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In the days after Sao Chau was booked into the Metropolitan Detention Center he reported feeling ill, being short of breath and having a tingling in his hands, according to incident reports released to the Journal.
The 41-year-old who came to the United States as a refugee from Vietnam in the 1990s was being held in the detox unit for people withdrawing from drugs or alcohol because he had told jail personnel he had used fentanyl before his arrest on Aug. 24.
That’s where over the course of 57 hours he vomited over and over – with some reporting that they “thought he had thrown up at least his body weight,” said Kate Loewe, an attorney representing incarcerated people in the McClendon settlement agreement that lays out reforms in the jail.
A little after midnight on Aug. 27 a detox nurse examined him and said if he “continued to vomit and feel sick medical needed to be contacted,” according to the reports.
More than 4½ hours later he again asked for help and said he could not move.
Medical personnel told officers to bring him to their unit and another inmate helped pick him up and put him on a wheelchair. On the way he lost consciousness, became limp and began to slide to the floor.
He died a short time later. An autopsy report detailing his cause of death was not immediately available.
“He had been really, really sick,” Loewe said. “Withdrawal is a life-threatening event and needs to be taken really seriously medically … How can it be that somebody is so sick that they can’t get up and out of their bed and medical doesn’t come to them? How can it be that medical doesn’t respond to an emergency?”
Expert Muthusamy Anandkumar was at MDC assessing its medical care, interviewing staff, reviewing reports and medical records at the same time Chau was there. Chau died two days after the expert left.
In the report Anandkumar found the medical team out of compliance with regards to screening for and managing inmate withdrawal symptoms appropriately.
He said the number of detox assessments done by each nurse is very high, impacting quality and increasing risk to inmates. No electrolyte powder and water was available for inmates going through withdrawal, who have a higher risk of getting dehydrated.
Furthermore, he said the process for getting sick inmates the medical attention that they need is “not reliable” and “not adequate.”
“Several sick call requests were reviewed, and the acuity level was not appropriate for the complaints,” wrote Anandkumar. “There is also a delay in responding to medical requests. The nursing assessments are not detailed. When inmates are treated, the nurses are not consistently reevaluating detainees when indicated.”
Chau was the 17th person to die in custody of the jail since the beginning of 2020, according to records kept by the Journal. Several of those people – including Chau – were withdrawing from drugs or alcohol at the time, others killed themselves or died from medical conditions.
In response to requests for comment about Chau’s case the jail’s medical provider YesCare – formerly called Corizon Health – said it is prohibited from talking about patient health publicly.
“We take the care of all patients very seriously and any death of a patient is a tragedy,” said CEO Sara Tirschwell in a written statement.
She said the company is deeply committed to the physical and mental health of its patients and is proud of its “longstanding and national reputation for providing exceptional healthcare services, which require persistence, investments in our health systems, commitment to quality improvements and dedicated trained professionals.”
“Since taking over as medical provider at Bernalillo, YesCare has eliminated hundreds of chronic care backlogs, and put new systems and protocols in place to improve patient care,” Tirschwell said. “We are confident that our proven techniques and plan of action will successfully address all patient needs from intake to reentry.”
From bad to worse
Complaints, whistleblowing and lawsuits over MDC’s medical care have been recurring themes for years. Correctional officers have been raising concerns of their own about jail conditions and over the past six months their vacancy rate has topped 50%.
In early 2021, shortly after the Journal published an article detailing the deaths of nine people in jail custody over the course of the previous year, its medical provider announced its intention to terminate its contract more than a year early.
In September 2021, Bernalillo County commissioners approved a new $64.9 million four-year contract for medical services – this time with Corizon Health.
Although the commissioners said at the time that the new agreement would boost staffing, in the months that followed medical personnel reported care got much worse and several key positions were not filled. A nurse who had been employed at the jail for 11 years filed a declaration in federal court saying “what is occurring now is the worst medical care has ever been.”
In late December, the attorneys representing the plaintiffs in the McClendon lawsuit filed a motion requesting a hearing after the previous medical expert – who has since retired – found care was “substantially deficient,” described “systemic deficiencies” and said “these problems were apparent in several deaths.”
Loewe said the plaintiffs have been negotiating with the county and are close to finalizing a settlement agreement that they hope will address “the current crisis of medical care.”
In his August report, Anandkumar – the new medical expert – found much the same as his predecessor, including that there is a “delay in care and inadequate care for sick inmates.”
“He provided a lot of details about some of the problems that were there: that there’s a lack of a chronic care program, that there’s issues with medication continuity, that there’s not enough staff,” Loewe said. “It’s their job to provide medical care. It’s beyond me why some of these issues are even an issue.”
In response to questions about the findings in the medical report Tirschwell said that since taking over medical care at MDC, YesCare has simplified reporting methods and logs, created checklists for medical staff and provided additional training.
“Doctor of Addiction Medicine Sylvie Stacy has been on site regularly to provide oversight and additional training for staff,” she said. “YesCare has also been collaborating daily with the on-site Contract Compliance Monitor for the County to foster a most integrated communication approach. Her cooperation with our team has allowed for a more successful coordination between YesCare and the County.”
‘Left to die on the floor’
Chau grew up in Vietnam and came to the United States legally with his family as a 12-year-old refugee.
“He was loved by his nieces,” said attorney Rick Sandoval who is representing Chau’s brother Ty Chau. “His family also had plans to purchase a commercial vehicle – a truck – and to get him back into a separate line of business, a trucking business with his brother. These are hardworking people who came to this country as refugees.”
But, Sandoval said, Sao Chau also suffered from addiction. He was trying to get treatment when he ended up in jail on a warrant for failing to appear in court in two cases – one from April 2022 charging him with possession of a controlled substance, receiving or transferring a stolen motor vehicle and shoplifting, and the other from 2020 charging him with aggravated assault with a deadly weapon.
“Ty Chau was very close to his brother,” Sandoval said. “They were going to go into business together … and then he didn’t hear from him for a while … we’re talking about a couple of weeks and then he got a call from the jail saying that his brother had died.”
Sandoval has requested records in the case and is expecting to file a wrongful death lawsuit soon.
“Even with the limited information we have it’s a picture of someone who was left to die on the floor of this detox wing, vomiting, and in pain to the point where he couldn’t even walk …,” Sandoval said. “You can’t have this many problems at the same facility without the administrators and the elected officials knowing about it and doing something about it. I don’t know how many deaths it’s going to take for them to address the problem.”