LOS ANGELES – Guards and medical personnel failed to acknowledge two mentally ill Los Angeles County jail inmates who refused to eat for several days, leading to their deaths from starvation, according to a report presented Tuesday.
The inmates were not identified by name. They appear to be two of nine inmate deaths between Jan. 1 and March 1 in county jails, eight of which were attributed in an earlier report to natural causes and one to suicide.
The two individuals in question had refused to eat, but jail guards and health service personnel “failed to identify their substantial food hoarding and drastic weight loss,” according to the Office of Inspector General.
“In one instance, (jail) medical personnel were notified by another prisoner rather than by custody of the patient’s refusal to eat for approximately eight days.”
Since the deaths, the Sheriff’s Department revised its policies handling inmates who refuse to eat, although the changes were not detailed in the OIG report.
An unrelated death was attributed in part to a lack of communication between jail guards and medical personnel.
A prisoner trustee who sought treatment for a chronic condition left the clinic for work before he was evaluated by a doctor.
Medical personnel tried to contact him, but based on the communication glitch, he didn’t return to the clinic that day and had a medical emergency related to his condition three days later that ultimately led to his death.
Inspector General Max Huntsman told the Board of Supervisors that medical care remains a challenge in county jails, despite changes in structure, including consolidating care under the Department of Health Services.
“We haven’t yet seen that pay off in terms of improving the conditions wildly,” Huntsman said.
“Wait times are still high in (the Inmate Reception Center) and there are still substantial issues. There were deaths this year that we are very concerned about. A recent death, as well.”
The average wait time at the IRC clinic — where inmates are processed into the jail system — is about 10 hours and when it exceeds 16 hours, inmates are sent to an overflow unit at the Twin Towers Correctional Facility. Patients there may wait days, the report found.
One man spent two days there before being transferred to the overflow unit and was still waiting until the afternoon of the following day to be seen. He was suffering from severe alcohol withdrawal and had been tethered to a bench for several hours.
“The prisoner became resistant to the fixed restraint and a use of force occurred,” the report stated.
Circumstances are exacerbated by a lack of cooperation between custody deputies and medical personnel, according to the OIG.
Custody personnel accuse some doctors of seeing only a few patients in an eight-hour shift and reported that some nurses either cannot or pretend not to speak English.
OIG personnel have spotted some medical personnel wearing name tags backwards, which deputies say is a way to avoid accountability.
Whether those accusations are true, they are symptomatic of a larger problem, the OIG report concluded.
“As long as personnel are permitted to shift blame between agencies, neither will be motivated toward meaningful solutions.”
Additional staffing is needed to alleviate some of the problems, but other improvements have been made to improve collaboration and patient care.
Multi-disciplinary meetings between custody, medical and mental health staff have been set up at the “high observation” units at Century Regional Detention Facility and Twin Towers, for example.
“These multidisciplinary teams are equally invested in patient care and are committed to working together to identify best treatment methods available to them,” the report stated.
An update on efforts to hire more staff is expected at a future board meeting.