at 11:00 a.m.
Although medical records are not available from the patient's hospital stay, a review of the patient's external autopsy report shows that he died of Pneumocystis carinii pneumonia and that he suffered from AIDS, Cryptococcal meningitis, AIDS dementia, and depression. This is one of the few patients reviewed who signed a Living Will. The Living Will was signed on 3/7/2000.
A review of this patient's extensive medical history shows that he was on multiple antiretroviral therapies and other treatment regimens. He was seen repeatedly by the nursing staff and occasionally by the medical staff addressing noncompliance of his medication regimens.
The patient was not capable of taking a one medication a day regimen to prevent Pneumocystis carinii pneumonia or to treat his Cryptococcal meningitis. Indeed, he was not capable of taking a complicated regimen to treat HIV. Most of the regimens to treat HIV involve medications which must be taken at least three times a day, with special attention to food intake.
This patient had great difficulty adhering to medication regimens which is reflected throughout the patient's chart. There is only one instance in the medical records where the patient received any counseling to help increase his adherence or to discuss what some of the issues were addressing his adherence. Most medical providers recognize these steps as necessary for noncompliant patients.
On 4/4/2000, a note in the chart by an LPN states, “noncompliance with antiretroviral medications and Septra,” [which is Pneumocystis carinii pneumonia prophylaxis]. “Inmate signed release of responsibility. Antiretroviral medications DC’d. Septra DC’d due to noncompliance.” It is very concerning that the patient's medications were completely discontinued despite his not being counseled on this issue. Discontinuing a patient’s medications are not within the scope of responsibility of a licensed practical nurse. This should have been addressed by the physician, or at least by a pharmacist.
Several instances are also documented in the patient's chart referring to a “counseling report.” In the counseling reports, there are warnings called “first warning” or “second warning” or “third warning.” These warnings are filled out by LPN’s. However, all the LPN does is fill out the form. The LPN does not counsel the patient addressing noncompliance. Then the LPN reports that the patient needs to be more compliant with medication treatment or be subject to discontinuation of medications. It is clear from the records that warnings are used as threats to the patient, and are not utilized to increase the patient's understanding or cooperation of noncompliance with their medication.
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While the patients need to be adherent, need to take their medications and need to recognize that it is necessary to take their medication on a regular basis, these types of warning tools used by the Limestone LPN’s are clearly not helpful to the patient.
On 3/7/2000, the patient presented to the physician with a differential diagnosis of pneumonia versus tuberculosis. The following day, the physician ordered an antibiotic which apparently was not available at the Limestone pharmacy. However, even though the drug was not available, the doctor was not informed about the unavailability. Thus, the patient was never given the antibiotic. The patient was administered medication for presumptive Pneumocystis carinii pneumonia, although he was not diagnosed with that date. The diagnosis of PCP is typically made by induced sputum or an invasive procedure called a bronchoscopy. PCP is not diagnosed according to symptoms.
Without a diagnosis, the patient declines fairly rapidly over the next few days. On 3/11/2000 his oxygen saturation was 71% on five liters. At this time, he was appropriately sent to the local hospital for treatment. However, his presumptive pneumonia was so severe that he eventually died on 3/27/2000.
IMPRESSION: This 36 year old patient presents a classic example of a noncompliant patient at Limestone Correctional Facility where the patient's reasons for noncompliance were never determined. Throughout the patient's medical record, it is clear that he was unable to take his medications -even a simple pill once a day. Yet, no medical or nursing staff ever discussed with him the importance of taking this medication, or such discussions were not documented in the chart.
This calls into question the effectiveness of the system that currently exists at Limestone Correctional Facility where all patients must stand in line for their medications, regardless of their medical condition or ability to comply. Many correctional institutions in the United States have adopted a system of treatment where patients are allowed to keep their own medications and are allowed to administer their own medications. In many ways, this increases the patient’s feeling of responsibility and increases the patient's adherence, given that it makes it much easier for the patient to take their medications, especially such simple medications as an antibiotic once a day to prevent pneumonia. This patient likely died of a pneumonia which was 100% preventable -- Pneumocystis carinii pneumonia.
This could have been prevented, yet it was not because the patient was not capable of taking his Pneumocystis carinii pneumonia prophylaxis. Despite the patient’s responsibility, it is also the responsibility of the correctional institution to assist patients in taking their medications and to create a healthy therapeutic environment to allow patients to take their medications, especially the patient who is more vulnerable or who may have underlying psychiatric illness such as this patient who was depressed and who had AIDS dementia, or who might not understand the consequences of his actions.
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DEATH SUMMARY Terrell Grey
Terrell Grey a 41-year old HIV-infected patient who died at an outlying hospital on 1/25/2003 at 12:40 p.m.
The significant part of this patient's medical history started in November 2002 when the patient was discovered to have cotton-ball lesions on both lung fields. This condition was discovered during a routine chest x-ray. The initial belief was that the patient may have metastatic cancer to the lungs. However, the patient never had an adequate evaluation which would have included a tissue diagnosis. Approximately one month later, the patient had a chest CT scan which revealed that the patient had some large lesions that might have been consistent with metastatic lung cancer.
The patient was seen by Dr. Simon on 1/25/2003 at 6:00 a.m. He was experiencing shortness of breath after being exposed to a large amount of dust caused by a piece of the ceiling that fell in his housing unit. The patient was placed on oxygen and was given albuterol. He improved somewhat. However, he was placed on a large amount of oxygen at 4 liters per minute. In Dr. Simon’s chart note from that day, it is noted that he had an oxygen saturation of 85% and a blood pressure of 100/60. A normal oxygen saturation is above 95%. 100% is an optimal normal level.
Dr. Simon then left the prison and instructed the nurses that if the patient’s oxygen saturation became less than 80%, he was to be sent out to the emergency room. It is unclear from the medical records how this number -- 80% -- was decided. At 8:30 a.m., as set forth in the nurse’s note in the chart, the patient was sitting on the side of his bed with shortness of breath. He was using his intercostals (rib) muscles to breathe, meaning that he was having great difficulty breathing. This is something that is often seen in patients who have very severe emphysema. The patient's oxygen saturation was 88% while on four liters of oxygen. 88% is a low saturation number. Also, the patient's skin color was ashen, signifying severe respiratory distress.
According to the notes in the chart, even though the patient was clearly in respiratory distress, the nurses observe “no respiratory distress noted at this time.” The vital signs were obtained. The patient's pulse was 120 and respirations were 26. Normal respirations are usually about 1/2 of this amount.
One-half hour later, at 9:00 a.m., the nurses noted that the patient was anxious and was breathing through his mouth. Oxygen saturation was extremely low at 74% with a very high pulse rate of 144. It was then decided that the patient would be transferred to the hospital. The patient's oxygen saturation dropped even lower to 69% when the patient was being transferred from the concentrated oxygen to portable oxygen. His respirations increased to 38 with a low blood pressure of 98/50.
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At 10:20 a.m., the nurse’s note in the chart states that the patient tolerated his transfer from the wheelchair to the Department of Corrections van quite well. However, this observation is not supported in their other notes in the chart. The portable oxygen tank was placed in the van. Officer Timothy Howard was concerned about the instability of the patient and actually makes a statement to the nurses, and there is a signed statement on 2/1/2003. In fact, the officer noted that “I saw the patient get out of bed one time to utilize the toilet. He appeared to be weak with labored breathing at that time. Inmate Gray had an oxygen SAT monitor on his index finger and it read 79, down to 72, and stayed between the two every time I looked at him.”
The officer continues, “I stated to Nurse Smith, if Inmate Gray is that bad, shouldn’t he be transported in an ambulance.” Officer Howard, in his signed statement, states that Nurse Smith told him that “He’ll be fine!” Office Howard then stated “I stated to Nurse Smith that the two officers transporting Inmate Gray do not have medical training to be able to transport an inmate with the problem that Inmate Gray was having. Nurse Smith stated, ‘He’ll be fine. I’ll put some oxygen in the vehicle with him and let him roll. He will be fine.’”
The two officers started transporting the patient. Instead of taking him to the nearby Athens Limestone Hospital, the officers were instructed to take him to Birmingham-- two hours away. Soon after the patient was en route, Officer Kossi and Newman who were transporting the patient, noted that the patient appeared quite ill. They noted that his eyes rolled behind his head. The officers were in a quandary about what to do. The officers decided to stop at a store to ask for the location of the nearest hospital. The patient was in respiratory arrest and in need of cardiopulmonary resuscitation. The officers stopped at the nearest hospital, which was the Woodland Medical Center.
The patient was removed by the Woodland Medical Center nurses approximately 30 minutes after going into cardiopulmonary arrest. The nurses attempted CPR. No CPR was attempted prior to the patient's arrival at the hospital. Even though the staff at the Woodland Medical Center made a valiant effort, the patient died soon thereafter.
A review of the chart reveals a signed statement by Mary Jones, LPN. The nurse states that she was asked by Ms. Elizabeth Smith to look at Inmate Terrel Gray. She reports that when she entered his cell, she observed a solemn facial expression with an ashen gray skin color. Nurse Jones further states that the patient's oxygen saturation was between 74% and 79% with a high pulse between 133 and 144. The patient’s blood pressure was very low at 98/50. The nurse’s assessment is “no respiratory distress or cardiac distress was observed, but I do suggest we go ahead and send him to the hospital.”
Then the nurse states “The inmate was sent to the hospital via Department of Corrections van for follow-up care. No indications were present for need of ambulance or emergency van.”
IMPRESSIONS: This is another example of a patient at Limestone Correctional Facility who was permitted to suffocate without receiving appropriate therapy. An oxygen saturation in the 80’s -- much less in the 70’s or 60’s -- on four liters of oxygen is very low. At this time, the patient was critically ill.
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However, the patient was allowed by the nurses and by Dr. Simon to stay at the Limestone Correctional Facility until his oxygen saturation was lower than 80%. There are signed statements in this patient's medical records by medically untrained officers. These statements indicate that the officers were uncomfortable transporting the patient in extremis. The officers were medically untrained. However, the officers were still able to recognize that he was critically ill. The nurses at Limestone did not recognize that this patient was critically ill or the nurses did not care and neglectfully chose to send the patient in the van despite the officers’ verbal concerns. Instead, the patient was transported in the van by the two officers and went into cardiac arrest and died with no medical personal present. This is a clear example of the grossest neglect and inappropriate care provided to this patient. The nursing staff should have recognized that the patient should be transferred emergently in an ambulance with trained paramedics to the nearest hospital. He should not have been transported to a hospital as distant as one in Birmingham. This death could have been avoided. The patient’s diagnosis is unclear from the medical records. A diagnosis of metastatic carcinoma was made by CT scan; not from a biopsy. This patient may have had a very treatable infection, such as a fungal infection of the lungs, or even tuberculosis. At any rate, Terrell Gray was permitted to die. This case demonstrates the lack of even a minimal level of medical care and the substandard nursing care at the Limestone Correctional Facility.
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DEATH SUMMARY Chelsea Hammac
Chelsea Hammac was a 34-year-old male who died at the Limestone Correctional Facility on 11/14/2002 at 3:25 a.m.
This patient had advanced AIDS, as well as multiple complications, including CMV, retinitis, wasting syndrome, herpes and candidal mouth infections, and chronic renal failure. Ultimately, he most likely died from Pneumocystis carinii pneumonia (PCP).
Of note, the patient did have a rather extensive history of noncompliance. His antiretroviral medications were reviewed multiple times by Dr. Simon, and the patient appeared to not want to go back on therapy, although he had been on antiretrovirals in past. In fact, the patient had done rather well in the past, but had been changed to a different regimen which caused nausea. It is assumed, but not delineated in the medical records, that the patient ceased his medication regimen because of their side effects. In none of the notes was the reason for the patient’s refusal to take the antiretroviral therapy discussed with the patient. This was in spite of the patient having very advanced AIDS and severe HIV complications.
In the end, the patient did decide to start antiretroviral therapy.
Of note, it appears that the patient also did not take his PCP or MAC prophylaxis. Again, the reasons were not included in the medical record.
IMPRESSION: The major issue in the patient’s case was that he appeared to be followed appropriately, but was unable to take his medications. In particular, the medication to prevent the illness that ultimately caused his demise (PCP), involved taking one tablet once a day or as little as three times weekly. It is suspected that as the patient became more and more ill, as his energy level decreased, he was unable or unwilling to stand in line for his medications. Medications at the Limestone facility are dispensed to HIV-infected prisoners in a pill line. The prisoners stand in line outside of Dorm 16 -- in the heat of the summer or the cold of the winter -- to receive their medication sometimes up to three times per day. A prisoner can wait up to one hour for their medication, which is difficult or impossible for someone who is ill. There is not an attempt at Limestone to assist patients and help them become more compliant.
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DEATH SUMMARY Eddie Harris
Eddie Harris was a 44-year-old male who was admitted to the Limestone Correctional Facility on 05/23/2000 and died one day later, 05/24/2000. Mr. Harris had a history of AIDS. He had also been diagnosed with pulmonary Mycobacterium kansasii, dementia, and AIDS wasting. His last T cell count had been 50. The patient had previously been at the Montgomery County Jail where he had a rather extensive evaluation and inpatient stay at the Baptist Medical Center. At that time he had been started on extensive medications and treatments including INH, rifampin, ethambutol, AZT, 3TC, efavirenz and Megace. All of these medications are appropriate. Given that the patient was at the Limestone Correctional Facility for only one short day, there are very few medical records available. The few records indicate that on 05/23/2000, the patient had a fever of 102. He reported experiencing chills and shortness of breath. He expired the next day. There is no further documentation addressing this patient. IMPRESSION: Given the short stay of this patient at the Limestone Correctional Facility, there are few medical records. This was a very end-stage patient who appears to have been transferred on the appropriate medications and who expired incredibly rapidly. It is unclear from the records why the patient expired so rapidly at the Limestone Correctional Facility. This is concerning because it is a pattern at Limestone Correctional Facility for HIV infected patients to expire rapidly. Another concern is that there are no medication administration records in this patient's medical record. Therefore, the patient may have never received his medication regimen as was intended.
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DEATH SUMMARY Kelvin Harris
Kelvin Harris was a 44-year-old male who died on 9/12/2001.
Conspicuously there is no information noted from the patient's chart from the year 2001, and absolutely no information available surrounding the months prior to his death. As a result, this review will focus on several other aspects of his chart and will not be able to focus on his death.
This is an AIDS patient who had a history of Pneumocystis carinii pneumonia and peripheral neuropathy who had been on HIV therapies. The patient noted in 3/1998 that he was not being given all three of his HIV medications. During that same month, in a physician note, the patient was labeled as noncompliant. Approximately one month later, on 4/1/1998 a note by Ms. Riggs (who was a nurse) stated “compliance of AZT and 3TC was only 50%.”
Guidelines were followed. It is difficult to read Dr. Moore’s notes because they are largely ineligible which is typical of his notes, but the notes suggest that “by guidelines compliance is less than 95% and the plan is to discontinue antiretroviral medications.” There was no discussion of why the patient was unable to take his medications if he indeed was noncompliant, or if the medications were not being supplied to him appropriately.
A health services request form from Mr. Harris pleads that he be restarted on his antiretroviral medications. This demonstrates that the patient was motivated to restart his medications.
There is also a letter from the patient dated 3/5/1999. The letter is addressed to Mr. H. Dobbs of the Health Care Unit. Mr. Harris writes:
“Mr Dobbs, I am having problems with the medication that I am presently taking, which is D4T, DDI, and Crixivan. The problem that I am having is my feet and hands are numb all the time and stay in pain. I am also throwing my food up; can’t keep it down in my stomach. I am bringing this to your attention because I don’t want to take myself off the medications. Maybe there is something that can be done to help these side effects or possibly change the medications. Your attention to this matter will be highly appreciated. Thank you. - Kelvin Harris”
At that time, it appeared that the patient was on a regimen that is very difficult to take consisting of D4T, DDI, and Crixivan. Specifically, Crixivan needs to be taken on an empty stomach. Crixivan causes a lot of side effects including abdominal pain and gastrointestinal (“GI”) upset. D4T and DDI classically cause neuropathy. The patient described these side effects which we see in patients on the same regimen.
At the bottom of this note, Dr. Moore callously writes: “Discontinue HIV treatment.” There is actually discussion about trying to help the patient take these medications or treat his side effects.
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The patient is seen several days later on 3/5/1999. He is complaining of nausea and vomiting with pain in his feet. He was experiencing vomiting for several days. Dr. Moore did not perform a neurologic examination, even though the patient was complaining of neuropathy. The assessment is HIV positive since 1985. “Side effects: Neuropathy, nausea and vomiting.” The treatment plan was to discontinue treatment for “drug holiday” (at patient's request). However, in the note, the patient did not want to be taken off the medications. This note demonstrates that the patient was not informed that the side effects could be treated and there were other medication options for this patient.
Other notes in the chart describe the patient’s problems with these medications and not being treated for side effects. The patient was eventually (six months later) started on a different regimen. Again, the regimen was d4T, abacavir, and nelfinavir. Of note, nelfinavir causes severe, horrible, watery diarrhea. Typically, treating physicians will immediately provide patients medication to stop the diarrhea, including such simple things as Tums or antidiarrheal agents. However, in this case, the patient was not administered any of antidiarrheal medication. In addition, this patient had a history of neuropathy and was inappropriately started on a full-dose of a medication (d4T) that appeared to cause his neuropathy in the past. This set the patient up for failure.
IMPRESSION: Although the cause of this patient’s death is unclear, and the medical records which would provide information concerning the cause of death are absent, since no medical records at the time of his death or for the year prior to his death were provided for review from the Department of Corrections, this chart provides another important focus addressing the medical treatment at Limestone.
The pattern that occurs over and over again at the Limestone Correctional Facility is one of patients being started on therapies which might be appropriate, but they are set up for failure. Patients at Limestone fail because they are not treated concurrently for known side effects, or are given regimens that are nearly impossible to adhere too given the environment of the Limestone Correctional Facility. In this case, it appears that this patient was started on a very difficult-toadhere-to regimen. In addition, the regimen caused rather significant and severe side effects. Yet, even though these side effects can often be treated very easily by decreasing the dose of the D4T for instance, or giving him medication for his GI upset from the Crixivan, instead Dr. Moore chose to discontinue the medication and place the patient on a “drug holiday” which is not only contraindicated in patients, but has been proven to lead to rapid deterioration.
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DEATH SUMMARY Michael Headon
Michael Headon was a 29 year old patient with class C3 AIDS who appears to have died on 09/18/2002, although I am unable to confirm because he died outside of the Limestone Correctional Facility.
It appears that the patient was originally diagnosed with Pneumocystis carinii pneumonia at the Huntsville Hospital. He was placed on antibiotics appropriately and was returned to the Limestone prison system, and accepted for transfer on 09/13/2002.
The patient was admitted to the Health Care Unit and the initial nursing notes from 09/14/2002, stated that the patient had “dyspnea” (shortness of breath) with an oxygen saturation of 81% while on five liters of oxygen. This is critically low. The assessment was “altered respiratory decreased oxygen saturation”. Despite the patient’s respiratory distress, the plan was to monitor the patient's condition and administer antibiotics as ordered. Despite the patient’s grave condition, Dr. Simon was not contacted, and the patient was only observed and continued to have a low oxygen saturation.
Over the next few days, the patient continued to deteriorate. At one point, there was an oxygen saturation recorded of 70% on 09/17/2002, while the patient was on large amounts of oxygen supplementation. This is impending respiratory failure.
Mr. Headon was finally seen by Dr. Simon on 09/16/2002, and was prescribed an additional antibiotic (Levaquin), given the concern that the patient most likely had a bilateral lobar pneumonia or had acquired pneumonia while he was hospitalized. Unfortunately, this antibiotic was not administered to the patient as ordered by the doctor. Consequently, his condition on 09/16/2002 was worse. He was breathing at 40 per minute while he was oxygen and IV Bactrim. (Normal breathing rate is 12 times per minute.)
Most concerning was that the patient's oxygen saturation continued to deteriorate until and on 09/18/2002 at 12:00 p.m., one of the nurses wrote that “the patient is respiratory distress.” The patient had been in respiratory distress for the past several days. “The patient has difficulty breathing and his oxygenation is at 55%.” This is an extremely low oxygenation, and not compatible with life.
IMPRESSION: This patient essentially suffocated to death. His patient’s death demonstrates gross neglect of a patient at Limestone Correctional Facility. This patient clearly deteriorated in front of the nursing and medical staff at Limestone. His oxygenation was so poor that were he to have been in a medical facility where appropriate care was administered, he would have been given emergency ventilatory support (i.e. placed on a “breathing machine”).
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Earlier on, it was discussed with the patient whether he wanted to have additional support (such as being placed on a “breathing machine”), and Dr. Simon did write on 09/16/2002 that the patient did NOT wish to sign a DNR (Do Not Resuscitate) form, which meant that the patient did wish to have more invasive treatment. The patient’s wishes were not followed! The patient was allowed to become ill beyond treatment, and he was admitted to Huntsville Hospital and expired soon thereafter. This patient was deathly ill and medications that were ordered were not administered. This is a failing of the nursing and/or pharmacy system at Limestone. Medications written for must be delivered to critically ill patients. This case represents extremely negligent care of this patient. It is almost unbelievable that he was allowed to basically suffocate to death.
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DEATH SUMMARY Dennis Hearns
Dennis Hearns was a 32-year-old male with C3 AIDS, cryptococcal meningitis, and AIDS wasting. He expired at Limestone Correctional Facility on 06/04/1999 at 9:40 p.m.
A thorough review of the patient's medical records revealed that the patient had been HIV infected for over one decade. The patient had been treated with multiple antiretroviral medications in the past, and prior to his death, he had been on an antiretroviral regimen. The review will focus on the patient's end-of-life care.
The patient was admitted into the inpatient unit at the Limestone Correctional Facility in approximately February 1999. At that time, it was noted that the patient had AIDS wasting syndrome. Wasting syndrome appears to be the cause of the patient's death. In reviewing the patient's inpatient medical records at Limestone, it does not appear that the patient ever received a thorough work-up for AIDS wasting syndrome. In addition, it is not clear from his chart whether he received any appetite stimulants, which would have been an appropriate treatment for his wasting syndrome.
In April, the patient was described as comatose. Yet, the medical staff decided that no further treatment interventions would be administered; that the patient would be “kept comfortable”; and that antiretroviral medications would be discontinued. For the next couple of months, the medical record notes and the nursing notes indicate that the patient continued to decline. At one point, the patient develops blindness. Again, the condition was merely accepted by the medical staff. The patient’s blindness was not evaluated by the medical staff.
A review of the patient's laboratory results indicates that he did not receive any laboratory testing after 3/30/1999 through his demise on 6/4/1999. No additional medical testing is evidenced in his medical records.
The patient also reported hearing voices. On 5/17/1999, it was recorded that the patient did have a history of psychiatric disease and had been on Mellaril (an antipsychotic). At that time, the patient requested that he be put back on Mellaril, but apparently he was not put back on any antipsychotic medications.
The nurses performed daily documentation of the patient's general status and occasionally documented the vital signs. However, there is no indication of the patient’s weight or any nutritional assessments of the patient that appears in the medical records.
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IMPRESSIONS: Mr. Hearns was a young 32-year-old AIDS patient who clearly had advanced AIDS. His advanced AIDS condition was evidenced by a very low T-cell count as well as Cryptococcal meningitis. In addition, he had quite severe wasting syndrome. Problematic in Mr. Hearns’ medical care is that he did not receive an appropriate or adequate work-up or treatment for AIDS wasting syndrome. Simple medications can assist in stimulating a patient’s appetite or help this patient gain life saving body mass. Due to this lack of treatment, the patient progressed to advanced disease and died from AIDS and wasting syndrome. An additional concern is that the patient became blind. Again, this condition was not evaluated by the medical staff. There are many diseases, including cytomegalovirus (CMV), which can cause blindness and are indeed treatable in AIDS patients. As with other HIV infected patients at Limestone, Mr. Hearns did not receive adequate end-oflife care, much less adequate Hospice Care. There is no indication in the medical documents that this patient requested such minimalist measures, or that he did not desire more aggressive types of treatment for his disease. This is most worrisome. It appears that this Limestone medical staff decided that the patient should not receive more aggressive treatment.
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DEATH SUMMARY Cletis Johnson
Cletis Johnson expired at the age of 36 on 05/24/2002 at 2:20 pm at Limestone Correctional Facility.
To understand this patient's clinical course, one must briefly review the records from Kilby Correctional Facility (the receiving center for incarcerated men into the Alabama Department of Corrections), where the patient was initially incarcerated in the Alabama DOC. This patient clearly had ongoing medical issues, including nausea and vomiting and malaise (just generally not feeling well). While at Kilby, the patient received only minimal care.
Prior to the patient's transfer to Limestone, he was evaluated at Kilby by a registered nurse on 04/24/2002. At that time the patient was only on minimal medications. The intersystem transfer form documents that the patient was stable and the nurse failed to check past chronic clinics, specialty referrals, or significant medical history. In fact, in the medical records, after the notation of significant medical history, there is a zero with a line through it, which signifies that the patient had no significant medical history, notwithstanding that the patient indeed had advanced AIDS.
The patient was transferred into the Limestone Correctional Facility with minimal history, as well as inaccurately designated as having no significant medical history. When he arrived on 4/25/2002 at 2 p.m., the patient was not evaluated by the Limestone healthcare staff. Rather, he was inappropriately evaluated by a correctional officer who designated in the medical records that the patient appeared stable, which is hard to believe because only five days later the patient filled out a health service request form, on 04/30/2003, and wrote in this form “feet have swollen real bad and lots of thrush in mouth.” At any rate, correctional officers are not adequately trained to make these types of decisions.
The patient’s medical request form was unfortunately not responded to until six days later, when on 05/06/2002, Jay Cook, LPN, responded “will wait to see MD per patient.”
Mr. Johnson was not seen in the health care unit until 05/09/2002 at which time an attempt was made to draw blood. He was not seen by a physician until 05/17/2002. At that time, Dr. Simon documented that “the patient looks pale and ashy, has oral thrush, his skin is dry.” The patient was immediately transferred to Huntsville Hospital.
On admission to the hospital, even though Dr. Simon indicated that the patient had no complaints, the patient reported to the staff “can’t keep anything down. Weak and dizzy.” Dr. Chassay, at Huntsville Hospital, performed a thorough evaluation and assessed the patient as having nausea, vomiting a likely opportunistic infection, and esophagitis. It is clear from Dr. Chassay’s evaluation that the patient, at the time of his transfer from Limestone, was very ill.
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Significantly, Dr. Chassay did elicit from the patient that he also had a 75-pound weight loss, and in fact, he had not been on antiretroviral medications because he was told that they were not available to him.
