Autopsy: Clots killed teen in
lockup
Scarring shows girl, 17, had an ‘ongoing problem,’ examiner says
BY AMY UPSHAW
ARKANSAS DEMOCRAT-GAZETTE
October 26, 2005
LaKeisha Brown likely had been
suffering from blood clots in her lungs for at least two days and
possibly as long as two weeks before she collapsed at the Alexander
Youth Services Center and then died on April 9, the state medical
examiner said Tuesday.
A preliminary autopsy report
released soon after 17-year-old “Keisha” died listed the cause of
death as blood clots from her legs that traveled to her lungs. Last
week, her mother, Juana Michelle Brown, gave the Arkansas
Democrat-Gazette a copy of the final autopsy report, which she had
just received. Autopsies are not public records in Arkansas.
Dr. Charles Kokes, the state
medical examiner, explained aspects of the final report in an
interview Tuesday.
“I think if she somehow had been
diagnosed in the days prior to her death, it’s possible she could
have survived,” Kokes said, but added that a pulmonary
thromboembolism — the medi- cal term for a blood clot in the lungs —
can be difficult to detect.
Keisha’s medical records show that
both nurses and some facility managers believed she was faking
sickness for attention at the time of her death.
An investigation this summer by the
state Board of Nursing found that nurses at Alexander did not
provide the teenage inmate with adequate medical care in the days
before her death and violated facility policy and state nursing
laws. Another investigation by the state Youth Services Division
found that senior management “was negligent” because it did not
ensure systems were in place to provide Keisha the medical care she
needed.
The role of the medical examiner is
not to judge a person’s medical care, Kokes said, but it is clear
that the symptoms Keisha displayed in the days before death were
“undoubtedly” related to the blood clots.
COLLAPSED SEVERAL TIMES
As Keisha left a softball field at
the Alexander unit on the evening of April 7, she collapsed. She
complained to a nurse of shortness of breath and a tightness in her
chest, according to medical records obtained earlier by the
Democrat-Gazette. When she collapsed again, employees took her to
the infirmary. Both times, a nurse who examined her found nothing
wrong.
Keisha spent the next day, April 8,
on a bench in the school office. Employees described her has being
“very sick” but treatment supervisor Joy Cole ordered employees not
to give Keisha any special treatment, according to the Youth
Services Division investigation. An administrative assistant to the
medical staff declined to dispatch a nurse to see Keisha, saying
that the teenager was just trying to get attention.
Keisha collapsed again that
evening. When an employee tried to write a report about the girl’s
worsening condition, the employee was told by Cole not to do so, the
Youth Services Division investigation showed. Nurses placed Keisha
on bed rest that night. The next morning, however, Joann McCoy,
secondin-command of the facility, ordered employees to make Keisha
walk to the cafeteria for breakfast even though she was complaining
about difficulties breathing and walking.
Too weak to make it back to her
dormitory after barely eating her breakfast, Keisha went to the
gymnasium instead. A grainy video surveillance tape shows Keisha
lying motionless on a gym mat — friends covered her with jackets
because she was so cold.
When an employee tried to walk her
back to the dorm, Keisha again collapsed. Only after she fell
unconscious did nurses call a doctor and 911. Efforts to revive her
were unsuccessful and she died at a nearby hospital the morning of
April 9.
CLOTS DISABLED HER LUNGS
During his examination of Keisha’s
body, Kokes found no evidence of external or internal trauma and no
evidence of drugs or alcohol in her system. The clots, he
determined, were the sole cause of death.
Only one-third of her lungs
functioned the day she died.
The right lung is divided into
three lobes; the left has two. The main pulmonary artery to the left
lung was “completely” blocked by a clot, as were the arterial
branches leading to both lobes of the left lung, the autopsy stated.
The artery to the right lung’s
lower lobe also was completely blocked, while the arteries to the
other two lobes remained free of clots. However, Kokes found some
blockage from clots in less significant vessels in the right lung.
“What that means as far as blood
flow to her lungs at time of death was that she was no longer
getting blood flow to the left lung and right lower lung lobe,” he
explained.
