John Coletti: Record $10 million judgment awarded in Washington County jail heroin withdrawal death
The Oregonian/OregonLive By Maxine Bernstein
A federal judge has approved a $10 million judgment against Corizon Health, Washington County and other defendants, settling a lawsuit brought by the parents of a 26-year-old woman who died pleading for medical help while detoxing from heroin in the Washington County jail.
Madaline Pitkin died on April 24, 2014, on her seventh day at the jail after her arrest on a warrant and heroin possession charge.
Her parents, Mary and Russell Pitkin, said they hoped sharing their daughter’s story, which was chronicled by The Oregonian/OregonLive in April 2016, would help prevent similar deaths from occurring and hold private health care providers accountable.
"We felt we needed to stand up for her,'' said Russell Pitkin, sitting with his wife between their lawyers Friday. "We’ve done all we can do to shine a light on it. It’s just tragic. It’s got to stop.''
The eight-figure judgment is the largest ever awarded against Corizon Health, the nation’s largest for-profit medical provider for prisons and jails. Corizon has faced multiple lawsuits nationwide that allege inadequate medical care similar to the Pitkins' suit.
In a statement, Corizon said its medical team at the jail “failed Madaline Pitkin and her family."
“The amount of this settlement is unprecedented for our company and reflects how far removed the facts of this case are from our standards and expectations of care. For whatever small comfort this may provide, the lessons we’ve learned from this case have been catalysts for significant changes we have made and are still making to our clinical program,” said Steve Rector, Corizon Health’s chief executive officer.
Tim Jones and John Coletti, lawyers for the PItkins, said jail staff met Madaline Pitkin’s serious medical needs “with deliberate indifference.”
“Up until the very end when she was abandoned by her physician, she could have been saved by transfer to a competent acute care center,’’ they wrote in court papers
Corizon Health failed to follow its own policies, which required at a minimum monitoring of detoxing inmates every two hours and that they be taken to an emergency room or acute care facility if they were experiencing severe withdrawal symptoms, according to Pitkins’ lawyers. Instead, inmates like Madaline Pitkin were monitored once every eight-hour shift, if at all, they wrote. Corizon also understaffed its medical services at the jail to maximize its profit, the suit alleged.
Corizon’s medical director at the jail, Dr. Joseph McCarthy, and the health services administrator, Mandy Forsmann, were unaware of the policy governing inmate monitoring requirements, according to court depositions. Forsmann also had complained about understaffing at the jail and that the least credentialed staff were handling the sickest patients in the jail, according to depositions.
“Forsmann determined the Corizon medical director was falsifying medical charts; charting he had seen patients, when, in fact, he had not. She complained to senior officials for months requesting Dr. McCarthy be fired,’’ according to legal depositions cited by the Pitkins' attorneys in a court brief. “After many months, Corizon fired Dr. McCarthy, leaving no physician in his place. The firing of Dr. McCarthy rendered the physician assistant Colin Storz unable to practice medicine the day of Madaline Pitkin’s death.’’ (McCarthy subsequently surrendered his medical license.)
Within days of Madaline Pitkin’s death, Corizon’s nursing director wrote an email to a regional supervisor, saying the nursing staff at the jail was overwhelmed, according to court papers.
Madaline Pitkin had made four written pleas for help that the medical staff mostly discounted or mishandled. She detailed her intensifying weakness on jail forms and twice wrote that she felt near death. Medical staff, meanwhile, repeatedly ranked her withdrawal symptoms as mild and nurses failed to track her low blood pressure.
In her final request for help, Pitkin wrote, “This is a 3rd or 4th call for help. I haven’t been able to keep food, liquids, meds down in 6 days ... I feel like I am very close to death. Can’t hear, seeing lights, hearing voices. Please help me.” Medical staff later that day sent Pitkin to the jail’s medical unit. She was so dehydrated, she couldn’t provide a urine sample. She died there the next morning, on the floor of a cell alone with a handwritten copy of the Lord’s Prayer and the Serenity Prayer with her.
Staff repeatedly ranked her withdrawal symptoms as mild, and nurses failed to track her low blood pressure. According to the lawsuit, no doctor was working in the jail when she died because the jail’s head doctor had been fired. He worked his last shift the day before she died, the suit said.
An autopsy determined her cause of death was dehydration, Coletti said.
"All Madaline Pitkin needed was an I.V.,'' Coletti said Friday. "Rather, they left her alone in her cell to die. Madaline Pitkin’s death was inhumane and it was preventable.''
Long before their daughter’s death in custody, administrators and policymakers in Washington County were well aware that medical care at its jail was subpar, understaffed and those on the staff were poorly trained, the Pitkins’ lawsuit alleged. The county auditor had warned the jail and sheriff in May 2013, but they did nothing, according to couple’s lawyers.
The Washington County auditor estimated that between July 1, 2008, and June 30, 2012, Corizon received at least $350,000 of county money for services never provided, according to court papers.
“These failures were a moving force behind the suffering and ultimate death of Madaline Pitkin,’’ the Pitkins' lawyers wrote in court papers.
A Corizon physician assistant, Chris Rettner, left her job at the jail months before Madaline Pitkin’s death. She said in depositions that she was worried she’d lose her medical license if she continued to practice medicine under Corizon’s practices. Her supervisors, she said, continued to pressure her to minimize inmates' emergency room visits. She met twice with Washington County Sheriff Pat Garrett to share her concerns in the months preceding Madaline Pitkin’s death, Jones said.
Jones said he hoped the case and the large settlement amount "impacts all jails'' and puts counties on notice to pay attention to their medical providers' contracts. In this case, he said, the Washington County auditor’s scathing report showed the county got too comfortable with Corizon and the county essentially "let them run the show.''
Corizon disputed that its policies or practices -- including staffing levels at the jail, training policies and failure to use suboxone (buprenorphine) to treat opiate withdrawal -- had any effect on the medical care Pitkin received or were responsible for Pitkin’s death. The company also disputed extra payments to doctors who prevented inmates’ visits to emergency rooms. It asserted that Pitkin received appropriate medical care while at the jail.
Yet the company offered the settlement amount, which was accepted this week by the Pitkins, after two years of litigation and 57 depositions. U.S. District Judge Ann Aiken approved the judgment.
The Washington County Sheriff’s Office said in a statement that it has made many changes in providing health care to its inmates. Corizon stopped providing medical services at the jail on May 31, 2015.
“The death of Madaline Pitkin was a tragedy, and our thoughts are with her family,” the Sheriff’s Office statement said.
“Our current healthcare provider, NaphCare, has piloted a program in Washington County to provide medication that helps inmates who are detoxing from drugs. The success of that program has been replicated in a number of other jails, and has proven to be an effective way to treat those suffering from drug addiction,” the statement said. “Washington County has also hired an experienced contract administrator to work full-time at the jail for the purpose of monitoring this healthcare contract and other contracts.”
The Sheriff’s Office also noted that Corizon had “fully indemnified Washington County” during the litigation and that Corizon is liable for 100 percent of the judgment and legal fees.
Corizon’s Rector said he wasn’t with the company when Madaline Pitkin died, but “am deeply disappointed in our performance at the time and feel tremendous sympathy for her parents and loved ones.”
“The company was reorganized in 2017, and today we operate with a new leadership team and new board that includes three independent directors,” he said. “We are committed to ensuring our company supports our teams in providing the best possible care.”
The Pitkin case, he said, “does not reflect the commitment and compassion that the vast majority of our staff bring to their jobs.”