The patient was admitted to the Huntsville Hospital and was evaluated and was found to have abscesses of the brain, which were most likely cerebral toxoplasmosis, a severe parasitic infection. The patient also had severe esophageal candidiasis (yeast in the throat), metabolic disturbances, as well as seizures from the severe brain infection that was thought to be toxoplasmosis. After several days and hydration and some therapy, the patient continued to be quite ill. Indeed, he required a large amount of oxygen because his oxygenation was so poor.
A call was made to Dr. Simon and the patient, despite being critically ill, was transferred back to the Limestone Correctional Facility. At the Limestone Correctional Facility, the patient was not treated for toxoplasmosis of the brain. He was admitted to the inpatient unit and was only continued on treatment for his thrush as well as given IV fluids. He was also given oxygen. At no time were antiretroviral medications initiated, despite the patient having only two T cells.
The nurses did evaluate the patient at least approximately every two hours until about 2:30 a.m. on 05/24/2002. There is no documentation indicating that the patient was seen by any medical personnel after 2:30 a.m. on 5/24/2002. The nurses note that the patient was rather ill, his skin was dry and cool, and that the patient had “copious amounts of yellowish-white discharge coming from his mouth and nares.”
The patient had an opportunistic infection (toxoplasmosis of the brain), as well as severe respiratory distress. He expired on 05/24/2002 at 2:20 p.m. It bears mention that, it was Officer Danny Albertson who found the patient dead and notified the medical staff. There is no indication that any medical staff had treated or assessed the patient during the 12 hour period from 2:30 a.m. through 2:20 p.m.
Mr. Johnson died one day after being discharged from the Huntsville Hospital, and the patient died of a very treatable illness for which he was not being treated.
IMPRESSION: This patient was an advanced patient with AIDS whose substandard care displays the profound problems that occur when a patient is not evaluated and treated in a timely fashion and not treated appropriate manner. Clearly this patient’s situation was advanced in both his AIDS diagnosis, as well as the toxoplasmosis of the brain. However, toxoplasmosis is treatable, and the patient was not treated for this illness. It is my opinion, within a reasonable degree of medical certainty that the patient died unnecessarily and from a treatable illness. Contributing to this patient's death was clearly the slow response of the medical staff to evaluate this very ill patient, as well as the acceptance of a patient from a hospital facility back to a prison that was not able to take proper care of a patient in an extremis condition.
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DEATH SUMMARY Leslie Johnson
Leslie Johnson was 45-years old when he died in the Limestone Healthcare Unit, cell #153, on 12/04/1999 at 3:05 a.m.
The patient was HIV positive with a T-cell count of approximately 100. It was also noted that he had liver disease. The medical records do not indicate whether the cause of the liver disease was ever determined. The patient ultimately died on 12/04/1999 when he was found to have a weak pulse and exhibited Cheyne-Stokes breathing.
The patient had an extensive discussion about end-of-life care issues with Dr. Khouri on 11/11/1999. According to this entry, the patient did not want any unnecessary prolonging of his life. The note in his chart outlines the future disease process that the patient might expect. The patient agreed and signed a “do not resuscitate” (“DNR”) order. This order was signed on 11/11/1999.
Soon after this patient signed this DNR order, the patient continued to decline in health. On 11/27/1999, the patient was noted to have a hematocrit of 15 (less than ½ normal), a prothrombin time of greater than 15 (indicating severe ‘thinning of the blood’), and an extremely low platelet count of 22,000. The question was raised about whether he needed a blood transfer; although apparently the Athens Hospital does not release blood. It was believed that the patient should receive blood from another hospital in Birmingham.
During the time, it was noted that the patient was not in distress, he was out in the yard, and that a blood transfusion was not to be administered.
A review of the patient's additional laboratory tests on that day revealed that the patient had a bicarbonate of 11, indicating that he was in rather severe acidosis (possibly an underlying infection), as well as a glucose of 49 (normal glucose levels are greater than 100).
IMPRESSIONS: Mr. Johnson was a 45-year old HIV positive patient with probable underlying chronic hepatitis C. His chart does not clearly document the condition. This is inappropriate. Any patient with underlying hepatitis or liver disease should have a diagnosis, or at least an attempt at making a diagnosis recorded in their chart.
On 11/27/1999, the patient had some laboratory tests drawn indicating that the patient was very severely ill. In fact, regardless of his symptoms, he was gravely ill. A bicarbonate of 11 demonstrates that the patient had a severe underlying acidosis and likely a severe infection. His laboratory tests indicated that he had profound anemia and thrombocytopenia (low platelets) and
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a severe coagulopathy (thinning of the blood). Such a condition may very well result in a patient bleeding internally. The patient was not provided any treatment intervention. In fact, no attempt was made to reverse his severe blood thinning (coagulopathy) or anemia. The patient died soon after these laboratory tests were drawn. While it was clear the patient had fairly advanced liver disease and agreed not to have life extending measures, such as intubation or cardiopulmonary resuscitation (CPR), the lack of adequate medical care was inappropriate and led to this death.
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DEATH SUMMARY Morris Johnson
Morris Johnson was a 30-year-old male who died on 7/25/1999 at the Limestone Correctional Facility. The incident report incorrectly dated the patient's death as 7/24/1999.
The patient carried a diagnosis of AIDS, chronic obstructive pulmonary disease, chronic bronchitis, asthma and renal insufficiency (kidney dysfunction).
This review will focus on the events that led to this patient's death.
Beginning in 5/1999, the patient was seen in clinic by Dr. Khouri. The patient was complaining of difficulty breathing. In fact, Dr. Khouri quoted the patient as stating, “Couldn’t breathe.” The patient was placed on Corticosteroids (Prednisone), but returned approximately three weeks later, on 6/14/1999, stating that he “can’t handle it in the dorm.” Dr. Khouri noted that the patient was having great difficulty breathing. Dr. Khouri also noted that the patient had a high viral load of 108,000.
At this time, the plan was to continue the patient on his current therapy and start him on the antibiotic erythromycin. During the next several days, the notes in the chart, including on 06/15/1999 and 06/16/1999, clearly show that the patient was not doing well. In fact, on 06/15/1999, Dr. Khouri wrote that the “patient is HIV positive with end-stage AIDS and? PCP” (abbreviation for Pneumocystis carinii pneumonia). The patient was on erythromycin which is not effective against Pneumocystis carinii pneumonia.
On 6/22/1999, the patient continued to have shortness of breath and was desaturating. This means that the patient was unable to breathe enough oxygen and was suffocating to death. Previous patient records at Limestone Correctional Facility have indicated a similar desaturating condition. The patient was taking clindamycin and erythromycin. These are two antibiotics which do not specifically treat Pneumocystis carinii pneumonia.
The patient was still short of breath. On 6/24/1999, he reported that “the oxygen helps a little.” On 6/25/1999, the patient was started on a subtherapeutic dose of Bactrim (even in the setting of renal insufficiency), which was one double strength tablet b.i.d. times 10 days.
The notes in the chart for the next several days report that the patient continued to worsen. The patient had a sulfa allergy and he had another allergic reaction to the Bactrim.
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Chest x-rays were obtained on 6/15/1999. These X-rays clearly demonstrated that the results were consistent with Pneumocystis carinii pneumonia. Another chest x-ray on 7/1/1999 showed results that were again consistent with Pneumocystis carinii pneumonia. A repeat chest x-ray on 7/15/1999 showed the same results. Given his initials on the reports, these chest x-rays were viewed by Dr. Khouri. However, no action was taken by the Limestone medical staff. On 7/21/1999, a pulmonary culture was obtained which showed the growth of a very resistant and deadly organism called Pseudomonas aeruginosa. The patient was not initiated on an antibiotic to fight this organism and on 7/23/1999 the culture results from blood obtained on 7/21/1999 confirmed the same results. Mr. Johnson died 4 days later on July 25, 1999. IMPRESSIONS: Morris Johnson likely died from PCP and a secondary deadly bacterial pneumonia which could have been prevented if he had received appropriate therapy. This an example of another patient at Limestone Correctional Facility who presented with a life threatening illness, was not appropriately evaluated, was treated with a subtherapeutic dose of a medication and then died. In addition, this patient became infected with a secondary bacterial pneumonia -- Pseudomonas aeruginosa. Despite his rapid deterioration, he was not started on a life-saving antibiotic. The treatment mismanagement of this AIDS patient demonstrates Limestone’s medical staff’s lack of knowledge in even basic HIV management. Dosages of antibiotics are easily found in simple texts, online, or can be obtained by calling the pharmacist.
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DEATH SUMMARY Stanley Lillie
Stanley Lillie was a 47-year-old male who died on Christmas Eve, 12/24/2001 at 7 p.m. at the Huntsville Hospital.
There is no Huntsville Hospital report and no autopsy available.
The patient had a diagnosis of AIDS with a T cell count of less than 20 and a viral load of 98,000 obtained on 11/1/2001. The patient was also diagnosed with hypertension and a lupus anticoagulant which caused him to experience recurrent deep venous thrombosis as well as a history of pulmonary emboli. As a result of this condition, the patient had a filter placed and had been on chronic high-dose Coumadin.
The patient was transferred from the Kilby Correctional Facility to the Limestone Correctional Facility on 10/03/2001. At the time of his transfer from Kilby, the patient was on Bactrim, azithromycin, low-dose Coumadin at 2.5 mg, and Maxzide.
On 10/08/2001, the patient sent a health care request form to the medical staff requesting a bottom bunk. He stated that he had a blood clot in his lower extremity. This was answered by LPN Kirk who responded that the patient would see the physician in “a couple of weeks.” The LPN did not understand that this patient, who was on Coumadin, should have been seen by the physician much earlier.
According to the medical records, the patient was not seen until at least 11/13/2001, six weeks after his transfer to the Limestone Correctional Facility where he was admitted into the infirmary with a swollen lower extremity. The concern was that he might have a clot in the lower extremity. In response, he was administered a higher dose of Coumadin in addition to subcutaneous heparin. However, he was not started on intravenous heparin. Because the physician was ruling out deep venous thrombosis in the setting of Coumadin treatment, intravenous heparin would have been the standard of care. Also, at this time he was not evaluated for a lower extremity deep venous thrombosis.
The patient was seen on 11/18/2001 and was found to have “difficult veins.” It appears that a blood draw was not done. In fact, the first blood draw that can be found the patient’s medical chart is on 11/20/2001. On 11/19/2001 an attempt at a blood draw was also unsuccessful. On 11/21/2001 the PA-C wrote that the patient “needs a blood draw as soon as possible.” Multiple attempts were made, but none were successful. The patient was not sent to the local hospital. There was no attempt to obtain blood through a large vessel, which is the standard procedure.
On 11/26/2001, the patient reported bleeding from his rectum. His anticoagulants were then held. The patient finally had a blood draw and the anticoagulation factor called PT-INR was normal.
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On 11/27/2001, the heparin was resumed. On 12/28/2001, the patient complained of fever and chills with a temperature of 101.8. For some reason he was diagnosed with a viral syndrome by the physician’s assistant. No blood cultures were drawn. The patient was not seen until 12/10/2001 when he was in acute renal failure. At one point, his creatinine increased to 3.9 (which is more than three times normal). He was sent to the Huntsville Hospital where he was placed on intravenous antibiotics and then returned to the Limestone Correctional Facility.
The patient returned to the Limestone Correctional Facility and on 12/11/2001 he continued to have a fever of 104 degrees. The physician notes that “the patient is an apparently healthy male in no respiratory distress.” No medications were started. On 12/13/2001 the patient continued to have fever of 103 degrees. Empiric antibiotics were appropriately started.
The patient's blood draw from 12/12/2001 showed that he had a blood stream infection with coagulase negative Staphylococcus. On 12/17/2001 the physician noted that the patient received his vancomycin on 12/15/2001 and then they ran out. Because they ran out of vancomycin, the patient was placed on a different antibiotic on 12/16/2001 which in fact was not appropriate for treating coagulase negative Staphylococcus. The vancomycin was resumed on 12/17/2001 because “a supply came in today.” The patient was also started on empiric antibiotics for another infection.
The patient continued to experience fevers and he continued to decline. A blood draw from 12/20/2001 showed that he was neutropenic with a neutrophil count of 576, INR quite high at 6.4, a very high glucose of 542. In particular, the low neutrophil count was not addressed. The patient was not put on G-CSF. He continued to decline.
The results of a blood draw on Christmas Eve, 12/24/2001, are present in the medical records. The patient had a PT of 72.8 (extremely high) indicating a severe coagulopathy (thinning of the blood). He was sent out to the Huntsville Hospital and died that night.
IMPRESSION: This patient rapidly succumbed under the care of the nursing staff at Huntsville Hospital. The patient had a long history of lupus anticoagulant, deep venous thrombosis and clotting which caused him to have clotting factors abnormalities. It is apparent from the management of this patient that he was not receiving appropriate or close enough monitoring of his anticoagulant medications.
The patient developed an infection, probably of his blood, although the type of infection is not known. He did have a severe coagulopathy (thinning of the blood) as evidenced by a very high PT prior to his death. The patient was sent to the Huntsville Hospital and died quite rapidly. It is not clear why the patient's low neutrophil count was not addressed nor why this patient was not given closer monitoring of his anticoagulation medications.
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In addition, there was absolutely no discussion of antiretroviral therapy or starting this patient on a regimen to help increase his CD4 count or his viral load. This patient could have benefited from antiretroviral therapy. The patient should have been evaluated much sooner. He appears to be yet another patient who slipped through the cracks at the Limestone Correctional Facility because the medical staff was overwhelmed.
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DEATH SUMMARY Wilford Lockett
On 3/15/2000 at 2:15 p.m. Wilford Lockett was pronounced dead at the health care unit at the Limestone Correctional Facility after having collapsed on the prison field while umpiring a softball game.
Mr. Lockett was a 68-year-old male with HIV infection, questionable seizure disorder, hypercholesterolemia, and hypertension. The patient received an external autopsy -- as did all HIV infected patients -- which is uninformative. In fact, the autopsy lists the patient's illnesses incorrectly. He is listed as having human diabetes (human diabetes is not a known medical term) and hypocholesterolemia (low cholesterol) as opposed to hypercholesterolemia (high cholesterol).
The patient was originally seen at the Kilby Correctional Facility and complained of left-sided pain. At that time, he was given Motrin and was found as having a high blood pressure at 144/102 (normal is less than 120/80). He was also found to have a high blood sugar of 375 (four times the normal range).
A review of the patient's medical records at Kilby also indicate that he had an extremely high glucose of 698. Nothing was done to address this condition because the patient arrived at the Limestone Correctional Facility on 2/19/2000 and the transfer form from Kilby did not list the patient on any medications and listed his only medical illness as being HIV infection. Specifically diabetes, hypertension, hypercholesterolemia, and seizure disorder were not listed as medical illnesses.
At the Limestone Correctional Facility, a third serum glucose was obtained and measured 232. This is more than twice the normal range. The patient also had a high cholesterol of 214. He was seen almost three weeks later by Dr. Khouri who reported that the patient had “high blood pressure. Rx Norvasc - 3 years.” The next line states “diabetes - no meds.” Dr. Khouri’s assessment was “ ? diabetic, ? hypertension” This demonstrates that Dr. Khouri had not reviewed this patient’s chart, much less obtained an adequate medical history.
Despite the fact that the patient had three high blood glucose results, no medications were initiated. These tests clearly indicated that the patient was a diabetic and hypertensive. The patient was not seen again until he collapsed out in the yard. An unsuccessful attempt was made to resuscitate the patient. However, it appears that he died of cardiac arrest.
IMPRESSIONS: Wilford Lockett was an elderly patient with multiple medical problems. He was at a very high risk for cardiac disease. The medical staff at Limestone Correctional Facility and Kilby, did not heed this patient's symptoms or his laboratory values and did not treat his underlying diabetes, hypertension or hypercholesterolemia. This patient clearly died of a cardiac arrest which could have been thwarted had he been treated appropriately.
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It is unclear why these very obvious laboratory values were not treated, and why the patient's underlying illnesses were not treated. This is an example of a pattern at Limestone and Kilby where laboratory tests are drawn and the patients suffers because they are not treated. This HIV-infected patient appears to have died from a cause unrelated to HIV, concerns about care at Limestone for patients with other serious diseases such as diabetes, coronary artery disease and hypertension must be brought into question.
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DEATH SUMMARY Joseph McClure
Joseph McClure was a 71-year-old male who died on 05/06/2002. The patient's medical records are incomplete. There are no medical records after 03/30/2002. This is a full five weeks prior to the patient's death.
Mr. McClure had the diagnosis of AIDS with a low T cell count of 28; he was originally diagnosed at the Kilby Correctional Facility. The patient also had diabetes mellitus and hypertension, renal failure, and benign prostatic hypertrophy. Additionally, the patient also suffered from severe anemia.
It is important to review the patient's medical records from Kilby Correctional Facility which showed the patient had a T cell count of 32, a viral load of 75,300 and a creatinine of 3.7 (a normal creatinine level is less than 1.4). The blood test was obtained on 08/03/2001.
While at Kilby, this patient’s renal failure was never evaluated. The patient was placed on medication to treat his hypertension and diabetes. However, the patient went into a hypoglycemic coma. Soon thereafter the patient was transferred to the Limestone Correctional Facility on 10/03/2001.
On 10/08/2001, the patient was seen by Dr. Simon. Dr. Simon started the patient on an antiretroviral regimen. Yet, at Kilby, the patient had inappropriately not been placed on MAC prophylaxis. So, MAC prophylaxis was started. He was continued on Pneumocystis carinii pneumonia prophylaxis, as well as his other multiple medications.
The patient complained of difficulty urinating as evidenced by a health services request form as early as 10/28/2001 which stated “I’m having problems urinating; at times I can’t urinate.” The nursing staff’s response to this is that the patient “seen MD on 10/18/2001.” The nurse did not even address the patient's’ problems of urinary retention.
Despite the patient's complaints and evidence of renal failure, he did not get an initial evaluation for his renal failure until February 2002. At that time, the patient was seen in consultation by a urologist who obtained a renal ultrasound which showed that the renal pelvises and ureters of the kidneys were very large. The condition is concerning because it can cause obstruction from his enlarged prostate. The Limestone Correctional Facility obtained a laboratory test on 03/27/2002 indicating a BUN of 91 (which is approximately four times the normal level) and a creatinine of 8.3, which demonstrated that the patient was in almost total renal shutdown. His potassium was also critically high at 6.4. His hematocrit was 13 which was about one-third of normal. His bicarbonate was 10, also demonstrating that the patient had very severely impaired renal function. Attempts were made to lower the patient's potassium.
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At the point, there are no further medical records. This absence of medical records is very concerning. IMPRESSION: This patient was an elderly and fragile gentleman who clearly had evidence of an obstruction in his urinary tract secondary to an enlarged prostate. As early as August 2001, the patient had very severe kidney function problems. It was not until a full six months later, when the patient was at the Limestone Correctional Facility, that he received an evaluation for this kidney failure. By that time, it was too late. The patient's kidneys shut-down. There are also missing records from this patient's chart. It is unclear what caused this patient’s death. Yet, it is most likely that Mr. McClure died from the renal failure with complications caused by the HIV infection, diabetes mellitus and hypertension. There is a pattern that occurs over and over again at the Limestone Correctional Facility where patients who are extremely ill, are examined, evaluated and laboratory tests are sometimes obtained with no follow-up, no work-up, and no further evaluation when warranted. Sometimes these results, such as a creatinine of 3.7, as was the case in this patient, which demonstrates that the patient needed an evaluation of his kidney function, are not evaluated, and the patient progresses to a severe worsening of his disease. Additionally, this patient had a very low T cell count and should have been transferred to Limestone on Mycobacterium avium complex prophylaxis which consisted of azithromycin.
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DEATH SUMMARY George McHeard
George McHeard was a 48 year old patient who died on 11/12/2001 at 12:15 a.m. at the Limestone Correctional Facility. This patient was HIV positive and had noninsulin-dependent diabetes mellitus which was poorly controlled. He also had hypertension and hypercholesterolemia, as well as a seizure disorder.
On 11/11/2001, the patient presented to the Health Care Unit complaining of abdominal pain, vomiting, and headache, but no fever or diarrhea or other symptoms suggestive of a viral illness. The patient was also complaining of chest pain, as this was documented in the nursing notes of 11/11/2001 at around 10 p.m. When the patient reported that “my chest and stomach is hurting; I feel weak and trembling and am throwing up,” the patient was given some IV fluids and medication. The patient continued to be ill throughout the evening. He continued to have abdominal pain and appeared to be rather sick.
At 10:30 p.m., the patient was moaning and groaning, moving from side to side, with labored respirations. He was breathing at 24 per minute, which is fairly rapid. Obviously the patient was in a significant degree of pain. Again, he continued to have increased pain at 11 p.m. By 11:30 p.m., the patient had no complaints and appeared sleepy. He was assessed at least a couple of times by the nurses. He was then found, at least initially, by the inmates to be pulseless and dead.
IMPRESSIONS: This is a diabetic who had multiple risk factors for having a heart attack, yet he was not evaluated for this condition. His medical records contain no reference to an EKG. Nurses as Limestone are unaware of different presentations of heart attacks and patients die needlessly.
This patient most likely died of a myocardial infarction (a heart attack), but that cannot be ascertained with any degree of certainty. After the inmates placed the patient's body in a body bag, which is standard procedure at Limestone Correctional Facility, the inmate did undergo an autopsy which really consisted of a visual autopsy. There was no organ inspection or evaluation of the patient's coronary arteries. Of note, only VISUAL autopsies are performed in the Alabama correctional system.
This inmate, who had diabetes, presented with almost classic angina or chest pain for a diabetic; yet the patient was not evaluated for this condition. It is assumed that he had an ongoing heart attack and died as a result. The patient was not properly evaluated.
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DEATH SUMMARY James Pryor
James Pryor was a 36-year-old male who died on 10/13/2001 from cryptococcal meningitis secondary to AIDS. The patient had only recently been diagnosed as HIV positive at the Kilby Intake Correctional Facility. He was diagnosed as HIV positive on 9/26/2001. The patient was transferred to the Limestone Correctional Facility on 10/4/2001.
Upon being received by the Limestone Correctional Facility, the patient complained of fever, chills, dizzy spells and headache. He stated that “I’m not feeling good.” He was noted to have a very high pulse and to be ill. He was immediately sent to the Athens Hospital and given a presumptive diagnosis of bacterial pneumonia versus Pneumocystis carinii pneumonia.
The patient was transferred back to the Limestone Correctional Facility on 10/7/2001 and seen by Dr. Simon. Dr. Simon appropriately administered tests for toxoplasmosis and cryptococcal meningitis titers. The cryptococcal meningitis titer returned extremely high at 1:4096 which indicated that he had very severe cryptococcal meningitis.
Dr. Simon immediately sent the patient back to the hospital for further management of his severe cryptococcal meningitis and also ventilatory support because he had such severe respiratory symptoms. Unfortunately, the patient died soon thereafter on 10/13/2001, after it had been decided by his family, given his advanced cryptococcal meningitis, that they would not pursue any further life-saving measures.
It was also noted that he had a T cell count of 35 and his viral load was 26,000 at the time of his death.
IMPRESSIONS: This is an example of another patient in the Alabama correctional system who was very unstable and was inappropriately transported from the Kilby Intake Facility to Limestone. This clearly demonstrates that there is little or no communication between the Kilby Correctional Facility and the Limestone Correctional Facility because it is doubtful that any reasonable medical personnel would have accepted this patient given that he was recently diagnosed HIV positive and had such severe complaints. Instead, the patient should have been immediately sent to a hospital.
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DEATH SUMMARY Willie Robinson
Willie Robinson was a 48-year-old male with AIDS and a T cell count of 20 in 9/2000. He died on 11/5/2002 in the health care unit at the Limestone Correctional Facility, although there is little documentation. The patient has a history of HIV infection, but no confirmed opportunistic infections.
On 8/29/2002, the physician noted in the chart that “the officer reported that patient has been looking disoriented lately.” The patient reported that he had experienced fever for two days and was feeling lazy and tired. The physician reported that the patient was on Bactrim, which “he does not take regularly.” The note further indicates that the patient is a chronically ill-looking male. There was no mention of discussion with the patient addressing why he was not taking his medications, nor was there a neurologic exam documented. Minimal labs were done. On 9/3/2002, a toxoplasmosis titer was negative and a Cryptococcal antigen was also negative.
By this time, the patient had been in the health care unit for four days. He was then released from the health care unit. He was seen on 9/11/2002, by the physician. At that time, he was complaining of poor appetite. The physician noted in the chart that the patient was a wasted looking male. The physician’s diagnosis was wasting. Antiretroviral therapy was started. There was no mention of even a discussion of starting the patient on any type of appetite stimulant or any kind of medications to increase his critical body mass.
On 10/16/2002, the patient was complaining of being fairly sick and of throwing up. He reported that he thought he needed more food to take with his medications. The patient was not offered any more food. However, he was given some oral supplementation. On 10/22/2002, the patient complained of an upset stomach with his medications.
On 10/31/2002, the patient was seen by the physician and reported that he had been becoming confused. There were multiple nurse’s notes that the patient had been in fact getting confused. The diagnosis at this time was HIV dementia, although no head CT was done -- only a minimal work-up consisting of toxoplasmosis and Cryptococcal antigen tests.
On 11/01/2002, the patient had an unsteady gait. Before the patient's death, the toxoplasmosis titer came back positive. He was started on medications for toxoplasmosis, and he died the next day of an unknown cause.
IMPRESSIONS: Mr. Robinson’s case represents another instance of a Limestone patient who had advanced AIDS and proceeds to a rapid death from most likely a preventable, opportunistic infection. This patient was clearly lost in the medical system and a follow-up should have addressed prevention for opportunistic infections. While it is clear that any patient can refuse a medication, it is incumbent upon the medical staff to make medications easily available to patients and to explain to the patients in a thorough manner why it is important for them to take these medications.
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There were multiple times when this patient missed his medications and it can be assumed that this may have been because he was unable to stand in the long pill line, as evidenced by the reports of the patient looking wasted, disoriented, and confused, and even unable to walk or having an unsteady gait. He was unable to take his medications and was not monitored. A review of the medical records are of further concern because the patient clearly had a mental process (a neurologic defect) occurring for quite a while. Yet, no imaging studies were conducted of his brain. It is very important for the medical staff to at least have done a scan of the patient's brain to evaluate for a central nervous system process. As is the case with many patients who have died, this patient also had severe AIDS wasting. It is concerning that these patients are not getting enough calories. This patient reported not getting enough food to eat. Although he was not supplemented with any more food, he was given oral supplementation. It is clear that patients who are very, very ill and have AIDS, have high caloric needs (sometimes twice the normal level) and if their needs are not met, they ultimately die of starvation. It is concerning that these patients at Limestone are in fact dying of starvation given that they are not receiving adequate nutrition, much less do not have access to a nutritionist.
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DEATH SUMMARY Tony Rowland
Tony Rowland was a 30 year-old male who died on 01/22/1999 at 7:00 a.m. at the Limestone Correctional Facility health care unit.
Mr. Rowland had end-stage AIDS, polyarteritis nodosa, end-stage renal failure, AIDS wasting, and cardiac arrhythmias. Again, I will focus mainly on the patient's lack of end-of-life care on this summary. The patient was admitted to the inpatient infirmary on 12/28/1998 after it had been noticed at least a week prior that he had had fevers up to 104 degrees F. At that time, it was noted that the patient had a bacterial pneumonia and he was placed on oral antibiotics. Throughout the inpatient stay, however, the patient's course was one of continued decline. The documentation of his treatment was extremely poor. Very few notes were written by the physician. The notes that were written by him are extremely difficult to read or are not informative.
It is clear from the medical record that the patient was admitted to the inpatient infirmary and he continued to have fevers. However, his fevers were not evaluated appropriately. The patient died in the inpatient unit.
Of note, on review of the patient's medication administration record, he was not on any Pneumocystis carinii pneumonia prophylaxis and was not on any prophylaxis for Mycobacterium avium complex. These medications would be indicated given his low T cell count (on 08/1998) of 25 and a high viral load of 295,000. It is clearly the standard of care to place patients on prophylaxis for these infections, especially if they are on an inpatient unit.
