Medical experts disagree on cause of inmate’s death; lawsuit against Douglas County continues

In this AP photo from Monday, Aug. 18, 2014, former New York City chief medical examiner Dr. Michael Baden speaks during a news conference to share preliminary results of a second autopsy done on Michael Brown in St. Louis County, Mo. Baden is one of several high-profile medical experts offering his opinion in a lawsuit surrounding the 2012 death of 32-year-old Rachel Hammers in the Douglas County Jail.

A simple visit by a nurse or a doctor likely could have prevented the 2012 death of a Douglas County jail inmate, multiple medical experts now argue as part of a high-stakes lawsuit.

In a lawsuit that could cost the county more than $1 million, the arguments among expert witnesses are becoming more pointed on why Rachel Hammers died at age 32 while in the custody of the Douglas County Jail.

Experts for Hammers’ family — the plaintiff in the lawsuit — argue that medical visits by either a nurse or a doctor could have saved Hammers’ life. Instead, she received no such visits and died of a seizure while her cellmate listened.

“No one questioned (Hammers) or appeared to be concerned about the consequences of suddenly stopping her drinking a quart of rum per day,” wrote Dr. Michael Baden — on behalf of the plaintiff — in a report filed in federal court. “There were no such outward signs or symptoms of alcohol withdrawal recorded because no nurse or doctor spoke with Mrs. Hammers or examined her.”

But experts with Douglas County argue that the seizure was neither predictable nor preventable.

The fatal seizure hit Hammers the morning of May 12, 2012, while she was confined to a jail cell alongside another woman. She had been booked into the jail the day before after violating the terms of her parole, which stemmed from a DUI arrest.

As previously reported by the Journal-World, Joe Harvey, Hammers’ father and a Lawrence orthodontist, filed a federal lawsuit claiming that the jail’s administration and medical staff should have known about her medical risks. Harvey’s lawsuit, which is seeking $1.35 million in compensation, argues that his daughter’s death was needless, painful and the result of negligence.

The lawsuit’s outcome likely will hinge on a determination of how exactly Hammers died and whether and how the death might have been prevented. The case is entering a key period as a federal judge must decide which experts are allowed to testified in a future trial.

Douglas County officials declined to comment on the ongoing lawsuit. However, through court filings, they deny Harvey’s claims.

Harvey also declined to comment on the lawsuit, previously saying only: “My family and I have great faith in our legal team.”

High profile lineup

Harvey’s legal team is putting together a list of experts culled from across the country. Baden acted as chief forensic pathologist for the U.S. Congress Select Committee on Assassinations, which investigated the deaths of President John F. Kennedy and Dr. Martin Luther King Jr. He has worked as a consultant for the FBI, DEA, Bureau of Alcohol, Tobacco, Firearms and Explosives and the U.S. Department of Justice. He is currently a member of both the New York State Correction Medical Review Board and the New York State Justice Center for the Protection of People with Special Needs.

In all, Harvey has requested to allow the testimony of four expert witnesses at the trial. Alongside Baden, the list includes the following:

• Dr. Alan Wartenberg, of Attleboro, Mass., an affiliated faculty member at the Brown University Center for Alcohol and Addiction Studies, who has treated, by his own estimate, more than 15,000 patients with alcoholism, including more than 5,000 with “severe withdrawal.”

• Dr. Joe Goldenson, from Berkeley, Calif., who has testified as a medical expert in 10 federal lawsuits in the past four years.

• Madeleine LaMarre, an expert in correctional health, who has testified in five federal lawsuits within the past four years.

Each of Harvey’s four experts reviewed the circumstances surrounding Hammers’ death and submitted reports of their findings. Each also addressed the reports of medical experts submitted by the defendants.

Changing diagnosis

Hammers’ death was likely related to her severe alcoholism, her 2012 autopsy report said.

Coroner Erik Mitchell, a pathologist at Frontier Forensics in Kansas City, Kan., who performed the autopsy, diagnosed Hammers’ death as sudden death due to “seizure disorder probably related to acute ethanol withdrawal.”

Mitchell attributed the seizure to “chronic ethanolism.”

Four years later, however, Mitchell amended his report, writing that alcohol withdrawal was probably not a contributing factor in her death.

“Hammers does not fit the anatomic findings of someone who died as a result of an acute withdrawal from alcohol,” he wrote in a March 25 affidavit, filed in federal court.

Justifying his amended statements, Mitchell said “that there was no evidence Hammers was experiencing any outward signs or symptoms that would have been consistent with acute alcohol withdrawal during her incarceration.”

Mitchell declined to comment on the case, citing the ongoing lawsuit.

Dueling experts

Alongside Mitchell’s change of opinion, other medical experts disagree on what might have caused Hammers’ death.

