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FARMINGTON — A police investigation into the death of Jesus Marquez at the San Juan County Adult Detention Center indicates that medical staff contracted to deliver medical care at the facility argued against transporting the inmate to the emergency room shortly before his death from pneumonia, according to a San Juan County Sheriff's Office report.

The report also indicates that Marquez filed three forms requesting medical help on March 2, the day before his death. He stated in one report filed the evening of March 2 that he needed to go to the emergency room immediately due to severe chest pain.

Investigations by sheriff's detectives into the deaths of inmates Sharon Jones and William "Billy" Carter also turned up evidence that nurses may have ignored their medical requests or provided inconsistent medical care in the days before their deaths. Those three inmates died in the first three months of 2015.

The Daily Times has reported on the challenge of filtering out spurious requests for medical care while ensuring the health of inmates. Dr. Jacqueline Moore, of Greenwood Village, Colo., who had no connection to any local facilities, has said it is common to charge co-pays, which the local jail does, to cut down on false claims. However, a national correctional health care group formed by the American Medical Association recommends against the policy, which it says can lead to delayed care and more costly medical interventions.

"They don't recommend it, but so many of the counties are doing it because of frivolous inmate complaints," Moore said. "Inmates would send a lot of sick calls, and you couldn't staff so many requests."

But the Sheriff's Office report details situations in these three cases where requests for medical care and medications were consistently denied in the hours before the inmates' deaths.

A jail guard interviewed by investigators said, "this is an ongoing issue with the medical staff at the jail, not taking medical requests seriously and talking about the inmates faking their illnesses. ... He went on to say the medical staff appears bothered by the inmates and their relentless requests."

According to the report on Billy Carter's death on Feb. 13, Carter's prescription inhalers appear to have been out of stock at the time of his death and medical staff failed to regularly provide him other prescription medications, including some used to treat breathing problems. A medical investigator later determined that Carter died of chronic obstructive pulmonary disease, a respiratory illness linked to tobacco use.

Several inmates told a detective that Sharon Jones complained of severe pain and asked to be taken to the emergency room multiple times before she was found dead in the medical ward of the jail on the morning of Jan. 5, 2015, according to the investigative report.

Medical staff at the jail told detectives they provided Jones pain medication on the night of Jan. 4, but no narcotics were found in Jones' system at the time of her death, according to a toxicology report.

All three deaths are the subject of lawsuits filed last year against the detention center, the county and the detention center's medical provider, San Juan Regional Medical Center.

San Juan Regional Medical Center provides medical care to inmates at the detention center and the alternative sentencing division under a $2.15 million contract with San Juan County.

Laura Werbner, a spokeswoman for the hospital, said it is not the policy of San Juan Regional Medical Center to discuss an ongoing lawsuit, but "the hospital believes it has meritorious defenses and will vigorously defend this litigation."

"We look forward to presenting our viewpoint in court," Werbner said.

The hospital also cited medical and personnel privacy in declining to comment on the death investigations.

Both San Juan County Executive Officer Kim Carpenter and jail administrator Tom Havel declined to comment, citing the pending litigation.

The San Juan County Sheriff's Office is responsible for investigating deaths at the detention center. The investigations into the deaths of Carter, Jones and Marquez began when each inmate was first reported dead. Generally, they concluded when detectives obtained autopsy and toxicology reports from the New Mexico Office of the Medical Investigator.

Sheriff's detective Lt. Kyle Lincoln said  his office has completed its investigations into the jail deaths, but declined to draw any conclusions. No charges related to the investigation had been filed as of Friday.

Lincoln said he was not certain whether criminal penalties existed for medical negligence in a detention setting, and that it is easier to seek redress through a lawsuit.

He said no inmates have died at the detention center since March, but attorneys with the law firm of Tucker, Burns, Yoder & Hatfield — who are representing the deceased inmates' families — claim current inmates continue to receive negligent medical care at the detention center.

A judge was expected to rule this week on whether a court-appointed doctor should provide medical oversight at the detention center, but nothing had been filed as of late Friday, according to court records.

The Farmington law firm is also representing more than two dozen current and former inmates who claim they received negligent medical care while incarcerated at the detention center.

The law firm is not only requesting compensatory and punitive damages for its clients, but also court-ordered changes in policies, procedures, supervision, training and contractual payments for medical services at the jail.

The jail and hospital have denied all claims made by the plaintiffs.

The detectives' investigative reports were obtained by The Daily Times through a New Mexico Inspection of Public Records Act request.

The death of Jesus Marquez 

A sheriff's detective was dispatched at approximately 5:47 p.m. March 3 to the San Juan Regional Medical Center after receiving reports that Marquez had died, according to the report.

Marquez, 34, was incarcerated for about a year on felony assault charges and was housed in the medical wing of the jail at the time of his death, the reports states.

Marquez first filed a mental health request form on March 2 complaining of chest pains, according to the report. A therapist checked on him and told a nurse that she was concerned about him, the report states.

Marquez filed medical request forms twice more on March 2. In both forms he complained of a bad cough and severe chest pain, according to the report.

The inmate told staff at 9 p.m. on March 2 that he had severe chest pain and was "begging" to go to the emergency room, the report states, but it is not clear to whom the complaint was made.

According to the report, an electrocardiogram test was performed on Marquez and the results were faxed to San Juan Regional Medical Center.

A notation on the test indicates it was not reviewed by the jail's medical director, Dr. Eric Ketcham, until 11:15 a.m. the next day, according to the report.