On 04/16/1998, there was a very worrisome note by a licensed practical nurse (LPN) who advised the patient of his “poor compliance with antiretroviral therapy.” This LPN “advised the patient that therapy would be discontinued secondary to his poor compliance.” The LPN goes on to list that two of medications he is “34% compliant with” and one of his medications he is “52% compliant with.” Unfortunately, there was no discussion with the patient as to why he was not being compliant. He was not asked if he was having any side effects. He was not educated on the importance of adherence. Given the patient's advanced illness, it was unclear whether the patient was even capable of standing in the pill line to obtain his medications. The patient became upset during this medical visit.
I was unable to find any DNR (Do Not Resuscitate) orders, no advanced directive, and no discussion of how aggressive the patient wished therapy to be undertaken. It appears that this was decided by the medical staff at the facility.
IMPRESSIONS: This is yet another example of a patient at the Limestone Correctional Facility who had a rapid decline in his HIV status. His condition was extremely advanced and he had complications that
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included kidney failure. There was very little documentation provided, but I was unable to find any evaluation of his kidney failure, much less any treatment for this. Unsurprisingly, the patient died rather rapidly of infection. Also, it is concerning that there was no discussion regarding end-of-life care, advanced directive, or DNR status of this patient. The staff at the Limestone Correctional Facility seemed very quick to take medications away from patients if there were “noncompliant.” It should be the role of the physician, not an LPN, to assess patients and decide if a prescription should be discontinued. The medical staff does not seem to understand the importance of a good therapeutic relationship or the value of discussing compliance issues with patients. The appropriate questions were not asked: was he able to obtain his medications, was he able to stand in line, was he having any side effects, or were other therapies necessary? These questions should have been asked by an physician. LPN’s at Limestone are routinely practicing outside the scope of their licenses. Another issue of concern when treating a patient with such advanced AIDS, is whether the patient was depressed. Depression was never discussed with this patient. This further shows the lack of care that is provided to the patients at the Limestone Correctional Facility. Inexpensive and easy to offer medications, such as prophylaxis for Pneumocystis carinii pneumonia and Mycobacterium avium complex, were not offered to this patient. He might have died from one of these easily prevented infections. This patient, as were many others, was labeled with end-stage AIDS. This term became a death sentence for patients so labeled at Limestone Correctional Facility. It appears that the nursing and medical staff at the facility do not perform any further interventions or evaluations on these patients.
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DEATH SUMMARY Dionicio Salazar
Dionicio Salazar was a 41 year old HIV positive male who died on 9/16/1999 at 3:42 p.m. at the Limestone Correctional Facility health care unit.
This review will focus on the patient's last few days prior to his death. The patient had no prior opportunistic infections, even though he was HIV infected and had a relatively low T cell count earlier in the year of 159. These results were obtained in 1/1999.
In 11/1998, the patient had “refused HIV treatment” per Dr. Moore’s note despite treatment being indicated. It is unclear whether the patient understood English well enough to comprehend this refusal of HIV treatment. Just prior to Dr. Moore’s note, there is a nursing note that states the following on 7/29/1998: “The inmate has a problem with communication, understanding English language and speaking English language. This nurse tried to advise inmate of increased viral load and decreased CD4 count and treatment with antiretrovirals ….” There was absolutely no attempt at obtaining interpretive services.
The patient was not placed on any treatment for his HIV infection. The patient was transferred from the Kilby Correctional Facility on Haldol and trazodone for an unspecified psychiatric illness. These medications were for treating either depression and/or schizophrenia. It is noteworthy that the patient did not have any clear evidence of uncontrolled psychiatric disease and took all of his psychiatric medications while incarcerated at the Limestone Correctional Facility and was quite compliant in that respect.
There are several handwritten notes by other inmates for the patient. He probably relayed information regarding different complaints. It is clear from his record that he was unable to write in English. It is evident that these were not his notes because the handwriting of the signature is different from the handwriting which completed the health services request notes.
The patient’s severe decline in health appears to have started several days prior to his death as evidenced on 9/7/1999 when he had a very large increase in his liver enzymes with a SGOT of 1248 (30 times normal) which signified that he had liver failure. He also had a creatinine at that time of 2.7 (normal is less than 1.3) which signified that he had a loss of kidney function. He also had abnormalities in his electrolytes.
The patient's liver abnormalities remained severe and his kidney function declined. The patient was in the inpatient unit at the Limestone Correctional Facility. He was followed and subsequently died of what appeared to be fulminant liver failure and kidney failure with a bacterial pneumonia, possibly Pneumocystis carinii pneumonia. It was recognized that the patient might have pneumonia. A chest x-ray had been obtained on 9/10/1999, six days prior to his death. The patient was started on medication for presumptive Pneumocystis carinii pneumonia and bacterial pneumonia at that time.
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The patient died after a rather rapid downhill course. IMPRESSION: This patient most likely died of liver disease in addition to kidney disease which was complicated by HIV infection. There was actually no underlying cause of his liver disease. He never received a thorough evaluation of his liver disease. The patient should have had an evaluation by a liver specialist. However, this evaluation never occurred. This demonstrates a pattern at the Limestone Correctional Facility where patients are not seen by specialists and are instead evaluated by generalists or by others who are not adequately trained to deal with such specialized fields of medicine. In addition, this patient appears to have acquired possible Pneumocystis carinii pneumonia. Although he refused HIV medications, it is unclear whether he refused any prophylaxis or whether he understood the ramifications of refusing prophylaxis. In the end, he did not refuse any of his other medications. This questions whether he understood the ramifications of his decision. Also, the patient had language barriers. There was no attempt at the Limestone Correctional Facility to provide an interpreter for this patient to try to assist him in obtaining better medical care.
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DEATH SUMMARY Milton Smiley
Milton Smiley was a 43-year-old male who died on 2/12/2003 from complications of cirrhosis. The patient had carried the diagnosis of AIDS with a T cell count of 118, hepatitis C with secondary cirrhosis, low platelet count, AIDS wasting, osteonecrosis of his hips bilaterally, chronic bleeding hemorrhoids, chronic nausea and vomiting.
Mr. Smiley’s medical records are extensive in that they demonstrate that he had multiple major medical problems which resulted in his being seen in the infirmary on frequent occasions. The most significant visits were for excessive bleeding. He had bleeding from his nose which needed packing and also bleeding from a hemorrhoid in the rectal area. The rectal hemorrhoid bleeding was exacerbated by the patient's difficult clotting secondary to cirrhosis and his low platelet count. There is no documentation in the chart demonstrating that the patient was ever surgically evaluated to stop the rectal bleeding, although it was a significant medical problem.
Another major issue for this patient involved chronic nausea and vomiting. These symptoms of the patient's illness were not investigated. On 10/25/2002, one of the nurses accused the patient of self-inducing his vomiting.
There are multiple entries in the chart where the patient experienced decreased mental status in which he was “too groggy, too sedated, as well as unable to walk.” In all of these entries, there was no further evaluation of this patient. In many of these instances, the patient was unable to take his medications. When the patient was not in the health care unit, he was often unable to stand in the pill line to obtain his medications. When he did not stand in the pill line, the nursing staff did not administer the patient his medication.
On 10/1/2002, the nurse responded to a call that “Smiley fell.” It is not documented in the chart that the nurse rendered assistance to the patient. No physician was called even though it is the standard of care that a physician must be contacted and an evaluation conducted when a patient in an inpatient unit falls.
The medical chart does not contain a death certificate or an autopsy. As with all of these patients, the actual cause of death must be ascertained by review of all available medical records since no post mortem autopsies are performed. Only external autopsies are performed on HIV infected individuals. There is no “Do Not Resuscitate” order and no Advanced Directive for this patient. There was also no discussion addressing end-of-life care for this patient. Mr. Smiley was pronounced dead at 5:45 a.m. on 02/12/2003.
IMPRESSIONS: 1. This is a patient with advanced cirrhosis from hepatitis C. The major manifestation of this
disease in this patient is rectal bleeding. The patient was never evaluated by a surgeon or a gastroenterologist in an attempt to stop the bleeding. Yet, the bleeding created great problems for the patient.
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2. There were also numerous documentations that the patient experienced decreased mental status when he was almost unable to stay awake. He was highly sedated and unable to take his medications. A review of the patient’s medical records clearly demonstrates the lack of care that he received by the nursing staff. For example, when the patient was not in the inpatient unit, he would not be administered his medications by the nursing staff.
3. The patient also experienced chronic nausea and vomiting which was not evaluated. This condition was treated, but should have been further evaluated. Chronic nausea and vomiting in an advanced AIDS patient must be taken seriously and such treatable and deadly illnesses as lactic acidosis and pancreatitis must be part of an initial evaluation. They can both be easily evaluated by a blood draw.
4. In addition, as with most patients reviewed, there is no discussion of end-of-life care, although it is reasonable that in a patient who is this ill, a “Do Not Resuscitate” order should be instituted. It is an accepted medical standard that patients have this discussion rather than the medical staff making these decisions for the patient.
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DEATH SUMMARY Lamar Smith
Lamar Smith was a 49-year-old patient at the Limestone Correctional Facility who died on 01/21/2002.
The patient suffered from AIDS co-infected with hepatitis C and was on appropriate antiretroviral therapy which consisted of Viracept, Zerit, and Ziagen. He was fairly stable, although he did suffer from chronic anal herpes infections and rectal prolapse, until he was seen initially on 01/15/2002 by the physician’s assistant, Ms. Ebbe. At that time, the patient had some facial swelling as well as was noted to be jaundiced. At that time liver enzymes were obtained which showed that the patient clearly had a severe hepatitis (inflammation of the liver) in that his liver enzymes were very high. His AST was 542, ALT was 508, bilirubin was 7.5. Carbon dioxide was 21.
The patient was seen the next day on 01/16/2002 and admitted to the health care unit. At that time, it was noted that the right side of his face had further swelling, that his right eye was in fact swollen shut, and that he had a distended abdomen. The patient was seen on 01/17/2002 by Dr. Simon, and at that time, the patient was noted to be complaining of “tightness of the throat,” as well as “difficulty swallowing.” The patient was given Benadryl without any improvement. He continued to have throat tightness and difficulty swallowing.
The patient had some mild abdominal distention and a rash, and some mild desquamation – a process where the outer layer of the skin falls off. It was thought that the patient had acute hepatitis secondary to an allergic reaction to medications. He was followed in the Inpatient Unit, but did not improve. According to the nurses’ notes, in fact, the patient not only did not improve, but he continued to deteriorate and was having bouts of increasing confusion and difficulty arousing him. In fact, on 01/20/2002, one day before the patient died, it was noted that the patient at 6 p.m., was not moving and did not respond to command, only reflexes. He apparently did not respond to painful stimuli. The patient was very ill at this time and very severely, profoundly neurologically depressed. Suppression of the neurologic system was determined to be the assessment.
Unfortunately, at that time no one was called, and the patient was assessed 3:30 a.m. on the following day, January 21, 2002 and was found dead.
IMPRESSION: It is my opinion within a reasonable degree of medical certainty, that this patient should have been followed very closely in a hospitalized setting. Six days prior to his death, on January 15, 2002, this patient’s HIV was under fairly good control with a T-cell count of 439. He potentially had a fairly long life span. It appears that this patient had a toxic hepatitis secondary to his medications. He died of fulminant hepatic failure most likely as a result of his medications. More attentive medical surveillance could have resulted in saving his life.
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Of note, in this patient (as with other patients), it appears as if inmates were asked to help prepare the patient's body, as well as to place the patient in a body bag. This practice is inappropriate.
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DEATH SUMMARY Timothy Summers
Timothy Summers was a 32-year-old male with a history of AIDS, but no known opportunistic infections. He had a low T cell count (less than 50) and he died at the Limestone Correctional Facility on 3/11/2002.
The patient’s medical records, as is the case with many of the other medical records, demonstrate multiple times that the patient was labeled as noncompliant with his medication regimens, and multiple times in which the patient's medications were discontinued. However, nowhere in the chart is there a discussion as to why the patient was unable to take his medications and no efforts were made to help this patient become more compliant.
The patients at Limestone Correctional Facility are made to stand in a long pill line to take their medications. Many of these patients are unable to stand in line or unable to understand the importance of taking their medications.
This patient suffered from a chronic severe skin rash as evidenced by his multiple pleas for assistance to the medical staff. There are many health service request forms from the patient stating that he had a severe rash. At times the rash appeared to be even ulcerating and causing a secondary bacterial infection.
The patient was initially received on 7/15/2001. By 7/25/2001 he was using health service request forms to contact the staff that he was having blisters. On 11/27/2001, he reported that he had bumps that “itches like mad, sores on face that hurt and don’t want to heal.” The nurse states that the patient remains noncompliant with all medications. Yet, she does not attempt to discuss noncompliance with the patient. The patient is concerned about noncompliance. He is also concerned about another medical disorder that he is experiencing.
On 12/16/2001, the patient stated that he “needs for his records to be sent from the Kirkland Clinic” and he requests an MRI given that he might have an aneurysm, although he does not spell aneurysm correctly. It was clear from his note that he is referring to a brain aneurysm. He spells it “anarivem of brain.” On 12/18/2001, in a health services request form, the patient complains of chronic skin rash. He was seen by the physician who diagnosed the patient with HIV dermatitis. The patient was not seen by a dermatologist. No biopsy was done. Although there was no attempt to document a noncompliance discussion with the patient, the physician reported that the patient was noncompliant and the patient “still does not want antiretrovirals.”
In the patient's chart, records arrive at some time from the outside hospital and these are available for review. There is a clinic visit that states that the patient has a history of an aneurysm. The source of this information is unclear, but the information is dated 7/16/1999. There is also a brain CT result from 7/19/1999 which describes the following. Impression: 13mm left and 9 to 10-mm right prominently hyperdense masses just anterior-superior to the internal carotid artery, supraclinoid segment bifurcations. It states “aneurysms are expected.”
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This patient’s condition is showing aneurysm, Dr. Simon writes “aneurysms” on the CT result and initials it on 11/09/2001. Despite this result, the patient has no further work-up at the Limestone Correctional Facility.
On the day of the patient's death, 3/11/2002 at 2 a.m., a nurse is called to the room by the inmate stating, “he was having a seizure.” The nurse writes that upon entering the patient's room, the patient is having severe tremors. His eyes rolled back into his head. He had no verbal response to his questions. The nurse turned the patient’s head so that he will not aspirate. She took some vital signs. The patient started to respond. Soon thereafter, the nurse left the room. At 2:25 a.m. the nurse was called back to the room. The patient was seizing again. The patient was described as being restless, moaning, rolling back and forth in the bed when his head rolled back and the patient went rigid.
At that point Dr. Simon was notified and gave the patient Valium 10 mg IM at 2:33 a.m. At 3:15 a.m., the nurse left the room. The patient was having difficulty breathing. Respirations were labored. He had Kussmaul breathing noted which was very worrisome. Respirations were between 9 and 12 with periods of apnea lasting up to 30 seconds. Dr. Simon was notified at 3:25 a.m. and IV normal saline was started and the patient was given an antiepileptic drug called Dilantin. During the procedure, the patient became cyanotic, cold and gray. Apparently his color improved slightly. The patient remained unconscious without any verbal response. Prior to 4:45 a.m., the nurse again left the patient alone in the room.
At 4:45 a.m. the nurse returned to the patient's room. The patient’s respirations were uneven and labored; they were 4 to 6 times per minute. Again, this patient was barely breathing. The patient was moved to a private room and oxygen was administered. Upon moving, the patient stopped breathing. Apparently cardiopulmonary resuscitation (CPR) was started at 5:15 a.m., but only after a mere 10 minutes, CPR was stopped. There was absolutely no documentation as to what was done as far as the CPR went; there was no advanced cardiac life support. At 5:30 a.m. on 3/11/2002, the inmate is pronounced dead by Dr. Simon. However, the note was signed by L. Robertson, RN.
IMPRESSIONS: This note, dated 3/11/2002, displays the almost incredible lack of insight by the medical and nursing staff at the Limestone Correctional Facility into the seriousness of severe illness and how these types of illnesses need to be handled. This patient had a grand mal seizure. He initially showed signs of being quite ill. He had a history of having had aneurysms which were ignored previous to this disastrous medical event. With the exception of one outside medical record, this was not even documented in the patient's chart. The nurse was unaware of this medical history. The nurse tended the patient, then left the room. She did care for him appropriately. This was a patient who was severely ill and who should have received one-on-one patient care in a highly skilled medical facility (hospital). The care provided to this patient was unprofessional, showed poor judgment and was highly negligent. This patient should have been sent immediately via emergency medical services to a hospital where he would have received an emergent CAT scan of the head, supportive respiratory care, and aggressive therapy for his grand malignancy
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seizures. The medical records demonstrate how this patient was poorly managed and how quickly he deteriorated and died. There was no adequate postmortem on this patient. The reason for death is unclear, but it is concerning that he might have had an aneurysm that ruptured, especially given his history. The patient pleaded for an evaluation of his aneurysms but this was not addressed by the medical staff at Limestone Correctional Facility. Additionally, the patient had a low T cell count. He could have had an infectious process of the brain, especially in light of the fact that the patient had difficulty taking his medications. It is an established pattern at the Limestone Correctional Facility that, despite indications of an ongoing disease process, rather than evaluate the patient for a definitive diagnosis, the minimum of care is provided until a medical crisis presents itself. And in the case of Timothy Summers, the crisis could not be overcome and the patient died as a result.
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DEATH SUMMARY Rickey Thompson
Rickey Thompson was a 30-year-old male with AIDS who died on 9/2/2002 at the Limestone Correctional Facility.
Mr. Thompson apparently died suddenly after being administered magnesium citrate for constipation and then vomited a bright red material. Unfortunately, the documentation from a week prior to his death was not available from the chart. The only exception is a note on 9/2/2002 by Dr. Simon which lists the patient's problems. Dr. Simon also reports that the patient had signed release of responsibility forms and a DNR. (Do Not Resuscitate)
The patient also had cirrhosis, but review of the records showed that he was hepatitis B and hepatitis C negative. I was unable to find any further evaluation for his cirrhosis, including no hepatitis C viral load. Many patients who are co-infected with HIV and hepatitis C can be hepatitis C antibody negative, yet have hepatitis C virus detectable in their blood. The patient also had depression of his bone marrow cells as well as a history of clinical depression.
On review of the patient's chart, there were multiple occasions when the patient apparently did not go through the pill line to receive his antiretroviral therapy or his medications for prophylaxis against opportunistic infections. He was counseled to go through the pill line, but there was no attempt to understand why the patient was not going through the pill lines or why he was not able to take the medications.
On 08/09/2002, the patient was seen by the physician and diagnosed with probable pneumonia. He was written for a prescription of Levaquin. Interestingly, this medication was withheld by a nurse claiming that the patient might have had a possible allergy. Unfortunately, the nurse did not call the physician, but instead decided to withhold the medication permanently. The nurse’s withholding of a prescribed medication is only with precedent for one dose; she should have called the physician to verify her suspicions.
IMPRESSIONS: There are clear patterns of lack of care and inadequate care at this facility.
This is another patient from the Limestone Correctional Facility who had AIDS and chronic hepatitis and cirrhosis with no known cause. In a standard system of medical care, any patient with cirrhosis should have an appropriate diagnosis. Any patient who is infected with hepatitis C can show no antibodies, yet have the virus present in the blood. However, these tests were not obtained in this patient. The patient did have very advanced cirrhosis and did die from his disease at the Limestone Correctional Facility.
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The patient had a history of depression. A review of the records shows his frustration with the system. It is uncertain whether he had a good understanding of why it was important for him to take his medications. There are many notes in the chart that document that he did not show up in the pill lines to take his medications. However, there was no documentation of discussions with the patient why it was important for him to take his medications. There was no recent psychiatric or psychological assessment in his record.
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DEATH SUMMARY Henry Turner
Henry Turner was 35-years-old and died of AIDS on 8/3/2002 at the Limestone Correctional Facility at 4:06 p.m.
Mr. Turner carried the diagnosis of AIDS with a low T cell count of less than 20 and a viral load of greater than 500,000. He was also diagnosed with AIDS wasting, Mycobacterium avium complex, and bed sores. The patient was on a complicated antiretroviral regimen consisting of Bactrim, Mycobutin, ethambutol, clarithromycin, HAART. The patient was also receiving oral supplementation for AIDS wasting.
The patient was initially housed at Kilby Correctional Facility. On 5/15/2002, he was seen by a nurse on intake. On 6/27/2002, the patient was found by one of the officers and noted to have “five old trays” in his room, “three bags of old garbage, and in filthy clothes. The officer sends for a runner.” On 6/28/2002, the patient was transferred to Limestone Correctional Facility health care unit. While on the inpatient unit, the patient had 100% compliance with his medications. 100% compliance would be expected because the nurses brought his medications to him. He continued to take all of his medication every day until 8/1/2002. Two days before his death, the physician made the decision not to treat the patient with any more medications because she felt that it would not make any difference.
There was no team consultation or consultation with other physicians or medical ethicist before the patient’s treatment was stopped. The patient deteriorated rapidly after his medications were discontinued. He continued to have fevers and severe wasting.
IMPRESSIONS: This patient was an end-stage AIDS patient who deteriorated rapidly at the Limestone Correctional Facility. He appeared to have a severe infection which did not appear to be responding to treatment. Unfortunately, no other possible infections were investigated in this patient, so it is uncertain whether he died of the Mycobacterium avium complex or of some other infection. Regardless, the patient passed away from a febrile illness.
It is noteworthy that the patient was 100% compliant to all his medications. Patients who are in the inpatient health care unit take more of their medications because it is much easier for them to be compliant. Non-compliance is often a function of the design of the pill line in Dorm 16.
I was unable to find any discussions regarding end-of-life care, DNR orders, or advanced directives in this patient’s record.
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As in many of the other patients’ charts, poor care at Kilby is a common problem. This advanced- AIDS patient had been found after three weeks of living in a dirty room without having bathed. The condition of the room described is unacceptable.
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DEATH SUMMARY Freddie White
Freddie White was a 51-year-old male with AIDS who died on approximately 6/9/1999. His entire medical records have been reviewed which do not contain an autopsy or the documentation from the last day of his life. Therefore, it is unclear to tell exactly which day he died.
The patient had a rather extensive inpatient hospitalization when he was diagnosed with Cryptococcal meningitis and was appropriately started on an antifungal agent. He was also diagnosed with pancreatitis and C. difficile colitis. The patient was put on medications and had multiple complications from these medications which required rather intensive therapy while he was an inpatient. The discharge summary indicates that he was admitted for at least a one-month period and possibly longer. The patient was transferred back to the Limestone Correctional Facility on 6/3/1999.
When the patient was discharged from the hospital, his electrolytes were stable. At Limestone Correctional Facility, the patient’s electrolytes soon became dangerously unstable. He was given Potassium supplementation. On 6/6/1999, he had a high potassium level of 5.1 which increased to 6.9 on 6/9/1999. He was then given medication -- Kayexelate -- to decrease his potassium level. It appears that he also went into acute renal failure and his creatinine on 6/6/1999 increased to about 2.4, which means he lost about half of his kidney function.
The labs from 6/6/1999 indicate that he went into rapid liver failure. The patient continued to be managed at Limestone Correctional Facility by Dr. Khouri, who documented the patient’s condition very poorly and illegibly. On 6/8/1999, the patient had critical lab values of bicarbonate of 7 (meaning profound metabolic acidosis), potassium of 7.3 (nearly twice the normal level), and a creatinine of 3.3 (a loss of more than ½ of the kidney function). He had multiple EKG’s with abnormalities.
The patient rapidly expired on 6/9/1999 of an unknown cause. There was no indication that the patient signed any Do Not Attempt Resuscitation orders or had any Advanced Directive.
IMPRESSION: This is a poorly documented series of medical records. This patient had a treatable illness. He had a prolonged hospital stay and was stable on his discharge from the hospital and died within six days of his discharge to the Limestone Correctional Facility.
It is evident that given his electrolyte fluctuations, that he was not being managed appropriately. It is likely he died as a result of his very rapid liver and kidney failure. The records are unclear as to why this patient was not readmitted to the Intensive Care Unit given his severity of illness soon after his discharge.
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Mr. White is another AIDS patient at the Limestone Correctional Facility who was poorly managed, neglected, rapidly declined and died after a prolonged hospital stay where he had been stabilized.
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DEATH SUMMARY Dewayne Wilder
Dewayne Wilder was a 37-year-old HIV positive patient who died of presumptive Pneumocystis carinii pneumonia at the Limestone Correctional Facility on 4/17/1999.
This review will focus on the medical records immediately prior to the death of the patient. These records are the most revealing addressing inadequate medical treatment.
On several occasions, the patient presented to the clinic at the Limestone Correctional Facility complaining of shortness of breath. An emergency treatment record dated 3/13/1999 noted that the patient was experiencing problems breathing. He was provided Tylenol and observed for a short period. He was then sent back to his dorm.
Another emergency treatment record dated 3/15/1999, documented that the patient was experiencing problems breathing. It was also noted that he had been ill for seven days with fever and weakness. On these two occasions, his condition was listed as “satisfactory on discharge.” This appears to be a pattern throughout his stay at Limestone.
A chest x-ray obtained on 3/17/1999 showed that the patient had worsening Pneumocystis carinii pneumonia. The patient was seen by a physician on 3/16/1999 and diagnosed with bronchitis. He was also diagnosed with wasting syndrome with profound weight loss. However, this diagnosis was not evaluated further, even though there are many potential causes for wasting in HIV infected patients.
Because the patient continued to experience severe respiratory difficulty, he was seen again on 3/29/1999 by a physician and started on treatment for Pneumocystis carinii pneumonia. The physician started the patient on oral therapy for mild Pneumocystis carinii pneumonia, even though he clearly had severe Pneumocystis carinii pneumonia. On 4/5/1999, the patient declined and his oxygen saturation was noted by the physician to be 70%. This was his oxygen saturation on 5-1/2 liters of oxygen, indicating severe respiratory distress. In fact, the physician’s assessment reported “respiratory failure secondary to Pneumocystis carinii pneumonia.” Yet, no further treatment was initiated. The patient was kept on his current therapy and no further evaluation was conducted.
On 4/12/1999, the patient experienced some improvement. However, the patient continued to have fevers. On 4/14/1999, the physician reported that the patient was “slowly resolving, but still in respiratory distress.” Meanwhile, nursing notes in the chart documented that on 4/10/1999, the patient stated “I am afraid to go to sleep. Please stay and talk to me and watch me.” The nurses noted that his oxygen saturation was low at 81% on five liters and the patient was in respiratory distress with rapid respirations.
