ANDERSON & MASON

May 20, 2020

Via E-mail

Salt Lake County Mayor Jenny Wilson

jwilson@slco.org
Salt Lake County Council Member Shireen Ghorbani
shireen@slco.org
Salt Lake County Council Senior Policy Advisor Marla Kennedy
mkennedy@slco.org
Salt Lake County Council Member Richard Snelgrove
rsnelgrove@slco.org
Salt Lake County Council Senior Policy Advisor Sam Klemm
sklemm@slco.org
Salt Lake County Council Member Jim Bradley
jbradley@slco.org
Salt Lake County Council Senior Policy Advisor Bobby Sampson
rsampson@slco.org
Salt Lake County Council Member Arlyn Bradshaw
arbradshaw@slco.org
Salt Lake County Senior Policy Advisor Isaac Higham
ihigham@slco.org
Salt Lake County Council Member Michael Jensen
mhjensen@slco.org
Salt Lake County Senior Policy Advisor Lisa Hartman
lhartman@slco.org
Salt Lake County Council Member Aimee Winder Newton
anewton@slco.org
Salt Lake County Senior Policy Advisor Jen Ball
jenball@slco.org
Salt Lake County Council Member Ann Granato
agranato@slco.org
Salt Lake County Senior Policy Advisor Will Kocher
wkocher@slco.org
Salt Lake County Council Member Steve DeBry
sldebry@slco.org

Ross C. “Rocky” Anderson Judge Building, Eight East Broadway, Suite 450, Salt Lake City, Utah 84111
Walter M. Mason 801-349-1690 | RockyAnderson.org | e-mail: Justice@AndersonLawOffices.org
May 20, 2020
Page 2

Salt Lake County Senior Policy Advisor Richard Jaussi

rjaussi@slco.org
Salt Lake County Council Member Max Burdick
mburdick@slco.org
Salt Lake County Fiscal Manager Dave Delquadro
ddelquadro@slco.org
Salt Lake County Budget & Policy Analyst Brad Kendrick
bkendrick@slco.org
Salt Lake County Legal Counsel Mitch Park
mpark@slco.org
Salt Lake County Legislative Director Kara Trevino
ktrevino@slco.org
Salt Lake County Communications & Administrative Coordinator Shykell Ledford
sledford@slco.org
Salt Lake County Sheriff Rosie Rivera
rrivera@slco.org
Salt Lake County District Attorney Sim Gill
sgill@slco.org
Members, Utah State Legislature
By individual e-mail

Re: Deaths and Other Tragedies at the Salt Lake County Jail Caused by
Indifference, Recklessness, a Brutal Culture, and Lack of Oversight;
Potential Felonious Criminal Misconduct and Possible Cause for
Revocation of Licenses

Dear Mayor Wilson, Members of the Salt Lake County Council, Sheriff Rivera, District
Attorney Gill, Other Various County Officials, and Members of the Utah State Legislature:

Many victims or families of deceased victims, as well as former staff of the Salt Lake
County Jail (“Jail”), have described to us horrific accounts of mistreatment, cruelty, and
contempt at the hands of guards and medical staff at the Salt Lake County Jail. The
May 20, 2020
Page 3

dire situation is reflected in the appalling number of deaths there, which has contributed to
Utah having the highest number of deaths per capita in county jails in the country.1

The information we have received, which we are endeavoring to share with you so
you can, and will, assume the responsibility that comes with such knowledge, reflects
that the Salt Lake County Jail is, in many respects, like a medieval dungeon, where
detainees are treated with verbal and physical abuse and denied life-saving medical and
mental health services, and where the culture of disdain, cruelty, and indifference is
perpetuated by people from the top of the administration down to nurses and housing
officers (“guards”). It is the responsibility of each of you to reform the culture, customs,
policies, and practices that have caused tremendous misery for detainees and their loved
ones and a great deal of wasteful expense for the County and others. It is also your
responsibility to make sure there is full accountability for all whose wrong-doing
caused or contributed to Lisa Ostler’s death.

This is not about an isolated case. It is about systemic failures and a long-time
culture and custom of disdain, contempt, and abuse toward inmates and indifference to
their serious medical and mental health problems.

As you should be aware, Salt Lake County recently settled a lawsuit brought by our
clients, the parents and children of Lisa Ostler, who, at the time of her tragic death was a
37-year-old mother of three young children. Lisa died solely because she was treated
with appalling disdain and indifference by Jail personnel and was denied medical
treatment for a horrifically painful, yet easily treatable, perforated gastrointestinal ulcer.

1
Michael Sainato, “Why are so many people dying in US prisons and jails?,” The
Guardian, May 26, 2019 (“In Utah, at least 71 people died in jail over the past five years,
with half those deaths a result of suicide and most within a week of an individual entering
jail. The state’s jails have the highest death rate per capita in the US.”).
May 20, 2020
Page 4

During the last 24 hours of her life, Lisa, who was kept alone in a cell in Unit 8C of
the Jail, screamed and cried out for hours, pleading for medical help. During that time
numerous other detainees also requested help on her behalf, and Lisa repeatedly pressed
the emergency button in her cell and conveyed to the Central Control operator her pain and
need for medical attention. During the entire day, night, and early morning before Lisa
was found unresponsive and not breathing in her cell in Unit 8C of the Jail, no one
provided her any medical treatment or meaningful assessment.

The settlement of the case brought by Lisa’s family cost the County $950,000, in
addition to the costs of two years of intensive, extremely expensive litigation, including
37 depositions and numerous motions, all of which likely consumed thousands of hours of
May 20, 2020
Page 5

staff time at the District Attorney’s Office. The case could have settled much earlier, long
before much of that expensive and time-consuming litigation. Indeed, the Ostler family
offered settlement early in the litigation at an amount lower than the final settlement, but,
because of a failure to competently investigate and evaluate the matter, the County rejected
the offer of settlement without a counter-offer and without any expression of a willingness
to negotiate a resolution until almost a year later.

Much more importantly, Lisa should still be alive today, her children should have
their beloved mother, her parents should have their daughter, and her siblings should have
their sister. Lisa would be alive if reasonable oversight had been in place at the Jail and had
those responsible for the administration and operations of the Jail done their jobs. Clearly,
there is not responsible oversight of the Jail––and, ultimately, the buck stops with each
of you.

Through the lengthy and intense course of litigation regarding Lisa’s death, we
learned of numerous tragic and wholly unjustifiable deficiencies in management and
oversight, as well as grave errors and indifference, in the provision of medical care.
The correction of any one of them would have saved Lisa’s life. Some of what occurred
we believe may have been criminal in nature—and also should subject some County
employees with the revocation of their professional licenses. Nevertheless, there has
been no accountability for anyone involved––no internal investigation, no discipline,
and not even any additional training required for those responsible for Lisa’s death.
Again, this is not unusual; it is typical that no one is held accountable and disciplined or
terminated when they have caused or contributed to the death of an inmate.

Please do not listen to the excuses and obfuscations of jail administrators or the DA’s
Office. Instead, we urge that you each do everything possible to obtain and
conscientiously consider the facts. When you do, we are certain you will be as appalled
as we are––and as angry as we and Lisa’s loved ones are––that Lisa’s life was lost and
her family has suffered this unnecessary tragedy because of the recklessness and
indifference of those responsible for the management, administration, and operations
of the Jail.
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Page 6

The failures, both systemic and individual, that led to Lisa’s death compel a
thorough investigation and audit, full accountability, and corrective action, including
perhaps criminal prosecutions and discipline, including termination of employment and
of licensing, for certain County employees. We strongly believe that criminal
prosecutions for negligent homicide and fabrication of official medical records should
be considered.

Also, reasonable actions by the Utah Legislature could provide the means for
legal accountability that are too often unavailable because of current draconian Utah
statutes, including (1) the repeal of the sub-sections of the Utah Governmental
Immunity Act that preclude actions for negligence if the harm or death arose from
incarceration or from violations of civil rights (Utah Code Ann. § 63G-7-201(4) (b)
and (j)) and (2) the repeal of the outrageous and blatantly discriminatory and
unconstitutional cost bond statute, § 78B-3-104, which requires any plaintiff suing a law
enforcement officer to post a bond before a lawsuit, in an amount found by the court to be
the total fees and costs that will be incurred by the law enforcement officer in the future––
the ascertainment of which would be impossible.

We respectfully urge the Salt Lake County Council (“the Council”) to provide
effective oversight for the Jail, beginning immediately with an independent audit and
investigation into the following tragic mistakes and deficiencies, all of which are
supported by substantial evidence, including documentation and statements made by
County employees under penalty of perjury. We will also urge the Utah Division of
Occupational and Professional Licensing (“DOPL”) to investigate this matter and to
take appropriate disciplinary actions. (Nearly all of the facts described here are supported
by documentary evidence and deposition testimony. Upon request by anyone, the
documentary evidence and all depositions, except for materials subject to a protective
order, will be made available electronically. Paper copies will be provided upon request
and payment for copying charges.)
May 20, 2020
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1. Lisa’s medical record was almost certainly falsified in material ways,

covering up her obvious, life-threatening medical emergency.

A medical order issued at the Jail required that Lisa’s vital signs be monitored, and
that other assessments be done, at least twice a day for five days. After one day of being in
custody at the Jail, Lisa’s vital signs reflected she was in dire need of emergency
medical attention. First, on the morning of March 31, 2016, Lisa’s resting heart rate
was 119. Then, on that afternoon, her heart rate increased to an alarming 133 and
her blood pressure dropped to 89 (systolic) and 68 (diastolic). (As described below,
there was no follow-up relating to Lisa’s dangerously abnormal vital signs; the nurses
violated the Jail’s written policy that required them to contact a physician if a detainee’s
heart rate exceeded 110.)

The next supposed measurement of Lisa’s vital signs occurred on the morning of
April 1, 2016, the last time anyone purported to measure her vital signs before she was
found unresponsive and not breathing approximately 24 hours later. Lisa’s medical record
contains entries reflecting that her heart rate then was a normal 95 and her blood
pressure was 105/75, as if she had miraculously recovered (which obviously did not occur
because, as we know now, she was dying of peritonitis). The records also reflect that two
extensive withdrawal assessments were done on the morning of April 1. The evidence that
those entries in Lisa’s medical record at the Jail were completely fabricated is
compelling, yet the District Attorney’s Office (“DA’s Office”) has overlooked that
evidence in its relentless efforts to defend those responsible for Lisa’s death.

It clearly appears that Lisa’s medical record reflecting the April 1 supposed
vital signs and withdrawal assessments is fabricated.

First, the vital signs reflected in the medical chart for April 1 were medically
impossible given what is known about Lisa dying of peritonitis and the fact that her
vital signs had previously been severely declining in the prior two assessments.
May 20, 2020
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Second, Lisa’s interactions with nursing staff on the morning of April 1, 2016, are
recorded on video. Those video recordings reflect that no one measured her vital signs
or did the required withdrawal assessments at that time. Any competent investigator,
with the assistance of a medical professional, can ascertain that.

Those conclusions are supported by the expert opinions of Dr. H. Tae Kim, Chair of
Surgery at LDS Hospital, and Suzanne Ward, a registered nurse with many years of
experience practicing in prisons and jails.2 Dr. Kim stated as follows:

The last entry of Lisa’s vital signs at the Jail, which occurred on the morning
of April 1, 2016, is highly suspect. The numbers themselves reflect normal
values, which would not be clinically possible with the now known
untreated gastrointestinal ulcer perforation. The video shows the nurse
interaction for the vital signs lasted 30 seconds (approximately 8:30:15 to
8:30:45), during which time the nurse is addressing both Lisa and another
patient simultaneously. Standard automated blood pressure machines usually
take at least 45 seconds to measure. This does not include the time to put on
the blood pressure cuff.3

Nurse Ward described the same suspect vital signs as follows:

On 4/1/2016 at approximately 8:20 or 8:30 AM, Nurse Ron Seewer

documented a CIWA Withdrawal Assessment for Lisa including vital signs
plus an assessment of ten clinical signs and symptoms of potential withdrawal
(SLCo Ostler 000155). Video footage of Unit 8C at this point in time
pictures a nurse bending down toward Lisa, who was sitting on the floor.
The exchange lasts a mere 30 seconds. Nurse Seewer testified that taking

2
The expert reports of Dr. H. Tae Kim and Suzanne Ward, R.N., are attached as Exhibits
“A” and “B”, respectively.
3
Report of Dr. H. Tae Kim, at 29 (emphasis added).
May 20, 2020
Page 9

vital signs would take about a minute or two using an automatic blood
pressure monitoring machine (Seewer Deposition, pp 33-34). Monitoring of
respirations would take another 30 seconds to 1 minute (Seewer Deposition,
p 146) and would require full attention of the nurse to count each chest rise
and fall. The nurse, was also attending to another inmate at the same time as
Lisa so did not devote full attention to her. To obtain the vital signs and
symptom assessment recorded on 4/1/16 AM for Lisa would have taken a
minimum of 2-3 minutes and could not have been accomplished in 30
seconds. Several of the symptoms that Seewer recorded as not present would
have required an inquiry and conversation with Lisa in order to record the
result as they could not have been objectively observed: nausea, anxiety,
tactile disturbance, auditory hallucinations, visual disturbance, headache or
fullness in the head and orientation. To determine sweating or tremors, Mr.
Seewer or another nurse would have had to touch Lisa’s skin or ask her about
the symptoms in order to record an accurate status. It would not be possible
for Nurse Seewer or another nurse to have taken Lisa’s vital signs and
completed a symptom assessment in 30 seconds. The assessment,
documented by Nurse Seewer on the CIWA worksheet on 4/1/2016, could
not have been the result of an actual assessment. A WOWS assessment for
the same time was recorded by another nurse. It is unclear why two nurses
recorded an assessment for the same time when neither nurse was
observed on the video tape performing the actions that would have been
obvious if an assessment had actually been done.4

Such apparent falsification of medical records of a person who died in Salt Lake
County’s custody cannot be tolerated and should be referred for thorough criminal
and DOPL investigations, with the full cooperation of Salt Lake County and Jail
personnel. Any criminal investigation should be conducted by the Utah Attorney General’s
Office or some other County Attorney or District Attorney, not the Salt Lake County
District Attorney’s Office, which has doggedly defended the tragically reckless and

4
Report of Suzanne Ward, R.N., at 44–45 (emphasis added).
May 20, 2020
Page 10

indifferent lack of care for Lisa and has overlooked the apparent fabrications in the medical
records. Further, a thorough investigation should be conducted on behalf of, but not by,
Salt Lake County to determine exactly what happened regarding the apparent falsification
of medical records, as well as the numerous blatant errors in the medical records, and
appropriate employment terminations and other disciplinary actions should then be taken.

2. The Jail administration trained nurses at the Salt Lake County Jail to
cover up negative information that might expose the County to liability, even to the
point of mischaracterizing the facts in medical records.

The custom, culture, and purposeful training at the Jail regarding the
falsification of medical records must also be investigated and reformed immediately
and there should finally be effective accountability and oversight so that such fabrications
never again occur. Medical records should honestly and transparently reflect all medically
relevant information, without regard to whether entries in the medical records might reflect
poorly on the County or its employees and other agents. Richard Bell (“Bell”), who,
ironically, had the title of “Responsible Health Authority” at the time of Lisa’s death,
testified, shockingly, that nurses are trained to deliberately omit or misleadingly
phrase information, including information highly relevant to treating a patient, that
could establish the County’s liability for medical errors. (A power-point presentation
used in such training is available to anyone investigating this matter.) Bell’s appalling
testimony included the following:

Q. So if a pod nurse failed to provide medications, you teach your nurses

at the jail not to include in the medical record a statement that the pod
nurse failed to provide medications?
A. Correct.
* * *
Q. Is it the custom of the Salt Lake County Jail also to train nurses not to
use words that are associated with errors?
A. Yes.
* * *
May 20, 2020
Page 11

Q. I’m asking about errors in the treatment of the patient. Nurses at the
Salt Lake County Jail are trained to steer clear of words associated with
errors.
A. Yes.
Q. And they’re also trained not to use any terms that suggest that an error
was made or that a patient’s safety was in jeopardy?
A. Yes. That suggests, yes.5

The culture at the Jail, from top to bottom, is one not only of indifference,
recklessness, and lack of accountability, but it is also one that places a premium on the
protection of the County, even when lives are lost and when the fabrication of medical
records is thought to be useful to cover up what actually occurred. That culture of
dishonesty, callousness, and dereliction of duty has caused, and will continue to cause,
detainees to die from inadequate medical care. For elected officials and others in
positions of responsibility to fail to investigate these matters, disclose the truth to the
public, and put in place a system of effective oversight would render them complicit
in the perverse, cruel culture at the Salt Lake County Jail.

3. The failure of nurses to alert a physician about Lisa’s alarming and

deteriorating vital signs, in violation of a written policy requiring physicians to be
contacted if a detainee’s heart rate exceeds 110, is consistent with an admitted custom
to disregard such a written policy––the compliance with which would have saved
Lisa’s life.

When Lisa’s vital signs reflected an alarming increase in her heart rate and a
decrease in her blood pressure, it was clear Lisa needed an emergency assessment for what
might be a life-threatening medical condition. Written policy required nurses to notify a
physician if they observed that Lisa had a heart rate over 110 beats per minute. However,
nurses followed an admitted widespread custom of ignoring that policy. When Lisa’s
heart rate was recorded at 119, then 133, no physician was contacted, notwithstanding the

5
Deposition of Richard Bell, May 20, 2019, 100:6–10; 100:13–16; 101:6–15.
May 20, 2020
Page 12

written policy requiring they do so. Lisa was clearly in the midst of a medical crisis and
was likely septic, yet no physician was ever alerted. When asked about this, nurses and
administrators admitted it was the custom at the Jail to disregard that written policy.
There was no disciplinary action taken against any nurse with respect to the care given to,
and withheld from, Lisa, including their violation of that written policy.

4. Nurses at the Jail failed to provide Lisa her prescribed over-the-counter

acid blocker, which a jail physician ordered she be provided.

According to Dr. Kim, had Lisa timely received that medication, Prilosec, her ulcer
likely would never have perforated the intestinal lining, preventing Lisa’s medical
emergency, suffering, and death. Nothing in Lisa’s medical record reflects any reason for
the denial of that potentially life-saving medication, which would have cost pennies to
provide. Further, it appears that, after Lisa’s death, no one at the Jail performed any
inquiry as to why that medication was withheld or sought to hold anyone accountable
for that grave, easily avoided error. The fact that such a blatant blunder was overlooked,
and that the systemic problems leading to it were never considered in reviewing Lisa’s
death, demonstrates the urgent need for effective, external oversight.

5. Nurses failed to conduct mandatory assessments for patients

experiencing withdrawal symptoms.

Dr. Todd Wilcox, the Medical Director at the Jail, published an article, “Managing
Opiate Withdrawal: The WOWS Method,” describing opiate withdrawal as “a life-
threatening medical condition” that is “clinically severe and can frequently result in death
if not managed appropriately.” Despite this knowledge about the deadliness of opiate
withdrawal, nurses at the Jail failed in Lisa’s care to follow the mandatory––yet often
ignored and unenforced––protocols at the Jail to prevent the deaths of detainees, costing
Lisa her life.
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Page 13

The Jail’s protocols required that Lisa be assessed at least twice per day for five
days. However, as Lisa’s condition worsened, nurses––unjustifiably and without any
6

excuse––failed to perform those assessments, which cost Lisa her life because such
assessments would have shown she was obviously in crisis. One nurse, Ron Seewer, who
provided nursing care in the location of the Jail where Lisa was housed, has denied any
responsibility for performing the assessment. The chaos and mismanagement of the Salt
Lake County Jail is reflected in the fact that, to this day, no one can identify who was
responsible for doing assessments, the performance of which would have saved Lisa’s
life.

Even during and after the Morbidity and Mortality Review of Lisa’s death,
nothing was done to identify who should have, but did not, perform the assessments
that would have prevented Lisa’s death. Neither has anyone been held accountable for
the fatal failure to conduct the life-saving assessments or for failing to make certain that
the person responsible for conducting the assessments was clearly identified.

At least one nurse attempted to explain his disregard of Lisa’s obvious medical
emergency by stating he thought her symptoms were caused by withdrawal, yet the simple,
life-saving procedures to protect patients experiencing withdrawal were not followed. This
appeared entirely consistent with a widespread practice and culture of casually
dismissing the need to perform mandatory withdrawal assessments, which is reflected
in the medical records of numerous detainees who have died in the Jail’s custody, as noted
in the expert witness reports of both Dr. Kim and Nurse Ward.

6
Further, jail staff are required to monitor detainees who are identified as being at risk for
opiate withdrawal to ensure they receive adequate hydration. That was not done for Lisa
and, yet again, this simple measure would have made clear to any nurse that Lisa, who
consumed almost no food or liquids for two days, needed emergency medical evaluation
and treatment, which would have saved her life.
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6. Contrary to the County’s written policies and information provided to

detainees upon booking and thereafter, detainees are routinely denied emergency
assessments or treatment because they have not filled out a sick call request form,
creating deadly delays in medical treatment.

When asked why Lisa was not provided a medical assessment in the hours before
she was found unresponsive and not breathing, even though two nurses were within a few
steps of Lisa that morning, Richard Bell testified that she could have received an
assessment—if only she had filled out a sick call request form and waited for a nurse to
perform medical triage. Bell, the top health care administrator at the Jail, did not seem
to recognize that the sick call request forms are to be utilized only when the medical
problem is not an emergency. He also failed to recognize that, for many hours, Lisa was
dying and suffering immensely and, by the time a nurse would have come into the unit to
perform triage, Lisa would already have been unresponsive and not breathing, near death.

Richard Bell, who was primarily responsible for ensuring detainees have access to
adequate, timely, and reasonable medical care, did not see a problem with the system he
described, which prevented Lisa from being assessed before it was too late. He also did not
see a problem with the fact that the system he and others testified were in place, requiring
a detainee to fill out a medical request form, was directly counter to the instructions
provided to detainees on signs in the Jail and in a handbook provided to detainees,
which stated that if detainees are experiencing an emergency medical problem, they
are to tell a guard, who is then to tell a nurse, who is to immediately go to the detainee
and make a medical evaluation. Again, no one has been held accountable for failing to
cause a nurse to evaluate Lisa without the need for a medical request form or, as in Bell’s
case, for failing to train and supervise guards and nurses so that when a detainee
complained of an emergency medical problem, guards would contact nurses and the nurses
would go to medically evaluate the detainee.

Within approximately one hour before Lisa was found unresponsive and not
breathing, after a nightmarish evening and early morning of screaming out and begging for
help, Guard Zachary Frederickson (“Frederickson”) gave Lisa, who was dying, a sick call
May 20, 2020
Page 15

request form and then, according to Nurse Colby James (“James”), told James that Lisa
“refused” to fill out the form. Nurse James then failed to walk a few paces over to Lisa’s
cell to even talk to her or check on her. This astounding level of disregard of Lisa’s
serious medical needs prevented Lisa from receiving lifesaving medical treatment
and, along with all the other neglect and massive blunders, caused her to be denied life-
saving treatment for her peritonitis.

Equally, if not more, appalling and infuriating, staff at the Jail (including top
administrators), as well as the District Attorney’s Office, now know this information
and have not yet done anything to discipline and hold accountable the people
responsible for Lisa’s death or do anything to prevent other detainees from dying
because of the same callous disregard of their medical needs.

We have heard repeatedly—from detainees who could not access medical treatment,
from family members of detainees who died in custody, from former staff at the Jail who
genuinely care about the well-being of the people in their custody, and from guards
testifying under oath—that detainees do not have access to emergency medical care and
are required to fill out a sick-call request form for their medical complaints unless the
detainee’s medical complaint fits into a narrow category of obvious and extreme
emergency, such as “excessive” bleeding or obviously broken bones. This sick-call
request form procedure created deadly delays for life-saving treatment for Lisa, as
well as for Angie Turner and Meagan Deadrich, whose tragic accounts are discussed
below, in addition to numerous other victims at the Jail.

7. Guards customarily instructed Central Control operators to ignore

emergency communications from certain detainees, including Lisa, which
contributed to her death.

Had Jail staff responded to Lisa’s calls for medical help, including her many
communications with Central Control operators by means of an emergency button and
intercom, she would be alive today.
May 20, 2020
Page 16

Scott Sparkuhl, a Central Control operator, testified that during the night before Lisa
was found unresponsive and not breathing in her cell, he received up to sixteen calls from
Lisa through the emergency intercom button in her cell. Lisa told him repeatedly that she
was in pain and needed medical help, but Mr. Sparkuhl did not communicate that
information to any medical staff or to a guard because a guard instructed him to
“ignore” communications from Lisa. One must wonder why, if there were any semblance
of a real investigation concerning Lisa’s death, that guard has not been terminated or
otherwise severely disciplined (if not criminally prosecuted).

This was not an isolated event. Mr. Sparkuhl testified that on “a dozen or so” other
occasions he had been instructed by guards to “ignore” communications from detainees
when they hit their emergency buttons in their cells. Mr. Sparkuhl also spoke of a culture,
which he regretted participating in along with others in Central Control, of dehumanizing
and even laughing at detainees who used the emergency intercom buttons in their cells to
express that they were in pain and to ask for help.

8. Guards are not trained to fulfill their role as medical gatekeepers, yet
nurses inappropriately rely on guards to exercise medical judgment to determine
whether a detainee is experiencing a medical emergency.

According to the Jail’s administrators, guards are supposed to serve as the “eyes and
ears” of the Jail, ensuring that detainees can access a nurse if the detainee has a medical
emergency. However, guards are not trained what to do if a detainee complains of
abdominal pain (which, obviously, can signal a potentially life-threatening emergency,
such as appendicitis or peritonitis); they are not trained regarding what information they
are supposed to provide to nurses about detainees’ medical complaints; they are not trained
to recognize signs and symptoms of substance withdrawal; and they are not trained to treat
detainees who are withdrawing from a substance any differently than other detainees. This
unconscionable lack of training leaves medically untrained guards to guess what the
appropriate response should be when a detainee has a medical complaint or demonstrates
through her actions that she may be suffering from a serious medical problem.
May 20, 2020
Page 17

As happened with Lisa, it is apparently the custom that when a guard does finally
choose to communicate a detainee’s medical complaint to a nurse, the nurse might ask the
medically untrained guard to determine whether the detainee is experiencing a medical
emergency. That is obviously the nurses’ job and something that cannot be performed by
medically untrained guards. Further, to rely upon guards to determine if there is a medical
emergency is contrary to written policies of the Jail.

Less than two hours before Lisa was found unresponsive and not breathing in her
cell, Guard Frederickson notified Nurse Brent Tucker (“Tucker”) that Lisa had a medical
complaint. Nurse Tucker instructed Frederickson to determine whether it appeared to
Frederickson that Lisa was having a medical emergency. Again, there was no discipline
and no corrective action for Nurse Tucker or Frederickson, who totally abdicated their
responsibilities and, in absolute violation of their duties, permitted the delegation of
medical decision-making to a medically untrained guard—another egregious and reckless
error and abandonment of responsibility that cost Lisa her life since Frederickson, without
any medical training, “determined” Lisa was not experiencing a medical emergency when,
in fact, she was dying at that very moment from her excruciating peritonitis.

9. Nurses spent hours during their shifts watching videos, engaging in social
media, and otherwise entertaining themselves rather than providing necessary care
to detainees, all without any personal accountability.

One nurse at the Jail told another employee, “All I do is hand out medications and
watch movies.” Indeed, Sheriff Jim Winder testified that he received numerous complaints
about staff failing to perform their duties and, instead, engaging in personal entertainment,
such as browsing social media and watching videos, and that he made several unsuccessful
attempts to end the practice. The extent of the testimony on this issue of Richard Bell, who
was charged with supervising medical staff and ensuring that detainees had unimpeded
access to reasonable and adequate medical care, was a casual and disgraceful aside that he
“wouldn’t encourage [nurses] watching movies” and that he “do[es]n’t know” about
television shows. This cavalier and uncaring response from the top medical authority at the
Salt Lake County Jail was characteristic of Bell’s attitude and testimony throughout his
May 20, 2020
Page 18

three depositions in the Ostler matter, which we urge anyone concerned about the customs,
policies, and practices at the Salt Lake County Jail to read.

Detainees do not receive mandatory assessments, medications are not provided even
when ordered by a physician, detainees are told to fill out a medical request form even
when they need an emergency evaluation, and detainees have all too often died from a lack
of reasonable medical treatment while in custody at the Jail. At least some of this occurs,
no doubt, while nurses are watching videos or engaging in social media instead of doing
their jobs––and there has been no discipline and, apparently, no effective supervision by
Jail administrators, from Bell on down.

10. Nothing was logged or recorded by guards, supervisors, or nurses about

Lisa’s night and early morning of extreme suffering and dying, even though her
persistent screams in pain and pleas for help were well known by Jail staff.

Guard Frederickson testified that he and a room full of guards were informed, merely
a couple of hours before Lisa was found unresponsive and not breathing, that Lisa had been
pressing the emergency intercom button in her cell “all night.” Guard Holly Harris admits
that three or four detainees approached her that night or early morning and communicated
their concerns that Lisa needed medical help. Scott Sparkuhl testified he received up to
sixteen calls from Lisa that night saying she was in pain and needed medical help.
Despite all of that, not one word was written in any jail log or in any part of Lisa’s medical
record about Lisa that night. This complete absence of information reflects either an
intentional cover-up or an astounding level of indifference and disdain. Yet no
discipline, corrective actions, or changes in training or policy were implemented as a result,
except we have been informed that Central Control now logs repeated calls from detainees.

11. The Morbidity and Mortality Review is a sham process that, because it is
largely focused on protecting the County from liability, is not capable of providing
understanding about, accountability for, or correcting problems relating to
preventable deaths of detainees at the Jail.
May 20, 2020
Page 19

After each death in custody, various officials at the Jail are to meet to review the
circumstances of the death, determine if anyone did anything wrong, and to identify
changes in Jail policies or practices that can be made to prevent similar deaths in the future.
The way this process is actually implemented, however, is a complete sham.

Those attending the meetings are instructed not to prepare any written documents or
notes, which ensures there is no trail of evidence regarding what the committee does and
does not do. Also, there is no final written report generated during the Morbidity and
Mortality Review process. Again, it appears that covering up the culpability of the
County and its staff or other agents is the overriding concern among Jail
administrators, rather than determining what caused an inmate’s death, whether
there should be personal accountability, and what can be done to deter or prevent
future in-custody deaths.

At the Morbidity and Mortality Review for Lisa’s death:

• the participants in the Review did not even know the cause of Lisa’s death;

• there was no follow-up review conducted after her cause of death was determined to
ascertain what had gone wrong;7

• although the Medical Director is supposed to review a deceased detainee’s medical

records to ascertain if there were any problems with, or reflected by, the medical

7
Bell testified as follows:

Q. So if the purpose of the mortality and morbidity review meeting is to

review the death and identify any problems and any remedial measures
that might be taken so it doesn't happen again in the future, why haven't
you held another meeting with regard to Lisa Ostler since finding out
the cause of her death?
A. Yeah. I'm just thinking in my head that I can't think of a reason.

Deposition of Richard Bell, March 25, 2019, 73:15–22.

May 20, 2020
Page 20

records, no one noticed or brought to the attention of the people involved in the
Morbidity and Mortality Review process numerous glaring errors in Lisa’s medical
record (six glaring highly material errors on just one sheet), including obviously
incorrect vital sign measurements (such as a zero oxygen saturation level and a
respiratory rate of 98 breaths per minute), incorrectly scored withdrawal assessment
forms that erroneously minimized the severity of Lisa’s symptoms, and many
instances of omitted information;8

8
Q. So it’s six errors on one sheet. Is this the kind of quality control you
have at your jail?
A. I haven’t compared this to others to know if it’s a all-the-time thing or
not. It’s never been brought to my attention that it’s a problem.
Q. Does this look like it’s a problem?
A. It does have some incomplete information.
Q. Incomplete and erroneous, true?
A. And I’d have to go to whoever made the note to see – on the respiratory
rate, I’d have to go to that person to see what they intended there.
Q. So we’ve got two wrong respiratory rates, a wrong oxygen saturation,
a wrong CIWA score – or a wrong WOWS score, rather, for resting
pulse rate on the second sheet, and no total CIWA score, and no notice
as to who the assessing nurse is. This is one patient, Lisa Ostler. What
are you going to do about it?
A. I need to look into it further and meet with the people who made the
notes and gather some more information.
* * *
Q. And you said that you all examined the medical records, and, in fact,
those are the only records other than the logs that you examined at the
Morbidity and Mortality Committee meeting. None of this was noted
by anybody?
* * *
Did you ever talk to anybody about any one or six of the errors or
omissions on Exhibit 9?
A. I don’t recall that I have.
Q. It would have stuck out in your mind, wouldn’t it, if you had?
A. I think so.
(Cont’d.)
May 20, 2020
Page 21

• no one identified the many obvious failures to provide medical assessments,

evaluations, diagnosis, treatment, or care for Lisa in the hours and days prior to
being found unresponsive and not breathing.

Outrageously, jail administrators and other personnel failed to conduct interviews

with any witnesses regarding what happened to Lisa before she was found unresponsive
and not breathing to assist the Morbidity and Mortality Review committee to discover what
happened, why Lisa died, and whether anyone had caused or contributed to Lisa’s death.9

Q. Do you expect better than this of nurses working at the Salt Lake
County . . . Jail?
A. Yes.

Deposition of Richard Bell, March 25, 2019, 151:16–1.

9
Q. You’re the Responsible Health Authority. Have you done anything to
investigate what happened and who was involved in the events leading
up to Lisa Ostler’s death?
A. Yes.
Q. What have you done?
A. We hold a mortality and morbidity review, and, per our policy, that is
held within 30 days of the inmate’s death.
Q. And is somebody charged with investigating, going out and doing
interviews with people in connection with that review?
A. I’m not – I don’t recall on this one, if it was or wasn’t, but typically –
and I can’t speak to the sworn policies, but they will most often have
investigation, particularly if it’s a suicide.
Q. I’m asking in Lisa Ostler’s case.
A. I don’t recall. I don’t recall. When you say “investigation” –
A. Yeah. Did anybody go out and interview anybody to find out what
happened?
A. Interview, like, other prisoners, inmates?
Q. Anybody.
A. I’m not aware of interviews.
(Cont’d.)
May 20, 2020
Page 22

The failure to interview or obtain reports from witnesses who could describe what
happened to Lisa, and what was not done that should have been done by Jail staff, is
compelling proof of what a sham the Morbidity and Mortality Review is. It was made clear
from Bell’s testimony that the Review is simply a formality––a pretense at doing what it is
supposed to do, while not actually determining the relevant facts, the potential
responsibility of Jail staff for a detainee’s death, or what could be done in the future to
prevent similar tragedies.

Had the Morbidity and Mortality Review process been properly implemented
regarding the many prior deaths in custody at the Jail, then the administration would have
learned that mandatory assessments of detainees were often not being performed as
required, that patients were told to use a sick call request form even when they were
experiencing a medical emergency, that medically untrained guards were inappropriately
called upon to decide whether patients are experiencing a medical emergency, and that
written policies are customarily disregarded, including when nurses are required to contact
a physician about a detainee’s condition and that guards instruct operators in Central
Control to “ignore” certain detainees. Had the Morbidity and Mortality Review process
previously been taken seriously and implemented appropriately, serious problems in the
provision of medical evaluations and treatment for detainees would have been identified
and resolved, which would have saved Lisa’s life.

Q. Not with anybody?

A. No.

Deposition of Richard Bell, March 25, 2019, 64:11–65:11.

May 20, 2020
Page 23

12. As a result of intentional obstruction of justice or of outrageous

recklessness, medical records, video records, radio recordings, and e-mails were
destroyed or otherwise rendered inaccessible, obstructing the search for the truth
about what happened to Lisa, without any accountability for the destruction of
evidence or for the failures of the DA’s Office and others to gather and retain the
evidence.

Litigation hold letter. Within days of Lisa’s death, her father sent a letter to Jail
officials notifying them to preserve records relating to Lisa’s death. That letter prompted
the DA’s Office to send a formal written instruction (“litigation hold letter”) to Jail officials
to preserve all evidence relating to Lisa or her death, including e-mails, video records,
audio recordings, and all other documents. Despite those clear instructions, nothing was
done to preserve much of the critical evidence regarding what happened to Lisa.
Although the litigation hold letter noted that the DA’s Office would gather and
preserve all evidence related to Lisa, it wholly failed to do that, resulting in the loss of
highly relevant evidence.

Destruction of video evidence. Video evidence ought to be the gold standard to be

relied upon for determining, objectively and unequivocally, what occurs inside the Jail.
However, for nearly twenty-four hours before Lisa was found unresponsive and not
breathing, her cell was in a “blind spot” of the Jail’s video cameras. Further, the best video
evidence of Lisa’s condition, which would have reflected her bearing and general
appearance as she was transferred from one unit of the Jail to another, approximately
twenty-four hours before being found unresponsive and not breathing, was not preserved,
as the DA’s Office and Jail personnel were legally required to do, and was
inexplicably destroyed.

We brought to the attention of the Court the fact that critical video evidence was
missing. The Court then instructed the County and the other defendants to produce a sworn
statement describing why the missing video was unavailable. The DA’s Office then
produced a declaration signed by Rocky Finocchio (“Finocchio”), which, in substantial
ways, appeared to us to be untrue, prompting us to seek to depose Finocchio. Tellingly, the
May 20, 2020
Page 24

DA’s Office opposed the deposition, arguing that Finocchio’s declaration “speaks for
itself.” The Court, of course, rejected that argument and allowed us to depose Finocchio.
He testified under oath that the DA’s Office drafted his declaration and presented it to
him to sign––and that multiple paragraphs in the sworn declaration were untrue.

We later deposed a witness designated by Salt Lake County to testify regarding the
preservation of video evidence relating to Lisa. Notwithstanding the litigation hold letter
from the DA’s Office, she testified she knew of nothing that was done to ensure all
video of Lisa was preserved.

Destruction of radio recordings. There may have been radio communications

about Lisa during the night before she was found unresponsive and not breathing, but we
will never know because no one reviewed the radio recordings to see if they contained
anything about Lisa. That was directly contrary to the instruction from the DA’s
Office to retain all audio recordings about Lisa. Those recordings would have been
accessible for months after Lisa’s death, but, because apparently no one, including the
DA’s Office, reviewed them or did anything to collect and retain them, they were
allowed to be permanently destroyed.

Destruction of e-mails about Lisa not eating. In the days prior to her death, Lisa
did not eat meals provided by the Jail. That, in itself, was a major sign that Lisa was
experiencing a serious medical problem. In each instance of Lisa not eating, a guard was
to have e-mailed a message about it to his or her supervisor as well as the nursing
supervisor. Those e-mails would have contained the reasons she told the guards that she
was not eating, which would be crucial evidence in determining what was known about
Lisa’s life-threatening medical condition. However, despite the instruction from the
DA’s Office to preserve all e-mails about Lisa and despite that Jail officials knew that
such e-mails were customarily created, Jail officials deliberately did nothing to ensure
May 20, 2020
Page 25

those e-mails were preserved.10 Also, the DA’s Office did nothing to gather and retain
such records.

Destruction of medical records. Even access to certain medical records, which the
Jail has multiple legal duties to preserve, has been destroyed. After Lisa’s death, the Jail
terminated its relationship with KaZee, Inc., a company that had provided electronic
medical record software to the Jail. Representatives from KaZee offered to provide access
to an archive of medical records. Jail administrators inexplicably rejected that offer, then
ineffectively attempted to back up the records, destroying access to an unknown number
of records. Included in the records the Jail failed to adequately preserve are all documents
in a backchannel that was used to communicate about Lisa’s death and, presumably,
records relating to other deaths in custody at the Jail.

10
Q. Does Salt Lake County admit that Sheriff Jim Winder, Chief Pamela
Lofgreen, and Richard Bell were aware of customs at the jail in which
Housing Officers or nurses would commonly send e-mails about
inmates, yet did nothing to ensure that the e-mails of Housing Officers
or nurses relating to Lisa Ostler were preserved? . . . Does Salt Lake
County admit that?
A. Admits that, yes, they would have knowledge, yes; admits that they
took no action, I have no evidence that they took action, that they
forwarded the Litigation Hold. I have no evidence of that.
Q. Or that they did anything else?
A. That's correct.
* * *
Q. So, despite an instruction from the District Attorney's Office to preserve
all e-mails, it was the custom at the jail in April of 2016 to deliberately
not retain transitory e-mails; is that correct?
A. That's correct.
Q. And transitory e-mails included e-mails reflecting that an inmate
missed a meal?
A. Yes.

Deposition of Lt. Kathy Berrett, 72:25–73:14; 91:17–25.

May 20, 2020
Page 26

13. Both before and after Lisa’s death, numerous detainees have needlessly
died in the Jail due to inadequate medical care and a callous, inhumane indifference
toward their medical needs. Without substantial reforms of policies and practices,
without accountability, and without effective oversight, the tragedies will no doubt
continue.

A few additional examples of the outrageous disdain and indifference toward

detainees at the Jail, and the consequent tragedies, are as follows:

Angie Turner. For several days, Angie Turner pleaded with nurses at the Jail for
help for her severe headaches, yet received no meaningful assessment or treatment. She
told her cellmate she was terrified she would die of a stroke if she did not receive treatment.
One morning, she screamed out in pain and terror. Her face was going numb. A guard,
Ryan Giles, approached the cell. As Angie was desperately begging him to provide her
access to life-saving medical treatment, he callously dismissed her obvious emergency and
told her, as he admits in his log, to stop “acting like an asshole”. When he walked away
from the cell, detainees reportedly heard him mutter, “Fuck her.” Nearly fifteen minutes
passed before a nurse arrived to assess Angie, and another fifteen minutes passed before
an ambulance was called. Those delays in treatment were fatal because Angie, while
untreated, was having a stroke. Her death, which was likely preventable had she received
timely medical attention, cut short the loving, caring relationships between her, her
daughter, her eight grandchildren, and her two great grandchildren.

Meagan Deadrich. Meagan Deadrich was 27 weeks pregnant while she was in the
Jail. She became extremely distressed when she discovered that she was bleeding vaginally
and, over the course of several days, begged nurses and a physician for urgent help. She
was denied any examination or testing and was merely told by Jail medical personnel that
bleeding was normal and that she should just rest. She continued to ask for medical help at
every opportunity until she was finally transferred to a hospital. There she learned that her
fetus had died. In fact, it had been dead for so long that her uterus had to be removed. As a
result, Meagan will never have a child and she suffers from severe postpartum psychosis.
May 20, 2020
Page 27

David Walker. David Walker spoke to a mental health worker in the Jail about his
suicidal thoughts and his fears that he would kill himself. In response, the mental health
worker did nothing other than provide David a brochure. The mental health worker wrote
in the medical record that David said he did not think the brochure would help. Nothing
else was done for David and, being denied any further mental health treatment, he
committed suicide in his cell. There was every indication that David would commit suicide,
there existed the means of preventing it, but no one did anything to save David’s life. The
emotional impact on David’s mother and brother are beyond description.

For each of these unjustifiable and outrageous failures to provide adequate treatment,
we are aware of no discipline of anyone responsible and no changes in policy or
practices to make certain preventable deaths do not occur in the Jail in the future.
Each of those events should be investigated through an independent, outside review,
including by DOPL and an independent expert retained by the County or the State, and
should be analyzed for referral to the Attorney General’s Office or another county attorney
or district attorney for criminal investigation, as appropriate.

14. The County rejected all of our proposed changes to the policies and
practices of the Jail that could result in saving lives otherwise unnecessarily lost at the
Jail.

We have attached as Exhibit “C” a list of meaningful changes that would address
some of the reprehensible deficiencies at the Jail and would save lives. In attempting to
resolve the claims relating to Lisa’s death, however, the County refused to accept any type
of external oversight or measures that could be used to hold the County or any of its staff
accountable in the future. We vigorously urge the implementation of all the changes in
policies and practices set forth in Exhibit “C”.

15. The abhorrent conditions at the Jail have been caused, in part, by
discriminatory, unjust legislation that provides unnecessary, and often
insurmountable, barriers for victims seeking accountability for misconduct and
inadequate medical care at the Jail.
May 20, 2020
Page 28

The Utah Legislature has decided, generally, that the state and local governments
should be held accountable for injuries caused by the negligent acts of their employees, but
that laudable goal is defeated in many instances by numerous exceptions for which the
government and its employees retain immunity for their negligent acts. Under Utah Code
Section 63G-7-201(4)(b) and (j), “a governmental entity, its officers, and its employees are
immune from suit, and immunity is not waived, for any injury proximately caused by a
negligent act or omission of an employee committed within the scope of employment, if
the injury arises out of or in connection with, or results from: . . . violation of civil
rights; . . . [or] the incarceration of a person in a state prison, county or city jail, or other
place of legal confinement.”

That discriminatory preclusion of any claim by detainees or their heirs for

negligently caused serious injuries or deaths immunizes Utah jails and prisons from being
held to account for grave injuries and injustices. As a result, Jail staff and leadership are
essentially allowed by Utah’s disgraceful immunity statute to harm or even kill
detainees through negligent misconduct, without any accountability. This has led to a
culture of providing grossly inadequate medical care with no threat of legal
accountability.

Greater protection for detainees is unlikely to come from the courts. In a

justifiably scathing dissent, Justice Stewart (joined by Justice Durham) described a bizarre,
incredibly unjust majority 3-2 opinion of the Utah Supreme Court that upheld the
constitutionality of the statutory preclusion of claims for death or injury negligently
inflicted on detainees as follows:

On the specific facts of this case, the question is whether a physician who
treated an incarcerated person had a legal duty not to commit
malpractice on that person. The majority holds that the physician has no
legal duty to refrain from malpractice. In short, incarcerated persons are
not entitled to competent medical treatment and have no legal remedy for
negligent treatment that may endanger one's health or life, unless the
malpractice is either so extreme as to constitute “cruel and unusual
punishment” or is fraudulent or malicious. See Bott v. DeLand, 922 P.2d 732
May 20, 2020
Page 29

(Utah 1996), also issued today. In effect, prisoners are treated as a

subspecies of the human race who are not entitled to reasonable,
competent medical care.11

Accordingly, it is for legislators to end the dehumanizing and discriminatory

limitation of the rights of detainees to bring claims for negligence against the government
and its employees.

Further, detainees are subject to nonsensical and unnecessary procedural barriers to

seeking justice, which are not faced by plaintiffs who do not sue a member of the
government. For instance, before filing a complaint, those who sue a law enforcement
officer (which includes jail guards) must first post a bond in an amount the court
determines will be the defendant officer’s costs and attorney fees incurred in
defending the suit. See Utah Code Section 78B-3-104. (The current version of that statute,
which makes it mandatory for a court to require a bond in the amount described, was
sponsored by a legislator who, at the time, worked for Sheriff Winder.)

Although legislators should know better, meeting the requirements of that bond
statute is virtually impossible, requiring the plaintiff to somehow appear before the court
prior to filing the complaint, then requiring the court to engage in the impossible task of
determining the amount of costs and fees that will be incurred in the future. These
requirements are so absurd that the Utah Office of the Attorney General has, at least
twice, declined to defend the statute when a constitutional challenge has been raised.
Unfortunately, when those constitutional challenges have been made, the cases have been
resolved without a court’s determination of the constitutionality of the statute.12

If, as is often argued, the statute is intended to prevent frivolous lawsuits against law
enforcement officers, its reach is far broader than that. It applies to all lawsuits, including

11
Ross v. Schackel, 920 P.2d 1159, 1168 (Utah 1996) (emphasis added).
12
The constitutional challenge was made in the Ostler matter and oral argument was held
on the issue, but the federal court did not rule on it before the case was settled.
May 20, 2020
Page 30

those that are meritorious and brought in good faith. A non-discriminatory statute
already provides for the award of attorneys’ fees when a party asserts a claim or
defense “without merit and not brought or asserted in good faith.” Utah Code Ann.
§ 78B-5-825.

All prospective plaintiffs injured by state and local governmental actors are also
required by statute to file a “notice of claim.” See Utah Code Section 63G-7-401(2). This
discriminatory requirement is part of the statutory legal minefield for prospective plaintiffs
and their counsel. In our experience, and the experience of many with whom we have
discussed the matter, the filing of a “notice of claim” never prompts the more efficient
resolution of claims and does nothing other than delay justice and, too often, cause
the outright dismissal of claims where plaintiffs and their counsel were unaware of
the requirement.

CONCLUSION

We as a community, and you as leaders and government officials, are accountable

for ensuring that the people we incarcerate are treated humanely, not as some disregarded
subspecies not entitled to basic dignity and reasonable care.

Lisa’s death was the result of systemic disregard of, and disdain for, that most
basic right to receive medical care, which led to the failure to provide to her the
medication ordered by a physician, the falsification of her medical records, the failure
to follow written policies that required nurses to notify a physician about Lisa’s
alarming vital signs, the failure to perform assessments required by written policy
and medical orders, an instruction (which was followed) to “ignore” her pleas for
help, the failure to document anything about her torturous night of screaming and
begging for help, the failure to provide any assessment at all in response to Lisa’s
near-constant pleas for help over the course of that hellish night, the disregard of
multiple detainees’ urgent demands that Lisa needed medical help or might die, and
the failure for any nurse to simply walk a few steps over to Lisa’s cell and evaluate
May 20, 2020
Page 31

her while she was dying rather than simply instruct a guard to give her a sick call
request form.

Any reasonable, decent person with respect for the proper role of government would
expect that this long laundry list of egregious failures and mistakes must have led to severe
discipline and meaningful, system-wide changes at the Jail. However, from the time of
Lisa’s death, the focus of the County, the DA’s Office, and Jail administrators has
been merely to protect against liability, a perverse goal for public servants that led to
an incompetent and undocumented review of the circumstances of her death, the wholly
unnecessary loss and destruction of several categories of critical evidence, an utterly
wasteful legal defense that dragged on for two incredibly expensive years, and the abject
failure to impose any discipline or meaningful changes to prevent others from
suffering from the same pain, indignity, and death as Lisa Ostler.

What happened to Lisa Ostler must never happen again in the Salt Lake County Jail,
or in any other jail in this state. While you must think that you would never turn your back
on the most vulnerable and would never leave someone to suffer torturous pain and
unnecessarily die after begging for medical assistance, if you do not act and if you do not
make necessary reforms then you will be complicit in future deaths and other
tragedies. Please rise to this crucial challenge and do what is necessary to save lives,
restore common decency, humane treatment, and basic compassion to our penal
system, and provide the necessary means of achieving accountability. Otherwise, there will
be no justice. And, almost certainly, if you do act, unnecessary tragedies will be prevented
in the future.

Sincerely,

Ross C. Anderson

Enclosures
 EXHIBIT “A”
Expert Report of
H. Tae Kim, MD, FACS, FASCRS
Colon & Rectal Surgery
lntermountain Healthcare
��'� Int�rmountain· Gascroen terology

ll�r�·
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Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Sale Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

November 12, 2019

Rocky Anderson
Judge Building
Eight East Broadway, Ste 450
Salt Lake City, UT 84111

To Whom It May Concern:

WITNESS QUALIFICATIONS

My name is Tae Kim. I am a board-certified colon & rectal surgeon practicing with lntermountain
Healthcare in Salt Lake City, UT. I received my medical degree from the University of Nevada School of
Medicine. My general surgery residency was at the University of Utah. I completed my colon & rectal
surgery residency at Western Pennsylvania/Allegheny General Hospital in Pittsburgh, PA. I have been
practicing at LOS Hospital within the lntermountain Healthcare System for the past 11 years. I serve as
the Chair of Surgery at LDS Hospital. I am the medical director for the GI Oncology program for the
lntermountain Healthcare System. I have had vast experience in understanding, diagnosing, and treating
peritonitis in my medical education, surgical training, extensive reading, and my treatment of hundreds
of patients with peritonitis. I am the Chair of Western USA Committee for the International Society of
University Colon & Rectal Surgeons. I am a clinical instructor with the St. Mark's Health Care Foundation
Colon & Rectal Surgery Residency. I am an editorial reviewer for Diseases of Colon & Rectal Surgery and
World Journal of Colorectal Surgery. Enclosed please find my CV.
I have published the following articles:
• Swords DS, Brooke BS, Skarda DE, Stoddard GJ, Tae Kim H, Sause WT, Scaife CL. Facility Variation
in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of
Neoadjuvant Therapy. Journal of Gastrointestinal Surgery. 2019 Jun; 23(6):1206-1217.
• Swords DS, Skard DE, Sause WT, Gawlick UT, Cannon GM, Lewis MA, Scaife CL, Gygi JA, Tae Kim
H. Surgeon-level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage 11-111
Rectal Adenocarcinoma. Journal of Gastrointestinal Surgery. 2019 Apr; 23(4):659-669.
• Bagshaw H, Sause W, Gawlick U, Kim H, Whisenant J, Cannon G. Vu Ivar Recurrences After
Intensity-modulated Radiation Therapy for Squamous Cell Carcinoma of the Anus. Am J Clin
Oneal. 2018 May;41(5): 492-496.
• Kim H, Bruen K, Vargo D. Human Acellular Dermis in the Management of Complex Abdominal
Wall Defects. Am J Surg 2006; 192(6): 705-9.