Because blood flowing through the
lungs back to the heart was only going through a portion of her
right lung, Kokes added, the right side of Keisha’s heart was
working overtime and could not keep up with the work demanded of it.
With a lesser degree of blockage, the human body is sometimes able
to handle the additional work.
Keisha had compensated for earlier
clots, Kokes said. He found scar tissue and spots of dead tissue on
her lungs, called infarcts, that showed her body had been dealing
with clots in the days and weeks before her death.
“This was an ongoing problem,” he
said.
Kokes found clots that were
reddish-purple in color, which he said indicated that they were a
couple of days old. Other clots were a grayish-tan color, which
Kokes said meant that they were likely up to two weeks old.
One area of the right lung had
scarring that could have been caused a month or more before Keisha’s
death, a time when she complained almost daily about shortness of
breath and tightness in her chest.
However, the scarring also could
have been caused by pneumonia or asthma, Kokes said. Keisha’s
medical records show that she had slight asthma, though her mother
said a doctor never diagnosed Keisha with that disease. Whatever
caused that scar did not contribute to Keisha’s death, Kokes said.
The most likely cause of the clots
is deep vein thrombosis — clots in the legs. Kokes found none when
he examined the veins in Keisha’s legs but said that was not
unusual.
He found tiny clots and scar tissue
that could have been weeks or months old near Keisha’s adrenal
glands, which are on top of the kidneys. These clots were so small
they could only be seen under a microscope, and it’s unlikely they
produced any symptoms or contributed to her death, Kokes said.
However, the clots do point to a
possible cause of blood clots in a person so young. Keisha might
have suffered from a condition that caused her blood to clot easily,
though no one will ever know for sure because the test to determine
this condition has to be done on a living person.
Kokes ruled that Keisha died from
natural causes.
STATE MAKES CHANGES
The autopsy confirmed Michelle
Brown’s worst fears — that her daughter suffered and nurses at
Alexander did nothing to help her.
“What Alexander said conflicted
with what the autopsy said,” Brown said Tuesday afternoon.
“Alexander said Keisha did not complain until April 8 but the
autopsy proved she had old blood clots.”
She believes that Keisha complained
but no one documented her complaints, or that she suffered in
silence because her anticipated May 1 release date was threatened if
she complained unnecessarily about her health.
Keisha had been at Alexander for
two years after being adjudicated delinquent for rape and drug
charges. Though she at first had some disciplinary problems, written
complaints about her behavior ended in late 2004, psychological and
facility records showed.
She earned her GED and was making
plans for college upon her release.
Because of Keisha’s death, the
Youth Services Division of the state Department of Health and Human
Services uncovered widespread problems with the medical system at
the state’s largest lockup for youthful offenders, the head of the
Youth Services Division told state legislators this summer. The
problems, Kenneth Hales explained, have been or are being corrected.
For one, the state, which has
contracted with the private company Cornell Cos. Inc. to run
Alexander, has begun auditing medical files of youths at the
facility to ensure they are receiving proper care.
Before Keisha’s death, the state
only audited the company to make sure it was meeting contractual
obligations in operating the facility.
This summer, Cornell fired two
contract nurses, the center’s nurse manager and its program
supervisor, who also is the second-in-command at the Alexander
center, Jane Miller, director of behavioral health services for
Cornell, has said.
Three other employees were
disciplined, and more than a dozen quit. Cornell has apologized for
Keisha’s death but maintains it is not at fault.
Messages left Tuesday with a
Cornell spokesman and Alexander’s director were not returned. A
Department of Health and Human Services spokesman also did not
fulfill a request for information related to Keisha’s death.
The state Nursing Board plans to
send out letters of reprimand this week to some of the nurses
working at Alexander when Keisha died, said Faith Fields, executive
director of the board. Fields did not name the nurses or say how
many would be receiving such letters but explained the letters would
go only to nurses indirectly involved in Keisha’s care.
The other nurses, whom she again
did not name, will be sent notices in December explaining that the
board will meet in January to decide their punishment. They could
lose their licenses to practice.
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