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On 4/12/1999, the patient's oxygen saturation recorded by the nurse was 76% on 4-1/2 liters. On 4/13/1999, the patient was observed to be “weak, groggy, very dyspneic” (short of breath). He was complaining of “great difficulty breathing.” Despite no clear reasoning, the nurses encourage this suffocating patient to attempt to ambulate. On 4/14/1999, the nurses reported that the patient was restless and panicky. “His anxiety is high.” Again, the nurses noted that the “patient refuses to try to ambulate.” On 4/14/1999, the patient had a visit from his family. At that time, he was started on prednisone which was indicated for treating worsening Pneumocystis carinii pneumonia. Yet, it was too late. On 4/15/1999, the patient was placed on “high oxygen” at 10 liters per minute. As expected, given that the patient had severe Pneumocystis carinii pneumonia or some other diagnosis, that he was on sub-optimal therapy and that he was started on prednisone too late in the course of his disease, he expired two days later on 4/17/1999 from respiratory failure. IMPRESSIONS: There is a pattern addressing the care at the Limestone Correctional Facility that even the minimal standards of acceptable care are not being followed. Numerous patients are permitted to drown in their own respiratory secretions and suffocate while under the care of the medical and nursing staff. It is improper that this patient had such severe respiratory difficulties and that his condition was permitted to worsen without being treated or worked-up appropriately for some other possible illness. The treatment this patient received was sub-optimal and inappropriate. In addition, the patient had a high viral load. The patient was not appropriately treated with antiretroviral therapy. A review of his medical records demonstrates that he expressed some complaints addressing side effects. These side effects were most likely secondary caused by the medications not being administered with food. His side effects were secondary to taking the medications on an empty stomach.
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DEATH SUMMARY Iverson Williams
Iverson Williams was a 36-year-old HIV positive patient who died at the Huntsville Hospital on 11/15/2000 at 11:07 p.m.
The patient apparently died of Pneumocystis carinii pneumonia with possible secondary bacterial pneumonia, although medical records from the Huntsville Hospital are unavailable. The patient went into respiratory distress approximately five days prior to his death and was transferred to the hospital. He had a very low T cell count on 11/08/2000 of 15. The patient's chart is riddled with notes of his refusing blood draws and refusing medications throughout almost his entire incarceration.
Most significant in this patient's medical record is the volume -- pages upon pages -- addressing the patient's severe psychological problems. The patient spent a large amount of time in administrative segregation for behavioral problems. There is many years of documentation that the patient was threatening to harm himself. At one point, he even set some fires or threatened to set some fires. Thus, as documented in the medical record describing his behavior, the patient had severe behavioral problems.
There were also notes documenting that the patient had a depressed affect and was on suicide watch multiple times. His depression was also evidenced by his multiple complaints and possible somatization from his multiple health service request forms for complaints such as headaches, dizziness, nausea and vomiting throughout the course of his incarceration.
The patient's chart is filled with disciplinary segregation -- medical type diaries -- which exist soon up to his dying days when he was transferred to the hospital on 11/10/2000. I was unable to find any detailed psychiatric or psychological evaluations in the medical records, although there were some present. On 6/13/2000, there is a cursory psychological evaluation which states that the patient has a personality disorder. There is a note in his chart on 8/19/2000, apparently from a psychiatrist, which states that the patient was seen in the inpatient unit. In the note, it was discussed that the patient was coherent, calm and refusing to take his medications. His diagnosis was personality disorder and continued psychiatric evaluation.
IMPRESSION: Mr. Iverson’s biggest problem was that he was unable to comply with his HIV medications due to his psychological and psychiatric problems. Psychological and psychiatric issues are not my area of specialty. However, one can review these medical records and not find any in depth psychiatric or psychological assessment. This is appalling. The patient spent most of his entire period of incarceration in administrative segregation, and experienced severe psychological and psychiatric problems. It would seem appropriate that a patient with this many problems would have had a thorough evaluation. Yet, such an evaluation was not indicated in the medical records.
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In addition, this patient may not have been competent to make the decisions refusing his own medical care, which he was permitted to do. His chart contains his own handwritten notes documenting his own paranoia and delusions.
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DEATH SUMMARY John Willis
John Willis died at the age of 35 on 03/28/2002 at the Huntsville Hospital Critical Care Unit.
The patient was a previously fairly healthy HIV positive gentleman who, at least prior to his death had a fairly high T cell count of 373 (24%) and a moderately low viral load at 9,900. As a result, he was appropriately not on any antiretrovirals.
The patient died of kidney failure.
In December 2000, the patient had a normal creatinine of 1.3. This was reassessed on 07/27/2001 when his creatinine had increased to 2.3. This represented a loss of approximately ½ of his kidney function at that time. Apparently the patient was seen one month later. During that month, there was no workup (not even a simple analysis of urine much less a biopsy) concerning why this otherwise relatively healthy patient should have such an acute change in his kidney function with a potential life-threatening shut-down of his kidneys.
Unfortunately, the patient was not seen again for more than four months until 12/06/2001. At that time, it is noteworthy, his kidney failure was not even mentioned as a problem by Dr. Simon. The patient returned to clinic almost three months later, on 02/28/2002. At that time, the patient was found to be in total kidney failure. He had a BUN of 68, a creatinine of 7.9, and a high potassium of 5.5.
The patient, at this point, did have an evaluation and was seen by a kidney specialist, who recommended that the patient go on hemodialysis (artificial “kidney machine”).
The patient continued to be followed. On 03/20/2002, the patient was scheduled to have a urine collection, which was not properly collected. By 03/25/2002, the patient's renal function had deteriorated further as evidenced by a rising BUN and creatinine. It was assumed at that time that the patient was oliguria (i.e., had low renal output), or was totally anuric (i.e., no renal output), although the patient was not followed. On 03/25/2002, he was showing evidence of fluid overload as evidenced by his swollen face. On 03/25/2002, the patient was scheduled to have a chemistry panel and electrolytes. Patients in renal failure have disturbed electrolytes and can die of cardiac arrhythmias.
The blood test was not picked up that day; it was not picked up, according to Dr. Simon’s notation, until the following day, 03/26/2002. Two days later, on 03/27/2002, the BUN was exceedingly high at 165 with a creatinine also incredibly high at 25. These laboratory values are as high as I have previously ever seen. The patient's potassium was 6.5, approximately twice the norm. On 3/27/02, Dr. Simon prescribed magnesium citrate, which would induce diarrhea. Magnesium citrate was not a reasonable treatment for elevated potassium; there are more aggressive and better measures. The patient was sent for emergency dialysis to the Huntsville Hospital. Unfortunately, the patient died the next day on 3/18/2002.
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IMPRESSIONS: This patient’s case highlights the problems that occur repeatedly at the Limestone Correctional Facility. A patient with a potentially very serious illness is not thoroughly evaluated, or the patient is not followed regularly or closely because of a lack of access to care or a lack of chronic care clinics. As a result, the patient will present in extremis and has past the stage for any medical treatment. This patient had very high T cells, and no complicating illnesses. His kidney dysfunction initially could have been evaluated and treated appropriately. In fact, his renal failure could have been supported by hemodialysis. There was no reason that this patient could not have lived for several years at least after this diagnosis. Unfortunately, his kidney disease was allowed to progress to such a severe degree and so rapidly that the patient again was admitted to the hospital. In all probability, this patient died either of cardiac arrhythmia, or from an infection. His listed cause of death is sepsis. The major cause of the patient's death is simply that his kidneys shut down and the patient was not supported appropriately. The patient’s high potassium was not managed appropriately.
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DEATH SUMMARY Earnest Wynn
Earnest Wynn was a 39-year-old male with AIDS who died at the Limestone Correctional Facility on 02/16/2002.
The patient had advanced AIDS with a T cell count of 20. He had a history of Pneumocystis carinii pneumonia, a history of treated tuberculosis, and a history of AIDS wasting. Wasting was ultimately the cause of his death.
The patient’s most recent incarceration began in 06/2001. He had a fairly rapid decline thereafter. The patient was seen regularly in the health care unit complaining of diarrhea and vomiting. He reported an inability to take his antiretroviral medications because of nausea. Patients at Limestone Correctional Facility do not receive their antiretroviral therapy with food. This causes many Limestone patients to have severe nausea. Antiretroviral medication would have been vital to this patient because his T cell count was only 20.
The patient continued to have chronic gastritis. Because he was experiencing such severe weight loss, he was seen by Dr. Simon. She prescribed extra meals and extra bread for the patient. It appears in the medical record that the patient did not receive this extra food. He continued to complain of being hungry.
The patient was seen on 12/26/2001 by the physician assistant. She reported that the patient was not able to take his medications secondary to nausea. He was then seen by Dr. Simon on 12/29/2001. This is a very disturbing note. The quote is “begging for sandwiches because he can’t eat solid food. Burst into tears during evaluation. Emaciated looking.” At that visit, the physician did little intervention. At that time the patient was given some intravenous fluids. He was also given medication to decrease his diarrhea, but no medications are given to increase his appetite or to decrease the HIV wasting syndrome. The patient continued to decline.
He was seen three days before his death on 02/13/2002, again by the physician. Again, he was diagnosed with AIDS wasting and chronic diarrhea. No proper evaluation and intervention was done at that time. The patient expired on 02/16/2002 of HIV wasting.
A review of the patient's medical administration records indicate that eventually he was given anti-diarrheal agents. However, there is no notation in any of the medical records indicating that the patient was administered any extra food or any medication for the AIDS wasting.
IMPRESSIONS: This was a patient with advanced AIDS. Like many of the patients at the Limestone Correctional Facility, he had extreme difficulty taking his medications because the medications are administered without coordination with meals. He also had AIDS wasting exacerbated by the lack of proper nutrition at the Limestone Correctional Facility. The patient was prescribed extra food, but it did not appear to be administered. He continued to complain of needing food. At one point, the patient was put in the inhumane position of begging the doctor for food. This patient
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was literally starving to death. In fact, the patient was feeling so poor that he burst into tears. He appeared emaciated, yet the medical staff did nothing to try to increase the patient's critical mass or alleviate his suffering. After reviewing dozens of volumes of medical records, I have seen a pattern of the medical staff at Limestone doing little to help their patients’ misery and suffering. For many years, it has been the standard of care to give patients life-saving medications to increase their critical mass when they have severe wasting. However, none of these medications have been prescribed at the Limestone Correctional Facility. There have been a large number of patients who have died of AIDS wasting over the past several years. In my review of all of their medical records, I have not witnessed one patient treated with the proper medications to treat AIDS wasting syndrome.
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DEATH SUMMARY Marvin Youngblood
Marvin Youngblood was a 39-year-old male with an HIV infection who died on 9/5/2000 at the Limestone Correctional Facility.
The patient died of multiple myeloma, a cancer of the bone marrow cells. The patient develops secondary problems from this condition. These problems include kidney failure, wasting and decreased mental status.
On 12/22/1999, the patient presented for a laboratory draw. It was discovered that he had a protein of 9.9 and an albumin of 3.0. This laboratory report was signed by the attending physician, Dr. Khouri. However, no further work-up was administered. These laboratory values were very abnormal, and the elevated protein should have had further evaluation, especially for multiple myeloma which the patient ultimately was diagnosed with and died from 9 months later.
The patient was lost in the medical system and a follow-up was not conducted, or he received no further evaluation for this problem. In fact, the next blood draw was not until approximately five months later on 2/3/2000. The patient’s blood draw showed critical laboratory values with a calcium of 14.5, among other abnormal laboratory values. 14.5 is an extremely high calcium level that should have been addressed immediately. But the laboratory values were not co-signed until four days later by the attending physician, Dr. Khouri. There were no immediate responses by the medical staff to this critical laboratory value or several others until the patient was admitted to Huntsville Hospital four days later, on 2/7/2003.
During his stay at the Huntsville Hospital, the patient was diagnosed with very advanced multiple myeloma. Multiple myeloma is a cancer involving bone marrow tissues. He also had severe secondary complications, which included renal failure. The Huntsville Hospital staff appropriately documented that “after discussing the situation with the family and the patient on at least three different occasions, the family decided to defer aggressive treatment.” Thus, the patient was placed on Do Not Resuscitate status and Do Not Attempt Aggressive Therapy.
The patient was transferred back to the Limestone Correctional Facility where he remained in the inpatient facility until his demise several months later. On 2/10/2000, during re-intake to the Limestone Correctional Facility, Dr. Khouri recommended “hospice care” and then followed this recommendation with “by fellow inmate and friend.” This recommendation demonstrates that Dr. Khouri did not understand hospice care and that it is inappropriate for fellow inmates and friends to provide this kind of care.
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The patient was placed in the inpatient unit at Limestone. He was placed on minimal comfort care. Given the lack of adequate nursing at Limestone, the patient developed a severe bed sore on his back side. Chelsea Hammac died on 9/5/2000. IMPRESSIONS: This patient presented with clearly abnormal laboratory values. He had a protein of 9.9 which was above the normal level and an albumin of 3.0. These levels indicate that there was an obvious medical problem, including multiple myeloma. The Limestone Correctional Facility physician did not work-up these abnormal laboratory values. Instead, he waited until the patient presented several months later, looking very ill and having advanced cancer. Once the patient presented in extremis, his laboratory values indicated that he needed to be treated urgently. However, the physician and medical staff did not initiate treatment. A calcium of 14.5 is very high and will cause a patient to have decreased mental status with cardiac arrhythmias. The patient was then sent to Huntsville Hospital. Given his advanced disease, the Huntsville Hospital staff discussed the prognosis with the family and the patient who decided on no further aggressive therapy. Yet, the patient was sent back to the Limestone Correctional Facility where he was provided minimal care by the nursing staff. The care was so minimal, he developed a severe bed sore. Another concern is that Dr. Khouri writes in his note in the medical chart that the patient should receive hospice care by fellow inmates and friends. Hospice care is a multidisciplinary approach to caring for patients who have terminal illnesses. Clearly the Limestone Correctional Facility does not have a medically acceptable hospice care program. This case is another example of a patient whose health care was below any acceptable standard of care. In fact, this patient was grossly neglected by the medical and nursing staff at the Limestone Correctional Facility.
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SUMMARY Stephen Tabet, MD, MPH
SUMMARY OF THE CARE AT LIMESTONE CORRECTIONAL FACILITY
The most egregious medical failure at Limestone is the number of preventable deaths. I reviewed the medical records of 38 HIV-infected patients who died at Limestone since 1999. In almost all instances the death was preceded by a failure to provide proper medical care or treatment. Consistently, patients died of preventable illnesses. Patients with serious diseases experienced serious delays in medical care or were not treated at all. Chronic care clinics are unheard of at Limestone. Life-threatening laboratory results were treated routinely instead of urgently. Other tests such as radiographs showing pneumonia were commonly not assessed until many days later. At least one patient had such severe pneumonia that he suffocated in front of the medical staff – despite the patient’s requests for treatment, he was not sent to a hospital until his condition was irreversible. CPR was rarely attempted in any critically ill patient that I reviewed.
The deaths of HIV infected inmates at Limestone are not reviewed internally. The coroner provides only a physical description of the patients’ bodies. The medical staff’s documentation of the events leading up to the deaths of inmates is deplorable. There are no internal or external mortality reviews or quality improvement reviews of deaths. Without the medical staff assessing why so many patients are dying, they cannot identify and solve the problems within their system.
The current medical system does not appreciate the cost-effectiveness of ensuring patients receive preventative care. For instance, assuring that a patient receives life-saving Bactrim (one pill only three times per week) costs merely pennies per day yet prevents a deadly, expensive-to-treat infection called Pneumocystis carinii pneumonia (PCP) – a disease that many patients at Limestone seemed to have needlessly died from. Patients, who clearly do not understand the consequences of not taking these life-saving antibiotics, are allowed to stop taking them without being counseled by the medical staff. Patients in such closely observed settings should at least receive preventive therapy. Such a simple measure as allowing the patient to take the medication back to his unit (often called “keep on person”) is not even an option for patients at Limestone. It is unclear why.
Patients at Limestone are treated like they are nuisances. They are forced to interrupt their much-needed sleep at 3:00 a.m. each early morning to stand in a pill line outside, often in cold, wet weather or sweltering heat, for up to forty-five minutes to receive their life-saving medications. Many of these AIDS patients are too sick or unable to stand long enough to wait in line. Thus, they can not obtain their medications, and sometimes the medications are not available. This leads to lapses in medical care, increases the potential for resistant forms of HIV, and results in further mistrust by the patients in the medical system.
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HIV-infected patients at Limestone Correctional Facility are totally segregated from other inmates. This presents a serious problem in terms of medical emergencies. Limestone administration apparently require that the prison facility be “shut down” when moving HIVinfected patients. “Shutting down” an entire prison takes a considerable amount of time; if an HIV-infected patient has a medical emergency and needs to be transferred off the facility, the critical time period is quickly lost and many patients have needlessly died.
Medically necessary dietary requirements for diabetics or undernourished patients are virtually non-existent. Staff indicates that they are strongly discouraged from writing (by the Department of Corrections) for special diets for patients, even when indicated. It must be acknowledged that certain patients have specific dietary needs that must be adhered to. Specific dietary requirements for diabetic patients, patients in renal failure, or under-weight patients is a medical issue that requires attention. A large proportion of patient who died at Limestone were severely malnourished and not receiving adequate nutrition or vitamin/mineral supplementation.
The physically handicapped and disabled suffer disproportionately. They are denied access to baths. The only way of cleaning their bodies in Dorm 16 or Dorm 7 is by showering an often impossible task for patients who are unable to get out of their wheelchairs and step over a high ledge to access the shower. There are numerous areas I toured in the facility where accessibility for the handicapped is disregarded and neglected. For example, there are not adequate railings or ramps for wheelchair access. The medical understaffing also leads to the inappropriate use if inmates caring for disabled patients.
The open warehouse where approximately 2501 HIV-infected patients live is overcrowded. Side-by-side and head-to-toe bunk arrangements place these immune compromised patients and the staff at an undue risk of acquiring contagious diseases. This is evidenced by the recent widespread outbreak of a staphylococcal bacteria infection. I examined many patients who had clear evidence of staphylococcal skin infections – both new infections and scars. Reports from other facilities underscore the need for clean and separate living facilities particularly for patients who are immune compromised and more likely to spread diseases. I suspect the patients will continue to keep getting and spreading boils and abscesses that spread like wild-fire given the over-crowded sleeping and living conditions at Limestone. I have been told that Summer, 2003 has heralded additional skin infections as evidenced by increased complaints from patients to their attorneys.
1NaphCare=s inmate population statistics for Limestone are as follows: December 2002 - 309 HIV infected inmates and 57 AIDS infected inmates; January 2003 - 307 HIV infected inmates and 55 AIDS infected inmates; February 2003 - 310 HIV infected inmates and 54 AIDS infected inmates; March 2003 - 288 HIV infected inmates and 52 AIDS infected inmates.
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Without adequate infection control practices, the possibility of an outbreak of drugresistant tuberculosis and the subsequent deaths is acute. Some patients request to be transferred to the lock-down units where they will at least be afforded some privacy and physical barriers to potentially deadly infectious diseases.
Because of a broken, severely stressed or often non-existent medical system, patients are needlessly dying and suffering from AIDS-related complications and other illnesses that could be prevented. The conditions at Limestone Prison are unsafe for both the incarcerated and for the staff. There is a sense of hopelessness and helplessness among the patients at Limestone -- to a degree that I have not witnessed prior.
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INITIAL RECOMMENDATIONS Stephen Tabet, MD, MPH
Limestone Correctional Facility has a vast array of significant medical problems. Moreover, the standard of medical care rendered at Limestone falls far below the standards in the community or those standards set by organized bodies described in the introduction to this report. For this report, I will make only recommendations that I feel need to be addressed urgently. In addition to these minimal recommendations, there are many changes that could be put into place to develop a sound system of medical care that are not currently being addressed at Limestone. The following recommendations address what I see to be the most serious problems at the prison
1. Deaths. The number of deaths and the manner in which HIV-infected patients are dying at Limestone is a huge concern and present issues of potentially serious medical liability. All deaths need to be thoroughly evaluated by a medical doctor with expertise in the area. Full autopsies should be performed on all patients dying at Limestone until this disturbing trend is reversed.
2. Physician and mid-level staffing. Limestone is dangerously understaffed in terms of medical personnel according to accepted guidelines for incarcerated medical settings. Dr. Simon has an overwhelming task to perform with only one Physician s Assistant. One medical doctor serving as Medical Director and providing care to over 2800 patients-including 300 with the HIV or AIDS-- is overwhelming and dangerous. At least another full-time physician and two other mid-level practitioners (physician s assistants or nurse practitioners) are needed to adequately provide care for the large number of sick patients at Limestone. Limestone staffing levels are far below what is normally accepted for provider staffing in a facility of this size with this level of acuity in terms of patient load.
3. Inmates providing care. Because of the shortage of nurses, inmates are called upon to provide nursing care -- especially in the inpatient unit. Inmates can provide comfort and company to other inmates, but must not provide nursing care.
4. Nursing. Nursing is very understaffed and many nurses are poorly trained at Limestone. Nurses need training in CPR as well as ongoing continuing education. Nurses at Limestone have made serious errors and patients have died or suffered needlessly. The numerous unfilled nursing positions need to be staffed. The National Commission on Correctional Health Care (NCCHC) guidelines need to be followed in terms of adequate nursing levels and training.
5. Infection Control. Infection control practices and guidelines are not being adhered to. Inmates with contagious diseases should be treated and isolated from the population especially given an HIV-infected person’s extreme vulnerability to these diseases. Outbreaks of infections need to be investigated and treated accordingly. National
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resources such as the Centers for Disease Control and Prevention need to be called upon for assistance when necessary. Staphylococcus bacterial infections, in particular, are a problem and need to be eradicated as one would in any closed setting. Prevention, with respect to infectious diseases, is severely deficient at Limestone and needs to be integrated as a part of a patient’s medical care to decrease morbidity, mortality, and unnecessary costs.
6. Pharmacy and Medication Supply. Multiple patients disclosed that Limestone did not provide adequate medications because the nursing staff often ran out. Patients need to be provided medications on a regular and consistent basis. Running out of medications is unacceptable. The pharmacy needs to be adequately stocked and the inventory properly managed. HIV-infected patients need to take their antiretroviral medications consistently or they will develop drug-resistant HIV, fail medication therapy, and die. Additionally, inmates should not provide medical care, distribute medication, or provide emergency transport for other inmates.
7. Patients not taking essential medications. Too many patients are not taking appropriate medications. It is unclear whether some patients comprehend the dire consequences of not taking antiretroviral medications or preventive antibiotics. There needs to be appropriate education and documentation that the patient understands the consequences of not taking medications or antibiotics. Patients who are not taking simple medication regimens such as Bactrim (one pill is taken three times per week) or Dapsone (one small pill taken once daily) to prevent deadly Pneumocystis carinii pneumonia should be counseled, encouraged, and supported so they can easily take these inexpensive, life-saving medications. Opportunistic infections are deadly and very expensive to treat. Food (a sandwich or even crackers) needs to be provided to patients so they can take their medications without unnecessary side effects. For medications that need to be taken on an empty stomach, then patients need to be counseled regarding this.
8. Pill Line. Making patients stand in line outside, often in the cold or extreme heat, to receive any and all medications is counter-productive for a good therapeutic relationship. Patients should be taken their medication on a pill cart into their dorm and/or allowed keep-on-person” medications when appropriate. “Keep on person” medications is a common practice in correctional settings which allows patients to keep a few weeks or one month of medication in their possession. They can take their medications at the correct times and with the correct food requirements. A “keep-on-person” program excludes any medications that are potentially dangerous and may be bartered such as psychotropics, narcotic pain medications, and sleeping medications. Pill line at 3:00 a.m., or even 3:30 a.m., and then breakfast in the early morning is inappropriate. Patients should be administered medications that do not interrupt their normal sleep patterns. For example, medication could be provided at 7:30 a.m. after eating breakfast. Many of the medications are Food and Drug Administration (FDA) approved to be taken with food, so all patients on medications that need to be given with food must have access to food. This will decrease the amount of side effects like nausea and vomiting, and increase
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medication compliance, as well as potentially decrease the number of illnesses.
9. Dietary requirements. Nutritional supplementation and diets are currently not satisfying the needs of patients with illnesses that require special diets. In particular, malnourished AIDS patients need evaluation for supplementation and mediations to increase lead body mass. Many chronically ill patients, such as patients on dialysis and patients with diabetes mellitus have special dietary needs. The dietary options provided at Limestone require an assessment by a nutritionist. AIDS patients need to be given vitamin/mineral supplementation especially given that the combination HIV therapies toxicities.
10. Medical Emergencies. Emergency response by medical staff at Limestone is either nonexistent or dangerously slow. Patients are needlessly dying of medical emergencies. The current rule of “locking down” the prison before providing care to a patient with a medical emergency needs to stop. This needless delay in treatment during the first few golden minutes of a medical emergency has undoubtedly hastened the death of patients at Limestone. Patients who declare an emergency need to be either attended to immediately by trained medical staff or transported to the infirmary for immediate evaluation and treatment. Correctional officers should not be making medical decisions and deciding what is a medical emergency as they are presently doing. The issues of Do Not Resuscitate (DNR) and advanced directives needs to be consistently and compassionately discussed with patients and the patient’s wishes need to be respected. The current standard of the Limestone medical staff deciding for the patient how much to do for the patient needs to cease.
11. Americans with Disabilities Act. This is an area that is so replete with deficiencies that to adequately catalog them would require an extensive report, separate and apart from this report. I highly recommend an extensive evaluation of these problems before a disabled patient endures serious injury.
12. Crowded conditions and the housing unit. Patients at Limestone live in an open warehouse with extremes in temperatures. Overcrowded conditions and the close proximity of the beds fosters transmission of serious infections from one patient to another. HIV-infected persons at Limestone should not be housed in such crowded, dangerous, and inhumane conditions.
13. Monitoring. Developing an appropriate system of medical care at Limestone is going to take time, resources and a serious commitment by the medical providers. I recommend that health care delivery at the prison be monitored closely by an outside HIV specialist until the program has been brought up to acceptable standards.
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Curriculum Vitae STEPHEN R. TABET, MD, MPH

