It should have raised a red flag or two when Damien Tucker stopped breathing after having a seizure in his Tulsa jail cell, but no one called an ambulance for almost an hour.

When medical staff found the 31-year-old having difficulties breathing and with an altered level of consciousness in 2010, they didn’t call an ambulance. Instead, Tucker was taken from his cell to a medical unit.

“He’s not breathing,” a nurse said.

Another nurse asked the jail’s medical director whether someone should call an ambulance. One nurse said she asked the doctor twice.

“No. I got it,” answered the doctor, Andrew Adusei.

A nurse eventually called an ambulance, but Tucker died at a hospital less than an hour later. A medical examiner’s report found he died from a blood clot.

“There was a 42-minute delay in calling EMSA,” an independent review of the incident found.

“Although outcome may not have affected based on extent of this (blood clot), an inmate with his clinical findings … would certainly have chances for survival optimized with prompt 911 call and hospital transport.”

Tucker’s death was not an isolated incident.

He’s among at least 10 people over the past decade who might still be alive today if jail detention and medical staff had followed state jail standards, auditors’ recommendations and their own policies, according to an investigation by The Frontier.

An analysis by The Frontier of records from the state jail inspector, the state medical examiner’s office and other sources shows that since 2006, at least 30 people have died in Tulsa’s jail or shortly after being transported to hospitals from the jail.

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Experts and medical records state that outcomes for at least 10 of those people could have changed with proper medical and mental health care. The number could be higher, as several inmate deaths resulted in claims or lawsuits quickly settled by the jail’s medical provider before detailed records were produced.

A Tulsa physician hired by the Tulsa County Sheriff’s Office to review the quality of medical care criticized the jail’s treatment of Tucker and five other people who died in 2009 and 2010.

Dr. Howard Roemer’s November 2011 report questions whether the deaths could have been prevented with better medical and mental health care.

Increased risk of preventable death (p. 6) Dr. Howard Roemer, a Tulsa physician, was hired by TCSO to review prisoner medical care at the jail. Roemer's 2011 report was highly critical of the jail's medical provider, saying multiple deviations from protocols and guidelines increased the risk of preventable deaths. View entire document on DocumentCloud

Four other inmate deaths since 2006 are the subject of federal lawsuits in which records show serious lapses in medical care that experts say contributed to or led to their deaths.

Attorneys for the Sheriff’s Office did not return calls seeking comment for this story. Chief Deputy Michelle Robinette, who supervised jail operations during most of the period in question, declined an interview request.

In court filings, TCSO says the jail provides health care that meets legal requirements. Jail medical and detention staff are not indifferent to the medical needs of individuals in the jail, many who come into the jail with complex medical and mental health issues, the Sheriff’s Office says.

The agency acknowledges Roemer’s report found areas for improvement for the jail’s medical contractor but denies it ignored the problems.

However, Roemer was not the first expert nor the last to warn the Sheriff’s Office that medical and mental health care provided to inmates fell far short of what state law and accrediting agencies require.

Audits and reviews from 2007, 2009, 2010, 2011 and 2012 concluded that the Sheriff’s Office and its private medical provider, Correctional Healthcare Companies Inc., were failing to abide by the state’s jail standards law and accrediting agency standards governing inmate mental and medical care.

Meanwhile, TCSO left Robinette in charge of the jail and county commissioners approved multiple contract renewals with CHC until 2013, which paid the Colorado-based company about $5 million per year.

It’s unlikely the jail could have prevented all or even most of the deaths since 2006. Some inmates come into the county’s 1,700-bed jail with serious medical and mental health issues that are difficult to treat in a jail.

However, the cases reviewed by The Frontier add up to one in three inmate deaths in the last decade that experts and medical records state might have been prevented. The Sheriff’s Office also failed to take important steps its own consultants said must be taken to reduce the risk of additional deaths and injuries.

Five of those deaths are the focus of lawsuits pending against the Sheriff’s Office in federal court, including the 2011 death of Elliott Williams, set to go to trial beginning Wednesday.

In all of the lawsuits, including Williams’ case, attorneys must prove the Sheriff’s Office was “deliberately indifferent” to the inmate’s civil rights in order to prevail. To do that, they must show that the sheriff was aware of systemic deficiencies that contributed to the death.

