In this April 16, 2020, photo a gloved hand points to a holding cell at the hospital ward of the Twin Towers jail in Los Angeles. Across the country first responders who've fallen ill from COVID-19, recovered have begun the harrowing experience of returning to jobs that put them back on the front lines of America's fight against the novel coronavirus. (AP Photo/Chris Carlson)
AP Photo/Chris Carlson

When Asthma in Jail Becomes a Death Sentence

Deaths like Savion Hall’s are tragically common in Texas jails. What’s unusual are the criminal charges against the people responsible for treating him.


Above: A gloved hand points to a holding cell at the hospital ward of a jail.

Growing up, Matt Santana and Savion Hall were inseparable. The two met in middle school while hanging out with mutual friends in Midland, a West Texas oil town. After realizing they lived on the same block, Hall, a year younger than Santana, started sleeping over so they could play video games late into the night. As they got older, Hall and Santana remained dear friends, often turning to each other for help. Santana, who suffers from anxiety, says Hall sometimes spent hours by his side helping calm him down. “He would stay with me until I felt better, whether it was just driving around, listening to music or talking,” he says. When Hall had asthma attacks, Santana would make sure he got his breathing treatments, which included inhalers and nebulizers, sometimes taking him to the hospital three or four times a month. The two looked out for each other. “It was special having a friend like that since childhood,” Santana says. “I was hoping we would grow old together.”

Then Hall was arrested and taken to the Midland County jail last summer. Court records show that he was accused of failing to wear a GPS monitor and testing positive for amphetamines—violations of the probation agreement he’d signed with the local district attorney’s office to resolve a drug possession charge earlier that year. Nearly three weeks after Hall entered lockup for the alleged probation violations, jail doctors shipped him to a local hospital due to breathing problems and low oxygen levels, according to a report filed with the Texas Attorney General’s office.

Savion Hall.
Savion Hall.  Facebook

Friends say Hall’s asthma attacks were frequent and severe enough that they learned to recognize the wheezing and heaving as signs that he needed immediate treatment. But by the time Hall arrived at the hospital from the jail, his condition had deteriorated to the point that medical staff had to resuscitate him. Santana, who saw Hall in the hospital, says his friend showed little brain activity and suffered back-to-back seizures before his family decided to take him off life support eight days later, on July 19, 2019. He was 30 years old. (Hall’s family declined to comment for this story.)

Seemingly preventable in-custody deaths like Hall’s are common. But while allegations of medical neglect proliferate in lockups across Texas and the rest of the country, rarely do they result in criminal charges. Hall’s case is different. Following a Texas Rangers probe, a Midland County grand jury this summer indicted six jail nurses on charges of manslaughter, criminally negligent homicide, and knowingly falsifying records for Hall’s breathing treatments.

Midland County initially reported that Hall died from “natural causes,” the most common cause of death reported by jails in Texas. Nearly 800 in-custody deaths since 2005—slightly more than half of all jail deaths recorded in the state during that time—were attributed to natural causes, according to data compiled by the Texas Justice Initiative. But in recent years, lawsuits, Texas Rangers reports, and newspaper investigations have shown many of those to be preventable tragedies that appear to result from negligence on the part of jail staff. Still, justice for families and accountability for those responsible is elusive.

Local jails in Texas, which mostly hold pretrial detainees who haven’t been convicted, have been required to report all deaths in custody to the state since 2009. In 2017, the Sandra Bland Act forced jails to appoint third-party investigators, often the Texas Rangers, to look into all in-custody deaths. Jails have avoided this scrutiny by misclassifying deaths or not counting ones that resulted from jail conditions but occurred outside lockup. In a report filed with the state last year, the Texas Commission on Jail Standards stated that jails haven’t counted, and therefore haven’t investigated, such deaths on “multiple occasions.” But in Hall’s case, even though Midland County officials technically released Hall from jail custody before he died at the hospital, they correctly labeled his case an in-custody death since his problems began in lockup, triggering a Rangers investigation that led to the indictments.

The criminal cases against the Midland County jail nurses is the latest in a string of recent problems at the West Texas jail. The Rangers are currently investigating the death of Christopher Duboise, 36, who was arrested on a public intoxication charge last April. After allegedly attacking another inmate, he was thrown into an isolation cell, where he took his own life two months before Hall’s death.

