» AJC INVESTIGATES | Twelve who died from diabetes in jail or prison

» RELATED | Another victim adds to Georgia prison doctor's grim legacy

In some of the cases examined by the AJC, inmates died from diabetic ketoacidosis when their dependence on insulin and other drugs should have been known to doctors and nurses based on intake screening exams. Had the inmates received their regular dosages of insulin and other drugs, DKA could have been prevented.

Others apparently weren’t known to have diabetes when they were locked up. Yet, according to experts, their symptoms should have been a sign that they needed immediate medical attention, including monitoring of their blood sugar. If they’d been treated, usually with insulin and hydration, they could have recovered.

Douglas Brown died due to diabetic ketoacidosis on Oct. 19, 2013, in the Fulton County Jail. He was 41. FAMILY PHOTO Credit: HANDOUT Credit: HANDOUT

“This is just a bad situation — really bad — and it shouldn’t happen to anyone,” said Brown’s 80-year-old father, Robert Brown, himself an insulin-dependent diabetic.

Some states have treated such failures as crimes. In Mississippi and Arkansas, nurses have gone to prison or jail themselves for neglect of diabetic inmates. So, too, has an Oklahoma county jail administrator charged by federal prosecutors with depriving an inmate of insulin. Yet none of the deaths documented by the AJC led to criminal charges.

What’s more, neither of the two agencies responsible for medical care in the Georgia prison system has a comprehensive policy for treating the thousands of incarcerated diabetics, nor can they say exactly how many diabetics are being treated.

Because diabetes is such a pervasive problem in correctional institutions, the American Diabetes Association has written policies to guide inmate care. One of the ADA's key points is that diabetics "at all levels of custody" should have access to medication and dosing consistent with their usual treatment plans. The organization also says staff must be trained to recognize and respond to acute health crises.

Based on the ADA’s recommendations, the Federal Bureau of Prisons has adopted detailed protocols for diabetes management in its facilities.

But the AJC’s investigation indicates that across Georgia, in correctional facilities of all kinds, those concepts have yet to take hold.

“I know it’s not easy working in a jail,” said Dr. Bruce Bode, an Atlanta diabetes specialist and Emory School of Medicine faculty member. “They (inmates) can tell you anything and everything to get what they want. But if it’s a medical issue, you’ve got to evaluate it, and diabetes is clearly something that has to be evaluated. If you don’t give them insulin, they’re going to die.”

Defining a problem

Diabetes has become an increasingly significant issue in prisons and jails across the country as the inmate population has aged. Between 2004 and 2012, the rate of diabetes among state and federal inmates nearly doubled, according to a 2016 report by the U.S. Department of Justice.

There is no data, though, that show how many die from diabetic ketoacidosis.

Sarah Fech-Baughman, the director of litigation for the American Diabetes Association, said the AJC’s investigation is the first she’s aware of to document DKA deaths for one state or prison system. The 12 Georgia deaths speak to a nationwide problem, she said.

"In a prison, it shouldn't happen. There should be a system of care that's effective enough to prevent DKA deaths most of the time." —Dr. Michael Puerini, a past president of the American College of Correctional Physicians

“Unfortunately, that statistic is not surprising to me, and is in line with what I would expect, based on what we hear from folks,” she wrote in an email.

To identify DKA deaths in Georgia, the AJC analyzed in-custody deaths since 2008 and found the condition reported as the cause for 11 men and one woman.

Seven of the deaths were in county and city lockups, including the Fulton County Jail, the Atlanta City Detention Center and the Cobb County Adult Detention Center. Five were in prisons operated by the Georgia Department of Corrections.

In half of all cases, evidence developed by the Georgia Bureau of Investigation and other agencies indicated that doctors, nurses and jailers knew or should have known that those in their care were diabetics, yet failed to make sure they received proper dosages of insulin or other drugs.

The National Commission on Correctional Health Care, which sets standards for health services in prisons and jails, says screening exams for inmates must cover current medications and past and present health issues and symptoms of any chronic diseases. Anyone with diabetes should have a blood glucose screening.

Many family members contacted for this story expressed outrage as they learned for the first time that their loved ones died from a condition that can be prevented.

“We just thought it was probably a freak situation,” said Sandra Smith, whose brother, 34-year-old Tyrence Mobley, died at Hays State Prison in 2011. “Then we hear this. Something’s definitely wrong.”

‘It shouldn’t happen’

The deaths in Georgia’s state prison system raise particular questions because those facilities, unlike smaller city and county jails, typically have full-time medical directors and others in place to deal with chronic health issues.

In Oregon, Dr. Michael Puerini, a past president of the American College of Correctional Physicians, said he couldn’t recall a single death due to diabetic ketoacidosis in the 10 years he worked as medical director in his state’s prison system.

“In a prison, it shouldn’t happen,” he said. “There should be a system of care that’s effective enough to prevent DKA deaths most of the time.”