Time and time again during the past decade, records show the Sheriff’s Office received such warnings.

An audit of the jail by the federal government a month before Williams’ death concluded there is “a prevailing attitude among clinic staff of indifference.”

Doctors were using standing orders, nurses weren’t properly trained and at least two immigration detainees had not been seen by a doctor for mental health and medical problems, the report by the U.S. Dept. of Homeland Security’s Office of Civil Rights and Liberties found.

A 2009 report completed four months before Tucker died warned the Sheriff’s Office of systemic problems with the jail’s medical and mental health care.

Consultant Betty Gondles’ report raised issues with the medical unit’s cleanliness, staffing and need for oversight. The infirmary had an “odor” and parts of it were “very dirty,” Gondles’ report says.

“Inmates often miss their medications either because they are at court or because their next dosage it too close to the time when health services finally reaches them.” her report says.

Gondles’ report states jail administration was concerned about ongoing nursing shortages and noted problems with nurses not having corrections training or experience.

Her report concluded the jail lacked a way to monitor health care delivered by its contractor. Gondles wrote that it was “extremely important” to create such a position.

However, the Sheriff’s Office did not create the recommended oversight position until four years after Gondles’ report.

Even then, the nurse hired for that job worked for the jail’s medical contractor and was married to a captain overseeing the jail. The nurse wrote only one report about the medical provider in two years, which wasn’t about inmate deaths, an investigation by The Frontier found.

Attorney Dan Smolen said the Sheriff’s Office and county commissioners “have done everything but address the problem” that led to preventable deaths in the jail. The Smolen, Smolen & Roytman firm has filed numerous civil rights lawsuits on behalf of inmates who have died or been injured in the jail, including Williams’ case.

In March, the firm won a verdict in a federal case it filed against Glanz and Robinette on behalf of a woman who was sexually assaulted by a jail detention officer at age 17.

New jail pods won’t provide better medical and mental health care for inmates, Smolen said.

“There are people dying who should not be dying and there are many people in a position to stop it. They are paying these people to give them the warning signs, but no matter how many people they pay to tell them what is so obviously wrong, they haven’t addressed the systemic indifference.”

Former Sheriff Stanley Glanz and Sheriff Vic Regalado are defendants in the lawsuit by Williams’ estate. The plaintiff has settled claims with the former medical provider for an undisclosed amount.

Because attorneys representing TCSO missed a deadline to certify proposed experts, a judge overseeing the case has ruled the defense will be unable to put on their own medical experts to counter testimony from the plaintiff’s experts about Williams’ care.

The 37-year-old veteran had no criminal record and was arrested after a mental breakdown in Owasso. He sustained a broken neck in the jail and detention staff dragged him into a medical cell, where jail video shows he was left on the floor, unable to eat or drink.

Williams was given no medical treatment and died 51 hours later, records show.

During the years when most of the 30 deaths occurred, including Williams’ death, Robinette was in charge of jail operations for the Sheriff’s Office. She stated in a deposition that the jail’s treatment of Williams lacked “human decency” but wasn’t intentional.

Rather than being disciplined or reassigned for the jail’s repeated poor performance on jail audits, Robinette was essentially promoted. She served as acting sheriff last year before Regalado was elected to fill Glanz’s term.

Last week, Regalado named her to a newly created civilian job as the jail’s mental health coordinator at a salary of $79,000.

A spokeswoman for Regalado said Robinette’s duties will include “overseeing all our mental health programs, community partnerships … as well working with all the agencies involved in those partnerships.”

Robinette will also oversee the “crisis intervention training” for detention officers who will work in the mental health pods, the spokeswoman said.

At least three of the deaths reviewed by The Frontier during Robinette’s tenure over the jail involved men with mental illness.

Two of the men submitted requests for mental health assistance and waited days for help before they hanged themselves. A third, Williams, repeatedly begged detention and medical staff for help and said he couldn’t move.

A former director of nursing for the medical provider while Robinette supervised the jail said in an affidavit that the mental health staff was “understaffed and overwhelmed.”

“Because of the backlog of requests and inadequate staffing, there were often long delays, upwards of two to four weeks, in inmates seeing someone from the mental health team,” states the affidavit, from Tammy Harrington.