In June 2018, Stephanie Gonzales arrived at the jail having already told police she’d taken 10 Xanax pills and suffered from depression, post-traumatic stress, and bipolar disorder. Court records show Gonzales, 36, was so disoriented that the officer in booking almost sent her to the hospital instead when police took her to jail on a public intoxication charge. Jail staff flubbed her state-required mental health screening, marking that Gonzales had no history of mental illness despite evidence that she received mental health treatment in the past. Her screening form also stated that she hadn’t recently been hospitalized even though she was wearing a hospital bracelet at the time of her arrest.

“Despite all these red flags, they just left her alone in that cell for a lengthy amount of time without even checking. There’s really no excuse.”

A lawsuit filed by Gonzales’ family in March against Midland County and the city of Midland alleges that staff didn’t check on her for more than an hour; in that time, Gonzales turned her jail-issued pants into a ligature to strangle herself. “She was distraught and pretty clearly suicidal when she showed up,” says Dean Malone, a Dallas attorney representing the family. “Despite all these red flags, they just left her alone in that cell for a lengthy amount of time without even checking. There’s really no excuse.”

After the suicide, the jail standards commission concluded that the Midland County lockup had violated minimum standards for mental health screening and cell checks. Malone echoed those concerns, along with accusing Midland officials of violating a Texas law requiring that police seek emergency treatment for people in mental health crises instead of taking them to jail. But reformers have argued that the commission, which is currently undergoing its first top-to-bottom review by state lawmakers in more than a decade, is hamstrung by limited enforcement power and a shoestring budget.

It appears nobody was disciplined or fired for any lapses that preceded Gonzales’ death, let alone criminally charged.

Meanwhile, attorneys representing Midland County have pointed the finger at the jail’s medical contractor, Soluta Health, blaming it for any failures that may have led to Gonzales’ death. The Austin-based company, which employed the nurses charged in Hall’s death, has for years faced allegations of shoddy care leading to deaths in other Texas jails where it contracts for medical services. Soluta was named as a defendant in a lawsuit filed by the family of Jesse Jacobs, who died in the Galveston County jail in 2015. Jacobs suffered a fatal seizure after his prescribed Xanax was withheld, despite a note from his doctor upon booking that stressed the importance of him taking it. The lawsuit alleges that Jacobs died during a forced and unnecessary detox and exhibited symptoms associated with severe withdrawal.

The family of Jorge Cortez, who died at the Galveston lockup in 2017, has also sued the company, accusing Soluta of failing to provide him with adequate medical care, even after he punctured his lung falling off a top bunk and grew “too weak to eat.” Soluta’s track record is hardly unique: Jail medical contractors accused of negligence and preventable deaths have been big, small, public and private.

“A victim shouldn’t be ignored simply because they’re an inmate. They’re still a person.”

Soluta didn’t respond to requests for comment for this story. Midland County Sheriff David Criner punted questions about the jail to County Attorney Russell Malm, who didn’t respond to requests for comment, and to the Texas Rangers, which referred questions to local prosecutors. Justin Low, a defense attorney representing one of the nurses charged in Hall’s death last year, insisted the criminal case against the medical contractors would fizzle under further scrutiny.

About the same time Hall’s case was brought to a grand jury, Soluta began to pull out of Midland County. During a county commissioners court meeting on June 8, Malm announced the company would be ending its contract but didn’t explain why, saying Soluta had simply “decided to get out of the inmate medical business.”

Midland County DA Laura Nodolf, who presented the Rangers’ findings to the grand jury, acknowledged that criminal charges for jail deaths are uncommon but wouldn’t discuss details of the charges or why they were brought in this case. “We have a duty to victims regardless of whether they’re in inmate clothing or wearing a uniform or just a civilian,” she added. “A victim shouldn’t be ignored simply because they’re an inmate. They’re still a person.”

Last summer, Santana learned that Hall was on life support just as he was heading to a family reunion in Fort Davis. He and his wife cut the trip short to go see Hall the next day. Santana says his stomach was in knots the entire three-hour drive back, then his heart sank when he got to the hospital and saw his longtime friend unresponsive and hooked up to machines. He was driving when he got a call the next week saying that Hall had died, five days before Santana’s birthday. He says he’ll always remember that day, and the spot on the side of the road in Midland where he had to pull over when he heard the news.

“I lost it when I learned that he was gone,” Santana says. “It was a hard birthday. It’s the birthday my best friend left us.”

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