By Darrell L. Ross, Ph.D.
On any given day, the nation’s jails house approximately 700,000 detainees. From 2000 to 2005 the Department of Justice, Bureau of Justice Statistics reported 5,935 detainees died in custody (2006). Of these deaths, 47% involved a natural illness, 30% died from suicide, 7% died from drug/alcohol intoxication, and 5% died due to AIDS. When compared to the high number of annual admissions and releases, the total number of detainee deaths is considered statistically low.
While less than 1,000 detainees die in custody annually, a custodial death of a detainee should not be unexpected given their unhealthy lifestyles. A significant number of detainees enter a period of confinement with numerous physical aliments and mental health illnesses. The BJS reported that over 40% of all detainees participate in binge drinking, 47% are dependant on alcohol, and about 50% of the detainees were under the influence of alcohol at the time of committing the offense.
Since a number of detainees enter a period of confinement, intoxicated symptoms of alcohol withdrawal are commonly observed by detention officers. Alcohol withdrawal can be a serious condition and in some cases fatal. During confinement in detention withdrawal from alcohol can pose numerous problems for detention officers and working in concert with health care professionals is important. Officers should be aware that over a course of time intoxicated detainees can move through several phases of withdrawal including psychotic and perceptual symptoms known as delirium tremens or the “DT’s.”
Because dependency on alcohol affects people differently the initial stages of alcohol withdrawal can vary among detainees. Generally, the first stages of withdrawal may occur within 6 to 8 hours, where depression, nausea, laughing, crying, belligerence, or withdrawing may occur. Slight shaking and more pronounced shaking may occur accompanied by psychotic symptoms (hallucinations and delusions) can develop from 8 to 12 hours. Seizures (classic sign of withdrawal) may occur in 12 to 24 hours and during 72 hours DT’s develop (in some cases progression in this order may not occur). Other symptoms may include general irritability, nausea, vomiting, hyperactivity, unsteady in balance, high anxiety, sweating, arousal, facial flushing, rapid heat beat, and excessive dilation of the pupils. Intoxicated detainees may fall and sustain subdural hematomas and fractures to the face. Detention officers observing such symptoms should err on the side of caution and refer the detainee to a health care professional.
Although rare, detainees have died in custody from the effects of withdrawal. Such cases will most assuredly generate a civil rights legal action for being deliberate indifferent to the medical needs of the detainees. The courts have ruled that correction officers owe a level of care to detainees but also have also held that they are not absolute guarantors of their welfare during confinement. A case in point is worth noting.
A highly intoxicated arrestee was detained in a small-sized county jail and placed in a detoxification cell at about 2:00 am. At 10:00 am the detainee was seen by a physician’s assistant for a respiratory problem, a fever of 100 degrees, a dry hacking cough, prescribed medication, and he took the first dosage. He ate the evening meal, refused a second dosage of the medication and an officer noted it in the log, but did not inform health care personnel. Officers noted that around 10:00 pm that the detainee began to suffer the initial effects of withdrawal and noted it in the log.
The midnight shift observed the detainee shaking in the cell and fall down several times around midnight. About 45 minutes later, officers observed the detainee more agitated, more unsteady in balance, falling down several times, exhibiting hallucinations as he picked imaginary bugs from the glass cell door, and noticed that his hands and fingers were severely shaking. The hospital was two blocks away and rather than call for an ambulance (which they had done previously), or call a road deputy off of the road, or call health care, the officers decided to video tape the behaviors of the detainee. The detention officer testified in his deposition that he video taped the detainee so that he could show the video to a DARE class.
One hour later, the detainee experienced the DT’s as noted by the officers. He was observed on the cell floor several minutes later. An officer entered the cell and found the detainee unresponsive and summoned paramedics. Revival efforts were unsuccessful and the detainee died at the hospital. His core body temperature was 105 degrees. The detainee’s estate filed a Section 1983 lawsuit. Retained counsel for the County, the risk manager, and the County Commission decided to settle the case after several years for just over $2 million.
This case illustrates a classic example of the DT’s and underscores the legal standard of deliberate indifference which the courts use in assessing claims of failing to respond to the medical needs of detainees. The lessons learned from the case are numerous but some of the critical areas include the following. Detention administrators need to develop and direct officers through policies which address the medical needs of “special needs populations” like substance abusers, the mentally ill, the disabled, and those who cannot care for themselves.
- Administrators need to ensure that officers have direct contact with a supervisor in order to request assistance in these types of cases (here no supervisor was assigned to the midnight shift).
- Supervisors and officers should know how to implement all policies of the agency and respond to medical emergencies within the facility.
- Administrators should provide training in all policies/procedures to ensure officers know how to implement them.
- Administrators should review all intake procedures for admitting detainees with medical needs.
- Administrators should work closely with their health care providers to ensure that a system of intake, classification, and ongoing monitoring of detainees who need medical or psychiatric care is provided (including the development of policies pertaining to substance abuse withdrawal).
- Administrators should conduct a risk assessment of their current system in order to determine whether there are deficiencies similar to the ones presented in this case and correct them as warranted.
This case should prompt correction officers and supervisors to ask the question, “if I were presented with similar facts at my facility, would I know how to properly respond?” The case facts should also prompt supervisory and line officers to study the case and discuss it at the next roll-call or other scheduled training. Briefing the case within the context of specific agency practices and procedures is suggested. Bringing in health care workers to discuss the case is also recommended.
Correction officers are the first line of response when referring health care services for detainees within the facility and must adequately perform their duties within the scope of their training and agency policies. Periodic training in basic health care, agency policies, and medical emergencies for custodial personnel should be considered. Such training should involve response to “mock” emergencies which address specific agency issues. Training should involve officers, health care personnel, and administrative personnel. Monitoring the activities and behaviors of detainees and keeping abreast of potential risks within the facility and working to minimize those risks which would jeopardize the health of detainees can reduce the likelihood of an in-custody death and simultaneously protect their rights.
