San Diego County will pay nearly $5 million to the mother of a young man who died almost six years ago in a San Diego jail.
Michael Wilson already suffered from congestive heart failure when he was booked into the downtown Central Jail on Feb. 5, 2019, but he never was given the prescription medications he relied on to stay alive. He died nine days later at 32 years old.
“Without medication, his lungs would fill with fluids, causing a medical emergency,” his mother’s lawsuit said.
The lawsuit was filed by Phyllis Jackson in federal court a year after Wilson’s death. It was settled on Oct. 23, less than three weeks before the trial was scheduled to start.
Eugene Iredale, one of the attorneys representing Wilson’s mother, said the case stretched on far longer than it should have.
“We were willing to resolve the case, had we been able to, much earlier,” Iredale said. “Had we done that at an earlier time, it would have been for a lower figure.”
The settlement comes four months after the county agreed to pay $15 million to the family of Elisa Serna, who also died in a San Diego jail in 2019. Her family’s lawsuit was also nearing trial when the county agreed to settle.
While it is not unusual for a defendant to seek additional time to craft a defense, Iredale said county counsel engages in “a deliberate attempt just to exhaust the emotional resources of the family and the legal and financial resources of the lawyers to grind them down.”
“The policy that they have is to delay, to defer, to refuse to disclose critical information, to put everything off as long as possible,” he said.
A county spokesperson declined to comment.
Wilson was one of 16 people who died in a San Diego County jail in 2019 and among 185 who died between 2006 and 2020, making the county jail system one of the deadliest in California.
‘Serious medical issues’
Wilson was an infant when he was diagnosed with hypertrophic cardiomyopathy and congestive heart failure. The former causes the heart muscle to thicken and struggle to pump blood. Congestive heart failure can cause fluid to build up in the lungs, making it difficult to breathe.
With the help of a pacemaker and several medications, Wilson was able to live a normal life, his mother said.
“This was life-sustaining medication for him,” she told The San Diego Union-Tribune.
Wilson was arrested Feb. 5, 2019, on a probation violation. The judge sentenced him to a “flash” incarceration, meaning he would be taken to jail immediately for a brief stay — in his case, two weeks.
The judge added to the record: “Court orders medical staff to be aware that this defendant has some serious medical issues.”
During booking, records show, Wilson told the intake nurse that he suffered from congestive heart failure, had a pacemaker and took multiple medications daily, including Lasix to prevent fluid retention and metoprolol to keep his heart rate down.
The nurse noted this in the jail’s online records system and also flagged the judge’s order. But for days the order went ignored by other jail medical staff.
On Feb. 7, Wilson put in a request to see a doctor, noting that he had not received any of his medications.
On Feb. 8, Wilson submitted another request, and his mother called, telling a nurse that her son had a serious heart condition and needed to be seen by a doctor.
On Feb. 9, he filed a third request, writing that he had developed a cough “that won’t go away.”
He received medical attention only after his mother called the jail the morning of Feb. 11, demanding that her son be taken to a hospital.
The nurse who saw Wilson noted he was struggling to breathe and had a constant cough and a dangerously low blood-oxygen level. He also had an elevated heart rate, indicating possible cardiac distress.
Wilson told her that he could not breathe when he was lying down, a sign of heart failure.
She put in a request for a doctor and described Wilson’s condition as “an emergency.”
That doctor visit “occurred in the hallway, not on an examination table,” and without the doctor having reviewed Wilson’s chart, according to court records.
The doctor gave Wilson a single dose of Lasix and some Robitussin for his cough. He later noted in Wilson’s chart that his cough had resolved, that his breathing was normal and that Wilson said he did not need to go to the hospital.
That evening, according to jail medical records, Wilson’s sister called to tell a nurse that her brother was in medical distress and short of breath. She said the Lasix Wilson was given earlier had helped only a little bit.
A nurse who saw Wilson after his sister’s phone call noted he had “ineffective airway clearance” and initiated a treatment for asthma, despite Wilson telling her he had congestive heart failure. The nurse noted in his chart that he “reported relief” after being treated with a nebulizer.
The county’s defense to the lawsuit hinged on whether Wilson was up front about symptoms with medical staff who examined him.
A doctor, at least two nurses and a deputy reported that Wilson said he was fine or had begun feeling better. But his mother, a retired school nurse, and sister say that during multiple phone calls, he was struggling to breathe and complaining of chest pain.
“I’m not an advanced nurse, but from my nursing, from my medical knowledge, when Michael was on the phone, I could hear him gasping for breath. I could hear his struggle,” Jackson said.
“Basic nursing skills, even if you had no medical experience, would allow you to know a person is in distress,” she added.
Men in his jail module told Sheriff’s Office investigators that Wilson was “wheezing” and “coughing the whole time.” One said he could “barely even speak.” Another said he summoned a nurse repeatedly to bring Wilson an asthma inhaler.
The evening of Feb. 13, Wilson was “was gasping for air,” one man recalled.
The morning of Feb. 14, 2019, nine days after his arrest, Wilson fell from his top bunk and collapsed in his cell. He died later at UCSD Medical Center. An autopsy report found that his lungs had doubled in size from fluid.
The judge presiding over the case was not swayed by the county’s argument that Wilson did not appear sick enough to require closer monitoring.
Jail medical staff knew he had gone days without medication and should have recognized his nagging cough and shortness of breath as signs of heart failure, Judge Ruth Bermudez Montenegro wrote in an order denying the county’s request for summary judgment.
“Repeated failure to provide all prescribed cardiac medications” to such a patient, especially one known to have the serious heart problems he did, “could very well be a matter of life and death,” Montenegro wrote.
‘Substantial improvements’
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Documents and depositions obtained by attorneys representing Jackson’s mother revealed a chaotic medication distribution system.
In depositions, multiple nurses reported that the jail had no way to track whether a patient had received their medication. If a medication needed to be ordered, there was no way to alert medical staff when it arrived.
Two years before Wilson’s death, consultants hired by the county to review jail medical operations had flagged these problems. A nurse deposed in Jackson’s lawsuit said she also had repeatedly, unsuccessfully, raised the issue of poor inventory control of medication with supervisors.
Wilson normally took 40 milligrams of Lasix, the diuretic used to treat congestive heart failure, twice a day, but it was available at the jail only in 20-milligram pills. Two nurses testified that they were not allowed to combine pills to achieve a prescribed dosage.
Over the almost nine days Wilson was jailed, he received a single dose of Lasix. He was not given Metoprolol until the day before he died. He received only one dose of blood-pressure medication Lisinopril.
A spokesperson for the Sheriff’s Office declined to comment on the lawsuit but said there have been “substantial improvements” in the county’s jails since Sheriff Kelly Martinez took office last year.
“These initiatives represent the Sheriff’s Office’s commitment to improving healthcare services within county jails and ensuring that detained individuals receive necessary and timely medical attention,” Kimberly King wrote in an email to the Union-Tribune.
There have also been improvements to electronic record-keeping so medical professionals in and outside the jail can coordinate care, King said, “enabling better treatment plans and reducing treatment gaps upon release.”
Other improvements include a comprehensive nurse assessment during intake and a new system for inventorying and securing prescription medication.
Jackson said she is still devastated over the loss of her youngest son. Because of Michael’s illness, she kept him close when he was a child.
“He was so loving and caring,” she recalled. “He thought about others always more than himself.”
She hopes the new medical protocols adopted after her son’s death have saved lives.
“I know that we have to accept death,” she said, “but this is so different, because it didn’t have to happen.”