A jail sergeant told detectives Marquez began complaining he had trouble breathing at about 4 a.m. on March 3. A nurse checked Marquez's blood sugar and vitals and gave him insulin, according to the report.

By 9:10 a.m., Marquez's skin had turned pale, he was cool to the touch and his breathing was labored, according to the report.

At 9:30 a.m., a nurse medically cleared Marquez to attend court, but a jail sergeant instead transported him back to his cell, according to the report. The sergeant told the detective he had to use a wheelchair to transport Marquez back to his cell.

Ketcham was notified of Marquez's condition at 10 a.m., the report states.

A jail guard later states that she was checking the cells in the medical unit for contraband at 12:21 p.m. when she saw Marquez was very pale and his lips were grey, according to the report. The guard alerted the on-duty nurse, but said she did not seem concerned about Marquez's condition, the report states.

The nurse briefly inspected Marquez and again medically cleared him, the report states.

Jail guards called for emergency transport, despite the nurse's assessment, according to the report, and asked for medical staff to be present to monitor Marquez.

In response to the request, the nurse said, "I'm sorry; I didn't realize we had to be present during a non-emergency transport," and apologized for breaking protocol, according to the report.

Another jail guard said no medical staff were present when emergency medical technicians arrived at the jail at 12:47 p.m., according to the report.

Marquez flat-lined while enroute to the hospital and died at the hospital at 3:36 p.m., the report states.

The cause of death was pneumonia, according to an autopsy report.

The sheriff's office closed its investigation into Marquez's death on June 24.

The death of Sharon Jones

A sheriff's detective was dispatched to the detention center at 4:57 a.m. on Jan. 5, 2015, after receiving reports of Jones' death, according to the report.

Jones, 50, was found in the medical wing unresponsive and transported to the hospital, where she was pronounced dead, the report states.

Delphine Jose, an inmate in the medical wing, told the detective that Jones first complained of pain on the afternoon of Jan. 4. Jose claimed Jones requested to go to the emergency room several times, but her requests were denied, according to the report.

Jose said that Jones complained of pain throughout the night and was having difficulty getting out of bed, the report states.

Jose's statement was supported by Ashley Thode, another inmate in the medical wing on the night of Jones' death.

Thode told The Daily Times in May that she and other inmates repeatedly requested medical care for Jones, but those requests were ignored.

Thode made similar claims to detectives, according to the report.

Both Jose and another inmate, Anita Garcia, told detectives they pressed the medical emergency button in the pod several times, but nurses never responded.

A guard told the detective she did not typically work in the medical unit, but she was assigned there on the night of Jan. 4.

She said she checked on Jones every 30 minutes, and found her dead after returning with a bedpan Jones had requested, according to the report.

The guard said she could not recall whether Jones had specifically requested transport to the hospital, the report states.

The on-duty nurse told the detective she gave Jones her pain medication at 7 p.m. and Jones had requested more medication at 9 p.m. The nurse said she refused to give Jones more medication and stated that Jones' medical history indicated she had tried to overdose in 2013.

The report notes that jail staff said Jones "regularly states she needs medication and will ask for more than her standard dosage."

The nurse said she received a medical call when Jones was found dead, according to the report. It does not indicate in the report whether she responded to the other requests for medical attention.

Jones died of sepsis, or blood poisoning, according to the autopsy report. The toxicology report for Jones indicates she had medication in her system to treat depression and antihistamines, but no narcotic medication.

The sheriff's office received the autopsy report on April 22, according to the investigative report, but the case was not officially closed until Dec. 17.

The death of Billy Carter

Carter, 57, was found by a jail guard naked and laying face down in his cell at 7:30 a.m. on Feb. 13, according to the report.

The guard entered Carter's cell and discovered he was dead, the report states.

The sheriff's detective noted during an inspection of Carter's body that he had large bruises on his elbow and his left hip, the report states.

According to Carter's medical file, he was transported to the hospital on Feb. 11 after suffering a hip injury from a fall, the report states.

An x-ray performed at the hospital showed no fracture and Carter was transported back to the jail, the report states.

The medical file also indicated that Carter was prescribed medication daily to treat anxiety, pain, constipation, allergies and breathing problems, according to the report.

However, the detective notes in the report that those medications were provided infrequently throughout the month, and it was documented that Carter periodically refused them. An inhaler that Carter was told to use twice daily was prescribed on Feb. 2, but the detective states it does not appear in Carter's file that he was offered medication until the day before his death.

Elsewhere in his file, it was noted that Carter complained about not receiving his inhalers, according to the report. Medical staff noted in his file that the jail had run out of his prescription inhalers and they would be provided to him when they were back in stock, according to the report.

A jail guard told the detective a nurse had complained to him about Carter during a lunch break. The guard said the nurse claimed Carter faked dizziness and did not need to be in the medical unit, according to the report.

A different nurse interviewed by the detective said Carter was "an angry little man," who was upset he could not keep his inhalers with him, according to the report.

She told the detective Carter had to go to the medical unit to receive his inhaler if he needed to use it, and claimed he had "attention seeking behavior," the report states. She said she "did take every patients (sic) complaint seriously," according to the report.

Carter contacted his attorney, Eric Morrow, twice on Feb. 11 requesting emergency medical assistance, according to the report.

Morrow told The Daily Times in June that Carter's skin was loose and translucent before his death and he had trouble getting around the jail.

Carter's death was due to chronic obstructive pulmonary disease, according to an autopsy report. The sheriff's office closed its investigation into Carter's death on Sept. 7.

Steve Garrison covers crime and courts for The Daily Times. He can be reached at 505-564-4644. 

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