About 50 physicians work in Georgia prison facilities as employees of Georgia Correctional HealthCare, a branch of Augusta University that contracts with the Department of Corrections to provide medical services.

In a statement for a state mortality review panel, Dr. Monica Hill acknowledged that inmate Esteban Mosqueda-Romero died because she and other physicians in the state prison system failed to diagnose his diabetes. Mosqueda-Romero’s blood sugar when he entered the prison system was outside the normal range, but there was no follow-up to see if he had diabetes. He died nine months later due to diabetic ketoacidosis.

Even some of the prison system’s most experienced physicians have failed to diagnose diabetes, as revealed by a federal lawsuit the state settled last year for $215,000. The suit was brought by the family of 63-year-old Esteban Mosqueda-Romero, who died from DKA in January 2014 at Hays State Prison.

Mosqueda-Romero never was treated for diabetes even though a blood sugar test indicated that he had the disease when he entered the prison system in April 2013 to begin serving a 25-year sentence for child molestation in Hall County, records show.

On the day before he died, his blood sugar was 1,472, nearly 13 times a normal reading and one so high that healthcare workers rarely see it.

After reviewing Mosqueda-Romero’s medical records, the medical director for the Salt Lake County Jail System, Dr. Todd Wilcox, wrote that the inmate died “very painfully as his bodily systems gradually deteriorated to the point that he was no longer responsive.”

Dr. Monica Hill is the medical director at Lee Arrendale State Prison. While she was the medical director at Hays State Prison, inmate Esteban Mosqueda-Romero died of diabetic ketoacidosis after his blood sugar spiked to a level nearly 13 times what’s considered normal.

The physician who was then the medical director at Hays State Prison, Dr. Monica Hill, acknowledged in an account for the state’s mortality review that Mosqueda-Romero’s death would have been prevented had she and other doctors paid closer attention to his medical records.

“This resulted from failure by the upper-level providers at three institutions to diagnose Type II diabetes,” she wrote.

Hill and the physician responsible for the inmate’s initial evaluation, Dr. Joseph Fowlkes, still work in the prison system. Fowlkes remains at the Georgia Diagnostic and Classification Prison, while Hill is the medical director at Lee Arrendale State Prison, the state’s largest facility for women.

Christen Engel, Augusta University’s senior associate vice president of communications, declined to make those physicians or Dr. Billy Nichols, the statewide medical director for Georgia Correctional HealthCare, available to be interviewed.

Instead, she issued a written statement saying Georgia Correctional HealthCare would partner with the Department of Corrections to review the deaths documented by the AJC and “act accordingly.”

The state prison system's ability to deal with diabetes has previously drawn scrutiny as a result of lawsuits by two diabetic inmates who each had to have a leg amputated after minor cuts became severely infected. One of those cases was settled with the state paying the inmate, Michael Tarver, $550,000.

Grim death in Atlanta

Georgia’s city and county correctional facilities also have failed to recognize and adequately treat those with diabetes, with some of the most troubling cases in Atlanta.

Wickie Bryant, 55, died in October 2015 after a month in the Atlanta City Detention Center, where she was being held on a disorderly conduct charge. When her body was discovered, she was lying on her bunk in full rigor, an indication that she had been dead for hours. Vomit was on the floor, on her face and on the sheet underneath her.

Wickie Bryant died in 2015 at the Atlanta Municipal Detention Center. Her family alleges the city jail neglected her and she died after suffering a diabetic coma. Credit: HANDOUT Credit: HANDOUT

Reporting on the death for the Fulton County Medical Examiner’s office, investigator Betty Honey wrote that she couldn’t find anyone at the jail who could explain why Bryant was in such a state.

“I asked if she was taking medications while in jail and what her history was,” Honey wrote. “No one could tell me about her history or if meds were given while she has been there.”

Bryant’s sister, Mildred Sims, is suing the city in federal court. The lawsuit notes that Bryant, who had a history of mental problems, refused insulin and blood sugar testing while she was in jail, but it contends that those overseeing her care should have referred her to a physician or seen that she was hospitalized.

» MORE | Georgia to pay $550,000 to convicted murderer because of amputation

Brown's death in the Fulton County Jail in October 2013 was the first of two in the facility as it cycled through two companies to provide medical care, Corizon Health and Correct Care Solutions. The jail has since moved on to a third firm, NaphCare Inc.

In a lawsuit alleging medical malpractice on the part of Corizon and others, Brown’s father claimed that a nurse took no action when she found Brown on the floor, groaning and incapable of following commands, in the hours before his death.

The lawsuit was resolved through a confidential settlement with Corizon, according to Robert Brown’s attorney, Mawuli Davis. That’s small consolation for the elder Brown, who said he visited the front desk at the jail four times in an effort to convince administrators that his son needed insulin.

“My son didn’t get (his medication) for his diabetes,” he said in a recent interview. “How can that happen in this day and time? More should be done to hold people responsible other than going to court and getting money for losing a loved one.”