August 2003

Personal Data Date of Birth

November 21, 1961

Birthplace

Belen, New Mexico

Citizenship

United States

Social Security Number

Street Address

HIV Vaccine Trials Network (HVTN) 1100 Fairview Avenue N. J3-100 PO Box 19024 Seattle, Washington 98109-1024

Electronic Address

stabet@fhcrc.org

Telephone Numbers

(206) 667-2047 Facsimile (206) 667-7711

Education

1987

Biology and Business Administration (Presidential Scholar)

University of New Mexico, Albuquerque, NM

1987-91

Doctor of Medicine

University of New Mexico School of Medicine, Albuquerque, NM

1991-93

Master of Public Health, Epidemiology

University of Washington School of Public Health, Seattle, WA

Postgraduate Training

1991-1992 Intern in Internal Medicine

University of Washington School of Medicine, Seattle, WA

1992-1993 Resident in Public Health and Preventive Medicine

University of Washington School of Public Health and Community Medicine, Seattle,

WA

1993-1994 Resident in Internal Medicine

University of Washington School of Medicine, Seattle, WA

1994-1997

Senior Fellow in Infectious Diseases

Division of Allergy and Infectious Diseases, University of Washington School of

Medicine, Seattle, WA

Faculty Positions Held 1997- 1999 Acting Instructor, Division of Infectious Diseases, UW School of Medicine 1998 –present Faculty Educator, Northwest AIDS Education and Training Center 1999– present Assistant Professor of Medicine, Division of Allergy and Infectious Diseases, UW School
of Medicine 2002 – present Faculty Member, Fogarty International AIDS Research Training Program 2003 – present Senior Clinical Trials Physician - Antiretrovirals, HIV Vaccine Trials Network (HVTN) 2003 – present Affiliated Assistant Member, Fred Hutchinson Cancer Research Center (FHCRC)

117

2003 – present Associate Professor of Medicine (proposed) Division of Allergy and Infectious Diseases, UW School of Medicine

Hospital Positions 1994- 2003 Attending physician
Sexually Transmitted Disease Clinic, Harborview Medical Center, Seattle, WA 1997- 2003 Attending physician
Infectious Disease Clinic, Harborview Medical Center, Seattle, WA 1997- present Attending physician (Primary provider 1992 - 2003)
Madison (HIV/AIDS) Clinic, Harborview Medical Center, Seattle, WA

Other Positions 1995 – present Medical Director, Pacific Professional Medical Services (Supervise physician services to
Washington Department of Corrections and Department of Social and Health Services)

Honors and Awards

1991

Alpha Omega Alpha, University of New Mexico School of Medicine, Albuquerque, NM

1991

University of New Mexico School of Medicine Faculty Award for Excellence Albuquerque,

NM

1996-98

American Social Health Association (ASHA) Research Fellowship in STDs

Board Certification

1997

Diplomate, American Board of Internal Medicine

1998

Diplomate, Infectious Diseases

Medical Licensure 1991- present State of Washington, Physician and Surgeon #MD00031074

Professional Societies American College of Physicians, Member Infectious Disease Society of America, Member

Teaching Responsibilities and Mentoring Daniel Corey, UW School of Medicine MS 1 – Project assessing costs associated with OI treatment and ARV
use in Lima, Peru Nina Kim, MD, Senior Fellow in Infectious Diseases – Issues Associated with Antiretroviral Therapy in the Context of Phase III Vaccine Trials Raul Salazar, MD, Almenara Hospital (Peru Social Security System) – UW AIDS Clinical Trials Unit

Regular Lecturer Northwest AIDS Education and Training Center Seattle Sexually Transmitted Diseases Prevention Training Center

Courses UW Center for Health Education and Research CME Regional Conference on HIV in the Correctional Setting (Course Director)

May 2003

CME/Invited Lectures UW Emergency Medicine Grand Rounds “HIV Issues of Particular Importance in the Emergency Room” UW School of Nursing – 10th Annual Clinical Update for Nurses

July 2002

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“Update on HIV Disease” Country Doctor Community Health Center
“Toxicities Associated with use of Antiretrovirals” Seattle HPTU/HVTU Community Forum
“What’s going on in the area of HIV prevention?” University of Nevada School of Medicine – Networking for HIV Care
“Correctional Medicine: Maximal Adherence / Minimal Resistance in the Setting of Intermittent Patient Contact” National Conference on Correctional Health Care “Real Life Examples: Managing Infectious Disease in Corrections” UW Hospital Clinical Pathology Conference Northwest AETC and Seattle STD Training Center Provider’s Update “Care of the HIV-infected Incarcerated Patient” “STDs in the Correctional Facility” Pacific AETC HIV, OIs, and Hepatitis C Conference Honolulu, Hawaii “The Special Case of Working with Corrections” Northwest AETC and STD Training Center Training for Washington Corrections Center for Women, Gig Harbor International Adult Clinical Trial Group Latin American / Caribbean Course on HIV (Multiple lectures) Peruvian Conference on HIV, Pathogenesis and Treatment “New Antiretrovirals” “Update on Occupational Exposure to HIV, HBV, and HCV” “Management of Treatment Failure” “Metabolic Complications of Antiretrovirals and HIV” Northwest AETC Montana Corrections Training Programs Billings and Butte, Montana (Course Director) Seattle AIDS Education and Treatment Program (STEP)
Community Forum on Antiretrovirals – Focus on QD regimens Northwest Nevada Correctional Facility Training Program and
Preceptorship, Reno, Nevada

July 2002 September 2002 September 2002
October 2002 October 2002 October 2002 October 2002 February 2003
April 2003 May 2003
May 2003 May 2003
June 2003
August 2003 September 2003

Editorial Responsibilities 1998 – present Reviewer, Journal of Infectious Diseases 2000 – present Reviewer, Journal of the American Public Health Association

Special National/International Responsibilities 1999 – present Deputy Editor, HIV and Hepatitis Education Prison Project, Brown University, Providence, RI 1999 – 2003 Member, US Dept. of Health and Human Services HIV/AIDS Bureau Advisory Committee 2003 – present Member, US Dept. of Health and Human Services CDC/HRSA Advisory Committee 1999 – 2003 Chair, US Dept. of Health and Human Services HIV/AIDS Bureau Treatment and Access
to Care Committee 2000 – present Member, Advisory Committee to the National Clinician’s Consultation Center, San Francisco 2003 – present Medical Editor, HIV and Hepatitis Education Prison Project Case Study Section, Brown
University, Providence, RI 2002 – present Liaison, UW International Clinical Trials Unit – Lima, Peru Site

119

2003 World Health Organization/UNAIDS consultation on modalities for access and standard of treatment for participants with intecurrent HIV infections during vaccine, microbicide and other prevention research trials. Geneva, Switzerland

Special Local and Regional Responsibilities 2000 – present Member, UW Sexually Transmitted Diseases Prevention Training Center Advisory Committee 2000 – present Editor, NW AIDS Education Center Correctional Medicine Update 2001 – present Director, Northwest Correctional Medicine Education Program

Research Funding, Current

9/01/02 – 8/31/05

NIH/NIAID

Co-Investigator (10%)

AACTG International Therapeutic Clinical Trials Initiative

(P.I. Ann Collier)

Publications 1. Tabet S, Weise W. Medications obtained in Mexico by patients in southern New Mexico, Southern
Medical Journal 1990;83:271-73.

2. Tabet S, Voltura A, Wallerstein N, Koster F. Fear of AIDS: An assessment of knowledge and attitudes of medical, nursing, and medical technology students. Teaching and Learning in Medicine 1992;4:156-61.

3. Tabet S, Palmer D, Wiese W, Voorhees R, Pathak D. Seroprevalence of HIV-1 and hepatitis B and C in prostitutes in Albuquerque, New Mexico. American Journal of Public Health 1992; 82:1151-54.

4. Tabet S, Goldbaum G, Hooton M, Eisenach K, Cave M, Nolan C. Restriction fragment length polymorphism analysis detecting a community based tuberculosis outbreak among persons infected with HIV. Journal of Infectious Diseases 1994;169:189-92.

5. Tabet S, De Moya E, Holmes K, et al. Sexual behaviors and risk factors for HIV infection among men who have sex with men in the Dominican Republic. AIDS 1996; 10:201-6.

6. Tabet S, Krone M, Hooton T, Koutsky L, Holmes K. Bacterial infections in adult patients hospitalized with AIDS: Case-control study of prophylactic efficacy of trimethoprim-sulfamethoxazole vs. aerosolized pentamidine. International Journal of STD and AIDS 1997;8:563-9.

7. Tabet S, Krone M, Paradise M, Corey L, Stamm W, Celum C. Incidence of HIV and sexually transmitted diseases (STDs) in a cohort of HIV-negative men who have sex with men. AIDS 1998;12:2041-8.

8. Krone M, Tabet S, Paradise M, Wald A, Corey L, Celum C. Herpes simplex virus shedding among HIV-negative, men who have sex with men (MSM): Site and frequency of herpes shedding. JID 1998;178:978-82.

9. Tabet S, Surawicz C, Horton S, Paradise M, Coletti A, Gross M, et al. Safety and toxicity of Nonoxynol-9 gel as a rectal microbicide. Sex Transm Dis 1999;26:564-71.

10. Gross M, Celum C, Tabet S, Kelly C, Coletti A, Chesney M. Acceptability of a bioadhesive nonoxynol-9 gel delivered by an applicator as a rectal microbicide. Sex Transm Dis 1999;26:572-78.

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11. Krone M, Wald A, Tabet S, Corey L, Celum C. Herpes Simplex Virus Type 2 shedding in HIVnegative men who have sex with men: Frequency, patterns, and risk factors. Clin Inf Dis 2000;30:261-7.
12. Casper C, Wald A, Pauk J, Tabet S, Corey L, Celum C. Correlates of prevalent and incident Kaposi’s Sarcoma-associated Herpesvirus infection in men who have sex with men. J Infect Dis 2002;185:990-3.
13. Tabet S, Sanchez J, Courtois B, Lama J, Goicochea P, Campos P, et al. HIV, syphilis and heterosexual bridging among Peruvian men who have sex with men. AIDS 2002;16:1-7.
14. Schwartz M, Tabet S, Collier A, Wallis C, Carlson L, Nguyen T, Kattar M, Coyle M. Central venous catheter-related bacteremia due to Tsukamurella species in the immunocompromised host: A case series and review of the literature. CID 2002;35:72-76.
15. Renzi C, Tabet S, Stucky, Eaton N, Coletti A, Surawicz C, et al. Acceptability and safety of the Reality condom for anal sex among men who have sex with men. AIDS 2003; 17:727-31.
16. Tabet S, Callahan M, Mauck C, Gai F, Coletti A, Profy A, Moench T, Poindexter A, Frezieres R, Walsh T, Kelly C, Richardson B, van Damme L, Celum C. Safety and acceptability of penile application of 2 candidate topical microbicides: BufferGel and PRO 2000 Gel: 3 randomized trials in healthy low-risk and HIV-positive men. J Acquir Immune Defic Syndr 2003; 33:476-83.
Books and Chapters 1. Tabet S, Celum C. Nongonococcal urethritis, Conn’s Current Therapy. Philadelphia: W.B. Saunders
Co., 1995.
2. Tabet S, Berg A. Screening for Cerebrovascular Disease (Chapter 4). Guide to Clinical Preventive Services: An assessment of the effectiveness of 169 interventions. Baltimore, Maryland: Williams and Wilkins, 1996.
3. Tabet S, Berg A. Screening for Peripheral Vascular Disease (Chapter 5), Guide to Clinical Preventive Services: An assessment of the effectiveness of 169 interventions. Baltimore, Maryland: Williams and Wilkins, 1996.
4. Tabet S, Root P. Continuous quality improvement in AIDS care. (USPHS publications 1999).
Electronic Publications Tabet S. Northwest AIDS Education Training Center Correctional Medicine Update (Monthly publication focusing on HIV, HCV, and HBV and related issues for providers working in correctional settings.)
Videos 1. Tabet S. Washington Department of Public Health and Northwest AIDS Education and Training
Center. Taking control: Adherence and HIV/AIDS Medication. 1998.
2. Tabet S. Northwest AIDS Education and Training Center. Positive in prison: Women on combination therapy. 1998.
3. Tabet S. Northwest AIDS Education and Training Center. Caring inside the wall: HIV treatment in the correctional setting. 2001.
121

4. Tabet S, Shuhart M. Northwest AIDS Education and Training Center. Diagnosis and treatment of HIV and
Hepatitis C co-infected patients. 2002.
Selected Presentations/Published Abstracts Tabet S, Voltura A, Wallerstein N, Koster F. Fear of AIDS: An assessment of knowledge and attitudes of
medical, nursing, and medical technology students. (Clinical research, Vol. 39, p. 7A); Western Regional Meetings, Carmel, California, February 1991.
Tabet S, Palmer D, Voorhees R, Wiese W, Pathak D. Prostitution, drug use and HIV/AIDS on the streets of Albuquerque, New Mexico, USA. Seventh International Conference on AIDS, Florence, Italy, June 1991.
Tabet S, Goldbaum G, Hooton T, Eisenach K, Cave M, Nolan C. DNA fingerprinting analysis detecting a community-based tuberculosis outbreak among HIV-infected persons. (Abstract no. B07-1121); Ninth International Conference on AIDS, Berlin, Germany, June 1993.
Tabet S. Tuberculosis in high risk populations. University of Washington School of Public Health Grand Rounds, Seattle, November 1993.
Tabet S, Goldbaum G, Hooton T, Eisenach K, Cave M, Nolan C. Restriction fragment length polymorphism analysis detecting a community-based tuberculosis outbreak among HIV-infected persons. (Abstract no. 010); American College of Physicians Annual Session, Miami Beach, April 1994.
Tabet S, Hooton T, Koutsky L, Krone M, Holmes K. Bacterial pneumonia in adult HIV-infected patients. American College of Physicians Annual Session, Miami Beach, April 1994.
Tabet S, Krone M, Paradise M, Stamm W, Corey L, Celum C. Herpes, the most common STD in a cohort of high-risk HIV-negative men who have sex with men. (Abstract no. Mo.C.1634); Eleventh International Conference on AIDS, Vancouver, July 1996.
Tabet S, Root P. The role of Continuous Quality Improvement (CQI) in federally-funded HIV/AIDS clinics. US Department of Health and Human Services Health Resources and Services Administration AIDS Conference, Bethesda, Maryland, April 1997.
Celum C, Tabet S, Dondero D, et al. HIV viral load in rectal mucosa and plasma: Implications for pathogenesis studies and transmission. 35th Annual Meeting of the Infectious Diseases Society of America, San Francisco, September 1997.
Tabet S, Krone M, Paradise M, Corey L, Stamm W, Celum C. Prevalence and incidence of HIV and STDs in a cohort of HIV-negative men who have sex with men (MSM) (Abstract no. O-138). International Congress of Sexually Transmitted Diseases. Seville, Spain, October 1997.
Krone M, Tabet S, Paradise M, Wald A, Corey L, Celum C. Herpes simplex virus shedding among HIVnegative, HSV-2 seropositive patients (Abstract no. O-189). International Congress of Sexually Transmitted Diseases. Seville, Spain, October 1997.
Celum C, Tabet S, Paradise M, et al. Safety, acceptability, and biologic effects of nonoxynol-9 as a rectal microbicide (Abstract no.O-258). International Congress of Sexually Transmitted Diseases. Seville, Spain, October 1997.
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Lama J, Goicochea P, Chion M, Alva J, Ueda L, Cairo J, Watts D, Campos P, Sanchez J, Tabet S, Holmes K. Comportamiento sexual y factores de riesgo para ETS e infeccion VIH entre hombres que tienen sexo con otros hombres de Lima, Peru. XI Latin American Conference on STDs and Panamerican Conference on AIDS, Lima, Peru, December 1997.
Tabet S, Celum C, Surawicz C, et al. Rectal sno-strips and biopsies: A simple method to assess rectal viral load and lymphoid architecture. 12th World AIDS Conference, Geneva, June 1998.
Tabet S, Collier A, Deeks S. Post-Geneva update on antiretrovirals. Harborview Medical Center AIDS Clinical Conference. Seattle, September 1998.
Tabet S. Adherence issues of HIV-infected incarcerated persons. Current Strategies for the Management of HIV in Corrections. Brown University School of Medicine. New York City, October 1998.
Tabet S. Current issues in the medical management of HIV-infected patients. UCSF – Fresno Grand Rounds. Fresno, California, October 1998.
Tabet S. Update on STD diagnoses and treatments. AIDS Healthcare Foundation, Los Angeles, California, November 1998.
Tabet S. Antiretroviral adherence issues. Alaska Native Health Association and AIDS Education Project, Anchorage, Alaska, January 1999.
Tabet S. A case-based approach to the advances in the treatment of HIV Disease. University of Hawaii Grand Rounds. Honolulu, HA, October 2000.
Tabet S. Update on viral load, CD4 count, and antiretroviral resistance testing and salvage therapy. NW AIDS Education and Training Center Training on HIV/AIDS in the African American Community. Seattle, WA, November 2000.
Tabet S., Celum C, Dondero D, Haggitt R, Huang M, Kelly C, Brodie S. HIV-1 localization, shedding, and CD4+ T-cell depletion in rectal mucosa. 8th Conference on Retroviruses and Opportunistic Infections. Chicago, IL, February 2001.
Tabet S., Brodie S, Dondero D, Haggitt R, Huang M, Kelly C, Celum C. The rectal mucosa is a site of HIV-1 replication and shedding and CD4+ T-cell depletion in men with chronic HIV-1 infection. Abstract 22. 1st International Conference on HIV Pathogenesis and Treatment. Buenos Aires, Argentina, July 2001.
Brodie S, Tabet S, Krieger J, et al. Intestinal mucosal macrophages are a principle reservoir of HIV replication and sustain high levels of infectious virus in persons with chronic-progressive HIV infection. Abstract 27. 9th Conference on Retroviruses and Opportunistic Infections. Seattle, WA, February 2002.
Celum C, Tabet S. Penile safety studies on PRO-2000 and BufferGel. Microbicides 2002. Antwerp, Belgium, May 2002.
Bartholow B, Royal S, Niedig J, Buchbinder S, Mayer K, Dyslin K, Tabet S, Goli V; The VISION Study Team. HIV vaccine efficacy trial site characterstics associated with the enrollment of trial participants at increased risk of HIV infection. XIV International AIDS Conference. Barcelona, Spain, July 2002.
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Bartholow B, Royal S, Niedig J, Buchbinder S, Mayer K, Dyslin K, Tabet S, Goli V; The VISION Study Team. HIV vaccine efficacy trial site communications practices associated with enrollment of trial participants at increased risk of HIV infection. XIV International AIDS Conference. Barcelona, Spain, July 2002.
Ackers ML, Buchbinder S, McKirnan D, Mayer KH, Novak R, Popovic V, Heywood W, Para M, Fuchs J, Tabet S, Vax004-Vision Study Team. Post-exposure prophylaxis among HIV-uninfected participants in a phase III HIV vaccine efficacy trial. XIV International AIDS Conference, Barcelona, Spain, July 2002.
Bartholow B, Royal S, Niedig J, Buchbinder S, Mayer K, Dyslin K, Tabet S, Goli V; The VISION Study Team. Enrolling high-risk HIV vaccine efficacy trial participants: Media coverage, advertising, and opinion leader endorsement. XIV International AIDS Conference. Barcelona, Spain, July 2002.
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 SUPPLEMENTAL REPORT OF STEPHEN TABET, M.D., MPH
Leatherwood v. Campbell Case No. CV-02-BE-2812-W IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ALABAMA WESTERN DIVISION DATED: MARCH 11, 2004

TABLE OF CONTENTS

TAB PAGES

A. QUALIFICATIONS

3

B. BASIC SCIENCE OF HIV

4

C. STANDARDS OF CARE

5

D. REVIEW OF THE LIMESTONE CORRECTIONAL FACILITY 6-7

E. PATIENT EXAMINATIONS 1. PATIENT 1 2. PATIENT 2 3. PATIENT 3 4. PATIENT 4 5. PATIENT 5 6. PATIENT 6 7. PATIENT 7 8. PATIENT 8 9. PATIENT 9 10. PATIENT 10 11. PATIENT 11 12. PATIENT 12 13. PATIENT 13 14. PATIENT 14 15. PATIENT 15

8 9 10-11 12 13 14-15 16 17 18 19 20 21-22 23 24 25-26

F. MORTALITY REVIEWS 1. GERALD LEWIS 2. ROBERT STRICKLAND 3. NATHAN SULLIVAN 4. ALFRED THOMAS 5. ROBERT WALKER

27 28-29 30-31 32-33 34-36 37

G. SUMMARY

38-42

H. RECOMMENDATIONS

43-46

ATTACHMENTS I. CURRICULUM VITAE

II. INDEX TO IDENTITY OF PATIENT EXAMINATIONS

QUALIFICATIONS Stephen Tabet, MD, MPH Reference Expert Report of Stephen Tabet, M.D., MPH, dated August 26, 2003.
3

BASIC SCIENCE OF HIV Stephen Tabet, MD, MPH This report uses the same basic science referenced in Expert Report of Stephen Tabet, M.D., MPH, dated: August 26, 2003.
4

STANDARDS OF CARE This report draws upon the same standards of care referenced in Expert Report of Stephen Tabet, M.D., MPH, dated: August 26, 2003.
5

THE LIMESTONE CORRECTIONAL FACILITY
On February 23, 2004, I toured and observed the Limestone Correctional Facility. I reviewed both living conditions and the common areas of units 6A, 6B, 7A, and 7B. I was not permitted to interview correctional or medical staff.
Presently, living conditions are such that each patient lives either one to two persons per cell. Most of the patients actually complained of the cells being cold. When I made a walk-through and reviewed the cells, I concurred with that assessment. The cells were cold with a draft. Many of the windows are broken and covered with plastic or have been covered with blankets. Also, many of the windows appear to be inoperable. (See photographs 1, 2, 3, 4 &5)
The patients are locked in their cells all night and there are no emergency call buttons.
I also noticed that none of the toilets have railings, including the room of a wheelchair bound patient. (See photograph 6)
There is a railing in one of the showers of each unit, but it is very difficult to access this shower with a wheelchair. There is no seat in the showers for a handicapped patient to sit. (See photograph 7)
There is also dirty water on the floors outside of the showers. (See photographs 8 & 9) But, units 7A and 7B were very clean compared to units 6A and 6B.
I observed the entire pill line for at least an hour. The pill line was a disaster. NUMEROUS patients did not have their medications on hand and were told to come back, or were told that they did not have the medications altogether. Such common medications as tenofovir and d4T were not available. This was confirmed by reviewing the Medication Administration Records (MAR) of several patients, including Patient #2, who has not had tenofovir for the last four days.
Also, as described in the previous visit to Limestone Correctional Facility, many of the medications that are FDA approved to be administered with food, were in fact not being administered with food. Such medications as Fortovase, ritonavir, and Viracept, are being administered on an empty stomach. Sometimes the separation of the medications with food is as much as 1-1/2 hours. This leads to excessive side effects, including nausea, vomiting, and diarrhea, and poor medication absorption.
I was also told that the a.m. pill line can occur at anytime between 12:30 a.m. to 3 a.m.
I observed multiple patients, including Patient #181765, who did not receive his efavirenz, but was given his other HIV medications. Patient #149422 was given his medications except for nevirapine. Patient #099831 was not given his d4T.
6