1
��� Int�rmountain· Gastroenterology
�,P Medical Group General Surgery

l(�f-�• Internal Medicine

Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

OTHER CASES IN WHICH I HAVE TESTIFIED

I have testified or provided consultation as an expert or a fact witness in the following cases:
a. Ghekiere vs. Mortensen, Montana Eighth Judicial District Court, Cascade County; No. CDV-17-
0632
b. Young vs. Grace, Montana Medical Legal Panel; Helena, Montana; Claim No. 1802
c. Barbara Jensen, deposition on 10/26/12, (Lawyer contact: Anne Armstrong) (Utah)
d. Blanke v Trowbridge, Case No. 150900827, 3rd District Court, State of Utah
e. Jensen v. lntermountain Health Care, Inc., Case No. 150900735, 3rd District Court, State of Utah
f. Dicenzo v. Stewart, Case No. 160900823, 3rd District Court, State of Utah

COMPENSATION

My compensation for review of documents, consultations, preparation of this report, and providing
expert testimony in the matter of Ostler v. Harris, et al. is $500 per hour.

FACTS AND DATA CONSIDERED IN FORMING MY OPINIONS

I have received and reviewed medical and other records from the Law Offices of Rocky Anderson in
regard to Lisa Marie Ostler. These records include the following:

A. Event timeline, summary narrative, (proposed) second amended complaint totaling 162 pages.
B. Salt Lake County Metro Jail Shift Logs 3/29 - 4/2. Incident Log 3/30-4/2. Control Room Shift Log
4/1-4/2.
C. Medical records from Office of Medical Examiner, Salt Lake County Metro Jail/Pearl Clinic, and
lntermountain Medical Center.
D. Defendants' answers to Plaintiffs' interrogatories
E. Defendants' answers to Plaintiffs' requests for admissions and reformulated requests for
admission.
F. Letter from Bridget Romano, dated October 4, 2019.
G. Inner Facility Movement History.
H. Three depositions of Richard Bell.
I. Deposition of Kristine N. Pugh.
J. Deposition of William J. Harris.
K. Deposition of Colby Grey James.
L. Deposition of Nicole Danielle Bates.
M. Deposition of Holly Patrice Harris.
N. Deposition ofTodd Allan Booth.
0. Deposition of Brent LeeTucker.
P. Deposition of Zachary Frederickson.
Q. Deposition ofTodd R. Wilcox, MD.

2
�"il� lnt�rmountain· Gasrroencerology
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Medical Group General Surgery
Internal Medicine
Midwifery
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324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801. 408.7500 Urology

R. Deposition of Heather Beasley.

S. Deposition of Bradley K. Lewis, MD.
T. Deposition of Ronald Seewer, Jr.
U. Deposition of Scott Sparkuhl.
V. Deposition of Alisha C. Woodruff.
W. Deposition of Kellie Marie Sheppard.
X. Deposition of Jason Power.
Y. Deposition of Nathan Dean, MD.
Z. Deposition of Samuel Brown, MD.
AA. Deposition ofTodd Riser, RN.
BB. Deposition of Matthew Dumont.
CC. Deposition of Kathy Berrett.
DD. Deposition of Pamela Ulmer, DO.
EE. Videos of Lisa Ostler in unit SC on March 31 and April 1 and in unit 8C on evening of April 1.
FF. "Managing Opiate Withdrawal: The WOWS Method," by Todd Wilcox, MD, MBA, CCHP-P,
CCHP-A.
GG. Salt Lake County Jail Medical records of , , ,
, , , and .

In addition to my review and consideration of the facts and data contained in the documents
described above, I considered the following facts and data, which were provided to me by Plaintiff's
counsel and conform with my review of the documents, in forming my opinions in this matter:

1. Lisa Ostler was booked into the Salt Lake County Metro Jail ("Jail") in the early morning of
3/30/2016. (SLCo Ostler 000017.)

2. Lisa Ostler underwent a "Pre-screen Examination" and "Comprehensive Nurse Examination"

dated 3/30/2016. (SLCo Ostler 000128 - 000130.) Those examinations included the reporting of,
among other findings, the following:
a. "Level 3" medical acuity rating for "multiple medical issues,"
b. Positive risk factors for withdrawal from Xanax, heroin, and prescription opiates,
c. Temperature of 98.3 degrees Fahrenheit,
d. Blood pressure of 115/75,
e. Respiratory rate of 15 per minute,
f. Oxygen saturation of 99%,
g. Height of 69 inches,
h. Weight of 124 pounds,
i. Body mass index of 18.3,
j. Tobacco use,
k. Heroin use,
I. Methamphetamine use,
m. Dental findings of "broken/missing,"

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n. Rectal neuropathy,
o. Spondyloarthritis,
p. History of gastric bypass surgery in 2006,
q. Abscesses on right breast and right anterior chest,
r. Victimization through "violent abuse/assault," domestic violence, and "sexual
abuse/assault/rape,"
s. Post-traumatic stress disorder.

3. Lisa Ostler was placed on the Wellcon Opiate Withdrawal Scale ("WOWS") protocol due to her
history of heroin use and prescription opioids. (SLCo Ostler 000129, 000155, 000214.)

4. Lisa Ostler was placed on the Clinical Institute Withdrawal Assessment ("CIWA") protocol due to
her use of prescription Xanax. (SLCo Ostler 000129.)

5. Both the WOWS and CIWA protocols required assessments twice daily for a minimum of five
days. ("Managing Opiate Withdrawal: The WOWS Method," by Todd Wilcox, Medical Director,
Salt Lake County Jail.) On 4/1/2016, Lisa Ostler was provided those assessments only once (if, in
fact, the assessments, including monitoring of vital signs, were done at all on 4/1/2016), in the
morning. (SLCo Ostler 000155-000156.) Defendants admit that the Jail was required to provide
Lisa Ostler each of those assessments twice on April 1, 2016. (Defendants' Answers to Plaintiffs'
Reformulated Requests for Admissions Nos. 6 and 7.)

6. As reflected in emails sent on 3/30/2016 between Brad Stoney, Dr. Brad Lewis, and Paula Braun
(SLCo Ostler 000142 - 000145), medical staff at the Salt Lake County Metro Jail verified that Lisa
Ostler had active prescriptions for Prilosec, Lexapro, Gabapentin, Adderall, Xanax, Oxycodone,
Norco, and Ambien.

7. Paula Braun ordered a "librium taper for bzd w/d" on 3/30/2016. (SLCo Ostler 000144.)

8. Dr. Brad Lewis noted on 3/31/2016 as follows: "The patient was on a verified dose of Prilosec.
We will go ahead and order 40 mg p.o. daily for this medication." (SLCo Ostler 000214.)

9. The medical record indicates that Lisa Ostler was not provided Prilosec while she was
incarcerated. While Prilosec is included on her medication administration chart, that document
indicates that Prilosec was never administered to Lisa Ostler. (SLCo Ostler 000151- 000152.)

10. Dr. Brad Lewis also noted on 3/31/2016 as follows: "The patient was also on oxycodone and
Norco. Due to the nature of these medications and we are not a chronic pain or withdrawal
facility and neither one of them have been filled since December 2015, request for both have
been denied. The patient will be placed on WOWS as a precaution." (SLCo Ostler 000214.)

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11. Dr. Brad Lewis also noted on 3/31/2016 as follows: "Apparently the patient is on Lexapro,
gabapentin, Adderall, Xanax, and Ambien. All of these are referred to Mental Health as the
patient is on them for posttraumatic stress disorder, depression, or attention deficit disorder,
insomnia." {SLCo Ostler 000214.) Nothing in the medical record reflects that any member of the
mental health staff followed up regarding these medications for Lisa Ostler. Her medication
administration chart reflects that those medications were not ordered and that she was not
provided any of these medications. {SLCo Ostler 000151- 000152.) The medical record reflects
that no follow-up was provided regarding those medications and none of them were ever
administered to Lisa Ostler.

12. Lisa Ostler's vital signs on the morning of 3/31/2016 were recorded as follows: blood pressure of
106/76, heart rate of 119 beats per minute, temperature of 98.1 degrees Fahrenheit, respiratory
rate of 16 breaths per minute, and oxygen saturation of 97%. {SLCo Ostler 000155, 000156.)

13. The "Intoxication and Withdrawal" policy of the Salt Lake County Jail states that "signs of
withdrawal" include "[h]eart rate greater than 11011 and that a registered nurse "will" "[n]otify
the physician immediately for signs of withdrawal." {SLCo Ostler 001717 -001718.)

14. In violation of the "Intoxication and Withdrawal" policy, the medical record does not reflect that
any physician was informed that Lisa Ostler's heart rate significantly exceeded 110 on the
morning of 3/31/2016.

15. Todd Riser, RN, testified, as the designated witness for Salt Lake County, as follows (Deposition
of Todd Riser, 122:7-12):
Q. And at least according to written policy, with a heart rate over 110, the physician
should be notified immediately; correct?
A. Correct.
Q. But that wasn't the practice?
A. That's correct.

16. Richard Bell testified, as the designated witness for Salt Lake County, as follows (Deposition of
Richard Bell, May 20, 2019, 109:13- 21.)
Q. Right. But if there's a sign of withdrawal, which would include a heart rate greater
than 110, a physician is to be immediately contacted?
A. That's what it says, yes.
Q. All right. And that's the one thing that's in this written policy that you don't actually
do at the Salt Lake County Jail; correct? You don't strictly comply with that?
A. Yes.

17. Lisa Ostler's vital signs on the afternoon of 4/1/2016 were recorded as follows: blood pressure
of 89/68, heart rate of 133 beats per minute, temperature of 98 degrees Fahrenheit, respiratory
rate of 16 breaths per minute, and oxygen saturation of 97%. (SLCo Ostler 000155, 000156.)

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18. Nothing in the medical record reflects that a physician was notified about Lisa Ostler's heart rate
of 133, in violation of the "Intoxication and Withdrawal" policy.

19. The medical record reflects that no follow-up whatsoever was performed regarding Lisa Ostler's
troubling vital signs on 4/1/2016.

20. At approximately 6:26 p.m. on 3/31/2016, Officer Grant noted as follows:

Prisoner Ostler, Lisa SO# 236212 (SC04B [Lisa's cell number]) came over
to the officer station and asked me if I knew were [sic] Claudia was and
that she is supposed to be going to a wedding with her. I told prisoner
Ostler that I didn't know a Claudi [sic]. Prisoner Ostler returned to her
cell. I contacted MH worker Esther and informed her about prisoner
Ostler. She said that she would come down and talk with her.

(SLCo Ostler 000098.)

21. At 6:33 p.m. on 3/31/2016, mental health professional Esther Israel noted as follows:

Met with Lisa for a crisis call. Officer reported he had a strange interaction with
her when she got up from sleeping and asked where Claudia was because they
need to go to a wedding.

(SLCo Ostler 000153.)

22. The medical record reflects that no follow-up was performed regarding the change in Lisa
Ostler's mental status evidenced by the incident of Lisa Ostler speaking about Claudia and a
wedding.

23. Lisa Ostler's purported vital signs were recorded on the morning of 4/1/2016 as follows: blood
pressure of 105/75, heart rate of 95 beats per minute, temperature of 97.6 degrees Fahrenheit,
respiratory rate of 18 breaths per minute, and oxygen saturation of 95%. (SLCo Ostler 000155,
000156.)

24. Video records reflect a woman (who is seen entering and leaving Lisa Ostler's cell in Unit SC)
displaying the following characteristics and behaviors at the following approximate times:

3/31/2016 8:55 a.m. She walks slowly, bent forward, holding her abdomen.

3/31/2016 8:56 a.m. She bends over at the waist while waiting to see a nurse.

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3/31/2016 9:10 a.m. She walks to a nursing cart while bent forward and holding her
abdomen. She continues to hold her abdomen and remains bent
forward while waiting in line and speaking to a nurse.

3/31/2016 2:33 p.m. She speaks to a nurse and bends forward at the waist.

3/31/2016 2:42 p.m. She is walking slowly while bent forward, holding her abdomen. She
sits down while waiting to be seen by a nurse. She then stands in
line waiting to be seen, during which time she bends forward
several times and holds her abdomen. While speaking with the
nurse, she appears to use her hands to direct the nurse's attention
to her abdomen.

4/1/2016 8:29 a.m. She bends forward several times while sitting down and waiting to
be seen by a nurse. She is hunched forward while walking back to
her cell.

4/1/2016 8:56 a.m. She walks slowly to the nurse while holding her abdomen with a
hunched forward posture. She returns to her cell, appears to pick up
a piece of paper, which she then appears to give to the nurse.

4/1/2016 9:04 a.m. She leaves her cell with a bundle of white clothing or linen, hunched
forward, with her head down. She lays on the floor and moves very
little for nearly forty-five minutes.

4/1/2016 9:49 a.m. She stands up along with other detainees to leave the unit and
holds her abdomen.

25. Video records reflect a woman, identified by Kellie Sheppard as Lisa Ostler, in Unit 8C displaying
the following characteristics and behaviors at the following approximate time:

4/1/2016 11:10 p.m. She leaves her cell for clothing exchange, walking slowly, holding
her abdomen. She appears confused as she wanders in the wrong
direction, away from her cell.

26. There are no records reflecting that Lisa Ostler consumed any food or liquids from March 31,
2016, until she was found unresponsive and not breathing on the morning of April 1, 2016.

27. The medical records reflect that nothing was done to assess whether Lisa Ostler was adequately
hydrated.

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28. Jail logs reflect that Lisa Ostler did not receive a breakfast tray on 3/31/2016. (SLCo Ostler
000096.)

29. Jail logs reflect that Lisa Ostler did not receive a lunch tray on 3/31/2016. (Officer Shift Log, SLCo
Ostler 000097.)

30. Jail logs reflect that Lisa Ostler refused her lunch tray on 4/1/2016 because she was "sick."
(Officer Shift Log, SLCo Ostler 000111.)

31. Jail logs reflect that Lisa Ostler refused her breakfast tray on

on 4/2/2016, that it
was reported to him by detainees that "Prisoner Ostler (236212) has not eaten since she arrived
in the unit yesterday." (SLCo Ostler 000117.) Lisa Ostler was transferred to that unit, Unit 8 , at
approximately 10:00 a.m. on 4/1/2016. (SLCo Ostler 002510.)

33. Lieutenant Kathy Berrett, designated to testify on behalf of Salt Lake County, testified that a
Housing Officer was to send an e-mail each time a detainee did not take a meal tray; that Salt
Lake County failed to preserve at least four e-mails reflecting that Lisa Ostler did not take her
meal tray; and that those emails were expected to contain the communications from Lisa Ostler
to the Housing Officers about why she was refusing the meal trays. (Deposition of Kathy Berrett,
50:1-51:23.) Ms. Berrett also testified it was the custom at the Jail to deliberately not preserve
"transitory e-mails," which included the e-mails about detainees' missed meals, even when
instructed by the District Attorney's Office to preserve all e-mails relating to a particular
detainee. (Deposition of Kathy Berrett, 91:3-25.)

34. The WOWS and CIWA assessment forms for Lisa Ostler reflect that Lisa was given one bottle of
Gatorade each on the morning and afternoon of March 31, 2016. All other dates and times for
Lisa Ostler's WOWS and CIWA assessments reflect either a blank or zero in the space for"# of
Gatorade given." (SLCo Ostler 000155-000156.)

35. Nurse Esther Israel noted on March 31, 2016, at 6:33 p.m. that there "were three bottles of
Gatorade in [Lisa Ostler's] cell, one of them was spilled on the floor." (SLCo Ostler 000153.)

36. Nurse Todd Riser testified on behalf of Salt Lake County as follows:
Q. And both CIWA and WOWS protocols require vitals to be taken twice a day for five
days?
A. Yes.
(Todd Riser Deposition, 41:15-17)

37. Todd Wilcox, Medical Director of the Salt Lake County Jail, stated in his article, "Managing
Opiate Withdrawal: The WOWS Method," as follows: "In my facility, any patient undergoing

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opiate withdrawal is assessed twice per day for a minimum of five days by nurses who have
been trained in the WOWS protocol."

38. Lisa Ostler's purported vital signs were recorded on 4/1/2016 only once, around 8:00 a.m. (SLCo
Ostler 000155 - 000156.) The medical record reflects that Lisa Ostler's vital signs were not
recorded from that time until after she was found unresponsive and not breathing in her cell on
the morning of April 2, 2016.

39. The medical record reflects that Lisa Ostler was not given WOWS or CIWA assessments on the
afternoon or evening of April 1, 2016, and, instead, a circled 3" is noted on the WOWS and
11

CIWA forms, erroneously indicating that she was unavailable for the assessment even though
she was available in her cell, having been moved from Unit SC to Unit 8C on the morning of April
1, 2016. (SLCo Ostler 000155-000156, 002510.)

40. OfficerTodd Both recorded on 4/1/2016 at approximately 3:25 p.m. in his shift log the
following: "Nurse Ron is in the unit for medication pass and diabetic check, Prisoner Ostler, Lisa
so#26212 complaining of pain. Nurse Ron examined prisoner Ostler and cleared her to stay in
the unit." (SLCo Ostler 000112.)

41. Nothing was recorded in Lisa Ostler's medical record reflecting anything about any purported
interaction between "Nurse Ron" and Lisa Ostler on the afternoon of 4/1/2016.

42. Nurse Ron Seewer testified that he does not "have any recollections about Lisa Ostler" and has
"no recollection whatsoever of anything" that he did concerning Lisa Ostler. (Deposition of Ron
Seewer, 42:24-25, 46:1-4, 93:14-24.) He further testified that if he measured her vital signs he
would have entered them on the medical records; that he does not recall examining Lisa Ostler;
that if he examined her, he would have charted the examination in the medical record; and that
he did not chart any examination of Lisa Ostler or any conclusion he drew about her condition.
(Deposition of Ron Seewer, 50:14-51:4; 78:4-14; 171:20-172:20; 174:24-175:4.) The officer
shift log reflects that Nurse Ron Seewer was in Unit 8C to pass medications and to perform
diabetic checks on 4/1/2016. (SLCo Ostler 000111-000112.)

43. Nurse Ron Seewer testified that it was not his responsibility to provide the second set of WOWS
and CIWA assessments for Lisa Ostler on 4/1/2016. (Deposition of Ron Seewer 100:7-13.)Todd
Riser testified that it was the responsibility of the "pod nurse" to provide those assessments.
(Deposition ofTodd Riser, 96:9-97:17) The Health Services Unit Daily Assignment Log indicates
that "Disa" was the nurse assigned to C Pod on 4/1/2016. (SLCo Ostler 030924.) However,
counsel for Defendants state that relevant records contain "no indication 'Disa' provided
services in that pod on that day" and that the log is not treated "as a reliable or official log."
(Letter from Bridget Romano, dated October 4, 2019.) Nurse Ron Seewer provided services in
that pod on that day. (SLCo Ostler 000112.) Ron Seewer was not subject to any discipline or
corrective action relating to his failure to perform the WOWS and CIWA assessments for Lisa

9
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Ostler on the afternoon of 4/1/2016, but he was "coached" "just to make sure his
documentation is there." (Richard Bell Deposition, May 20, 2019, 53:11-18.)

44. Officer Todd Booth testified that he does not "recall anything on that day [April 1, 2016];" that
to his knowledge he did not have any view as to whether Lisa Ostler was withdrawing from
drugs; and that he knew Lisa Ostler had been sick, refused her lunch tray, and was complaining
of pain. (Deposition of Todd Booth, 39:9-40:9, 68:3-24.) There is no description in the shift log
of what examination took place and there is nothing in the medical records reflecting anything
about such an examination or that such an examination took place. (SLCo Ostler 000112.)

45. Detainee Nicole Bates testified that she remembered "more than one inmate" trying to get a
guard's attention, who she believed was Officer Todd Booth, to let him know that "something
wasn't right" with Lisa Ostler and that "she needs medical attention." She further testified that
the guard responded by saying "mind your own fucking business and leave her alone," telling
them Lisa Ostler already "knew to put a sick call in to see triage in the morning," and
threatening that the detainees would not continue to have time out of their cell if they did not
mind their own business. (Nicole Bates Deposition, 51:15-54:13.) Todd Booth noted in his log, at
4:39 p.m. on April 1, 2016, that he "had to tell [the detainees] twice to quiet down" and that
"[p]risoners will lose one hour of their recreation time out of their cells." (SLCo Ostler 000112.)
Nicole Bates also testified that Summer Johnson spoke to Todd Booth about Lisa Ostler and he
responded by saying he would take away Summer's job if she did not mind her own business.
(Nicole Bates Deposition, 67:11-25.)

46. Detainee Nicole Bates testified that on other occasions she has heard Todd Booth say "what the
fuck are you standing over there for," "you guys are just a bunch of fucking drug addicts," and
"get the fuck away from my desk" and that he has taunted her about being away from her kids
while she is incarcerated. (Nicole Bates Deposition, 66:2-67:10). Todd Booth admits saying
things like "get away from my fucking desk." (Todd Booth Deposition, 48:23-25.)

47. In a separate incident, when ought help from a guard because she believed she
was having a stroke, the log of Officer Ryan Giles reflects that he "told her not to act like an
asshole towards" him and that it took 13 minutes from the time she began screaming until a
nurse arrived in the unit. (SLCo Ostler 012785. oon thereafter died from a stroke.
(SLCo Ostler 026477.)

48. Nurse Ron Seewer testified that he uses the Jail's desktop computers to access the internet
"probably every day;" that he watches television shows or YouTube videos while on the job,
sometimes alone and sometimes with other nurses; that nurses watching television shows or
YouTube videos at the Jail is fairly common and occurs on a daily or almost daily basis; that he
has seen nurses watch videos or surf the internet for "an hour or two" on a day; that he has
spent an hour or two watching videos at the Jail on a single day; and that he does not know of

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any policy applicable to nurses watching videos on the job. (Ron Seewer Deposition, 20:12-
23:25.)

49. Former Sheriff James Winder testified that throughout his tenure as Sheriff he had received
complaints of nurses sometimes spending hours outside of their break time engaging in
entertainment; that he had conversations "on several occasions" to address that issue; that he
received complaints from "inmates, visitors, and other staff members" about that issue; that the
issue occurred for a fairly long period of time and continued even after he attempted to "put an
end to it;" that he attempted to address the issue with "road officers and their MDTs," "office
staff," and "Housing Officers, et cetera;" and that it was "an ongoing issue." (James Winder
Deposition, 128:8-131:9.) Richard Bell testified that he "wouldn't encourage [nurses] watching
movies" and does not know about television shows. (Richard Bell Deposition, March 25, 2019,
115:8-116:10.)

50. Detainee Nicole Bates testified that when Lisa Ostler was transferred into Unit 8C at
approximately 10:00 a.m. on 4/1/2016 "she was really frail, sickly looking," "[t)here wasn't really
an expression on her face," and "[s]he just looked down, had her stuff in her hand, her bedroll."
(Nicole Bates Deposition, 45:20-46:2.)

51. Detainee Alisha Woodruff testified that when Lisa Ostler was transferred into Unit 8C at
approximately 10:00 a.m. on 4/1/2016 she "looked dead," "it was kind of scary," "she looked
just like a skeleton," her skin was "gray," she was "hunched over," "she didn't come out of her
cell," she was "rocking" on her bed, and the other detainees in the unit were talking about the
fact that "she needed help." (Alisha Woodruff Deposition, 7:16-8:22.)

52. Detainee Nicole Bates testified that on 4/1/2016, after dinner, Lisa Ostler "was sitting on her
bed with her -- she was sitting with her legs up to her -- both legs up to her, holding her stomach
going like this, like moaning, crying." (Deposition of Nicole Bates, 47:13-16.)

53. Detainee Nicole Bates also testified as follows about how Lisa Ostler appeared on 4/1/2016:

And [s]he was holding herself, sitting on her bunk rocking back and forth
moaning and crying, like she was in severe pain. And I tapped on her glass. I was
like, hey, are you okay? I didn't get no response from her. She didn't even seem
like she -- like she didn't acknowledge me at all. It didn't even seem like she
heard me or anything. That was when we were told by the officer to mind our
own fucking business and to leave her alone.

(Deposition of Nicole Bates, 52:21-53:6.)

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She seemed more like she was suffering from pain, a severe pain than she was anything
else. It didn't seem like she was withdrawing from anything. It seemed like she had more
abdominal pain, like something abdominally was bothering her severely.

(Deposition of Nicole Bates, 55:19-23.)

54. Detainee Alisha Woodruff testified that on 4/1/2016 Lisa Ostler "didn't move around a lot,"
"was rocking back and forth," appeared to be in a lot of pain, "looked miserable," "didn't get
up," "just sat on the edge of her bed," looked more sick than anyone Ms. Woodruff had seen in
her life, looked "horrible," "didn't look coherent at all," looked "much worse" than someone
withdrawing from heroin, was "gray" in color, "was always hunched over," "looked awful,"
"looked like death," and "looked dead." (Alisha Woodruff Deposition, 7:16-8:22, 10:21-11:19,
13:7-14:4, 15:23-16:14, 21:22-22:16, 23:3-8, 34:4-14, 38:18-39:1). Alisha Woodruff was
worried when she saw Lisa Ostler that she looked like she might die. (Alisha Woodruff
Deposition, 10:21-11:19.)

55. Detainee Kellie Sheppard testified that on 4/1/2016 Lisa Ostler had "yellowish" "really pale"
skin, "looked very weak and sick," appeared desperate, appeared to be in agonizing pain, was
rocking back and forth on her bed, and held up her hands and said to Sheppard "please help
me." (Deposition of Kellie Sheppard, 7:5-13, 7:23-8:7, 8:10-23, 9:6-14.)

56. Scott Sparkuhl, who was employed to work in the jail's Central Control, testified as follows:

When I came on shift [on the evening of 4/1/2016], we were given a briefing -- I
was given a briefing from my panel that included information about Lisa Ostler
as someone who had been repeatedly calling in for medical care, medical
attention. I'd been told that she'd been doing this for several days and that she
had seen nurses and doctors and medical staff, and they'd all checked her out
and said that she was coming off of heroin, and that was the information I had
on my account on shift.

(Deposition of Scott Sparkuhl, 41:16-25.)

I contacted the Deputy the first time she [Lisa Ostler] called in to make sure that he was
aware of the situation, and I asked him how he wanted to respond, and he said, "Go
ahead and ignore the cell," . . . .

(Deposition of Scott Sparkuhl, 51:6-10.)

57. Scott Sparkuhl also testified "it didn't seem odd" to be instructed to ignore Lisa Ostler's
communications and "that's the way" he "was trained to handle situations." (Deposition of Scott
Sparkuhl, 101:22-102:7.) He testified that he had experienced "a dozen or so" prior instances

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where Housing Officers instructed him to ignore a detainee's calls when the detainee was
reporting experiencing a serious medical problem and needing medical help. (Deposition of
Scott Sparkuhl, 67:20-68:6.)

58. Scott Sparkuhl also testified that through the night of 4/1/2016 into the morning of 4/2/2016 he
received communications from Lisa Ostler about her pain and her need for medical treatment
"many times that night," "perhaps once or twice an hour," which amounted to approximately 16
separate occasions. In those communications, Lisa Ostler "said that she was in pain" and "was
requesting medical." (Deposition of Scott Sparkuhl, 40:18-41:11, 45:12-18, 49:10-14.) Mr.
Sparkuhl also testified that during the same night a detainee communicated with him about her
concern for Lisa Ostler's medical problem and another detainee communicated with him to
complain about the noise Lisa Ostler was making. (Deposition of Scott Sparkuhl, 69:22-70:6,
70:11-23, 72:25-73:19.)

59. Scott Sparkuhl testified that no record is maintained of the contents of shift briefings for Central
Control operators or of the communications between detainees and operators. (Scott Sparkuhl
Deposition, 42:24-44:2, 66:14-22.) He testified that after Lisa Ostler's death, the practice
changed in that operators were then required to log when they were ordered to ignore
communications from certain detainees if there were repeated calls. (Scott Sparkuhl Deposition,
66:22-67:5.)

60. Officer Holly Harris was the guard responsible for supervising the unit in which Lisa Ostler was
housed on the "graveyard" shift the night of 4/1/2016. Ms. Harris stated in her answers to
interrogatories that "[a] few of the female prisoners were concerned about her (Lisa Ostler], so I
called the nursing staff and had asked about Lisa Ostler" and that the nurse informed Ms. Harris
that Lisa Ostler's "vitals were taken a few hours prior and her vitals were good." (Holly Harris
Answers to Interrogatories Nos. 2 and 22.) However, the medical record reflects that the last
time Lisa Ostler's vital signs purportedly had been recorded was approximately 15 hours prior to
the exchange described by Ms. Harris. (SLCo Ostler 000155-000156.) Nothing in the medical
record or shift log corroborates Ms. Harris's account of communicating to a nurse. Ms. Harris did
not log anything about Lisa Ostler or any purported cail to a nurse. (SLCo Ostler 000114-
000116.) She testified it is her normal practice to log when she communicates to a nurse about a
detainee. (Deposition of Holly Harris, 83:6-85:1.)

61. In his answers to interrogatories, Officer Zachary Frederickson stated the following regarding
the beginning of his shift, at approximately 6:00 a.m. on 4/2/2016:

I recall that I was told there was an inmate in 8 Charlie that had been asking for
medical help all night. I was informed she constantly pushed her intercom
button asking for a nurse. I was also told that medical had been down several
times over the course of the night and she had been evaluated and cleared to
remain in her housing unit.

13
�,f) ��r�·
:�/iii� lnt�rmountain·
Medical Group
Gastroenrerology
General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 !Och Avenue Obstetrics & Gynecology
Sale Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

* * *
[Inmate workers] did tell me about Ms. Ostler refusing her meals. I also spoke
with another inmate while walking along the top tier. I do not recall her name
either, but she was concerned about Ms. Ostler and told me she had been
yelling for help all night.
* * *
The Deputy from grave yard shift tells me I had 64 inmates and no issues other
than a female in cell 16 who had been asking for medical all night. I was told
then she had been assessed by medical and cleared.

62. Officer Zachary Frederickson testified that Officer Holly Harris briefed him on the morning of
4/2/2016 by saying "you've got a woman in [Lisa Ostler's cell] who's been crying and screaming
all night." (Deposition of Zachary Frederickson, 100:21-101:6.)

63. Officer Zachary Frederickson testified he spoke with Summer Johnson, a detainee, on the
morning of 4/2/2016 before Lisa Ostler was found unresponsive and not breathing and that Ms.
Johnson told him that "[Lisa Ostler] had been yelling out of her cell for help all night long," that
"nobody was doing anything," and that Ms. Johnson was "really worried" about Lisa Ostler.

64. During the night of 4/1/2016, Lisa Ostler left her cell during clothing exchange. Detainee Nicole
Bates testified that Lisa Ostler "was incoherent," "stumbling," "having a hard time," and
"struggling to even be moving;" that "her color wasn't right;" that "[s]he didn't really seem like
she knew where she was;" that "she couldn't understand why she was being yelled at;" that
[s]he looked like she was in a lot of pain;" that "she was "crouched down" and "walking really
11

slow, kind of stumbling over her feet" and holding her clothes to her stomach;" that she looked
11

like "[s]he was in pain somewhere in her abdomen;" that she looked "grayish" in color, similar
to the nightgowns given to detainees. (Deposition of Nicole Bates, 49:1-7, 49:14-50:25.)

65. Detainee Nicole Bates testified that during the night of 4/1/2016 and early morning of 4/2/2016
she could hear Lisa Ostler "crying all night long," "crying for help, moaning," and saying
something is not right, something is wrong with me, I really need Medical, I'm in pain."
11

(Deposition of Nicole Bates, 61:16 -62:25, 68:11-24). Ms. Bates also testified that during the
same night Officer Holly Harris was "extremely rude to Lisa [Ostler]," kicked her window, yelled
at her, threatened to "write her up for misusing Medical," and told her "you shouldn't do drugs"
and "something along the lines of you shouldn't come to jail if you don't want to be sick."
(Deposition of Nicole Bates, 61:16-62:25.)

66. Detainee Kellie Sheppard testified that during the night of 4/1/2016 and early morning of
4/2/2016 she could hear Lisa Ostler "screaming, saying help me' throughout the night," that her
1

screams were loud and sounded "as if she was in agonizing pain," that Lisa Ostler was
shrieking/ that Ms. Sheppard had never heard anyone scream like that before, that it was
11

14
:J�0.. Int�rmountain· Gasuoencerology

ll�r�·
�'ff') Medical Group General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

obvious to Ms. Sheppard that Lisa Ostler was in pain and needed emergency medical help, that
Ms. Sheppard was worried Lisa Ostler "wasn't going to make it through the night," and that she
never saw a nurse come down to help during the night. (Deposition of Kellie Sheppard, 21:7-16,
21:23-22:13, 22:18-24, 25:5-27:9, 73:6-74:1.) Ms. Sheppard also testified that a detainee told
Officer Holly Harris that "[Lisa Ostler]'s going to die" and that Ms. Harris's response was, "Well,
don't do drugs." (Deposition of Kellie Sheppard 17:3-14.)

67. Nothing in the medical record reflects that anything was communicated to any medical staff
about Lisa Ostler's cries, screams, and numerous calls for help during the night of 4/1/2016 and
the early morning of 4/2/2016.

68. According to the shift log written by Officer Zachary Frederickson, after Officer Zachary
Frederickson started his shift on the morning of April 2, Nurse Brent Tucker came to Unit 8C for
diabetic checks at approximately 6:34 a.m. on 4/2/2016. (SLCo Ostler 000116 -000117.) Officer
Frederickson mentioned to him that Ms. Ostler had been hitting her emergency button intercom
"all night." (Deposition of Zachary Frederickson, 190:22-25.) Yet Nurse Tucker did not even go
to see and evaluate Ms. Ostler or, if he did go to her cell, he did no medical evaluation of her
whatsoever. Nothing reflects that Nurse Tucker went to Lisa Ostler's cell.

69. Officer Zachary Frederickson stated in his answers to interrogatories that on the morning of
4/2/2016 he spoke with Lisa Ostler "about why she hadn't been eating and urged her to try to
eat something at lunch time" and that he "told her that [eating] would help her feel better and
that her body needed food to get her through her sickness." (Zachary Frederickson Answer to
Interrogatory No. 2.)

70. Officer Zachary Frederickson also stated in his answers to interrogatories that Lisa Ostler told
him "she had some vaginal bleeding," that he "placed a call to medical to inform them," and
that he was told medical staff "were aware of Ms. Ostler and that unless she was having a
medical emergency then she would need to fill out a Sick Call Request Form and turn it in when
they made their rounds." (Zachary Frederickson Answer to Interrogatory No. 2.) During the call
by Frederickson to Nurse Tucker, Frederickson only told Tucker that Ms. Ostler had missed some
meals and had complained of vaginal bleeding. He did not say anything about his knowledge
that Ms. Ostler screamed out in pain all night, repeatedly asked for medical help, rang her
emergency button and spoke over the intercom to Central Control all night, and exhibited
obvious signs of abdominal pain, or that other inmates had expressed their urgent concerns
about Lisa's medical condition, their fear that she would die without medical assistance, and the
fact that no medical assistance had been provided.

71. Dr. Samuel M. Brown, who provided care to Lisa Ostler at lntermountain Medical Center after
she was transferred from the jail, noted as follows: "While it's not entirely clear what caused the
arrest, her request for medical assistance was by report regarding vaginal bleeding. [W]e
haven't seen any here." (Ostler 001264.)

15
��'tl� Int�rmountain· Gascroenrerology

;r�r�·
�'ff) Medical Group General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

72. Dr. Pamela Ulmer, who performed the autopsy of Lisa Ostler, testified that Lisa Ostler "didn't
have any vaginal bleeding." (Deposition of Pamela Ulmer, 158:14-15.)

73. Officer Zachary Frederickson stated in his interrogatory answers as follows: "I told Ms. Ostler
about the sick call request form and placed one in her cell for her to use. She thanked me."
(Zachary Frederickson Answer to Interrogatory No. 22.)

74. Officer Frederickson stated in his answers to interrogatories that he "also told [medical] that
[Lisa Ostler] had not eaten for a few meals" and that he was told by Nurse Brent Tucker that it
"would not be considered a serious concern until 72 hours had passed." Officer Frederickson
further stated in his answers that he notified his supervisor about his interactions with Lisa
Ostler and that his supervisor told him "just to keep an eye on her." (Zachary Frederickson
Answer to Interrogatory No. 2.)

75. Matt Dumont, designated by Salt Lake County to testify on its behalf, testified that no training is
provided to Housing Officers regarding what information they are to provide to medical staff
relating to detainees' requests for medical assistance. (Deposition of Matt Dumont, 60:21-24.)
He further testified that it was in conformity with policy for Officer Zachary Frederickson to only
tell Brent Tucker that Lisa Ostler had missed some meals and was experiencing vaginal bleeding
and to refrain from telling him that Lisa Ostler had been asking for medical help all night, that
she had been pressing her emergency button all night, and that another detainee was worried
that Lisa Ostler might die. (Deposition of Matt Dumont, 170:5-22.)

76. Nurse Brent Tucker described his interaction with Officer Zachary Frederickson as follows:

I was working C-pod on 4/2/16 and received a radio call to call 8c, I called the unit and
the officer stated that he has a female that is c/o vaginal bleeding and not eating her
meals. I asked the officer if the bleeding was from her menstrual, he replied he did not
know. I asked him to ask her and then looked up this individual and saw she was W/D
from ETOH and Drugs which explains why this pt. may not want to eat. I then asked if
there was any visible blood from her bleeding or any excessive blood on her. The officer
said no, the current time was about 0715-0730 the triage nurse had not been through
the unit yet and the Nurse instructed that the officer have the pt fill out a SCR as the
unit would likely be triaged in the next 30 minutes and I would check on her during my
medication pass. I then finished preparing for my medication pass and went to start
passing Charlie meds, triage came through 8c and the pt refused to fill out SCR for and
denied triage, around 0745 and 0755. Not shortly later I was in 2 c and an emergency
response was called to 8c to this pt and she was unresponsive.

(SLCo Ostler 026515.)

16
�,f) ll'�r�·
�'ii.� lnt�rmountain·
Medical Group
Gastroencerology
General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Sale Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

77. Zachary Frederickson stated in his interrogatory answers that Brent Tucker asked him "[i]s [Lisa
Ostler] having a medical emergency?" and that his answer was "that it did not appear to be
one." (Zachary Frederickson Answer to Interrogatory No. 22.)

78. Nurse Colby James noted that while he was in Unit 8C shortly before Lisa Ostler was found
unresponsive and not breathing, that Zachary Frederickson stated Lisa Ostler "was told to place
a [sick call request] form in for her medical concerns" and "she had told him that she did not
want to." Colby James further noted that he told Zachary Frederickson if Lisa Ostler "had a
medical emergency to contact medical and if she had a triage kite [he) would take it at that
time." (SLCo Ostler 026514.)

79. Nurse Colby James did not walk the several yards from where he was on the morning of April 2,
2016, to see Lisa Ostler, speak with her, or evaluate or monitor her. (Deposition of Colby James,
93:15-94:25.)

80. Richard Bell testified that the customs of the Jail allowed Colby James to refrain from walking
over to Lisa Ostler's cell to check on her, even if he was informed that she had been crying out in
pain, was begging for medical treatment, and hitting the emergency button all night long and
that an another detainee had expressed concerns that Lisa Ostler was going to die and had not
been provided any medical treatment. (Deposition of Richard Bell, May 20, 2019, 220:2-222:1.)

81. Richard Bell testified that he would "not necessarily" expect that if a nurse is made aware of an
inmate screaming out in pain and requesting medical treatment that that would be included in
the medical record. (Deposition of Richard Bell, March 25, 2019, 179:15-20.)

82. Nothing in Lisa Ostler's medical record reflects that a physician ever saw, monitored, diagnosed,
treated, or examined Lisa Ostler after she was brought to the jail on 3/29/2016 until after she
was found unresponsive and not breathing on 4/2/2016.

83. Nothing in Lisa Ostler's medical record reflects that a nurse ever saw, monitored, or examined
Lisa Ostler, or referred her for monitoring, examination, or treatment from the time she first
entered Unit 8C on the morning of April 1, 2016, until she was found unresponsive and not
breathing on the morning of April 2, 2016.

84. Richard Bell testified, as the designated witness for Salt Lake County, that determining whether
abdominal pain is an emergency is "a collaborative effort between the inmate and the officer;"
that if it appears to the officer that the detainee's medical complaint may be an emergency then
the housing officer is to contact a nurse to immediately assess the detainee; that the officer is
"going to have to make" the determination of whether the detainee is experiencing an
emergency "based on their observations;" and that "[i]f the patient just appears to be really in
distress, they could look at other objective criteria[,] [a]nd if the patient appears to be

17
�'}I� lnt rmountain·
E:: Group Gascroenterology

l/�r�·
�,P Medical General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

unresponsive, close to it, incoherent, you know, just various observations, they will-they're
instructed to call medical." (Deposition of Richard Bell, May 20, 2019, 84:5-85:7.)

85. Richard Bell further testified on behalf of Salt Lake County that what information about a
detainee's medical complaint is communicated to a nurse "would be the officer's decision to
make," including that an officer could, in accordance with custom at the Jail, decide not to
convey to a nurse that the officer learned the "inmate had been calling out in pain and begging
for medical treatment all night long" and "hitting her emergency button several times."

86. Richard Bell testified that if an inmate is crying out in pain and asking for medical help, nurses
are not always expected to check it out. (Deposition of Richard Bell, March 25, 2019, 180:6-19.)

87. Richard Bell testified that when Lisa Ostler was sick and in pain and calling out for help, she
could have been triaged on April 2, 2016, and then seen a doctor, which would have occurred, if
at all, after she was found unresponsive and not breathing in her cell. (Deposition of Richard
Bell, March 25, 2019, 215:3-19.)

88. Richard Bell testified that Lisa Ostler was not medically assessed or examined because, based on
his review, he "wouldn't see that it would raise to that level." (Deposition of Richard Bell, March
25, 2019, 209:23-210:7.)

89. Richard Bell testified that even now, knowing that Lisa Ostler died of peritonitis and that she
was found unresponsive and not breathing in the Jail, she did not have a "serious medical need"
when she was in Unit 8C of the Jail. (Deposition of Richard Bell, March 25, 2019, 122:3-19.)

90. Medical records from lntermountain Medical Center ("IMC") indicate that Lisa remained
unconscious; unresponsive to voice, sternal rub, and pain; and had no corneal reflexes. (Ostler
001250-001264.)

91. The Medical examiner's report stated the immediate cause of Lisa Ostler's death was peritonitis
due to a perforated gastrointestinal ulcer. It also reported peritoneal effusion of 1000 ml,
described as a "cloudy red-brown fluid." (Ostler 001270, 001273.)

92. The Jail conducted a "Morbidity and Mortality" review relating to the death of Lisa Ostler, the
purpose of which is "to determine the appropriateness of custody and medical's emergency
response actions surrounding the death" and "to assess the appropriateness of medical care
received prior to the death." (SLCo Ostler 001596.) Richard Bell testified that at the time of the
review of Lisa Ostler's death, he did not know Lisa Ostler's cause of death and that he could not
think of a reason why a further review was not conducted once her cause of death was learned.
(Richard Bell Deposition, March 25, 2019, 71:10-16, 73:15-22.) Richard Bell testified that no one
was interviewed in connection with the morbidity and mortality review of Lisa Ostler's death.
(Richard Bell Deposition, March 25, 2019, 65:5-11, 77:10-25.) Richard Bell also testified it was

18
�l�0, Int�rmountain• Gastroenrerology

lf�r�·
�,P Medical Group General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

"correct" that there is no report or document generated by the entire Morbidity and Mortality
review process. (Deposition of Richard Bell, May 20, 2019, 111:25-112:5.)

93. Lisa Ostler's Jail medical record contained the following errors:

(a) On March 30, 2016, Lisa Ostler's respiration rate was recorded as being 98 breaths per
minute. (SLCo Ostler 000155.)

(b) On March 30, 2016, Lisa Ostler's oxygen saturation rate was recorded as being zero.
(SLCo Ostler 000155.)

(c) On the afternoon of March 31, 2016, Lisa Ostler's resting heart rate of 133 beats per
minute was scored as a "2" on the WOWS worksheet, even though a resting heart rate
at or above 110 beats per minute was required to be scored as a "4." (SLCo Ostler
000156.)

(d) The times recorded in the electronic medical record for her CIWA and WOWS
assessments and the monitoring of her vital signs do not reflect the actual times those
assessments and monitoring occurred. (SLCo Ostler 000124, 000127, 000155-156.)

(e) On April 2, 2016, Lisa Ostler's weight was recorded as 200 pounds. (SLCo Ostler 000123,
000126.)

(t) In violation of written policies requiring documentation in the medical record about
"communication with outside resources that might have relevant information about the
patient," nowhere in the medical records is there any mention of highly relevant
information, including communications between Officer Zachary Frederickson and
Nurse Brent Tucker regarding requests for medical help for Lisa Ostler, information
provided by Frederickson to Nurse Colby James that Lisa Ostler had a "medical
condition" to which there was no medical follow up, and any communication, if there
were one, from Officer Holly Harris to any nurse about Lisa Ostler on the night of April 1,
2016.

(g) The CIWA assessment form contains blanks for the afternoon of March 31, 2016, where
information was supposed to be noted regarding Lisa Ostler's (i) signs and symptoms of
tremor; (ii) signs and symptoms of paroxysmal sweats; (iii) signs and symptoms of
anxiety; (iv) signs and symptoms of agitation; (v) signs and symptoms of tactile
disturbances; (vi) signs and symptoms of auditory hallucinations; (vii) signs and
symptoms of visual disturbances; (viii) signs and symptoms of headache; (ix) orientation
to time, place, and person; and (x) total CIWA score. (SLCo Ostler 000155.)

19
�'ii� Int�rmountain· Gasrroenterology

ll�r/fe•
�'fl' Medical Group General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 !Och Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

(h) Lisa Ostler's electronic medical record does not include the majority of her substance
withdrawal assessments and nearly all of the measurements of her vital signs were not
entered in the electronic medical record as text or displayed within the graphical
representation of her vital signs. (SLCo Ostler 00123-127)

(i) Lisa Ostler's electronic medical record does not include any information about why no
one recorded her vital signs or recorded CIWA and WOWS assessments on the
afternoon of April 1, 2016, or the morning of April 2, 2016.

94. Richard Bell testified that at the Morbidity and Mortality review of Lisa Ostler's death, no errors
were noticed in the medical records (Richard Bell Deposition, March 25, 2019, 143:6-14),
notwithstanding that the score on the CIWA assessment form for Lisa Ostler's resting pulse was
marked as "2" rather than "4+" (144:191-145:21); notwithstanding a notation of a zero oxygen
saturation (which would mean the patient is dead) (146:16-147:12); notwithstanding that, in
violation of jail policy, no vital signs were taken after April 1, 2016, at approximately 8:00 a.m.
(148:7-149:11); notwithstanding two erroneous entries for respiratory rate (149:17-151:4); and
notwithstanding the omission of the total CIWA score at 2:50 p.m. on April 1, 2016 (151:6-10).

95. Salt Lake County provided nurses a training presentation titled "Nursing Documentation" which
stated, in part, as follows:

Protect the organization and other disciplines .. .

Use appropriate terms - "altercation with officers" vs "beat up by officers"
* * *
[Documentation Should] Not implicate others for failures / mistakes
* * *
Steer clear of words associated with errors
Terms such as "by mistake," "accidentally," "somehow," "unintentionally," and
"miscalculated" are bonus words to a plaintiff's attorney.
Don't use a term that suggests an error was made or that a patient's safety was
in jeopardy.
* * *
A patient was given Norco 10/325 when he was ordered Norco 5/325

You could chart "Pt was given Norco 10/325 mg 1 tab PO for back pain. Dr. Wilcox was
notified but gave no orders. Patient's vital signs remained stable.

This entry would let other healthcare professionals who looked into the chart know that
the patient was overmedicated without calling undue attention to it.
* * *
Avoid reporting staffing problems.

20
�'ii� lnt�rmountaine Gastroenterology
�'fl' Medical Group
ll�r�·
General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500 Urology

Don't refer to staffing shortages in a patient's chart

* * *
Don't chart that you informed a colleague of a situation if you only mentioned it.

(SLCo Ostler 025305-025306, 025309-0253111.)

96. Richard Bell, the Responsible Health Authority at the Jail, testified regarding the training of
nurses to create medical records as follows:

Q. So if a pod nurse failed to provide medications, you teach your nurses at the jail not to
include in the medical record a statement that the pod nurse failed to provide medications?

A. Correct.

(Deposition of Richard Bell, May 20, 2019, 100:6-10.)

Q. Is it the custom of the Salt Lake County Jail also to train nurses not to use words that are
associated with errors?

A. Yes.

(Deposition of Richard Bell, May 20, 2019, 100:13-16.)

Q. ... I'm asking about errors in the treatment of the patient. Nurses at the Salt Lake County
Jail are trained to steer clear of words associated with errors?
A. Yes.
Q. And they're also trained not to use any terms that suggest that an error was made or that a
patient's safety was in jeopardy?
A. Yes.That suggests, yes.

(Deposition of Richard Bell, May 20, 2019, 101:6-15.)

97. Housing officers are not trained to recognize abdominal pain or the signs or symptoms of
serious abdominal medical conditions. (Deposition of Zachary Frederickson, 20:14-21:11;
Deposition of Matthew Dumont, 57:16-18.)

98. The medical records of numerous other detainees at the Jail reflect that nurses did not perform
WOWS and CIWA assessments twice per day for five days, in violation of physician orders and
official policy.The Jail's failures to provide all required WOWS and CIWA assessments include
the following:

21
�"ii� lnt�rmountain· Gastroenterology
�,P Medical Group
cl(�7r�·
General Surgery
Internal Medicine
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Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake Ciry, Utah 84103 Plastic Surgery
801.408.7500 Urology

a. WOWS assessment was ordered on (SLCo Ostler 003328,

3347) but was only performed once on and twice on . Only 3 of 10
assessments were completed.

b. CIWA assessment was ordered on by Dr. Wilcox (SLCo Ostler

003722, 003917-21, 4072-76) but was only performed 7 times from - .
Only 7 of 10 assessments were completed. In a separate period of incarceration, WOWS
assessment was ordered (SLCo Ostler 003699, 003779, 003993). He was booked on
. WOWS was only performed once on and once on .

c. - CIWA assessment was ordered on (SLCo Ostler 29654-29656).

On , only one assessment was performed. No assessments were performed
on . In total, only 7 of 10 assessments were completed.

d. as incarcerated numerous times, with many documented

failures by the Jail to perform all WOWS and CIWA assessments.

CIWA assessment was ordered on for alcohol abuse (SLCo Ostler

004478,4911). She was booked on . CIWA was only performed twice on
(SLCo Ostler 4794-95).

WOWS assessment was ordered on (SLCo Ostler 004533-34, 4935-36).

The assessment was performed just 4 times of 10 on , , and . She
refused one assessment on .

WOWS assessment was ordered on (SLCo Ostler 004536, 4937). She was
booked on . The assessment was performed 3 out of 7 times (she was
discharged on , less than five days after the WOWS assessment was
ordered).

WOWS assessment was ordered on (SLCo Ostler 004550, 4945). The

assessment was performed 4 times of 10.

WOWS assessment was ordered on (SLCo Ostler 004581, 4962). The

assessment was performed 5 times of 10.

WOWS assessment ordered on (SLCo Ostler 004591-93). 5 out of 10

assessments were performed.

WOWS assessment ordered on (SLCo Ostler 004621-23, 4986-88). 6

out of 10 assessments were performed.

22
�lll.i� Int�rmountain· Gastroenterology
�:yP
ll�r�·
Medical Group General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Salt Lake City, Utah 84103 Plastic Surgery
801.408.7500
Urology

WOWS assessment ordered on (SLCo Ostler 4638-40, 4991-93). 5 out of

10 assessments were performed.

WOWS assessment ordered on (SLCo Ostler 4657-59). 6 out of 10

assessments were performed.

WOWS assessment ordered on (SLCo Ostler 4672-74, 4700, 5007-09). 4

out of 10 assessments were performed.

WOWS assessment ordered on (SLCo Ostler 4701, 5021). 7 out of 10

assessments were performed.

CIWA assessment ordered on (SLCo Ostler 4719). 6 assessments out of

10 were performed.

CIWA assessment ordered on (SLCo Ostler 4736). 3 out of 10

assessments were performed.

