State prison officials failed for 17 months to tell the state health department about the death of an inmate at the San Carlos Correctional Facility — a case in which corrections staff can be heard joking and laughing while the inmate was dying.
When contacted by The Denver Post, the Colorado Department of Health and Environment opened an investigation into the circumstances leading to the death of former San Carlos inmate Christopher Lopez, 35, on March 17, 2013. Lopez died on a cell floor after two severe seizures and other obvious and dire symptoms didn’t prompt staff to help him.
“The facility was obligated to report it (within one day). They did not. A death is a reportable offense,” said Judy Hughes, senior branch chief of the health department’s Health Facilities and Medical Emergency Division.
Adrienne Jacobson, spokeswoman for the Colorado Department of Corrections, said Lopez’s death was not reported to the health department because Lopez did not die in the clinic. When deaths occur in prison clinics, they are reported, Jacobson said.
“We handled this the way we thought we were supposed to,” Jacobson said Friday.
But Randy Kuykendall, director of the department’s Health Facilities division, said prisons are unique settings where inmates can receive care only through the clinic staff, whether in the clinic itself or in their own cell.
Because of San Carlos’ failure to report Lopez’s death, the agency responsible for oversight and licensing of Colorado’s 2,000 health care facilities has not even begun to analyze what led to the schizophrenic man’s death.
Health inspectors will now review San Carlos’ clinical policies and practices and make recommendations for correcting any deficiencies they identify, Kuykendall said. If the state discovers deficiencies, health care facilities are obligated to develop a plan of correction, he said.
“If there is a need for making changes, we are certainly open to that,” Jacobson said.
Lopez’s family filed a federal lawsuit in June against the prison and state employees. Lopez died of severe hyponatremia, a condition that occurs when sodium levels are too low, the suit says.
The inmate’s medical condition was brought on by too much psychotropic medication, which is usually treatable with prompt action, the lawsuit filed by the Denver law firm of Killmer, Lane & Newman says.
San Carlos correctional officers found Lopez in an intake cell at about 3:30 a.m. He was shaking and lying on his stomach. His arms were under his chest, and his face was on the floor.
An hour later, six correctional officers dressed in riot gear entered his cell and dragged him out. They stripped him, chained and cuffed him to a wheeled transport chair, and pulled a spit mask over his head. They left him in the chair, slumped forward, held to the chair by a chain around his belly, the suit says.
Sometime after 6 a.m., Lopez began shaking uncontrollably while having a grand mal seizure, the lawsuit says. At about 9:10 a.m., after a second seizure, Lopez’s body, which had been heaving with each breath, stopped moving as he died.
Officers called mental health clinician Cheryl Neumeister, who arrived at 9:15 a.m.
“I can see you breathing,” Neumeister called to the dead man, the lawsuit says.
She left the area after chatting and joking. It took staff another 15 minutes to determine Lopez was dead.
Jacobson said the department has taken steps to prevent what happened to Lopez from happening again.
Since then, CDOC has required every employee to receive health protocol training. Officials said they fired three employees and disciplined five others.
Kirk Mitchell: 303-954-1206, denverpost.com/coldcases or twitter.com/kirkmitchell
