On November 30, 2015, Toya Frazier was transferred to the Satellite Jail in Champaign County after turning herself in for theft at the courthouse that morning. Allegedly begging for help over the next 24 hours, she died from a medication overdose after being denied medical attention and being moved to solitary confinement.
Four months later, jail inmate Paul Clifton died from respiratory failure. He was in the county jail for driving on a suspended license.
On June 10, 2016, Veronica Horstead died in the Satellite Jail from congestive heart failure.
The three deaths in Champaign County jails and the events involved with those deaths have been thoroughly documented in federal court cases, such as Frazier’s $1 million federal case against Champaign County.
“These were very, very preventable deaths,” attorney Shayla Maatuka said recently.
Maatuka, who represents Frazier, Clifton and Horstead, said, “There needs to be change— there has to be change.”
Maatuka, who is a partner in the firm Maatuka Al-Heeti Emkes in Champaign, has filed wrongful death cases for all three.
Each of the cases is bound by one issue: lack of adequate medical care, whether routine or emergency, at the two Champaign County jail facilities. It is not only a local issue, but also echoes a national crisis in medical care at county jails.
Since 2016, there have not been reported deaths at the Champaign facilities, but complaints from inmates about poor health care in the jail have continued.
At least 105 medical grievance forms were filed by inmates in Champaign County Jail for the years 2017 and 2018.
The documents, obtained under a Freedom of Information Act request, range from inmates’ medical conditions being ignored to inmates being given incorrect medication to rude behavior by medical staff toward inmates. The responses from the jail staff generally do not mention a change in medical care or further action.
The medical grievances filed with jail officials each received an official response from the jail.
Jail staff responses generally include the history of inmates’ medical conditions and care. The staff sometimes changes the kind of care. The grievance forms are filed with the jail guards, not medical staff directly.
“You were seen at Carle Foundation Hospital, and you were cleared medically for admission into the Champaign County Jail,” one response said. “…The doctor did not approve the prescribed medications from the emergency department, did not find cause for further treatment related to your fall, and did approve to continue offering you Tylenol for pain.”
Unofficial grievances have also been documented.
For example, electronics business owner Christopher Hansen from Urbana published an open letter entitled Corrupt-CU last December criticizing the jail and police in Champaign County. Hansen alleges he was stripped naked on the floor of his cell, then denied medical treatment over 20 times in one night for a blood clot condition.
A History of Structural Flaws
The Corrections Division of Champaign County Jail is split between the Satellite Jail, built in 1996, on Lierman Ave. and the Downtown Jail, built in 1980, on Main St. in Urbana. The county contracts its medical care for $62,000 a month through Correct Care Solutions. The company regularly staffs the jails with one part-time doctor, one full-time nurse, two full-time and one part-time licensed practical nurses. It also provides mental health services.
The Satellite Jail was designed for 170 beds and the Downtown Jail was designed for 84 beds, but over the years, due to overcrowding in both facilities, but the total beds had increased by at least 40 by doubling up beds in single-occupancy detention rooms. Today, the current max capacity of the jails is 313 beds, with the majority in the Satellite Jail.
Correct Care Solutions has been criticized in over 140 lawsuits around the country, some of which are outlined in a February New Yorker article about jail medical care. The documents were collected by Columbia University journalism students for long-term journalist Steven Coll, who is dean of the school.
Two outside assessments of the Champaign County’s jail system have recommended the jail expand its medical unit with increased medical coverage throughout the day. Currently, the medical staff is not present 24 hours a day, seven days a week. The medical staff is absent around 40 hours a week, leaving correctional officers to respond to inmate health issues during those time periods.
The two jail studies also point to repeated medical flaws, even classifying the health care facilities in the jails as “legally indefensible.”
The Institute for Law and Policy Planning, a non-profit planning agency and frequent partner with the National Institute for Corrections, was contracted in 2013 for almost $120,000 to produce a jail system assessment. It concluded the jail facilities’ ability to provide medical care has “not been feasible.”
“Jail medical and mental health services should always be viewed through the lens of public health,” the report says. “Custody should not worsen public health.”