Willie Green was an insulin-dependent diabetic who died from diabetic ketoacidosis in 2017 after eight days in the Fulton County Jail. He was 41. Credit: HANDOUT Credit: HANDOUT

Four years later, Willie Green III died eight days after he was booked into the Fulton jail. The 41-year-old was arrested at the Greyhound bus station downtown on charges of criminal trespass and obstruction of a law enforcement officer while changing buses on his way home to Simpsonville, S.C.

Green was transferred to Grady Memorial Hospital four days after his arrest when his blood sugar spiked to four times the normal range and his body was “ice cold,” according to jail records. He died at the hospital.

According to Green’s friends and family members, he was an insulin-dependent diabetic who stayed on top of the disease, keeping his medications in a case.

Fulton County’s chief jailer, Mark Adger said Green should have been taken directly to Grady after his arrest because his blood sugar was so high when he entered the jail. If that had occurred, he might have survived, Adger said.

“My concern before he passed was when they checked his blood sugar, it was higher than I’d ever seen, and, for some reason, we decided to take him,” Adger said.

A prosecution declined

The circumstances in several of the Georgia deaths are similar to those in the case of 20-year-old Morgan Angerbauer, who died of DKA in a Texarkana, Arkansas jail in 2016. The case made national headlines because a nurse, Brittany Johnson, pleaded guilty to negligent homicide and was sentenced to three months in jail herself.

The prosecutor, Stephanie Barrett, told the AJC she had no hesitation in charging Johnson after jail video showed her refusing to check Angerbauer’s blood sugar as the inmate begged for help.

“If I saw something like this, someone just refusing when an inmate asked for help, I’d prosecute every time,” she said.

Barnes Nowlin Jr. died from diabetic ketoacidosis on June 5, 2008, in the Whitfield County Jail. Credit: HANDOUT Credit: HANDOUT

The AJC could find only one case in Georgia in which criminal charges were contemplated. A coroner’s inquest in Whitfield County in 2009 ruled that the death of 39-year-old truck driver Barnes Nowlin Jr. was a homicide. Yet even then, the county’s district attorney at the time, Kermit McManus, declined to prosecute.

Nowlin died three days after being booked into the jail for failing to pay a fine for a traffic accident in which he clipped a mailbox and left the scene. He had driven to Dalton from his home in Rome to pay the fine, but he was taken into custody because he had missed an earlier court date.

The GBI concluded that Nowlin died from natural causes. But it also found evidence that the nurse in charge left the jail just hours before Nowlin’s death even though the nurse knew the inmate was a diabetic and that his health was failing.

In statements to the GBI, two jailers said they told the nurse, Robert Pierce, that Nowlin had been vomiting and repeatedly falling down. In response, they said, Pierce instructed them to have Nowlin fill out a medical request form so he could be seen the next day.

Pierce, in his statement to the GBI, confirmed the jailers’ accounts but said he didn’t believe Nowlin was in serious jeopardy. Pierce also noted that he had previously been admonished by his superiors for being “too nice” to inmates.

This statement by a Whitfield County Jail officer, Durad Martin, describes the hours prior to the death of Barnes Nowlin Jr. In it, Martin states that the nurse, Robert Pierce, had Nowlin fill out a medical request form and that Pierce said that he had been getting in trouble for checking in on inmates at night.

At the inquest, jurors heard from a GBI deputy medical examiner, Dr. Jacqueline Martin, who testified that had Nowlin’s blood sugar been tested at the time the officers expressed their concerns, it might have saved his life.

“If they would have tested the sugar at an earlier time and it was noted that it was elevated, yes, this condition could have been treated,” Martin testified.

In 2012, Whitfield County, which employed Pierce, paid $850,000 to settle a lawsuit filed by Nowlin’s wife.

McManus, who retired in 2012, wrote in an email to the AJC that he didn’t have an “independent recollection” of the case. Interviewed by the Dalton Daily Citizen-News at the time of the inquest, he downplayed the finding, saying it “does not create a case and has no meaning whatsoever.”

﻿Data specialist Jennifer Peebles contributed to this report.

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The cost to taxpayers

Some 80,000 people held in U.S. prisons or jails have diabetes, according to the American Diabetes Association.

If diabetics aren’t provided with proper care, they can develop other serious health issues that are costlier to treat. Some state and local governments also have had to pay out hundreds of thousands to millions of dollars to resolve lawsuits accusing them of deliberate indifference to the medical needs of diabetic inmates.

What is Diabetic Ketoacidosis?

Diabetic ketoacidosis, commonly known as DKA, is a serious and potentially fatal complication of diabetes that develops when the body can’t produce enough insulin.

The lack of insulin leads to severely elevated blood glucose levels, causing the body to break down fat as fuel. That turns the blood acidic. And that, if left untreated, causes organs to fail.

DKA is more common for people with type 1 diabetes because they are totally insulin dependent, but it also can affect those with type 2.

Symptoms include nausea and vomiting, frequent urination, thirst, weakness or fatigue and confusion. Treatment involves administering insulin and fluids.