TEXAS COMMISSION ON JAIL STANDARDS
EXECUTIVE DIRECTOR
Brandon S. Wood

P.O. Box 12985
Austin, Texas 78711
Voice: (512) 463-5505
Fax:· (512) 463-3185
http://www.tcjs.state.tx.us
info@tcjs.state.tx.us

February 10, 2015
Subject:
Date of Death:
Facility:

VM David Courtney Death-In-Custody Review
December 22, 2014 at approximately 1935 hours
Montgomery Co. Jail

On 12/22/2014 at approximately 1935 hours, Inmate David Courtney passed away at the Columbia
______ Conroe Regional Ho§Jlli&_after being_hosp_italiz_ed.ior_approximately_.25...deys-1LM.Co�s_death..was..--­
ruled a natural death as a result of Acquired Immune Deficiency Syndrome.
During my initial review, it was discovered that there were some inconsistencies in the medical
documentation submitted by county officials. The following is a chronological listing of events by
medical staff and course of action taken:
August 20, 2014- Inmate seen by medical staff for checkup.
September 6, 2014 - Inmate presents to medical complaining of blood in stool.
September 16, 2014 - Inmate presents to medical complaining of blood in stool and abdominal pain. He
was evaluated by a medic and referred to clinic.
..
October 25, 2014 - Inmate presents to medical complaining of blood in stool and abdominal pain at 6am,
is seen by the medic and is referred to clinic. At 1Oam, inmate makes the same medical complaints as he
did at 6am and this time, he is referred to see a doctor.
October 31, 2014 - Inmate is seen by doctor at lpm "in the afternoon. This is 55 days after his first
complaint of passing blood in his stool. This is also the first documentation that shows a referral being
followed-up on for the inmate.
Medical staff failed to follow-up on referrals for treatment for the inmate in a timely manner. The
administration will need to provide a plan of action outlining corrective measures to prevent future
occurrences.
A notice of non-compliance was issued on February 9, 2015 in regards to lack of referral follow-up and
not providing efficient care for acute situations as required.

Stanley D. Egaer, Abilene, Vice Chair
Irene A. Armendariz, Austin
Jerry W. Low ry. New Cane y

Sheriff Dennis D. Wilson, Groesbeck
Sheriff Gary Painter, Midland

Dr. Michael M. Seale, M.D., Houston
Larry S. May, Sweetwater
Alltn D. Caln Carthage
,
'"Tite Commission on Jail Standards welcomes all suggestions and will promptly respond to all complaints directed against the agency or any facilities under its purview".

To empower local government to provide safe, secure and suitable loca/jai/Jaci/ities through proper rules and procedures while promoting innovative programs and ideas

Texas Commission on Jail Standards

Montgomery County Jail
Conroe, Texas

Adminfe1rative Nonoomplialce

February 9, 2015
Date(s) of Inspection

SPECIAL INSPECTION REPORT

SUBJECT:

State Law requires periodic Inspections of county jail facilities (VTCA, Local Government Code,
Chapter 351, VTCA, Government Code, Chapter 511; Chapter 297.8, Texas Commission on Jail
Standards).

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The facility was inspected on the date(s) indicated above, and it was determined that
deficiencies exist. You are urged: (1) to give these areas of noncompliance your serious
and immediate consideration; and (2) to promptly initiate and complete appropriate
corrective measures. The Commission is available to discuss or assist you with the
appropriate corrective measures required.
Failure to initiate and complete corrective measures following receipt of the Notice of
Noncompliance may result in the issuance of a Remedial Order (Chapter 297.8, et seq.).

O This facility was inspected on the date(s) indicated above. There were no deficiencies
noted and upon review of this report by the Executive Director of the Texas Commission on
Jail Standards, a certificate of Compliance may be issued per the requirements of VTCA,
Chapter 511 and Texas Minimum Jail Standards.
Inter-Office Use Only

Authenticated:

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P�l�u�. TC��or

,1 • c , • v 0·-FEB 1 o 2015

Received by:

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I .301 i"
Date

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TEAA� C0MM1SS10N ·
_QN JAIL STANDARD$ __

cc:

Date

Judge,

Sheriff

lndlvlduai. and/or antltl•• ..-gulated by

the Te,;n Camml"lon on Jail Standard$ shall direct all complaints regarding the commission
P.O. Box 12985 A&.tatln, Taxas 78711 ($12) 463·5505 Fax (512) "83-3185 or at our

procedures and fu<1e1fons 10 the Executive Director at:

agem:y website at www.tcjt.atate.tx.ua.

TE. COMMISSION ON JAIL STAND.$
JAIL INSPECTION REPORT
Facility Name: Montgomery County Jail
Date:
Item

Section

273

P1raQ111ph

February 9, 2015

Commen11

.2(2)(3) Each facility shaU have and implement a written plan, approved by the Commission, for
inr:nate medical, mental, and dental services. The plan shall: (2) provide procedures for
referral for medical, mental, and dental services; (3} provide procedures for efficient and
prompt care for acute and emergency situations

Documentation received and reviewed by commission staff revealed that Montgomery
County is not following. their approved Health Services Plan. The. procedures for the
referral of medJcal services and providing for efficient and prompt care for acute
situations were not being followed as required by Minimum Jail Standards.

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Phllltp Bosquez, T.C.J.S. Inspector

_R.

EC!IVED
FEB 1 o 2015

i

j TEXAS CUMMtoSION

. ON.JAIL $TANOAFJD.$_