Gorski Reifsteck Architects was contracted by the county for almost $120,000 for a 2015 jail assessment that said, “The conditions in which special needs (mental health and medical health) inmates are confined within the booking areas of both facilities are very inadequate and should be remedied.”
The county jail facilities have not seen many improvements since 2016.
The downtown jail was made compliant with the American Disabilities Act, but the studies’ recommendations for larger architectural changes have not been followed. Voters in the county rejected a sales tax increase in November 2016 that would have provided funds to repair Champaign County facilities.
The county’s budget will need to be updated to include the architectural changes recommended by the assessments, and Sheriff Dustin Heuerman spoke at an August 6, 2019 County Board facilities meeting to find the funding needed.
For the meeting, Heuerman “discussed his vision for the future, regarding the need to close the Downtown Jail…” and his concerns for the jail in its current state without having County funds to make repairs.
Heuerman also said he is willing to explore 24/7 medical coverage once the current medical contract expires on March 31, 2020, but the determining factor is whether the County Board feels there is sufficient funding for it.
“Unfortunately, with the different classifications of inmates we have, it is impossible to simply move the inmates to the Satellite jail without addressing physical changes to the facility,” Heuerman said.
Champaign County’s 2019 budget included a call to, “Address the immediate facility needs of the Sheriff’s Office/Jail,” as one of its goals, but does not address the architectural problems.
Instead, it calls for updates to jail management software and technology.
The budget also cites a poor rating on the what is known as the “Facilities Condition Index” for the jails from an outside study by Bailey Edward, an architecture and engineering firm in Champaign.
Plans and cost estimates for renovating the Satellite jail were not included in the budget, but the 2015 assessment estimated $32 million will be needed.
Previous County Board President Pattsi Petrie disputed the figure in 2016, saying it would need $12.8 million instead.
Heuerman wrote in an email to CU-CitizenAccess, “While we are currently in compliance with applicable laws and regulations, renovating the Satellite Jail would give us the opportunity to create a space that better addresses our special population of inmates and would allow us to adapt to changing needs.”
County Board Member Mike Ingram said the board has had recent discussions about the jail facilities internally.
“There is a subset of people who will stay there no matter how much we can improve the system, and currently they have very little space at the satellite to let those people do anything,” Ingram wrote in an email. “One all-purpose room that serves as a classroom, religious service space, staff meeting locale, client/lawyer private room, and more.”
Ingram said the obstacles for renovations are largely budgetary.
Denied Medical Assistance
When inmates have complaints, they must fill out an inmate grievance form and submit them to a correctional officer. Below is an example of the form they fill out:
The inmate handbook, made available to inmates in the jails, states that emergencies are to be reported to the guards immediately. But, when medical staff is not present 24/7, an inmate like Frazier can be left in the care of the jail staff on duty, who then decides on the right medical response.
The attorney Maatuka said about Toya Frazier’s case:
“All night long she was crying and screaming and she was begging for help. They refused to even call the doctor.”
In another complaint, one inmate recently cited broken bones and increased pain from being forced to sleep on the floor of the Downtown Jail.
In the case of Hansen, he said he was denied the chance to file a medical request or grievance during his detention.
Hansen’s account details lack of medical treatment to treat his open wounds from broken glass and take simple anticoagulants. He received his injuries during his arrest when a Champaign police officer shattered his car window during Hansen’s arrest. The dashcam footage can be viewed on Hansen’s website.
Stripped naked at the jail, Hansen said he was left with only a small pad to stand or sit on in the corner of his cell, which allegedly had a puddle of urine on the floor prior to his entry to the jail.
After requesting help over 20 times, a nurse was finally brought in to see him in his cell. Hansen was stripped because he was put on suicide watch after refusing booking questions.
In an email, Hansen wrote, “I had a DVT (blood clot in my leg) sometime before this and the conditions that caused it were immobility and dehydration.”
Hansen also wrote, “I am at high risk for a recurrent clot and always keep a syringe of enoxaparin with me just in case something happens. I explained this to nurse Lois, and when she wouldn’t let me talk to a doctor, I urged her to at least give me some aspirin (which serves as a mild anticoagulant, and I take daily), and she wouldn’t even do that.”