The patients were moved several months ago from dorm 16 to dorms 6A, 6B, 7A and 7B. This is somewhat of an improvement but there are still many problems with the current living arrangements and there are many ways in which the Department of Corrections can improve the living conditions of these inmates, especially for the handicapped or disabled. One patient was given his insulin and was made to inject the insulin into his thigh right in front of everybody, as opposed to in a private setting. This is an infringement on the patient's privacy. At the Limestone Correctional Facility it is important to note that one of the patients who expired from active tuberculosis was put in the HIV general population. As a result, all the patients in the dorm who are HIV positive were placed on INH therapy prophylaxis. The patient with active tuberculosis was inappropriately placed in the general population, and as a result exposed numerous patients, and perhaps all patients, with HIV to tuberculosis. As a result, all HIV patients and some correctional officers are on INH prophylaxis. The infection control procedures were not being adhered to, so the Public Health Department was called into Limestone for assistance. The infection control procedures at Limestone Correctional Facility need to be reviewed and strictly adhered to, given the serious problem that is presently occurring.
7

PATIENT INTERVIEWS
PATIENT #1
Interview: 02/23/2004
I spent extensive time reviewing the patient's medical record and interviewing him. The patient is currently being housed in the inpatient unit. He is a 39-year-old male who is HIV-positive and has a history of asthma and tuberculosis exposure. His main issue is that for the last several years, he has had persistent rectal bleeding. A review of his medical record shows that the patient had been referred to surgery and had been diagnosed with anal fissures as well as anal stenosis. Apparently the surgeon did not recommend surgery. The most recent surgical consultation could not be located in the patient’s medical records. The patient continues to have persistent rectal bleeding. He has not been seen by a gastroenterologist and he has not had a colonoscopy or endoscopy performed for a thorough examination despite his chronic rectal bleeding and pain.
Upon further discussion with the patient, he reports that he has large amounts of blood in his stool every single day and significant pain. The patient states that he feels the medical care at this institution has not changed since I was last at the facility approximately one year ago.
Although this is not documented in the records, it appears that the patient may have had a hepatitis A and B screening. Again, there is no documentation of this screening or any results. The patient received a hepatitis A and B vaccinations. He also received a Pneumovax vaccination in April 2003.
In September 2002, the patient informed Dr. Simon that he felt the Viracept was causing him to bleed. At the patient's request, Dr. Simon discontinued the patient=s antiretroviral therapy.
IMPRESSION: This is an HIV-infected patient whose main issue is chronic rectal bleeding. Unfortunately he has not had a thorough examination of his gastrointestinal tract and the source of the bleeding is unknown. The patient has tried different therapies and none have been successful. This patient needs to be seen again by a gastroenterologist for a thorough examination in addition to more aggressive intervention.
Additionally, the patient had been placed on nonsteroidal anti-inflammatory drugs for quite some time consisting of Motrin 800 mg t.i.d. This could be contributing to the patient's rectal bleeding. This patient also had the mistaken perception that his antiretroviral Viracept caused his rectal bleeding. As a result, he stopped his medications. There is no documentation that the patient received an explanation that the Viracept was not causing his rectal bleeding.
8

PATIENT #2
Interview: 02/23/2004
This patient is a 32-year-old male with a history of class C3 AIDS and chronic Cryptococcal meningitis which is a severe, life-threatening fungal infection. I last saw the patient at my 02/13/2003 and 02/14/2003 visit when I first visited the Limestone Correctional Facility. At that time, the patient had been unable to take all his medications because at times he was not hearing the call for the pill line. Currently the patient reports that he has been taking all his medications as directed when they are available. However, he reports that on several occasions his life-saving medication called fluconazole, which is used to treat deadly Cryptococcal meningitis, is unavailable. In particular, it appears as if on the dates of 12/30/2003, 12/31/2003, 01/08/2004, 01/09/2004, 01/28/2004, and 01/29/2004, the patient did not receive his medications for his Cryptococcal meningitis. The patient adamantly denied that he did not show up for his pill call. Instead, the medications were not available to him. In fact, he was told by the staff that they ran out of these life-saving medications. He also states that the medical staff had fluconazole available for other patients, but they did not administer him the medication.
Currently the patient is on a regimen of d4T, ddI, and Viracept. He has had an excellent response, which shows that he has been largely compliant. His CD4 count is up to 680, where before it was very, very low. His viral load is almost undetectable at about 800. The patient, like all other patients, is currently on INH for TB prophylaxis which he receives at 1:30 in the morning. The patient usually goes to sleep around 12 o'clock, but is awakened 1-1/2 hours later to take the medication, which severely disturbs his sleep. Also, the patient has received very little explanation of INH toxicity.
IMPRESSION: This patient is a 32-year-old male with class C3 AIDS and chronic Cryptococcal meningitis and has had an excellent response to therapy as evidenced by his high CD4 count. Most concerning, is that the patient states, and it is documented, that he does not receive all of his medications. In fact, Limestone Correctional Facility is still running out of life-saving medications such as fluconazole. This patient needs to receive his fluconazole every single day. It is very critical. During pill call in dorm 7 on February 23, 2004, it was observed that a large number of patients missed doses of life-saving medications. These medications were not made available to the patients. It is critical that the patients receive these medications.
Also, the patient is on a regimen, which consists of d4T and ddI and Viracept. d4T and ddI are often very toxic together and largely not used unless under unusual circumstances (i.e., salvage or rescue therapy). Being that this is the patient's first regimen, it does not make sense why he would receive d4T and ddI. If taken together, these medications can cause an increase in mitochondrial toxicity and lactic acidosis. Because of the increase in toxicity and acidosis, this dual regimen has largely been abandoned in the treatment of HIV infection.
9

PATIENT #3
Interview: 02/23/2004
This patient=s medical records were thoroughly examined. The patient was interviewed and examined.
The patient is a 58-year-old male with HIV infection, hepatitis C, coronary artery disease, and a history of a myocardial infarction. The patient is being housed in the inpatient unit after a recent visit to Huntsville Hospital for pneumonia. He is currently on antibiotics to treat the pneumonia. The patient also carries the diagnosis of severe wasting.
The patient reports that while being in the inpatient unit, his medications are often missing. In fact, he reports that up to three to four times a week his medications are not available. He is told that the medications have been discontinued, only to be informed the next day that they have not been discontinued or have been restarted. The patient states that he wants to take all of his medications as directed. However, they are not administered to him on a regular basis.
He also stated that he had approximately a 40-pound weight loss in the last year. This is substantiated by his medical records. The patient has rather severe facial wasting and appears very emaciated and fatigued. (See photograph 10) Until recently, the patient's HIV medications were d4T, ddI, and efavirenz. Today, the patient was seen by Dr. Simon who changed the d4T to tenofovir.
A thorough review of the patient’s chart reveals that he has not had any fasting lipids and had not had any cholesterol obtained.
IMPRESSION: This patient is a 58-year-old male whose major issue right now is that he is emaciated and has lost what appears to be over 20% of his total body weight in the past year. He also has very severe facial wasting. As with other patients, a thorough review of the medical records shows that he has not had a thorough evaluation of his wasting. This may include such simple laboratory draws as a testosterone level. Yet, the patient is receiving Resource protein supplement three times a day. However, this does not appear to be enough to keep up his needs because he continues to lose weight.
Until today, the patient was also on a regimen consisting of d4T, ddI and efavirenz. He responded well to this regimen. As previously noted, the combination of d4T and ddI has largely been abandoned because of their increased toxicity. The d4T has been switched to tenofovir. Also, the patient's facial wasting is likely the result of the d4T.
In addition, this patient has a history of a myocardial infarction as well as coronary artery disease. He is on multiple medications for coronary artery disease and hypertension. A thorough review of his chart reveals that the patient has never had a cholesterol or lipid panel drawn. This is a
10

problem. The patient needs to have this obtained, especially given his medical history and that he is on HIV medications which can increase the cholesterol level. The patient is an elderly patient with hepatitis C who is on INH and who does not appear to be receiving regular liver enzyme monitoring. Given the patient’s high risk of hepatoxicity, this decision should be thoroughly discussed again with this patient.
11

PATIENT #4
Interview: 02/23/2004
I have interviewed, examined, and reviewed the patient's medical records on 02/23/2004.
The patient is a 36-year-old male with HIV, chronic hepatitis B, hepatitis C, as well as chronic gastroesophageal reflux disease. The patient is currently on a regimen consisting of Kaletra, Fortovase, and Sustiva. He is being administered these medications in a Akeep-on person@ manner.
The patient is also on INH prophylaxis given that he may have had exposure to another patient with active tuberculosis. The patient reports, however, that the INH is being administered to him sometimes as early as 1 AM by the nursing staff. The patients often do not go to bed until just a couple of hours before this time. There is a pill call that occurs sometime between 1 a.m. and 3:30 a.m.
I reviewed the patient's chart regarding his chronic abdominal pain and reflux type symptoms. There is no appointment in the patient’s chart with a gastroenterologist, despite the fact that the patient appears to have failed H2 blockers as well as treatment for Helicobacter pylori.
IMPRESSION: This patient is a 36-year-old male with HIV who has had a good response to his antiretroviral therapy. His CD4 count is 697. The viral load is less than 75. However he reports, that some of his medications ran out in January 2004, before he was able to keep them on his person.
He also carries the diagnosis of chronic hepatitis B and chronic hepatitis C and is currently on INH prophylaxis, which places him at a fairly high risk for INH hepatotoxicity. It is not clear from the medical records, but this patient needs to have his liver enzymes monitored closely for the duration of his INH therapy.
This patient also needs a thorough evaluation, including a consultation with a gastroenterologist, to ascertain the etiology for his chronic abdominal pain, nausea, and reflux symptoms.
As with the other patients, the timing of the medication administration (between 1 AM and 3 AM) then breakfast at 3:30 AM is completely counterproductive to sick patients= receiving muchneeded sleep and rest.
12

PATIENT #5
Interview: 02/23/2004
The patient is a 51-year-old male who is HIV positive. He also carries the diagnosis of hypertension. As with all of these patients, he has been exposed to tuberculosis and is on INH prophylaxis. The patient is also on d4T, ddI, and Viracept. He has been on this regimen since 2001 and has had an excellent response with a CD4 count above 1000, and a viral load of less than 50. This was his first regimen. Prior to this regimen, he had been antiretroviral naïve.
During discussion with the patient, he states that he has not had his blood pressure medications since 01/29/2004. This is confirmed by review of the Medication Administration Records (MAR). Procardia is currently not available at this institution. As a result, they will be starting him on a new medication which is called Sular. However, this medication is also not available at Limestone. Therefore, the patient is not receiving any medications for his high blood pressure. Blood pressure check at his last visit on 01/29/2004 was a systolic blood pressure of 158, a diastolic blood pressure of 99 which are too high and need treatment. The patient reports being dizzy and has headaches since he was taken off his medications.
Review of the patient's laboratory records shows that on 05/21/2003, he had lipids drawn, but they were not drawn fasting. His triglycerides are 277 which is two times normal. They have not been rechecked since then.
IMPRESSION: This patient is a 51-year-old male with HIV infection who has had an excellent response to therapy. Unfortunately, as with many other patients, he is on a regimen which has a high toxicity profile consisting of d4T, ddI, and Viracept. d4T and ddI should be reserved only for patients who have no other therapy options given that the increased propensity for mitochondrial toxicity and lactic acidosis are potentially deadly side effects of these drugs.
Also the patient had lipid panels drawn less than a year ago with triglycerides that were elevated. Since then, this has not been rechecked.
Very concerning for this patient is that he has a history of hypertension and has had at least one visit in which he had high blood pressure. He is experiencing symptoms consistent with high blood pressure. Yet he continues to go without his blood pressure medications because of a breakdown in the medical delivery system. His blood pressure medication was discontinued, and another medication was supposed to be started, but it has not been available. His blood pressure medications need to be started immediately. This is yet another patient who is on INH for tuberculosis exposure. He receives the INH between 1:30 to 2 in the morning, which interferes with the patient's ability to get sustained sleep.
13

PATIENT #6
Interview: 02/23/2004
This patient is a 31-year-old male who has AIDS and had a recent episode of very severe anemia. The anemia was likely secondary to AZT toxicity of the bone marrow.
A review of the patient's records show that he has been on a triple drug regimen consisting of Combivir (which is AZT and 3TC) and nevirapine since his initial admission to Limestone Correctional Facility. The patient reports that he has been on this regimen since approximately one year before his admission to Limestone. The patient reports that he has been taking all his medications as directed.
A review of his records show that there are multiple sick call request forms which appear to start some time around 12/03/2003 when the patient started reporting severe headache. On 12/14/2003 he reported another headache. It was documented that the patient was a Ano show@ but he reported that he was never called about his appointment. He was very upset about this; it was distressing to him.
On 12/23/2003 there is another sick call request form reporting headache, dizziness and suffocation. He stated that he was unable to walk because he was so short of breath. On 01/02/2004, the patient further reported more dizziness and headache, which he said he had had for the past three to four months. The patient informed me that he had been discussing these symptoms with the nurses verbally for at least several months before his sick call request forms, but he was not being seen.
The last time the patient was seen by Dr. Simon was in mid August 2003. At that time, his hematocrit was in fact 39.6. A normal hematocrit level should be in the range of 40. His CD4 count was 193 and viral load was less than 75. The patient was not seen again until 01/15/2004, which is a full five months later. During that interim time, he did not have any monitoring for toxicity that is documented. When the patient was finally seen after having requested multiple times to be seen, and having complained of very severe symptoms, he is seen and a hematocrit was finally obtained which shows a near-death hematocrit of 12. This is dangerously low.
He was emergently sent to the Huntsville Hospital where he received an incredible amount, six units of packed red blood cells, which brought his hematocrit to an acceptable level. Since he was initially seen, the patient has only had one repeat blood draw which shows some stabilization of his hematocrit. However, he has not had any further blood draws.
He had been receiving Combivir (which is AZT and 3TC), which was discontinued, and he is currently on a regimen which consists of tenofovir, 3TC, and nevirapine and he is tolerating this quite well.
IMPRESSION:
14

The biggest problem with this patient's care is that he was on a drug called AZT. A well know side effect of AZT is serious anemia. His verbal pleas with the nurses, as well as his sick call request forms, clearly show that he was suffering from anemia which was causing him to be short of breath, as well as being tired and having a headache. He was not seen in an appropriate time period. When the patient finally was seen, his hematocrit was critically low. Fortunately, the patient did not suffer any myocardial infarction or a severe fall, and was appropriately cared for at the Huntsville Hospital. This is yet another patient who is not being followed regularly, given the vast number of patients that need to be followed by Dr. Simon.
15

PATIENT #7 Interview: 02/23/2004 The patient is a 41-year-old male with AIDS who reports a history of multiple episodes of Pneumocystis carinii pneumonia (PCP). The patient also has a significant history of psychiatric disorder and has been diagnosed with bipolar affective disorder as well as schizophrenia and is on psychiatric medications at this time. He also has a history of anemia and oral candidiasis. In discussion with the patient, he reports that he has had multiple episodes of PCP, his last episode being in November. On review of the patient's medical records, there is no documentation of multiple episodes of PCP. There is also no documentation of his hospital visit to the Caraway Hospital where the patient reports that he was there for almost a month recovering from his pneumonia. The patient also states that he has been hearing voices and seeing things that other people do not see. On exam, the patient appears to be a thin male with some wasting. He has tangential speech and is a poor historian. IMPRESSION: This patient is a 41-year-old male with AIDS who, by history, reports having PCP multiple times, the last time being November 2003. It is unclear why his medical records do not document this, or why the records from the Caraway Hospital are not part of his current medical records. The records from the hospital should be in the chart if indeed he was at the hospital. Because of the lack of documentation of his illness, not much insight into the patient’s care can be provided.
16

PATIENT #8 Interview: 02/23/2004 The patient is a 31-year-old male who I previously saw during my February 13/14, 2003 visit. Since October, he has been off antiretroviral therapy when he signed a refusal form. The patient has a history of non-adherence and has a large amount of frustration with the medical system. He has experienced multiple side effects and toxicities from the medications and states that he gets the same medications restarted, even though he has had toxicity in the past while on the same medications. The patient reports that he supports the Akeep-on person@ or KOP medication distribution system that is in place. However, it is not working. Patients are not able to refill any of their medications until they run out of their medications and then often there are no medications available. This means that they sometimes run out of medications for two to three days. This has been consistently reported by all the patients at the Limestone Correctional Facility -- that medications are still not being supplied in a regular manner. The patient is also on INH for tuberculosis prophylaxis. He states that he has been getting his breakfast at the usual time of 3 a.m. in the morning. This does not permit him a regular night=s sleep. IMPRESSION: This patient is frustrated with the Limestone Correctional Facility medical system, or lack thereof medical system. He is currently not on antiretroviral therapy. He had been on HIV medications and due to multiple toxicities and side effects was taken off. However, he states that when he had these medications restarted, he was put on the same medications. He reports that the KOP or Akeep-on person@ is a positive step, but that it is not working correctly and that they are running out of medications. This has been supported by many other patients.
17

PATIENT #9
Interview: 02/23/2004
This patient is a 49-year-old male who has a history of AIDS and non-insulin dependent diabetes mellitus. The patient also has been diagnosed with bilateral avascular necrosis, the first occurrence in his left hip in 2001, the second occurrence being in the right hip in October 2003. Of note, the patient has had radiographic examinations, which demonstrate that the patient in fact has avascular necrosis with collapse. This has led to his not being able to walk any longer. He currently gets around by using a wheelchair. He has very severe, persistent pain in both of his hips. Again, he is unable to walk or stand.
The patient has been seen by an outside surgeon, Dr. Dueland, several times, the last visit in October 2003. A referral for to be seen by Dr. Dueland is in the chart, but Dr. Dueland=s consultation report can not be found. According to the patient, he was told by Dr. Dueland (and Dr. Simon was told by Dr. Dueland) that Dr. Dueland would in fact do the surgery for this patient. However, it has been several months now and the patient has been told that because of the switching of the medical system, they are not going to do the surgery at this time, and that it needs to be reevaluated.
Also, the patient states that he is currently on a regimen of efavirenz, abacavir, saquinavir, and ritonavir. He is on a mixed regimen and is able to keep two medications, efavirenz and abacavir, on him. Unfortunately he still has to go to the pill line for the ritonavir and saquinavir. The patient reports that they run out of his medications. The last time that they ran out of his medications was on 02/20/2004 and 02/21/2004.
IMPRESSION: This patient has a very severe problem in his hips, which has led to his being severely disabled and dependent upon a wheelchair for mobility. Although he had an evaluation several months ago, he has not had much-needed surgery. Apparently the surgeon felt that the patient was eligible for surgical treatment, especially given his excellent response to therapy. His CD4 count went from 138 recently to 309. Of great concern is that medical records appear to be missing.
In addition, the patient is receiving a mixed regimen of both Akeep-on person@ as well as directly observed therapy, which is very confusing and leads to the patient not being given his medications correctly. In addition, the patient is receiving INH at 1 a.m.. This is completely unacceptable.
18

PATIENT #10
Interview: 02/23/2004
The patient is a 53-year-old male with AIDS as well as brittle insulin-dependent diabetes who has been very difficult to manage regarding his diabetes.
The patient is compliant with all his medications as well as his appointments. He tries to stabilize his blood sugar, but is unable to do so. The patient states that while he was at the Mobile County Metropolitan Jail, his blood sugars were stabilized. Yet, at that time he needed five meals a day and was receiving an insulin regimen that helped control his diabetes. Currently, the patient has multiple episodes of hypoglycemia and hyperglycemia. At one point, the patient had such a low blood sugar that he actually fell down. This was likely due to his hypoglycemia.
The patient also reports some pus filled bumps on his head. On examination, he does in fact have these bumps on his head. This is consistent with impetigo (staph infection).
On further questioning, the patient reports that he does not receive a diabetic diet. He receives the regular diet that everyone else receives. He receives a Adiabetic snack@, which consists of half a cup of applesauce or two slices of pineapple or half a pear.
His current HIV medications are tenofovir, 3TC, nevirapine, and nelfinavir. He is also receiving INH for his potential tuberculosis exposure, although he has not had any liver enzyme monitoring. The patient=s CD4 count on 08/13/2003 was 397 with a viral load of less than 75.
IMPRESSION: This is a patient with very brittle diabetes mellitus. Given that he is not receiving an adequate diabetic diet or small meals, as he had been before, it is going to be impossible to control his diabetes. As a result, the patient has suffered because of his uncontrolled diabetes as evidenced by the recent fall. The patient stated that he has requested diabetic diets, but they are not available at Limestone Correctional Facility. Thus, he is given a regular diet.
Also concerning is that the patient is on INH. In view of his antiretroviral therapy and AIDS, he should have his liver enzymes monitored. This is not being done.
Also, upon reviewing the chart, the patient had a lipid panel drawn. According to the patient, as corroborated by other patients, this was not obtained while the patient was fasting, even though he had an elevated triglyceride level of 349. This makes it very difficult to actually assess the level’s importance.
The patient=s last CD4 count and viral load were 08/13/2003. These were not repeated until 02/21/2004, which is a six-month lag. This is much too long between test results.
19

PATIENT #11 Interview: 02/23/2004 This patient is a 37-year-old HIV positive male with a CD4 count of 448 and a viral load of 1200 on 09/17/2003. He is currently not on any antiretroviral medications or any HIV medications. He is taking INH prophylaxis for a possible tuberculosis exposure. The patient also has hepatitis C. The patient received hepatitis A and hepatitis B vaccinations on 10/04/2003. After much discussion with the patient, the patient does not have a good knowledge of hepatitis C and has not been counseled at Limestone. He also is not aware that there is treatment for hepatitis C, much less the mechanisms of transmission. Yet, the patient is interested in treatment. However, treatment is apparently unavailable at the Limestone Correctional Facility. On examination the patient looks rather healthy. He is not wasted and he does not show any evidence of chronic liver disease. IMPRESSION: This patient is a 37-year-old male who has stable HIV and chronic hepatitis C. While he has been appropriately vaccinated, which is something that is new to the Limestone Correctional Facility, he has not had any reasonable counseling on hepatitis C has had no discussion regarding therapy. More and more, treatment for hepatitis C-infected patients in the presence of HIV is becoming the standard of care.
20

PATIENT #12
Interview: 02/23/2004
The patient is a 33-year-old male who is HIV positive and has hepatitis C. He also has a history of multiple skin Staph infections.
The patient reports that he is currently on medication for his HIV, which includes tenofovir, ddI, and efavirenz. Until recently, the patient was on too high a dose of ddI, which was recently decreased to an appropriate dose. The patient states that the medications are not delivered to him on a regular basis. In fact, they often miss doses. They are often out of his medications. Currently he has not had his tenofovir for the past four days. In addition, several weeks ago they ran out of his ddI for several days. He is currently receiving only one medication as Akeep-on person@ which is the ddI. The rest of his medications he receives as directly observed therapy, which is fairly complicated.
The patient has absolutely no knowledge of hepatitis C, including its mechanism of transmission or its pathophysiology. In addition, he does not understand that there is treatment for hepatitis C, although I discussed with him that there is available treatment. He informed me that Dr. Simon told him AI am here to treat your HIV only; not to treat your hepatitis C. This is none of my concern.@
The patient states that he has had multiple abscesses of his buttock area as well as other parts of his skin, including his face. He states that he was seen by Dr. Simon about this issue. However, Dr. Simon did not address this issue. As a result, he had to have another inmate help him drain these lesions. He reports draining a large amount of pus.
Currently, the patient is on INH therapy and has one scheduled followup liver enzyme test, although there is no regular followup testing for liver enzymes, even though he has chronic hepatitis C.
IMPRESSION: This is a patient who fits the pattern of not receiving his medications on a regular basis. This is a huge problem given that this will set him up for resistance and these medications will ultimately fail. Also, it is unclear why the system currently exists where some patients get part of their medications as Akeep-on person@ and the other part of their medications as directly observed therapy. This is counter productive to the patient=s care and creates a lot of confusion.
Also, the patient has absolutely no knowledge of hepatitis C and is unaware that there is available treatment. Apparently, Limestone Correctional Facility does not treat hepatitis C infected inmates.
Also, on examination the patient is edentulous. (See photograph 11) Review of his medical
21

records show that he has lost about 10% of his body weight or more. This needs to be addressed. All patients need to have some sort of mechanism for eating and he does need to have dentures.
22

PATIENT #13 Interview: 02/23/2004 The patient is a 56-year-old male with HIV infection who was examined on 02/23/2004. This was in followup of an examination on 02/14/2003. The patient was initially seen on 02/14/2003 and at that time he had a non-healing irregular ulcer on his right forearm. Since that time, after several months, on October 2003 the patient finally had the lesion removed. On pathology it showed a basal cell carcinoma. Before the lesion was removed, he had multiple visits and was told that the lesion was not carcinoma. He has had the lesion removed and it appears to be healing quite well. The patient is currently on d4T, ddI, and nevirapine and is doing quite well. His CD4 count is 519 with a viral load of 527. IMPRESSION: This is a patient who had a lesion, which was very consistent with cancer (basal cell carcinoma). It took the Limestone Correctional Facility an inordinately long period of time to finally have this lesion removed. Luckily, the patient has had it removed and it appears, at least at this point in time, to be under control. HIV infection: The patient is currently on a regimen of d4T, ddI and nevirapine. Again, as with previous patients, this patient is on d4T and ddI. Given the excessive mitochondrial toxicity and potential for lactic acidosis, this therapy needs to be reassessed. d4T and ddI are only used in combination in very unusual cases where patients have no other therapy options.
23