CIWA assessment ordered on (SLCo Ostler 4787-89, 5069-71). A total of

4 assessments were performed. No assessments were performed on , one
was performed on , no assessments were performed on , one was
performed on , and 2 assessments were performed on , at which time
she was released.

e. �OWS assessment ordered on (SLCo Ostler 006329-31). 4 of 6

assessments completed for , , . Released .

f. CIWA assessment ordered on (SLCo Ostler 006420-22). 5 of

10 assessments performed. In a separate period of incarceration, CIWA assessment
ordered on (SLCo Ostler 006427). No assessment was performed on ,
and she was released .

g. IWA assessment ordered on (SLCo Ostler 008041-42). 6 of 10

assessments performed. In a separate period of incarceration, CIWA assessment was
ordered on (SLCo Ostler 008028-32). 7 of 10 assessments were performed. Only
1 assessment performed on each , , and .

h. WOWS assessment ordered on (SLCo Ostler 004218-19).

Only 1 assessment was performed on and only 1 was performed on .

EXHIBITS

23
�\I� lnt�rmountain· Gastroen terology
�Tl' Medical Group
ll�r�·
General Surgery
Internal Medicine
Midwifery
Avenues Specialty Clinic Neurology
324 10th Avenue Obstetrics & Gynecology
Sale Lake City, Urah 84103 Plastic Surgery
801.408.7500 Urology

Any of the documents to which I have referred in this report may be used to summarize or
support my opinions in this matter.

STATEMENT OF ALL OPINIONS TO BE EXPRESSED AND THE BASIS AND REASONS FOR THEM

The following is a complete statement of all opinions I will express at trial, which are based on
the facts described above, my review of the case documents described above, and my education and
experience:

1. There can be no question that Lisa was suffering from a serious, potentially life-threatening medical
condition, a perforated ulcer and peritonitis, from at least March 31, 2016, until she was found
unresponsive and not breathing on the morning of April 2, 2016. My opinion is based, at the very
least, on a reasonable degree of medical certainty.

2. With appropriate monitoring and evaluation, Lisa's life-threatening medical condition would have
been timely and accurately diagnosed and successfully treated, most likely saving Lisa's life. From at
least March 31, 2016, forward, Lisa's signs and symptoms indicated Lisa should have been
immediately and urgently taken to a hospital for further diagnosis and treatment. The perforation
caused by Lisa's gastrointestinal ulcer could be repaired through surgery. To a reasonable degree of
medical certainty, even though Lisa required surgery to repair the perforation, if Lisa had not
suffered a cardiac arrest and the anoxic encephalopathy sequelae, there is nothing in her history or
status that would have prevented her from recovering had she been admitted for surgery and other
appropriate treatment prior to her cardiac arrest.

3. Because Lisa's life-threatening condition was not timely and properly diagnosed, it continually
became worse. Her symptoms became so severe, by at least the time Lisa was moved from unit SC
to unit 8C around 10 a.m. on April 1, 2016, it would have been obvious not only to any trained
medical person, but also to lay persons, that Lisa was suffering from significant pain and a serious
medical problem that required urgent diagnosis and treatment. In fact, as indicated by Holly Harris,
Zachary Frederickson, Nicole Bates, Kelly Sheppard, and Alisha Woodruff, it was obvious to other
detainees that Lisa was suffering from significant pain and a serious medical problem that required
urgent diagnosis and treatment.

It is not possible that Lisa, while suffering from a perforated gastrointestinal ulcer and peritonitis,
would not be exhibiting signs and symptoms of extreme abdominal pain. Neither is it possible that
Lisa, suffering from peritonitis, would not be perceived as being in extreme pain, having a serious
medical condition, and needing urgent medical attention.

The fact that Lisa was experiencing severe abdominal pain and a serious medical problem that
required immediate diagnosis and treatment, or urgent referral for diagnosis and treatment, has to
have been evident to anyone, including other inmates and, especially, nurses or others charged with
observing inmates and reporting medical problems to nurses or physicians. Included among the

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signs and symptoms indicating that Lisa was suffering from a serious medical problem were Lisa's
bending over from the waist and holding her abdomen, as Lisa did several times from at least the
time just before and after she had her vital signs checked on the morning of April 1, 2016, in unit SC;
sitting on the floor in unit SC while other inmates were walking around, while Lisa was waiting to be
transferred to unit 8C; her slow and tentative walking when she can be seen on video during the
morning of April 1, 2016, and at clothing exchange on the evening of April 1, 2016, in unit 8C; her
pale and gray complexion as noted by other inmates; her demeanor, as described by other inmates;
Lisa's lack of movement outside of her cell in unit 8C, except during mandatory clothing exchange,
which was unusual compared to the other inmates in Lisa's housing unit who are seen moving about
the unit freely for many hours of the day; and Lisa's frequent moaning, groaning, "growling," and
screaming out in pain, her cries for help, her begging for medical help, and her hitting her
emergency button up to 16 times during the evening of April 1 and early morning of April 2, 2016,
communicating to a person in Central Control at the Jail that she was in pain and needed medical
help.

4. I work with healthcare professionals, including registered nurses, almost every day and am aware of
their training and what they are expected to know, observe, and do. Anyone who has received
medical training to become a nurse or a physician (had a physician been notified, as should have
occurred) would have known that Lisa was extremely ill, would have known that she needed to be
evaluated, monitored, and referred for diagnosis and treatment, and would have known how to
evaluate her, including the monitoring of her vital signs, speaking to her about the location and
severity of pain, palpating her abdomen, or even just bumping into her bed or her body to ascertain
her response. The Defendants' actions and failures to act fell far below any applicable standard of
medical care for any medical professional, could not have been the result of medical judgment, and
reflect a deliberate indifference toward the serious medical needs of Lisa Ostler, specifically, and the
serious medical needs of inmates, generally, at the Salt Lake County Jail.

5. Lisa died of peritonitis secondary to a gastrointestinal ulcer perforation near the site of her remote
gastric bypass surgery. To a reasonable degree of medical certainty, Lisa's cardiac arrest was
secondary to her perforated ulcer and peritonitis. A gastrointestinal ulcer starts by inappropriate
gastric acid creating injury to the lining of the bowel. If left untreated, the ulceration erodes
through the wall of the bowel to create a full thickness perforation. This allows for leakage of food,
bacteria, digestive products, and digestive enzymes to be released into the sterile body cavity of the
peritoneum, which houses most of the internal organs. When the peritoneum suffers an insult of
this kind, peritonitis develops. A patient suffers from increasingly severe pain, followed by a
worsening clinical condition as the inflammation/infection spreads. The body will react to the
noxious stimulus by developing systemic inflammatory response syndrome. This is associated with
increased heart rate, decreased blood pressure (at first, the blood pressure may be increased
because of the onset of pain), increased or lowered body temperature; and, if allowed to progress,
sepsis will develop. This is associated with mental status changes (such as the altered mental state
manifested by Lisa Ostler when she spoke about meeting someone to go to a wedding), continually

25
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l/�r�·
�,� Medical Group General Surgery
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increasing pain, significant hemodynamic instability, and ultimately, if the patient is left untreated as
Lisa was, death.

6. Gastrointestinal ulcers, when diagnosed appropriately, can simply be treated with an acid blocking
medication, usually a proton pump inhibitor (e.g. , Prilosec). This medicine is readily available over
the counter. Lisa was prescribed Prilosec before she entered the Jail and a Jail physician ordered
that it was to be provided to her while she was in Jail. However, Prilosec was never provided to Lisa.
The Medication Verification Sheet confirms Prilosec, an acid blocking medication, was one of the
medications ordered to be provided to Lisa. Per the Medication Sheet, Prilosec was listed as "APR"
under the column "Hour" with a circled "3". The Medication Sheet explanation of code states a 3 as
not given because inmate not in cell. There is no explanation for the code "APR," but it appears to
be referencing the month of April. These records reflect that Lisa did not receive any of the Prilosec
that was ordered for her. That is tragic as this medication could have prevented the progression of
the gastrointestinal ulcer to perforation, which ultimately caused Lisa's suffering and death.

7. The most common symptom of gastrointestinal ulcers is abdominal pain. As the ulcer progresses, it
will perforate the peritoneal wall, which is very painful. Then, as fluid travels into the peritoneal
cavity, patients with a perforated ulcer like Lisa's uniformly experience increasingly excruciating pain
if left untreated. On a pain scale of 1 - 10, my clinical experience is that such patients report pain
between an "8" and a "10." There can be no mistaking that a person with peritonitis, particularly
after it has progressed, is in tremendous pain, is suffering from a serious medical condition, and
requires urgent medical attention. To fail to provide or obtain medical attention for a person
suffering from peritonitis, particularly that that person is incarcerated or otherwise unable to obtain
medical treatment on her own, would be cruel and, at the least, deliberately indifferent.

8. The prognosis for a perforated ulcer is inversely related to the time of diagnosis and intervention.
Delay in diagnosis and treatment results in rapidly escalating hypotension, metabolic acidosis, acute
renal failure, exponentially increased pain, and likelihood of death. Per Rhodes et al. Surviving Sepsis
Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive
Care Med (2017) 43:304-377: "Infectious foci suspected to cause septic shock should be controlled
as soon as possible following successful initial resuscitation. A target of no more than 6-12 h after
diagnosis appears to be sufficient for most cases. Observational studies generally show reduced
survival beyond that point... Therefore, any required source control intervention in sepsis and
septic shock should ideally be implemented as soon as medically and logistically practical after the
diagnosis is made." My clinical experience and numerous studies demonstrate that delay in
diagnosis leads to worse outcomes.

9. As stated above, the prognosis for a perforated gastrointestinal ulcer is inversely related to the time
of diagnosis and intervention. Accordingly, Lisa had the greatest chance of a full recovery had she
been provided an appropriate medical assessment and intervention on March 31, 2016. The failure
to provide Lisa appropriate diagnosis and treatment, or referral for diagnosis and treatment, on

26
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March 31, 2016, caused the worsening of Lisa's condition, a high degree of continuously increasing
pain and suffering to Lisa, and a significant negative effect on her prognosis for survival. While
written policy at the jail reflected that a physician was required to be called when a substance
withdrawal patient had a heart rate greater than 110, the medical record reflects that no physician
was called when Lisa had a heart rate of 119 on the morning of March 31, 2016, or when she had a
heart rate of 133 on the afternoon of March 31, 2016. If a nurse failed to notify me about such
alarming vital signs for one of my patients, I would ensure that nurse's employment was terminated.
The failure to notify a physician of Lisa's alarming vital signs on March 31, 2016, falls far below any
applicable standard of care, could not have been the exercise of medical judgment, and reflects a
deliberate indifference toward Lisa and her serious medical condition. Any physician being notified
of Lisa's vital signs on March 31, 2016, would have known that Lisa required immediate further
assessment and failure by any nurse to ensure such an assessment occurred could not be the
exercise of medical judgment.

10. Throughout April 1, 2016, Lisa's prognosis for survival was good, with a likelihood of survival, had
she been properly assessed and referred for diagnosis and treatment. On the afternoon of April 1,
2016, the failure of Todd Booth to ensure that Lisa received a medical assessment for her
complaints caused a worsening of Lisa's condition, a high degree of pain and suffering to Lisa, and a
significant negative effect on her prognosis for survival. Similarly, on the same afternoon, Nurse Ron
Seewer's failure to provide an appropriate medical assessment of Lisa Ostler or referral for diagnosis
and treatment caused a worsening of Lisa's condition, a high degree of pain and suffering to Lisa,
and a significant negative effect on her prognosis for survival.

11. During the night of April 1, 2016, and early morning of April 2, 2016, Lisa's clearly manifested
abdominal pain and her repeated screaming, crying, moaning, and pleas for help reflect a severe
worsening of her condition. However, through the night, Lisa's prognosis for survival remained good
if she had been properly assessed or referred for diagnosis and treatment. Within a reasonable
degree of medical certainty, Lisa stood a good chance of survival had she received medical attention
during the evening of April 1 and early morning of April 2. The failure of Holly Harris during that
night and early morning to ensure that Lisa received a medical assessment for her complaints
caused a severe worsening of Lisa's condition, a high degree of severely increasing pain and
suffering to Lisa, and a highly negative effect on her prognosis for survival. Similarly, the practice at
the Jail of Central Control employees "ignoring" complaints from certain inmates and the fact that
Scott Sparkuhl was instructed to, and did, "ignore" Lisa's complaints of pain and requests for
medical attention caused a serious worsening of Lisa's condition, a high degree of severely
continuous increasing pain and suffering to Lisa, and a significant negative effect on her prognosis
for survival.

12. On the morning of April 2, 2016, after Zachary Frederickson and Nurse Brent Tucker began their
shifts, Lisa had a fair chance of recovery had she been immediately referred to and transported to a
hospital for diagnosis and treatment. However, once Lisa arrested at approximately 8:00 a.m. on
April 2, 2016, as is apparent from her subsequent treatment and assessment at the hospital, she

27
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suffered irreparable brain damage from lack of oxygen because she was lying in her cell without
breathing. If at any time during Zachary Frederickson's shift, prior to her cardiac arrest, Lisa had
been placed in the care of a hospital, Lisa likely would not have experienced an extended period of
time without oxygen. Accordingly, the failure of Zachary Frederickson to urgently obtain medical
assistance for Lisa and the failure of Nurse Brent Tucker to ensure that Lisa was provided referral
and transportation to a hospital for urgent diagnosis and treatment caused a severe worsening of
Lisa's condition, a high degree of increasing pain and suffering to Lisa, and a reduction of her
prognosis for survival from fair to assured death.

13. A trained medical provider can, and should be able to, diagnose peritonitis, particularly as it
progresses. Nurses, at the least, would certainly be able to recognize that a person suffering from
peritonitis is suffering from a serious medical condition that requires immediate evaluation,
monitoring, and referral for diagnosis and treatment. At the very least, any trained medical
professional, including all nurses and paramedics, should be able to recognize symptoms and signs
that would alert them to the possibility of peritonitis or some other serious abdominal medical
condition, regarding which they should notify a physician at once. A physical exam, which can be
performed by any trained and licensed nurse, and certainly should be performed for any person
exhibiting the signs and symptoms that accompany peritonitis, will reveal an ill-appearing patient,
abnormal vital signs, and a concerning abdominal exam that requires urgent follow-up. Examining
the abdomen would disclose tenderness and perhaps distension. As the peritonitis worsens with
time between the onset of symptoms and diagnosis and treatment, the physical exam will reflect
rebound tenderness and rigidity, which would be ascertained by any trained nurse engaging in the
most minimal of evaluation and monitoring that must always be done for a person who is
demonstrating the signs and symptoms that always accompany peritonitis. As a matter of
professional standards and simple common sense, these concerning findings must prompt further
emergent workup, which would include cross-sectional imaging and/or surgery, as well as the
administration of antibiotics.

Upon first suspecting that someone is suffering from peritonitis, antibiotics should be administered
immediately, or the person should be urgently referred for diagnosis and treatment, including the
administration of antibiotics. It was far below any applicable standard of care, and could not have
been the exercise of medical judgment, for Nurse Ron Seewer to fail to provide and record an
appropriate assessment for Lisa on the afternoon of April 1, 2016, or refer her to a physician for
diagnosis and treatment. Similarly, it was far below any applicable standard of care, and could not
have been the exercise of medical judgment, for Nurse Brent Tucker to rely on a guard with no
medical training to determine whether Lisa was experiencing a medical emergency on the morning
of April 2, 2016, rather than gather information by visiting and evaluating Lisa to make that
determination himself.

14. Lisa's vital signs were very concerning on March 31, 2016, and must have alerted any nurse paying
any attention to Lisa that she was likely suffering from a serious medical condition. She was both
tachycardic (fast heart rate) and hypotensive (low blood pressure). There was a worsening trend to

28
 Gastroencerology
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her vital signs at this time. These abnormal vital signs were associated with her witnessed altered
mental status. She thought she was at a wedding. This reflects her progression to sepsis from the
perforation of her gastrointestinal ulcer and peritonitis. To a reasonable degree of medical certainty,
Lisa's mental status changes and abnormal vital signs reflect early signs of sepsis beginning, at the
latest, on the morning or afternoon of March 31, 2016.

15. The last entry of Lisa's vital signs at the Jail, which occurred on the morning of April 1, 2016, is highly
suspect. The numbers themselves reflect normal values, which would not be clinically possible with
the now known untreated gastrointestinal ulcer perforation. The video shows the nurse interaction
for the vital signs lasted 30 seconds (approximately 8:30:15 to 8:30:45), during which time the nurse
is addressing both Lisa and another patient simultaneously. Standard automated blood pressure
machines usually take at least 45 seconds to measure. This does not include the time to put on the
blood pressure cuff.

16. Medically trained personnel, including physicians, nurses, paramedics and anyone charged with
observing and reporting possible serious medical conditions, should always consider life threatening
causes of abdominal pain, especially in patients with known chronic abdominal comorbidities such
as Crohn's disease and post-gastric surgery, both of which are noted on Lisa's medical records
created at the Jail, which should have been reviewed by anyone responsible for monitoring or
observing Lisa. Screening with vital signs is an efficient tool to determine the potential for life
threatening problems, such as peritonitis. From all appearances on the videos showing Lisa in units
SC and 8C of the Jail, as well as the statements of witnesses, Lisa was suffering from obvious
abdominal pain, which should have been evaluated, or referred for evaluation, immediately by a
nurse or physician. An abdominal exam is imperative to determine the etiology of the pain. The
nursing pre-screen examination acknowledges Lisa's prior gastric bypass and her Crohn's disease
(incorrectly spelled by the nurse as "Chron's"). It is a potentially fatal error to assume a benign
pathology, such as minor drug withdrawal, is the cause of abdominal pain without screening for
potentially life-threatening causes of abdominal pain.

17. I am very familiar with the signs and symptoms of drug withdrawal. My knowledge is based on my
medical education, my extensive training, and my involvement in the treatment of, or consultation
regarding, hundreds of patients experiencing drug withdrawal. The hospital at which I have worked,
and where I am Chair of Surgery, is the detoxification unit for the entire lntermountain Healthcare
system, where many hundreds, perhaps thousands, of patients withdrawing from drugs are treated
every year. From my careful review of the records and video, Lisa did not act or appear like a person
experiencing classic drug withdrawal. Classic heroin withdrawal patients are somnolent with
outbursts of pain when aroused. Lisa was continuously complaining and showing obvious signs of
abdominal pain. It is telling that several of her cellmates who have experienced/witnessed heroin
withdrawal noted she did not appear to be withdrawing from heroin. They describe her skin as
ashen and "gray." This is far more consistent with sepsis. Generally, heroin withdrawal patients have
normal skin color or are flushed. Any medically trained people working at the Salt Lake County Jail,
where many inmates go through drug withdrawal, must be familiar with the signs and symptoms of

29
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drug withdrawal, as compared with the signs and symptoms of a perforated gastrointestinal ulcer
and peritonitis.

18. I have read "Managing Opiate Withdrawal: The WOWS Method," and I agree with the statements of
its author, Dr. Todd Wilcox (who I understand is the Medical Director at the Salt Lake County Jail),
that opiate withdrawal is "clinically severe and can frequently result in death if not managed
appropriately" and is "a life-threatening medical condition." For any medical provider or anyone else
to ignore a person exhibiting signs of abdominal pain, screaming out in pain, and asking repeatedly
for medical attention is professionally outrageous and reflects deliberate indifference because,
under those circumstances, the person is obviously at risk of a serious, perhaps life-threatening,
medical condition that cannot be ignored. That is true regardless of whether the person failing to
respond to those circumstances believes the person in pain and screaming out is withdrawing from
drugs or not. As Dr. Wilcox notes, withdrawal from drugs is "clinically severe" and is "a life­
threatening medical condition."

I agree with Dr. Wilcox that it is appropriate and medically necessary to assess patients undergoing
opiate withdrawal at least twice per day for a minimum of five days. I agree with Dr. Wilcox that
patients with a low body mass index are particularly susceptible to "extreme distress." Patients with
a low body mass index are more susceptible to morbidity and mortality from opiate withdrawal. A
body mass index below 18.5 is considered underweight. Lisa's BMI was recorded as 18.3 soon after
she was booked into the Jail, but would have declined throughout the time she was incarcerated
because she was refusing all or almost all of her meals, was not leaving her cell to drink water, and
was only given 3 bottles of Gatorade in an approximately 72-hour period (one of which was noted
by Esther Israel to have been spilled on the floor). A decline in her body mass index is consistent
with the description that Lisa was "very cachectic appearing" noted by Dr. A. Koy Lombardi. Lisa's
weight was described as being 200 pounds in the Jail medical records, but that is clinically
impossible.

Because opiate withdrawal is a life-threatening medical condition, it was a complete abandonment

of care, and could not have been the result of medical judgment, to ignore the signs of abdominal
pain reflected on the limited video made available and witnessed by other inmates, and the crying,
screaming, and repeated requests for help of Lisa Ostler throughout the night of 4/1/2016 and the
early morning of 4/2/2016. Similarly, it was a complete abandonment of care and could not have
been the result of medical judgment (a) for Nurse Ron Seewer to fail to perform and record an
assessment of Lisa, including her vital signs, on the afternoon of April 1, 2016, or refer her for
immediate diagnosis and treatment and (b) for Nurse Brent Tucker to rely on a medically untrained
guard, Zachary Frederickson, to determine whether Lisa was experiencing a medical emergency
rather than gathering information and making that determination himself.

19. The medical records reflect that Lisa was not assessed for dehydration, in contradiction of Dr.
Wilcox's statements in the above article that it is important to "hydrate, hydrate, hydrate" and that
the medical staff at the Jail "place[s] a significant emphasis on oral hydration." I agree with Dr.

30
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tit'� Int€:rmountain· Gastroenterology

lf�r�·
Medical Group General Surgery
Internal Medicine
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Wilcox that it is vitally important to ensure that patients experiencing heroin withdrawal are
hydrated. Providing two or three bottles of Gatorade to Lisa (with or without any documentation
that she consumed any of it), while she was refusing most or all of her meals and was not leaving
her cell to drink any water, reflect that Lisa was likely severely dehydrated. The failure to ensure
Lisa's hydration falls far below any applicable standard of care, cannot be the result of medical
judgment, and reflects deliberate indifference toward Lisa's obviously serious medical condition,
which was manifested by earlier concerning vital signs; Lisa's altered mental state; Lisa's refusal of
food; Lisa's bearing demeanor, complexion, and overall appearance; and Lisa's screaming in pain
and repeated requests for medical help for many hours.

20. Zachary Frederickson's description in his interrogatory answers of his interaction with Lisa is
clinically impossible. It is impossible for someone dying of peritonitis to engage in anything close to a
normal conversation. During the time of Lisa's interactions with Zachary Frederickson, Lisa must
have been in extreme distress and likely had a highly altered mental status.

21. The records from lntermountain Medical Center reveal significant concerns. The intake history from
the care providers in the Emergency Room reflects they were informed by EMS only of a history of
drug abuse and a vague potential vaginal bleeding. There was no communication by EMS or anyone
from the Jail of her abdominal pain that was going on for the previous days, or of Lisa's screaming
and moaning in pain, her repeated requests for medical attention, the expressed concern of other
detainees about Lisa's serious medical condition and the continuing failure to provide her with
medical attention, her abnormal vital signs on April 1. The failure to provide relevant information
about Lisa's signs and symptoms led to a workup by physicians at IMC involving drug-related
problems and not anything remotely related to the cause of her death. If properly informed about
signs of Lisa's abdominal pain and her abnormal vital signs, her screaming in pain, and pleading for
medical attention prior to her arrest, the Emergency Department physician at IMC would have
obtained an abdominal-pelvic CT scan which would have confirmed the findings of free air in
association with free intrabdominal fluid. These are findings consistent with those from Lisa's
autopsy. Because of the omissions of pertinent information, the workup of her arrest led to a wild
goose chase. The lack of CT scan prevented diagnosis and surgical intervention. Surgery was the only
intervention that could have saved her life. However, it is highly likely that because of Lisa's
condition by the time she was finally taken to a hospital, she would have succumbed because of
severely delayed diagnosis and treatment due to the indifference of medical and other personnel at
the Jail. The failure to provide accurate and complete information to IMC about Lisa's serious
medical problem reflects further deliberate indifference toward Lisa and her serious medical
problem.

22. I am concerned with the Salt Lake County Jail's practice of determining medical emergency and find
that it is not only obviously inadequate to protect the health and safety of inmates but is the
product of practices evidencing a systemic and deliberate indifference toward the serious medical
needs of inmates. The process that I reviewed shows the inmate contacts the guard. The medically
untrained guard then determines if there is a medical emergency. In Lisa's case, a guard called a

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�L�i� Int�rmountain· Gastroenterology
�Tl'
lf�r�·
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Internal Medicine
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801.408.7500 Urology

nurse and the nurse, completely inappropriately, left it for the guard to determine if Lisa's medical
condition was an emergency requiring the attention of a nurse. The guard, who had not provided
significant pertinent information to the nurse (including her altered mental state, her indications of
abdominal pain, her screaming and moaning in pain for hours the prior evening, her pleas for
medical attention, and the expression of other inmates that they were concerned that Lisa might die
if she did not receive immediate medical attention) made the wholly unfounded determination
there was not an emergency. Having a non-medically trained guard triaging potentially life­
threatening conditions is a set up for disaster-a product of obvious deliberate indifference toward
inmates' serious medical problems by people, including jail and health administrators and medical
personnel at the Jail, who know the inappropriateness of leaving it for non-medically trained guards
to make judgements about whether inmates are suffering from emergency medical problems.

23. The medical records of other detainees at the Jail reflect a widespread practice of failing to perform
all required WOWS and CIWA assessments. That practice, in light of the knowledge of the policy
requiring such assessments at least twice a day for five days, and in light of the obvious importance
of monitoring and evaluating inmates and contacting a physician when there are signs or symptoms
of drug withdrawal, seems the very definition of deliberate indifference, since jail personnel knew of
the importance of performing the assessments, they must have known of the risks of not doing the
assessments, yet they failed to do them anyway. Plaintiff's counsel has provided me medical records
of
, all of which reflect on their face a failure to
complete all ordered WOWS and CIWA assessments. I have been informed by Plaintiff's counsel that
this sample of 7 detainees' records with failure to comply with WOWS and CIWA assessments comes
from a set of less than thirty detainees' medical records who were ordered to be on a WOWS or
CIWA protocol that were provided by Defendants. The noncompliance with the requirement that
the assessments be done reflects a pattern of non-compliance that is shockingly high. Based on my
clinical experience, education, and research, that many errors reflect a widespread practice and
systemic failure to ensure that all WOWS and CIWA evaluations are performed as ordered, clearly
constituting a pattern of deliberate indifference.

23. After reviewing the case, it is my opinion that Lisa developed a perforated gastrointestinal ulcer and
life-threatening peritonitis while incarcerated. She did not receive any medication that was already
prescribed to her that could have prevented the perforation. Her obvious signs and symptoms of a
serious abdominal medical condition, as well as her screaming and moaning in pain and her multiple
requests for help regarding her abdominal pain,as well as the expressions of deep concern about
Lisa by other detainees, were ignored. She objectively, clinically deteriorated severely during her
incarceration. Her condition was not evaluated, monitored, or referred for diagnosis and treatment
by nurses who were responsible for her care. This led to her respiratory arrest and transfer to
lntermountain Medical Center, where the breach in handoff led to an erroneous diagnostic workup.
The actions and failures to act by the Defendants, reflecting their deliberate indifference toward
Lisa's serious medical condition and reflecting the County's pattern and custom of deliberate
indifference toward detainees' serious medical conditions generally, caused Lisa to suffer

32
���� Int�rmountain� Gastroenterology
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exponentially increasing excruciating pain, a drastic worsening of her condition, and a continual
worsening of her prognosis for survival from near certain recovery to no chance of recovery.

All of the foregoing opinions are rendered within a reasonable degree of medical certainty.

Please feel free to contact me with any further questions.

Sincerely,

H. Tae Kim, MD, FACS, FASCRS

Colon & Rectal Surgery
lntermountain Healthcare

Chair of Surgery
LDS Hospital

33
Curriculum Vitae
H. Tae Kim, MD, FACS, FASCRS

BUSINESS ADDRESS:
Avenues Specialty Clinic
324 10th Ave, Ste 200
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Phone: (801) 408-7660
Fax: (801) 408-7650
tae.kim@imail.org

EDUCATION:
Bachelor of Science, in Radiologic Technology Dec 1994
University of Nevada at Las Vegas
Las Vegas, NV

Doctorate of Medicine May 2002

University of Nevada School of Medicine
Reno, NV

INTERNSHIP:
General Surgery Jun 2002- Jun 2003
University of Utah Affiliated Hospitals
Salt Lake City, UT

RESIDENCY:
General Surgery Jun 2003- Jun 2006
University of Utah Affiliated Hospitals
Salt Lake City, UT

Chief Residency in General Surgery Jun 2006 – Jun 2007

University of Utah Affiliated Hospitals
Salt Lake City, UT

FELLOWSHIP TRAINING:
Colon and Rectal Surgery Jul 2007 - Jun 2008
Western Pennsylvania-Allegheny General Hospitals
Pittsburgh, PA

LICENSURE: Utah Active

BOARD CERTIFICATIONS:
Board Certification in General Surgery Jan 2008
Board Certification in Colon and Rectal Surgery Sep 2009

FELLOWSHIP IN SPECIALTY COLLEGES

Fellow, American College of Surgeons Oct 2011
Fellow, American College of Colon & Rectal Surgery May 2013
HOSPITAL APPOINTMENTS:
Active appointment. LDS Hospital, Salt Lake City, UT. Sep 2008-present
Active appointment. Intermountain Medical Center, Murray, UT. Sep 2008-present

ACADEMIC APPOINTMENTS:
Clinical Instructor, Trauma Surgery. University of Utah General Surgery Residency. Salt Lake
City, UT. Sep 2008 - Jun 2009

Clinical Instructor. St. Mark’s Health Care Foundation Colon & Rectal Surgery Residency. Salt
Lake City, UT. Nov 2016-present.

HONORS & AWARDS

General Surgery Chief Resident Outstanding Teaching Award Jun 2007
Presented by the medical students of University of Utah School of Medicine

Jack A. Barney Award Apr 2006

Presented by the Southwestern Surgical Congress for surgical resident presenting the
outstanding manuscript at the SWSC 58th Annual Meeting

Surgical Intensive Care Unit Resident of the Year Jun 2005

Presented by the SICU

Clark County Medical Society Scholarship Jun 1998

Presented by the University of Nevada School of Medicine for academic excellence.

PROFESSIONAL SOCIETY MEMBERSHIPS:

Alpha Omega Alpha Honor Society
American College of Surgeons
∙ Utah Chapter
American Medical Association
American Society of Colon and Rectal Surgeons
International Society of University Colon & Rectal Surgeons
Southwest Surgical Congress
Utah Medical Association

PROFESSIONAL OFFICES:
Chair of Western USA Committee, International Society of University Colon & Rectal Surgeons
2017-present

Medical Director, General Surgery Development Team, Surgical Services Clinical Program,
Intermountain Healthcare 2016-2017

Chief, Department of Surgery, LDS Hospital 2015-present

Medical Director, GI Cancer Team, Oncology Clinical Program, Intermountain Healthcare

2011-present

Chapter President, American Medical Association 1998- May 1999

PROFESSIONAL ACTIVITIES:
Sub-Investigator, Pilot study to determine the technical feasibility of circulating tumor DNA
2015-present
Sub-Investigator, MT4420 prospective colorectal cancer biomarker study 2015-present

Sub-Investigator, MT0265 Study of Frozen Tissue and Whole Blood in Crohn’s Disease and
Ulcerative Colitis Patients 2014-present

Reviewer for World Journal of Colorectal Surgery 2014-2018

Sub-Investigator, Randomized, Double Blind, Placebo Controlled Study to Study Intermountain

Healthcare's Enhanced Recovery Protocol for Colon Surgery With and Without Alvimopan Use
2010-2012

Physician Member
Robot Committee, Intermountain Healthcare 2011-present

Physician Member
General Surgery Development, Intermountain Healthcare 2012-present

Physician Member
Physician Advisory Group, Intermountain NSL Region 2011-2014

Surgical Director 2010-2012

Huntsman-Intermountain Multidisciplinary Anal & Rectal Cancer Clinic

Board exam contributor Jul 2010-present

American Board of Colon & Rectal Surgery

Physician Member 2010-2012

Intermountain Healthcare Product Development Team

Course Director Mar 2010

GelPort HALS Workshop & GelPOINT GI Single Site Workshop
Salt Lake City, UT

Faculty Nov 2009

GelPORT HALS Workshop. San Francisco, CA

Reviewer for Diseases of Colon and Rectum Jul 2008-present

BIBLIOGRAPHY
Publications

Surgeon-level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III
Rectal Adenocarcinoma. Journal of Gastrointestinal Surgery.

Sword D, Brooke B, Skarda D, Stoddard G, Kim H, Sause, W Scaife C. Facility Variation in Local
Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant
Therapy. Journal of Gastrointestinal Surgery. 2018 Nov.

Bagshaw H, Sause W, Galick U, Kim H, Whisenant J, Cannon G. Vulvar Recurrences After

Intensity-modulated Radiation Therapy for Squamous Cell Carcinoma of the Anus. Am J
Clin Oncol. 2016 Jul 19.

Kim H, Bruen K, Vargo D. Human Acellular Dermis in the Management of Complex Abdominal
Wall Defects. Am J Surg 2006; 192(6): 705-9.
Tom Herbert & Tae Kim. “Supplemental Evidence, Are They Performance Boosters or Snake
Oils?” Climbing No. 208, Dec 15, 2001.

Presentations
Swords, DS, Sause, WT, Gawlick, U, Cannon, GM, Lewis, MA, Scaife, CL, Gygi, JA, Kim, HT,
Skarda, DE. Surgeon-level Variation in Utilization of Local Staging and
Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma. Plenary Presentation at
the 2018 meeting of The Society of Surgery for the Alimentary Tract (SSAT) & 33rd
Annual SSAT Residents and Fellows Research Conference. Washington, DC. Jun 2018.

DS Swords, DE Skarda, H Kim, WT Sause, GJ Stoddard, CL Scaife. Facility Variation in

Upstaging Adjuvant Chemoradiation in Clinical Stage I Rectal Cancer. 13 th Annual
Academic Surgical Congress Abstract. Jan 2018.

Douglas S. Swords, David E. Skarda, Gregory J. Stoddard, H. Tae Kim, William T. Sause,
Courtney L. Scaife Facility variation in clinical staging of rectal adenocarcinoma and its
contribution to underutilization of neoadjuvant therapy. 2018 ASCO Gastrointestinal
Cancers Symposium. Jan 2018.

Kim HT. Speaker. Updates in Anorectal Disease in the Emergency Room. University of Utah
School of Medicine Emergency Medicine Residency Education Conference. Salt Lake
City, UT. Jul 2017.

Kim HT. Speaker. Updates in Colorectal Surgery. Rocky Mountain Regional WOCN Fall
Conference. Sandy, UT. Oct 2016.

Kim HT. Speaker. Problem Solving: Surgical Site Infections. CRICO (Risk Management Division
of Harvard Medical Institutions) Visit to Intermountain Healthcare. Apr 2016.

Kim HT. Speaker. Anorectal Disease in the Emergency Room. University of Utah School of
Medicine Emergency Medicine Residency Education Conference. Salt Lake City, UT.
Feb 2016.

Bagshaw HP, Sause WT, Gawlick U, Kim HT, Whisenant JR, Cannon GM. Vulvar Recurrences
Following Intensity Modulated Radiation Therapy for Squamous Cell Carcinoma of the
Anus. American Society for Therapeutic Radiology and Oncology 57th Annual Meeting.
Oct 2015.

Kim HT. Speaker. Stoma Education. Ostomy Support Group. Intermountain Employee Service
Center. Salt Lake City, UT. Jul 2015.

Kim HT. Participant. Deseret News/Intermountain Health Hotline. Colorectal Cancer. Salt Lake
City, UT. Feb 2012

Kim HT. Speaker. Stomas: When and Why. Ostomy Support Group. Intermountain Doty
Education Center. Salt Lake City, UT. Feb 2012.

Kim HT. Moderator. Anastomotic Leak: How can I prevent it? Lunch Symposium. American
Society of Colon & Rectal Surgeons Annual Meeting. Vancouver, Canada. May 2011.

Kim HT. Speaker. Parastomal Hernias. Ostomy Support Group. Intermountain Doty Education
Center. Salt Lake City, UT. Mar 2011.

Kim HT. Speaker. 21st Century Anorectal Disease. SelectHealth Care Management Clinical
Education. Salt Lake City, UT. Aug 2010.
Kim HT, Christensen, BJ. Speaker. Transanal Endoscopic Microsurgery: An Alternative Method.
American Society of Colon & Rectal Surgeons Annual Meeting. Minnesota MN. May
2010.

Kim HT. Speaker. Single Incision Laparoscopic Sigmoidectomy for Diverticulitis. 19th Annual
Winter Meeting: Midwest Society of Colon & Rectal Surgeons. Breckenridge, CO. Mar
2010.

Kim HT. Surgical Cricothyroidotomy. Speaker. Difficult Airway Management Course. LDS
Hospital Education Center, Salt Lake City, UT. May 2009.

Kim HT. Chasing the Truth. Podium Presentation. Surgery Grand Rounds. Allegheny General
Hospital. Pittsburgh, PA. May 2008

Kim HT, Read TE. Diverticulitis in Immunocompromised Patients. Podium Presentation. 9 th

Annual Surgical Resident Research Day. Western Pennsylvania Hospital. Pittsburgh,
PA. Apr 2008.

Wooten A, Kim HT, Read TE. Case Report: Iatrogenic Colonic Perforation Closed Using
Endoclips. Podium Presentation. 9th Annual Surgical Resident Research Day. Western
Pennsylvania Hospital. Pittsburgh, PA. Apr 2008.

Kim HT. ‘Cause That’s The Way We Do It. Podium Presentation. Surgery Grand Rounds.
Western Pennsylvania Hospital. Pittsburgh, PA. Apr 2008.

Kim HT. To Drain or Not to Drain. Podium Presentation. General Surgery Grand Rounds.
University of Utah Medical Center. Salt Lake City, UT. Apr 2007.

Kim HT, Glasgow RE. Laparoscopic Resection of a Gastric Glomus Tumor; a Case Report and
Review of the Literature. Podium Presentation. Southwestern Surgical Congress 59 th
Annual Meeting. Rancho Mirage, CA. Mar 2007.

Kim HT, Sklow B. Laparoscopic Sigmoid Colectomy. Video presentation. American Society of
Colon & Rectal Surgeons Annual Meeting. Seattle, WA. Jun 2006.

Kim H, Bruen K, Vargo D. Human Acellular Dermis in the Management of Complex Abdominal
Wall Defects. Podium presentation. Southwestern Surgical Congress 58th Annual
Meeting. Kauai, HI. Apr 2006

Kim H, Vargo D. Single Institution Series Utilizing Human Acellular Dermis. Poster presentation.
American College of Surgeons, Utah Chapter Annual Meeting. Park City, UT. Feb 2006

Kim HT, Murray KD. Sternal Closure – Review, Analysis, and Recommendations. Podium
presentation. University of Nevada School of Medicine George G. Bierkamper Student
Research Convocation. Reno, NV. Jan 2002

VOLUNTEER ACTIVITIES:
Volunteers in Medical Missions. Honduras 1999

Outreach Clinic, Reno, NV 1998-1999

 EXHIBIT “B”
Expert Report of
Suzanne L. Ward, RN, MS, LNC
 CONFIDENTIAL

Expert Opinion Report

In The Matter Of:

LISA OSTLER v. SALT LAKE City County Jail Staff

Prepared by Suzanne L. Ward, RN, MS, LNC

for

Attorney Rocky Anderson

and
Attorney Walter Mason

1
 CONFIDENTIAL

CONTENTS Page

I. ENGAGEMENT...........................................................................................................4
II. QUALIFICATIONS.....................................................................................................4
III. COMPENSATION.......................................................................................................4
IV. MATERIALS REVIEWED.........................................................................................5
V. EXHIBITS THAT MAY BE USED.............................................................................5
VI. SUMMARY OF RELEVANT CASE EVENTS.......................................................5
VII. OPINIONS.................................................................................................................14
OPINION #1: Nursing Staff of Salt Lake County Jail..................................................14
OPINION #2: Nursing Staff of Salt Lake County Jail, Medication Continuation........24
OPINION #3: Nursing Staff of Salt Lake County Jail, Pain Assessment.....................27
OPINION #4: Nursing Staff of Salt Lake County Jail, Dehydration............................31
OPINION #5: Nursing Staff of Salt Lake County Jail, Nutritional Status....................35
OPINION #6: Nurse Ronald Seewer.............................................................................39
OPINION #7: Nurse Brent Tucker................................................................................49
OPINION #8: Nurse Colby James.................................................................................56
OPINION #9: Nurse Brad Stoney..................................................................................61
OPINION #10: Culture of Disregard.............................................................................64
OPINION #11: Failure to Conduct CIWA/WOWS Assessments.................................67
OPINION #12: Failure of Jail Nursing Staff to Follow Policy/Procedure……………72
OPINION #13: Scott Sparkuhl, Central Control Operator............................................73
Preface to Opinions #14 and #15………………………………………………………77
OPINION #14: Richard Bell, Responsible Health Authority (RHA)............................80
OPINION #15: Pamela Lofgreen, Chief Deputy...........................................................90
VIII. Conclusion...............................................................................................................94

Appendix 1: Suzanne L. Ward Curriculum Vitae............................................................95

Appendix 2: Suzanne L. Ward List of Prior Deposition and Court Testimony...............98
Appendix 3: Materials Reviewed....................................................................................100
Appendix 4: Protocol, Standards, and Guidelines Used in the Formulation of
Opinions………………………………………………………………………….....103

A. CIWA and WOWS WITHDRAWAL PROTOCOL…………………………..103

B. STANDARDS OF CARE……………………………………………………..104
1. National Commission on Correctional Health Care (NCCHC) Standards ...104
a. NCCHC, Receiving Screening……………………………………..104
b. NCCHC, Access to Care……………………………………………104
c. NCCHC, Sick Call and Triage……………………………………...106
d. NCCHC, Assessment……………………………………………….107
e. NCCHC, Staffing…………………………………………………...108
f. NCCHC, Correctional Officer Training……………………………108
g. NCCHC, Delegation………………………………………………..109
h. NCCHC, Continuation of Medication……………………………...110

2
 CONFIDENTIAL

PAGE

C. STATE OF UTAH NURSE PRACTICE ACT for RN’s…………………........110

D. STATE OF UTAH SCOPE OF NURSING PRACTICE

IMPLEMENTATION………………………………………………….110

E. AMERICAN NURSES ASSOCIATION (ANA) SCOPE AND

STANDARDS of PRACTICE, NURSING………………….................111
F. AMERICAN NURSES ASSOCIATION (ANA) SCOPE AND
STANDARDS of PRACTICE, CORRECTIONS NURSING
G. AMERICAN NURSES ASSOCIATION (ANA) SCOPE AND
STANDARDS of PRACTICE, PAIN MANAGEMENT
H. AMERICAN NURSES ASSOCIATION, CODE OF ETHICS FOR
NURSES WITH INTERPRETIVE STATEMENTS
1. ANA, Assessment…………………………………………………………..111
2. ANA, Delegation…………………………………………………………...112
3. ANA, Documentation………………………………………………………113
4. ANA, Delivery of Nursing Care for All Regardless of Circumstance
Or Offense………………………………………………………………113
5. ANA, Pain Management…………………………………………………...114

I. Nursing Expectations for Emergency Care Delivery in Correctional

Facilities………………………………………………………………...115
J. Nursing Expectations for Response to Abnormal Vital
Signs…………………………………………………………………….116
K. Salt Lake County Jail Policy and Procedure, Job Descriptions, Prisoner
Rules and Regulations
Handbook……………………………………………………….116
L. Dr. Todd Wilcox article ““Managing Opiate Withdrawal: The WOWS Method”,
CorrectCare, printed Summer 2016…………………………………….117

3
 CONFIDENTIAL

I. ENGAGEMENT

I have been asked to provide an expert opinion regarding care or lack of care
provided to Ms. Lisa Ostler at the Salt Lake County Metro Jail from March 30, 2016 thru
April 2, 2016. In this report I have provided a summary of applicable standards of care
and set forth my opinions as to how the treatment Ms. Lisa Ostler did or did not receive
at the hands of the Defendants compared to those standards. Lisa Ostler’s estate, parents,
and children brought claims against the Salt Lake County Metro Jail and its staff, arising
from her death, for their deliberate indifference in failing to provide or arrange for
reasonable and adequate medical care for Ms. Ostler who was found unresponsive and
not breathing in her cell approximately three and a half days after being booked into the
jail.

II. QUALIFICATIONS

I am a Registered Nurse licensed in the State of Wisconsin with more than 46 years
of experience as a practicing nurse. I hold a Multi-State Registered Nursing license.
Wisconsin and Utah are part of the eNLC (Enhanced Nursing Licensure Compact) and
permit my nursing practice in both states. My practice includes more than 10 years of direct
clinical service in jails, prisons, and forensic mental health treatment facilities. I have been
a hospital manager responsible for all care and operations of a county inpatient unit serving
individuals legally detained under alcohol, drug, and mental health statutes and a unit
manager of a secure detention treatment facility where patients were assessed for legal
competence to stand trial. My nursing license has never been revoked or suspended for any
reason.

A curriculum vitae outlining my career experience is included as Appendix 1.

A list of my prior deposition and court testimony experience for the past 5 years is
included as Appendix 2.

III. COMPENSATION

I am being compensated for the professional services in connection with the

preparation of this report based on my customary hourly fees, which are $75.00 per hour
for medical record review and report writing. I charge $200 per hour for expert witness
and deposition preparation, services, and testimony. I charge $1800 per day plus actual

4
 CONFIDENTIAL

expenses for travel and trial appearance. I have no financial interest in the outcome of
this litigation.

IV. MATERIALS REVIEWED

The materials I reviewed to reach my opinions in this matter are listed in

Appendix 3.

In the event additional relevant information becomes available after the issuance
of my report, I reserve the right to amend my report and incorporate such information as
necessary. I also may incorporate additional information in response to any expert report
or opinions proffered on behalf of the Defendants.

V. EXHIBITS THAT MAY BE USED TO SUMMARIZE OR SUPPORT

OPINIONS

I may use any of the materials and documents cited or referenced herein to support
or summarize my opinions.

VI. SUMMARY OF RELEVANT CASE EVENTS

Ms. Lisa Ostler was booked into the Salt Lake County Metro jail on March 30,
2016 at 2:21 AM. A Pre-screen Examination and a Comprehensive Nurse Examination
was conducted on 3/30/2016 (SLCo Ostler 000128-000130). Documentation in the
examinations included:
• Vital Signs: Temperature of 98.3, Blood Pressure of 115/75, Respirations
of 15, an oxygen saturation of 99%, Height of 69 inches, weight of 124
lbs., and a body mass index (BMI) of 18.3
• Substance abuse including tobacco, ½ pack/day, e-cig; heroin, 1 g QD;
meth
• No injuries (SLCo Oster 000129)
• Broken or missing teeth
• Abnormal abdominal findings of rectal neuropathy related to sexual
assault (SLCo Ostler 000129)
• Crohn’s Disease (SLCo Ostler 000128)
• Abnormal musculoskeletal findings of arthritis
• History of gastric bypass in 2006
• No [menstrual] periods (SLCo Ostler 000128)
• A ½” abscess on the right breast areola and a ½” abscess on the right
anterior chest (AC) with scant erythema, no drainage, and not fluctuant.
• Positive risk factors for withdrawal (SLCo Ostler 000129)

5
 CONFIDENTIAL

• First time in jail (SLCo 000130)

• Victim of violent abuse/assault, victim of domestic violence, victim of
sexual abuse/assault/rape, PTSD secondary to victimization (SLCo Ostler
000130)

Ms. Ostler’s medications verified on 3/30/2016 for diagnoses of PTSD (Post

Traumatic Stress Disorder), Depression, Anxiety, Crohn’s Disease, Rectal Neuropathy,
ADD (Attention Deficit Disorder), Arthritis, Reflux, and Insomnia included Lexapro,
Xanax, Gabapentin, Adderall, Oxycodone, Hydrocodone, Prilosec and Ambien. A
prescription medication Pentaza (sic, Pentasa) for Crohn’s disease was not verified
(SLCo Ostler 000131).

An e-mail regarding Lisa was sent to Brad Lewis and Paula Braun on 3/30/2016
at 2:10 PM by Brad Stoney, RN (SLCo 000142, 000144) after she was booked in to the
jail. The e-mail included a Patient Problem List with assigned medical diagnoses
including International Classification of Diseases, 10th Revision (ICD-10) diagnoses
codes and the list of verified medications. Dr. Brad Lewis documented a DOCTOR
NOTE the next day, 3/31/2016, and wrote he received an e-mail regarding Lisa M.
Ostler’s medications on 3/31/2016. He referred continuation of her medication for post-
traumatic stress disorder, depression, attention deficit disorder, and insomnia to the jail
mental health providers, denied pain medications of oxycodone and Norco due to the
nature of the medications, the jail not being “a chronic pain or withdrawal facility” and
not being filled since December 2015. He denied Pentasa and prenatal vitamins and noted
there was no record of those medications. Dr. Lewis ordered Prilosec (SLCo Ostler
000214) and placed her on the Wilcox/Wellcon Opiate Withdrawal Scale (WOWS)
protocol. Paula Braun, via e-mail to Brad Stoney, RN, ordered a Librium taper for
benzodiazepine withdrawal (SLCo 000144). Dr. Todd Wilcox was listed in Lisa's jail
record as the Admitting, Attending and Ordering MD (SLCo Ostler 000148). There was
no evidence to suggest that any of the physicians listed in Lisa Ostler’s medical record -
Dr. Todd Wilcox or Dr. Brad Lewis - knew her, ever saw or examined her, or had any
direct clinical knowledge of her.

Lisa Ostler was booked, or rolled in to the Salt Lake County Jail on March 30,
2016, and initially placed in Housing Unit 5C. She was transferred to jail Unit 8C, Cell
number 16 on April 1, 2016, at about 10 AM. Cell 16 was located in a blind spot from
the camera on the unit. Ms. Ostler did not have a cellmate.

Lisa was identified to be at risk for substance withdrawal and was placed on
protocol for alcohol and benzodiazepine withdrawal entitled Clinical Institute
Withdrawal Assessment (CIWA) (SLCo 000155) and protocol for opiate withdrawal
entitled Wellcon or Wilcox Opiate Withdrawal Scale (WOWS) (SLCo 000156). She
admitted to heroin use and was apparently placed on the WOWS protocol for that reason.
Lisa was prescribed a benzodiazepine, Xanax, prior to her detention at the Salt Lake
County Jail, a medication that was not prescribed or continued at the jail. She was

6
 CONFIDENTIAL

apparently placed on the CIWA protocol for that reason. Lisa was required by written
policies, physician orders, facility training documents and protocol directions to be
assessed for withdrawal signs and symptoms twice per day for five days.

Vital signs were recorded on handwritten CIWA and WOWS protocol assessment
sheets with dates and times of 3/30/16 at 0500 and 1500, 3/31/16 at 0920 and 1450 and
4/1/16 at 0830. Vital signs recorded in her Electronic Medical Record (PEARL EMR)
were not consistent with the handwritten withdrawal protocol worksheets and reflected
dates and times of 3/30/16 at 0457, 3/31/16 at 1100 and 1555 and 4/1/16 at 1105. Not
only did none of the assessment times coincide, the assessment on 3/30/16 at 1500 was
not recorded at all in the EMR. The information recorded in Lisa's electronic medical
record for CIWA and WOWS assessments and the monitoring of her vital signs do not
reflect the actual times the assessments and monitoring activities occurred.

The CIWA and WOWS withdrawal protocol worksheets contained numerous

errors and omissions and alarming clinical findings that were not followed up or
evaluated by nursing or clinical staff. On March 30, 2016, Lisa’s respiration rate was
recorded as 98 breaths per minute; on March 30, 2016, Lisa’s oxygen saturation rate was
recorded as zero or as not being assessed at all; on March 31, 2016, Lisa’s resting heart
rate was recorded as 133 beats per minute and was scored as a “2” on the WOWS scoring
worksheet, even though a resting heart rate at or above 110 beats per minute was to be
scored as a “4”. Lisa’s heart rate of 133 on March 31 followed a heart rate of 119 earlier
the same day. There is no record about the failure to alert a physician about the heart rates
over 110, and the written policy required that nurses contact a physician in these
circumstances. Her weight on 3/30 was recorded as 124 pounds, while her weight on
4/2/16 was listed as 200 pounds. Minimal, if any, hydration was provided to Lisa over the
course of four days. Salt Lake County Jail training on WOWS assessment specifically
stressed the importance of identifying dehydration or elements leading up to dehydration
and highlighted prevention of dehydration as a main issue in opiate withdrawal. Protocol
assessment worksheets document Lisa received just two bottles of Gatorade in four days
and there is no information to suggest she drank either one. (Esther Israel, a mental health
professional, noted there were three Gatorade bottles in Lisa’s cell and one was spilled on
the floor.)

