Doctors say Jackson County jailhouse death might have been avoided

ReGina Thurman, 53, died at the Jackson County Detention Center on Jan. 20, 2017 after nurses failed to recognize her symptoms as being a serious cardiovascular condition.
ReGina Thurman, 53, died at the Jackson County Detention Center on Jan. 20, 2017 after nurses failed to recognize her symptoms as being a serious cardiovascular condition.

Jackson County jail inmate ReGina R. Thurman displayed classic symptoms of someone whose main blood vessel, the aorta, was about to burst.

The 53-year-old Kansas City-area woman complained of burning chest pains and backache, and her left leg had gone numb. Anyone with those symptoms should have been transported immediately to a hospital emergency room, two cardiologists told The Star.

Yet records show that the only medical care Thurman received at the Jackson County Detention Center during the hour that passed between first seeing a nurse about her chest pain and slumping to the floor lifeless were two antacid tablets and a bit of advice.

“Breathe and relax,” a nurse said as she searched for Thurman’s pulse and found none.

“It’s sad,” Thurman’s brother Brian Chavez said after reading the sheriff’s department investigative report obtained by The Star, which details the events before and after his sister was pronounced dead at 2:11 a.m. Jan. 20. “Somebody has to be accountable because, man, it was just terrible, the whole thing from start to finish.”

According to the separate autopsy report, also obtained by The Star through an open records request, Thurman’s cause of death was “aortic dissection,” of which “hypertensive cardiovascular disease was a contributing factor.” The manner of death: “natural.”

But Chavez and one of Thurman’s daughters say the center’s contracted medical staff was negligent for not getting Thurman to the hospital, where her life might have been saved. (Chavez works in The Kansas City Star’s engineering department.)

The Mayo Clinic and other experts say tears in an artery’s walls, known as dissection, almost always result in a fatal rupture if not treated with drugs or surgery. Indeed, 20 percent of patients with aortic dissection die on their way to the hospital, according to the Merck Manual, the world’s best-selling medical textbook.

The two nurses who saw Thurman and the doctor who one of them consulted with the night of her death could not have diagnosed the condition without an X-ray or a CT scan. But they should have recognized the seriousness of Thurman’s symptoms and gotten her to the emergency room for tests, two Kansas City heart surgeons with no direct connection to the case told The Star based on the events described in the 11-page sheriff’s report.

“No question they should have sent her to the ER with that background,” cardiologist Alan Forker said, referring to Thurman’s hypertension. Forker, who recently retired after long stints at Truman Medical Center and St. Luke’s Hospital and was a professor of medicine at the University of Missouri-Kansas City, added, “Clearly, that was not the way to handle her.”

Thurman’s relatives, who are considering a lawsuit, say the incident speaks to the dysfunction of a facility that has been the subject of multiple investigations the past two years. Those investigations include an FBI probe into allegations of physical abuse of prisoners by guards, and a former U.S. district attorney’s investigation on behalf of the county into lax security that allowed inmates to commit sexual assaults on other prisoners without detection.

Jackson County and the FBI investigated four cases in 2015 of inmates who alleged physical abuse by guards at the county jail. The investigation was an effort to determine whether the incidents were isolated or signs of a broken system.

Medical care at the jail was one of the major shortcomings identified in a 2015 report written by a citizens commission appointed by county government in the wake of the FBI investigation. Among the recommendations since acted upon was to have a nurse evaluate inmates at intake.

“How are we as a community OK with this facility still holding our people?” one of Thurman’s four grown children, Nichole Aguirre, said in a Facebook post a month after her mother’s death. “Not all inmates are bad people … it could be any one of us that had one too many drinks … or an old speeding ticket we forgot about … change will be had!! This place is very corrupt.”

In its initial statement about Thurman’s death on the afternoon of Jan. 20, the county made no mention of the hour that passed between her first complaints of chest pains and the fruitless attempt to save her life. The statement said only that she had suddenly become unresponsive.

County Executive Frank White’s top aide, chief of staff Caleb Clifford, declined Friday to discuss why that information was not included, but the county did issue the following comments:

“First, and foremost, our thoughts and condolences continue to be with the family of Ms. Thurman.

“Jackson County takes the health and welfare of all of our inmates very seriously. It is due to this commitment that we entered into a contractual agreement with Correct Care Solutions to provide professional medical care to our inmates. Correct Care Solutions is responsible for providing licensed medical professionals at our facility 24 hours a day, 365 days a year. These medical professionals are responsible for the screening of all inmates as they enter the facility, for providing care as needed while an inmate is in custody, and for advising our staff if an inmate requires treatment off-site.

“On the late evening of January 19, 2017, Department of Corrections staff contacted Correct Care Solutions staff and requested and received their assistance. Any questions regarding the medical care of Ms. Thurman in our facility should be directed to Correct Care Solutions.”

However, the Nashville, Tenn., company the county pays more than $3 million each year to provide on-site medical care declined to discuss Thurman’s death.

“Because the story you are developing deals with the specific health aspects of a patient,” a spokesman said, “by regulation we are unable to respond in detail. We consider the care of our patients to be a top priority at CCS, and we are giving this our full attention.”

“Call 911”

Twice married, ReGina Thurman was best known among family and friends by her maiden name, Gina Chavez.

Blonde, 5-foot-4 with a musical note tattoo below and slightly behind her right ear, Thurman was a warm but troubled soul who loved her kids and seven grandchildren. In recent years, she’d struggled with substance abuse, her brother said, and would sometimes lash out on her Facebook account when she felt judged or betrayed.