PATIENT #14
Interview: 02/23/2004
The patient is a 29-year-old male who was initially incarcerated at the Limestone Correctional Facility in January 2003. Soon after the patient=s admission, he was found to have a BUN of 14 and a creatinine of 1.6. These are both abnormal. The creatinine of 1.6 signifies that he has lost close to half of his renal function.
According to the patient's incomplete medical records, it looks like his kidney function tests were not obtained until 06/16/2003. At that time, his kidney function was severely compromised; his BUN was 46, creatinine 4.6. One week later the patient=s renal function continued to decline; his BUN was 57 and creatinine was 7.1.
By this time, the patient was in renal failure. He was then referred to a kidney specialist. He was seen on 08/15/2003, which was eight months after his initial renal insufficiency. He was then diagnosed with AIDS nephropathy. It was believed that he should be observed. The patient had recently received an AV shunt placement.
Soon thereafter, the patient was placed on renal dialysis and has been on dialysis for approximately two months. Since then, he has not been feeling well. Currently, the patient reports that he does not feel well overall, has low energy and generalized malaise.
On 12/19/2003 the patient was seen by Dr. Simon complaining of body aches, fever and headache. He was diagnosed with a viral syndrome. He was seen 10 days later on 12/29/2003 by Dr. Hamer who is a new part time physician here at Limestone Correctional Facility. The patient was diagnosed with severe pneumonia and admitted to the inpatient unit where he was treated with broad-spectrum antibiotics. His condition has improved.
IMPRESSION: This patient is a 29-year-old male who, upon entering the Limestone Correctional Facility, clearly had some kidney dysfunction as represented by a creatinine of 1.6. A vast majority of the medical records have been pulled from his chart prior to July. A referral slip outlining the patient’s follow-up could not be found in his medical chart. Most disturbing is that it did not appear that the patient's creatinine or renal function was checked until several months later. By that time, he was in full renal failure and progressed rapidly to end-stage renal disease. Several months later he had to be put on dialysis.
This represents yet another patient at the Limestone Correctional Facility who was not followed closely enough, given the large number of patients and the small number of providers. However, it is encouraging to see that the patient is on a triple drug regimen of AZT, 3TC, and nevirapine. This may assist his HIV status given that his CD4 count is quite low at less than 20. However, it will not at all help out his renal failure. His renal failure at this point is irreversible.
24

PATIENT #15
Chart Review: 02/23/2004
The patient is a 34-year-old gentleman who has a history of AIDS as well as multiple documentations by Dr. Simon in the chart that he is not compliant.
The patient reported to clinic on 01/23/2004 complaining of general body aches and weight loss. Per her examination, he looked chronically ill. Dr. Simon diagnosed the patient with bronchitis versus pneumonia. He was housed in a single room and given Levaquin as an antibiotic for bacterial pneumonia. Just two days later the patient was continued on this antibiotic and sputum was obtained for AFB.
Dr. Simon also documented that the patient had a history of noncompliance. However, Dr. Scheibel actually saw the patient at that time and initially the patient was very interested in starting a regimen. He started him on a once-a-day regimen of Emtriva, Viread, Reyataz and Norvir. This was surprising given that the patient had been reported to be noncompliant. This was an excellent starting regimen for the patient.
On 02/04/2004, the patient continued to have a productive cough. He was continued on his current medications with a serum cryptococcal antigen that was obtained. On 02/06/2004, the patient was continued on his current medications. On 02/09/2004, he was on the same medications despite having increasing respiratory demands and a fever. On 02/11/2004 the patient was on four liters of oxygen which is a lot. The patient signed a DNR for Dr. Simon. The patient was given the diagnosis of rule out PCP and started on atovaquone. Interestingly, the patient did not receive a chest x-ray, an induced sputum, or a bronchoscopy. None of these tests are indicated in the chart.
The patient continued to deteriorate until 02/17/2004 when the patient was on six liters of oxygen with a fever of 104. This is very high amounts of oxygen. There are no oxygen saturations recorded in Dr. Simon=s note. The patient was in severe respiratory distress and was transferred from Limestone by ambulance to Huntsville Hospital.
The current status of the patient is unclear. Most likely, he is still at Huntsville Hospital and is critically ill. Hopefully, he has not died.
IMPRESSION: Mr. Watkins is a young, 35-year-old patient with AIDS who was listed as noncompliant. Yet he was seen by Dr. Scheibel and started on a once a day regimen. Dr. Scheibel is a Prison Health Service medical director of the western region and apparently consulted with Dr. Simon at the facility.
The patient had a pulmonary process in his lungs, which was treated without ever getting a diagnosis. Unfortunately the patient deteriorated at the Limestone Correctional Facility, had
25

increasing respiratory requirements despite not having a diagnosis and was transferred to the Huntsville Hospital. Early on, this patient should have received induced sputum or bronchoscopy to try to get a diagnosis because he probably has Pneumocystis carinii pneumonia. Also, there are no arterial blood gases, which would have determined whether the patient needs steroids. It is unfortunate. This patient is very critically ill and may not survive.
26

SUMMARIES OF HIV INFECTED PATIENTS’ DEATHS AT LIMESTONE CORRECTIONAL FACILITY OCTOBER 2003 TO FEBRUARY 2004

TAB NO. A. B. C. D. E.

NAME

AGE AT DEATH

GERALD LEWIS

35

ROBERT STRICKLAND 37

NATHAN SULLIVAN 40

ALFRED THOMAS

42

ROBERT WALKER

48

DATE OF DEATH 2-26-2004 1-2-2004 10-13-2003 10-26-2003 11-6-2003

PAGES

27

DEATH SUMMARY GERALD LEWIS
Gerald Lewis was a 35-year-old male with AIDS and wasting who died on 02/06/2004 at 12:40 PM at the Limestone Correctional Facility.
A review of the patient's medical records prior to his death, reveals that the patient had a significant weight loss. In fact, the patient's weight recorded in July 2003 was 171 pounds. Although his weight was not regularly documented, in January 2004 the patient=s weight was 110 pounds which is an extreme amount of weight loss; one-third of his total body weight was lost. The patient's weight loss was fairly progressive. As far back as 10/08/2003, the patient was seen by PA Ebby because of weight loss as well as diarrhea. At that time, no workup was done and no assessment of his diarrhea was initiated. Notes from January 2004 document that the patient had significant weight loss, which was reported consistently in the notes by Dr. Simon. At one point she documented the patient=s significant weight loss and wanted to rule out hyperthyroidism, a rare cause of weight loss in this setting, and heart failure. Unfortunately there was no assessment of this patient for more common diseases that might cause such severe wasting.
Also listed in the patient's chart were multiple references to noncompliance. There was no thorough counseling that the patient underwent because of his supposed noncompliance. The patient was placed on protein supplementation. At one time, however, Dr. Simon felt that the patient should have received a high protein drink, but was told Akitchen was called for high protein drink, but is not available since milk was added to the diet at Limestone.@ So, the patient did not get what the doctor believed he should have received.
On 01/15/2004 the patient had blood cultures for MAC and tuberculosis. Again, there was no workup of his stool for any kind for pathogens that might have caused wasting. No testosterone level, repeat blood cultures or any medications that might have increased the patient's lean body mass were performed.
IMPRESSION: Mr. Lewis is yet another patient at the Limestone Correctional Facility who had AIDS, was labeled noncompliant, and had a progressive course. It is clear that he either had AIDS wasting, or some common HIV-associated pathogen that was causing him to have such wasting. However, there was no thorough workup of the patient's wasting syndrome. Even such a simple laboratory test as a testosterone level, which is a male hormone, which can often be low in AIDS patients, was not even assessed.
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The patient was not given any common medications that would increase his lean body mass or that would have increased the patient's appetite. There is a large body of literature that currently exists that shows that there are multiple medications that can increase a patient's appetite, increase their weight and increase their decreasing body mass. A few examples can be found in Clinical Infectious Diseases, 2003, volume 36, pages 69-78, HIV Clinical Trials, May-June 2003, volume 4, pages 150-163, Journal of Parenteral Enteral Nutrition, November-December 2002, volume 26, pages 357-365, The Journal of the Acquired Immunodeficiency Syndromes and Human Retrovirology, 1999, volume 20, pages 137-146, and Annals of Internal Medicine, 1998, volume 1, pages 18-26. These are just a few examples of the large body of literature that currently exists which demonstrate that patients who have wasting from AIDS can be administered different whole modality medications. Many of these medications are not expensive, such as testosterone or androgens, appetite stimulants, or even thalidomide. These medications have all been shown to increase body mass and furthermore, increase a patient’s quality of life. It is puzzling why these medications are not being used at the Limestone Correctional Facility.
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DEATH SUMMARY ROBERT STRICKLAND
Robert Strickland was a 37-year-old male with AIDS who died on 01/02/2004 at 11:35 p.m. at the Limestone Correctional Facility. The patient's medical history is significant for being HIV infected and having (1) AIDS (CD4 count less than 20) in 03/2001; (2) hepatitis C with cirrhosis; (3) presumptive metastatic cancer to the lungs of unknown primary; and (4) pancytopenia. The patient was incarcerated multiple times prior to this incarceration at the Limestone Correctional Facility. The patient’s medical records date back to the mid-late 1990=s.
The patient died in the inpatient facility at Limestone Correctional Facility on 01/02/2004. Dr. Hamer notes on 12/31/2003 that the patient Aneeds DNR@ because the patient was coughing up blood. On 11/17/2003 there was a discussion regarding end-of-life care and Astates that he does not wish to be on life support. He understands his condition, so we can let him go when the time comes.@ This was documented by Dr. Simon.
The events leading to the patient's death are that he was vomiting blood in early November 2003 when he was seen by Physician=s Assistant Ebby. As a part of this workup, a chest x-ray was done which incidentally showed that the patient had lesions in the lung. The patient was then sent out to the local hospital where he was evaluated. No records can be found in the patient’s chart from this hospital visit. It was decided that he would not have an invasive diagnostic workup given his advanced AIDS, and that this appeared to be metastatic cancer, likely originating from the liver.
Reviewing the patient notes, it is obvious that on many occasions he reported having uncontrolled vomiting starting as far back as November, then worsening in December. He was put on a drug called Phenergan which did not appear to control his nausea or vomiting. I am not able to find where any other drug was tried. There are multiple notes stating that the patient refused meds. On 10/02/2003 Dr. Simon writes Anot on any medications. Had refused all of them.@ On 09/30/2003, she also writes that Astill does not wish to take any meds whatsoever.@ On 06/05/2003, it is documented in the patient's notes that he was counseled regarding the need to take his medications. Earlier that year on 03/25/2003, the patient apparently just stopped his medications, but from August 2002, the patient had a CD4 count of 81 and a viral load of less than 50, indicating that he did have full suppression of the virus, was responsive to therapy and was able to be compliant.
On 04/09/2003, the patient's total white blood cell count was 1500 with 437 neutrophils (normal neutrophil count is 1500 to 7800). A low neutrophil count is something that we call neutropenia and places the patient at high risk of getting an infection and dying; it is concerning that the patient=s neutropenia was not addressed. The patient did not receive any medications to bring up his neutrophil count. It is unclear why this was not done.
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Further back in the chart, dating back to 02/02/1998, the patient was seen by Dr. Moore. At that time, the patient was on three-drug therapy with d4T, 3TC, and Indinavir. But the patient told Dr. Moore that he wants to stop his Indinavir. So Dr. Moore continued him on a two-drug regimen of d4T and 3TC for an unspecified time period. It is unclear why a third drug was not substituted for the Indinavir.
Also, during that time on 09/09/1998, the patient signed an HIV adherence agreement. I have seen these agreements before, and they have always struck me as being an impediment to a good therapeutic relationship. One of the statements in this agreement provides that Aif you do not follow the treatment as prescribed, you will be taken off the medication permanently.@ The patient is forced to sign this agreement if he wants to go on HIV medications. Later on, the patient was put on appropriate therapy with triple drugs of Combivir (which is AZT and 3TC) and efavirenz.
IMPRESSION: Mr. Strickland was an unfortunate gentleman who had AIDS as well as hepatitis C and likely developed cancer possibly from the liver, which then spread to the patient's lungs. His end-of-life care was somewhat appropriate in that he decided not to pursue any aggressive workup or treatment, so he received hospice care. From the notes, it appears that his pain was well controlled.
What is concerning is that his vomiting was not well controlled on the medication he was prescribed. It is unclear why another medication was not tried such as ondansetron. This is a medication used for cancer patients and AIDS patients with severe nausea. Yet, the patient continued to suffer needlessly from nausea and vomiting
Also, a Do Not Resuscitate form signed by the patient can not be found in the medical records. On 12/31/2003, Dr. Hamer writes in the note that the patient Aneeds a DNR.@
Also of concern, is that the patient was apparently forced to sign an adherence agreement on 09/09/1998. This forces the patient into either perfect adherence (something that is rarely possible when taking combination therapies) or, as a consequence, the medication(s) can be stopped. Since failure is in most cases unavoidable, this adherence agreement can be construed as a setup for failure.
The patient had a low neutrophil count which is technically diagnosed as neutropenia. This was not addressed and it was not treated. Again, the treatment for neutropenia is a drug called GCSF. It is the standard of care that when a patient is neutropenic that he be given GCSF.
The patient also had hepatitis C. The treatment for this disease was never addressed previously in the patient's visits at the Limestone Correctional Facility because they apparently do not treat hepatitis C, even though it is becoming the standard of care to treat hepatitis C, even in HIV infected patients. The National Institutes of Health do NOT exclude HIV+ patients from being treated given the secondary complications that can occur such as cirrhosis, cancer and liver failure.
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DEATH SUMMARY NATHAN SULLIVAN
Nathan Sullivan was a 40-year-old male who died on 10/13/2003 at the Huntsville Hospital.
The patient=s history is significant. He had AIDS with multi-drug resistance and uncontrolled high blood pressure.
The patient's medical records reveal that he had been on multiple medications in the past and in fact was noncompliant on many occasions. There are several notes where the patient was asking for his medications to be discontinued; that he was feeling the medications might be toxic to his body. Absent from the chart are any very good explanations to the patient why he should be taking the medications. The patient’s medications were just stopped. Yet, the patient agreed to continue with his prophylactic type medications that would prevent PCP and MAC.
The patient=s inciting event that caused his death appears to have started on 10/05/2003 when the patient presented to the clinic. There was an emergency note treatment record by RN Weaver that states AI am so sick, I can=t even walk. Inmate crying, praying to God to deliver him from this illness. Achy head to toe, nausea, headache, diarrhea after taking meds.@ Diagnosis: Rule out PCP.@ Further, the nurse documents that the patient has an increased respiratory rate of 24 which is almost twice the normal rate. He also has a high fever of nearly 103.
At that time, physician=s assistant Ebby is called and the patient is housed in the infirmary and given IV fluids. While the patient is in the infirmary, the RN writes that the patient's condition is Apoor.@ The patient's skin temperature is Ahot.@
The next day, 10/06/2003, the respiratory rate had increased to 28, pulse 120, and the fever had increased to over 103 degrees. The patient continued to have fever. It was not until three days later that blood cultures as well as Cryptococcal titers and a chest x-ray were ordered. Unfortunately, the results of the chest x-ray can not be found in the chart.
During this time, when the patient was clearly in severe respiratory distress, there is no documentation of any oxygen saturations or near complete workup until 10/09/2003 when the patient was noted to be confused. Again, PA Ebby is called who requests a CT of the head as soon as possible. However, this is not done. On 10/10/2003 the patient has increased confusion. His respiratory rate had further increased. His fevers continued. This is the first and only time an oxygen saturation is documented. The oxygen saturation level was a very low 89% on two liters.
When the ambulance personnel arrived, they initially refused to transport the patient because the patient=s oxygenation status was so poor. Yet, after talking with the nursing staff, they decided to transport the patient immediately to Huntsville Hospital, where the patient died only three days later.
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Unfortunately, no medical records from the Huntsville Hospital can be found in this patient's chart, so it can not be determined what was done at the hospital. It is expected that a complete workup including the head CT, cultures for MAC and induced sputum from bronchoscopy were performed. However, these were not performed while the patient was declining at the Limestone Correctional Facility. Also, on 09/25/2003, the patient's CD4 count was 1% and the viral load was 35,000. IMPRESSION: This patient represents a patient who was critically ill. It is clear that this patient's critical illness was not appropriately evaluated and the severity of the patient's illness was not appreciated. This was evidenced by the fact that the patient felt that he was dying a full week before his actual death, given his written own statements and the statements of the nursing staff describing the patient's condition as poor, noting that the patient continued to decline and having poor respiratory status. Unfortunately no workup of his oxygenation was performed until the patient was sent out in extremis by ambulance to the local Huntsville Hospital where he died.
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DEATH SUMMARY ALFRED THOMAS
Alfred Thomas was a 42-year-old male who died on 10/26/2003 at Carraway Hospital while in the custody of Limestone Correctional Facility.
The patient was received from the Kilby Correctional Facility on 09/29/2003 and carried the diagnosis of AIDS, tuberculosis, and drug-induced hepatitis. A review of his laboratory results show that the patient had very severe hepatitis (inflammation of the liver) which, according to the notes, was diagnosed at the Kilby Correctional Facility.
The patient also had a CD4 count of less than 20 which was obtained on 10/02/2003.
During a previous incarceration in the Department of Corrections during 2001, the patient received INH therapy for TB exposure. At that time, he had liver dysfunction from the INH and his treatment was discontinued.
The patient was again started on TB treatment on 03/24/2003 with four drugs which later was decreased to two drugs. Several months later, while at Kilby Correctional Facility, the patient had very high liver enzymes. In fact, laboratory tests from 09/19/2003 show an AST of 1,095 which is about 25 times above normal; an ALT of 387, which is approximately 10 times above normal; and a bilirubin of 16, which is about 15 times above normal. This indicates severe liver dysfunction.
When the patient was received at the Limestone Correctional Facility, he was not on any medications (TB treatment or otherwise) and his liver dysfunction was somewhat improved. The patient was seen on 10/02/2003 by Dr. Simon. He was then housed in the HIV dormitory.
While at the Limestone Correctional Facility, the patient deteriorated very quickly and was transferred on 10/16/2003 to Carraway Hospital. At that time, the patient was housed in a respiratory isolation room at the hospital. The patient was noted to have a fever and progressive liver failure, and was also noted to have a mediastinal mass in his chest, as well as kidney failure and severe anemia.
The patient progressively deteriorated at the Carraway Hospital and subsequently died, most likely from liver failure, renal failure, and an overwhelming infection.
A review of the patient's chart shows that at one time he was negative for hepatitis C antibodies, although no PCR was done. The patient had also stated on his intake screening form that he had hepatitis C. He had no further work-up of his hepatitis.
The patient's records from the Kilby Correctional Facility are not complete in the patient's current
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medical records at the Limestone Correctional Facility. This is very concerning.
After the patient was already transferred to Carraway Hospital, Dr. Simon received results of a chest x-ray which appeared to show active tuberculosis in the patient. Sometime after the patient’s death, the medical staff was notified by the Health Department that Mr. Thomas had active tuberculosis during autopsy. Because Mr. Thomas was housed in the population of the HIV dormitory, the entire HIV infected inmate population at Limestone is currently being treated with INH tuberculosis prevention medication.
IMPRESSION: Mr. Thomas was at the Limestone Correctional Facility for only a short time. He progressively deteriorated and then was admitted to an outlying hospital and died.
Of most concern about this patient's care and medical records is that there are not complete medical records from the Kilby Correctional Facility, even though the patient was transferred from that institution with severe, life-threatening conditions. It is clear that there is very little communication between the prison facilities and charts are almost never transferred with the patient. The charts should be transferred with the patient. This lack of continuity of care is dangerous for the patient.
Also, this patient clearly had INH toxicity on 09/15/2001 during a previous incarceration. INH was restarted with three other TB medications on 03/24/2003 when the patient was at the Kilby Correctional Facility. It is uncertain whether this patient had any liver enzyme monitoring during this time, which he clearly should have had before he became very symptomatic and presented with very severe liver toxicity.
Many of the patients I examined at the Facility on 02/23/2004 are co-infected with HIV and Hepatitis C and are now being given INH therapy. Most of these patients are not having their liver enzymes monitored appropriately.
In addition, HIV positive individuals with liver dysfunction and test negative for hepatitis C antibodies, should be in fact screened for hepatitis C using a PCR which is a much more sensitive test. In fact, approximately 20% of patients who have AIDS and who have hepatitis C, will screen hepatitis C antibody negative. Thus, hepatitis C PCR is the standard of care for screening for hepatitis in a patient who is hepatitis C antibody negative yet is suspected of having hepatitis C. Stated more simply, the screening test was inappropriate for this patient and he may have had hepatitis C. It was also inappropriate that the INH was restarted given that he already had INH toxicity previously. He most likely did not receive appropriate monitoring of his liver enzymes, although again the Kilby Correctional Facility records were not complete for this patient. This is a tremendous problem.
Finally but very importantly, this patient had active Tuberculosis of the lung and was placed in general population and thus all the other HIV-infected patients (and staff) were potentially exposed to TB. This case demonstrates the lack of an organized system of infection control at
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Limestone Correctional Facility. As a result of not putting this patient in respiratory isolation, numerous patients (and possibly even some staff) are having to take INH for TB prevention.
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DEATH SUMMARY ROBERT WALKER
Robert Walker=s date of birth was 10/01/1955. Because of incomplete medical records, the exact date of his death is unclear. It appears that he died on 11/07/03.
Mr. Walker was an HIV positive patient. He also had hepatitis C and poorly controlled diabetes mellitus. His last CD4 count that was recorded in the chart was in 08/2003 which was 276 with a viral load of approximately 3000. The patient was seen by Dr. Simon on 06/19/2003 with painful swelling in his neck. It was so painful, he was unable to swallow. The patient was given Keflex for lymphadenitis. He returned approximately two weeks later on 07/03/2003, and at that time Dr. Simon documented that the patient had resolved lymphadenitis and had no more lymphadenopathy.
The patient returned on 09/04/2003 and was conspicuously found to have a large mass at the angle of the temporomandibular joint. He subsequently underwent a workup of this swelling which was found to be a lymphoma. At that time, he was also noted to have lymphadenopathy in his neck. On 10/22/03, the patient underwent lymph node dissection and chemotherapy. The procedure was performed four months after initially presenting to the physician with symptoms.
There are multiple entries stating that the patient was not on antiretroviral therapy. Any entries that discussing whether this should be initiated can not be found in the chart, even though the patient=s CD4 count met the Department of Health and Human Services criteria for starting treatment.
IMPRESSION: Mr. Walker is an unfortunate AIDS patient who appears to have died of lymphoma at the Limestone Correctional Facility. This is yet another patient with incomplete medical records that appear to have been thinned. It is unclear why there are no records prior to his death. The biggest problem with this patient's care is that he was diagnosed with lymphoma and then not treated with antiretroviral therapy. The standard of care for an HIV positive individual with lymphoma should include HAART. Multiple studies have shown that patient=s who have lymphoma and are treated with HAART therapy, and chemotherapy, will do much better than patients who are only treated with chemotherapy, as this patient was treated.
Also concerning is the lack of full medical records, especially at the time prior to his death. These records should be reviewed to further evaluate the care of this patient which is clearly suboptimal.
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SUMMARY OF THE MEDICAL CARE AT
THE LIMESTONE CORRECTIONAL FACILITY Stephen Tabet, MD, MPH
ASSESSMENT
The medical care at Limestone Correctional Facility has improved in a few areas, has declined in other areas, but has generally remained the same since my last visit on February 13 and 14, 2003 (as detailed in my initial report of August, 2003). In this section of the report, I will review my last report’s summary, paragraph by paragraph, and discuss the specific issues supporting the overall assessment of the Limestone Correctional Facility’s medical care. More strongly than ever, I feel that the Limestone Correctional Facility is in dire need of outside intervention and oversight.
DEATHS
One of the most egregious medical failures at Limestone is the number of preventable deaths. In the initial report, I reviewed 38 deaths since 1999. Since that time, I have reviewed five additional HIV patient deaths at the Limestone Correctional Facility. Patients continue to die because of the failure of the medical system. One of the most disturbing problems described in the prior report addressed a patient who literally suffocated in front of the medical staff. Sadly, another patient has recently declined right in front of the medical staff and suffered the same fate at the Limestone Correctional Facility.
Cardiopulmonary resuscitation (CPR) continues to rarely, if ever, be attempted in any deceased patient that was reviewed. This is a very concerning trend that continues at Limestone Correctional Facility. It is still relevant to question whether the nursing staff at Limestone Correctional Facility is adequately trained in CPR.
The deaths of HIV-infected inmates at Limestone continue without any appropriate thorough internal review. A cursory review is conducted by Dr. Simon. However, Dr. Simon’s cursory reviews contain no substantive content and are of no real value. It is extremely disturbing that officials at Limestone, and particularly the Medical Director, would not want to review the deaths at this institution in detail, if only to identify and attempt to resolve the problems that so obviously exist within the current medical system. This is unacceptable.
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PREVENTATIVE CARE
The medical system at Limestone continues to undervalue the cost-effectiveness of insuring that patients receive preventative care. A positive step is that hepatitis A and B vaccinations are now being provided. However, there continue to be a large number of patients who are not receiving their prophylactic or maintenance medications. These medications are life-saving medications used to treat or prevent such common and preventable illnesses such as Pneumocystis carinii pneumonia. Despite being addressed in the previous report, this pattern continues unabated.
It is also clear that patients continue to not fully understand the consequences of failing to take these life-saving antibiotics. From limited documentation, there appears to be some attempt by the medical staff to try to explain to a few patients why they must take their medications. However, the documentation for addressing this issue is wholly inadequate. There are many more patients who receive no counseling at all regarding the importance of medication compliance. And there are no attempts to solve the problems that cause noncompliance in the first instance.
Currently, one of the positive new measures at Limestone Correctional Facility is the “keep-on person” system. The biggest problem, however, with the “keep-on person” system is that it is not being effectively managed. As a result, patients often do not receive enough supply of their medications and run out. This may eventually lead to individual resistance to the medication(s). It is also accepted among infectious disease specialists that the effectiveness of the medications is largely dependent upon consistent dosing, which cannot exist in this kind of situation.
PILL LINE
During the first visit to Limestone, one of the concerning issues was that patients were treated like nuisances. This attitude continues to occur. Previously much-needed sleep was terminated for medication dosing at 3 a.m. or earlier. This was further compounded by breakfast at 3:30 in the morning. Currently, however, sleep is further interrupted so that patients can be distributed their much- needed medication dosing at 1 a.m. in the morning. This seems to be an arbitrarily imposed dosing time. This dosing time makes no practical sense and clearly is not healthy, mentally or physically, for an HIV- infected patient. However, this practice continues to occur, largely for the convenience of the staff and because of staffing needs. It is an unacceptable practice to have a patient go to bed at 10 or 11 p.m., or even midnight, and then to wake him up at 1 o’clock or 3 o’clock a.m. for medication distribution. Clearly, this will cause serious sleep deficits for the patients who are ill and have depressed immune systems.
During this visit, a considerable amount of time was spent observing the pill line at the Limestone Correctional Facility. There were numerous problems with the pill line during the previous visit. It is distressing to report that the pill line, which is the patient's life- line to receive his life-saving medications, continues to pose a significant problem. Multiple medications were not available for the patients. Patients were told either to return at a later time, or at a later date,
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thereby missing their dosing. For patients on HIV medications, this can lead to drug resistance, rendering the drugs ineffective and useless in the battle against HIV. Ultimately, this can lead to death. It is absolutely unacceptable that the facility continues to run out of much-needed HIV and other medications as frequently as it is occurring at Limestone.
ACCESS TO PROGRAMS AND ACTIVITIES
Previously HIV- infected patients at Limestone Correctional Facility were completely segregated from other inmates. This segregation is ongoing. Although it now appears that some of the HIVinfected inmates will be allowed to participate in limited activities with HIV- negative inmates.
RESPONSE TO MEDICAL EMERGENCIES
At this time, an accurate assessment of what occurs during a medical emergency at the facility could not be ascertained. Previously, the slow response time to medical emergencies was concerning. However, the response time to medical emergencies could not be reassessed during this visit.
DIET
Medically necessary dietary requirements for HIV patients, such as diabetics or under-nourished patients, are still virtually nonexistent at Limestone Correctional Facility. The medical staff continues to write orders for special diets for patients, and the Alabama Department of Corrections consistently ignores and refuses to honor these medical orders. This is a problem, especially for patients who are under-nourished or malnourished, because it can result in death. Documentation exists of patients dying of malnourishment at Limestone Correctional Facility. Medications which can increase a patient's lean body mass are still not being used at Limestone Correctional Facility.
ACCESSIBILITY
Previously, the physically handicapped and the disabled suffered disproportionately at Limestone Correctional Facility. This remains true. While the Alabama Department of Corrections has made a half- hearted attempt to install some railings for the disabled to shower, there were no shower chairs. Shower chairs are needed for patients who are wheelchair-bound who need to shower in a sitting position.
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HOUSING
The HIV-positive patients at Limestone were previously housed in an open bay warehouse where over 250 inmates lived in over-crowded conditions. Currently, the inmates have been moved into other housing units with one or two-person cells. These housing units are slightly better. However, there are still drafts and broken windows in these housing units, making living conditions unbearable for these immune-compromised patients. Also, the presence of standing water in the housing units is concerning, and there is a lack of cleanliness in some of the areas of the housing units.
INFECTION CONTROL POLICY
Unfortunately, infection control policy and practices are virtually nonexistent at Limestone Correctional Facility. Although some infection control policies exist on paper, it seems these practices are not in place at Limestone. In the prior report’s summary, a concern about the possibility of an outbreak of tuberculosis was raised. True to the warnings and concerns, because there is no infectious disease prevention protocol in practice, a patient with active tuberculosis was housed with the HIV population. The result is that virtually all of the HIV- infected inmates, and possibly some of the staff, were directly exposed to tuberculosis. Infectious disease prevention protocols are incredibly important in correctional institutions. They need to be strictly adhered. Few of these infection control policies are being followed at the Limestone Correctional Facility.
MEDICAL RECORD TRACKING SYSTEM
Although patients continue to be followed on a somewhat regular basis, the medical system at Limestone Correctional Facility continues to be highly stressed. Such basic services as the dictation and transcription of medical records, simply do not exist at Limestone. In fact, the medical providers hand write their notes into the chart. This method of medical record keeping has largely been abandoned in the medical profession.
In addition, the Limestone Correctional Facility has an extremely poor to non-existent medical record tracking system. This is caused by not having a computerized system of medical care. This poses a problem in a large institution, such as Limestone, that has a large population of HIVinfected inmates and other medically ill inmates.
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STAFFING One of the recent positive changes at Limestone is the presence of another part-time physician. While this is a positive step, Limestone Correctional Facility continues to be understaffed. Because of understaffing, patients will continue to suffer and die from a lack of reasonable medical care and adequate nursing personnel. There is still a sense of hopelessness and helplessness among the patients at Limestone. This was also observed during the last visit. While some of the changes that have been described are somewhat positive, the improvements have been far outweighed by the problems that continue to plague Limestone Correctional Facility. Additionally, new problems have arisen at Limestone.
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RECOMMENDATIONS
Limestone Correctional Facility continues to have a vast array of significant medical problems. The medical care provided at Limestone Correctional Facility falls well below the standard of medical care for patients in the community or those standards established by organized bodies described in the beginning of this report. For this report, I will continue to only make follow-up recommendations of issues that need to be addressed urgently. The following recommendations must be addressed, or patients will continue to needlessly suffer and die at the Limestone Correctional Facility.
1. DEATHS: The number of deaths and the manner in which HIV- infected patients are dying continues to be a problem and is potentially a serious medical liability. Unfortunately, despite describing this issue in the previous report, there remains no thorough, organized system of reviewing patient deaths. The Department of Forensic Sciences provides cursory external autopsies which are not routinely reviewed by the Warden, Dr. Simon, the Medical Advisory Committee or any other reviewing body. In addition, there is no attempt to try and decrease the number of deaths. This is evidenced by Dr. Simon’s own statement that she was not concerned about the number of HIV patient deaths at Limestone Correctional Facility. This is a very disturbing problem that needs to be urgently addressed. All patient deaths need to undergo a full internal and external autopsy, and all deaths need to be reviewed in detail by an outside physician/monitor.
In addition, the staff needs to provide more compassionate education to patients before signing “do not resuscitate” orders.
2. MEDICAL DIRECTOR: Currently, there does not exist a Medical Director at the Limestone Correctional Facility. The Medical Director’s role is defined by understanding the system of care and working administratively in the system of care. Although Dr. Simon is designated as the Medical Director in the policies and procedures for PHS, she does not perform the administrative or leadership duties required by this position. In fact, Warden Mitchem was not even sure who the Medical Director is at Limestone, and has absolutely no contact with Dr. Simon. This is almost impossible to believe. This confusion explains why so many medical system problems are occurring at Limestone Correctional Facility. The Alabama Department of Corrections leadership has no understanding about what the medical staff is doing and the medical staff does not communicate with the Alabama Department of Corrections. The analogy I would use that exists at Limestone is that the head of the institution (the Warden) has been severed from the body (the Medical Director). Initially, the Medical Director should write detailed monthly reports describing the components of the medical system and ongoing medical activities. This report should be reviewed by an outside, independent monitor. An outside independent monitor should review Dr. Simon’s clinical decisions.
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3. PHYSICIAN AND MID-LEVEL STAFFING: While Limestone added one part-time physician to their staff, it remains obvious that the Limestone Correctional Facility continues to be dangerously understaffed with medical personnel. According to the National Commission on Correctional Health Care Guidelines, a facility with 2,200 inmates is expected to have a minimum of 110 physician hours per week. With the current number of patients, including approximately 250 HIV-positive patients, Limestone should have at least two full- time physicians, and two additional mid-level practitioners, in addition to the current physician’s assistant. This staffing number was recommended in the previous report. It has not been followed.
Patients need to be followed more closely. Patients need to have their T-cells and viral load checked regularly. Also, liver enzymes of patients with any liver disease on INH need to be monitored on a regular basis. When patients have irregular lab values that need medical intervention, patients should receive automatic follow-up visits.
Hepatitis C testing and treatment is becoming the standard of care. Therefore, patients should receive hepatitis C testing and treatment. In addition, patients presenting with signs of liver dysfunction should receive a HCV PCR test (when the HCV antibody test is negative).
Patient care is compromised because Limestone medical records contain little or no medical records from Kilby C.F. or other outside facilities. A patient’s medical records from Kilby need to be transferred with the patient to Limestone. In addition, the staff needs to retrieve all records of off-site medical care that was provided while the patient was housed at Limestone.
4. INMATES PROVIDING CARE: It was noted in the last visit that inmates were providing health care to other inmates. This practice continues. Inmates can assist other inmates with certain needs, but should not provide health care. Limestone needs a written policy detailing the services that inmates can provide to sick inmates. In addition, those inmates providing services need to have ongoing training.
5. NURSING: Nursing continues to be severely understaffed and many of the nurses are poorly trained at Limestone. The nurses at Limestone continue to make serious errors, especially at the pill line. As stated in the prior report, the nurses at Limestone are poorly trained and need better training, training in cardiopulmonary resuscitation, and ongoing medical education. The Limestone Correctional Facility needs to mandate that nurses receive certified nursing education as part of their continuous training and education. In addition, the current lack of nurses at the Limestone Correctional Facility is a problem and the National Commission on Correctional Health Care Guidelines need to be followed in terms of adequate nursing levels and training.
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6. INFECTIOUS DISEASE CONTROL: Infection control practices and guidelines either do not exist or are not followed at the Limestone Correctional Facility. As detailed in this report, an inmate with active tuberculosis was placed in the general population and, unfortunately, likely exposed all HIV- infected patients as well as staff members to tuberculosis. Tuberculosis can be a deadly disease. The concern that this event might occur was raised in the prior report’s recommendations. Unfortunately, this has occurred. The Limestone Correctional Facility needs an active infection control department and a well-trained, full time infection control nurse. They also need to have a high suspicion for patients with tuberculosis in order to avoid another potential disaster, like the one that has already occurred when a patient with active tuberculosis was housed in the HIV inmate population.
7. PHARMACY MEDICATION SUPPLY: During this visit, a large amount of time was spent observing the pill line and watching the patients receiving, or in many cases, not receive their medications. Unfortunately the patients continue to be told that their medications are not available. This is a significant problem for HIV- infected patients and can lead to deadly drug-resistant HIV where the patient will fail therapy and die. The Limestone Correctional Facility needs a more organized pill line distribution system. The current system is antiquated and largely nonfunctional. As a result, patients are not receiving their medications appropriately.
8. PATIENTS NOT TAKING THEIR ESSENTIAL MEDICATIONS: This problem continues to occur. Patients continue to be administered medications that should be taken with food on an empty stomach. This is a significant problem which causes poor medication absorption and side effects. When necessary, the Limestone Correctional Facility needs to coordinate the dosing of their medications with food. Many patients also take themselves off of medications after getting medications inconsistently at pill line because they fear becoming resistant to the medications. Often these patients are blamed for this failure in the medical system and are labeled noncompliant.
9. PILL LINE: As stated above, the pill line is a disaster at the Limestone Correctional Facility. The Limestone Correctional Facility has instituted a “keep-on person” program, in which the patient is allowed to keep the medications on his person to be taken later. However, this program has not worked properly because patients run out of medications. Also, certain HIV medications are “keep on person”, while other medications still require the patient to stand in line. This system needs to be coordinated better. One problem that continues is that medications are administered not only at 3 or 3:30 in the morning, but now at 1 in the morning. As described in the previous report, this needs to stop. Patients need to be administered medications at normal hours and not during hours that are convenient only to the medical and correctional staff.
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10. DIETARY REQUIREMENTS: Nutritional supplements and diets continue to not satisfy minimal medical requirements of patients. Patients are given only one meal twice a day on weekends and on holidays. This is not adequate. The special needs of malnourished AIDS patients need to be met and adequate supplementation and medications to increase lean body mass need to be used. This continues to be a significant problem at the Limestone Correctional Facility.
11. MEDICAL EMERGENCIES: This report does not reassess whether medical emergencies continue to be a problem at Limestone Correctional Facility. However, the medical emergency system at Limestone needs to be reviewed and emergency care of HIV- infected patients needs to timely and adequate.
12. AMERICANS WITH DISABILITIES ACT: The Limestone Correctional Facility has made a half- hearted attempt to try to comply with some of the Americans with Disabilities Act regulations. They fall far short of the minimal requirements. Wheelchairbound inmates continue to struggle with mobility in the housing units with access to toilets and beds and moving between buildings that are not wheelchair accessible. The Limestone Correctional Facility should hire an expert to help them in this area to make sure that they are compliant with the Americans with Disabilities Act.
13. CROWDED CONDITIONS IN THE HOUSING UNITS: This is less of a problem. However, the patients continue to live in cold, drafty housing units. The housing units need to be renovated so that patients can have their basic housing needs met.
14. MONITORING: The Limestone Correctional Facility has made a very minor attempt to try to correct their current failed system. While the current contractor for medical services with the Department of Corrections in Alabama, Prison Health Services, has policies and procedures for providing medical care, and a system of medical care that is provided at other facilities throughout the U.S., it is clear that they will be unable to implement such policies and procedures and to provide medical care unless there is oversight and monitoring to assure that such medical care is going to be provided to the patients. Therefore, the Limestone Correctional Facility needs to be monitored closely by an outside HIV specialist, as well as experts in the field of health care management, until they provide medical care that complies with acceptable standards.
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 SUMMARY Stephen Tabet, MD, MPH
SUMMARY OF THE CARE AT LIMESTONE CORRECTIONAL FACILITY
The most egregious medical failure at Limestone is the number of preventable deaths. I reviewed the medical records of 38 HIV-infected patients who died at Limestone since 1999. In almost all instances the death was preceded by a failure to provide proper medical care or treatment. Consistently, patients died of preventable illnesses. Patients with serious diseases experienced serious delays in medical care or were not treated at all. Chronic care clinics are unheard of at Limestone. Lifethreatening laboratory results were treated routinely instead of urgently. Other tests such as radiographs showing pneumonia were commonly not assessed until many days later. At least one patient had such severe pneumonia that he suffocated in front of the medical staff – despite the patient’s requests for treatment, he was not sent to a hospital until his condition was irreversible. CPR was rarely attempted in any critically ill patient that I reviewed.
The deaths of HIV infected inmates at Limestone are not reviewed internally. The coroner provides only a physical description of the patients’ bodies. The medical staff’s documentation of the events leading up to the deaths of inmates is deplorable. There are no internal or external mortality reviews or quality improvement reviews of deaths. Without the medical staff assessing why so many patients are dying, they cannot identify and solve the problems within their system.
The current medical system does not appreciate the cost-effectiveness of ensuring patients receive preventative care. For instance, assuring that a patient receives lifesaving Bactrim (one pill only three times per week) costs merely pennies per day yet prevents a deadly, expensive-to-treat infection called Pneumocystis carinii pneumonia (PCP) – a disease that many patients at Limestone seemed to have needlessly died from. Patients, who clearly do not understand the consequences of not taking these life-saving antibiotics, are allowed to stop taking them without being counseled by the medical staff. Patients in such closely observed settings should at least receive preventive therapy. Such a simple measure as allowing the patient to take the medication back to his unit (often called “keep on person”) is not even an option for patients at Limestone. It is unclear why.
Patients at Limestone are treated like they are nuisances. They are forced to interrupt their much-needed sleep at 3:00 a.m. each early morning to stand in a pill line outside, often in cold, wet weather or sweltering heat, for up to forty-five minutes to receive their life-saving medications. Many of these AIDS patients are too sick or unable to stand long enough to wait in line. Thus, they can not obtain their medications, and sometimes the medications are not available. This leads to lapses in medical care, increases the potential for resistant forms of HIV, and results in further mistrust by the patients in the medical system.