Documentation of meal intake reflected that Lisa was not eating meals. There is
no record of her intake for 3/30/16. On 3/31/16 she refused breakfast and lunch; there is
no record of her intake for dinner. On 4/1/16 there is no record of her intake at breakfast;
she refused lunch and other inmates in Unit 8C reported she did not eat dinner. On
4/2/16 Lisa refused breakfast before she was found unresponsive and not breathing in her
cell and was transported to the hospital. Lisa's BMI (Body Mass Index) at the time of her
booking on 3/30/16 was 18.3. The Centers for Disease Control (CDC) and Prevention
categorizes BMI below 18.5 as "underweight".1

1
Centers for Disease Control and Prevention (CDC). Healthy Weight. About Adult BMI.

7
 CONFIDENTIAL

Throughout Lisa's electronic medical record there was no indication that any
errors, omissions or inconsistencies in assessment findings were followed up by any
nursing or clinical staff. There is no indication that Lisa was evaluated for dehydration,
not eating, or weight loss despite nursing staff knowledge that she was not eating meals
and she had only been provided two or three bottles of Gatorade since being booked into
the jail and no one had monitored whether or how many she drank. Lisa was not referred
for a medical examination, evaluation, or for treatment by an advanced care provider at
any time, and no advanced care provider ever saw her.

Lisa Oster saw Jamie Facholas, a mental health professional, on March 31, 2016
at approximately 3:30 PM (SLCo 000154). Facholas reported past severe trauma with
sexual assault. She documented an assessment of Lisa and noted she had “visible marks
all over her body”, would not look Facholas in the eye, “had visible signs of anxiety” and
“reported symptoms of depression”. There is no evidence in Lisa’s medical record that
the report of trauma, assault, anxiety, depression, or the visible marks all over her body
was followed up or communicated to medical or mental health staff for further
investigation. There is no evidence in the record that any nurse identified or addressed
"visible marks all over her body" or followed up on identified anxiety or depression.

On 3/31/2016, at 6:23 PM Lisa Ostler was seen for four minutes by Esther Israel,
a mental health professional for a crisis call. Israel documented the Housing Unit Officer
had a strange interaction with Lisa when she got up from sleeping and stated she was
supposed to meet Claudia to go to a wedding. Ms. Israel spoke to Lisa. Lisa told her she
was involved in a “murder-suicide” and she was sometimes living in the past. Lisa Ostler
was oriented to place. Ms. Israel noted there were three bottles of Gatorade in Lisa’s cell
and one of the bottles was spilled on the floor. She provided Lisa with a mood chart and
educated her on the triage process. Ms. Israel's documentation of her contact with Lisa
was present in Lisa's medical record. Lisa was not referred for a medical evaluation for
her symptoms of disorientation or confusion.

Lisa Ostler’s vital signs were not monitored as ordered and withdrawal protocol
assessments were only partially completed. The last charted assessment, including
purported monitoring of her vital signs, was on the morning of 4/1/2016. The vital signs
recorded on that morning are highly suspect. After 4/1/2016 at approximately 8:30 AM,
no vital signs were recorded and no assessments were performed until Lisa Ostler was
found unresponsive and not breathing in her cell approximately 24 hours later.
Withdrawal protocol assessments were to be performed twice daily for five days
according to physician orders, established protocol, and training programs2. No vital signs
or symptom assessments were performed after 8:30 AM on 4/1/2016, and, likely, vital
signs had not been monitored since 3/31/2016. No vital signs or symptom assessments

2
Salt Lake County Jail Training Program, Wellcon Opiate Withdrawal Scale (WOWS), SLCo Ostler
025540.

8
 CONFIDENTIAL

were performed on 4/2/2016 prior to Lisa being found unresponsive and not breathing.
Nurse Seewer testified it was not his responsibility to perform the CIWA/WOWS
assessment for Lisa Ostler on 4/1/2016 in the afternoon because he was not assigned to
Charlie (“C”) Pod that day (Seewer Deposition, pp 141 – 142; Exhibit A), although Nurse
Seewer was working in C Pod that day. The responsibility for CIWA and WOWS
assessments was the responsibility of the “pod nurse”. An HSU daily assignment log
(SLCo Ostler, 030924) identified the C Pod nurse as Disa and Ron was assigned to the
Acute Mental Health Unit and not to Charlie Pod/8C. There is no evidence whatsoever
that Nurse Disa provided any health care services on 8C in the afternoon of 4/1/2016, and
Defendants’ counsel has informed Plaintiffs’ counsel that the HSU daily assignment log
is not reliable. Jail medical staff reportedly did not consider the log as reliable or official
as assignments often changed, unit needs required frequent, daily adjustments, and staff
often traded assignments (Amended Responses to Requests for Admission and Responses
to Reformulated Requests for Admission, p 2). Deposition testimony by the Responsible
Health Authority (RHA), Richard Bell, indicated it was up to the pod nurse to ensure
vital signs were taken (Bell Deposition, March 25, 2019, pp 44 - 46). No vital signs or
withdrawal assessment was performed by any nurse on the afternoon of 4/1/2016, just
hours before Lisa was found unresponsive and not breathing. None of the abnormal vital
signs recorded on the CIWA and WOWS assessment forms that had actually or allegedly
been taken previously were followed up, addressed or reported to an advanced level
health care provider. The vital signs recorded on the morning of 4/1/2016 by Nurse
Seewer were impossibly “normal” for a patient complaining of pain who had received
none of her prescribed medication for existing medical conditions, who was unable to
walk upright, who had the prior abnormal vital signs, and who was suffering from
peritonitis.

On 4/1/16 at 3:25 PM, Officer Todd Booth recorded in the Officer Shift Log for
Unit 8C that Nurse Ron was in the unit for medication pass and diabetic checks. Booth
recorded that Lisa was complaining of pain and testified he informed Nurse Ron of her
pain complaints. According to Officer Booth, Nurse Ron examined her and cleared her to
stay in the unit (SLCo Ostler 00012). Nurse Seewer stated he did not recall assessing
Lisa Ostler, did not recall taking her vital signs, and recorded no assessment or encounter
whatsoever with Lisa Ostler, which he said he would have done had he had a medical
encounter with Lisa Ostler. No vital signs were recorded on the CIWA or WOWS
protocol assessment records for the afternoon of 4/1/16 or any time on 4/2/16. In fact, a
notation of a circled number "3" was recorded for those dates and times, a notation
representing that Lisa was not available or was not on the unit. There was no evidence
that Lisa left the unit at any time for any reason. She was given medication three times
on 4/1/16 verifying she was on the unit, available to the nurse, and therefore would also
have been available for an assessment. The medication nurse was reportedly Ron Seewer
and Lisa appeared to have received medication three times on 4/1. If Lisa was available
to the medication nurse she would also have been available for an assessment. The
notation on the CIWA and WOWS assessment forms that she was unavailable was a false
entry.

9
 CONFIDENTIAL

Multiple inmates on Unit 8C while Lisa was there described that her pleas for
help and signs that she needed emergency medical help were obvious throughout the
afternoon of 4/1/2016. The inmates reported they spoke to Officer Todd Booth about
their concerns but he rudely dismissed them. Officer Booth was aware of Lisa’s
complaints of pain and pleas for help but failed and refused to help her or ensure that any
other staff helped her.

Alisha Woodruff, Kellie Sheppard and Nicole Bates were inmates on 8C at the
Salt Lake County Jail during the time Lisa Ostler was there. Each of them testified they
saw Lisa, observed her behavior and health condition, heard her cries and pleas for
medical help, and expressed concerns, or heard other inmates express concerns, to
officers about the seriousness of her health and need for medical help based upon their
observations. Each inmate reported Lisa did not receive medical help.

Alisha Woodruff testified that everyone was talking about Lisa when she first
came into the unit. Lisa "looked like she was dead on her feet . . . She looked dead . . .
scary . . .looked just like a skeleton" (Woodruff Deposition, p 7). Ms. Woodruff noted
that the color of her skin was gray and she sat hunched over on her bed (Woodruff
Deposition, pp 7 - 8) and stated she looked like she might die. She was skinny and did
not move. Ms. Woodruff stated it was very obvious she needed medical attention
(Woodruff Deposition, pp 11 - 12).

Kellie Sheppard testified she saw Lisa on April 1st, 2016. She stated Lisa looked
weak and sick and her skin color was yellowish and pale (Sheppard Deposition, p 7). She
stated Lisa said to her "Please help me" and she looked like she was in pain (Sheppard
Deposition, pp 8 - 9). Ms. Sheppard stated another inmate went to the guard to get
medical help for Lisa but she did not observe a nurse respond (Sheppard Deposition, p
12). She saw Lisa try to put her clothes in a bin during clothing exchange but noted that
Lisa was not strong enough to throw the clothes and they landed in front of her on the
floor (Sheppard Deposition, p 16). Ms. Sheppard testified that one of the girls went to
the guard and said "She's going to die." and the guard's response was "Well, don't do
drugs." Ms. Sheppard stated she heard the conversation. She did not see or hear the guard
call for a nurse (Sheppard Deposition, p 17). The guard, Holly Harris, did not summon
medical attention for Lisa. On the night of April 1st, Ms. Sheppard heard Lisa screaming
and saying "Help me" throughout the night. She heard the guard, Holly Harris, say that
Lisa shouldn't have done drugs and did not provide any help for Lisa at any time
(Sheppard Deposition, p 21). Kellie could hear Lisa screaming loudly all night and
thought she was going to die. She stated it was obvious to her she needed emergency
medical treatment and she was going through something more than withdrawal (Sheppard
Deposition, p 24 - 25). She stated her observation was based on common sense
(Sheppard Deposition, p 32 - 33).

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 CONFIDENTIAL

Nicole Bates received training as a certified nursing assistant (Bates Deposition, p

8). She reported that if an inmate was going through bad heroin withdrawal the officers
would have a nurse come to check them (Bates Deposition, p 26) but she did not see
officers call a nurse for Lisa (Bates Deposition, p 30). She felt Lisa really needed help.
Nicole testified that the unit officers were made aware Lisa was very sick. Lisa was
sitting on her bed moaning (Bates Deposition, p 47). Nicole could tell Lisa was in a lot
of pain by the way she was moaning. Her color was gray. She testified that more than one
person tried to get the guard's attention (Officer Booth) to let him know something wasn't
right with Lisa but the officer told them to mind their “own fucking business” and to
leave her alone (Bates Deposition, pp 52 – 54). Bates told the officer Lisa needed
medical help as something was wrong with her. She testified that Lisa wasn't
withdrawing from drugs, it was more than that. Officer Booth told her if she was that
sick, she would get up and see triage in the morning (Bates Deposition, p 52 - 53). When
the inmates continued to try to get help for Lisa, they were warned they would lose their
free time out of their cells if they did not leave her alone. Nicole described Lisa during
clothing exchange as incoherent, stumbling, and having a hard time walking. She
struggled to even be moving, didn't seem like she knew where she was, couldn't
understand why she was being yelled at and looked like she was in a lot of pain
somewhere in her abdomen (Bates Deposition, p 49 - 51). Nicole testified that Lisa told
Officer Holly Harris (the graveyard shift officer) that Lisa needed help (Bates Deposition,
p 128), but Harris did not summon medical to see her. Lisa's vital signs were not checked
when she was in 8C (Bates Deposition, p 93). Upon her return to the unit Harris told the
nurse Lisa did not need to see medical, that she could fill out a sick call kite and see
triage in the morning. Lisa told Harris that something was really wrong, she was in pain,
and she needed medical help but Harris told her to shut up, threatened her, kicked her cell
window, and accused her of misusing medical and jail staff (Bates Deposition, p 62).
Ms. Bates heard Lisa crying all night long, crying for help and moaning (Bates
Deposition, p 68). Nicole Bates testified that as a lay person she knew Lisa was
experiencing a serious medical condition that required medical attention and that it did
not require someone who was medically trained to determine that it was a serious medical
condition that needed to be addressed (Bates Deposition, p 132). Lisa’s serious need for
medical attention was obvious to the medically untrained laywomen detainees that simply
saw her, heard her, and used their common sense to identify another human being in
abject distress.

On 4/1/2016 at approximately 11:10 PM Lisa Ostler left her cell for mandatory
clothing exchange. She was observed on jail video holding her abdomen, bent over,
walking very slowly and shuffling (Jail Video). She appeared disoriented and confused;
at one point she walked aimlessly in the wrong direction away from her cell (Jail Video).
Nicole Bates testified that Lisa "looked like she was in a lot of pain" and was "incoherent,
she was stumbling, she was having a hard time walking . . .You could tell she was
struggling to even be moving (Bates Deposition, p 49). Kellie Sheppard testified that
Lisa "was clearly not in the right frame of mind" and too "weak" to throw her clothes in
the clothing bin (Sheppard Deposition, pp 15, 16). Clothing exchange was the only time

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 CONFIDENTIAL

Lisa left her cell while she was on 8C before she was taken to the hospital by ambulance
unresponsive and not breathing the following morning.

The graveyard shift Control Room Operator Scott Sparkuhl received a shift report
from Operator Dalton and testified he was told Lisa Ostler had been calling a lot for
medical treatment for several days, that medical nurses and doctors had seen her, they’d
checked her out and she was coming off of heroin (Sparkuhl Deposition, pp 41-42).
Sparkuhl testified that Lisa Ostler rang the button and said she was in pain and was
requesting medical (Sparkuhl Deposition, p 45). He testified he contacted the Housing
Officer the first time she called and the Housing Officer told Sparkuhl to “Go ahead and
ignore the cell.” (Sparkuhl Deposition, p 51). Sparkuhl testified that before his contact
by Lisa Ostler he had previously experienced on a dozen or so occasions Housing
Officers telling him to ignore inmates’ calls when inmates reported they were
experiencing a serious medical problem and needed help. Sparkuhl stated he followed
the instructions to ignore the calls (Sparkuhl Deposition, p 68). Mr. Sparkuhl testified he
received a call from an inmate checking on Lisa Ostler because she heard Lisa crying and
sounding like she was in pain (Sparkuhl Deposition, p 98). Officer Sparkuhl received
communications from Lisa Ostler approximately 1-2 times per hour, all night long, that
she was in pain and needed medical help (Sparkuhl Deposition, pp 40-41). Lisa contacted
Scott Sparkuhl up to 16 times throughout the night, but because he had been instructed to
"ignore" Lisa's cell, he only passed on one or two of those communications to a Housing
Officer (Sparkuhl Deposition, pp 49, 57, 59).

Housing Unit Officer Holly Harris (graveyard shift officer) stated in response to
Plaintiff’s Request for Interrogatories that on 4/1/2016 at approximately 11:30 PM she
contacted medical and informed them other female prisoners in the unit (Unit 8C) were
concerned about Prisoner Ostler. She states that she contacted medical and stated a male
nurse informed her that her [Lisa Ostler’s] vitals had been taken in the previous hour and
were fine. (Responses to Plaintiff’s Request for Interrogatories, Interrogatory No. 22),
(Harris Deposition, pp 84-85, 98). No evidence, including shift logs and medical records,
corroborates Officer Harris’ claim that she called a nurse and no medical record
documentation reflects that Ms. Lisa’s vital signs had been monitored since
approximately 8:30 that morning (if, in fact, her vital signs were monitored that
morning). Officer Harris testified she did not record in her log that other inmates told her
Lisa Ostler needed medical treatment or that she contacted a nurse (Harris Deposition, p
126), despite her typical practice of logging contacts with a nurse (Harris Deposition, p
84). The failures and refusals of custody and medical staff to take Lisa’s complaints and
requests for medical attention seriously demonstrated a complete disregard and an
astonishing indifference to her obvious needs across multiple levels of the jail
organization. The staff that functioned as gatekeepers to essential medical care for the
inmates failed and refused to fulfill a basic duty and responsibility of their jobs when Lisa
Ostler was obviously suffering from a serious medical condition.

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 CONFIDENTIAL

On 4/2/2016 at 6:00 AM Officer Zachary Fredrickson began his shift. He was

informed by Holly Harris and his supervisor, Heather Beasley, that Lisa Ostler had been
crying and screaming all night (Frederickson Deposition, p 100) and asking for medical
help (Frederickson Deposition, p 142). Officer Frederickson also noted that Lisa reported
some vaginal bleeding. He testified that concerned him enough to call medical staff
(Frederickson Deposition, p 113).

On 4/2/16 at approximately 6:38 AM Nurse Brent Tucker was on Housing Unit

8C to conduct diabetic checks. Housing Officer Zachary Frederickson informed Nurse
Tucker that Lisa had been hitting the intercom all night (Frederickson Deposition, p 190).
But Frederickson did not inform Tucker that Lisa had been crying and screaming all
night, and repeatedly asking for medical assistance or that other inmates expressed their
concerns to Frederickson that Lisa had not received medical help and might die.
According to Frederickson, Nurse Tucker spoke with Lisa Ostler briefly and then left the
unit. There is no evidence that Tucker did any medical evaluation of Lisa, at which time
she was dying of peritonitis, which is always extremely painful. Officer Frederickson
learned Lisa reported vaginal bleeding and she was not eating, which Officer
Frederickson reported to Nurse Tucker by phone. Frederickson did not tell Tucker during
that call that Lisa had been crying and screaming all night, repeatedly asking for medical
assistance, and pressing her emergency button all night or that other inmates expressed
their concerns to Frederickson that Lisa had not received medical help and might die.
Nurse Tucker reportedly responded that not eating was not a concern until 72 hours had
passed. Nurse Tucker submitted a note, written after Lisa Ostler’s death, stating that he
reviewed her medical record and assumed that because she was “W/D from ETOH and
Drugs” (withdrawal from alcohol and drugs) that “explains why she may not want to
eat.” (SLCo Ostler 26515). Nurse Tucker asked Officer Frederickson if the bleeding was
menstrual and Officer Frederickson stated he did not know. Nurse Tucker instructed
Officer Frederickson to ask her and have Lisa fill out a triage kite if Frederickson did not
assess her complaint as an emergency (Frederickson Deposition, pp 187-191). There was
no indication that Nurse Tucker made any attempt to assess, investigate, or determine if
Lisa Ostler had a medical issue or an emergency, an action that was the sole
responsibility of a nurse in that instance. It was wholly inappropriate for Tucker to leave
it to Frederickson to determine if Lisa had an emergency medical condition. There was
no indication that Nurse Tucker considered that Lisa Ostler may have been bleeding due
to an injury, or an urgent medical issue. Of note, was the entry in Ms. Ostler’s medical
record on the Nursing Pre-Screen Examination, a record that Nurse Tucker claims to have
reviewed, that Lisa Ostler had no [menstrual] periods, had a significant medical history
for Crohn’s disease, gastric bypass and splenectomy. There was no indication that Nurse
Tucker considered any of this information despite it being just as present in her medical
record as the notation she was withdrawing from alcohol and drugs.

Bleeding, particularly in conjunction with severe abdominal pain, can indicate a

serious medical emergency. Severe pain should heighten the concern for a serious
underlying cause and should prompt immediate concern about a potential intra-abdominal

13
 CONFIDENTIAL

catastrophe. The general appearance of the patient should be noted. An "ill-appearing"

patient with abdominal pain is always of great concern given the variety of potentially
lethal underlying causes. Immediate assessment would be indicated. Reports of pain
accompanied by reported bleeding are serious symptoms and should be assessed
emergently. Bleeding from the vagina can be mistakenly identified by the patient and
actually be from the rectum or in the urine. Lisa's presenting constellation of symptoms
including pain, vaginal bleeding, and not eating – or any one of them - required an
immediate nursing assessment by Nurse Tucker when he was made aware.

There was no indication that Nurse Tucker ever considered returning to Unit 8C
to see Lisa, that he reported Lisa's medical symptoms to anyone, or that he considered
arranging for another nurse to see her. He did not even make a notation in the medical
record. There was no evidence to suggest that Nurse Tucker took any action in the face of
the obvious potential that Lisa Ostler was experiencing a medical emergency and
required assessment before symptoms were simply dismissed or referred to an untrained
officer to follow up.

On 4/2/16 at approximately 7:30 AM (less than one hour after Nurse Brent
Tucker was on the unit) Nurse Colby James entered the unit to conduct triage. Housing
Officer Zachary Frederickson talked with Colby James about Lisa Ostler requesting to
see medical. In an e-mail after Lisa Ostler’s death, Nurse James described "the event
timeline of triage" before the medical response was called for Lisa being unresponsive
and not breathing. Nurse James stated he arrived on Unit 8C to start triage. He stated the
unit officer informed him that Cell 8C16B [Lisa Ostler] was told to place a SCR [sick call
request] form in for her medical concerns however she told him [the officer] that she did
not want to and that she was refusing to (SLCo Ostler 026514). Nurse James told Officer
Frederickson that if Lisa Ostler had a medical emergency to contact medical and if she
had a triage kite, he would take it at that time. There was no indication that Nurse Colby
James took any action or made any attempt to walk a few steps across Unit 8C to see or
talk with Lisa Ostler. There was no indication he made any attempt to determine if she
was having any medical issues or a medical emergency despite knowing she verbally
made a request to the housing officer to see medical AND that he was on the unit for the
very purpose of conducting triage, a process used to determine which inmates needed to
be seen for medical attention. Instead, Nurse James directed Officer Frederickson to
make a determination about whether or not Lisa's request for medical attention and
concerns were emergent. Again, it is highly inappropriate and irresponsible for a nurse to
leave it to a medically untrained Housing Officer to determine if an inmate was suffering
from an emergency medical condition. It is shocking that any nurse would know that an
inmate had requested medical attention and the nurse would not walk a few steps to the
inmate’s cell to check on her. We now know that Lisa Ostler was near death when Nurse
Colby James failed and refused to walk to her cell and check her condition.

On 4/2/2016 at 8:07 AM, just 37 minutes after Nurse Colby James failed and
refused to assess Lisa Ostler’s request for medical attention, Officer Frederickson was

14
 CONFIDENTIAL

alerted by another inmate that Lisa was not breathing and discovered her in her cell
unresponsive and not breathing. Lisa was transported to Intermountain Medical Center,
did not regain consciousness, and was declared dead on 4/3/2016 at 1:14 AM. The cause
of her death was determined to be peritonitis. She suffered a perforation of her bowel.

The protocol, standards and guidelines used in the formulation of my opinions

are listed in Appendix 4.

VII. OPINIONS AND THE BASIS AND REASONS FOR THEM

The opinions that follow are based on my clinical experience, my education,

my research, my consideration of the facts and data contained in the documents and
materials described above and in Appendices 3 and 4, and the facts and reasons set
forth below.

OPINION #1: The registered nurses at the Salt Lake County Jail, including at
a minimum, Nurses Ron Seewer, Brent Tucker, and Colby James, who provided care,
who was in a position to provide care, or who was in a position to ensure the provision
of care to Lisa Ostler breached professional standards of nursing care and their duty
to act as any medically trained nurse would have acted in a similar circumstance to
that of providing or ensuring care to Lisa Ostler. Those breaches are so egregious
that their actions, as well as their failures and refusals to act, cannot have been the
result of the exercise of professional nursing judgment. They failed and refused to
perform obviously required assessments, failed and refused to follow up on abnormal
results of assessments that were performed, failed and refused to address Lisa’s
serious medical conditions and needs, failed and refused to address signs and
symptoms of illness that were obvious and recognizable to laypersons and would be
obvious and recognizable to a medically trained and licensed nurse, failed to arrange
for a physician to evaluate, diagnose, and treat Lisa Ostler, failed to arrange for Lisa
Ostler to be transported for emergency care at a hospital, and failed and refused to
ensure her health and safety. Those breaches were caused by a widespread practice
and custom of deliberate indifference toward the serious medical needs of patients,
generally, which resulted in the deliberate indifference toward the serious medical
needs of Lisa Ostler, specifically.

Basis for Opinion #1

A. The Salt Lake County Jail registered nursing staff, including at a minimum,
Nurses Ron Seewer, Brent Tucker, and Colby James failed and refused to
complete assessments, follow up, report or address abnormal results and failed
and refused to address Lisa Ostler's serious medical needs and conditions. The
Salt Lake County Jail registered nursing staff, including at a minimum, Nurses

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 CONFIDENTIAL

Ron Seewer, Brent Tucker, and Colby James did not, at any point, contact an
advanced care provider to report abnormal results or seek orders or direction for
ensuring necessary and appropriate care for Lisa’s serious medical needs.

Lisa Ostler was admitted to the Salt Lake County Metro Jail and was seen
by nursing staff for a receiving screening and comprehensive nursing
examination. Her history of Crohn’s disease, arthritis, and previous gastric
bypass surgery in 2006 was documented. Her diagnoses of PTSD, Depression,
Anxiety, Rectal Neuropathy, ADD, Arthritis, Reflux, and Insomnia were also
documented. Her prescribed medications were listed and verified with the
exception of Pentasa and Prenatal Vitamin. Lisa was also determined to be
suffering from heroin and benzodiazepine withdrawal and she was placed on
withdrawal protocol assessments - CIWA and WOWS. The majority of her
prescribed medication was not ordered, rather was deferred to mental health. Lisa
was never seen by a mental health provider to have her medications evaluated or
prescribed. Prilosec, an over-the-counter antacid that could have prevented the
perforation of Lisa’s gastrointestinal ulcer, which led to her peritonitis was
ordered by Dr. Brad Lewis, but Lisa was denied even that medication – she did
not receive a single dose.

The comprehensive nursing exam performed on 3/30 noted two minor skin
abscesses on the right side of Lisa’s chest and breast. The day following her
booking into the jail, the mental health worker documented Lisa had "marks all
over her body". Nursing documentation did not mention any bruises or marks on
her body. Lisa was noted by laywomen detainees in the jail to be extremely sick,
in obvious pain and distress, and in need of medical help. None of the nurses
documented any abnormal medical findings for Lisa other than minor skin issues,
some nausea, vomiting or diarrhea. No documentation reflected Lisa’s seriously
debilitated, declining medical condition. Nurses are the medical “eyes” on
patients in any health care facility. The nurses’ failure and refusal to identify
medical issues for Lisa was unbelievable given the condition present and
progressing inside of her abdomen, manifested by her cries and pleas for help, her
obviously debilitated appearance, and her altered mental state.

Todd Wilcox, MD, medical director of the Salt Lake County Jail, in an
article describing management of opiate withdrawal in corrections, described
opiate withdrawal as a life-threatening condition requiring medical support to
ensure a safe withdrawal. He developed the Wilcox Opiate Withdrawal Scale
protocol (WOWS) to improve the care for this serious condition. In the Salt Lake
County Jail withdrawal assessments were required to be completed twice daily for
five days.

Not all withdrawal assessments were completed for Lisa Ostler. After
4/1/2016 AM no assessments, including the monitoring of vital signs, were

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 CONFIDENTIAL

performed. Ms. Ostler was found unresponsive and not breathing in her cell
approximately 24 hours later. Had the nursing staff performed the physician-
ordered assessments and provided the basic medical care that was ordered or
provided the basic medical care that was obviously needed, Lisa’s dire, life-
threatening condition would have been identified and she would have received
life saving care.

Of the five assessments that were allegedly performed from 3/30/2016

through 4/1/2016 AM, conflicting information occurred on two of the assessments
and alarming clinical findings were present on four of the assessments. The 3/31
PM CIWA assessment of symptoms was blank. Significantly abnormal findings,
such as a pulse of 119 and 133, were recorded with no evidence of follow up or
notification to an advanced care provider, contrary to a written policy requiring
that a physician be contacted when a patient has a heart rate of over 110. Incorrect
medication information and incorrect scoring of vital signs appeared on at least
two occasions.

Conflicting information: On 3/31 the CIWA assessment recorded a

Gatorade was given however the WOWS assessment done at the same time did
not document any Gatorade given. On 3/31 the WOWS worksheet noted that
vomiting or diarrhea was present during both the AM and PM assessments but no
as needed (PRN) Phenergan (for vomiting) or Imodium (for diarrhea) medication
was given despite there being an implied order for both medications. On 4/1 a
CIWA and WOWS assessment was recorded at 0820 and both Phenergan and
Imodium medications were administered. After the AM assessment on 4/1 a
circled "3" was recorded that signified Lisa was "not on the unit" or "not
available" and a second assessment was not done on that day, although policy
required it to be done. There was no evidence that Lisa left her cell on 4/1 for any
reason or was unavailable to nursing staff. Furthermore, the Medication
Administration Record (MAR) for 4/1 reflects that Lisa received Librium
medication TID (3 times), verification that she was available to a nurse on at least
3 occasions throughout that day. Librium is a medication that is given with
several hours in between doses, therefore Lisa would have been available to the
nurse for vital signs and an assessment at mid-day, in the afternoon or in the
evening of 4/1 when she received medication, yet no vital signs or assessments
were ever done. Nursing staff failed and refused to perform physician-ordered
assessments, which, if done, would have led to actions that likely would have
saved Lisa’s life.

Alarming clinical findings: On 3/30 Lisa’s Respiratory Rate was recorded

as 98 with no subsequent evaluation or follow up. Lisa's Heart Rate on 3/31 was
recorded in the AM as 119 (well above the range requiring MD contact) and was
133 (well above the range requiring MD contact) at the very next assessment that
day. Her O2 Sat was recorded as "zero" on 3/31 PM. Nursing staff failed and

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 CONFIDENTIAL

refused to report alarming findings that signaled a dramatic change in her

condition. Incredibly, no advanced care provider was ever notified.

Missing assessments: No CIWA symptom assessments were performed in

the PM of 3/31 - the column to record findings was left blank. No assessments at
all were completed after 4/1 AM in the 24 hours before Lisa was found
unresponsive and not breathing in her cell.

Abnormal findings: On 3/31 PM Lisa's BP was recorded as 89/68, a

significant drop from any of her previous BP readings and her pulse was 133, a
dramatic and significant increase over previous readings and an alarming increase
from a previously elevated heart rate of 119 taken earlier in the day. Those vital
signs required a physician’s attention, but no physician was contacted. Lisa was
given Gatorade on just 2 occasions in 3 days but it did not appear she drank the
liquids. Nursing staff failed and refused to notify an advanced care provider of
abnormal vital signs that signaled a significant change of condition. No nursing
assessment for dehydration was done.

Incorrect information: A handwritten entry on Lisa’s CIWA assessment

noted: "Rx: Klonopin" however Lisa was never on Klonopin. On 3/31 PM Lisa's
pulse rate of 133 was scored as a severity of "2" instead of a "4", which it should
have been, resulting in an incorrect total WOWS score. Lisa was recorded as "not
on the unit" after an AM assessment on 4/1/16, therefore a second assessment on
that date was not done and no assessment whatsoever was done on the morning of
4/2; however, Lisa had not left the unit or her cell.

Inconsistent assessment times in record: Vital signs and symptom

assessments were recorded on handwritten CIWA and WOWS protocol
assessment sheets reflecting dates and times of 3/30/16 at 0500 and 1500, 3/31/16
at 0920 and 1450 and 4/1/16 at 0830. The vital signs and assessments recorded in
Lisa's Electronic Medical Record (PEARL EMR) reflected dates and times of
3/30/16 at 0457, with no information recorded in the EMR for 3/30/16 PM,
3/31/16 at 1100 and 1555 and 4/1/16 at 1105. No further CIWA or WOWS
assessments were performed after 4/1 AM.

The record reflects so many serious, sloppy errors and omissions that no
one could reach any conclusion except that the administration of the Salt Lake
County Jail and its nurses were deliberately indifferent toward the serious medical
condition and needs of inmates, generally, and Lisa Ostler, specifically, which led
to her suffering and death.

Absence of positive interventions: The notes section at the bottom of the

WOWS protocol assessment for Lisa was blank. According to the WOWS
training for opiate withdrawal issues presented to Salt Lake County Jail staff, the

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 CONFIDENTIAL

notes section at the bottom of the form was for nursing staff to document the
positive interventions they did to save the patient's life and for them to take credit
for their work.3 Not one nurse recorded any positive intervention they took to save
Lisa's life from 3/30/16 at 0500 through 4/2/16 AM when she was found
unresponsive and not breathing in her cell. Nursing staff of the Salt Lake County
Jail knew of their responsibilities to take positive interventions to maintain Lisa
Ostler's health and life and to document the actions they took in that regard. The
nursing staff failed and refused to provide Lisa with any positive nursing
interventions for her serious medical condition and, if implemented, would more
likely than not have saved her life.

B. The registered nursing staff at the Salt Lake County Jail, including, at a
minimum, Nurses Ron Seewer and Brent Tucker, knew their responsibilities to
manage and respond to Lisa Ostler's medical needs and conditions.

The registered nursing staff, including, at a minimum, Nurses Ron Seewer

and Brent Tucker, was responsible to complete drug withdrawal assessments of
Lisa Ostler twice daily for five days and fully and accurately document their
findings according to facility protocol, policy, procedure, training information and
physician orders. They were responsible to follow up and to notify an advanced
level provider of abnormal findings. The medical director of the Salt Lake County
Jail, Dr. Todd Wilcox, was the individual who designed the WOWS assessment
protocol specifically for the Salt Lake County Jail. Dr. Wilcox wrote the
following in an article:

. . . . opiate withdrawal is . . . clinically severe and can

frequently result in death if not managed appropriately. . . . In the
modern world, opiate withdrawal is a life-threatening medical
condition. . . . Assessment, including vital signs and self-harm
assessment, should be done twice per day for five days minimum.
Assess for dehydration. Assess for comorbidities including . . .
underlying chronic diseases and malnourishment. . . . Hydrate,
hydrate, hydrate using something that the patients will actually
drink. Obtain lab work on any patients not responding to the basic
protocol. Admit to an inpatient setting if the patient’s clinical
presentation or laboratory results dictate. . . . In my facility, any
patient undergoing opiate withdrawal is assessed twice per day for
a minimum of five days by nurses who have been trained in the
WOWS protocol. The assessment includes a full set of vital signs,
serial tracking of the patient’s clinical progress and interventions

3
Salt Lake County Jail training slide presentation, WOWS, Opiate Withdrawal Issues, SLCo Ostler
025554.

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 CONFIDENTIAL

as necessary based on clinical presentation. . . . [W]e have found

that many of our opiate withdrawal patients are physiologically
fragile and require medical support to withdraw from opiates
safely. Patients with an abnormally low body mass index are
common and they frequently experience extreme distress during
opiate withdrawal.4

The nursing staff of the jail was medically trained and educated to
accurately perform and completely document patient withdrawal assessments,
provide follow up care, and notify an advanced level provider when abnormal
findings occurred. Nursing staff of the Salt Lake County Jail knew what their
responsibilities were for performing drug withdrawal assessments as ordered for
Lisa Ostler. However, The registered nursing staff at the Salt Lake County Jail,
including, at a minimum, Nurses Ron Seewer and Brent Tucker, failed and
refused to provide the most basic assessments that, if performed, would have
revealed Lisa’s progressively serious medical condition and likely saved her life.

Nurses are medically trained to monitor patients competently and must

promptly and effectively communicate changes in status to the physician. The
British Medical Journal found that the overall mortality rate for secondary
peritonitis was just 6%, but mortality rose to 35% in patients who developed
severe sepsis5. Had the nursing staff who came in to contact with Lisa for any
reason performed the assessments her condition and complaints warranted, any
one of the trained medical nurses would have identified that Lisa had a serious
medical condition exclusive of drug withdrawal and was in need of immediate
referral to an advanced level provider. Lisa’s likelihood of survival diminished
substantially with the passage of time since the onset of her symptoms. No one
should die of peritonitis if medical professionals are available.

Nurses provide the first line of care to patients in the jail setting. They are
in the best position to monitor a patient’s condition. Importantly, they are trained
to observe and report changes in the signs and symptoms of a patient. The types
of changes to a patient’s condition that should be reported to an advanced care
provider are numerous and include: bleeding, blood pressure changes, changes in
skin color, cognitive changes, confusion, disorientation, fatigue, heart rate that is
abnormal, loss of body movement or function, neurological changes, oxygen
saturation, pain level and weakness. The nurses report of a condition change must
be timely and give the doctor or advanced provider enough information to
determine the course of treatment. A patient assessment would be required to
obtain enough information to provide sufficient details to a higher level provider.
The nursing staff at the Salt Lake County Jail functioned as gatekeepers for
4
Wilcox MD, Dr. Todd, “Managing Opiate Withdrawal: The WOWS Method”, CorrectCare, printed
Summer 2016.
5
Ross, James T., surgical resident, “Secondary peritonitis: principles of diagnosis and intervention”, BMJ.

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 CONFIDENTIAL

medical services and held all the keys for medical care and patient access to
physician care. Lisa Ostler had to depend upon jail nursing staff for whatever
medical care she received – she had no other options. She also had to depend on
Housing Officers to notify nursing staff of her pain, her signs of medical distress,
and her reasons for medical help.

A training session on "Nursing Documentation" presented by Colby Harris

RN to the Salt Lake County Jail staff described the nurses responsibility for
6

documentation of care and stated: "If it wasn't documented, it wasn't done."

(SLCo Ostler 025554). A training slide in the WOWS presentation began with a
similar statement "Everyone knows 'If it wasn't documented it wasn't done'.''7 The
phrase is a known and often cited adage in the nursing field. Clearly not every
nursing action warrants an entry into the medical record, however documentation
of any significant or potentially significant nurse-patient interaction and patient
care action was to be completed as soon as possible after the care was provided at
the jail. Nurse Harris noted that the times care was provided needed to be correct
and documentation needed to be complete, accurate, organized and concise. The
American Nurses Association (ANA) requires nurses to document relevant data in
a retrievable format. Jail nurses are responsible to practice at a community level
standard of care and must be able to demonstrate that standards of care were met.
Documentation of care provided is essential to verify it occurred and is a standard
measure to identify nursing actions taken on behalf of a patient. The absence of
documentation reveals the failures and refusals of nursing staff to provide
essential care and is particularly revealing in the instance of adverse, preventable
events.

Nurse Colby Harris stated in his training of Salt Lake County Jail nurses
that abnormal vital signs required intervention and disposition. Monitoring of a
complete set of vital signs was required and any abnormalities needed to be
addressed. He addressed the nursing responsibility for conducting a focused
assessment that was based upon the patient's chief complaint and the importance
of researching the issue in the patient's chart. Nursing staff of the Salt Lake
County Jail knew of their responsibilities to completely and correctly document
relevant patient care that was provided to Lisa Ostler in response to her
complaints and to intervene for the abnormalities that occurred. They knew the
importance of conducting a focused assessment to evaluate Lisa’s medical
complaints and requests for medical help yet they failed and refused to afford Lisa
even the most basic nursing interventions.

6
Nursing Documentation slide presentation by Colby Harris RN, Salt Lake County Jail, LCCo Ostler, pp
025286 - 025410.
7
Salt Lake County Jail training slide presentation, WOWS, Opiate Withdrawal Issues, SLCo Ostler
025554.

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 CONFIDENTIAL

Lisa Ostler was available on Unit 8C for required assessments on 4/1 and
4/2. Her location was handwritten on the MAR and on the withdrawal assessment
protocol worksheets. Nursing staff knew her location – it was handwritten on her
medical record when she was transferred from 5C. Lisa was given medication
twice in the afternoon of 4/1 but nurses, including Nurse Ron Seewer, did not
complete required assessments on 4/1 or 4/2. Instead, documentation on the
assessment worksheet reflected that Lisa was not available or not on the unit, a
designation the nurses, including at minimum Nurse Ron Seewer, knew to be
false. They failed and refused to complete required assessments.

Any medically trained licensed registered nurse providing care to a patient

such as Lisa Ostler in a similar circumstance would know the importance and
necessity of performing assessments to evaluate a patient’s health care status.
They would know the importance of following standards of care, facility policies
and procedures, designated protocol, and training directives. Any medically
trained registered nurse would know the importance of following up abnormal
findings such as abnormal vital signs or changes in a patient's condition and of
notifying an advanced care provider for further care directions. Any medically
trained nurse would know that documentation of care provided is essential to
memorialize information about a patient's condition, assessments, and care
provided. Accurate documentation is the basis upon which to ensure the patient’s
health condition and need has been appropriately identified and addressed and
continuity of care provided. Documentation is the nurse's roadmap for outlining
and verifying the patient's care and communicating with other caregivers.
Medically trained registered nurses also know the importance of taking positive
interventions to maintain and promote a patient's health and to prevent
deterioration, degeneration or death.

C. Salt Lake County Jail registered nursing staff including, at a minimum, Nurses
Ron Seewer and Brent Tucker, egregiously breached nursing standards of care for
assessment, identification, intervention and follow up of Lisa Ostler's serious
medical needs. The registered nursing staff including, at a minimum, Nurses Ron
Seewer and Brent Tucker failed and refused to follow required standards of
nursing care and practice. The registered nursing staff including, at a minimum
Nurses Ron Seewer and Brent Tucker, failed and refused to assess Lisa’s
declining medical condition and her pain and failed and refused to refer abnormal
findings to a physician or advanced care provider.

The medically trained, licensed registered nurses at the Salt Lake County
Jail failed and refused to complete the CIWA and WOWS assessments as required
for Lisa Ostler. They failed and refused to respond to Lisa Ostler's requests for
medical attention and failed and refused to conduct essential assessments to
evaluate her medical needs. They did not respond to abnormal findings present

22
 CONFIDENTIAL

during the assessments they did conduct and, in fact, provided no interventions
whatsoever to address Lisa's rapidly declining health condition. They failed and
refused to see Lisa in response to officer reports that she requested to see medical.
They failed and refused to notify an advanced care provider about abnormal vital
signs. On 4/1 PM and 4/2 AM, within the last hours of Lisa's life they failed and
refused to conduct any assessments at all. They recorded she was not available or
not on the unit but knew she was in her cell and had not left the unit. Lisa's
medication administration record verifies she was available as she was given
medication by nursing staff on two occasions on Unit 8C. The nurse responsible
to conduct the PM assessment knew it needed to be done and refused to complete
it or arrange for another nurse to complete it.

Any medically trained licensed registered nurse, who was not deliberately
indifferent to a person’s serious medical needs, conducting an assessment on 4/1,
just before Lisa spent a night repeatedly calling out for medical help and was
subsequently found unresponsive and not breathing in her cell, would have noted
her grave appearance, would have been prompted to ask about her health, and
would have conducted a focused assessment. Medically untrained inmates
(laywomen) on the unit with Lisa observed her and were able to identify that she
badly needed medical help. Registered nurses had contact with Lisa at least 6
times on 3/31 and 4/1 to administer medication and three times to perform
withdrawal assessments. Vital signs on the two withdrawal assessments on 3/31
were abnormal. Any medically trained nurse providing care in a similar
circumstance to that of providing care to Lisa Ostler could have identified her
worsening condition by reviewing her medical record, monitoring her vital signs,
observing her appearance and behavior, by talking with her, and by performing a
very basic physical or abdominal exam based on Lisa's report of pain. A pain
assessment and physical exam are basic skills that any registered nurse would
know to perform yet none of the nurses at the Salt Lake County Jail conducted
any basic focused assessment or exam to assess her complaints or requests for
medical help. The nurses failed and refused to perform essential assessments for
Lisa that were indicated and obviously needed based upon her clinical condition,
appearance, and requests for medical care.

The failure and refusal to note Lisa's dramatic physical deterioration,

worsening appearance, outward indications of pain, or marks all over her body
over the course of several encounters and alleged withdrawal assessments reflects
the nurses' failure and refusal to repeatedly and appropriately recognize and
document Lisa's medical needs. For the medical needs that were documented,
Lisa was not provided essential, basic care. Several nurses at the jail were in
contact with Lisa for intake, withdrawal assessments, medication administration
and at the request of officers, yet NOT ONE of them took any action to address
her medical needs (including not having any of her prescribed medications),
abnormal vital signs, physical appearance of deterioration, and symptoms of

23
 CONFIDENTIAL

serious illness or pain. Any medically trained nurse providing care to Lisa Oster
in a similar circumstance would know that patients with suspected or potential
drug withdrawal could also have an unrelated serious medical condition and
should be assessed to rule out the presence of potential urgent or emergent
conditions. Any medically trained nurse would know that abnormal findings and a
patient’s urgent or emergent health needs must be reported to an advanced care
provider. The jail nurse functions as chief gatekeeper to advanced medical care. If
the nurse fails or refuses to permit access to medical care, the inmate simply does
not receive it.

Any medically trained registered nurse working in the jail environment

knows they must respond to an inmate's request for medical attention in a timely
manner. When a clinical symptom such as bleeding or pain is reported or when
an inmate stated they need medical help, a face-to-face assessment must be
conducted by a nurse, who are the members of staff who are supposed to be
qualified and available to evaluate patient health status. Determination of the
seriousness of a patient's medical concern must be made by a qualified medical
person and may not be ignored or delegated to a non-medical unqualified staff
person. Nursing staff was the only qualified staff that could have seen Lisa and
obtained essential care for her serious medical condition yet they did not see her
to assess her status, they did not provide care and did not obtain care for her until
she was unresponsive and not breathing on the morning of 4/2.

The "Notes (Intervention documentation)" section on Lisa Ostler's WOWS

protocol worksheet, designed for nurses to document the positive interventions
they took to save a patient's life was BLANK. In fact, not one nurse over the
course of 4 days and 7 assessment events from 3/30 through 4/2 documented a
single positive intervention they took to save Lisa's life.

OPINION #2: The registered nursing staff of Salt Lake County Jail, including, at a
minimum, Nurses Ron Seewer, Brent Tucker, and Brad Stoney, so breached
professional standards of nursing care and their duty to act as any medically
trained nurse would have acted in a similar circumstance to that of providing or
ensuring care to Lisa Ostler by knowingly refusing and failing to take actions to
ensure that her prescribed medication regimen was evaluated to ensure continuity
of care for her serious medical needs. Those breaches were so egregious that their
actions, failures to act and refusals to act cannot have been the result of the exercise
of professional nursing judgment. Those breaches were caused by a widespread
practice and custom of deliberate indifference toward the serious medical needs of
patients, generally, which resulted in the deliberate indifference toward the serious
medical needs of Lisa Ostler, specifically.

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 CONFIDENTIAL

Basis for Opinion #2

A. Salt Lake County Jail registered nurses including, at a minimum, Nurses Ron
Seewer, Brent Tucker, and Brad Stoney, failed and refused to ensure that Lisa
Ostler's medication regimen was evaluated, continued, or that a disposition of her
prescribed medication was made by a qualified advanced level provider.

Along with being placed on withdrawal protocol assessments, Lisa Ostler

was prescribed a Librium medication taper for withdrawal symptoms and Prilosec
for gastric reflux. Her prescribed medications for PTSD, Depression, Anxiety,
Rectal Neuropathy, ADD, Arthritis, and Insomnia were referred to mental health
staff for review and not ordered even though they had been verified. No
medication for Crohn’s disease or Arthritis was provided.

No evidence suggested that any appointment with a mental health provider

was scheduled to follow up on ordering the medications that had been deferred.
The one medication, Prilosec, actually ordered for Lisa Ostler, was never
administered – she did not receive a single dose. There is no evidence, whatsoever,
that any assessment of Ms. Ostler’s medical conditions was completed to determine
the impact of the sudden cessation of ALL of her prescribed medications.

According to Dr. Ross J. Baldessarini, professor of psychiatry and

neuroscience at Harvard Medical School and director of the psychopharmacology
program at the McLean Division of Massachusetts General Hospital: “Stopping
[medication] abruptly is especially dangerous,” Baldessarini stated. "Depending
on the medicine, stopping abruptly or 'cold turkey' can cause a variety of
distressing reactions, ranging from mild to moderate early discontinuation
symptoms with antidepressants, rapid return of the illness being treated, or even
potentially life-threatening seizures with a high dose of benzodiazepines."8

Individuals entering jail are suddenly separated from their routine care and
may be separated from their medication. One function of the jail intake screening
is to identify patients with chronic diseases to ensure timely continuity of
treatment. A patient with chronic disease requires prompt physician attention,
especially for prescribing required medications. Immediate post-booking
physician-directed evaluation and re-institution of therapy for patients with
chronic illness is needed.9

8
Tartakovsky, Margarita M.S., Discontinuing Psychiatric Medications: What You Need to Know,
October 8, 2018.
9
Puisis, Michael, D.O., and John M. Robertson, M.D., M.P.H., Chronic Disease Management, Clinical
Practice in Correctional Medicine.

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 CONFIDENTIAL

The Salt Lake County Jail Medical Director, Todd Wilcox, MD, presented
a list of "critical commandments" at NCCHC's Correctional Health Care
Leadership Institute designed to help correctional medical directors and
administrators deal with difficult institutional problems that impact health care
services. The "Critical Commandments in Correctional Health Care" appeared as
a 3-Part Series in the NCCHC Journal, CorrectCare. His presentation included a
commandment for dealing with medication continuation: "Thou Shalt Ensure
Continuity of Care for Medication From Booking" and identified an approach
to ensure the disposition of all medications within 24 hours and of critical
medications immediately".10

No decision other than deferral or discontinuation was made about Lisa

Ostler's medication regimen, with the exception of Prilosec (which she never
received) at any time during her detention in the Salt Lake County Jail much less
immediately or within 24 hours. No evaluation was ever done to determine
whether any of her medications were critical for continuation. No advanced level
prescriber ever addressed continuity of care regarding her prescription medication
despite this being a "critical" commandment in correctional health care handed
down by the jail medical director.

Salt Lake County Jail staff training materials stated that verified
medication information was forwarded to the on-call provider for ordering.11 Lisa
Ostler's verified medication was forwarded to Dr. Brad Lewis who ordered
Prilosec 40 mg daily but deferred all the rest of her medication to mental health.
The deferred medications were never reviewed by mental health. The Prilosec that
Dr. Lewis ordered was never administered despite the Salt Lake County Jail
Pharmacy "stocking approximately 200 different medications" and having "access
to virtually every medication currently available."12

B. Salt Lake County Jail registered nursing staff, including, at a minimum, Nurses
Ron Seewer, Brent Tucker, and Brad Stoney, knew of their responsibility to
facilitate continuation of Lisa Ostler's medication and failed and refused to take
any action to ensure her medications were reviewed or continued.

Any medically trained licensed registered nurse knows the importance of

continuing medication prescribed for a patient's serious medical condition and
would know that abrupt cessation of ALL medications for a patient such as Lisa
Ostler who had multiple known serious medical and mental health needs could
result in withdrawal and decline in the patient’s physical and mental health. The

10
Wilcox, Todd, MD, MBA, CCHP-A, CorrectCare, Critical Commandments in Correctional Health Care:
Part 1, Part 2, Part 3, Spring, Summer, Fall 2013.
11
Salt Lake County Jail training program, Medication Administration, Brett Clement RN, p SLCo 025183.
12
Ibid., SLCo, p 025182.

26
 CONFIDENTIAL

nurses at Salt Lake County Jail knew that not providing any of Lisa's prescribed
medication could be dangerous and should be immediately evaluated by an
advanced level prescriber. Any medically trained nurse providing care in a similar
circumstance to that of providing care to Lisa Ostler would know the importance
of medication adherence and continuation of prescribed medication for serious
chronic medical and mental health conditions.

C. Salt Lake County Jail registered nursing staff, including, at a minimum,

Nurses Ron Seewer, Brent Tucker, and Brad Stoney, nursing staff did nothing to
ensure the continuity of prescribed medication for Lisa Ostler. One medication
that was ordered for Lisa was never given.

Registered nursing staff of the Salt Lake County Jail, including, at a

minimum, Nurses Ron Seewer, Brent Tucker, and Brad Stoney, refused to ensure
continuation of Lisa's medication that had been prescribed for her prior to her
detention. Any medically trained nurse providing care for a patient such as Lisa
Ostler in a similar circumstance would know the importance of continuity of care
regarding medication prescribed for serious medical needs. The nursing staff
failed and refused to take any action to arrange for a medical or psychiatric
medication review in a timely manner to determine whether Lisa’s medications
should be continued or safely discontinued. When Dr. Brad Lewis deferred Lisa's
medication to mental health for review no nurse contacted a psychiatrist or mental
health advanced care provider to review or determine which of Lisa's medications
should be continued, substituted, or safely tapered and discontinued despite the
medical director of the jail describing the need to ensure disposition of
medications immediately or within 24 hours as a "critical commandment" in
correctional health care. There is no indication that any nurse took any measures
to assess the impact of abrupt cessation of Lisa's medication on her health and
safety when all of her medications were suddenly stopped. The nursing staff did
nothing to ensure that Lisa was continued on essential medication or safely
discontinued from medication that would not be ordered. There is no rationale in
the record to explain the delay or the failure to arrange for a medication review
and reasonable disposition of her medication regimen.