Nurses were also told to falsify records before inspections and medical staff tried to revive dead inmates and ordered ambulances “so TCSO would not have to report a jail death,” states her affidavit.

‘She did not deserve to die that way’

Lisa Salgado was dead for about four hours in a medical cell before CHC staff realized it, according to a lawsuit.

Salgado was hospitalized shortly before her DUI arrest on June 14, 2011, and medical records indicate she had a long history of serious heart issues requiring treatment and prior operations.

The day after her arrest, Broken Arrow police took Salgado to St. John Medical Center because of medical concerns.

After being discharged from the hospital, she was taken to Tulsa’s jail with instructions to watch for “warning signs” signaling a heart attack. She told medical staff she was on prescription medications.

The day after Salgado entered the jail, she was seen “hyperventilating and rubbing her chest,” jail medical records show. She complained of nausea, increased chest pain and shortness of breath.

An EKG from St. John showed abnormal results that weren’t reviewed by the jail’s medical director, Phillip Washburn, her medical records show.

In a deposition, Washburn said as a matter of practice, he never actually reviewed the EKG results himself but relied on nurses to read the results to him. He said having results relayed to him is “better than nothing.”

Records indicate that medical staff gave Salgado a bag to breathe into and returned her to a cell.

Salgado continued to complain of chest pains, dizziness, weakness and similar symptoms as her health deteriorated, but she wasn’t sent to a hospital.

Three days after Salgado entered the jail, a nurse found her dead in a medical cell.

“(The nurse) began loudly calling for help,” the lawsuit says. “However, it was far too late.”

A medical expert for the plaintiff called the decision not to send Salgado to the hospital “reckless.” TCSO’s own expert said in his deposition that the jail’s medical system “failed” Salgado.

A motion filed Feb. 4 states records show at one point Salgado was given an antibiotic, but no record shows she was given “cardioprotective” medication.

In a motion filed late last year, attorneys for Glanz and Regalado denied they violated Salgado’s constitutional rights. She “received more than adequate medical care during her stay in the jail,” the motion states.

“No individual was indifferent to her care, no individual looked the other way while she suffered and no individual violated her constitutional right against cruel and unusual punishment,” defense attorneys state.

The motion notes CHC was aware of Salgado’s medications, which were given to her, but didn’t state what medications.

In a recent interview with The Frontier, Salgado’s sister said the jail neglected to get her sister health care when she clearly needed it.

“She did not deserve to die that way and alone,” Christine Wright said. “My sister, I know her so well, and from what I understand is she cried out and nobody helped her.”

Wright described her late sister — a certified medical aide — as outgoing, friendly and a talented artist. The sisters were born only 15 months apart, with Salgado being the youngest, and grew up together.

Salgado wasn’t able to meet Wright’s first grandchild, who was born in November 2014. Wright said her sister “would have made a wonderful great aunt.”

Wright lost her mother in 2010 and her sister the following year.

“I thought my mom’s death would hit me harder but my sister’s death affected me the most,” she said. “I didn’t realize how close and what an important part in my life she was.”

The motion Salgado’s estate filed says her death was “no freak accident.”

The motion alleges inadequate medical treatment inmates received under Glanz and alleges jail staff falsified records.

A nurse on duty at the time of Salgado’s death, Karen Metcalf, did not check on Salgado’s conditions during her 12-hour shift, the lawsuit claims. The suit says the nurse has a history of falsifying medical records.

Diane Maloy, the jail’s medical records supervisor, said in a deposition that Glanz told department heads to keep any “problem” medical charts away from auditors. She said nurses were instructed to create “dummy charts” by omitting unanswered sick calls from medical records and hiding charts of ill inmates.

Maloy said a Correctional Healthcare Inc. representative would go through the charts and remove parts she felt were “damning.”

In a motion filed late last year, attorneys for the county denied that TCSO violated Salgado’s constitutional rights. She “received more than adequate care during her stay in the jail,” the motion states.

They also denied the claim Metcalf was unqualified to provide medical care at the jail.

An audit completed seven months after Salgado died noted some inmates had incomplete health records.

“Nurse notes an EKG was done … but physician note never comments on it and the EKG is not in the (medical record),” the report says.

A few months after that, the Sheriff’s Office hired another consultant to audit the jail’s health care system.

The report, which focused on a single day of health care system in May 2012, noted “significant” delays between nurse and physician visits to patients who requested them.

