Report: Jails Could Have Prevented Inmate Death
Now, the top state agency charged with monitoring jails and prisons has finally issued a detailed report on the incident.
Obtained through a Freedom of Information request, the heavily redacted state Commission on Correction report finds that Livermore's death may have been prevented if medical officials in the jails had simply diagnosed the condition and treated it.
Medical care in the jails is supplied by Prison Health Services, a private contractor. And according to the commission, they dropped the ball.
Commission investigators found that Livermore's condition was not only untreated, but unrecognized--even though his paranoid ramblings and thrashing in his cell were both clear indications that something was seriously wrong.
"The conclusions in the report track the allegations in the federal lawsuit, that they failed to comply with their own protocol," says Jonathan Chasen, a Legal Aid lawyer representing Livermore's widow.
Specifically, when he was brought into the jail, Livermore reported that he was a heavy drinker. But the person examining him failed to follow a city requirement that a special form be added to his file, the report says. In addition, the medical staffer failed to evaluate him for alcohol withdrawal symptoms--another violation of city rules.
Livermore started behaving erratically less than 24 hours after his arrival in the system. At 10 p.m. on May 10, a guard referred him to mental health. While waiting in a holding area, he was anxious, crying, sweating, disoriented and paranoid.
A captain ordered him to the medical clinic. What happened there has been redacted, but for some reason, he was ordered back to his cell three hours later. That was a huge mistake.
In the cell, Livermore began hitting and kicking the walls and making paranoid statements, the report says. An officer brought him out of his cell, where Livermore promptly ran down a staircase and fell heavily. Then, he began saying that the police were coming to get him, and they wanted to operate on his penis.
An officer and an inmate tried to hold him still. He jumped up and ran to the other end of the unit. Two officers forced him to his knees and handcuffed him.
What happened after that is redacted.
The commission asked the Health Department to investigate the actions of two PHS medical employees, and come up with a way to improve communication in the medical operation at the jails.
We called the Department of Correction for comment, but have yet to hear back.