OPINION #3: The Salt Lake County Jail registered nursing staff, including, at a
minimum, Nurses Ron Seewer, and Brent Tucker breached professional standards
of nursing care and their duty to act as any medically trained nurse would have
acted in a similar circumstance to that of providing or ensuring care to Lisa Ostler
by knowingly failing and refusing to conduct any pain assessment despite Lisa's
appearance, complaints of pain, and requests for medical care. Those breaches were
so egregious that their actions, failures to act, and refusals to act cannot have been
the result of the exercise of professional nursing judgment. Those breaches were

27
 CONFIDENTIAL

caused by a widespread practice and custom of deliberate indifference toward the

serious medical needs of patients, generally, which resulted in the deliberate
indifference toward the serious medical needs of Lisa Ostler, specifically.

Basis for Opinion #3

A. Salt Lake County Jail registered nursing staff, including, at a minimum, Nurses
Ron Seewer and Brent Tucker, failed and refused to conduct any pain assessment
of Lisa Ostler despite numerous indications that she had pain and requested
medical attention on numerous occasions.

No medical record documentation, including the pre-screen examination

and nursing comprehensive examination, reflected that Lisa Ostler was ever
assessed in any way for pain. Lisa Ostler was never asked about pain, monitored
for pain symptoms, or assessed for pain even (1) when she complained of pain
and requested medical attention; (2) when she outwardly demonstrated the
presence of pain by holding her abdomen and walking slowly in a bent over
position, did not leave her cell, was inactive and not moving; (3) when other
inmates reported she was crying out for help and needed medical attention; or (4)
when she pressed the emergency call button in her cell at least 16 times during the
night of 4/1 through the morning of 4/2 to request medical help for pain.

No pain medication was provided for Lisa Ostler at any time during her
detention at Salt Lake County Jail despite her being on pain medication before she
was detained. No medication for Crohn’s disease or Arthritis was provided. No
evidence suggests that any consideration was given to ordering pain medication
that would have been acceptable for use in the jail setting to substitute for the pain
meds Lisa had been taking. Review of medical records for other inmates revealed
that certain inmates received pain medication as well as follow up for abdominal
pain (Medical record of , SLCo Ostler, pp 029170, 029213,
029219, 029221, 029247, 029326).

Dr. Todd Wilcox’s, presentation of a list of "critical commandments" at

for correctional health care previously referenced included a commandment for
dealing with pain: "Thou Shalt Deal With Pain in a Reasonable, Modern
Way”. Good faith management of pain requires a good history and an
excellent physical exam. The Joint Commission standards for pain management
may be useful. The “no opiates in custody” policy is unreasonable and out of
sync with current medical standards of care. It is important to distinguish between
addiction and pseudo addiction. Acute pain management may involve Tylenol,
nonsteroidal agents and short-acting opiates such as Lortab."

There was no indication that any staff person, including Dr. Brad Lewis or
any nurse attempted to identify the reason Lisa was on pain meds, the

28
 CONFIDENTIAL

characteristics of her pain or her pain level despite this being a "critical"
commandment in correctional health care handed down by the jail medical
director. There was no documentation or evidence to suggest that Lisa was ever
assessed for pain at any time even when she was screaming, moaning, crying out,
requesting medical help, pressing her emergency call button at least16 times
throughout the night on 4/1, and when pleas from other inmates were received
about her horrific appearance and her need for medical help.

Standard nursing practice in response to complaints of abdominal pain is

to obtain a history of the pain and, at minimum, palpate the abdomen. Any
medically trained nurse would be aware of this standard practice, which, if
performed, would have obviously indicated Lisa Ostler required urgent follow up
that would have likely saved Lisa Ostler’s life.

Despite Lisa Ostler complaining of pain, remaining in her cell in a

crunched up position holding her abdomen, refusing meals, not taking adequate
fluids, holding her abdomen while walking in a bent over posture whenever she
was out of her cell, there is no documentation to suggest that any nurse evaluated
or attempted to evaluate Lisa Ostler at any time regarding pain, a pain level, or for
a cause for her complaints or appearance. As a result, the peritonitis that she was
actually experiencing went unaddressed and undiagnosed. Her complaints of pain
alone warranted an immediate assessment.

Lisa's medical history of Crohn’s disease and arthritis simply added to the
obvious need for a nursing evaluation since her medications for those conditions
were abruptly discontinued and she was not approved to receive any of the pain
medications previously prescribed to her. She was also not prescribed any
alternative medications for those conditions. No nurse evaluated Lisa when she
was screaming, moaning, crying out, pressing the emergency button in her cell at
least 16 times during the night of 4/1, when other inmates requested medical
assistance for her, or when nursing staff was notified by officers that she
requested medical attention, had not eaten, and was bleeding.

Lisa Ostler was seen by the mental health worker, Jamie Facholas, who
documented that Lisa had visible marks all over her body. Entries on the
Comprehensive Nursing Examination indicate she had a significant history of
victimization including violent abuse/assault, domestic violence, sexual
abuse/assault/rape, and PTSD secondary to victimization. There is no indication
to suggest that any nurse, after Lisa Ostler was booked into the Salt Lake County
Jail, conducted a physical exam to determine if she arrived at the jail with a pre-
existing injury, any internal injuries or whether she sustained an injury while
housed on Units 5C or 8C that would have explained the presence of visible body

29
 CONFIDENTIAL

marks all over her body. Nursing documentation did not mention any marks or
bruising or that they conducted any evaluation sufficient to identify any
physical abnormalities in Lisa’s health.

Several inmates on Unit 8C were aware of Lisa's desperate medical

situation and attempted to inform housing unit officers of her need for medical
care. As laywomen, the inmates recognized Lisa needed medical care and her
verbalizations of pain were inconsistent with any drug withdrawal they had ever
seen or experienced. The nursing staff that was informed she was in pain failed
and refused to conduct any pain assessment, refused to perform any focused
assessment and refused to perform any hands-on assessment to verify, identify or
address her complaints of pain. In fact, the nurses that were informed she was in
pain and had requested medical attention failed and refused to conduct any
assessment whatsoever. No documentation in Lisa's medical record suggested
that any nurse conducted an assessment for pain or tried to identify the nature of
her medical concerns. The decisions to ignore complaints of pain and refusals to
conduct any pain assessment at all was an intentional action that any medically
trained nurse would recognize as an unprofessional breach of nursing standards
and duty to their patient.

B. Salt Lake County Jail registered nursing staff, including, at a minimum, Nurses
Ron Seewer, and Brent Tucker, knew of their responsibility to conduct pain
assessments and failed and refused to take any action or make any attempts
to assess Lisa Ostler for pain.

Pain is the most common nursing diagnosis in all delivery-of-care models;

therefore, the assessment and management of pain is within the purview of every
professional registered nurse (RN).13 Addressing patients' pain is a primary
nursing responsibility.14

Standards of nursing practice require nurses to conduct a careful physical

assessment when they assess patients. They are not merely assessing and treating
minor health complaints, but must screen for the possibility of more serious health
problems that need advanced provider intervention.15 When Lisa received PRN
(as needed) medication for nausea (Phenergan) and diarrhea (Imodium) during the
CIWA/WOWS protocol assessments on 8 occasions, the level of clinical
assessment and decision making at those times required the registered nurse to be
mindful for conditions other than drug withdrawal. Nurses must be

13
American Nurses Association, Scope and Standards of Practice, Pain Management Nursing, 2005.
14
American Nurses Association, "The state of pain", The American Nurse, Official Publication of the
American Nurses Association, January, 2014.
15
Smith, Sue, MSN, RN, "The Nurse Is In: Designing Effective Nursing Sick Call Guidelines",
CorrectCare, Summer 2009.

30
 CONFIDENTIAL

capable of critical thinking and have an ability to draw on their expert

knowledge to determine if different or additional information is needed. The
nurse must be prepared to include additional assessment data, consider different
nursing diagnoses, and develop a plan of care that addresses any additional
problems.

Poor appetite, nausea, vomiting, diarrhea, and a dull abdominal ache or

tenderness that quickly turns into persistent, severe abdominal pain that is
worsened by any movement or touch can be symptomatic of a number of acute
abdominal conditions including peritonitis. Crohn's disease can lead to peritonitis.
Clearly, a physical assessment would identify abdominal ache, tenderness, and
severe pain worsened by movement or touch. Any medically trained registered
nurse providing care to a patient such as Lisa Ostler in a similar circumstance
would know the importance of conducting a careful and thorough patient
assessment to ensure that the presence of a serious health problem was identified
and not missed. Hence, the failure to conduct a careful and thorough patient
assessment must have been a product of deliberate indifference toward the serious
medical condition suffered by Lisa Ostler.

C. Registered nursing staff at the Salt Lake County Jail, including, at a minimum,
Nurses Ron Seewer and Brent Tucker, failed and refused to assess Lisa for pain or
ensure pain management.

Not one nurse at the Salt Lake County Jail conducted a pain assessment or
made any appropriate referral for a pain assessment for Lisa Ostler. They not
only did not conduct a careful or thorough assessment for pain, they did not
conduct an assessment at all despite outward signs that Lisa was in pain, reports
of other inmates appealing for medical attention for her, her own cries for
medical help, and officers reporting her calls for help and requests to see medical.

OPINION #4: The registered nursing staff of the Salt Lake County Jail, including,
at a minimum, Nurses Ron Seewer and Brent Tucker breached professional
standards of nursing care and their duty to act as any medically trained nurse
would have acted in a similar circumstance to that of providing or ensuring care to
Lisa Ostler by knowingly failing and refusing to assess Lisa Ostler for signs and
symptoms of dehydration and ensuring adequate hydration for a patient
undergoing drug withdrawal. Those breaches were so egregious that their actions,
failures to act, and refusals to act cannot have been the result of the exercise of
professional nursing judgment. Those breaches were caused by a widespread
practice and custom of deliberate indifference toward the serious medical needs of
patients, generally, which resulted in the deliberate indifference toward the serious
medical needs of Lisa Ostler, specifically.

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 CONFIDENTIAL

Basis for Opinion #4

A. The Salt Lake County Jail registered nurses, including, at a minimum, Nurses
Ron Seewer and Brent Tucker, failed and refused to assess Lisa Ostler for signs
or symptoms of dehydration and refused to provide adequate hydration to her.

A Salt Lake County Jail staff training program for opiate withdrawal
issues emphasized early intervention for vomiting and diarrhea, aggressive lab
monitoring, aggressive monitoring for fragile patients and emphasized the
identification of dehydration or elements leading up to dehydration as a strategy
for prevention. Nursing staff of the Salt Lake County Jail knew of their
responsibilities for early identification of dehydration and taking measures to
prevent a patient in a fragile condition, such as Lisa Ostler, from worsening.

Dr. Todd Wilcox stated in his article: “The primary focus of WOWS is to
identify clinical scenarios that cause dehydration and electrolyte abnormalities”.
He noted that “a targeted assessment for clinically relevant dehydration became
the focus of the WOWS protocol” at the Salt Lake County Jail and made a point
of stressing “Hydrate, hydrate, hydrate using something that the patients will
actually drink”.16

The CIWA and WOWS assessments conducted by nursing staff reflected

that Lisa Ostler was provided with just two bottles of Gatorade in four days. It
was possible she received one additional bottle of Gatorade as the mental health
professional that saw her on 3/31/2016 noted three bottles of Gatorade in Lisa’s
cell, though one was spilled on the floor. Other than responding to the clothing
exchange, Lisa did not leave her cell while in Unit 8C, therefore would not have
accessed fluids that may have been provided on the unit. She was refusing meals
and likely did not intake any fluids that may have been provided at mealtimes.
Based on the evidence on the CIWA and WOWS assessment forms that Lisa was
only provided two bottles of Gatorade, any medically trained nurse would know
she was at serious risk for dangerous levels of dehydration.

On 3/31/16, Lisa was disoriented and told the Housing Unit Officer she
was supposed to meet someone to go to a wedding. When the mental health
worker, Esther Israel spoke with her briefly, Lisa said she was involved in a
“murder-suicide” and sometimes lived in the past. Ms. Israel noted she was
oriented to place, however made no mention of her orientation to person, date,
time or circumstance. Ms. Israel noted the three bottles of Gatorade in the cell,
one of which was spilled on the floor.

16
Wilcox MD, Dr. Todd, “Managing Opiate Withdrawal: The WOWS Method”, CorrectCare, printed
Summer 2016.

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 CONFIDENTIAL

Disorientation, confusion, fatigue and sleepiness are symptoms of

dehydration. A drop in blood pressure and oxygen saturation can signal
impending low blood volume shock, one of the most serious and sometimes life-
threatening complications of dehydration. Low blood volume causes a drop in
blood pressure and a drop in the amount of oxygen in the body.17 Lisa Ostler’s
blood pressure declined from an initial reading of 115/75 on 3/30/2016 to 89 /68
on 3/31/2016.

The registered nursing staff at Salt Lake County Jail, including, at a

minimum, Nurses Ron Seewer and Brent Tucker, knew that Lisa was only
provided two bottles of Gatorade and was not eating. The information about
Gatorade provided was recorded on the withdrawal assessments; housing unit
staff notified nursing staff that Lisa was not eating meals. The nurses failed and
refused to assess Lisa for dehydration.

Despite the reported emphasis placed on hydration at the Salt Lake County
Jail, the CIWA and WOWS protocol assessments documented that Lisa Ostler
may have been given a bottle of Gatorade on 3/31/2016 AM and one on
3/31/2016 PM. There is no indication, suggestion, or documentation to suggest
that any nurse evaluated Lisa Ostler at any time for hydration status or conducted
any assessment of her for dehydration. Severe dehydration requires immediate
medical treatment. A doctor should be consulted in cases where an individual has
diarrhea for 24 hours or more, is disoriented, is much sleepier or less active than
usual, can't keep fluids down or has bloody or black stool. No evidence suggests
that any nurse evaluated Lisa Ostler's lack of fluid intake, disorientation, or
decreased activity to determine if she was medically compromised in any way. No
evidence suggests that any nurse evaluated reports that Lisa was bleeding.

Clinical symptoms of drug withdrawal, dehydration, and more serious

conditions such as peritonitis can overlap. For this reason, a face-to-face, hands-
on nursing assessment is paramount to identifying the symptoms, potential cause,
and the appropriate level of care required. Nursing staff failed and refused to
conduct any assessments of Lisa Ostler.

B. The registered nursing staff at the Salt Lake County Jail, including, at a
minimum, Nurses Ron Seewer and Brent Tucker, knew of their responsibility to
assess Lisa Ostler for dehydration and take measures to prevent dehydration.

Any medically trained licensed nurse would know the importance of

adequate nourishment and hydration, particularly with a patient that is

17
Mayo Clinic, Patient Care & Health Information, Diseases & Conditions, Dehydration.

33
 CONFIDENTIAL

underweight, not eating, and not being provided adequate hydration. Any
medically trained nurse would know that two bottles of Gatorade over a period of
more than 3 days is insufficient to ensure adequate hydration and would know
that a patient such as Lisa that was not consuming the Gatorade given was at a
high risk for severe dehydration. The nursing staff of Salt Lake County Jail failed
and refused to ensure that Lisa Ostler was adequately hydrated. An assessment to
follow up on hydration status would have informed any nurse that Lisa Ostler was
at risk. An assessment to identify whether her mucous membranes were dry or
moist, whether her skin turgor was good or poor, and whether her mental status
was within normal limits or not would have revealed her worsening physical
status and would also have provided Lisa an opportunity to discuss the abdominal
pain she experienced related to the condition that ultimately resulted in her
becoming unresponsive and not breathing 24 to 36 hours later. Hospital records
later revealed minimal urine output, just 5 ml. of cloudy, dark, yellow urine from
a Foley catheter that was inserted, demonstrative of severe dehydration (Ostler
001274, 001258). While jail nursing staff would not have known the miniscule
amount of urine in Lisa's bladder, any physical assessment would have alerted
them to dry mucous membranes, dry skin with poor turgor, confusion,
disorientation, minimal intake and severe abdominal pain.

Any medically trained registered nurse would know the importance of

conducting a focused assessment to follow up mental status changes, reduced
intake, and changes in vital signs that could signal development of a more serious
condition. The nurses working at the Salt Lake County Jail knew that a
significant emphasis was placed on hydration, assessing for comorbidities
including underlying chronic diseases and malnourishment as these were
significant clinical “Takeaway Points” made by their medical director, Todd
Wilcox, in his description of the WOWS Clinical Assessment protocol. Yet no
assessment whatsoever was performed by any of the jail nurses.

C. The registered nursing staff at the Salt Lake County Jail, including, at a
minimum, Nurses Ron Seewer and Brent Tucker, failed and refused to assess and
took no actions to prevent dehydration for Lisa.

The registered nursing staff at the Salt Lake County Jail, including, at a
minimum, Nurses Ron Seewer and Brent Tucker, took no action to assess Lisa's
mental status, hydration status, food or fluid intake and refused to conduct any
assessment for an underlying disease process. Any medically trained registered
nurse would know that a change in a patient’s mental status or vital signs over the
course of monitoring them for a serious and potentially life-threatening condition,
such as drug withdrawal, would require a focused assessment to determine
potential causes and determine the level of care required for treatment.

34
 CONFIDENTIAL

The nursing staff at no time took any action to institute any checks for
dehydration such as orthostatic blood pressure to identify changes and took no
action to contact an advanced level provider to determine if urine specific gravity,
electrolytes, BUN, or creatinine should be checked. Lisa's weight was never
rechecked to determine if additional weight loss occurred during detention or if
her BMI dropped to a level below 18 when additional monitoring would have
been clearly indicated. Nursing staff failed and refused to reassess Lisa's clinical
status at any time. Orthostatic blood pressures had been done on other inmates,
but were not done for Lisa (Medical record of , SLCo Ostler
029163).

OPINION #5: The registered nursing staff of the Salt Lake County Jail, including,
at a minimum, Nurses Ron Seewer and Brent Tucker, breached professional
standards of nursing care and their duty to act as any medically trained nurse
would have acted in a similar circumstance to that of providing or ensuring care to
Lisa Ostler when they failed and refused to address her meal refusal and nutritional
status. Those breaches were so egregious that their actions and refusals to act
cannot have been the result of the exercise of professional nursing judgment. They
had to have known of the risks of suffering or death resulting from their failures to
address Lisa Ostler’s nutritional status, yet they still failed to address it. Those
breaches were caused by a widespread practice and custom of deliberate
indifference toward the serious medical needs of patients, generally, which resulted
in the deliberate indifference toward the serious medical needs of Lisa Ostler,
specifically.

Basis for Opinion #5

A. Salt Lake County Jail nurses failed and refused to assess Lisa Ostler, an inmate
identified with weight loss, potential drug withdrawal, and Crohn's Disease for
not eating meals and, in fact, completely dismissed the issue without conducting a
face-to face assessment when the concerns were brought to their attention by a
housing unit officer.

Housing Officer Unit logs reflected that Lisa refused meals from, at
the latest, dinner on 3/30/2016 until she was found unresponsive and not
breathing on 4/2/2016. On 4/1/2016 at 11:30 AM the Housing Officer recorded
that Lisa Ostler was sick and refused lunch. Multiple inmates reported that she
had not eaten any meals since being transferred to Unit 8C on 4/1/2016 at
approximately 10 AM. Registered Nurse Brent Tucker was informed by Officer
Frederickson that Lisa had not been eating and stated it would not be a
concern until she had not eaten for 72 hours. There is no evidence that any

35
 CONFIDENTIAL

housing officer or nursing staff attempted to talk with Lisa Ostler about her not
eating or attempted to determine how long it had actually been since she last ate.
There is no evidence that Nurse Tucker attempted to determine how long Lisa had
not been eating. He verbalized an absence of any concern about her nutritional
status or intake without attempting to verify or obtain any information about
Lisa's failure to eat meals.

Declining meals for 2-3 days is concerning. However, when accompanied

by not drinking adequate fluids, weight loss, low BMI, abdominal pain, nausea,
diarrhea, a deteriorating physical appearance and condition, and requests for
medical help, failure to eat meals is dangerous and warrants, at a minimum, a
face-to-face patient assessment to try to identify the cause. Lisa's Body Mass
Index (BMI) at the time she was booked into the Salt Lake County Jail was 18.3.
According to Todd Wilcox, MD, inmates at the Salt Lake County Jail were given
heightened scrutiny when their BMI was <18. The Centers for Disease Control
(CDC) and Prevention cite a BMI of 18.5 as "underweight". There is no evidence
that any concern or attention was paid to Lisa being very close to the Salt Lake
County Jail cutoff for BMI when she was noted to be refusing meals or that any
consideration was paid to her low body weight in the context of abdominal pain,
gastrointestinal symptoms, abnormal vital signs, or her requests for medical
attention.

A training program prepared for the Salt Lake County Jail nursing staff
on opiate withdrawal specifically stated that many opiate users were metabolically
fragile with low Body Mass Index and limited physiological reserves.18 The
approach identified was to try to recognize these patients in booking. Lisa Ostler
was not identified with a low BMI at any point in her jail detention despite
being identified at booking with weight loss and Crohn's Disease, and later
repeatedly refusing meals and declining physiologically. Training information
identified "A low BMI is a risk factor for a bad outcome to occur more quickly.
These patients don't have the physiological reserves to handle opiate withdrawal
symptoms as well."19 A patient with a low BMI would also not have the
physiological reserve to handle an acute abdominal infection and pain without
timely medical support that took her risk factors and symptoms seriously.

It is essential for patients with Crohn's Disease to maintain good nutrition.

Crohn’s Disease can reduce appetite while increasing the body’s energy needs.
Crohn’s symptoms like diarrhea can reduce the body’s ability to absorb
protein, fat, carbohydrates, as well as water, vitamins, and minerals. It would be
prudent for a registered nurse to assess a patient with Crohn's Disease who was
not eating, was noted to have weight loss, was low weight and was not receiving

18
Salt Lake County Jail, WOWS training program, SLCo Ostler 025525.
19
Ibid, SLCo Ostler 025535.

36
 CONFIDENTIAL

any previously prescribed medication for control of the disease to determine a

cause for not eating and identify their nutritional and physical status.

After Lisa Ostler’s death, Nurse Tucker submitted a note in which he

stated he reviewed her medical record after learning she was not eating and was
bleeding. He assumed her withdrawing from alcohol and drugs explained why she
may not want to eat. There was no indication that Nurse Tucker or any other
nurse took any action to assess Lisa's specific situation or identify why Lisa Ostler
was not eating. Nothing in Lisa Ostler's medical record justifies Tucker's belief
that Lisa was withdrawing from alcohol and her drug withdrawal scoring was
very low. The symptoms presented to Nurse Tucker of not eating and bleeding
required an immediate face-to-face assessment. Additionally, abnormal vital signs
recorded on the CIWA and WOWS assessments should have further prompted
Tucker to follow up with a face-to-face encounter and assessment of Lisa's
condition however there is no indication that he viewed abnormal vital signs, not
eating in the context of a low BMI, and not being hydrated with any concern
whatsoever. Tucker's refusal and failure to assess Lisa when he reviewed her chart
and knew that she was displaying clinical symptoms was a breach of the clear
requirement to conduct a face-to-face assessment when clinical symptoms were
present. He triaged Lisa's not eating and bleeding reported to him by a non-
medical unit officer over the telephone solely upon information he gleaned from
Lisa's medical record. He conducted a "paper triage".

One of the "critical commandments" outlined by Dr. Todd Wilcox, in his

presentation previously mentioned in this report included a commandment dealing
with ensuring that all prisoner health requests are triaged properly: "Thou Shalt
Ensure All Prisoner Health Requests Are Triaged Properly."20 He stated: "To
conduct triage a proper scope of license is required".21 This statement confirmed
that triage of Lisa's complaints could not be completed by a housing unit officer
or other staff that was not medically qualified to perform triage of health requests.
He went on to say "All five vital signs must be completed through face-to-face
triage; paper triage is not safe or effective and should not be used."22 Yet nursing
staff, specifically Nurses Brent Tucker and Colby James, refused to appropriately
triage Lisa's health requests despite this being a "critical" commandment in
correctional health care handed down by the jail medical director. Nurse Brent
Tucker used an unsafe and ineffective paper triage to address, or refuse to
address, Lisa's concerns.

20
Wilcox, Todd, MD, MBA, CCHP-A, CorrectCare, Critical Commandments in Correctional Health Care:
Part 1, Part 2, Part 3, Spring, Summer, Fall 2013.
21
Ibid.
22
Ibid.

37
 CONFIDENTIAL

B. Registered nursing staff at the Salt Lake County Jail, including, at a minimum,
Nurses Ron Seewer and Brent Tucker, knew the importance of ensuring adequate
nutrition for a patient with a history of weight loss and low weight who was
undergoing drug withdrawal. They would know a patient with Crohn's Disease
presented additional concerns for gastrointestinal co-morbidity.

Todd Wilcox, Salt Lake County Jail medical director stated that an
effective withdrawal screening and management program included assessments
with attention to orthostatics, clinical signs and comorbidities.23 Nursing staff did
not at any time evaluate orthostatic blood pressures for Lisa Ostler, and did not at
any time consider co-morbidities. In fact, their care and management of Lisa's
health care included no assessment or follow up of her abnormal vital signs, no
evaluation of her clinical signs or symptoms, and no assessments with any
attention to potential comorbidities whatsoever. Their refusal to consider Lisa's
presenting appearance, clinical signs and symptoms, and complaints resulted in
wholly inadequate assessment, monitoring, and care by nursing staff.

Determination of the seriousness of a patient's medical issues must be

made by a qualified medical person and may not be ignored or delegated to a non-
medical staff person. The determination about a patient's meal refusal, lack of
intake, and the potential adverse effects cannot be left to a housing unit officer
for evaluation. Nursing assessment is required when an issue that could affect
a patient's health is presented.

Any medically trained licensed nurse knows the importance of adequate

nourishment particularly with a patient that is underweight, not eating and being
monitored for drug withdrawal. There is no evidence in Lisa Ostler's medical
record that she had any food intake since being booked into the jail.

Any medically trained registered nurse providing care to a patient such as

Lisa Ostler in a similar circumstance would know the importance of conducting a
focused assessment to follow up on an officer's report to them of an inmate's
refusal of meals, repeated calls for assistance, and vaginal bleeding in the context
of concurrent drug withdrawal. Any medically trained registered nurse would
know that this constellation of symptoms could signal the presence or
development of a more serious condition. Any nurse should have been able to see
in Lisa Ostler’s medical record that she had abnormal vital signs, nausea and/or
vomiting and diarrhea, a history of weight loss, no menstrual periods, and
previous GI surgeries. Any medically trained registered nurse would know that
the constellation of symptoms and Lisa's history could signal the presence or
development of a more serious condition - a comorbidity. Any medically trained

23
Wilcox, Todd, MD, MBA, CCHP-A, CorrectCare, Critical Commandments in Correctional Health Care:
Part 2, Summer, 2013.

38
 CONFIDENTIAL

nurse working in the Salt Lake County Jail would know of the medical director's
"takeaway point" for managing opiate withdrawal that directed nurses to assess
for comorbidities including chronic disease and malnourishment. There is no
evidence whatsoever that Nurse Tucker or any of the nurses working at the Salt
Lake County Jail, including Nurse Seewer and Nurse James, assessed Lisa in a
manner consistent with the directives of medical leadership.

C. The Salt Lake County Jail registered nurses, including, at a minimum, Nurses
Ron Seewer and Brent Tucker, failed and refused to address Lisa Ostler's meal
refusal and nutritional status despite documented Crohn's Disease, weight loss,
low weight, and potentially life-threatening drug withdrawal.

There is no evidence that any nurse at the Salt Lake County Jail paid any
attention whatsoever to Lisa's food or fluid intake. When informed she was not
eating Nurse Tucker immediately dismissed the concern and informed the officer
it would only be a concern if it had been 72 hours. There is no evidence that
Nurse Tucker considered information he had also received about Lisa that she had
been hitting her intercom button all night and was bleeding vaginally. There was
also no evidence to suggest that Nurse Tucker attempted in any way to determine
how long Lisa had actually been refusing food though he could not know if Lisa
had been without food for 72 hours without checking with her and he took no
action to talk with Lisa about her intake or medical concerns. Nurse Tucker later
reported he reviewed Lisa's medical record and assumed the information she was
withdrawing from alcohol and drugs explained why she was not eating. He could
not know if his assumption was at all accurate. No evidence suggested Nurse
Tucker assessed Lisa for the complaints reported to him by Officer Frederickson
or that he took any actions to assess Lisa's failure to eat in the context of reported
events (hitting her emergency intercom button all night and bleeding vaginally)
all of which signaled the need for a nursing assessment. Nurse Tucker failed and
refused to exercise his medical judgment and inappropriately referred decisions
about Lisa needing care for her health concerns to the housing unit officer.

Opinion #6: Nurse Ron Seewer, a registered nurse employed by the Salt Lake
County Jail, breached professional standards of nursing care and his duty to act as
any medically trained nurse would have acted in a similar circumstance to that of
providing or ensuring care to Lisa Ostler. Those breaches are so egregious that his
actions, failures to act, and refusals to act cannot have been the result of the exercise
of professional nursing judgment. Nurse Seewer failed and refused to protect Lisa
Ostler's health and safety. Those breaches were caused by a widespread practice
and custom of deliberate indifference toward the serious medical needs of patients,
generally, which resulted in the deliberate indifference toward the serious medical
needs of Lisa Ostler, specifically.

39
 CONFIDENTIAL

Basis for Opinion #6

A. Nurse Seewer knowingly failed and refused to take actions to protect Lisa
Ostler's health and safety and provide appropriate nursing care to meet her serious
medical needs. Nurse Seewer knowingly failed and refused to perform a pain
assessment, and refused to document his actions or non-actions in response to a
correctional officer’s request for him to see Lisa Oster for her complaints of
pain.

Nurse Ron Seewer, a registered nurse at the Salt Lake County Jail for 17
years, was an experienced, medically trained nurse. He knew the nursing
standards for patient care and treatment for which he was responsible and
accountable. He was trained and knew the policies, procedures, and protocol of
the Salt Lake County Jail (Seewer Deposition, pp 24-26).

The Salt Lake County Jail Nurse Job Description stated that essential
functions of the Jail Nurse job included assessing the physical condition of
prisoners by performing physical examinations and obtaining medical histories,
formulating medical plans based on the patient’s condition, and initiating triage
and determining priority of emergent/urgent care. Another essential function of
the Jail Nurse job included complying with medical record policies regarding the
complete and accurate documentation of patient care, initiating and maintaining
required records and legal documents (SLCo Ostler 000263-000264).

On 4/1/2016 at approximately 3:25 PM the 8C housing officer, Todd

Booth, noted in his unit log that Nurse Ron was on the unit for medication pass
and diabetic checks and testified to this in his deposition. Booth testified he told
Nurse Seewer to check Lisa Ostler because of her complaints of pain (Booth
Deposition, p 34) and noted in his shift log that Lisa Ostler was complaining of
pain. He stated he heard Lisa Ostler complaining of pain. He testified that Nurse
Seewer examined Prisoner Ostler, that he spoke with her about her pain, and
checked her temperature (Booth Deposition, pp 33-34). Officer Booth testified
that Nurse Seewer and cleared Lisa Ostler to stay in the unit with no further
medical needs and no further medical evaluation or treatment.

An untrained, non-medical officer reported Seewer “examined” Lisa

and “cleared” her to remain in Housing Unit 8C. Nurse Seewer had no
recollection of Lisa Ostler and no recollection of his examination of her on 4/1.
He did not document any contact with Lisa or information from any encounter
with her. Other than an untrained officer's mention of a temperature taken (that
was not documented by Seewer) there was no evidence to suggest that any
"examination" took place or that Seewer talked with Lisa about pain and no
documentation suggested Lisa was medically cleared. There is no documentation

40
 CONFIDENTIAL

in Lisa's medical record to suggest she had any encounter with Nurse Seewer
related to her complaints of pain or that she was evaluated in any way.

Seewer was trained to document all potentially significant patient

encounters and knew that an inmate examination or assessment for pain at which
he provided clearance to remain on a general housing unit as opposed to transfer
to a medical unit or hospital was a significant encounter that required
documentation in the patient's medical record. Seewer knew the importance of
assessing and providing treatment that was responsive to patient complaints. He
knew how to conduct assessments, including pain assessments and how to access
appropriate care at the level the patient's condition required. He knew what his
options were to address a patient presenting with pain issues and knew how to
document an assessment or encounter with an inmate he evaluated for pain if he
actually performed such an assessment.

Nurse Seewer knew the requirements and importance of documenting

patient encounters and treatment in the medical record. He knew his legal
responsibility to document patient observations and care in the jail medical record
and knew that if care was not documented, it was not done. He received training
on documentation and assessments. He knew he had an ethical and professional
duty and obligation to protect Lisa Ostler's health and safety.

B. Any medically trained nurse providing care to a patient such as Lisa Ostler at
the Salt Lake County Jail would know the importance of adhering to nursing
standards for patient care, policies and procedures of the organization, assessment
requirements, documentation requirements, and ethical behavior.

Any medically trained nurse providing care to a patient such as Lisa Ostler
being monitored for drug withdrawal would know the importance of completing
withdrawal protocol assessments as ordered and would completely and accurately
document their findings in the medical record. A medically trained nurse would
know the importance of monitoring for co-morbid conditions, a deteriorating
physical status, abnormal vital signs, and other signs or symptoms of a condition
that was described by their own medical director as life-threatening.

Any medically trained nurse providing care to a patient such as Lisa Ostler
in a similar circumstance who was informed that she was complaining of pain
would know the importance of conducting a careful pain assessment and of not
ignoring the patient’s report of pain.

Any medically trained nurse would know the importance of meeting their
responsibility for conducting assessments and documentation and would complete
their assigned tasks as required with honesty and integrity. A medically trained

41
 CONFIDENTIAL

nurse would not rely on an untrained, non-medical housing officer to describe or

document their nursing actions taken on behalf of a patient with medical requests
or needs.

"Inmates have several ways to access health care, such as by submitting a

request slip ... or through oral communication, for example, by telling a
correctional officer of a need to be seen by medical or mentioning a health
concern to the nurse during medication administration. Regardless of the method,
the nurse has a legal and ethical obligation to respond to the request for care. In
general, the nurse should see the patient to evaluate health needs and determine
the level of care required. If the communication is from the officer to the nurse,
the nurse has a responsibility to speak to the inmate ... Based on the information
provided, the nurse must determine the type and level of nursing intervention
required and then implement an action ... the nurse must document the health
needs, how notification of the health need occurred, actions taken and the patient
outcome."24 Triage can be initiated by verbal notification to a nurse or officer. An
inmate could request help by verbally notifying the nurse or an officer (Riser
Deposition, pp 11 – 12). There is no information to suggest that Lisa was ever
instructed about how to access health care or more specifically, how to access
emergency health care. Yet she managed to appropriately request care via oral
communication. Despite this, nursing staff did not respond in a professional, legal
or ethical manner.

Any medically trained nurse, including any nurse working in the

correctional health care setting, would know of their professional duty and
responsibility to see patients for assessment of health care concerns. Any
medically trained nurse would know of their duty and responsibility to see a
patient in response to their request for medical attention and document actions in
a way the information could be retrieved and reviewed. Any medically trained
nurse would know of their ethical duty, responsibility, and obligation to promote,
advocate for, and protect the health and safety of the patient as outlined in the
Code of Ethics for Nurses, a nonnegotiable ethical standard for every individual
nurse who enters and works in the profession.25

Peritonitis is a serious medical condition characterized by severe,

worsening abdominal pain, abnormal vital signs, abdominal tenderness and
guarding, rebound tenderness, decreased bowel sounds, abdominal rigidity,
distension, and an overall ill appearance. Any medically trained registered nurse
would know the importance of evaluating a patient who was complaining of pain
and appeared very ill. Even the most basic pain evaluation of Lisa Ostler would
have revealed severe abdominal pain and her emergent condition would have
24
Muse, Mary MS, RN, CCHP-RN, CCHP-A, Ethical and Legal Issues, National Commission for
Correctional Health Care, CorrectCare, Winter 2011.
25
American Nurses Association, Code of Ethics for Nurses with Interpretive Statement. 2001.

42
 CONFIDENTIAL

been immediately obvious. Any attempt at palpation of her abdomen on 4/1/2016

would have elicited an overwhelming pain response - that is, if Lisa Ostler would
have been able to lie on her back to permit such an abdominal exam due to the
level of her pain.

Registered Nurse Ron Seewer was bound by nursing standards of practice

and ethical standards and by the policies and procedures of his organization. He
knew the standards and what his professional obligation was to provide care for
Lisa Ostler yet he knowingly failed and refused to meet his duties and obligations
to her. He performed no assessment of Lisa. He did not assess her pain. He took
no action to identify her medical history or risk factors for co-morbid conditions.
He refused to consider Lisa was experiencing any condition other than drug
withdrawal, a condition he did not treat seriously and he did not treat her
complaints of pain.

C. Nurse Seewer had been employed since 1999 as a Registered Nurse at the
Salt Lake County Jail as a jail nurse (approximately 17 years) at the time he
encountered Lisa Ostler. He knew or should have known the responsibilities and
duties of his job position and knew or should have known the nursing standards
and ethical responsibilities that applied to his nursing profession as it related to
care of patients such as Lisa Ostler. Nurse Seewer breached standards of nursing
care, policies and procedures of the jail, breached the nursing code of ethics and
refused to protect the health and safety of Lisa Ostler, a patient under his care and
supervision.

Nurse Seewer had ample time available to assess Lisa's health status and
provide essential nursing care for her serious medical needs. He testified that it
was common for nurses to utilize jail computers to watch videos on YouTube and
television shows and testified that he would surf the internet for an hour or two
throughout his shift (Seewer Deposition, pp 20-23). He testified it was common
for the jail nurses to watch movies, TV shows, or surf the internet every day. An
assessment of Lisa Ostler's pain complaint and medical needs would likely have
taken fifteen minutes or less.

Lisa's medication administration record reflected that Lisa was given

medication in the afternoon of 4/1 by a nurse, a task that verified she was
available and within close eyesight of the nurse. The housing unit officer recorded
that at 1525 hours on 4/1, Nurse Ron was in Unit 8C for a medication pass
(Seewer Deposition, p 174). Seewer knew Lisa was available and knew her
location. The initials recorded on the Medication Administration Record certainly
do appear to reflect "RS". Seewer was the nurse available and responsible to
assess Lisa’s medical condition.

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 CONFIDENTIAL

Nurse Ron Seewer knowingly failed and refused to perform any pain
assessment of Lisa and refused to assess Lisa's complaints of pain that were
reported to him. Officer Todd Booth told Seewer to check Lisa because of her
complaints of pain (Booth Deposition, p 34). There is no evidence whatsoever to
suggest that Nurse Seewer performed any assessment or examination of Lisa for
her complaints of pain. He did not even perform CIWA and WOWS assessments,
including the monitoring of Lisa’s vital signs, that were ordered and required. An
assessment of Lisa Ostler was clearly indicated in response to knowledge that she
was complaining of pain and was being monitored for life-threatening
withdrawal. Documentation that was present in Lisa’s record reflected that Lisa
was not available for an assessment despite her being available to receive
medication. The documentation portrays a conflict in nursing staff reports and
reflects that no assessment was done. Officer Booth recorded that Seewer cleared
Lisa to remain on the unit (Booth Deposition, p 33). Seewer testified that clearing
an inmate to stay in their cell would have involved completion of an assessment
including vital signs (Seewer Deposition, p 77), however, no information,
including vital signs, was documented by Seewer and no evidence of an
assessment was recorded. Seewer would have noted any medical encounter with
Lisa Ostler, including any assessment or evaluation, in the medical records.

Information from other inmates housed with Lisa on 8C consistently

described Lisa as looking deathly ill and in pain, obviously in need of medical
attention. There was no information to suggest that Seewer made even a visual
observation of Lisa's status, much less a focused assessment for pain, at the time
he allegedly administered medication to her on 4/1, approximately 12 hours
before she was found unresponsive and not breathing in her cell.

On 4/1/2016 at approximately 8:20 or 8:30 AM, Nurse Ron Seewer

documented a CIWA Withdrawal Assessment for Lisa including vital signs plus
an assessment of ten clinical signs and symptoms of potential withdrawal (SLCo
Ostler 000155). Video footage of Unit 8C at this point in time pictures a nurse
bending down toward Lisa, who was sitting on the floor. The exchange lasts a
mere 30 seconds. Nurse Seewer testified that taking vital signs would take about a
minute or two using an automatic blood pressure monitoring machine (Seewer
Deposition, pp 33-34). Monitoring of respirations would take another 30 seconds
to 1 minute (Seewer Deposition, p 146) and would require full attention of the
nurse to count each chest rise and fall. The nurse, was also attending to another
inmate at the same time as Lisa so did not devote full attention to her. To obtain
the vital signs and symptom assessment recorded on 4/1/16 AM for Lisa would
have taken a minimum of 2-3 minutes and could not have been accomplished in
30 seconds. Several of the symptoms that Seewer recorded as not present would
have required an inquiry and conversation with Lisa in order to record the result
as they could not have been objectively observed: nausea, anxiety, tactile
disturbance, auditory hallucinations, visual disturbance, headache or fullness in

44
 CONFIDENTIAL

the head and orientation. To determine sweating or tremors, Mr. Seewer or

another nurse would have had to touch Lisa’s skin or ask her about the symptoms
in order to record an accurate status. It would not be possible for Nurse Seewer or
another nurse to have taken Lisa’s vital signs and completed a symptom
assessment in 30 seconds. The assessment, documented by Nurse Seewer on the
CIWA worksheet on 4/1/2016, could not have been the result of an actual
assessment. A WOWS assessment for the same time was recorded by another
nurse. It is unclear why two nurses recorded an assessment for the same time
when neither nurse was observed on the video tape performing the actions that
would have been obvious if an assessment had actually been done

Any nurse would know that a patient evaluation cannot be performed

in the middle of a cell block common area. Asking medical health questions in an
open, non-private area violates a patient’s right to privacy of health
information and compromises the assessment process. Except in emergencies or
other life-threatening situations, it is not appropriate to evaluate patients in cell,
on tiers, in hallways, or other nonclinical settings.

The blood pressure, pulse, respirations, temperature and oxygen saturation

recorded for Lisa on the morning of 4/1/2016 was within normal limits. The
findings follow the significantly abnormal results of the previous day and precede
her being found unresponsive and not breathing less than 24 hours later. Lisa was
observed on the video tape holding her abdomen and having difficulty walking;
she was exhibiting obvious objective signs of pain. Lisa’s condition was
worsening NOT improving. It is not reasonable to believe that Lisa’s vital signs
and symptoms assessment were accurately recorded on the morning of 4/1/16, if
the assessment was actually completed. It is also not reasonable to believe that
Lisa’s vital signs had improved to completely normal given the degree of pain she
exhibited and the infectious process that was taking place. It is essential to view
the recorded vital signs and assessment for 4/1/16 AM in the context of the
notation on 4/1/16 PM that designated Lisa was not available for vital signs and
an assessment despite her being available for medication administration and being
given medication and no indications she had ever left her cell. The validity of the
documentation of Lisa’s completely normal vital sign on the morning of 4/1 s is
not believable.

Nurse Seewer failed and refused to provide any documentation of his

actions taken to address Lisa Ostler's health concerns. Nurse Seewer refused to
document any encounter with Lisa Ostler whatsoever and there was no
documentation by Nurse Seewer that he saw Lisa on the afternoon of 4/1 other
than initials on her MAR that suggest he administered medication to her. He
testified he had no recollection at all of examining her or of clearing her to stay in
the unit (Seewer Deposition, pp 174-175). A designation was entered on the
CIWA and WOWS assessment forms that Lisa was either not available or was not

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on the unit. No documentation in Lisa's record or in the unit records kept by

officers suggests she left unit 8C for any reason. Lisa's medication administration
record reflects she received Librium medication three times on 4/1, verifying
nurse contact three times at a minimum and administration of the medication in
the afternoon or early evening on 4/1. Nurse Seewer was the "medication nurse"
on 8C on 4/1 and appeared to have recorded medication administration to Lisa
Ostler on two occasions in the afternoon/evening of that day. If Lisa was available
to receive medication, she was also available for an assessment, yet neither
Seewer nor any other nurse recorded any assessment whatsoever and, in fact,
some nurse erroneously documented she was not available. Seewer's
documentation was, at the very least, contradictory and suggestive of a knowing
decision and refusal to perform a required assessment for a patient with serious
medical needs and needs for medical care.

Nurse Seewer refused to report or record care provided (or not provided).
The documentation and the absence of documentation available in Lisa Ostler's
medical record reflected Nurse Ron Seewer's failures and refusals to act and
demonstrated he provided no assessments, care, or interventions in response to
Lisa Ostler's serious medical needs or requests for medical help in the final hours
of her life. He refused to assess Lisa Ostler’s complaint of pain and reportedly
allowed her to remain in the Housing Unit 8C as opposed to transferring her to the
Medical Unit without conducting any focused nursing assessment or any
assessment at all to determine her actual needs and appropriate interventions. The
lack of any documentation in Lisa's medical record of any assessment done on the
afternoon of 4/1/2016 and Nurse Seewer's testimony that he had no recollection of
conducting an assessment of Ms. Ostler and did not document in her medical
record that he evaluated her in any way was consistent with no assessment
whatsoever. He testified that if he had taken Ms. Ostler’s vital signs or done an
assessment he would have documented the information in her medical record
(Seewer Deposition, pp. 50, 78). No such documentation existed.

Any assessment of Lisa Ostler performed on 4/1/2016 at 3:25 PM, just 17

hours before she was found unresponsive and not breathing (and later determined
to have peritonitis secondary to a bowel perforation), after she had been
requesting medical attention would have revealed a significant, emergent
condition that warranted immediate emergency intervention. Nurse Seewer
testified he was trained to distinguish abdominal pain caused by withdrawal from
abdominal pain caused by a different serious medical issue and had this nursing
knowledge (Seewer Deposition, p 210). He further testified that symptoms of
withdrawal and abdominal pain are the same thing so if a patient was having
withdrawal and abdominal pain it would be a symptom of withdrawal (Seewer
Deposition, p 211). Seewer’s testimony verified he would dismiss the possibility
that a patient with abdominal pain undergoing drug withdrawal could have a more
serious condition or disease process even though he had the nursing knowledge to

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make a clinical distinction. His testimony reflected his approach toward inmates
such as Lisa of a blatant disregard for the possibility that they could have a
serious medical condition manifested by abdominal pain even though he had the
knowledge to differentiate abdominal pain with withdrawal from potential
conditions that were significantly more serious. He stated that if a patient with
withdrawal had abdominal pain, he would assume it was the withdrawal and that
would not raise any red flags for him. His testimony reflects a disregard for
serious patient needs based upon the individual’s circumstance and offense, a
breach of nursing standards. His testimony also reflects a disregard of the fact
that, as Dr. Wilcox has emphasized, drug withdrawal is a serious medical
condition and can be life-threatening. He refused to follow the very first standard
of nursing practice that dictates the essential and significant nursing action of
assessment, the first authoritative statement of the duties that all registered nurses,
regardless of role, population, or specialty are expected to perform competently.

Nurse Seewer’s failure and refusal to address Lisa Ostler’s pain and
serious, worsening, life-threatening medical needs demonstrates a significant
breach in the standards of nursing care for assessment, diagnosis, and
intervention. Had Nurse Seewer simply done an assessment of Lisa Ostler’s
complaint of pain, he would have been prompted to TOUCH her abdomen and
would have obtained sufficient physical and clinical information to identify the
health crisis that was progressively unfolding and he would have been aware of
the degree of pain she was experiencing. At that point he would have had
sufficient information to arrange her transfer for required emergency care as
opposed to ignoring her serious medical needs and keeping her on the housing
unit, alone in 8C16.

At the time Nurse Seewer was asked to see Ms. Ostler for pain, she
had not eaten several, if not all, of the meals served to her since her arrival at the
Salt Lake County Jail, she had not left her jail cell, she was observed and
described by other inmates as looking deathly sick physically and having a gray
skin appearance and she had been observed holding her abdomen, moaning and
calling out in pain. Even the most basic attempt and effort to conduct an
assessment of Lisa Ostler’s pain would have revealed her health status
sufficiently enough to prompt a more careful and thorough examination, a report
to the physician, or transfer to the emergency room. Nurse Seewer was the
gatekeeper for Lisa’s access to appropriate medical care for her serious medical
needs at a critical time for instituting critical life saving measures on 4/1. He
failed and refused to implement any measures to assess, treat or intervene on
Lisa’s behalf.

If Seewer examined Ms. Ostler at the request of Officer Booth, as Booth

reported, he did not check her vital signs and did not document a single indication
of any examination. To the contrary, Lisa’s medical record reflects that she was

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"not available" a description that was not an honest or ethical description of the
reason he failed to perform or refused to arrange for performance of an
assessment. Nurse Seewer knew or should have known the responsibilities and
duties of his job position as it related to the performance of patient assessments.
He was experienced and trained. Nurse Seewer simply did not do the assessments
he was required to do for Lisa.

Nurse Seewer did not take any vital signs, did not perform any assessment
of reported pain, did not conduct an abdominal evaluation, did not conduct any
evaluation at all for Lisa Ostler, and did not provide any other medical help in
response to her complaints of pain and requests for medical help. Nurse Seewer
did not refer her for any other medical diagnosis or treatment. Nurse Ron Seewer
failed and refused to conduct a physical assessment of Lisa Ostler, an essential
and basic responsibility that is the sole purview of the registered nurse. Refusal to
conduct an assessment of a patient’s complaint of pain is a significant breach of
nursing standards and cannot be viewed as accidental or an oversight. The refusal
to perform an assessment in response to a patient request for help and complaint
of pain is an intentional disregard of a patient’s serious medical need. Nurse
Seewer was the gatekeeper with control over medical interventions that could
have been accessed for the care of Lisa Ostler on 4/1, a critical time period
during which lifesaving care and treatment could have been provided. He
failed and refused to provide any health care intervention whatsoever.

Nurse Seewer's failure and refusal to perform assessments that were

clearly indicated reflected a cultural, customary, and accepted practice among
nurses at the Salt Lake County Jail to minimize and discount pain complaints and
the need to do focused assessments for inmates with drug withdrawal and to
ignore the need for twice daily assessments despite doctor orders and program
requirements. Seewer was not the only nurse that knowingly and intentionally
refused to properly assess Lisa. NONE of the nurses who had contact with her
assessed her for pain, not eating, hydration, abnormal vital signs, declining
physical status, medication need, or the presence of co-morbid physical conditions
that resulted in the worsening of Lisa's progressive and obviously grave condition.
An accepted and pervasive staff attitude and approach of ignoring patient needs
was clearly and openly endorsed by registered nurses who were all trained and
educated to address health concerns for every patient regardless of circumstance
or offense.

I incorporate herein my Opinions numbered 1, 2, 3, 4, and 5, above. Each

of those opinions applies to Nurse Ron Seewer. Nurse Ron Seewer had all
knowledge attributed to nurses described in those opinions and failed to act as
described in those opinions.

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 CONFIDENTIAL

OPINION #7: Nurse Brent Tucker, a registered nurse employed by the Salt Lake
County Jail, breached professional standards of nursing care and his duty to act as
any medically trained nurse would have acted in a similar circumstance to that of
providing or ensuring care to Lisa Ostler on April 2, 2016. Those breaches are so
egregious that his actions, failures to act, and refusals to act cannot have been the
result of the exercise of professional nursing judgment. Nurse Tucker failed and
refused to protect Lisa Ostler's health and safety. Those breaches were caused by a
widespread practice and custom of deliberate indifference toward the serious
medical needs of patients, generally, which resulted in the deliberate indifference
toward the serious medical needs of Lisa Ostler, specifically.

Basis for Opinion #7

A. Nurse Tucker knowingly failed and refused to assess Lisa Ostler in response to
Officer Zachary Frederickson’s report to him that she had been hitting the
intercom button all night long, was not eating, and was complaining of vaginal
bleeding. He blatantly disregarded her not eating as a result of drug withdrawal,
took no action to verify his belief and made the assumption without any clinical
corroboration. He did not, in any way, evaluate Lisa's report of bleeding and, in
fact, instructed the non-medical, untrained housing unit officer to check into it.
Nurse Tucker conducted no clinical assessment of Lisa's medical needs or
complaints. Nurse Tucker breached his duty to obtain health information and
appropriately assess and secure care for Lisa Ostler. Tucker failed and refused to
exercise any medical judgment about Lisa Ostler’s health status and condition
and, instead, delegated his responsibility to an untrained housing unit officer.

Nurse Brent Tucker, a registered nurse at Salt Lake County Jail, was an
experienced nurse. He knew or should have known the responsibilities and
duties of his job position and knew or should have known the nursing standards
and ethical responsibilities that applied to his nursing profession as it related to
care of patients such as Lisa Ostler. Nurse Tucker breached standards of nursing
care, policies and procedures of the jail, breached the nursing code of ethics, and
refused to protect the health and safety of Lisa Ostler, a patient under his care and
supervision.

The Salt Lake County Jail Nurse Job Description stated that essential
functions of the Jail Nurse job included assessing the physical condition of
prisoners by performing physical examinations and obtaining medical histories,
formulating medical plans based on the patient’s condition, and initiating triage
and determining priority of emergent/urgent care. Another essential function of
the Jail Nurse job included complying with medical record policies regarding the
complete and accurate documentation of patient care, initiating and maintaining
required records and legal documents (SLCo Ostler 000263-000264).

