State rebukes nurse, deputy in inmate death

The New York State Commission of Correction has issued a blistering report involving the death of a pregnant inmate at the Onondaga County Justice Center last year.

21-year-old Chuniece Patterson died from a ruptured ectopic pregnancy. The reports states that "Had Patterson received adequate and competent medical care, her death would have been prevented."

In November, Onondaga County Sheriff Kevin Walsh said Patterson was seen by a registered nurse after complaining of shortness of breath while being held in the county jail. She was booked into the detention center on November 10, 2009 on a bench warrant for numerous mischief, weapons, theft and contempt charges.

According to the state report, at 6:00 p.m. on November 11 inmates in cells near Patterson's told the deputy on duty that Patterson had been vomiting. The deputy also saw Patterson vomit so the deputy then called the medical unit to check on Patterson.

The report states that a registered nurse, who is only identified as "M.C." arrived at Patterson's cell at 6:40 p.m. Information about what happened next has been redacted from the report. But the first line after the redacted section states "This is a violation of Onondaga County Justice Center's policy #333.0 dated 3/22/96 entitled Vital Signs which states: "Vital signs will be taken at each scheduled inmate encounter, emergency response, when there is a change in inmate condition, as ordered, and more frequently then ordered if nursing judgment deems it necessary. Any significant changes in vital signs will be reported to the physician by the charge nurse." The report goes on to say, "Nurse M.C. provided grossly and flagrantly negligent and incompetent nursing care to inmate Patterson in that she completely misinterpreted and minimized the significance of pain and vomiting at this juncture."

At 8:00 p.m., the report states that the same sheriff's deputy found Patterson in her cell wearing only her underwear. The deputy says Patterson said she was hot. Twenty minutes later, the deputy made another phone call to the medical unit stating Patterson was sick and lying on the floor. Nurse M.C. then returned to Patterson's cell. At this point, another portion of the report is redacted. The report goes on to say that nurse M.C. Did not record either of her encounters with Patterson until after the inmate's death, which is a violation of the justice center's policy. Again, nurse M.C. is criticized for her conduct. The report reads, "nurse M.C.'s professional conduct in this second encounter was again grossly negligent and incompetent, again failed to appreciate the gravity of Patterson's condition and appeared to be without training, background, orientation or supervision in the approach to this patient."

At 11:00 p.m. that night, there was a shift change and another deputy was put in charge of Patteron's cell pod. That deputy reports that from 11:00 p.m. - 12:00 p.m. Patterson's breathing was heavy and loud. In her statement the deputy described the breathing sounds as a "fake asthma attack". At 1:40 a.m., Patterson activated the emergency button in her cell. The deputy says she knocked on the door several times and that it took Patterson a few minutes to respond. The deputy says when she entered the cell, she saw Patterson sitting on the floor with her arm on the bunk. Patterson was breathing hard and stated, "I'm sorry I cannot breathe." The deputy says she asked Patterson if she would like to have a nurse called, to which Patterson answered yes. The deputy contacted a nurse identified as "R.D." Information about R.D.'s visit to Patterson's cell has been redacted from the report. He did state that he knew Patterson was pregnant because he had performed her pregnancy test the night before. He said he wasn't told by nurse M.C. about her encounters with Patterson. M.C. denies that statement, saying she did report them to R.D. The report says that R.D. violated justice center policy by not completing a full set of vital signs for Patterson.

The report says throughout the rest of the night, Patterson was frequently checked and no other calls to the medical unit were made.

At about 7:00 a.m. on November 12th, a deputy identified as "D.S." reported finding Patterson kneeling against the toilet in her cell and splashing toilet water on her face. Deputy D.S. told Patterson to stop it and says Patterson then slid down next to the toilet and onto the floor. During her rounds, D.S. says she heard Patterson moaning and told the inmate to "knock it off."

The report goes on to say, "at approximately 7:30am while completing her next supervisory round, Deputy D.S. observed Patterson still lying on the cell floor. The deputy observed a cup in the toilet and went into Patterson's cell to remove the cup. Deputy D.S. stated Patterson looked up at her from the floor. Deputy D.S. reported she ordered Patterson to get off the floor, to come out of the cell, and retrieve her breakfast tray. Patterson did not respond. Deputy D.S. left the cell and closed Patterson's door. Deputy D.S. stated she closed the door because she wanted Patterson to get up, ring her buzzer, come out and get her breakfast tray. Deputy D.S stated she observed Patterson was lying on the floor and not verbally responding to her orders. This should have been an indication that Patterson needed medical attention...At 7:45am, Deputy D.S...observed Patterson lying in the same position on the floor as she was at 7:30am. Deputy D.S. ordered Patterson to get off the floor. Patterson did not respond and Deputy D.S. shook her arm and leg with no response." The deputy then noticed Patterson's arms were cold and that white foaming liquid was coming out of her mouth. The deputy immediately called to report a medical emergency. At 7:45 am a sergeant responding to the call asked Deputy D.S. "where is she?" to which the deputy replied, "she has been faking all night." The sergeant says she found Patterson lying on her back with her eyes glazed over and that she was foaming at the mouth. When she couldn't detect a pulse, she started rescue breathing. The next two sections of the report are redacted. The report says that after Patterson's death, the Onondaga County Justice Center's administrative staff sent nurse M.C. a counseling memo regarding her lack of nursing documentation for the two encounters with Patterson. Nurse R.D. received a counseling memo for not completing a full set of vital signs on Patterson. All of the deputies who supervised Patterson stated that they were unaware she was pregnant.

In the report, the state makes several recommendations to Sheriff Walsh about the incident. They recommend a comprehensive review and revision of the justice center's policy and procedure for dealing with inmate pregnancies. It also suggests the nursing staff undergo in-service education. The report recommends disciplinary action be taken against Deputy D.S., who supervised Patterson from 7:00 a.m. to 3:00 p.m. on November 12th. The report also calls for improvements in the communication between the nursing staff that are giving and receiving shift reports. It also suggests the sheriff monitor nurses M.C. and R.D. during inmate sick calls for a period of six months.