It stated medical staff failed in four cases to comply with “chest pain protocol” that requires inmates with certain symptoms to have additional medical care.

“The above (cases) are of major concern for potential of the systems to allow serious outcomes,” the report says. “This should have an immediate systems improvement.”

The audit also noted inmates weren’t being given their medications, a warning that came three years after Gondles’ report uncovered the problem.

The Smolen firm represents Salgado’s estate, as well as the estates of Williams, Gregory Brown and Gwendolyn Young. They all died in Tulsa’s jail between October 2011 and February 2013. The cases are expected to go to trial later this year.

Williams died in the jail four months after Salgado from complications of a broken neck and dehydration.

Less than a year after Salgado, Brown entered the jail and went through an intake health review with nurse Kimberly Hughes.

Brown, who had a history of serious health problems, was put in a general population cell. He didn’t see a doctor for about four days, despite his requests for medical attention, the lawsuit alleges.

Brown’s pulse and blood pressure dropped dramatically, and he was reportedly vomiting throughout the night.

Brown was seen by Adusei later that day and Brown told him about his history of perforated gastric ulcers and other health issues. Adusei diagnosed Brown with kidney stone pain.

Five days later, Adusei noted Brown’s abdomen was distended and tender and had symptoms signaling small bowel obstruction. He suctioned black tarry fluid from Brown’s stomach through a tube, a civil lawsuit states.

The next day, detention officers and nurses reported Brown’s urine was black. Harrington told Adusei that Brown needed to go to the emergency room, but Adusei refused, the lawsuit alleges.

Another day passed before Brown was taken to a hospital. When he arrived, he was malnourished and dehydrated, the suit states. He went into surgery and then to ICU in critical condition. He stayed there until he died eight days later on March 8, 2012.

‘What else will be coming?’

Outside experts weren’t the only ones warning the Sheriff’s Office about inadequate medical and mental health care in the jail. The sheriff’s own attorneys were as well, records show.

In October 2010, six months after Tucker died, an assistant Tulsa County district attorney sent an email suggesting the Sheriff’s Office conduct an internal investigation of its medical provider, CHC. (The company was also known as CHMO.)

Assistant DA Andrea Wyrick warned TCSO not to ignore “any and all signs” of trouble with the jails healthcare system.

Assistant DA's email to TCSO risk manager (p. 1) Assistant Tulsa County DA Andrea Wyrick wrote this email to TCSO's risk manager, Josh Turley, in 2010 after he sent her a story about the jail's medical provider being sued. View entire document on DocumentCloud

Her email noted that Oklahoma County had sued CHC, which provided medical care in that county’s jail in addition to Tulsa’s, for falsifying medical records to cover up understaffing.

“This is very serious, especially in light of the three cases we have now — what else will be coming?” Wyrick asked. “It’s one thing to say we have a contract with CHMO to cover medical services and they are indemnifying us.

“It is another issue to ignore any and all signs we receive of possible issues or violations of our agreement with them for services in the jail. The bottom line is the Sheriff is statutorily (or the Trust Authority) obligated to provide medical services.”

Though much has changed since Wyrick’s email, the fact that the sheriff is ultimately responsible for what happens to people in the jail has not.

Under Regalado, men and women held in the jail have continued to die and suffer serious injuries, some in questionable circumstances. The new sheriff has claimed jail videos that could shed light on deaths and injuries aren’t public records, prompting an open records lawsuit by The Frontier.

Regalado also intervened to change terms of a proposed jail medical contract at the request of a bidder — also a state lawmaker — who contributed to his campaign. The bidder, Turn Key Health Clinics, won the lucrative contract to provide medical services at the jail, according to an investigation by The Frontier.

During a recent community forum, Regalado, Robinette and representatives from Turn Key Health said they were committed to providing the best medical and mental health care possible.

They showed pictures of the new mental health pods, flooded with natural light. The jail will have a 1-800 phone line for relatives to report concerns about medical care, Robinette said.

Smolen said until the Sheriff’s Office properly oversees the jail’s medical provider, nothing will change.

“What would a brand new mental health pod have done to save Elliott Williams’ life? Nothing. … They don’t seem to get that and they continue to pass taxes to build expansions to the jail but they never increase the staff.”