49
 CONFIDENTIAL

Nurse Tucker would have had ample time available to assess Lisa's health
status and provide essential nursing care for her serious medical needs. He did
nothing to assess her; he did not even take her temperature. There is no
information to suggest that Nurse Tucker even bothered to ask Lisa about her
repeatedly pressing the emergency button through the night, about her not eating,
or about vaginal bleeding, or that he considered Lisa may have a condition
unrelated to drug withdrawal. He failed and refused to respond to information
about an inmate’s medical condition that obviously needed an assessment by a
trained professional medical staff person as opposed to an untrained, non-medical
housing officer.

Tucker received training and knew the requirements and importance of

documenting patient encounters and treatment in the medical record. He knew he
had an ethical duty and obligation to protect Lisa Ostler's health and safety. He
knew his legal responsibility to document patient observations and care in a
patient's jail medical record and knew that if care was not documented, it was not
done. He was trained to document all potentially significant patient encounters.
Tucker testified that if there was not a note written by him in Lisa's medical
record, he did not assess her (Tucker Deposition, p 47). There was no note entered
by Nurse Tucker in Lisa's record.

On 4/2/2016 Housing Unit Officer Zachary Frederickson began his shift

and was informed by the graveyard officer, Holly Harris and his Supervisor,
Heather Beasley, that Ms. Ostler had been crying, screaming, pressing the
emergency intercom call button, and asking for a nurse continuously throughout
the night. Officer Frederickson spoke with nurse Brent Tucker about Ms. Ostler
and informed him she had been hitting the intercom all night (Frederickson
Deposition, p 190). Nurse Tucker reportedly spoke with Lisa briefly and then left
the unit. He did not document any contact, observation, or information in Lisa's
medical record. Officer Frederickson learned that Lisa reported vaginal bleeding
and was not eating He again contacted Nurse Tucker and reported Lisa's
complaint of vaginal bleeding and that she had been refusing meals.

Nurse Tucker knew the importance of conducting a review of Lisa Ostler's

medical record after receiving an officer report that she was bleeding and not
eating. Tucker knew that a face-to-face assessment of a patient reporting clinical
symptoms needed to be performed. Tucker also knew that a housing officer was
not medically trained to evaluate a patient's health status and would not be
qualified to determine if reported bleeding or not eating was an emergency, yet,
without performing any assessment whatsoever, Nurse Tucker told the officer that
eating was not a concern until 72 hours had passed and reportedly asked Officer
Frederickson if Ms. Ostler's bleeding was menstrual and if it was a medical
emergency. He instructed the officer to have Lisa fill out a triage kite/sick call
request form if it was not an emergency, leaving it for Frederickson to make the

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 CONFIDENTIAL

medical judgment as to whether there was a medical emergency. Nurse Tucker

did not ask additional questions and refused to take any action whatsoever to
evaluate Lisa or assess her for the presence of an
emergent condition as he was required to do.

Housing Unit Officers were trained to contact a member of the Health

Services staff if they become aware of an inmate complaining of an emergency
(Dumont Deposition, p 44). It was inappropriate for a Housing Unit Officer to
provide an inmate with a sick call request form if the inmate believed they were
experiencing an emergency and requested medical attention (Dumont Deposition,
pp 45-50). If an inmate communicated they had pain and wanted to see medical,
the Housing Deputy should contact medical (Dumont Deposition, p 121). Officer
Frederickson contacted Nurse Brent Tucker regarding Ms. Ostler’s repeated
requests for medical care and complaints of vaginal bleeding. He also reported
that Ms. Ostler had not been eating. He was not qualified to determine the medical
implications of vaginal bleeding or not eating or to observe and assess her signs
and symptoms. He was not trained to triage inmate medical complaints, but was
trained to report them to the medical staff.

Brent Tucker knew it was his responsibility to conduct a face-to-

face assessment of Lisa Ostler in response to her complaints of bleeding and the
officer's report that she was repeatedly hitting the emergency button all night and
was not eating. Tucker knew a housing unit officer was not qualified to conduct a
medical assessment to determine whether health care complaints constituted a
medical emergency and knew officers had no access to a patient's medical history
or record. Nurse Tucker had access to Lisa's medical history and medical record
and knew or should have known all of the information obtained at the time of her
booking including weight loss, Crohn's Disease, low weight, drug withdrawal,
sudden cessation of all of her medications, and no menstrual periods. At the time
he was contacted by Officer Frederickson, Nurse Tucker was the designated
medical staff person at the jail that could have intervened to evaluate Lisa Ostler's
medical issues and act on her behalf to ensure her health and safety and to assess
her serious medical issues. Nurse Tucker was the gatekeeper and controlled all
medical interventions that could have been accessed for the care of Lisa Ostler on
the morning of 4/2 at an absolutely critical time for instituting lifesaving
measures for her serious life-threatening medical condition. He failed and refused
to provide any health care intervention whatsoever.

B. Nurse Brent Tucker knew it was his responsibility to evaluate Lisa Ostler's
medical complaints. She contacted a Housing Officer regarding her medical
situation that she perceived was an emergency, she pressed her emergency button
to summon help approximately 16 times throughout the night, she was in pain,
and, according to Officer Frederickson, she complained of bleeding. It was

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appropriate for Lisa Ostler to request medical attention by verbally contacting a

correctional officer, as stated on sings posted in the jail and as described in a
handbook at the jail.

Any medically trained nurse providing care to a patient such as Lisa Ostler
in a similar circumstance who was informed she had been requesting medical help
throughout the night and was complaining of pain would know the importance of
conducting a careful pain assessment and of not ignoring the patient’s report of
pain. Any medically trained nurse would evaluate a patient's complaint of pain
and bleeding to determine the location, the amount, the intensity, and whether the
patient needed referral to a higher level of medical care. Any medically trained
nurse providing care to a patient such as Lisa Ostler at the Salt Lake County Jail
would know the importance of adhering to nursing standards for patient care,
policies and procedures of the organization, assessment requirements,
documentation requirements, and ethical behavior.

"Inmates have several ways to access health care, such as by submitting a

request slip ... or through oral communication, for example, by telling a
correctional officer of a need to be seen by medical or mentioning a health
concern to the nurse during medication administration. Regardless of the method,
the nurse has a legal and ethical obligation to respond to the request for care. In
general, the nurse should see the patient to evaluate health needs and determine
the level of care required. If the communication is from the officer to the nurse,
the nurse has a responsibility to speak to the inmate ... Based on the information
provided, the nurse must determine the type and level of nursing intervention
required and then implement an action ... the nurse must document the health
needs, how notification of the health need occurred, actions taken and the patient
outcome."26

Any medically trained nurse, including any nurse working in the

correctional health care setting, knows of their professional duty and
responsibility to see patients for assessment of their health care concerns. Any
nurse knows of their duty and responsibility to see a patient in response to their
request for medical attention and document their actions in a way the information
can be retrieved and reviewed.

Any medically trained nurse knows of their ethical duty, responsibility and
obligation to promote, advocate for, and protect the health and safety of the
patient as outlined in the Code of Ethics for Nurses, a nonnegotiable ethical
standard for every individual who enters and works in the nursing profession.27
Any medically trained nurse would know the importance of meeting their
26
Muse, Mary MS, RN, CCHP-RN, CCHP-A, Ethical and Legal Issues, National Commission for
Correctional Health Care, CorrectCare, Winter 2011.
27
American Nurses Association, Code of Ethics for Nurses with Interpretive Statement. 2001.

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responsibility for conducting assessments and documentation and would complete

their assigned tasks as required with honesty and integrity. Any medically trained
nurse would not rely on a medically untrained housing officer to describe or
document their nursing actions taken on behalf of a patient with medical requests
or needs and would not expect an officer to determine if a patient's complaints
were emergent or not.

Nurse Tucker knew it was inappropriate for him to expect the Housing
Officer to determine if Lisa Ostler was experiencing a medical emergency and
knew it was inappropriate for him to expect an inmate experiencing a medical
emergency to complete a sick call request form. Tucker knew that it was a breach
of nursing standards to refuse to exercise his medical judgment about the health
needs of a patient dependent upon his interventions for medical care.

At the time Nurse Tucker was approached about Ms. Ostler’s failure to eat
and vaginal bleeding she had not eaten several, if not all, of the meals served to
her since her arrival at the Salt Lake County Jail. She had not left her jail cell, was
observed and described by other inmates as looking very sick physically and
having a gray skin appearance, and she had been observed holding her abdomen,
moaning and calling out in pain, symptoms that were sufficient enough to prompt
a careful and thorough examination. Any medically trained nurse would know
the importance of conducting a careful assessment of vaginal bleeding in an
inmate who was no longer having menstrual periods. Any medically trained
nurse would know the importance of not ignoring the patient’s report. Any
medically trained nurse would know the need to assess a patient complaining of
bleeding to determine the source, nature and extent of the bleeding and would
know the importance of conducting such an assessment in any case, and
especially for a patient with documented Crohn's Disease who was being
monitored for drug withdrawal and had all of their prescription medication
abruptly stopped.

C. Nurse Brent Tucker failed and refused to address any of the medical concerns
brought to his attention by housing unit officer Frederickson on the morning of
4/2, just minutes before Lisa Ostler was found unresponsive and not breathing in
her cell.

Nurse Brent Tucker was on 8C conducting diabetic checks on 4/2/16 at

approximately 6:38 AM. He was told by Officer Frederickson that Lisa had been
hitting the intercom all night (Frederickson Deposition, p 190). Lisa was hitting
the emergency call button in her cell to obtain medical help for a health care
emergency. Nurse Tucker reportedly walked over to her cell, spoke with Lisa
briefly, and then left the unit. Tucker did not document any contact, conversation,
observation, or interaction in Lisa's medical record. No evidence in Lisa's medical
record provides any information as to her level of consciousness or

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 CONFIDENTIAL

responsiveness at the time Tucker reportedly spoke to her. In light of the fact that
Lisa had experienced a perforated ulcer and peritonitis, it is inconceivable that
Lisa would not have expressed and manifested her pain and her need for medical
help to a nurse standing at her cell door.

When Nurse Tucker was informed of Lisa's multiple requests to see

medical and reportedly walked over to her cell, he would have seen Lisa Ostler
just about 90 minutes before she was found unresponsive and not breathing in her
jail cell. Untrained laypersons on 8C noted Lisa's grave condition and her dire
need for medical attention hours before Tucker ever arrived. It is inconceivable
that a trained, experienced nurse would not have, at a minimum, questioned Lisa
about her concerns or visually noted her serious medical condition. Even a most
basic attempt and effort to conduct an assessment of Lisa Ostler’s complaints
would have revealed her dire medical difficulties on the morning of 4/2. No one
could have seen Lisa at that point and not perceived she was suffering extreme
pain and had a serious medical condition requiring urgent medical attention.

Nurse Brent Tucker was contacted a second time by Officer Frederickson

to report that Lisa Ostler was bleeding and had not been eating. Nurse Tucker
asked the officer if the bleeding was from her menstrual but the officer did not
know. Nurse Tucker instructed the officer to ask the inmate about the bleeding.
Tucker refused to follow up or check into the housing officer's report that Lisa
Ostler was bleeding and had not eaten meals. Also, had been informed by the
officer that Lisa had been hitting her emergency button all night. He asked the
officer if it was menstrual and if it was an emergency and then instructed him to
have Lisa complete a health services form if the medically untrained officer
determined it was not an emergency.

It was inappropriate for Nurse Tucker to require an inmate requesting

medical help for an emergency to complete a medical sick call form. It not only
does not make sense; it is not the procedure that the jail endorsed or directed
inmates and staff to follow. It was not the course that the National Commission
for Correctional Health Care endorses. Nurse Tucker was present on 8C when he
learned of Lisa's requests and concerns. There was no discernable reason he could
not have done an assessment or arranged for an assessment to be done
expeditiously – a task that was his responsibility to do.

Nurse Tucker conducted no assessment of Lisa for a reported symptom of

bleeding. He directed an unqualified, non-medical housing officer to ask Lisa if
her bleeding was menstrual and essentially to determine the nature of her
bleeding, an action that was completely inappropriate. Assessment of a patient's
reported medical complaint is the sole purview of the registered nurse when they
are the on-site medical provider as Nurse Tucker was. Delegation of an
assessment is a clear breach of nursing standards of practice. Delegation of a

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 CONFIDENTIAL

task to an individual who is not qualified to perform it is a breach of nursing

standards of practice as well. Determination of the nature of a patient's bleeding
would not be a task that could be delegated to a non-medical housing officer and
Nurse Tucker would know this. Tucker performed no assessment of Lisa, had no
information about the nature or degree of her bleeding, and knew that Lisa had
been pleading for medical help throughout the entire night. Yet he refused to
respond and ignored Lisa Ostler's report of a serious medical need.

Had Nurse Tucker bothered to check Lisa Ostler's medical record

information that he had ready access to, he would have verified the admission
information that Lisa had no menstrual periods. At that point bleeding should
have prompted Nurse Tucker to perform a focused assessment. He checked her
chart and noted her diagnosis of drug withdrawal. At that point he disregarded
all other potential causes for her complaints and assumed they were all related to
drug withdrawal. He performed no assessment whatsoever. Tucker did not even
question Lisa about her symptoms. Had Nurse Tucker bothered to conduct any
assessment at all of Lisa's complaint of bleeding he would very likely have
identified the emergent state she was in at that time and been able to emergently
refer her to a competent provider before she became unresponsive and stopped
breathing. Nurse Tucker refused to evaluate Lisa at an absolutely critical point in
time when she required emergent lifesaving intervention.

When Nurse Tucker was contacted for the second time on the morning of
4/2 and informed that Lisa was bleeding and not eating, he simply stated not
eating was not a problem unless it had gone on for at least 72 hours yet he took
no action to check how long Lisa had not been eating. Days after Lisa died, Nurse
Brent Tucker submitted an event timeline for 4/2/16 and reported he "looked up
this individual and saw she was W/D from ETOH and Drugs which explains why
this pt. may not want to eat." (Brent Tucker memo, SLCo Ostler 026515). There
is no evidence to suggest that Nurse Tucker considered any other reasons Lisa
was not eating or that he considered her medical history when he conducted the
paper triage of her medical issue. There is no indication that Nurse Tucker ever
considered returning to 8C to evaluate Lisa in any way or that he considered
asking another nurse, such as the triage nurse, to see her.

Mr. Richard Bell, the Responsible Health Authority at the Salt Lake
County Jail, testified that it would be inappropriate for a nurse called by a unit
officer to ask the Housing Officer whether the patient’s complaint was a medical
emergency (Bell Deposition, p 61). Mr. Bell testified that communication from
Brent Tucker asked the medically untrained housing officer if Ms. Ostler’s
bleeding was menstrual and the officer did not know. There was no indication
that Brent Tucker or any other health staff or medical staff ever checked on Lisa
Ostler to see if she was bleeding and, if so, from where and what source (Bell
Deposition, May 20, 2019, p 67). Brent Tucker apparently disregarded the

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 CONFIDENTIAL

obvious risk of urgent or emergent causes for Ms. Ostler’s bleeding, including
possible organ damage, injury, or an intra-abdominal illness.

The Prisoner Rules and Regulations Handbook instructed inmates who

had a medical emergency to notify the Housing Unit Officer immediately and
Health Services would respond as quickly as possible (Prisoner Handbook, SLCo
Oster p 009133). The housing officers and medical staff controlled all access to
medical care for the inmates at Salt Lake County Jail. As the gatekeepers of
medical care for Lisa Ostler they all failed and refused to ensure access to care
and the provision of essential life-saving interventions.

Nurse Tucker blatantly disregarded Lisa's not eating (stating after Lisa’s
death that he attributed it to drug and alcohol withdrawal), took no action to verify
his belief, and made the assumption without any clinical corroboration. Nurse
Tucker's knowing disregard of Lisa's symptoms under the purported assumption
that they were just due to withdrawal was remarkably similar to Nurse Seewer's
knowing disregard for performance of an assessment for abdominal pain due to
his purported assumption of it just being a result of drug withdrawal. The nursing
staff failures and refusals to conduct assessments that were clearly indicated
conformed to a cultural, customary, and accepted practice among nurses at the
Salt Lake County Jail that symptoms exhibited by inmates undergoing drug
withdrawal were not taken seriously. Rather, symptoms were assumed to be
related to withdrawal and ignored. Tucker was not the only nurse that knowingly
and intentionally failed and refused to properly assess Lisa. NONE of the nurses
who had contact with her assessed her for pain, not eating, hydration, abnormal
vital signs, declining physical status, medication need, or the presence of co-
morbid physical conditions that resulted in the worsening of Lisa's progressive
and obviously grave condition. An accepted and pervasive staff attitude and
approach of ignoring patient needs was clearly and openly endorsed by registered
nurses who were all trained and educated to address health concerns for every
patient regardless of circumstance or offense. They all knew -- Nurse Tucker and
Nurse Seewer both knew -- that refusal to assess a patient's presenting clinical
symptoms and secure appropriate treatment to meet their serious medical needs
was a violation of nursing standards, practice, duty and ethical responsibilities.

I incorporate herein my Opinions numbered 1, 2, 3, 4, and 5, above. Each of those

opinions applies to Nurse Brent Tucker. Nurse Brent Tucker had all knowledge
attributed to nurses described in those opinions and failed to act as described in
those opinions.

OPINION #8: Nurse Colby James, a registered nurse employed by the Salt Lake
County Jail, breached professional standards of nursing care and his duty to act as
any medically trained nurse would have acted in a similar circumstance to that of
providing or ensuring care to Lisa Ostler on April 2, 2016. Those breaches were so

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egregious that his actions, failure to act, and refusals to act cannot have been the
result of the exercise of professional nursing judgment. Nurse James failed and
refused to protect Lisa Ostler's health and safety. Nurse Colby James’ failure and
refusal to provide or ensure care to Lisa Ostler on April 2, 2016, was yet another
example and further evidence reflective of a widespread cultural, customary, and
accepted practice among nurses at the Salt Lake County Jail to ignore health
complaints and symptoms exhibited by inmates undergoing drug withdrawal and
assume health issues were only related to withdrawal and therefore not serious.

Basis for Opinion #8

A. Nurse James knowingly failed and refused to assess Lisa Ostler in response to
Officer Zachary Frederickson’s report to him that she was requesting to see
medical. Nurse James was the triage nurse for 8C at the time Officer Frederickson
informed him of Lisa's request.

Nurse Colby James, a registered nurse at the Salt Lake County Jail, was an
experienced nurse. He knew the nursing standards for patient care and treatment
for which he was responsible and accountable. He was trained and knew the
policies, procedures and protocol of the Salt Lake County Jail. James received
training and knew the requirements and importance of documenting patient
encounters and treatment in the medical record. He knew he had an ethical and
professional duty and obligation to protect Lisa Ostler's health and safety. He
knew his legal responsibility to document patient observations and care in a
patient's jail medical record and knew that if care was not documented, it was not
done. He was trained to document all potentially significant patient encounters.

The Salt Lake County Jail Nurse Job Description stated that essential
functions of the Jail Nurse job included assessing the physical condition of
prisoners by performing physical examinations and obtaining medical histories,
formulating medical plans based on the patient’s condition, and initiating triage
and determining priority of emergent/urgent care. Another essential function of
the Jail Nurse job included complying with medical record policies regarding the
complete and accurate documentation of patient care, initiating and maintaining
required records and legal documents (SLCo Ostler 000263-000264).

On 4/2/2016 at approximately 7:30 AM, less than one hour after Nurse
Brent Tucker left 8C, Nurse Colby James entered the unit to conduct triage of
inmate medical concerns and requests. Housing Unit Officer Zachary
Frederickson talked with James about Lisa requesting to see medical and that she
did not want to complete a sick call request. Nurse James disregarded Lisa's
verbal request and told the officer that if she had a medical emergency to contact
medical and that if she had a triage kite he would take it at that time (SLCo Ostler
026514).

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 CONFIDENTIAL

Nurse James was the second nurse to instruct Officer Frederickson he

should contact medical if Lisa Ostler had an emergency. The officer WAS
contacting medical. Officer Frederickson was a medically untrained jail officer
following jail procedure to contact a nurse for a patient's medical issues. Nurse
James knew that a medically untrained individual was not qualified to determine
if Lisa's request for medical attention constituted an emergency and knew that
was his job.

Without conducting any further inquiry into Lisa's complaints and without
conducting any assessment whatsoever, Nurse Colby James left the unit. He took
no action whatsoever to determine the emergent nature of Lisa's request or
evaluate her medical need and request. He made no attempt whatsoever to try to
determine why she purportedly did not want to complete a sick call request form.
His insistence that she complete a paper form in the context of her request for
medical help for an emergency is inappropriate, ridiculous, unreasonable, and a
complete abdication of his nursing responsibility and duty to a patient under his
care.

At 8:07 AM, just 37 minutes after Nurse James failed and refused to
assess her request for medical attention, Lisa Ostler was discovered by Officer
Frederickson not breathing and unresponsive in her jail cell. It is likely Lisa was
unresponsive, or at least obviously critically ill and at risk of imminent death,
when James was contacted by Officer Frederickson. His failure and refusal to see
her represents the degree of disregard the nursing staff had for patients like Lisa
undergoing drug withdrawal. He did not even bother to talk to her or check into
her request for medical help.

B. Any medically trained nurse would know the importance of responding to a

patient's request for medical care, particularly if triage was the nursing function
they were specifically assigned to do. Any medically trained nurse would know
the importance of not ignoring a patient’s request.

Like Nurses Ronald Seewer and Brent Tucker, Nurse James ignored
Lisa’s request for medical attention. He then instructed Officer Frederickson to
determine if she had a medical emergency. Any medically trained nurse would
know the determination of a medical emergency in a circumstance such as existed
with Lisa Ostler required a medical assessment by a registered nurse and should
not be referred to a medically untrained housing unit officer. Nurse James ignored
Lisa's request for medical attention and refused to conduct any assessment of her
condition or status whatsoever. He inappropriately delegated the nursing function
for assessment to determine whether or not an inmate's complaint was an
emergency to an individual that was not qualified to perform it. Any medically

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 CONFIDENTIAL

trained nurse would know that ignoring a patient request for medical help and
refusing to conduct any assessment of a patient's medical needs or requests is a
violation of nursing standards, facility policy and protocol, and a breach of their
ethical duty, responsibility, and obligation to promote, advocate for, and protect
the health and safety of a patient. As a result of Nurse Tucker's complete
disregard for Lisa's request for help to address her medical needs, Lisa was found
approximately 30 minutes later unresponsive and not breathing in her cell.

Any medically trained nurse acting in the job capacity of "triage nurse"
would know the requirements and essential functions of their position. The Salt
Lake County Jail policy and procedure for "Nonemergency Health Care
Requests", No. J-E-07 (SLCo Ostler 001662), stated a "jail triage nurse will visit
each housing section of the Jail daily to collect sick call requests and to allow all
patients the opportunity to voice health complaints. The purpose of the policy and
procedure was to ensure that all health care requests were documented and triaged
so that patients were treated in a timely manner by qualified health care providers.
The triage process consisted of addressing the patient's chief complaint, taking
and recording vital signs, if indicated, and performing an appropriate nursing
assessment. If the patient's condition was urgent or emergent, the nurse would
provide necessary immediate care and arrange appropriate referral for medical
treatment. Nurse James refused to perform a single step of the procedure to deal
with Lisa's health care request.

It is inconceivable that the nurse assigned to triage inmate complaints

on 8C on the morning of 4/2, who was present at the time a verbal request from an
inmate to see medical was made, took absolutely no action to perform the
function he was assigned to do. Nurse James knew of Lisa's request and blatantly,
knowingly and intentionally failed and refused to triage her request for emergency
medical help in the most egregious manner. Lisa Ostler made her request for
medical attention known in accord with facility policy and procedure. Nurse
James refused to follow facility policy, procedure, nursing standards, NCCHC
standards, ethical duty and responsibility, professional knowledge, and reasonable
decision-making.

It is absurd and unreasonable to expect that an inmate experiencing a

medical emergency should fill out a triage kite to request medical care yet Nurse
James did just that. He knowingly disregarded Lisa's verbal request for
emergency medical attention. There is no indication that Nurse Colby James
considered whether Lisa Ostler was able to complete a sick call request or
whether she had a legitimate reason for not wanting to complete a written request.
According to jail policies, if an inmate was experiencing a medical emergency,
they were not supposed to fill out a sick call request form. Instead, inmates were
instructed that if they had a medical emergency, they should tell the housing
officer or a nurse immediately (SLCo Ostler 024817). Lisa did as she was

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 CONFIDENTIAL

instructed. She notified an officer repeatedly. She was repeatedly ignored by

housing officers, but even when they did notify a nurse, it was to no avail. What is
evident is Nurse James's intentional choice not to see Lisa in response to her
request and his failure and refusal to respond to an inmate’s request for medical
care for a condition she felt was emergent. It is absurd and unreasonable for the
triage nurse present on the housing unit at the time of Lisa's emergent request for
medical attention to defer a medical determination of her need to an unqualified,
untrained, non-medical housing unit officer. Yet Nurse James did that too.

C. Nurse Colby James took no action whatsoever to respond to Lisa Ostler

despite knowing she had verbally requested medical attention and he was present
on unit 8C as the triage nurse at the time he became aware of her request. Lisa
had been pleading for medical attention throughout the night. His refusal to see
Lisa or assess her in response to her request for medical care is representative of
the widespread disregard the nurses at Salt Lake County Jail had for inmates
undergoing drug withdrawal.

Mr. Bell, the Responsible Health Authority, testified in his deposition that
when Colby James came to Unit 8C he never went over to Lisa Ostler’s cell to
check her out and did not make any attempt to determine if she was bleeding and,
if so, from where and what the source was (Bell Deposition, May 20, 2019, p 68).
Nurse James did not take any vital signs and did not perform any assessment
whatsoever for Lisa Ostler. He did not provide medical help in response to her
requests. Nurse James did not refer her for any other medical diagnosis or
treatment.

Just as Nurse Tucker before him had done, Nurse James left the
determination about whether Lisa had a medical emergency to an untrained, non-
medical housing unit officer. Patient assessment is the sole purview of the
registered nurse. Refusal to conduct an assessment of a patient’s complaint of
pain and request for medical care is a significant breach of nursing standards and
cannot be viewed as accidental or an oversight. The failure and refusal to perform
an assessment in response to a patient request for help and complaint of pain is an
intentional disregard of a patient’s serious medical need.

Nurse James's failure and refusal to perform an assessment in response to

Lisa Ostler's request for medical help clearly conforms to a cultural, customary
and accepted practice among nurses at the Salt Lake County Jail who minimized
and discounted pain complaints, patient needs and the need to do focused
assessments for inmates with drug withdrawal. James was not the only nurse that
knowingly and intentionally refused to properly assess Lisa. NONE of the nurses
who had contact with her assessed her for pain, not eating, hydration, abnormal
vital signs, declining physical status, medication need, or the presence of co-

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morbid physical conditions that resulted in the worsening of Lisa's progressive

and obviously grave condition. An accepted and pervasive staff attitude and
approach of ignoring patient needs was clearly and openly endorsed by registered
nurses who were all trained and educated to address health concerns for every
patient regardless of circumstance or offense.

OPINION # 9: Brad Stoney, a registered nurse employed at the Salt Lake County
Jail, breached professional standards of nursing care and his duty to act as any
reasonably prudent nurse would have acted in a similar circumstance to that of
providing or ensuring care to Lisa Ostler when he exceeded the scope of his nursing
practice in the creation of Lisa’s medical record information. Those breaches are so
egregious that his actions, failures to act, and refusals to act cannot have been the
result of the exercise of professional nursing judgment. Nurse Stoney failed and
refused to protect Lisa Ostler's health and safety. Those breaches were caused by a
widespread practice and custom of deliberate indifference toward the serious medical
needs of patients, generally, which resulted in the deliberate indifference toward the
serious medical needs of Lisa Ostler, specifically.

Basis for Opinion #9:

A. Nurse Brad Stoney was responsible to comply with medical record policies
regarding the complete and accurate documentation of patient care. Nurse Stoney
knowingly created a clinical record for Lisa Ostler that included medical
diagnoses with accompanying ICD-10 codes, an action that was outside the
scope of his practice. Stoney assigned erroneous diagnoses to Lisa Ostler in
the absence of clinical evidence and without corroboration of an advanced
licensed medical provider qualified to render diagnostic medical assignments.

Nurse Brad Stoney was an experienced, medically trained nurse. He knew

the nursing standards for patient care, treatment and documentation for which he
was responsible and accountable. He was trained and knew the policies,
procedures and protocol of the Salt Lake County Jail. He knew the scope of his
nursing practice and the importance of not exceeding the parameters of that
practice.

Nurse Stoney prepared a diagnostic template that he assigned to Lisa

Ostler via her medical record in the absence of qualified medical involvement.
Nurse Stoney was not qualified to render medical diagnoses for a patient. The
diagnoses listed in Lisa's chart served to create and support assumptions by
nursing staff that her complaints of pain were simply related to drug withdrawal.

Brad Stoney e-mailed Dr. Brad Lewis and Dr. Paula Braun on March 30,
2016, regarding a new detainee, Lisa Ostler. Nurse Stoney knew that Ms. Ostler

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 CONFIDENTIAL

had not been seen or evaluated by either of the physicians he contacted. She was
not seen by any physician or advanced care provider at the jail. She was seen by a
nurse for a physical exam. On March 30, 2016, Lisa's medical record and Nurse
Stoney’s e-mail included medical diagnoses, ICD-10 codes and a list of verified
medications. The medical diagnoses listed included:
OPIOID USE, UNSPECIFIED WITH WITHDRAWAL [F1193],
SEDATIVE/HYP/ANXIOLYC DEPENDENCE W WITHDRAWAL,
UNCOMPLICATED [F13230], AND
ENCOUNTER FOR SCREENING FOR RESPIRATORY TUBERCULOSIS
[Z111].

B. Diagnosing a patient’s condition is solely the responsibility of a qualified

advanced care provider. Only the physician, or other qualified healthcare
practitioners legally accountable for establishing the patient’s diagnosis, can
medically “diagnose” a patient. The assignment of a diagnosis code is based on
the provider’s diagnostic statement that the condition exists and diagnosis coding
must be based on provider documentation. It is appropriate for facilities to ensure
that documentation is complete, accurate, and appropriately reflects the patient’s
clinical conditions.28 There is no evidence to suggest that the Salt Lake County
Jail staff conducted any clinical verification that Lisa Ostler's assigned diagnosed
conditions actually existed.

A registered nurse is not licensed or qualified to diagnose patient medical

conditions. Lisa Ostler was not diagnosed with the conditions cited by Nurse
Stoney as a result of an advanced practitioner's examination and documentation.
Rendering a medical diagnosis is outside the scope of registered nursing practice
and is considered practicing medicine without a license. Entering medical
diagnoses not assigned by a physician who actually performed and documented
the patient evaluation or examination is a falsification of medical record
information. No physician or other qualified healthcare provider legally
accountable for establishing a medical diagnosis saw Lisa Ostler or provided
medical record documentation to support the diagnoses assigned to her on March
30, 2016.

On the date and at the time Nurse Stoney sent the e-mail to Doctor Lewis
and Paula Braun, Lisa Ostler was not in either opioid or sedative withdrawal and
was not positive for withdrawal at any time during the days of her incarceration at
the jail. Assignment of medical diagnoses by a nurse with insufficient education,
training, and licensure to perform that function who based the diagnoses on
inaccurate, ill-informed, erroneous clinical information demonstrated a knowing

28
Land, Daniel, RHIA, CCS, Director of Compliance Review Services, CD-10-CM/PCS Coding Clinic,
Fourth Quarter ICD-10 2016.

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 CONFIDENTIAL

breach of nursing standards of care and failed to account for the accurate
diagnosis of Lisa Ostler’s serious medical needs.

Nurse Stoney recorded Lisa's verified medications. The medication

Pentasa, for Crohn’s disease, was not verified and Nurse Stoney took no actions
to seek verification or determine the necessity of her medication for the arthritis
condition. When Dr. Brad Lewis deferred Lisa's prescribed medication to mental
health for review, Stoney took no action whatsoever to facilitate a timely
appointment with a mental health provider to ensure timely consideration of
continuing her medications and ensuring continuity of care for her serious
medical needs. Stoney took no actions to ensure that Lisa was monitored for the
sudden cessation of all of her medications.

Nursing staff minimized and even disregarded Ms. Ostler’s complaints of

pain, purportedly viewing them in the context of “typical” drug withdrawal. Brad
Stoney, RN, without proper knowledge, training, or licensure, recklessly created a
medical record reflecting an inaccurate clinical picture of Lisa Ostler’s serious
medical needs that overshadowed the actual and legitimate medical crisis she
ultimately experienced.

Any medically trained nurse providing care and treatment in the same or
similar circumstance to that of providing care for Lisa Ostler would know
assignment of a medical diagnosis sets treatment and care plans in motion that
guide the medical care a patient receives. Any medically trained nurse would
know they are not qualified to render a medical diagnosis and would know that
doing so could have a very negative impact on a patient’s treatment and health.

Any medically trained nurse providing care to a patient such as Lisa Ostler
would know that timely evaluation of a prescribed medication regimen is
essential for management of serious medical conditions and that continuity
of care was required to avoid disease progression or reoccurrence.

Any medically trained nurse would know the scope of their nursing
practice and the importance of practicing according to the limits of their
professional boundaries. Any medically trained nurse knows they cannot diagnose
medical conditions and would know the potential consequences of misdiagnosis
or failure to diagnose existing medical conditions.

C. Nurse Brad Stoney took no action to ensure that Lisa Ostler was properly
evaluated by an advanced level provider to diagnose her medical conditions.
Stoney took no action to ensure that Lisa Ostler was scheduled to be seen
by a mental health provider to evaluate continuation of medications that were

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deferred by Dr. Brad Lewis and Dr. Paula Braun and he took no action to contact
a mental health provider to discuss continuation of any of Lisa’s medications. He
took no action to ensure that the documentation in Lisa's medical record was
determined by a qualified advanced medical provider.

OPINION #10: A culture of widespread disregard for the serious medical needs of
patients at risk for drug withdrawal existed among the nursing staff of the Salt Lake
County Jail. Cultural, customary, and accepted practices among nurses at the jail of
ignoring required assessments, refusing to perform focused assessments, minimizing
and discounting pain complaints, refusing to respond to health care requests, and
refusing to monitor the ongoing health status of inmates diagnosed with drug
withdrawal resulted in a catastrophic outcome for Lisa Ostler.

Basis for Opinion #10:

A. All of the nurses involved in Lisa Ostler's care at the Salt Lake County Jail
ignored, minimized and discounted Lisa Ostler's pain complaints and requests for
medical help. Not one registered nurse conducted a pain assessment or performed
a focused assessment in response to Lisa's expressed health care needs and
requests or the concerns raised on her behalf by other inmates and housing unit
officers. Even the Central Control operator, Sparkuhl, subscribed to the pervasive
cultural approach of ignoring patient complaints when the individual was
identified as undergoing drug withdrawal if instructed by a housing officer to
ignore the repeated pressing of their emergency buttons and expressions of pain
and desire for medical assistance.

The accepted and pervasive staff attitude and approach of ignoring patient
needs was clearly and openly endorsed by registered nurses who were all trained
and educated to address health concerns for every patient regardless of
circumstance or offense.

NONE of the nurses who had contact with Lisa assessed her for pain, not
eating, hydration, abnormal vital signs, declining physical status, medication
need, or the presence of co-morbid physical conditions that resulted in the
worsening of Lisa's progressive and obviously grave condition. Lisa's requests for
medical help were ignored and her complaints were casually viewed as due to
drug withdrawal without consideration that an inmate could have a medical
emergency, related or unrelated to withdrawal. Nursing staff that were made
aware of Lisa's requests for medical help and the staff that came into contact with
her repeatedly and consistently ignored her signs and symptoms and pleas for
medical help. As a result, Lisa did not receive essential life-saving care, leading to
her death.

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 CONFIDENTIAL

The multiple failures and refusals by multiple nursing staff that reflected a
culture and widespread practice at the jail of ignoring Lisa Ostler's serious
medical needs included:
• Refusal to complete CIWA/WOWS assessments as ordered;
• Refusal to follow training directives;
• Refusal to follow directives of medical leadership;
• Refusal to conduct assessments in response to officer reports, inmate
requests for medical help, abnormal clinical findings, and clinical
symptoms;
• Repeated and consistent refusals to provide basic care to meet medical
needs including nutrition, hydration, pain management, and medication
continuation;
• Refusal to perform clinical duties and responsibilities in a thorough,
complete, and ethical manner;
• Refusal to accurately and completely document care actions,
observations, and clinical findings in an accurate, ethical, and thorough
manner to facilitate care follow up and continuity.

Lisa Ostler’s serious medical condition steadily worsened from 3/31/2016

to 4/2/2016. Within this critical time period jail nursing staff failed and
refused to provide essential medical assessments and care that would have
been lifesaving. Jail nursing staff contacted Lisa for CIWA and WOWS
assessments on five occasions following a comprehensive nursing examination
that took place at the time of her booking. Three of the withdrawal assessments
took place between 3/31and 4/2. Registered nursing staff at the Salt Lake County
Jail, including, at a minimum, Ron Seewer, had contact with her on six occasions
between 3/31 and 4/2. They had numerous opportunities to address Lisa's serious
medical needs in the hours that preceded her being found unresponsive and not
breathing in her cell. None of the nursing staff contacted by housing unit officers
per Salt Lake County Jail policy in the last two days of her life assessed Lisa
Ostler or in any way or attempted to address her serious medical needs.

By the morning of 4/1/2016, Lisa Ostler’s condition had become

exponentially more severe and her condition was grim. She followed the jail
procedure to try to obtain health care for her emergent condition. Nurse Ron
Seewer was informed she had pain by Housing Officer Todd Booth but
disregarded her complaints, performed no pain assessment, did not meet her
serious medical needs and, as a result, her serious medical needs worsened.

Lisa Ostler was able to walk, albeit with difficulty due to pain, in a bent
posture with her arms holding her abdomen, to the clothing exchange on 4/1/2016
at 11:10 PM. She made every attempt to follow the rules, procedures, and
requirements of the jail. One of the procedures to obtain needed health care was

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explained in a posted sign for inmates to see at the time they were booked. The
sign stated in part:

“Health care is available at all times in the jail.

If you need help with a medical, mental health or
dental problem, please follow this procedure:
1. If it is an emergency, notify any officer or nurse of
your need immediately…”

On the morning of 4/2/2016, Nurse Brent Tucker was informed of Lisa’s

repeated pressing of her emergency button, her failure to eat, and vaginal bleeding
but disregarded the information, performed no assessment, inappropriately
directed the Housing Officer to contact medical if it was an emergency. As a
result, Lisa’s serious medical needs continued to be ignored, not assessed, and not
met and her condition continued to deteriorate further. Nurse Colby James was
informed that Ms. Ostler was requesting to see medical but would not complete a
sick call request. Nurse Colby James ignored Lisa’s verbal request for medical
attention, inappropriately delegated the determination of whether she had an
emergency to the Housing Officer and for the third time nursing staff who were
directly informed by officers of Lisa's complaints conducted no assessments and
did not in any way address her medical complaints. Lisa Ostler did not have
another opportunity to request medical attention before she became unresponsive
and stopped breathing. Literally, she used some of her last breath to request
medical attention for her serious medical needs.

The nursing staff of the Salt Lake County Jail collectively demonstrated a
degree of disregard for Lisa's medical needs and requests that could only persist if
it was accepted as common or usual practice and was understood by nursing staff
to be "business as usual".

B. Medically trained registered nurses providing care to an inmate such as Lisa

Ostler in a similar circumstance would not ignore an inmate complaint, would not
dismiss officer reports of inmate symptoms and requests to see medical staff,
would not ignore inmate symptoms and would not refuse to perform health
assessments or refuse to provide essential nursing care. Any medically trained
nurse would conduct a face-to-face assessment after receiving notice of an inmate
complaint and request to see them. Based upon the nature of the complaint a
medically trained nurse would conduct a review of the patient's medical history
and would perform a face-to- face assessment to determine the appropriate actions
to take in response to the issues presented and observed.

C. For the medical needs that were documented, Lisa was not provided
reasonable, basic, essential health care. She experienced nausea and diarrhea and

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 CONFIDENTIAL

received PRN medication; however, she was never assessed for dehydration, she
was not provided adequate fluids, her nutritional status was completely ignored,
and no nurse evaluated her abnormal vital signs.

Several nurses at the jail came into contact with Lisa for intake,
assessments, medication administration, and at the request of officers yet not one
of them took any action to address abrupt cessation of medications, abnormal vital
signs, physical appearance of deterioration, symptoms of serious illness, or pain.
Not one of the nurses conducted a pain assessment or any physical assessment for
reported symptoms. Any medically trained nurse would know that patients with
suspected or potential drug withdrawal could also have an unrelated serious
medical condition and should be properly assessed to rule out the presence of an
urgent or emergent condition.

OPINION #11: The failure and refusal of nursing staff to conduct CIWA/WOWS
assessments at the Salt Lake County Jail did not simply occur with regard to Lisa
Ostler. A recurring and widespread practice of not completing assessments as
ordered or indicated included a failure of nursing staff to perform required
withdrawal protocol assessments for many inmates and an alarming number of
inmates who were not assessed, like Lisa Ostler, died at the jail or died shortly after
being released.

A review of the medical records for nine other inmates with orders for CIWA and
WOWS assessments revealed they all had missing or incomplete information or no
assessment information at all. All of the inmates died. None of the inmates received
assessments as ordered and the majority of the inmates received fewer than half of
the assessments that should have been performed. The documentation and absence
of documentation of withdrawal assessments for a life-threatening condition by the
nursing staff of the Salt Lake County Jail illustrates enough deficiencies to conclude
that the refusal by medically trained nursing staff to perform withdrawal
assessments as ordered and required was a widespread systemic problem. As a
medically trained nurse I am able to conclude that the frequency with which
assessments were not performed reflected a widespread acceptance among nursing
staff of a culture and custom of practice that ignored inmates’ serious medical needs
and demonstrated a failure and refusal to perform assessments designed to identify
those needs.

Basis for Opinion #11:

A. Nursing staff of the Salt Lake County Jail repeatedly failed and refused to
perform ordered CIWA and WOWS protocol withdrawal assessments,
demonstrating a failure to meet professional nursing standards, accreditation

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 CONFIDENTIAL

standards, facility policy and procedure, facility directives and training

requirements, demonstrating a widespread and accepted culture and practice
within a professional staff group.

B. The scope of practice of a registered nurse does not include unilateral authority
to decline to follow a physician’s order or the physician's expressed plan of care.
All nurses owe a duty to the patients they serve. According to the American
Nurses Association, a nurse “promotes, advocates for, and strives to protect the
health, safety, and rights of the patient." Additionally, a nurse is both responsible
and accountable for his or her individual nursing practice and is in a position to
monitor the patient's illness, response to medication and interventions, display of
pain and discomfort and general condition. Clearly the registered nurse is in the
unique position to control all aspects of an inmate's access to care, assessment,
treatment, medication, and life-saving interventions. They play a significant
gatekeeping role for determining whether inmates have access to medical care and
for determining what care the inmates receive. When nurses ignore inmate
complaints or officer reports of an inmate's needs or requests for care, the inmate
may be denied essential care for serious medical needs. This happened to Lisa
Ostler.

C. There is still apparent confusion as to who was responsible for conducting

WOWS and CIWA assessments, including the monitoring of vital signs, for Lisa
Ostler after she was moved to Unit 8C. Making certain that everyone knew their
nursing responsibilities was the responsibility of Richard Bell and other members
of the jail administration such as the nursing supervisor. To neglect that
responsibility leads to vital evaluations and other medical services not being done.
When people do not know what they are responsible for, things slip dangerously
through the cracks. In a medical setting, that can be fatal, as it was for Lisa Ostler.

Nurse Seewer testified he was not responsible for doing the assessments of
Lisa Ostler when she was in Unit 8C, including taking vital signs, even though he
was working in 8C on 4/1/2016. Curiously, he testified that a nurse from an
adjacent jail was responsible for doing the assessments. Others, including Todd
Riser, testified that the “pod nurse” was responsible for doing the assessments, not
a nurse from the adjacent jail.

No document has been produced indicating who was responsible for doing
the assessments. Curiously, counsel for Defendants, Bridget Romano, wrote to
counsel for Plaintiffs, explaining that a roster identifying who was working where
on 4/1/2016 identified “Disa” as being assigned on 4/1/2016 to C Pod. However,
jail records reflect that a Disa was never in C Pod on that date. Reinforcing the
chaotic situation leading to an absence of anything identifying who was
responsible for conducting the WOWS and CIWA assessments, Defendants’
counsel wrote a letter to Plaintiffs’ counsel stating as follows:

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And though the log does indicate that a nurse named “Disa” was
assigned to Charlie Pod for the shift beginning at 0600 hours and
ending at 1800 hours on April 1, 2016, a careful review of the
pertinent shift and medical logs now in the Jail’s possession
contains no indication “Disa” provided services in that pod on that
day.

Defendants’ counsel also wrote:

[T]he log is not considered by the Jail to be a [sic] reliable . . . .

Incredibly, Defendants and the Responsible Health Authority, Richard

Bell, and their counsel apparently are unable, to this day, to identify who was
responsible for doing the CIWA and WOWS assessments for Lisa Ostler after she
was taken to Unit 8C, which reflects incredible disorganization and a pattern,
custom, and ongoing practice of failing to make clear who among nursing staff
was responsible for doing what. That pattern, custom, and ongoing practice
contributed to the failure to provide the CIWA and WOWS assessments,
including monitoring vital signs, of Lisa Ostler, leading to her suffering and
death.

Although Richard Bell is responsible for making certain that inmates

receive timely, responsive, necessary medical services, there was no CIWA or
WOWS assessment of Lisa Ostler when she was in Unit 8C, although it was
ordered and was required by policy, yet neither Bell nor anyone else in the jail
administration ever disciplined or identified anyone as being the nurse responsible
for the assessments that were not done. That lack of response by Bell and other
supervisory or administrative personnel further evidences an unconscionable and
dangerous laxity in the provision of necessary medical services for inmates at the
jail. The sloppiness in identifying which nurses were responsible for conducting
assessments, including the monitoring of vital signs, likely explains, in at least
large part, why so many inmates at the jail did not receive their ordered CIWA
and WOWS assessments, including the monitoring of vital signs, recklessly and
obviously creating life-threatening risks to their health.

D. Inmates other than Lisa Ostler were denied access to care and assessments.
CIWA and WOWS assessments, when ordered, are to be performed twice daily
for 5 days. The CIWA Alcohol Withdrawal Assessment Scoring Guidelines cites
nursing assessment as vitally important. The refusal and failure of nursing staff to
conduct clinical withdrawal assessments for inmates experiencing drug
withdrawal were inexcusably common:

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- WOWS assessment was ordered on (SLCo Ostler

003328, 3347) but only performed once on and twice on - only
3 assessments of 10 were completed;

- CIWA assessment was ordered on by Dr. Wilcox

(SLCo 003722, 003917-21, 4072-76) but only performed 7 times from
- - only 7 assessments of 10 were completed;

WOWS assessment was ordered (SLCo 003699, 003779, 003993). He

was booked on . WOWS was only performed once on
and once on ;

– CIWA assessment ordered on (SLCo 29654-29656).

Assessments were ordered on . Only one assessment was
performed on . No assessments were performed on –
only 7 of 10 assessments were completed;

- CIWA assessment was ordered on for alcohol abuse

(SLCo 004478,4911). She was booked on . CIWA was only performed
twice on (SLCo 4794-95). A WOWS assessment was performed just
once on despite a nursing pre-screen showing use of and
;

WOWS assessment was ordered on (SLCo 004533-34, 4935-36).

The assessment was performed just 4 times of 10 on , , and .
She refused one assessment on .

WOWS assessment was ordered on (SLCo 004536, 4937). She

was booked on . The assessment was performed 3 times of 7 as she
was discharged on .

WOWS assessment was ordered on (SLCo 004550, 4945).

The assessment was performed 4 times of 10.

WOWS assessment was ordered on (SLCo 004581, 4962).

The assessment was performed 5 times of 10.

WOWS assessment ordered on (SLCo 004591-93)

5 assessments of 10 performed.

WOWS assessment ordered on (SLCo 004621-23, 4986-88)

6 assessments of 10 performed.

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 CONFIDENTIAL

WOWS assessment ordered on (SLCo 4638-40, 4991-93)

5 assessments of 10 performed.

WOWS assessment ordered on (SLCo 4657-59)

6 assessments of 10 performed.

WOWS assessment ordered on (SLCo 4672-74, 4700, 5007-09)

4 assessments of 10 performed.

WOWS assessment ordered on (SLCo 4701, 5021)

7 assessments of 10 performed.

CIWA assessment ordered on (SLCo 4719)

6 assessments of 10 performed.

CIWA assessment ordered on (SLCo 4736)

3 assessments of 10 performed.

CIWA assessment ordered on (SLCo 4787-89, 5069-71)

4 assessments performed
No assessments performed on , one performed on , no
assessment on , one performed on , 2 assessments on
and was released.

- WOWS assessment ordered on (SLCo 006329-31)

4 of 6 assessments completed for , , . Released .

- CIWA assessment ordered on (SLCo 006420-22)

5 of 10 assessments performed.

CIWA assessment ordered on (SLCo 006427)

No assessment performed on ; released .

- CIWA assessment ordered on (SLCo 008041-42)

6 of 10 assessments performed.
CIWA assessment ordered on (SLCo 008028-32)
7 of 10 assessments performed. Only 1 assessment
performed on , , and .

- WOWS assessment ordered on (SLCo 004218-19)

Only 1 assessment performed on and only 1 performed on .

– Seen by Robert Richards, CSW of mental health for a crisis visit

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OPINION #12: The nursing staff of Salt Lake County Jail failed and refused to
follow Jail policy and procedure to notify the physician immediately when signs of
withdrawal were noted. Those failures reflect a widespread practice and custom and
result from a failure to ensure proper training and supervision.

Basis for Opinion #12:

A. The Salt Lake County Jail, Health Services Unit, Procedure for Intoxication and
Withdrawal (SLCo Ostler 001717 – 001719), states that the physician is to be
notified immediately for signs of withdrawal. Signs of withdrawal include a
heart rate greater than 110. Todd Riser testified that a heartbeat greater than 110
can be a sign of withdrawal (Riser Deposition, p 98) and that the physician is to
be notified immediately if there is a sign of withdrawal (Riser Deposition, p 99).
Nursing Supervisor Riser testified that the practice of the nurses was not to notify
a physician for a heart rate greater than 110 (Riser Deposition, p 100).

B. On 3/31/2016, Lisa Ostler’s heart rate was 119 at 9:20 AM and increased to a
more alarming rate of 133 at 2:50 PM, coupled with a dramatic decrease in her
blood pressure. Shockingly, physician was contacted. In addition, no CIWA

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assessment of withdrawal symptoms was performed – the entire symptoms

assessment column was blank.

Any medically trained registered nurse would know the importance of following
the policy and procedure of the facility in which they provided patient care and
supervision. Any medically trained registered nurse would be able to evaluate a
patient’s vital signs and know the importance of reporting vital signs that are
significantly abnormal. The American Heart Association identifies a normal heart
rate for an adult as 60 – 100 beats per minute. A heart rate of 119 that elevates to
133 with a concurrent drop in blood pressure is an abnormal and alarming clinical
situation. For a patient such as Lisa Ostler, being monitored for life-threatening
drug withdrawal, notification of a physician was essential. Any medically trained
registered nurse would know to contact an advanced medical provider to notify
them of a patient’s abnormal vital signs and to receive further orders or directions
for patient care.

In the case of , on , an increased BP of 162/109 and reports

by the mental health social worker of his significant signs of withdrawal from
alcohol did not result in a CIWA assessment monitoring or report to a physician
or to mental health.

C. The nurses at the Salt Lake County Jail failed and refused to follow up with an
advanced care provider regarding Lisa’s significantly abnormal vital signs.
Similar failures and refusals are again evident with
demonstrating that nothing had changed in the approach to inmates
suffering alcohol and drug withdrawal as a result of Lisa’s death. The refusal to
seek care for Lisa’s clinical presentation was consistent with an accepted and
pervasive staff attitude and approach of ignoring patient health condition,
presentation and medical needs, clearly and openly endorsed by registered nurses
who were trained and educated to address health concerns for every patient
regardless of circumstance or offense.

OPINION #13: Scott Sparkuhl, the night shift (graveyard shift) Central Control
Operator on Unit 8C at the Salt Lake County Jail, knowingly and obviously ignored
Lisa Ostler's repeated calls for medical help for her serious medical needs in
violation of facility policy, procedure, training, and common knowledge that any
correctional staff person would possess. Nursing staff rely on custody staff to report
inmate requests for medical attention and depend on custody staff to notify them
when inmates verbally request care or appear to need care.