The following is a summary of expert reports filed in federal court as a part of Harvey’s lawsuit.

Dr. Robert Jones, an expert in correctional medicine, hired by the defendants, agreed with Mitchell’s 2016 report that Hammers didn’t suffer from alcohol withdrawal, adding that she showed no symptoms of the ailment when she was booked into the jail.

Sudden and inexplicable death can occur with certain people suffering from substance abuse, he wrote. And Hammers’ “presumed seizure was neither predictable nor preventable.”

Both Baden and Wartenberg strongly disagreed with Jones.

“This opinion is wrong, and so egregiously wrong as to establish a total lack of expertise and credibility in this area,” Wartenberg wrote. “It is distressing to me that Dr. Jones has apparently been responsible for assisting in the development of health protocols for substance abuse in other penal institutions.”

“I must also strongly disagree with Dr. Robert Jones’ claim that Mrs. Hammers’ death is ‘unrelated to the care or alleged lack of care at DCCF,'” Baden wrote. “She received no medical care. She was not seen by a nurse or doctor during her stay to evaluate and treat any illness she might have had.”

Hammers’ history is one of severe alcohol abuse, Baden wrote. At 32 years old she typically drank a quart of rum or more each day and attended a variety of substance abuse treatment programs without success. In addition, Hammers had been hospitalized multiple times for complications related to Alcohol Withdrawal Syndrome.

In the year leading up to her death Hammers was booked into the Douglas County Jail three times, Baden wrote. For each time she was booked, jail logs indicate her substance abuse was reported. In one case a booking officer noted seeing withdrawal symptoms, he continued.

“Despite this history, she was not seen by a nurse or physician during her entire stay, and she was not permitted to take any of her medications,” Baden wrote.

Donald Leach, an expert on jail administration, wrote in his report that not only did Hammers not display obvious symptoms of AWS, but she did not request to see the jail’s medical staff.

However, Wartenberg argued that Hammers should not be faulted if she did not request medical attention.

“It is not the job of the patient to know what care is required, or even when it is required; it is the job of the health professionals,” he wrote.

After Hammers’ death, investigators interviewed her cellmate, Baden wrote. She reported that Hammers got up twice the night before her death because of diarrhea and later that morning heard Hammers “‘snoring in a weird’ manner,” he wrote.

Years later the cellmate was interviewed once more and recalled Hammers telling her about a history of seizures, Baden wrote. She recalled Hammers saying she needed something, though her words were unclear at the time.

She also reported Hammers “was not seen by any medical person” and that she “heard her breathing funny… and having a hard time breathing,” Baden continued.

“This pattern of abnormal breathing is typical of someone going into a deep and fatal coma,” he wrote.

Goldenson and LaMarre both agreed with Baden’s and Wartenberg’s analysis.

“Despite (Hammers’) known history of heavy alcohol consumption and known prior history of severe withdrawal, staff failed to appropriately evaluate, monitor and treat her,” Goldenson wrote.

If a diabetic or hypertensive inmate died in the Douglas County Jail “one should think that not only the public, but the leadership of the institution would be outraged and would want to improve this sorry situation,” Wartenberg wrote. “However, in this case it involved a woman alcoholic, who was not always pleasant, and at least once was considered aggressive and combative.”


Harvey’s lawsuit lists the Douglas County Commission, Douglas County Sheriff Ken McGovern, then-Undersheriff Kenneth Massey, then-Undersheriff Steve Hornberger, Dr. Dennis Sale, the Douglas County Visiting Nurses Association and three anonymous men who are alleged to have been involved in Hammers’ death.

In total, the lawsuit claims six points where the defendants are at fault:

• Deliberate indifference to serious medical need and failure to provide access to medical personnel for evaluation and treatment.

• Failure to train/Inadequate training.

• Failure to supervise/Inadequate supervision.

• Wrongful death.

• Negligence.

• Breach of duty to third party beneficiary.

Many of the defendants listed in Harvey’s suit have been named in other, similar lawsuits by inmates claiming medical neglect, although most of those lawsuits have been dismissed for various technical reasons.

At least one of those lawsuits — since dismissed for lack of a proper legal filing — alleged that a Douglas County Jail inmate suffering from heroin withdrawal did not receive proper medical attention, and instead was left unsupervised in a cell where he choked on vomit, passed out and suffered other such symptoms.

The Douglas County Jail houses 186 inmates and employs 94 staff members. However, the county is considering moving forward with a $30 million jail expansion which would add 120 beds to the facility.

Hammers is the only inmate to have died in the jail, which opened in 1999.

The jail’s contract with the Visiting Nurses Association and Dr. Sale ended July 1. Advanced Correctional Healthcare now provides medical services for the jail.

A jury trial for Harvey’s lawsuit is scheduled to begin Oct. 23, 2017.