HIV-infected patients at Limestone Correctional Facility are totally segregated from other inmates. This presents a serious problem in terms of medical emergencies. Limestone administration apparently require that the prison facility be “shut down” when moving HIV-infected patients. “Shutting down” an entire prison takes a considerable amount of time; if an HIV-infected patient has a medical emergency and needs to be transferred off the facility, the critical time period is quickly lost and many patients have needlessly died.
Medically necessary dietary requirements for diabetics or undernourished patients are virtually non-existent. Staff indicates that they are strongly discouraged from writing (by the Department of Corrections) for special diets for patients, even when indicated. It must be acknowledged that certain patients have specific dietary needs that must be adhered to. Specific dietary requirements for diabetic patients, patients in renal failure, or under-weight patients is a medical issue that requires attention. A large proportion of patient who died at Limestone were severely malnourished and not receiving adequate nutrition or vitamin/mineral supplementation.
The physically handicapped and disabled suffer disproportionately. They are denied access to baths. The only way of cleaning their bodies in Dorm 16 or Dorm 7 is by showering - an often impossible task for patients who are unable to get out of their wheelchairs and step over a high ledge to access the shower. There are numerous areas I toured in the facility where accessibility for the handicapped is disregarded and neglected. For example, there are not adequate railings or ramps for wheelchair access. The medical understaffing also leads to the inappropriate use if inmates caring for disabled patients.
The open warehouse where approximately 2501 HIV-infected patients live is overcrowded. Side-by-side and head-to-toe bunk arrangements place these immune compromised patients and the staff at an undue risk of acquiring contagious diseases. This is evidenced by the recent widespread outbreak of a staphylococcal bacteria infection. I examined many patients who had clear evidence of staphylococcal skin infections – both new infections and scars. Reports from other facilities underscore the need for clean and separate living facilities particularly for patients who are immune compromised and more likely to spread diseases. I suspect the patients will continue to keep getting and spreading boils and abscesses that spread like wild-fire given the overcrowded sleeping and living conditions at Limestone. I have been told that Summer, 2003 has heralded additional skin infections as evidenced by increased complaints from patients to their attorneys.
1NaphCare=s inmate population statistics for Limestone are as follows: December 2002 - 309 HIV infected inmates and 57 AIDS infected
inmates; January 2003 - 307 HIV infected inmates and 55 AIDS infected inmates; February 2003 - 310 HIV infected inmates and 54 AIDS infected inmates; March 2003 - 288 HIV infected inmates and 52 AIDS infected inmates.

Without adequate infection control practices, the possibility of an outbreak of drug-resistant tuberculosis and the subsequent deaths is acute. Some patients request to be transferred to the lock-down units where they will at least be afforded some privacy and physical barriers to potentially deadly infectious diseases.
Because of a broken, severely stressed or often non-existent medical system, patients are needlessly dying and suffering from AIDS-related complications and other illnesses that could be prevented. The conditions at Limestone Prison are unsafe for both the incarcerated and for the staff. There is a sense of hopelessness and helplessness among the patients at Limestone -- to a degree that I have not witnessed prior.

INITIAL RECOMMENDATIONS Stephen Tabet, MD, MPH
Limestone Correctional Facility has a vast array of significant medical problems. Moreover, the standard of medical care rendered at Limestone falls far below the standards in the community or those standards set by organized bodies described in the introduction to this report. For this report, I will make only recommendations that I feel need to be addressed urgently. In addition to these minimal recommendations, there are many changes that could be put into place to develop a sound system of medical care that are not currently being addressed at Limestone. The following recommendations address what I see to be the most serious problems at the prison
1. Deaths. The number of deaths and the manner in which HIV-infected patients are dying at Limestone is a huge concern and present issues of potentially serious medical liability. All deaths need to be thoroughly evaluated by a medical doctor with expertise in the area. Full autopsies should be performed on all patients dying at Limestone until this disturbing trend is reversed.
2. Physician and mid-level staffing. Limestone is dangerously understaffed in terms of medical personnel according to accepted guidelines for incarcerated medical settings. Dr. Simon has an overwhelming task to perform with only one Physician s Assistant. One medical doctor serving as Medical Director and providing care to over 2800 patients-- including 300 with the HIV or AIDS-- is overwhelming and dangerous. At least another full-time physician and two other mid-level practitioners (physician s assistants or nurse practitioners) are needed to adequately provide care for the large number of sick patients at Limestone. Limestone staffing levels are far below what is normally accepted for provider staffing in a facility of this size with this level of acuity in terms of patient load.
3. Inmates providing care. Because of the shortage of nurses, inmates are called upon to provide nursing care -- especially in the inpatient unit. Inmates can provide comfort and company to other inmates, but must not provide nursing care.
4. Nursing. Nursing is very understaffed and many nurses are poorly trained at Limestone. Nurses need training in CPR as well as ongoing continuing education. Nurses at Limestone have made serious errors and patients have died or suffered needlessly. The numerous unfilled nursing positions need to be staffed. The National Commission on Correctional Health Care (NCCHC) guidelines need to be followed in terms of adequate nursing levels and training.
5. Infection Control. Infection control practices and guidelines are not being adhered to. Inmates with contagious diseases should be treated and isolated from the population especially given an HIV-infected person’s extreme vulnerability to these diseases. Outbreaks of infections need to be investigated and treated

accordingly. National resources such as the Centers for Disease Control and Prevention need to be called upon for assistance when necessary. Staphylococcus bacterial infections, in particular, are a problem and need to be eradicated as one would in any closed setting. Prevention, with respect to infectious diseases, is severely deficient at Limestone and needs to be integrated as a part of a patient’s medical care to decrease morbidity, mortality, and unnecessary costs.
6. Pharmacy and Medication Supply. Multiple patients disclosed that Limestone did not provide adequate medications because the nursing staff often ran out. Patients need to be provided medications on a regular and consistent basis. Running out of medications is unacceptable. The pharmacy needs to be adequately stocked and the inventory properly managed. HIV-infected patients need to take their antiretroviral medications consistently or they will develop drug-resistant HIV, fail medication therapy, and die. Additionally, inmates should not provide medical care, distribute medication, or provide emergency transport for other inmates.
7. Patients not taking essential medications. Too many patients are not taking appropriate medications. It is unclear whether some patients comprehend the dire consequences of not taking antiretroviral medications or preventive antibiotics. There needs to be appropriate education and documentation that the patient understands the consequences of not taking medications or antibiotics. Patients who are not taking simple medication regimens such as Bactrim (one pill is taken three times per week) or Dapsone (one small pill taken once daily) to prevent deadly Pneumocystis carinii pneumonia should be counseled, encouraged, and supported so they can easily take these inexpensive, life-saving medications. Opportunistic infections are deadly and very expensive to treat. Food (a sandwich or even crackers) needs to be provided to patients so they can take their medications without unnecessary side effects. For medications that need to be taken on an empty stomach, then patients need to be counseled regarding this.
8. Pill Line. Making patients stand in line outside, often in the cold or extreme heat, to receive any and all medications is counter-productive for a good therapeutic relationship. Patients should be taken their medication on a pill cart into their dorm and/or allowed keep-on-person” medications when appropriate. “Keep on person” medications is a common practice in correctional settings which allows patients to keep a few weeks or one month of medication in their possession. They can take their medications at the correct times and with the correct food requirements. A “keep-on-person” program excludes any medications that are potentially dangerous and may be bartered such as psychotropics, narcotic pain medications, and sleeping medications. Pill line at 3:00 a.m., or even 3:30 a.m., and then breakfast in the early morning is inappropriate. Patients should be administered medications that do not interrupt their normal sleep patterns. For example, medication could be provided at 7:30 a.m. after eating breakfast. Many of the medications are Food and Drug Administration (FDA) approved to be taken with food, so all patients on medications that need to be given with food must

have access to food. This will decrease the amount of side effects like nausea and vomiting, and increase medication compliance, as well as potentially decrease the number of illnesses.
9. Dietary requirements. Nutritional supplementation and diets are currently not satisfying the needs of patients with illnesses that require special diets. In particular, malnourished AIDS patients need evaluation for supplementation and mediations to increase lead body mass. Many chronically ill patients, such as patients on dialysis and patients with diabetes mellitus have special dietary needs. The dietary options provided at Limestone require an assessment by a nutritionist. AIDS patients need to be given vitamin/mineral supplementation especially given that the combination HIV therapies toxicities.
10. Medical Emergencies. Emergency response by medical staff at Limestone is either non-existent or dangerously slow. Patients are needlessly dying of medical emergencies. The current rule of “locking down” the prison before providing care to a patient with a medical emergency needs to stop. This needless delay in treatment during the first few “golden” minutes of a medical emergency has undoubtedly hastened the death of patients at Limestone. Patients who declare an emergency need to be either attended to immediately by trained medical staff or transported to the infirmary for immediate evaluation and treatment. Correctional officers should not be making medical decisions and deciding what is a medical emergency as they are presently doing. The issues of Do Not Resuscitate (DNR) and advanced directives needs to be consistently and compassionately discussed with patients and the patient’s wishes need to be respected. The current standard of the Limestone medical staff deciding for the patient how much to do for the patient needs to cease.
11. Americans with Disabilities Act. This is an area that is so replete with deficiencies that to adequately catalog them would require an extensive report, separate and apart from this report. I highly recommend an extensive evaluation of these problems before a disabled patient endures serious injury.
12. Crowded conditions and the housing unit. Patients at Limestone live in an open warehouse with extremes in temperatures. Overcrowded conditions and the close proximity of the beds fosters transmission of serious infections from one patient to another. HIV-infected persons at Limestone should not be housed in such crowded, dangerous, and inhumane conditions.
13. Monitoring. Developing an appropriate system of medical care at Limestone is going to take time, resources and a serious commitment by the medical providers. I recommend that health care delivery at the prison be monitored closely by an outside HIV specialist until the program has been brought up to acceptable standards.