Scott Sparkuhl, refused and failed to refer Lisa Ostler’s repeated calls for
emergency medical assistance throughout the night of 4/1/16 to the Housing Unit

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 CONFIDENTIAL

Officer, a violation of jail facility policy and procedure. He knowingly chose not to
refer her calls reporting she was in pain and needed help as facility policy and
procedure and his training required (Sparkuhl Deposition, p 21). He failed to
respond to numerous calls from Lisa for help despite her telling him she was in pain
and needed medical help and despite also receiving calls from other inmates
expressing concern for and about Lisa's health and well-being. Central Control
Operator Sparkuhl intentionally chose not to respond in a manner consistent with
facility requirements to refer an inmate's request for emergency medical attention.
Central Control Operators and Housing Officers are not qualified or trained to
determine if an inmate’s requests for medical care require an urgent medical
response. Medical staff are the only staff to make the determination about medical
need and require that custody staff follow facility procedure to notify them that an
assessment and evaluation is needed.

As a registered nurse, having worked with corrections officers and correctional

control room staff for many years, including on the night shift, I am able to state an
opinion that addresses staff responses to the medical requests of inmates. It is never
appropriate for staff to ignore a patient's request for medical help. It is never
appropriate for staff to ignore a patient's request for help in an emergency. It is
never appropriate for a staff member to ignore calls from a particular inmate unless
they report new information. A control operator is not trained or qualified to triage
a patient's requests for medical care over an intercom and is not qualified to
determine if a patient is reporting new symptoms or whether their request is new
information. Control Room Operators have no access to a patient's medical record
or medical history. Custody staff have a responsibility to report all medical requests
from an inmate to medical staff for triage and intervention - no matter how many
times the inmate calls to request medical help.

Sparkuhl’s conduct of “ignoring” Lisa’s repeated calls for help was pursuant to
instruction by a housing officer, which, reflecting a widespread practice and custom,
was the same instruction he had received “a dozen or so” times in the past. This
abhorrent custom was so pervasive that the so-called “ignore protocol” could be
initiated with the shorthand instruction to “ignore the cell.”

A. Scott Sparkuhl, was a Central Control Operator at the Salt Lake County Jail
during the night shift or graveyard shift on 4/1/16 from 11 PM through 7 AM
on 4/2/16. He testified that his job responsibilities included engaging in
communications with inmates if they pushed a button in their cells (Sparkuhl
Deposition, p 20). He was trained that inmates were to use the buttons in their
cells to communicate with the housing officer or for emergency situations when
the housing officer was not there (Sparkuhl Deposition, p 21). Sparkuhl testified
that the intercom system was an emergency communication tool (Sparkuhl
Deposition, p 22).

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 CONFIDENTIAL

Throughout the night of 4/1/2016, Operator Sparkuhl, received calls via

the emergency intercom from Lisa Ostler approximately 1-2 times per hour, up to
16 times throughout the night. She reported that she was in pain and needed
medical help. Operator Sparkuhl was instructed by the housing unit officer, Todd
Booth, to “Go ahead and ignore the cell” and only pass along new information
(Sparkuhl Deposition, p 51). Based upon the officer’s directive, Sparkuhl only
communicated to the housing unit officer once or twice about Lisa’s requests and
took no other action to ensure that medical assistance was provided to her. He
testified that he had previously been told by housing unit officers to ignore
inmates' calls when they were reporting serious medical problems and needed
help (Sparkuhl Deposition, p 67, 104) throughout the four and a half years he had
worked in the control room. There is no information to suggest that Operator
Sparkuhl questioned the direction to ignore an inmate’s request for emergency
medical help.

Sparkuhl knew that Lisa was calling for medical help repeatedly
throughout the night shift. He knew that the correct procedure was to notify the
housing unit officer each time he received a call from an inmate requesting
medical help. Operator Sparkuhl was not trained to triage calls for medical
help and he was not trained or qualified to determine if a medical need reported
by an inmate was "new information". Sparkuhl had no access to an inmate's
medical history or record.

Sparkuhl knew that intentionally ignoring an inmate's request for

emergency medical attention was not consistent with jail facility training and
expectations or in compliance with jail policy, procedure or protocol. Any
reasonable jail officer or control room operator would know that intentionally
ignoring an inmate's request for emergency help was not accepted practice. Any
housing unit officer should know that it was inappropriate and a violation of jail
policy, procedure and protocol to instruct another staff person to ignore calls from
a particular inmate who was requesting emergency help.

Sparkuhl would have known that if he did not report Lisa Ostler's requests
for medical care and assistance she would not be seen by a nurse or any other
medical person for evaluation of her complaints and any serious medical
condition would not be addressed. Sparkuhl would also know that he was not
qualified to determine whether Lisa needed medical attention or not. There is no
information to suggest that Sparkuhl was concerned about Lisa not receiving
medical attention or that he was at all concerned she was repeatedly reporting a
medical emergency for which she would not receive attention as he was
intentionally and knowingly ignoring her and disregarding her complaints as not
being "new information". There is no information to suggest he did anything but
simply ignore her calls in order to get through his job without being "crushed" by

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 CONFIDENTIAL

the horrible situations people like Lisa were going through (Sparkuhl Deposition,
p 108). Sparkuhl’s actions failed to serve Lisa’s serious needs in any way.

In addition to Lisa's repeated calls for medical attention, Sparkuhl also

received calls from other inmates on the unit checking on Lisa and reporting her
cries. One inmate reported she heard Lisa crying and sounding like she was in
pain (Sparkuhl Deposition, p 98). Sparkuhl took no action to ensure that Lisa
was referred for medical attention or had her pain evaluated in response to
multiple concerns expressed by other inmates. He simply ignored their calls too.
Any jail staff would know that an inmate crying out, pressing their emergency
call button and requesting emergency medical help in a manner that raised
concerns of people around them should be assessed by a qualified medical
provider. The established protocol was for a Central Control Operator to
communicate an inmate’s call expressing pain and the need for medical assistance
to the Housing Officer to contact a nurse, then for a nurse to come to the inmate
and conduct an evaluation. The failures at every one of those steps led to Lisa’s
suffering and death. Even the layperson inmates on 8C knew that Lisa should be
given medical help. Despite attempts to intervene on Lisa's behalf, calls from
other inmates were completely ignored just as Lisa's calls were ignored.

B. Regardless of the job position one holds in the jail, whether Housing Unit
Officer, Central Control Operator, or Registered Nurse, it is never appropriate or
acceptable to ignore an inmate’s requests for medical care for an entire shift of
duty, for hours, or at any time. Any custody, control room, or medical staff person
providing supervision and care in a jail facility in a circumstance similar to that of
providing care and supervision to Lisa Ostler would have known that ignoring
requests for medical care is a violation of jail standards, policy and procedure,
training, ethical and professional behavior, and common sense.

It would be clear and obvious to any jail officer, control operator or health
care provider that an inmate crying out repeatedly for hours, begging for medical
care, and attempting to summon help by calling on an emergency intercom system
1 to 2 times per hour required medical care or at the very least required a medical
contact for assessment. Lisa Ostler’s repeated appeals and cries for medical help
were knowingly and intentionally ignored by both Central Control Operator
Sparkuhl and Housing Officers. A Housing Officer specifically directed Sparkuhl
to ignore Lisa’s calls and Sparkuhl, without questioning the directive, complied.
As a result, Lisa's very serious medical condition of peritonitis progressed and
worsened and she did not receive the care or treatment needed to save her life.

C. Sparkuhl testified in his deposition that before his contact with Lisa Oster
he previously experienced housing officers telling him to ignore inmates' calls

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 CONFIDENTIAL

when inmates reported they were experiencing a serious medical problem and
needed help. He stated he followed the instructions to ignore the calls (Sparkuhl
Deposition, p 68). Sparkuhl intentionally ignored Lisa's cries for medical help
throughout the night shift on 4/1 into the AM of 4/2 - for 8 hours - and failed to
exercise any judgment whatsoever about whether his actions were reasonable or
consistent with the policy, procedure, or expectations of the jail or whether those
actions reflected ethical or responsible behavior toward individuals within his
control and custody. Operator Sparkuhl failed to ensure the health and safety
of an inmate over whom he had considerable control. When Lisa pressed the
emergency button in her cell and the call went to the control room, Operator
Sparkuhl owned the decision to determine how the call would be addressed. He
was the individual who would decide whether her calls were reported to the
housing unit officer. He repeatedly ignored her calls for emergency assistance and
did not report them to the housing officer, an action that was intentional,
deliberate, and inexplicable as it relates to his responsibility to ensure that an
inmate's request for emergency help received attention.

Sparkuhl testified that the instruction from the Housing Officer to ignore
inmate calls was part of his job. He stated he would ask if the inmate had new
symptoms and pass the information along to the Deputies and assumed they were
already aware of the situation. He testified he assumed that medical was
also aware (Sparkuhl Deposition, p 103). No evidence suggests that Sparkuhl did
anything to validate any of his assumptions when he ignored inmate calls for
emergency medical help. Sparkuhl did not have access to a patient's medical
information and was not trained or qualified to triage an inmate's medical
situation. He had no basis upon which to determine if an inmate's request for
emergency medical attention included new symptoms. He controlled the inmate's
access to medical care without having sufficient knowledge, training, or hands-on,
face-to-face information about their health situation or the urgency or their serious
needs.

NCCHC requires the health training program for correctional officers to

include a component for instruction in procedures for appropriate referral of
inmates with health complaints to health staff.29 Clearly, Operator Sparkuhl's
approach to referral of inmate complaints to health care staff was knowingly
deficient, inappropriate, and not consistent with essential requirements to
refer an inmate with health complaints to health care staff.

PREFACE TO OPINIONS #14 AND #15:

The Salt Lake County Jail Medical Director, Todd Wilcox, M.D., M.B.A.,

29
NCCHC, Health Training for Correctional Officers, CorrectCare, Summer 2013.

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 CONFIDENTIAL

CCHP-A performed an evaluation of medical care in Arizona prisons.30 His report,

published and reviewable on the internet and publicly available, was highly critical of the
care provided to inmates in several Arizona prisons and provided a remarkable and
revealing outline of glaring deficiencies in a privately managed correctional health care
delivery system. His evaluation included requirements and recommendations for medical
care in a correctional environment and deserves careful consideration in this report on the
medical care and treatment that Lisa Ostler received at Dr. Wilcox's Salt Lake County
Jail facility where the privately managed WellCon correctional health care delivery
system was contracted to provide inmate health care. In 2013 Dr. Wilcox’s report laid
bare failures that had serious negative effects for Arizona’s inmate care. Three years after
his report, in 2016, the very failures he cited in his assessment of the Arizona correctional
facilities were conspicuously reflected at the Salt Lake County Jail, where he directed
medical services - medical services that failed to ensure the health and safety of Lisa
Ostler.

Wilcox noted the most important major category of a functional medical care
delivery system was access to care: the seemingly simple task of getting patients to see
nurses and providers. He reported seeing delays in access to care and complete denials of
care where some delays were catastrophic and entirely preventable. He noted further that
the systematic failure to provide timely access to care placed all patients at an
unreasonable risk of serious harm. Patients with significant injuries or illnesses were not
safe and were at serious risk of preventable negative outcomes. Delay in access to care,
and denial of care to Lisa Ostler at the Salt Lake County Jail was indeed catastrophic and
preventable. The seemingly simple task of getting Lisa to see a nurse did not occur.

Wilcox described patient access to sick call as critical, with the most critical
component of a correctional healthcare sick call system being triage. He stated triage
must be done face to face by an appropriately licensed healthcare provider (RN or
above), and it must contain the basic elements of an assessment including brief history,
vital signs, exam, and a disposition. He noted that sick call was the doorway to care, and
patients must be seen quickly, sorted out, and provided quick referrals to urgent care or
provider appointments as needed. Lisa Ostler was not provided access to sick call, was
not triaged, did not see an appropriately licensed healthcare provider for an appropriate
assessment, was not seen quickly or referred for urgent care as needed.

Wilcox noted that custody support was essential to achieve physical access to
care. In Arizona, as in Salt Lake City, officers acted as gatekeepers to care, preventing
patients from reaching medical staff. In the absence of a functional sick call system,
custody staff acted as gatekeepers for medical care and patients had to persuade them that
they needed help in order to get to medical staff. Medical staff seemed to have almost
entirely abdicated responsibility to custody staff. Reliance on custody staff as gatekeepers

30
Report of Todd Randall Wilcox, M.D., M.B.A., C.C.H.P.-A, Parsons, et al. v Ryan, et. al., No. 2:12-cv-
00601-NVW November 8, 2013.

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 CONFIDENTIAL

to such a degree is a dangerous practice. Unlicensed, unqualified people are making

medical decisions. Lisa Ostler attempted mightily to persuade the gatekeepers, Control
Operator Sparkuhl and Housing Unit Officers Booth, Holly Harris, and Frederickson, of
her need to see medical staff, to no avail. The unlicensed, unqualified, untrained custody
staff at Salt Lake County Jail made the medical decisions about Lisa when nursing staff
abdicated healthcare decision-making and responsibility to them.

Wilcox went on to state that patients must be seen and care needs identified,
both on intake and throughout their prison terms. If access to care is poor, the system
blocks professional judgment from operating. Patients must not only be seen by
appropriate clinicians and given appropriate diagnoses and treatment orders; they must
actually receive the care – medications, labs and other diagnostic tests, special diets --
that is ordered. Teamwork, communication, and good documentation are essential to
ensure that care that is ordered is actually provided to patients. Orders written by
providers must actually be carried out. Prescribed medications must be provided to
patients in a timely, consistent manner. Lisa Ostler did not receive care from an
appropriate clinician, was not given appropriate diagnoses or treatment orders and did not
even receive the meager care that she was ordered - she was not assessed as ordered, she
did not receive the one prescribed medication that was ordered, she was not assessed as to
her need for medications she had been prescribed prior to her incarceration, she was not
referred to a physician as ordered, and she was not provided adequate nutrition or
hydration.

Wilcox opined that medical care in Arizona prisons was simply inadequate to
meet the basic needs of many of the prisoners who experienced illness and injury while in
custody. In Arizona, Dr. Wilcox found systematic violations of policies and significant
barriers to care; serious concerns regarding emergency and inpatient care; signs of
custody interference with care, failure to provide patients with appropriate provider
medical judgment due to chaotic and disorganized medical records, nurses acting outside
of the scope of their licenses, denial of specialty care consultations, substandard decision-
making; and inability to provide patients with medically necessary medications. He stated
all of these problems harm patients. And all of these problems applied to the care and
lack of care of Lisa Ostler at the Salt Lake County Jail. And, indeed, she was suffering
and died as a result.

In my opinion, the medical care provided at the Salt Lake County Jail was, to use
some of Dr. Wilcox's words, significantly below community standards and placed
patients such as Lisa Ostler at serious risk of harm. In order to provide community
standards of care in a correctional setting, a system must be in place that allows patients
reasonable access to healthcare providers, professional clinical judgment on their case,
delivery of the care that is ordered, and self-correcting processes designed to minimize
preventable negative outcomes. Lisa Ostler was not afforded reasonable access to
healthcare providers, did not receive professional clinical judgment about her serious
medical needs, and did not receive care that was ordered. The result of the failures in care

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at the Salt Lake County Jail resulted in the most egregious negative outcome. Her death
was prolonged and painful. It was also preventable.

The Salt Lake County Jail Responsible Health Authority, Richard Bell, and the
Salt Lake County Chief Deputy, Pamela Lofgreen were administrative supervisory staff
responsible for the direction, leadership, and supervision of jail nursing and custody staff
and responsible for ensuring that detainees received necessary medical services to
minimize preventable negative outcomes. Mr. Bell was responsible to arrange for all
levels of health care and assure quality, accessible and timely health services for inmates
including medical, dental, mental health, nursing, nutrition, and environmental concerns.
He was responsible to coordinate health care programs with jail administration (SLCo
Ostler 001586). Mr. Bell failed to adequately train and properly supervise the nursing
staff responsible for providing medical care to inmates at the Salt Lake County Jail,
including Lisa Ostler.

Chief Lofgreen was the administrative law enforcement person responsible for
supervising, planning, coordinating, and directing the activities and personnel of the
Corrections Bureau of the Sheriff's Office. Lofgreen was responsible for ensuring that the
staff at the Salt Lake County Metro Jail followed all jail policies and procedures
(Lofgreen Deposition, p 23). Chief Deputy Lofgreen supervised the Health Authority,
Richard Bell (Lofgreen Deposition, pp 25-26). Chief Lofgreen failed to ensure adequate
training and proper supervision of the custody staff who were in charge as gatekeepers
for inmate access to care.

OPINION #14: The Responsible Health Authority for the Salt Lake County Jail,
Richard Bell, refused and failed to ensure the nursing staff under his supervision
performed their patient care duties and responsibilities in keeping with standards of
nursing practice, NCCHC standards, facility policy and procedure, and the intent
and expressions of the Salt Lake County Jail medical director. Under his direction
and supervision, jail nursing staff exceeded their scope of practice, failed on
numerous occasions to conduct withdrawal assessments as ordered, failed to
conduct patient assessments as indicated, failed to perform their job duties as
required, inappropriately abdicated medical assessments to correctional officers,
failed to document care, failed to conduct any pain assessments when indicated,
failed to monitor patient food or fluid intake, failed to respond to abnormal vital
signs, failed to observe and intervene for a patient with a worsening physical
condition, failed to accurately and ethically document actions, and failed to respond
to a patient's verbal requests for health care. Under his authority, supervision,
direction and leadership, Lisa Ostler's serious health care needs were not identified,
assessed, or appropriately treated.

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 CONFIDENTIAL

Under Bell's leadership, a culture and pattern of failures to provide essential care
and monitoring for the inmates of Salt Lake County Jail existed and was accepted
by nursing staff despite their knowledge of the essential need to adhere to
professional standards of nursing practice, ethical nursing standards, accreditation
standards, the Utah state nurse practice act and the policies and procedures of the
Salt Lake County Jail. Jail nursing staff failed to ensure that the health and safety
of Lisa Ostler was maintained.

Pervasive, repeated failures to perform assessments, provide monitoring, and

render care reflected an acceptance by leadership for nursing behavior that
breached standards of nursing care, industry standards of practice, nurse practice
acts, facility policies and procedures and the nursing code of ethics. Nursing staff
attitudes and approaches were openly endorsed and resulted in patient needs being
ignored. Such a collective group approach could only exist in an organizational
culture of tolerance for the practice at an administrative level.

A. Mr. Richard Bell was the Responsible Health Authority (RHA) at the Salt
Lake County Jail. He was responsible to ensure that health care was accessible to
all inmates regardless of diagnosis or circumstance, that care was timely and
appropriate, and that there was adequate staffing to cover the health care needs of
the inmates. He developed policy and procedures related to the Health Services
Division, oversaw the policies and procedures, and ensured that the care provided
by jail staff met the policies and procedures and quality measures of care (Bell
Deposition, 3/25/19 pp 28-29). Mr. Bell testified his responsibilities included
making sure that staff of the Health Services Division were adequately trained to
perform their jobs within the scope of their practice (Bell Deposition, 3/25/19, p
31). Mr. Bell was responsible to train nurses working at the Salt Lake County Jail
to enter correct and complete information in the patient medical record, including
noting medical encounters (Bell Deposition, 3/25/19, pp 32-33). He was
responsible for training nurses to make certain that information in the medical
records at the Salt Lake County Jail was accurate and complete. There was no
evidence to suggest that Richard Bell took any action to address nursing staff
failures to follow facility policy or procedures or that he took any action to
address their breaches of nursing standards or ethical codes.

Richard Bell is responsible for determining, through a Morbidity and

Mortality Review process, which includes a Morbidity and Mortality Review
meeting, what led to in-custody deaths of inmates, whether there were any
problems with what jail staff did leading to the deaths, and what can be done in
the future to prevent similar occurrences. However, the Morbidity and Mortality
Review process is obviously merely a pretense of reviewing the circumstances
surrounding in-custody deaths at the jail, but failing to ever lead to helpful
answers as to whether an error by someone at the jail contributed to a death or

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what corrective actions could be taken to avoid deaths in the future. When
questioned about Morbidity and Mortality Review meetings, Richard Bell made it
clear that no one present was to take any notes or create any documents so there
would be nothing accessible if there was later litigation. He also failed to
remember even the names of several people, let alone the circumstances
surrounding their deaths, who have died in the jail during his time as Responsible
Health Authority.

In Lisa’s case, no interviews were even conducted to determine if

someone on jail staff caused or contributed to her death and no reports were
obtained from anyone, except those who responded after Lisa was found
unresponsive and not breathing. No report is generated from the Morbidity and
Mortality Review meeting or process. In Lisa’s case, no one involved in the
Morbidity and Mortality Review meeting had any idea about her cause of death.
Even after the Medical Examiner established the cause of death, no further
Morbidity and Mortality Review was conducted regarding her death. Richard Bell
testified he could not think of a reason why a further review was not conducted
once the cause of Lisa Ostler’s death was determined. It seems clear the reason is
that no one involved in the process really cares about identifying what happened
to inmates who have died, who may have been responsible, or what corrective
measures could be implemented to prevent deaths in the future.

It is evident that, as a matter of custom and practice, the Morbidity and

Mortality Review process is not taken seriously by Richard Bell or any other
participants. No changes have been made as a result of the process, other than
addressing barriers to emergency responders. No one has ever been identified as
doing anything, or failing to do anything, contributing to an inmate’s death.
Incredibly, no one interviewed any of the nurses or housing officers who dealt
with Lisa Ostler, except as to what some of them perceived or did after she was
found unresponsive and not breathing. There seems to be a collective shrug of the
shoulders by those participating in the Morbidity and Mortality Review process,
being able to say they participated in the review, but that nothing was found that
would implicate anyone as having done anything wrong. The record makes clear
the conscious indifference of Richard Bell and other participants in the Morbidity
and Mortality Review process toward determining what led to an in-custody
death, who on jail staff may have been responsible, and what corrective actions
could be taken to prevent such occurrences in the future.

At the Morbidity and Mortality Review meeting held regarding Lisa

Ostler’s death, no one identified six glaring errors on one withdrawal protocol
assessment worksheet, including such obvious errors as a 0% oxygen saturation, a
respiration rate of 98 breaths per minute, and a wrong value for a heart rate of 133
(marking a “2” instead of a “4” for that alarming heart rate). Neither was it

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determined that the assessments, including monitoring of vital signs, that had
been ordered had not been done for Lisa the entire time she was in Unit 8C.

The indifference and lack of caring about the deaths of inmates reflected
in the lax approach to the Morbidity and Mortality Review process is consistent
with the indifference and lack of caring reflected in the care, and lack of care, for
inmates at the jail generally. It appears that those participating in that process are
more interested in covering up what happened, so it will not be available during
possible future litigation, than in conscientiously determining whether anything
went wrong, identifying those responsible, and taking measures to make certain it
does not happen again in the future.

Had the Review process previously addressed the failure to provide CIWA
and WOWS assessments, including the monitoring of vital signs, for several
inmates who died, it is reasonable to conclude that measures would have been
taken to make sure that Lisa Ostler had received those assessments on 4/1/2016.
Had the assessments been conducted on that date, Lisa Ostler likely would not
have continued to suffer much long and would not have died. As a nurse, I am
familiar with the fact that, in the United States, it is rare for anyone to die of a
perforated ulcer and peritonitis if it is timely diagnosed and treated.

Salt Lake County Jail Policy and Procedure stated it was the responsibility
of the RHA to ensure that the Health Services Unit policies allowed patients
unrestricted access to health care in a timely manner, and that the policies were
enforced so that there were not any barriers to patients receiving professional
clinical judgments about their health care needs, and that care ordered was
received (SLCo Ostler 0001584). There was no evidence to suggest that Mr. Bell
took any action whatsoever to address the lack of access to care for Lisa Ostler or
the barriers to receiving a professional clinical judgment about the health care
needs she experienced or her failure to receive care that was ordered. That failure
to take corrective action is consistent with the custom and practice reflected by
the fact, as testified to by Mr. Bell, that no corrective action was taken in response
to any of the Morbidity and Mortality reviews he participated in prior to Lisa’s
death. That failure to correct practices and remove barriers to care contributed to
the perpetuation of the flawed system that caused Lisa’s death.

Mr. Bell's RHA position required that he was capable of arranging all
levels of health care and ensuring quality and accessible health services for
inmates. He oversaw the medical and mental health services and was responsible
to review the accessibility, quality, and timeliness of health services provided in
the jail (Responsible Health Authority, SLCo Ostler 001586).

He testified that correctional officers at the jail received no training to

recognize life-threatening situations involving abdominal problems (Bell

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Deposition, p 189). Bell testified that the policy and custom at the Salt Lake
County Jail was if an inmate experienced an emergency medical situation, they
could ask a nurse or a housing officer for help without filling out a medical form
(Bell Deposition, May 20, 2019, p 119); they just needed to let a housing officer
or a nurse know (Bell Deposition, May 20, 2019, p 119). There is no evidence to
suggest that Richard Bell took any action to address failures by Housing Officers
and nursing staff to provide any help or assistance to inmates like Lisa Ostler
when they asked for it.

Mr. Bell testified that the Salt Lake County Jail abided by National
Commission on Correctional Health Care (NCCHC) standards and nurses at the
jail were required to know the standards (Bell Deposition, 5/25/19, pp 173-174).
As RHA, Mr. Bell was required to be familiar with the scope of practice for each
type of health care person providing services and to have measures in place to
ensure that work assigned was consistent with scope of practice. There is no
evidence to suggest that Richard Bell took any action to review the practice of
Nurse Brad Stoney recording medical diagnoses in a patient's medical record in
the absence of clinical information from a qualified medical provider. There is no
evidence to suggest that Richard Bell took any action to address nursing staff who
failed to perform assessments or provide essential nursing care to an inmate with
a serious medical need.

Mr. Bell testified that the policy regarding CIWA and WOWS withdrawal
protocol required vital signs to be taken twice daily for five days (Bell Deposition,
3/25/19, p 149). He stated it was a violation of the policy when the nursing staff
did not take Lisa Ostler’s vital signs for a second time on 4/1/2016 and in the AM
of 4/2/2016. There is no evidence to suggest that Richard Bell took any action
when he learned that nursing staff failed to take Lisa Ostler's vital signs,
performed no withdrawal assessment at all, and failed to respond to significantly
abnormal results of the assessments they did perform.

Mr. Bell testified that people who aren’t eating are given liquids and
Gatorade type electrolytes, particularly patients undergoing withdrawal. He
stated it was not uncommon for inmates to lose their appetite or not enjoy the jail
food, but staff was always offering liquids so inmates were not dehydrated (Bell
Deposition, 3/25/19, p 172). There is no evidence to suggest that Richard Bell
took any action in response to staff failures to respond to inmates like Lisa Ostler
not eating, not drinking and exhibiting signs and symptoms of malnutrition and
dehydration.

The Health Authority was responsible to approve the method of recording

entries and the format of the chart (SLCo Ostler 001727). Lisa Ostler’s medical
record was a collection of medical records and information that was not
accurately reflective or representative of her actual medical status or condition

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and did not accurately reflect the care she received. The medical chart was
essentially a simulation of medical activity entries designed to suggest that Lisa
Ostler was appropriately assessed, evaluated, and was provided care that
addressed her serious medical needs. In fact, Lisa Ostler did not receive the care
that the Salt Lake County Jail claimed inmates received or care that the medical
record suggested she received. Lisa Ostler did not receive treatment that would
remotely reflect a community standard of care. There is no evidence to suggest
that Richard Bell addressed the medical record deficiencies present in Lisa
Ostler's Salt Lake County Jail medical record.

The medical record documents and the nature of documentation in Lisa

Ostler’s chart raise significant concerns and demonstrate that the care she
received did not meet or reflect her serious medical needs:

1) The admitting, attending, and ordering physician was recorded as Todd

Wilcox, MD – Dr. Wilcox had no involvement in admitting or attending to Lisa
Ostler and did not issue any orders for her care or treatment. His name was listed
as the ordering physician for standing orders of Phenergan and Imodium on the
WOWS protocol assessment worksheet but he had no involvement in the
determination of medication orders for Lisa. Dr. Wilcox provided no care to
Lisa whatsoever.

2) Doctor Brad Lewis was contacted by e-mail and submitted an e-mail response
in which he deferred all of Lisa's prescribed medication for review by a mental
health provider. He failed to direct or ensure that such a review would occur in
a timely manner or at all. He took no action and ordered no monitoring to ensure
that Lisa would be assessed for adverse effects of the sudden cessation of all of
her medications. Lisa's medical status related to sudden discontinuation of all of
her medication was never evaluated. Lisa was never seen by any advanced level
provider at any time. She was never referred to a qualified mental health provider
for review of her medication regimen. Her medical treatment at the jail was
designed and directed by Nurse Stoney in the absence of direct involvement by a
qualified medical provider.

3) A verified list of Lisa Ostler’s medications was present in the medical record.
None of her prescribed medication, with the exception of Prilosec, was ordered or
continued. Prilosec was ordered by Dr. Brad Lewis, however not a single dose of
the medication was ever administered. The rest of her prescribed medication
was all deferred for consideration by mental health per an e-mail written by Dr.
Brad Lewis who did not see, examine, or talk to Lisa Ostler. Lisa did not see a
psychiatrist at any time during her detention, and none of her medications were
ever reviewed, ordered or continued. There was no indication that she was
even scheduled to see a psychiatrist to ensure that her medication regimen would
be reviewed.

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4) Lisa’s Medical Problem List of medical diagnoses was entered without any
Salt Lake County Jail physician, physician’s assistant, or nurse practitioner
conducting any examination of her or even seeing her. The list of diagnoses was
e-mailed to the doctors by Registered Nurse, Brad Stoney, in the absence of
clinical information documented by an advanced level provider qualified to render
medical diagnoses.

5) The Comprehensive Nurse Examination conducted on 3/30/2016, was little

more than an expanded restatement of the Nursing Pre-screen Examination
conducted on the same date. The PHYSICAL EXAM section reflected a hands-
on measurement of Ms. Ostler’s vital signs and noted two small skin wounds.
The remainder of the physical exam reflected a systems review of oral responses.
There is no indication that a physical assessment was conducted (i.e., heart
sounds, lung sounds, auscultation of bowel sounds, palpation of the abdomen,
etc.). No pain assessment was conducted.

6) The CIWA and WOWS protocol assessments present in Lisa Ostler’s record
were replete with inaccuracies and omissions. On the afternoon of 4/1/2016 and
the morning of 4/2/2016 the protocol worksheets reflected that Lisa was not
in her cell despite her not leaving her cell for any reason other than for a
clothing exchange. Lisa’s location was always known and carefully tracked and
staff had access and knowledge of that information. Once she was housed on Unit
8C in Cell 16 she did not leave the unit. Her unit and cell number were written on
medical record documents that nursing staff all had access to. The information
entered on the protocol assessments was false.

All encounters by Health Services staff were to be entered into the

Electronic Medical Record (EMR) before the end of their shift the day care was
rendered (SLCo Ostler 001728). Mr. Bell testified that if medical information was
not documented it was not done (Bell Deposition, May 20, 2019, p 94). He noted
that missing entries for assessments and vital signs on the withdrawal protocol
worksheets after the morning of April 1st did not comport with the policies of Salt
Lake County Jail (Bell Deposition, May 20, 2019, p 107). There is no evidence
that Richard Bell took any action to address missing entries on assessment forms,
missing assessments, or staff failures to document and record patient encounters.

B. Mr. Bell was responsible to know the scope of practice for each of the staff he
supervised. Mr. Bell would know that a nurse was not permitted to render
medical diagnoses or enter information that was misrepresentative of actions or
care provided. He would know that the medical record entries of Brad Stoney,
RN, in Lisa Ostler’s medical record exceeded the scope of registered nursing
practice. Bell would know the medical diagnoses listed for Lisa Ostler were not

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the result of a physician evaluation or physician documentation. He would know

that the physicians listed as Admitting, Attending, and Ordering care for Lisa
Ostler had not actually seen her. He would know that the physician who ordered,
deferred, and discontinued her prescribed medication had done so without ever
seeing or talking with her.

The Salt Lake County Jail was accredited by NCCHC and Mr. Bell knew
the health standards that governed the jail. NCCHC required that prescribed
medications for inmates were reviewed and appropriately maintained according to
the medication schedule the inmate followed before admission. Mr. Bell would
know that inmate medications were not being maintained according to the
inmate’s schedule prior to detention and that Lisa Ostler's medications were
never reviewed and were clearly not maintained according to the medication
schedule she had prior to being detained.

Mr. Bell was responsible to ensure that inmate assessments were

performed and recorded completely and accurately and he would know that
inmates were to receive the care that was ordered for them. He would also
know the importance of inmate access to care and the process for inmates to
follow in order to access both routine and emergency care. Richard Bell would
know that Lisa Ostler did not receive the withdrawal assessments as ordered and
would know that inmates were not receiving the care that was ordered for them.
The absence of nursing documentation for patient assessments, medication
administration, evaluation, and response to requests for medical help provides
ample evidence that essential care was not provided. There is no evidence that
Richard Bell took any action to address Lisa Ostler not being assessed, not
receiving essential care and not being able to access emergency care when she
requested and needed it.

C. Under Richard Bell’s leadership, jail nursing staff deliberately failed to

respond to inmate requests to be seen for medical emergencies and
inmates were not seen according to the policy that allowed them to contact a
Housing Officer who would notify medical to see them as soon as possible.
Inmates such as Lisa Ostler with serious medical needs were ignored and their
serious needs were not met. Several inmates, including Lisa Ostler, had their
serious medical needs ignored and died as a result.

Under Richard Bell’s leadership, a custom and practice of disregard for an

inmate's medical concerns and requests and a pattern of failure to conduct face-to-
face or focused assessments flourished. Inmate complaints that included clinical
symptoms were not reviewed, were ignored and went unaddressed. The failure of
nursing staff to address the inmates’ serious needs demonstrated a group
acceptance of ignoring needs, requests and serious medical issues. The failures

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were not limited to a single practitioner but were evidenced in a general manner
among nursing staff at all levels performing job duties across all positions: the
admission nurse, the booking nurse, the medication administration nurse, the
diabetic check nurse, the treatment nurse, the withdrawal assessment nurse, the
triage nurse, and the nurses responding to officer requests for inmates needing
medical help. Richard Bell testified that the policy at the Salt Lake County Jail
provided for a Health Services staff to respond and examine an inmate as quickly
as possible in response to a housing officer communicating a request for medical
help (Bell Deposition, 5/20/19, p 175). He testified that the custom at Salt Lake
County Jail did not permit a nurse, who was notified by a housing officer
concerning an inmate's request for medical help, to refrain from responding as
quickly as possible to examine the inmate (Bell Deposition, 5/20/19, p 175). Bell
testified that a nurse, contacted by a housing officer about a medical problem
being experienced by an inmate, would have to make the determination about the
course of action needed after actually seeing the inmate rather than leaving the
determination as to whether a medical emergency existed to the housing officer
(Bell Deposition, 3/25/19, pp 58-59). He testified further that it would be
inappropriate for a nurse to ask a housing officer to determine whether an inmate
was experiencing a medical emergency if the nurse had not recently seen the
individual (Bell Deposition, 3/25/19, p 61).

Richard Bell testified that he was the individual at the Salt Lake County
Jail that arranged for all levels of health care and assured quality, accessible, and
timely health services for inmates (Bell Deposition, 3/25/19, pp 134-135). He
testified that no medical determination about Lisa Ostler's condition was made
because no nurse ever went to see her to make a determination. He stated the
report of the medically untrained officer did not appear to meet the level of a
medical emergency, and the decision about care for Lisa was essentially based
upon the officer’s observations - as a result, medical care that was needed was not
provided (Bell Deposition, 3/25/19, pp 137-139). Lisa did not have access to
quality or timely health care services. She was afforded no access to any health
care services for her serious medical needs. Yet, Richard Bell testified that he
ensured quality and accessible health services to Lisa Ostler and met his
responsibilities (Bell Deposition, 3/25/19, p 139, 142).

Lisa Ostler's medical records reflect that ordered assessments were not
completed at all, assessments that were completed were not completed accurately,
abnormal clinical findings were not followed up, clinical protocol that was
specifically developed to improve monitoring of inmates in withdrawal at Salt
Lake County Jail and was touted nationally as an “industry standard” was not
even followed, nurses failed to conduct essential assessments, nurses failed to
monitor inmates for dehydration or pain and nurses did not document inmate
encounters in accord with facility policy and nursing standards of care. Nursing

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staff failed to take basic preventive measures to reduce the likelihood that medical
problems progressed to catastrophic outcomes.

Richard Bell testified that he discussed entries on Lisa Ostler's CIWA and
WOWS assessment worksheets with Todd Riser, the Salt Lake County Jail
Nursing Supervisor (Bell Deposition, 5/20/19, pp 14-15). He stated they discussed
the errors and omissions evident in the withdrawal assessments done for Lisa
Ostler. He stated Riser noted errors, omissions, and abnormal findings but was
not concerned that a physician was not notified even though facility policy
required immediate physician notification (Bell Deposition, 5/20/19, pp 17-18).
Richard Bell was aware that Lisa requested medical care when Nurse Colby
James was on her unit just minutes before she was found unresponsive and not
breathing in her cell. He was aware that James did not even bother to walk over to
her cell to check on her request. Bell did not talk with James or try to learn any
information about why he didn't go to check on Lisa in response to her request
(Bell Deposition, 5/20/19, pp 56 - 61). Bell testified that to determine if an inmate
had a medical emergency the nurse would have to evaluate them. Bell testified he
was not concerned when he learned that Nurse Tucker or any other health staff
never checked Lisa regarding her report of bleeding. There is no evidence
whatsoever that Richard Bell was concerned about any of the failures of his
nursing staff to evaluate Lisa, respond to abnormal findings about Lisa, or provide
nursing care as ordered.

Richard Bell testified he was the person responsible for inquiring into
why an inmate who died had not had her vital signs taken when they were
supposed to be taken. He testified he had not inquired into why Lisa’s vital signs
were not taken. (Bell Deposition, 3/25/19, pp. 46-47). He stated he did not
inquire because there were no significant findings that there was a history of her
vital signs not being within normal limits (Bell Deposition, 3/25/19, p 47-48). In
fact, Lisa's vital signs were far outside of normal limits and in the 24 hours before
her death her vital signs had not been taken as ordered. None of this information
prompted Mr. Bell to inquire about or review the care that Lisa had received or
had not received.

Overwhelming systemic problems in the provision of health care at the

Salt Lake County Jail were a direct result of leadership acceptance of an attitude
for a knowing disregard of inmates' serious medical needs. Throughout his
deposition testimony Mr. Richard Bell reported no attempts to learn information
about why assessments were not done, why abnormal findings were not reported,
or why nursing staff failed to render care or document care. He consistently
reported lack of concern for care that was not provided (Bell Deposition, 5/20/19,
pp 25, 56, 58, 66-67, 132, 208, 212). No recommendations were made for
changes in policies or practices after review of what happened to Lisa Ostler (Bell
Deposition, 5/20/19, p 118). He testified that he had not taken any steps in his

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capacity as Responsible Health Authority to make certain that if an inmate was

complaining of severe pain or other major symptoms that may relate to something
other than withdrawal from drugs they were to get medical attention as opposed to
being waved off and treated as just another inmate going through drug withdrawal
(Bell Deposition, 4/17/19, p 45).

Richard Bell testified that in the course of discussion about Lisa Ostler's
case he recalled hearing that a housing officer instructed Scott Sparkuhl in central
control to ignore Lisa Ostler's emergency calls. He stated he did not discuss this
information with anyone and there is no evidence to suggest he took any actions
to ensure that inmate calls for emergency care would not continue to be ignored.
In fact, his testimony reflected that he believed ignoring some inmate calls may
actually be acceptable (Bell Deposition, 5/20/19, pp 188-190). Bell testified that
to ensure timely, responsive, quality medical response to the needs of inmates it
was crucial that central control not ignore an inmate's emergency calls and, in
each instance, they contact the housing unit officer about the calls and the
information they were receiving, yet he took no action whatsoever to ensure that
inmate emergency calls would be addressed and not ignored. His attitude and
approach reflect remarkable indifference toward an inmate that was found
unresponsive and not breathing minutes after the nursing staff he was responsible
to supervise was contacted but failed to provide care. Mr. Richard Bell was
responsible for the culture, customs, and attitudes of indifference that led to
catastrophic ends for patients such as Lisa Ostler.

Following Lisa Ostler’s death, Richard Bell did not speak with any of the
jail nursing or custody staff employees who were involved in the incidents
surrounding the care, failure to provide care, actions or failures to act, and refusals
to act or provide care to Lisa for her serious medical needs and repeated
requests for health care. Consequently, the failures, failures to act, and refusals of
jail staff to provide medical care to Lisa in the final days and hours of her life
were ignored by Richard Bell and therefore did not facilitate improvement to the
access to care for inmates of the Salt Lake County Jail.

OPINION #15: The Chief Deputy Sheriff of Salt Lake County, Pamela Lofgreen,
failed to ensure that jail staff under her direct and indirect supervision performed
their duties and responsibilities in keeping with NCCHC standards and facility
policy and procedures. Under her direction, supervision, and leadership, the
Responsible Health Authority failed to ensure that nursing staff at the Salt Lake
County Jail provided essential medical care to inmates entrusted to their care.
Under her direction, supervision, and leadership, custody staff at the Salt Lake
County Jail failed to notify medical staff of inmate needs and, as a result, failed to
ensure the health and safety of detainees over whom they had complete control.

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Under her authority, supervision, direction and leadership, Lisa Ostler's serious
health care needs were not identified, assessed, appropriately treated, or managed.

A. Pamela Lofgreen was the Chief Deputy of the Salt Lake County Sheriff’s
Office in 2016. She was the Chief Deputy over the Corrections Bureau and
oversaw overall operations, program development, and employee issues at the
Salt Lake County Jail. Ms. Lofgreen supervised the RHA/Health Authority,
Richard Bell.

The failures in the treatment and care Lisa Ostler experienced at the Salt
Lake County Jail prior to her death are illustrative of several systemic problems
with the medical care provided by jail personnel under the direction and oversight
of administrators responsible for the provision of care and treatment to her31 and
responsible for ensuring care and treatment was actually available and accessible
to jail inmates. There was a failure by nursing staff to take basic preventive
measures to reduce the likelihood of medical problems developing into a
catastrophic condition. There was a failure by the jail administrators (specifically
Richard Bell and Pamela Lofgreen) to hold medical and custody staff accountable
for their actions and failures to act.

Pamela Lofgreen oversaw a broken system of health care in the jail where
providers did not provide ordered or needed medical care, where a culture and
practice of ignoring inmates’ serious medical needs was permitted and
accepted, where false recordkeeping was accepted, where officers were not
sufficiently trained to identify potentially emergent conditions they were
frequently confronted with on an almost daily basis (e.g., abdominal pain in
inmates suffering withdrawal where nausea, vomiting, cramping was a frequent
occurrence) and where inconsistent or absent documentation and inconsistent log
entries, particularly related to contacts with medical staff for emergent inmate
needs, was common and accepted.

Under the leadership of Chief Deputy Lofgreen, Housing Unit Officers

ignored inmate requests for emergency medical care, a practice that was
customary and accepted. Even officers that knew they should report the inmate
requests to the Housing Officer followed instructions by other officers to “ignore
the cell”. Housing Officers testified with troubling complacency that they

31
Wilcox, Todd, Expert Opinion Report, Expert for the Plaintiff ,Walter Jordan 078789 Walter 078789,
Died on 9/7/2017 while in the custody of the Arizona Department of Corrections (ADC), Corizon Health
Care, Housed at ASPC-Florence, East Unit, Case 2:12-cv00601-DKD, Document 2496.

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followed directions to ignore inmates who reported they were experiencing a

serious medical problem and needed medical care including Lisa Ostler who said
she was in pain and needed help (Sparkuhl Deposition, p 45, 50, 67). Under
Lofgreen’s leadership, Housing Officers and Central Control Operators were not
trained to appropriately respond to every request for medical hep and were not
trained about the inappropriateness of choosing to “ignore” an inmate’s pleas for
help.

Chief Deputy Matthew Dumont testified that according to the Control

Room Operations Manual a Control Room operator was required to notify the
Housing Officer when they received an intercom communication from an inmate
that was in pain (Dumont Deposition, pp 136-137). Mr. Dumont testified that an
informal custom and practice was in place [in 2016] where Housing Deputies
could provide an instruction to Control Room Operators to ignore certain calls.

Under the leadership of Chief Deputy Lofgreen a culture of disregard for

inmates’ serious medical needs was allowed to persist. Her leadership and
supervision supported a knowing disregard for the serious medical needs of Salt
Lake County Jail inmates. Her tolerance for jail nursing and custody staff to
ignore inmates' medical needs and requests resulted in Lisa Ostler suffering
immense pain and ultimately loss of life.

B. Any individual qualified to be appointed as the Chief Deputy of Salt Lake

County would know or should know the absolute importance of creating a culture
of concern for an inmate’s serious medical needs among health care and custody
staff alike. A Chief Deputy would know or should know that the basis for
ensuring inmates received needed health care required that they had access to care
and their requests for care, emergent and non-emergent, were not ignored. A
Chief Deputy would know the importance of complete and accurate
documentation of events and that false reporting was a violation of facility policy
and procedure and was not acceptable. A Chief Deputy would know or should
know that custody staff were not trained to triage requests for medical care and
were not qualified to limit inmate access to health care providers. An
administrator in a position of Chief Deputy would ensure that custody and
medical staff understood their obligations and responsibilities to ensure that
inmates received competent and appropriate health care by qualified providers.

C. Chief Deputy Pamela Lofgreen knowingly and deliberately ignored the serious
medical needs of Salt Lake County Jail inmates such as Lisa Ostler when, under
her leadership, sworn officer staff were permitted to violate jail policy and
procedure in the handling of inmate emergency medical requests. The officers
followed directions to ignore inmate calls for emergent medical help in a casual

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and accepting manner, a verification that the practice was usual and customary
and they were familiar with the approach. Chief Deputy Lofgreen failed to create
and endorse a facility culture that would prevent and discourage jail officers from
openly violating policy and procedure. Under Chief Deputy Lofgreen’s
leadership, certain inmates were directly and repeatedly prevented from accessing
any medical care in an emergency.

Under Chief Deputy Lofgreen’s leadership, housing officers who dealt

with inmates withdrawing from drugs on a daily basis received no training to
inform them about how to distinguish gastrointestinal symptoms characteristic of
withdrawal from more serious emergent abdominal conditions that should be
referred to medical providers immediately. While officers were trained to refer
issues such as cardiac arrest, seizures, and excessive bleeding to medical, they
were not trained on gastrointestinal issues or abdominal pain even though
abdominal pain, nausea, and diarrhea was common for inmates undergoing
withdrawal, and was a condition they were confronted with frequently. Officers
were not trained about potentially related conditions such as appendicitis, bowel
obstruction, ulcer, bowel perforation, or ruptured organs which were equally
critical and should be discussed as part of a training program for emergency
response.

None of the officers at Salt Lake County Jail that testified in the Lisa
Ostler matter received any training at all on potential abdominal emergencies. In
the absence of sufficient, relevant training, the serious medical needs of inmates
who experienced emergent conditions involving the gastrointestinal system were
viewed as having “typical” symptoms of drug withdrawal when, in fact, an
alternate life-threatening disease process was perhaps unfolding.

Officers were not qualified to make medical or nursing determinations

about an inmate’s health complaints and in all cases, they were required to report
inmate medical complaints to the nurse. Officers received no training to increase
their awareness of when to report gastrointestinal symptoms or of potential
complications that would have provided knowledge for their reference and better
informed them about when to refer inmates to the nurse. Jail administration failed
to provide training related to the medical conditions officers on 8C were
frequently faced with, including nausea, vomiting, abdominal pain and
withdrawal despite any of the presentations and conditions having serious
potential for complications. Under Deputy Lofgreen’s leadership custody officers
did not have a consistent, clear directive or training about referring ALL medical
complaints to the medical staff for disposition.

Under Chief Deputy Lofgreen’s leadership, jail officers had no consistent

direction about completion of their shift logs, particularly related to logging
contacts with medical providers. As a result, communication about an inmate’s

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Appendix 1

SUZANNE L. WARD, RN, MS, LNC, CCM

N3798 County Hwy. F
Montello, Wisconsin 53949
Phone: (608) 697-0206
e-mail: SWardLNC@aol.com or miggsie2@aol.com

EDUCATION

2011 - Present - Certification as Case Manager

2007 Certification as Wisconsin Long-Term Care Functional Screener
2000 Course Completion for Legal Nurse Consultant
1997 Completed Core Curriculum in Criminal Justice Administration, Concordia
1987 Completed 3000 Supervised Hours with Mentally Ill/MR/DD Individuals
1986 Master of Science Degree, Health Care Management
1984 Bachelor of Science Degree, Health
1973 Associate Degree, Professional Nursing – Licensed Registered Nurse

PROFESSIONAL EXPERIENCE

1999 - Present
Legal Nurse Consultant, Nurse Consulting
Self-employed LNC for long term care, assisted living, developmental
disabilities, mental health, forensics and corrections.
Expert witness, Court testimony and Deposition experience.

November, 2010 – 2018 (Retired)

Case Manager, Humana
Telephonic case management for Humana insurance members with
specified chronic diseases.

July, 2007- October, 2010

Registered Nurse, Care Wisconsin (formerly ElderCare of Wisconsin)
Nursing Case Manager for frail elderly, physically disabled, and
developmentally disabled residents of Sauk and Columbia County

2006 – July, 2007

Staff Nurse, Wisconsin Dells Living Center – a Beverly Facility
PM shift nurse for Medicare, Long Term Care, and Rehab residents.
Wound care coordinator.

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 CONFIDENTIAL

Page 2
Suzanne L. Ward, Curriculum Vitae

1995 - 2006 (Retired from State Service - December, 2006)

Nurse; Unit Manager; Supervisor, State of Wisconsin
Nurse Clinician 2, Columbia Correctional Institute, 9/2003 – 12/2006
Nurse Clinician 2, Dodge Correctional Institute, 1/2003 – 9/2003
Unit Manager, Mendota Mental Health Institute, 7/2000 – 9/2002
Nursing Supervisor 2, Central Wisconsin Center-MR/DD, 7/99 – 7/2000
Nurse Clinician 2, King Veterans Home, 10/98 – 7/99
Nursing Supervisor 2, Central Wisconsin Center-MR/DD, 1/98 – 10/98
Nurse Clinician 2, Dodge Correctional Institute, 9/95 – 1/98

(*) Part Time employment concurrent with State of Wisconsin positions above:

*2002 - 2004
Registered Nurse, Sunnyview Health and Rehabilitation Center
AM and PM shift nurse for Medicare, Long Term Care and Rehab
residents
*1999 - 2002
Community Nurse Consultant, Create-Ability, Inc.
Nursing Case Manager for community MR/DD Program clients
*1997 - 2002
Pharmacy Nurse Consultant, Pharmerica
Facility Case Manager for pharmacy services to Long Term Care, CBRF,
Assisted Living, and Group Home clients, Wisconsin and Michigan
1993 -1995
Staff Education, Infection Control Coordinator, Dodge County Facilities
Coordinator for all staff education, infection control, quality assurance,
and utilization review programs. Charge nurse for Head/Spinal cord
injury unit, psychiatric unit, Alzheimers unit, MR/DD unit. State Certified
Nursing Assistant Instructor, MDS Coordinator
1992 - 1993
Public Health Nurse, Juneau County Public Health
Community Nurse Consultant, Case Manager Mental Health Programs
1991 -1993
Nursing Supervisor, Columbia County Nursing Home
Supervisor of Long Term Care and Alzheimers/Behavioral Units
1990 - 1991
QA, IC, UR Manager, HCA Parkway Hospital of Madison
Nursing Manager of QA, UR, IC, RM and Safety Programs
1989 - 1990
Associate Director of Nursing, Rural Wisconsin Hospital Cooperative
Coordinator of $1 Million Robert Wood Johnson Foundation Grant
1989 - 1990
Clinical Nurse Specialist, Dane County Jail/Mental Health Center Dane
County
Clinical Nurse Specialist on the Jail Mental Health Assessment Team

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 CONFIDENTIAL

Page 3
Suzanne L. Ward, Curriculum Vitae

1987 - 1989
Director of Review and Program Development, Wisconsin Peer Review
(WIPRO)
Directed Wisconsin review operations for Medicare and Medicaid
1982 - 1987
Director of Inpatient Services, Tri-County Human Services Center
Directed Mental Health, AODA, MR/DD inpatient staff and programs
1981 - 1982
Team Leader, St. Lukes Hospital of Milwaukee
Led inpatient team for general medical-surgical and psychiatric services
1979 - 1981
Charge Nurse, VA Medical Center, Wood/Milwaukee
Charge nurse for acute psychiatric and AODA services
1979
Nurse Clinician, Milwaukee County House of Correction
Nurse for minimum security prison health service
1977 - 1978
Nursing Supervisor, St. Mary’s Hill Psychiatric Hospital
Supervised Adult, Adolescent, and Child Psychiatric Treatment Units
1975 - 1977
Team Leader, McCauley Neuropsychiatric Institute of San Francisco
Nursing leader of acute forensic medical inpatient psychiatric service
1974 - 1975
Counselor, Case Manager, Wisconsin Family Drug Treatment Center
Case manager, Women’s group leader, Community Drug Treatment
1973 - 1975
Nurse Clinician, Elmbrook Memorial Hospital
Registered Nurse on medical, surgical, pediatric and AODA services
1970 - 1973
NA, Graduate Nurse, Registered Nurse, Community Memorial Hospital
of Menomonee Falls
Nursing Assistant, Nurse on medical, surgical, and pediatric units

PREVIOUS UNIVERSITY AFFILIATION:

1995 – 2015
Concordia University of Wisconsin
Adjunct Faculty in Adult Education Programs
Health Care Management

1986 – 2010
Cardinal Stritch University
Adjunct Faculty in Adult Education Programs
Business Management
Health Care Administration

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 CONFIDENTIAL

Appendix 2

May, 2019
Suzanne L. Ward RN, MS, LNC, CCM
Deposition and Trial Testimony – Rule 26 Disclosure

William Marsh v. Correctional Medical Services. (C.A. No. 09C-07-120 CHT). Balick
& Balick. Jim Drnec (Defense Attorney). Wilmington, Delaware. Expert Witness for
Defense - Delaware Correctional Center. DEPOSITION, 2/27 – 2/28/2013.