Hansen said his injuries did not represent an emergency, but he still needed medical attention.
“I was physically examined by an ambulance at the scene of my arrest,” Hansen said. “I remember dumping glass out of my shoe.”
As the jail death cases prepare for court, Maatuka said the jails need 24-hour nursing care at minimum in order to improve.
“The policy reflects their staffing,” she said. “Just because you’re detained, you shouldn’t have to risk your life.”
Jails Are ‘Medically Needy’
National civil rights organization Human Rights Defense Center advocates on behalf of prisoners and reports on criminal justice through their main project, Prison Legal News. Since 1990, the organization includes mainly former prisoners advocating for wrongful death cases and bringing awareness to new legal cases.
The center’s Associate Director Alex Friedmann said jails have a very large population turnover, characterizing a medically-needy population.
“There are windows for mistreatment for all inmates,” Friedmann said. “Jailors may not have the training or empathy to evaluate like the medical professionals.”
Build Programs Not Jails in Champaign-Urbana fought against jail expansion while Dan Walsh was the sheriff from 2002 to 2018.
The advocacy group most recently opposed the 2015 master plan to expand the Satellite Jail, “advocating for our county to devote our resources to decrease incarceration.”
The plans to expand the jail were denied in both 2013 and 2015, and members continued to write about the consequences, including both medical and mental health care, of expanding the jails further.
“Denying medical requests is standard operating procedure,” said co-leader Brian Dolinar. “Expansion would make it worse.”
Dolinar has worked with the Urbana-Champaign Independent Media Center and projects such as Books to Prisoners in addition to writing about the jail system for over 10 years.
County Board Member Ingram said something has to be done, but he wants to keep the community in mind when discussing possible renovations or expansions to the Satellite Jail.
“I’m hopeful that with the current board makeup (along with the current sheriff) we’ll be able to make sensible changes that will have restorative justice in mind,” he wrote. “I’ve not seen or heard a proposal that doesn’t require some expansion of the satellite jail, but I think if that’s for more office space and for more program and quality of life space (ie. not an increase in the current bed total between spaces), then I think we’d be doing the community (communities, really) a service.”
Inmates Rely on Gatekeepers
Maatuka, who represents families of Frazier, Clifton and Horstead, said the inmates failed to receive adequate treatment because guards are making decisions on whether a nurse or doctor needs to be called for inmate treatment.
“Gatekeeping is the central issue in these cases,” Maatuka said. “Correctional officers have to make a decision seeing if it’s worth calling the on-call doctor.”
Gatekeeping has been studied since the early 2000s, but has continued to be an issue both nationally and for Illinois.
The National Alliance on Mental Illness reported on medication access in 2018 and the National Sheriff’s Association recently hosted a webinar with the Director of the National Center for Jail Operations Carrie Hill about the state of medical care in jails across the U.S., also discussing gatekeeping medical attention as an issue.
“Bottomline is this, does every single instance need to go to medical — no it does not,” Hill said. “It never hurts to triage… and the way to do it is to raise the issue with a medical personnel.”
In the county medical contract, it is mentioned that correctional officers make a determination during booking about whether or not an inmate is deemed medically stable, but are not required to consult with medical staff when making these determinations.
The inmate handbook, provided to CU-CitizenAccess through the sheriff’s office, outlines procedures to request medical care. It is required to submit a health request for any services, with an exception for emergencies. However, the guards can determine if the case is an emergency.
The Human Rights Defense Center also shares Maatuka’s argument.
“Guards are the gatekeepers for medical care,” Friedmann said. “Universally, medical care in prisons and jails is subpar due to resources.”
The general condition of the Downtown Jail was a recurring complaint in inmate grievance forms, including the times that medical staff are present. The 2015 jail study also reported on staffing in the jails, further concluding, “The small numbers at the Downtown Jail tend to make the Downtown Jail inherently staff-inefficient.”
More inmate grievance forms can be viewed here.
Johnathan Hettinger contributed to this article.