“I have taken enough,” she wrote last Dec. 27. “I will not take it from Anyone again. when you get off your high horses and remember who your dealing with. You know where im at. Lets hope its not too late and i will be gone for good.”

Two days before she died, Thurman was arrested by Clay County sheriff’s deputies at a motel in Randolph when, during the course of an investigation, they ran her ID and discovered three outstanding warrants in Jackson County, records show.

Authorities would later say her arrest was connected to an alleged probation violation, but it’s unknown what crime she was on probation for because that court record has been closed to public inspection without explanation.

Thurman was unable to post bond that day at the Clay County Detention Center, so the Jackson County sheriff’s department arranged to pick her up the next morning.

“It should be noted that at no time did she complain of any pains or request for medical attention,” one of the two Jackson County deputies who drove her downtown on Jan. 19 wrote in his report. “Her only request was that we not apply the handcuffs too tight due to Arthritis in her wrists, to which we complied.”

Thurman said nothing else, the deputies said, during the 25-minute drive from Liberty to the red-brick fortress at 1300 Cherry St., where close to 900 people are incarcerated on any given day. Some are there awaiting trial on serious charges. Others are serving out short sentences for minor municipal offenses at the adjoining Regional Correctional Center.

All begin their time there in the first-floor intake area, where Thurman was turned over to the detention center staff around 10 a.m. Once there, she filled out a questionnaire. On it, she may or may not have disclosed that she suffered from high blood pressure.

The Star put in a request for that form Friday but had not received that record as of publication time.

For the next 14 hours, she sat in a kind of limbo. She wasn’t free to go, but neither was she fully processed into the facility while attempting to raise bond. When she began having chest pains around midnight, she was wearing the same blue and black shirt, blue jeans and white plaid socks she’d had on when she was arrested the previous day.

“A burning sensation in her chest” is how the sheriff’s report described it. The intake nurse checked her vital signs.

“They were good,” she told one of the sheriff’s deputies who investigated Thurman’s death.

So she gave Thurman two Tums tablets and sent her back to the holding area.

But the pain didn’t go away. Forty-five minutes later, jail staff advised the nurse that “Thurman was on the floor complaining about left leg numbness and back pain.” Again the nurse checked her vital signs. The report doesn’t specify what that entailed, although typically it means checking heart rate, blood pressure, respiration and temperature.

And again, everything seemed normal.

Speaking to a sheriff’s deputy later, the nurse volunteered that prisoners routinely fake illness to get out of jail temporarily. “She did not say this was the case here but did state it routinely happens all the time,” the report said.

It was around this time that Thurman’s daughter Aguirre got a phone call from an inmate at the jail.

Her mother had asked the unnamed inmate, who would have had free access to a phone in the intake section, to tell Aguirre to call 911.

According to the report: “The inmate advised that Thurman was lying in a cell curled up in a ball, advising that she was having chest pains and no one was listening to her.”

Aguirre, a hospital nurse, did eventually call 911. But first she began calling the jail to get information about her mother. She said she talked to four different staff members, and each time she was transferred to voice mail.

“She felt that she was not being helped,” the report said.

Aguirre recounted her frustration in a TV interview on the day of her mother’s death.

“I spent an hour trying to get ahold of somebody,” she told KCTV 5. “I just wanted a live person to help.”

But when contacted last week, Aguirre declined to comment on the advice of a lawyer who is preparing possible legal action.

As Aguirre frantically tried to get ahold of someone with knowledge of her mother’s condition, the nurse who’d given Thurman the Tums asked a nurse on duty on another floor to come down and give her a second opinion.

That second nurse theorized that Thurman’s back and leg pains might be her sciatic nerve acting up from sitting in intake all day. However, those same symptoms, when coupled with the chest pains, are indicative of either an oncoming heart attack or tear of the aorta, according to the doctors The Star consulted.

“Those are typical symptoms of aortic dissections,” said a prominent heart surgeon currently on staff at an area hospital who spoke on the condition that his name not be used. “It probably should have been suspected.”

Forker agreed in a separate interview.

“This is a familiar story of dissections being missed,” he said. “They think it’s an upset stomach. But I would say they should have sent her to the ER.”

Instead, about 1 a.m., one of the correctional officers decided it was time for Thurman to change into jail clothes. After being wheeled into the dressing room, Thurman sat on a bench for a moment before slumping and then sliding onto the floor.

The guard summoned the nurse, who first thought Thurman was holding her breath as she lay on the floor.

“She kept telling Thurman she needed to breath (sic) and relax and she needed to get dressed,” investigators said. But when she checked Thurman for a pulse and found none, the nurse began resuscitation efforts and asked someone to call paramedics.

They arrived at 1:25 a.m., and Thurman was pronounced dead 46 minutes later.

In the course of the investigation that followed in those pre-dawn hours, deputies took statements from the nurses and other jail personnel.

The report notes that the corrections officer who wheeled Thurman into the changing room “was visibly upset” as she gave her account.

Later that Friday, around 2 in the afternoon, an autopsy was performed at the county medical examiner’s office near the base of Hospital Hill. A deputy observing the procedure reported seeing “an extreme amount of blood” in Thurman’s chest cavity.

“It is my opinion,” deputy medical examiner Lindsey J. Haldiman wrote in the report, “that Regina R. Thurman died as a result of a ruptured aortic dissection. Hypertensive cardiovascular disease was a contributing factor.”

Six days later, on a chilly Thursday evening, Thurman’s family and friends gathered at Soul’s Harbor Assembly of God Church in Independence for an informal memorial service.

“Gina was very much a people person and didn’t know a stranger,” her obituary read.