Donald Martin v. SSM Health Care of Wisconsin. (Sauk County Case No. 12-CV-517).
Corneille Law Group. Melita Mullen Schuessler (Defense Attorney). Baraboo,
Wisconsin. Expert witness for Defense. DEPOSITION, 5/30/2014.

Estate of Margo Anderson v. Tellurian U.C.A.N., Inc. (Case No. 13-CV-3315). Gingras,
Cates & Luebke, S.C. Paul Kinne (Plaintiff Attorney). Madison, Wisconsin. Expert
witness for Plaintiff. DEPOSITION, 8/07/2014.

Coger, Cleveland v. Fairlane Senior Care & Rehab Center, LLC. (Case No. 14-013135-
NH).
Liss, Seder & Andrews, P. C. Nicholas Andrews (Plaintiff Attorney). Bloomfield Hills,
Michigan. Expert witness for Plaintiff. DEPOSITION, 1/05/2016.

Yambert/Callahan v. Office of Sheriff of Lee County, et al. (Case No. 09 L 10).

Cunningham, Meyer & Vedrine, P.C., Kipp Cornell/David Burtker (Plaintiff Attorney).
Chicago, Illinois. Expert witness for Plaintiff. Inmate death r/t alcohol withdrawal.
DEPOSITION, 3/08/2016.

Estate of Mark Richardson, et al. v. Correctional Healthcare Companies, Inc., et al.

(Case No.: 15 CV 3200). Thomas C. Lenz. First, Albrecht & Blondis, S.C. (Plaintiff
Attorney). Milwaukee, Wisconsin. Expert witness for Plaintiff. Inmate death r/t splenic
rupture. DEPOSITION, 7/25/2016.

Estate of Lawrence G. Griffin v. Extendicare Health Services, Inc., et al. (Dane County
Case No. 156). Jeff Scott Olson. Jeff Scott Olson Law Firm, S.C. (Plaintiff Attorney).
Madison, Wisconsin. Expert witness for Plaintiff. Patient fall and death. DEPOSITION,
8/25/2016.

Michael D. O’Connell v. Village of Mount Horeb, et al. (Dane County Case No. 15-CV-
1382). Jeff Scott Olson, Jeff Scott Olson Law Firm, S.C. (Plaintiff Attorney). Madison,
Wisconsin. Witness for Plaintiff. Excessive Force. COURT NARRATION, 8/30/2016.

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 CONFIDENTIAL

May, 2019
Suzanne L. Ward RN, MS, LNC, CCM
Deposition and Trial Testimony – Rule 26 Disclosure
Page 2

Carl E. Williams and/or Lorraine L. Williams Delaration of Trust. (Case No.: 15 PR

40). Wassel, Harvey & Schuk, LLP., Marra Spring (Plaintiff Attorney for Patricia
Ashenfelter), Elkhorn, Walworth County, Wisconsin. Expert witness for Plaintiff.
COURT TESTIMONY, 12/05/2016.

Tia Paradis v. Jon Nichols, et al. (Case No. 16-CV-225). Atterbury, Kammer & Haag,
S.C. Attorney Alexander Kammer (Plaintiff Attorney). Expert witness for Plaintiff.
DEPOSITION, 12/13/2017.

Ryan Clark v. County of Green Lake, et al. (Case No. 14-C-1402). Jeff Scott Olson Law
Firm. Attorney Jeff Scott Olson (Plaintiff Attorney). Expert witness for Plaintiff.
DEPOSITION, 12/20/2017.

Mario Avila. First, Albrecht & Blondis, S.C. Attorney Thomas Lenz (Plaintiff
Attorney). Life Care Plan. DEPOSITION. 6/19/2018.

DANTE WILSON. First, Albrecht & Blondis, S.C. Attorney James End (Plaintiff
Attorney). DEPOSITION, 6/11/2019.

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Appendix 3

Materials reviewed prior to reaching my opinions and preparing a report:

• Lisa Ostler’s jail medical record;

• First Amended Complaint and Proposed Second Amended

Complaint

• Documents produced/provided by the parties in this litigation,

including jail administrative documents regarding Lisa Ostler,

shift logs, training documents, video recordings of 5C and 8C,

medical records of Lisa Ostler and other detainees who died in

custody, and written policies;

• Deposition Transcripts with Attachments for the following

Deponents:

Nicole Danielle Bates

Heather Beasley
Kathy Berrett
Todd Booth
Christopher Braithwaite
Dr. Samuel Brown
Dr. Nathan Dean
Matthew Dumont
Zelma Farrington
Zachary Frederickson
Holly Harris
Calvin Kengike
Elizabeth Kengike
Brad Lewis
Pamela Lofgreen
Cal Ostler
Kim Ostler
Jason Power
Todd Riser
Ronald Seewer

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Kellie Marie Sheppard

Scott Sparkuhl
Brent Lee Tucker
Dr. Pamela Ulmer
Todd Wilcox
Alisha Carol Woodruff

• HSU Daily Assignment Log;

• Defendants’ Answers to Interrogatories

• Defendants’ Answers to Reformulated Requests for

Admissions;

• Letter re: Amended Responses to Requests for Admissions

and Responses to Reformulated Requests for Admission;

• Medical Records for Inmates with CIWA and/or WOWS

assessments;

• Utah Administrative Code;

• Utah Nurse Practice Act;

• American Nurses Association (ANA) Scope and Standards of

Practice, Nursing;

• American Nurses Association (ANA) Scope and Standards of

Practice, Corrections Nursing;

• American Nurses Association (ANA) Scope and Standards of

Practice, Pain Management;

• American Nurses Association (ANA) Code of Ethics for

Nurses with Interpretive Statements;

• National Commission of Correctional Health Care (NCCHC)

Standards;

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• independent research; and

• my skills, knowledge, professional background, education and

work experience.

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Appendix 4:

PROTOCOL, STANDARDS, and GUIDELINES USED IN

FORMULATION of OPINIONS

CIWA and WOWS Withdrawal Protocol,

National Commission on Correctional Health Care (NCCHC) Standards,
State of Utah Nurse Practice Act,
State of Utah Scope of Nursing Practice Implementation,
American Nurses Association (ANA) Standards, Standards for Corrections
Nursing, Standards for Pain Management, Code of Ethics,
Nursing Expectations for Emergency Care Delivery in Correctional Facilities,
Nursing Expectations for Response to Abnormal Vital Signs,
Salt Lake County Jail Policy and Procedure, Job Descriptions, Prisoner Rules and
Regulations Handbook
Dr. Todd Wilcox article ““Managing Opiate Withdrawal: The WOWS Method”,
CorrectCare, printed Summer 2016.

B. CIWA and WOWS PROTOCOL

The Clinical Institute Withdrawal Assessment (CIWA) protocol was a

quantification instrument developed for monitoring alcohol withdrawal. The Wellcon or
Wilcox Opiate Withdrawal Scale (WOWS) was a targeted tool customized for opiate
withdrawal at the Salt Lake County Jail. The WOWS assessment withdrawal protocol
was essentially an edited version of the Clinical Opiate Withdrawal Scale (COWS). At
the Salt Lake County jail withdrawal protocol required that vital signs be taken and a
clinical symptom assessment be performed twice a day for five days (Seewer Deposition,
p 136; Riser Deposition, p 41, 49). In his article “Managing Opiate Withdrawal: The
WOWS Method”32 Dr. Todd Wilcox, the medical director of the Salt Lake County Metro
Jail, stated “In my facility, any patient undergoing opiate withdrawal is assessed twice
per day for a minimum of five days by nurses who have been trained in the WOWS
protocol. The assessment includes a full set of vital signs, serial tracking of the patient’s
clinical progress and interventions as necessary based on clinical presentation”. He
highlighted several “Takeaway Points” including that “opiate withdrawal is a life-
threatening medical condition” and noted the importance of assessment for dehydration
and comorbidities including underlying chronic diseases. Dr. Wilcox stated a significant
emphasis was placed on oral hydration.

32
Wilcox MD, Dr. Todd, “Managing Opiate Withdrawal: The WOWS Method”, CorrectCare, printed
Summer 2016.

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C. STANDARDS OF CARE (Not all-inclusive)

1. National Commission on Correctional Health Care (NCCHC) Standards

In 2014 the Salt Lake County Metro Jail achieved accreditation by the National
Commission on Correctional Health Care (NCCHC) and maintained the accreditation in
2016. The jail facility was required to follow the NCCHC Standards for Health
Services.33 Accreditation reportedly benefits the health of inmates by assuring that those
incarcerated receive adequate and appropriate health care according to nationally
accepted standards.

a. NCCHC, Receiving Screening:

The receiving screening performed at the time an inmate is booked into the jail
serves as “a process of structured inquiry and observation designated to ensure that
patients with known illnesses and those currently on medications are identified for further
assessment and continued treatment."34

b. NCCHC, Access to Care:

The first standard in the NCCHC’s Accreditation Standards is “Access to Care”.

The discussion states that “this standard intends to ensure that inmates have access to care
to meet their serious health needs and is the principle on which all National Commission
on Correctional Health Care standards are based."35 Nurses are the first health care
professional an inmate is likely to see when they have a medical problem and it is the
nurse who will determine the inmate's subsequent access to care.

Nursing sick call is considered one of the signature practices defining the
specialty of correctional nursing. There are two legal principles underlying nursing sick
call. The first is that inmates have daily, unimpeded access to health care. The second is
that inmates are entitled to a professional clinical judgment regarding their health
concerns. Simply put, inmates can request health care attention every day and their
concerns must be addressed in a responsive, timely and clinically appropriate manner.

33
NCCHC, “First Facility Surveyed Under 2014 Standards, 2014.
34
National Commission on Correctional Health Care (NCCHC) 2008 Standards for Health Services for
jails
and prisons, E-02 Standard, Receiving Screening (essential), Spotlight on the Standards article, appeared
in CorrectCare, Winter 2011 edition, pp 7-8.
35
Burrow, Gayle, "Remembering Meaningful Milestones", NCCHC National Conference, November 2016,
reference: NCCHC, Accreditation Standard A-01, 2014 Standards, p 3.

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The failure to see patients is a violation of these underlying legal principles and puts
patients at risk of harm.36

Access to care is one of the basic rights guaranteed to prisoners in 1976 by the
U.S. Supreme Court in the Estelle v. Gamble case. Unimpeded access to care means that
the access is determined by qualified health care staff or health-trained staff and cannot
be denied or delayed by security staff. Although lay staff [such as housing unit officers]
may convey sick call requests by providing sick call request forms or contacting health
care staff about inmate health concerns, they may not decide whether inmates will receive
medical attention (Anno, 2001; Knox & Shelton, 2006)37. The right of access to care
evolved into access that is available daily and is a standard that is supported by the major
correctional accrediting organizations, the American Correctional Association (ACA) and
the NCCHC in mandatory or essential standards that require "daily access to care".38

Adequate sick call operations require professional clinical judgment by health

care personnel trained and licensed to carry out sick call procedures. Access to care must
be provided for any condition (medical, dental or psychological) if denial of care may
result in pain, continued suffering, deterioration, less likelihood of a favorable outcome,
or degeneration.39

Correctional nurses need to be aware that, except in emergencies or other life-

threatening situations, it is not appropriate to evaluate patients in cells, on tiers, in
hallways, or other nonclinical settings.40 The initial evaluation of a symptom or medical
complaint should occur in a clinical setting. The medical record should be available for
these encounters.41 A chief complaint is obtained followed by an assessment of objective
findings. A first impression about whether or not the patient looks sick is useful in
determining if the patient may need a secondary referral. The next step of the objective
assessment is an accurate recording of vital signs. Vital signs should be taken and
documented for every clinical encounter. While normal vital signs do not exclude
potentially life-threatening disease, abnormal vital signs should usually result in a
consultation with a physician or mid-level provider. Vital signs outside of threshold

36
Knox, Catherine, "Improving productivity of sick call", posted in Sick Call, December 23, 2014.
37
Anno, B.J. (2001). Correctional health care: Guidelines for management of an adequate delivery
system. Chicago: NCCHC, p 49 ; Knox, C., & Shelton, S. (2006). Sick call. In M. Puisis (Ed.), Clinical
Practice in Correctional Medicine (2nd ed.), Philadelphia: Mosby Elsevier.
38
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Underlying Principles of
Sick Call, Daily Access to Care, p 284, 2013.
39
Correctional Health Care: Guidelines for the Management of an Adequate Delivery System, Legal
Considerations in the Delivery of Health Care Services in Prisons and Jails, The Right to Access to Care, p.
47, 2001.
40
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Nursing Care Process,
Nursing Sick Call, p 287, 2013.
41
Puisis, Michael, Clinical Practice in Correctional Medicine, "Sick Call as Medical Triage" by Joseph E.
Paris, MD, Ph.D., CCHP, Clinical Assessments, p 69.

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ranges should be referred for a physician or midlevel examination on an urgent basis, or

at least result in a phone consultation with a higher-level provider.42

c. NCCHC, Sick Call and Triage:

The NCCHC standard for “Screening, Sick Call and Triage”43 states that inmates
may make a request for health care attention at any time. When the request describes a
clinical symptom it must be assessed in a face-to-face encounter. Obviously, if the
symptom is of an emergent nature the assessment must take place immediately.44, 45
Sick call is intended to identify inmates with minor health complaints and to triage health
complaints that need evaluation by advanced providers. Sick call provides an important
first level of health care services and a gatekeeper function in which nurses assess inmate
patients and determine the level of care needed. Adequate sick call operations require
professional clinical judgment by health care personnel trained and licensed to carry out
sick call procedures. Because sick call involves high-level assessment and clinical
decision-making it must be performed by a registered nurse in accordance with specific
state nurse practice acts.46

Nursing sick call is considered the backbone of health care delivery in

correctional settings because it is the primary way inmates can access health care during
incarceration. Common methods used to request health care attention are by filling out a
request slip, health care request form or a "kite" that is given to a health care provider,
signing up on a list, showing up at a particular time, or calling to request an
appointment.47

Regardless of which sick call procedure is used (verbal, written or a combination),

the important points are to ensure that—
• All inmates have an opportunity to make their health needs known on a daily
basis.
• Access is directly controlled by health care staff and not by correctional staff
(which, in a written request system, includes health care staff only picking up the
request slips).

42
Puisis, Michael, Clinical Practice in Correctional Medicine, "Sick Call as Medical Triage" by Joseph E.
Paris, MD, Ph.D., CCHP, p 69 - 70).
43
NCCHC, “Screening, Sick Call and Triage”, CorrectCare, Fall 2010.
44
Id.
45
Knox, Catherine, "Nursing Sick Call Part 2: Pitfalls with the Face-to-Face Encounter, April 8, 2014,
Posted in Sick Call.
46
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Nursing Sick Call, p 283-
284, 2013.
47
Knox, Catherine, "Nursing Sick Call Part 1: Receiving and Responding to Requests for Care, April 1,
2014, Posted in Sick Call.

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• Health care staff review all slips received daily and determine the appropriate
disposition (e.g., “inmate to be seen immediately” or “scheduled for next sick
call”).48
• Inmates are notified of the health unit's response to their requests.

The purpose of a written request form is to inform health care staff of the inmate's
health needs. If other inmates or correctional staff tell a health care staff member that an
inmate appears ill, it can be both foolish and costly to insist that the inmate complete a
written request form. A 1990 death in the King County Jail in Seattle demonstrated the
potential folly of this approach.49

Correctional health care is guided by several fundamental principles. Inmates

may make a request for health care attention at any time. Requests that are emergent are
attended to immediately. Nurses are the professionals responsible for reviewing and
responding to requests for health care attention via sick call and for immediately
responding to emergency requests.

d. NCCHC, Assessment:

NCCHC accreditation standards include certain standards that address individual

professional practice. Most come from Section E: Patient Care and Treatment and include
standards for Initial Health Assessment and Nursing Assessment Protocols.

Based on the assessment of the inmate and evaluation of the health complaint, the
nurse may initiate treatment, provide advice, educate, or refer for higher level care. The
nurse should, for example, refer for higher level care when the patient has abnormal vital
signs, when the evaluation requires diagnostics that exceed the limits of the protocol
(radiographs, lab studies, etc.), when the nurse is unable to come to a diagnostic
conclusion and when the patient's complaint has not resolved (seen more than twice for
the same complaint).50

48
Anno, Jaye, National Istitute of Corrections (NIC) and NCCHC (cooperative agreement), Correctional
Health Care, Guidelines for the Management of An Adequate Delivery System, A Communications and Sick
Call System, p 161.
49
id., p 160, 184. A 21-year-old man, sentenced to serve 15 days in jail, died 6 days after admission.
According to the newspaper account, both his requests for medical attention and those of other inmates on
his behalf were ignored. He was told repeatedly by the officers to “fill out a kite” (a written request slip).
At least two nurses making medication rounds spoke briefly to the individual and told him the same thing.
By the time anyone took his complaints seriously, he was in acute distress. His appendix had ruptured. He
died a few hours after being transported to a hospital. For more information on this occurrence, see
the Seattle Times, June 7, 1990, page 1.
50
Knox, Catherine, MN, RN, CCHP-RN, NCCHC accreditation surveyor, CorrectCare, Fall 2010 Issue,
"Screening, Sick Call and Triage".

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An essential step in the nursing process is the evaluation and reassessment of a

patient's condition so that the plan of care can be adjusted to prevent harm and promote
healing (ANA 2013).

e. NCCHC, Staffing:

The NCCHC Standard for “Staffing” requires that a facility have a sufficient
number of health staff of varying types to provide inmates with adequate and timely
evaluation and treatment consistent with contemporary standards of care.51 “Qualified
health care professionals do not perform tasks beyond those permitted by their
credentials."52

f. NCCHC, Correctional Officer Training:

The NCCHC standard for “Health Training for Correctional Officers”53 promotes
the training of correctional officers to recognize when they need to refer an inmate to a
qualified health care professional. They facilitate the workflow, and alert health staff to
inmates with possible health issues. They must be aware of the potential for emergencies
that may arise, know the proper response to life-threatening situations and understand
their part in the early detection of illness and injury. A required component of a
correctional officer training program is instruction in the procedures for appropriate
referral of inmates with health complaints to health staff. The intent of the NCCHC
standard is to promote the training of correctional officers to recognize when the need to
refer an inmate to a qualified health care professional occurs and to provide emergency
care until they arrive.54

NCCHC outlines required components of a correctional officer training program.

Minimum requirements include cardiopulmonary resuscitation training by an approved
body such as the American Heart Association, training in recognition of acute
manifestations of certain chronic illnesses such as asthma, seizures, diabetes, and adverse
reactions to medications. Officers must also be able to recognize and alert health staff to
inmates with symptoms of intoxication and withdrawal for early intervention and
treatment. Instruction in precautions and procedures with respect to infectious and
communicable diseases ensures that officers are knowledgeable in preventing the spread
of these diseases to other inmates, staff and visitors. In addition, proper training in the
handling of infectious wastes and how to protect themselves when respiratory isolation is

51
NCCHC, Standard C-07, Staffing.
52
NCCHC, Standard C-01, Credentials.
53
NCCHC, “Health Training for Correctional Officers”, Spotlight on the Standards. CorrectCare, Summer
2013
54
id.

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indicated is included in necessary training. Training in the administration of first aid is

required. Additional components to the first aid training should include topics that are
common to the correctional facility in which the officers work. Officers should be
trained on recognizing signs and symptoms of mental illness and procedures for suicide
prevention. The last required component of the training program is instruction in the
procedures for appropriate referral of inmates with health complaints to health staff.55

Professional boundaries must be understood as they relate to the scope of practice

of care team members. Both licensed and unlicensed staff is bound by the particulars of
their job descriptions as to the functions and responsibilities to each other and to the
inmate patient population. A clear delineation of responsibility between nursing staff and
custody staff is essential. Nurses are the care providers.56

Unqualified or unlicensed staff or correctional officers should not make clinical

evaluations under any circumstances. An essential standard of the NCCHC requires state
licensure, certification and registration requirements to apply to health care personnel.57

Correctional nurses are expected to respond to emergencies and, as the first

medical responder, to take charge, directing the response and arranging for definitive
care. Every emergency requires that health care staff assess the patient and decide what
clinical care is medically necessary.58 Correctional officers retain responsibility for safety
and security in a medical emergency. They secure and clear the area, direct traffic, carry
equipment, escort EMS, and facilitate on-site transport.59

g. NCCHC, Delegation:

NCCHC cites the “Nurses Scope of Practice and Delegation Authority” as a

resource for correctional health professionals. The position paper makes the key point
that “Nurses deliver the majority of health care in correctional settings and serve as the
gatekeeper for inmate access to all other health services”.60 The RN assigns or delegates
tasks based on the needs and condition of the patient, potential for harm, stability of the
patient’s condition, complexity of the task, predictability of the outcome, and abilities of

55
id.
56
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Overview of Correctional
Nursing, Safety for the Nurse and the Patient pp. 61-64, 2013.
57
Puisis, Michael, Clinical Practice in Correctional Medicine, "Sick Call as Medical Triage" by Joseph E.
Paris, MD, Ph.D., CCHP, p 69.
58
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Emergency Care Delivery,
Nursing Care Process, p 323.
59
Id., pp 308 - 309.
60 60
Blair, Patricia PhD, LLM, JD, MSN, CCHP, Catherine Knox MN, RN, CCHP-RN, Jessica Lee MSN,
CCHP, Mary Muse MS, RN, CCHP-RN, CCHP-A, Becky Pinney MSN, RN, CCHP-RN, and Patricia
Voermans MS, RN, APN, CCHP-RN, “Nurses Scope of Practice and Delegation Authority”, July 2014

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the staff to whom the task is delegated.61 All decisions related to delegation and
assignment are based on the fundamental principles of protection of the health, safety and
welfare of the public.62

h. NCCHC, Continuation of Medication:

The NCCHC standard requires that “prescribed medications are reviewed and
appropriately maintained according to the medication schedule that the inmate was
following before admission”.63

C. STATE OF UTAH NURSE PRACTICE ACT FOR RN’s64

The Utah Nurse Practice Act states that registered nursing acts include:

1) assessing the health status of individuals

2) identifying health care needs
3) establishing goals to meet identified health care needs
4) planning a strategy of care
5) prescribing nursing interventions to implement the strategy of care
6) implementing the strategy of care
7) maintaining safe and effective nursing care that is rendered to a patient directly
or indirectly
8) evaluating responses to interventions

STATE OF UTAH SCOPE of NURSING PRACTICE IMPLEMENTATION65

An RN shall be expected to:

1) interpret patient data, whether obtained through a focused nursing assessment

or through completion of a comprehensive nursing assessment
2) detect faulty or missing patient information
3) demonstrate appropriate decision making, critical thinking, and clinical

61
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Management and
Leadership, Professional Role and Responsibilities, p 332.
62
ANA (American Nurses Association) and NCSBN (National Council of State Boards of Nursing, "Joint
Statement on Delegation.
63
National Commission for Correctional Health Care (NCCHC) 2008 Standards for Health Services for
jails and prisons, E-02 Standard, Compliance indicator 9, CorrectCare, Winter 2011 edition, pp 7-8.
“Receiving Screening”, CorrectCare, Winter 2011.
64
Utah Nurse Practice Act, Title 58, Chapter 31b.
65
Utah, R156-31b-703b. Scope of Nursing Practice Implementation.

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judgment to make independent nursing decisions and to identify health care

needs
4) correctly identify changes in each patient’s health status
5) comprehend clinical implications of patient signs, symptoms, and changes as
part of ongoing or emergent situations
6) intervene on behalf of a patient when problems are identified
7) identify patient needs
8) attend to patient concerns or requests

E. AMERICAN NURSES ASSOCIATION (ANA) SCOPE and STANDARDS of

PRACTICE, NURSING
AMERICAN NURSES ASSOCIATION (ANA) SCOPE and STANDARDS of
PRACTICE, CORRECTIONS NURSING
AMERICAN NURSES ASSOCIATION (ANA) SCOPE and STANDARDS of
PRACTICE, PAIN MANAGEMENT NURSING
AMERICAN NURSES ASSOCIATION, CODE of ETHICS for NURSES
With INTERPRETIVE STATEMENTS

The American Nurses Association (ANA) Standards of Professional Nursing

Practice are authoritative statements of the duties that all registered nurses, regardless of
role, population, or specialty, are expected to perform competently. Registered nurses
are accountable for nursing judgments made and actions taken in the course of their
nursing practice.

1. ANA, Assessment:

The American Nurses Association scope and standards of practice for all settings
including corrections identifies assessment as the first standard of professional nursing
practice.66 Assessment requires the registered nurse to collect comprehensive data
pertinent to the healthcare consumer’s health and/or the situation and to document
relevant data in a retrievable format. It involves the systematic, orderly collection of
subjective and objective information about a patient's health status; it is the foundation on
which nursing care is planned.67 The registered nurse prioritizes data collection based on
the healthcare consumer’s immediate condition, or the anticipated needs of the healthcare
consumer or situation. Assessment and matters of nursing judgment are solely the
domain of the registered nurse. “Nurses may not delegate responsibilities such as
assessment and evaluation”.68

37
American Nurses Association, Scope and Standards of Practice, Standard 1. Assessment. Competencies.
2010 Edition and American Nurses Association, Scope and Standards of Practice, Corrections Nursing,
Standard 1. Assessment.
67
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Underlying Principles of
Sick Call, Assessment, p 293, 2013.
68
American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, 2001, p. 17.

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The registered nurse in corrections must be able to demonstrate good assessment

and organizational skills as well as critical decision-making and thinking skills. Facility
protocols and provider-generated order sets (such as CIWA and WOWS withdrawal
assessments) provide direction for the healthcare activities and specific patient care
measures. However, such structures do not allow the corrections nurse to abdicate one’s
professional nursing responsibility for appropriate assessment, critical thinking, decision-
making and patient advocacy activities.”69

A focused assessment is performed for urgent care visits and to address symptoms
related to the patient's concerns. The examination includes a subjective assessment, the
information the patient describes and offers about their health complaint. A thorough
history is an essential component of a focused assessment as it guides the objective
assessment that follows. All objective, or physical assessments should begin with
assessment of vital signs and weight as these measurements give valuable clues to the
nature of the patient's specific complaint(s) and overall well-being. The nurse should then
proceed to apply the techniques of inspection, palpation, auscultation, and percussion, as
needed to the body system(s) related to the complaint. The patient is referred to an
advanced level provider when assessment findings are significantly out of normal.
Patients with severe pain or health problems that may deteriorate if left untreated require
an immediate or urgent same-day referral to an advanced care provider.70

2. ANA, Delegation:

The American Nurses Association in collaboration with the National Council of

State Boards of Nursing (NCSBN) defines delegation as the process for a nurse to direct
another person to perform nursing tasks and activities. An RN can direct another
individual to do something that the person would not normally be allowed to do. A key
policy consideration is that the RN assigns or delegates tasks based on the needs and
condition of the patient, potential for harm, stability of the patient’s condition,
complexity of the task, predictability of the outcomes, abilities of the staff to whom the
task is delegated, and the context of the patient needs.71

Individual registered nurses bear primary responsibility for the nursing care that
their patients receive and are individually accountable for their own practice. The
registered nurse determines the appropriate delegation of tasks consistent with the nurse’s
obligation to provide optimum patient care. Registered nurses may not delegate
performance of assessment or evaluation of a patient's health care needs.

69
American Nurses Association, Scope and Standards of Practice, Corrections Nursing, 2007, p. 10.
70
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Sick Call, Nursing Care
Process, p 291 - 296.
71
American Nurses Association and National Council of State Boards of Nursing, “Joint Statement on
Delegation”.

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For example, a patient reporting an emergency and complaining of severe

abdominal pain requires an assessment to 1) determine the specific characteristics of the
pain and 2) determine the urgency or emergency of the condition. A focused assessment,
a highly specific assessment that focuses on the system or systems involved in the
patient's problem, is required and may only be performed by a registered nurse, mid-level
or advanced level practitioner. An untrained correctional officer would not be able or
qualified to perform any part of a focused assessment.

Assessment of abdominal pain necessarily includes observation of the patient's

overall physical appearance. The patient should be asked about pain onset, bowel and
bladder function, nausea, vomiting, food and fluid intake, and the presence of blood in
the stool or emesis. The abdomen should be palpated with the nurse observing the patient
for any change in pain level, guarding, rigidity, distention or masses. Particular
observation of the pain location, severity, radiation to another area or body part, and what
makes the pain better or worse is important. In addition to palpation of the abdomen, the
nurse should auscultate abdominal sounds and perform percussion testing. Patients with
peritonitis often lie very still and are very sick in general appearance as well as reporting
feeling seriously ill. Failure to assess a patient's complaint of severe abdominal pain is a
breach of nursing standards and practice.

3. ANA, Documentation:

The American Nurses Association, scope and standards of practice require the
registered nurse to document relevant data in a retrievable format. The corrections nurse
must be acutely aware of the need for appropriate documentation of care rendered.72

4. ANA, Delivery of Nursing Care for All Regardless of Circumstance or

Offense:

The American Nurses Association scope and standards of practice for corrections,
states “If the patient cannot present for healthcare services because of disability, injury or
seclusion restrictions, the corrections nurse must go to the patient’s location, conduct an
appropriate and timely assessment, render or secure appropriate healthcare services, and
accurately complete the necessary documentation record(s).”73 “The corrections nurse is
expected to demonstrate integrity and highly ethical and moral practice, appreciating the
legally mandated obligation to deliver nursing care regardless of the individual’s
circumstances or offenses.”74

72
American Nurses Association, Scope and Standards of Practice, Corrections Nursing, 2007, p 11.
73
American Nurses Association, Scope and Standards of Practice, Corrections Nursing, 2007, p. 11.
74
American Nurses Association, Scope and Standards of Practice, Corrections Nursing, 2007, p. 12.

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 CONFIDENTIAL

5. ANA, Pain Management

The standard of care for correctional institutions is the same as that in the
community. An inmate who suffers from chronic, intractable pain as well as an inmate
who develops acute, emergent pain has a valid need for adequate pain control. Pain
assessment and management have always been a key part of a nursing or medical
assessment. Assessment of pain is as important as vital signs that are routinely taken.
Pain level has been referred to as “the fifth vital sign” along with temperature, pulse,
respirations and blood pressure by organizations such as the American Pain Society.75

An initial pain assessment should include the location, onset, duration, quality,
radiation of pain, alleviating and provoking factors and pain level. Although the level of
pain is based on the patient’s subjective report, pain can be quantified (just as withdrawal
symptoms can be quantified). Numerous pain assessment scales are in use nationwide.

An inmate suffering from acute onset of pain requires careful assessment for
emergent or life-threatening conditions and possible referral to a higher-level practitioner
or to the emergency room if necessary.76 The first nursing Standard of Practice for Pain
Management is Assessment. The registered nurse is required to collect comprehensive
data pertinent to the pain problem. Appropriate pain assessment tools and techniques are
used to measure pain. The registered nurse is responsible to document relevant data that
facilitates retrieval, reassessment, and follow up.77

There are many misconceptions among healthcare workers that are barriers to
patients receiving adequate pain management. One of the most common and persistent
myths is is that drug abusers overreact to pain. Many times healthcare workers assume
that drug abusers are always seeking to satisfy their addiction and not eliminate actual
physical pain. While it is true that part of the drug-abusing syndrome involves drug-
seeking behavior, it is also true that people who abuse drugs can experience pain.
Unfortunately, inconsistent and incomplete assessments have been cited as major factors
contributing to inadequate pain management.78

F. NURSING EXPECTATIONS FOR EMERGENCY CARE DELIVERY IN

CORRECTIONAL FACILITIES

75
Falk, Kim Marie RN, BSN, MSN and Shelda L. Hudson, RN, BSN, PHN, Pain: The Fifth Vital Sign.
National Center of Continuing Education.
76
Grametbaur, Jane RN, CCHP-RN, CCHP-A, “Pain Treatment in Corrections: Striving for a Community
Standard of Care”, CorrectCare, Summer 2011.
77
American Nurses Association. Scope and Standards of Practice, Pain Management, Nursing. 2005.
78
Falk, Kim Marie RN, BSN, MSN and Shelda L. Hudson, RN, BSN, PHN, Pain: The Fifth Vital Sign.
National Center of Continuing Education.

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 CONFIDENTIAL

All correctional nurses are expected to respond to emergencies and, as the first
medical responder, to take charge, directing the response and arranging for definitive
care. They are expected to exercise their clinical judgment about the patient's immediate
care.79 Notification of an emergency may come by word of mouth, over the telephone, or
via radio communication. A nurse should not determine on the basis of telephone or radio
contact alone that an emergency does not exist. A face-to face assessment and evaluation
by the nurse must take place whenever staff or an inmate thinks that there is a medical
emergency.80

In a medical emergency, inmates are entitled to a professional medical judgment.

Since correctional nurses are most likely the first medical professional to respond to the
medical emergency, they are therefore expected to also exercise their clinical judgment
about the patient's immediate care."81 If the emergency is an illness, the nurse needs to
assess the person's health status immediately preceding the emergency. Additional
information to be gathered includes whether the individual has any preexisting medical
conditions and when they last consumed food or fluid. From this information the nurse
determines the urgency or priority of care and if additional resources are needed. Next,
the nurse systematically assesses the patient's condition. A quick 30-60 second initial
primary assessment includes the patient's general appearance, respiratory status, cardiac
status, and mental status. The primary assessment is followed by a quick 2-3 minute
head-to-toe assessment including a full set of vital signs, an inspection of the body, and a
relevant health history.82

G. NURSING EXPECTATIONS for RESPONSE to ABNORMAL VITAL SIGNS

Nursing response to abnormal vital signs is one of the most important levers in
patient safety by providing timely recognition of early clinical deterioration. Patient
deterioration is often preceded by changes in vital signs. This occurs through diligent
nursing surveillance, involving assessment, interpretation of data, recognition of a
problem and meaningful response (DeVita et al. 2011).83 Regular assessment of multi‐
parameter vital signs has been shown to be important in identifying patients at risk for
serious adverse events, allowing time for nursing interventions to prevent FTR [Failure to
Rescue] (Storm‐Versloot et al. 2014).84

79
Schoenly, Lorry and Catherine M. Knox, Essentials of Correctional Nursing, Emergency Care Delivery,
p 308, 2013.
80
Id., pp 310 - 311, 2013.
81
Id., p 308.
82
Id., pp 311-312.
83
DeVita MA, Hillman R & Bellomo K (2011) Textbook of Rapid Response Systems, Concepts and
Implementation. Springer, New York.
84
Storm‐Versloot MN, Verweij L, Lucas C, Ludikhuize J, Goslings JC, Legemate DA & Vermeulen H
(2014) Clinical relevance of routinely measured vital signs in hospitalized patients: a systematic
review. Journal of Nursing Scholarship 46, 39–49.

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 CONFIDENTIAL

It is not just the vital signs themselves but the interpretation and synthesis of this
data in the context of the particular circumstances of the patient that define the practice of
nursing. Possible causes for an abnormal low blood pressure include pain, dehydration,
and neurogenic or septic shock.85 The standard of practice for nurses with regard to
patient vital signs includes recognition of a patient's physiological deterioration,
identifying the urgency of the situation and summoning appropriate assistance.86

H. SALT LAKE COUNTY JAIL POLICY and PROCEDURE (Not an all-

Inclusive list)
SALT LAKE COUNTY JOB DESCRIPTIONS
PRISONER RULES and REGULATIONS HANDBOOK

The following policies and procedures, job descriptions, of the Salt Lake County
Jail and sections of the prisoner handbook were used in formulating my opinions
regarding the care that was or was not provided to Lisa Ostler at the Salt Lake County
Jail from March 30, 2016 through April 2, 2016:

Access to Care, SLCo Ostler 001584

Responsible Health Authority SLCo Ostler 001586
Health Record Format and Contents SLCo Ostler 001727
Training for Correctional Officers SLCo Ostler 001619
Diagnostic Services SLCo Ostler 001640
Emergency Services SLCo Ostler 001665
Volume H – Prisoner Health Care SLCo Ostler 000653
Medical Autonomy SLCo Ostler 002480
Intoxication and Withdrawal SLCo Ostler 001717
Nonemergency Health Care Requests and Services SLCo Ostler 001662
Communication on Patient’s Health Needs SLCo Ostler 002485
Procedure in the Event of An Inmate Death SLCo Ostler 001596
Staffing Plan SLCo Ostler 001625
Health Care Liaison SLCo Ostler 001627
Information on Health Services SLCo Ostler 001644

Job Description, Jail Health Administrator (Bell Deposition, Exhibit 3)

Jail Nurse SLCo Ostler 000264-000266
Correctional Officer
Chief Deputy Sheriff

Prisoner Rules and Regulations Handbook SLCo Ostler 009113-0009135

85
Knox, Catherine, "Vital Signs: Interpretation and Synthesis, February 17, 2015.
86
Knox, Catherine, "Vital Signs: How Often and What To Do, February 24, 2015.

116
 CONFIDENTIAL

I. SALT LAKE COUNTY JAIL MEDICAL DIRECTOR, DR. TODD WILCOX’S

ARTICLE: “Managing Opiate Withdrawal: The WOWS Method”, CorrectCare,
printed Summer 2016.

Todd Wilcox, MD, medical director of the Salt Lake County Jail wrote an article
about the management of opiate withdrawal in the correctional jail setting stating that
“the prescription strength of opiates today is substantially stronger, illegal opiates are
now of much higher purity and opiate withdrawal is more clinically severe and can
frequently result in death if not managed appropriately.” He went on to say that “In my
facility [Salt Lake County Jail] any patient undergoing opiate withdrawal is assessed
twice per day for a minimum of five days by nurses who have been trained in the WOWS
(Wilcox Opiate Withdrawal Scale) protocol. The assessment includes a full set of vital
signs, serial tracking of the patient’s clinical progress and interventions as necessary
based on clinical presentation.” He went on to say “In running this program we have
found that many of our opiate withdrawal patients are psychologically fragile and require
medical support to withdraw from opiates safely.”87

87
Wilcox MD, Dr. Todd, “Managing Opiate Withdrawal: The WOWS Method”, CorrectCare, printed
Summer 2016.

117
EXHIBIT “C”
Recommended Reforms at the
Salt Lake County Jail
 Recommendations for Reforms in Policies and Practices at the
Salt Lake County Jail for the Health and Safety of Incarcerated People
and the Prevention of Unnecessary In-Custody Deaths
(Previously Communicated to, But Rejected by, Jail and County Officials on
Behalf of the Plaintiffs in Ostler v. Harris, et al.)
___________________________________________________________________

What we discovered in the litigation about Salt Lake County’s abysmal

management of the Jail and clear signs of the indifference and recklessness leading
to so many tragedies at the Jail makes it imperative that major reforms at the Salt
Lake County Jail be implemented. The lack of care, compassion, and competent
training and oversight are appalling, and it must all be radically improved, from the
top down. The culture that permits the obvious disregard for the welfare and dignity
of incarcerated people cannot persist without top administrators either turning a
blind eye to it or actively encouraging it. That has to change. Among the many things
we have learned are:

• The many failures to continue monitoring according to the

established WOWS and CIWA protocols, notwithstanding written
policies and orders for those protocols to be followed, including the
measurement of vital signs, at least twice a day for five days. Had those
protocols been followed in Lisa’s case, she would be alive today.

• The failures to continue necessary medicines for incarcerated

people—even such simple medications as acid blockers for inmates
with GERD and other abdominal problems (such as the ulcer Lisa
had)—have cost lives (including Lisa’s) and caused untold misery. In at
least one instance, an inmate was denied acid blockers and anything to
raise his upper torso and head while he was lying down (which he
requested numerous times, as reflected on Sick Call Request forms—
some of which were rejected because he had submitted so many—and
Grievances, with astoundingly callous non-responses), and suffered
horrible pain for his pre-existing esophageal cancer, which was likely
exacerbated by the sadistic failures on the part of medical staff at the jail
to address his life- threatening reflux problems. (We met him for the
first time recently and will be adding him to our witness list.)

1
 • The unjustified and reckless reliance by the Jail, and by Jail nurses
and doctors, on the evaluations and “medical judgments” of
housing officers and their supervisors who have no medical training
or competence beyond simple First Aid and CPR, leading to horrific
failures to treat, evaluate, and transfer incarcerated people for diagnosis
and treatment, unnecessarily and barbarically costing lives of
incarcerated people. In addition to Lisa’s tragic and unnecessary death,
Angie Turner died because of the blatant disregard of her ultimately
fatal medical condition (after being ridiculed and called an “asshole” by
a housing officer) and Meagan Deadrich’s 27-week-old fetus died (and
Megan lost her uterus and has suffered post-natal psychosis) because of
the disregard of her bleeding and requests for evaluation while she was
in the Jail.

• The mental health staff are left on their own to find something to do
much of the time, instead of being able—or expected—to provide
constructive therapy for incarcerated people who are in need. (This was
going to be described at trial by people who worked inside the Jail.) As
with many nurses, mental health workers spent much of their time
watching movies, engaging in social media, listening to music, and
engaging in other non-work-related entertainment instead of
providing potentially life-saving services for inmates, as conceded
by Sheriff Winder. For example, David Walker made it clear to a
mental health worker he was suicidal, but that he did not want to kill
himself. He was merely offered a brochure by the mental health worker
and David responded that it would not help. The mental health worker
did nothing further for him, and did not bother to see David again.
David killed himself. His tragic death left in its wake the depression and
outrage of his loving, severely bereaved mother and brother.

The Jail’s administration, supervisors, and mental health workers—and a

District Attorney’s Office that does not seem to do anything about these matters
other than defend the County as if they are just defend-at-any-cost corporate lawyers
and allow vital evidence to be destroyed—are responsible for David’s death.

The County has been utterly irresponsible and callous toward incarcerated
people and they are being aided and abetted by taxpayer-supported counsel who

2
simply make excuses for them and do not help reach any solutions that can help
prevent the kinds of tragedies that are due to the indifference and incompetence at
the Jail.

The County, including the District Attorney’s Office (“DA’s Office”),

refused to include non-monetary elements in a voluntary settlement in the Ostler
matter. It seemed they were solely focused on what amount of money they would
have to pay to get rid of the lawsuit, regardless of our many efforts to achieve
changes in policies and practices as a part of the resolution of the case. That was a
major missed opportunity for the County to implement badly needed changes at the
Jail. Implementing such changes is not unusual in civil rights litigation. For
example:

• Several years ago, I (Rocky Anderson) was opposed by an imaginative,

problem-solving lawyer (Randall Edwards), who worked in the Salt
Lake City Attorney’s Office. I represented a plaintiff whose surgical rod
in his back was broken when a police officer dropped down on his back.
My client had been a Greyhound Bus driver, but he could not return to
work with his injury. He was depressed, had nothing to get up for in the
mornings, could not pay his child support payments, and was, I feared,
suicidal. The opposing counsel came up with the brilliant idea of the
City hiring my client to drive a bus at the Airport, in addition to the City
paying a fair amount in settlement of his claims. My client, who was
thrilled with the proposal, drove an Airport bus for decades, until he
retired, happy and with a purpose in life. The non-monetary aspect of
the settlement did everyone involved a lot of good.

• An attorney in Pennsylvania described to me that he settled a relatively

small case for a man wrongfully charged with trespass and disorderly
conduct for video-taping police. In addition to the monetary award, part
of the settlement included the commitment by the municipality that it
would enroll its police department in the Pennsylvania Chiefs of Police
Association accreditation program and that all police would be equipped
with, and use, body cameras. Again, the non-monetary aspects of the
settlement achieved something positive for the community and, it
seems, ultimately for the defendants.

3
 • In a New Mexico case against a police officer, in addition to a payment
of $8,500,000, the defendant city agreed to implement new measures
in policies, training, and oversight. (Growder v. City of Albuquerque
(1:13- CV-00599RB-KBM, settlement date: March 14, 2017).

• In a Colorado case against the City of Denver involving the death of a

pretrial detainee, the plaintiff estate settled for $4,650,000 and an
agreement by the City to policy changes, including the addition of two
mental health providers at its jail facilities, 24-hour mental health
coverage, and training on mental illness for all deputies, as well as other
policy changes. (Estate of Michael Marshall v. City of Denver, District
Court of Colorado, Second Judicial District, Denver County, settlement
date; November 17, 2017.)

NECESSARY REFORMS AT THE SALT LAKE COUNTY JAIL

If major changes are not made at the Jail, the Salt Lake County
Sheriff, the Salt Lake County Mayor, and the Salt Lake County Council, as
well as administrators of the Jail, should be held accountable by the media,
the public, and the courts. To prevent further unnecessary in-custody deaths
and other preventable tragedies at the Salt Lake County Jail, the following
positive reforms should be implemented:

1. The hiring and appointment by Salt Lake County of an Inspector

General to comprehensively assess compliance with all policies and
procedures and legal requirements relating to conditions of
confinement and provision of medical services at the Salt Lake County
Jail (“the Jail”), with written reports at least semi-annually
provided to the Salt Lake County Sheriff, the Responsible Health
Authority at the Jail, the Salt Lake County District Attorney, the
Salt Lake County Mayor, and the Salt Lake County Council.

2. A good faith effort to implement a drug-treatment program

pursuant to which every inmate with a substance abuse problem
and arrested on drug-related charges, and who is not also charged
with a violent offense and does not have a record of conviction for a
violent offense, should be, unless determined to pose an imminent
risk of harm to others, transported after booking to a substance
4
 abuse treatment provider for treatment and counseling, rather
than incarcerated in jail.

The following changes in the policies, practices, training, and

supervision at the Salt Lake County Jail should be implemented:

1. Medically trained staff should engage in watch tours of all

incarcerated people at the jail at least every four hours, or twice
during each eight- hour shift. In the case of incarcerated people
complaining of illness or pain, vital signs should be taken and logged
at least every four hours.

2. Mental health workers should engage in watch tours of all

incarcerated people at the jail at least once during each 8-hour
shift. All encounters by mental health workers with incarcerated
people should be logged in detail with names of other people involved
or present.

3. The watch tours of medically trained staff and mental health

workers, as provided in the immediately preceding two paragraphs,
should be logged in a manner similar to the watch tour logs for housing
officers, with names, locations, and times of watch tours.

4. Whenever an incarcerated person does not fill out a Sick Call

Request form but complains of a medical problem, housing
officers should communicate the complaint to a nurse and the
nurse should visit and evaluate the incarcerated person as soon as
possible. After the first such visit and evaluation, if the incarcerated
person is found by the nurse to be faking a medical problem, or if the
medical problem is determined to be minor and that it should be
subject to the same treatment as other minor medical problems, then
the nurse should not be required to continue visiting and evaluating
the incarcerated person, but should log the reasons for not further
visiting and evaluating the incarcerated person outside of the regular
sick call visits. All incidents and communications between housing
officers and nurses should be logged by both. In no instance should a
nurse or any other person on the medical staff at the Jail ask or

5
 depend on a housing officer to make any medical judgment,
including whether there is a medical emergency. Clear written
instructions, on paper or on a sign in each housing unit (and not just
available on a computer), should be provided to all incarcerated
people regarding how they can seek medical assistance or evaluation.

5. All communications by incarcerated people with Central Control

should be logged, including the ringing of cell buttons and requests
for medical assistance, whether the communications are by the
person purported to require medical assistance or by other inmates
seeking medical assistance for another incarcerated person. No
communication by an incarcerated person to Central Control
should ever be ignored and no housing officer or other Jail staff
member should ever indicate to anyone in Central Control that any
communications by incarcerated people should be ignored.

6. Any incarcerated person should be allowed to file a grievance,

regardless of whether the grievance relates to treatment toward
that person or another. Written responses, with signatures of
responders, should be provided in a timely manner in following each
grievance. Clear written instructions, on paper or on a sign in each
housing unit (and not just available on a computer), should be provided
to all incarcerated people regarding the grievance process. Such
instructions should include a notice that the grievance procedure must
be complied with in a timely manner if the incarcerated person later
seeks to file a legal claim.

7. A regular written audit, at least every three months, should be

conducted regarding all grievances and responses to the
grievances. That written audit, conducted by an auditor appointed by
the Salt Lake County Mayor, should be provided to the Salt Lake
County Sheriff, the Responsible Health Authority at the Jail, the Salt
Lake County District Attorney, and the Salt Lake County Mayor.

8. All communications by housing officers or other jail staff with any

medical staff members (including anyone employed by Wellcon)
concerning any medical complaint or sign of a medical problem
should be logged in detail, with an identification of the involved
6
 incarcerated person and a description of everything communicated in
terms of symptoms, complaints, evaluation, monitoring, diagnosis,
source of diagnosis, treatment, and treatment plan.

9. At least once a year, all housing officers, supervisors, and medical

staff should undergo training, to be provided by the Medical
Director of the Jail or his/her designee, to recognize serious acute
and chronic medical conditions, including abdominal pain, and
the appropriate means of logging information about those
conditions, including any symptoms, complaints, evaluation,
monitoring, diagnosis, source of diagnosis, treatment, and treatment
plan.

10. There should be a no-tolerance policy concerning the use of

profanity by any jail staff toward or within hearing of
incarcerated people. Use of profanity (to be clearly defined) toward
incarcerated people should be cause for termination. (The uses of
profanity about which we have learned during the course of the
Ostler matter are consistently in the context of humiliating,
abusive, or demeaning comments, escalating tensions and
conflicts, harming morale, increasing security risks, and causing
an unnecessary schism between incarcerated people and jail
staff.)

11. An audit of the provision of medical attention to incarcerated

people at the Jail should be conducted by an outside firm chosen
by an independent ad hoc committee of non-Jail medical providers and
Salt Lake County officials (designated by the Salt Lake County
Mayor), with a goal of eliminating deaths or unnecessary suffering
as a result of a failure to provide medical treatment to incarcerated
people.

12. An expert should be retained to oversee and conduct Morbidity

and Mortality Reviews of every in-custody death (including those
people known to have died within a week of being transported
from the Jail to a hospital) during the past five (5) years, with a
view toward identifying problems in the treatment or nontreatment of
incarcerated people and drafting and implementing new or revised
7
 policies and procedures to protect against deaths or aggravation of
medical or mental- health problems in the future. That expert should
obtain written witness statements and draft a written report, all of
which should be maintained by the Jail for at least ten (10) years. The
written report should provide conclusions about what led to each
death, who may have been responsible for any problems leading
to the inmate’s death, what (if anything) might have been done to
prevent each death, and any changes in policies or practices that
might help prevent such deaths or problems in the future.

13. CIWA and WOWS assessments should be clearly assigned to

particular nurses by nursing supervisors and should be conducted
at least twice a day for five days after such assessments have begun.
The responsibility for conducting such assessments should be
clearly communicated, in writing, by the Responsible Health
Authority.

14. If an incarcerated person has a heart rate over 110, a physician

must be contacted, as required by written policy.

15. Blood glucose levels should be monitored for all inmates who have
missed four or more meals in a 48-hour period.

16. Evidence of compliance with the above should be provided.

The above proposals were submitted to the DA’s Office in connection with
settlement offers on behalf of Lisa’s family members, in an effort to protect
incarcerated people from the types of neglect, abuse, and suffering experienced by
Lisa and many others, including Angie Turner, David Walker, and Meagan
Deadrich—and to improve the quality and morale of staff at the Salt Lake County
Jail. Salt Lake County refused to include in the settlement of the case any non-
monetary elements, including the reforms described above.