As the Jacksonville Sheriff’s Office dealt with a surge of jail deaths, its own review of those deaths were “minimal,” failed to meet national standards and took too long, a national accrediting agency told the department in March.

The National Commission on Correctional Health’s accreditation report criticized the Sheriff’s Office’s review of jail deaths. The position responsible for coordinating those reviews was vacant for 11 months in 2022, the report notes, and when reviews were done, they weren’t always shared with staff.

In some cases, the Sheriff’s Office took longer than the 30-day deadline to conduct a review of deaths. In one case, the Sheriff’s Office didn’t do the required psychological review after an inmate’s suicide.

The agency also found a history of delays in getting inmates medications and general medical care, an issue that The Tributary has reported on extensively since May.

Armor Correctional Health Services was the private company that handled jail medical care during the review. The next review is scheduled for the end of the year. At that point, a different private company — NaphCare — will handle medical needs. Both contracts with the companies mandate that they keep accreditation standards or face penalty fines. 

The Tributary asked the Sheriff’s Office how much Armor had to pay out in those fines since 2017, when the company was hired, but the office has not provided the records. 

As a result of the probation, the Sheriff’s Office was tasked with submitting a corrective action plan to the NCCHC. The Tributary is also waiting for a copy of that document.

The Sheriff’s Office declined to sit down with The Tributary for an interview to talk about the slew of issues found during the review, which included: a high number of health care-related grievances from inmates, a pattern of delay in providing timely medical and dental care, a delay in verifying prescriptions, delays in ordering prescriptions and delays in completing required health assessments within 14 days.

Delays in health screenings

The jail had already been given a negative mark during a state inspection in June 2022 for not completing full health assessments within two weeks. Though the NCCHC noted there had been an improvement in completing them, 30% were not done on time.

Susan McCampbell, the president of the Center for Innovative Public Policies and a seasoned court monitor, said it’s imperative that health reviews are done before the two-week deadline because the majority of deaths she’s seen at jails occur before those reviews take place.

In Duval County, nine people since 2022 have died within 14 days of their arrest. Two others died within 16 days.

The audit also found that initial health screenings, which are supposed to be done within four hours of an arrest, were not being completed about 65% of the time.

“Many completion times listed on the reports provided to us indicated a significant percentage of screenings were not completed for many hours to several days after admission to the facility occurred,” the report said.

Death reviews in Duval County

The inspection noted that JSO’s Continuous Quality Improvement Program needed improvements to how it reviewed the circumstances of jail deaths because the reviews of 31 deaths were “minimal.”

The CQI coordinator position was vacant for nearly a year, and a staff nurse was moved into the job months before the inspection occurred. The NCCHC suggested that the new coordinator reevaluate the program and include an in-depth review of deaths.

Of the 31 deaths examined, 18 were attributed to natural causes, five were overdoses, four were suicides, two were by unknown causes, one was ruled accidental and one was a homicide.

When deaths occur, the NCCHC requires jails to conduct a mortality review within 30 days. Suicides must also have a psychological review performed in the same time fame. 

Two of the death reviews were done beyond the required 30-day time frame, and one suicide did not have a psychological review completed.

“There has to be a substantial and objective review of those deaths or those near misses,” McCampbell said of jail deaths in general. “You have to figure out what went wrong and what didn’t.”

McCampbell did not review the NCCHC investigation but spoke of deaths in jails in general. Florida doesn’t mandate third-party reviews of deaths. When one occurs in the Duval County jail, JSO’s cold case unit investigates it. The Tributary asked JSO to detail what its in-custody jail death reviews entail, but the department didn’t answer.

“There has to be prompt, underline prompt, reviews of in custody deaths or near misses … in order to be able to prevent future harm,” McCampbell said.

Delays in medications and care

The jail partly met expectations on a dozen other issues, some of which the NCCHC said came down to staffing issues and ineffective communication between Armor and JSO staff. 

The review specifically noted that the jail didn’t always give inmates medicine “in a timely manner.”

“We also noted that there were delays in getting medications verified when a new person is being booked in and added delays in getting medications to the patients in a timely manner once the community-based prescriptions are verified,” the review said.

A copy of the review, which was obtained by The Tributary, didn’t give a time frame for when auditors were at the jail, so it’s uncertain if the November death of Dexter Barry played any part in their review. 

Barry, 54, went two days in jail without anti-rejection medications for his transplanted heart and died after he was released. An Armor representative said the company ordered his medications but that it would take at least  48 hours to receive them. Armor and JSO haven’t provided any documentation that the medication was ordered. Because he died after his release, Barry isn’t counted as an in-custody death. 

The jail also failed to get inmates to local medical and/or dental clinics in a timely manner due to “a breakdown in communication and processes in relation to following through with patients that are not transported to on-site medical and dental appointments.”

This story is published through a partnership between Jacksonville Today and The Tributary.