Investigative Report

STATE OF IOWA
CITIZENS’ AIDE/OMBUDSMAN

INVESTIGATION OF SCOTT COUNTY
JAIL’S USE OF FORCE
TO: Dennis Conrad
Scott County Sheriff
FROM: William P. Angrick II
Citizens’ Aide/Ombudsman

RE: Case File 0600421

Issued: June 27, 2007

Table of Contents
Table of Contents .............................................................................................................. 2
Role of the Ombudsman................................................................................................... 3
Complaint Investigated .................................................................................................... 3
Background ....................................................................................................................... 4
Analysis and Conclusions ................................................................................................. 4
Sickle Cell Disease ......................................................................................................... 4
Medical Assessment and Treatment by Jail Staff.......................................................... 5
Use of Excessive Force by Jail Staff............................................................................... 9
Restraint Chair Time................................................................................................... 9
Handcuffs (doublelocked) Behind the Back / Hard Restraint .................................. 10
Recommendations ........................................................................................................... 11
Appendix A, Page 1 of 3................................................................................................... 13
Scott County Reply ........................................................................................................... 16
Ombudsman’s Comments to Reply............................................................................... 21

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Role of the Ombudsman
The Office of Citizens’ Aide Ombudsman (Ombudsman) is an independent and impartial
agency within the legislative branch of Iowa state government. Its powers and duties are
stated in Iowa Code chapter 2C.
The Ombudsman investigates complaints about Iowa state and local government
agencies. The investigation can determine whether agency action is contrary to law, rule,
or policy, or is unreasonable, unfair, inconsistent, oppressive, in error or otherwise
objectionable. After completing an investigation, the Ombudsman may issue a report to
the agency stating the findings, conclusions, and any recommendations for improving
agency laws, policies or practices. The agency may reply to the report, but shall reply if
requested by the Ombudsman. If the Ombudsman decides to publish a report that
criticizes the agency, the Ombudsman will include in the report any unedited reply by or
on behalf of the agency.
Complaint Investigated
On January 30, 2006, the Ombudsman received a complaint regarding Lillian Slater’s
treatment by the Scott County Jail. The complaint was assigned to Assistant
Ombudsman, Barbara Van Allen. For reference purposes in this report, actions taken by
Ms. Van Allen will be ascribed to the Ombudsman.
Ms. Slater alleged that the jail staff failed to provide adequate medical assessment and
treatment for her medical condition on January 26, 2006. According to Ms. Slater, she
repeatedly reported to the jail staff that she was suffering from an acute sickle cell pain
episode and that she needed to be taken to the emergency room. Ms. Slater believed the
jail staff showed deliberate indifference to her condition and medical needs. This was
demonstrated by refusing her medical care and calling an ambulance to transport her to
the hospital only after her initial court appearance and release from jail.
In addition, Ms. Slater alleged that while in the jail’s custody for nine (9) hours, the jail
staff used excessive force by keeping her longer than necessary in a restraint chair, with
her hands cuffed behind her back. The use of the restraint chair and the type of cuffing
used caused considerable pain and increased sickle cell complications.
The purpose of this investigation was to determine whether the jail staff’s treatment of
Ms. Slater was unlawful, contrary to policy, unreasonable, unfair, oppressive, or
otherwise objectionable.

3

Background
Ms. Slater was arrested by the Bettendorf Police Department on January 25, 2006 and
transferred to the Scott County Jail at approximately 11:30 p.m. The Scott County
Detention Center’s morning report indicates Ms. Slater had been placed in a restraint
chair by 12:15 a.m. for her safety. The application of protective restraints document
stated “new arrest Slater was placed on the bench waiting to be booked in and started to
yell. Then laid on the floor refusing to answer any questions and stay on the bench.” Ms.
Slater is further described as trying to hurt herself by banging her head on a brick wall
and not listening to anything jail staff asked her to do. After being placed in cuffs and
shackles, she was placed in hard restraint / handcuffs (doublelocked) behind the back
when placed in the restraint chair. [All dates in this report are in 2006 unless otherwise
noted]
Health care notes entered at midnight describe Ms. Slater as “on floor rocking back and
forth yelling I have sickle cell and I need my f****** meds.” It was also noted that she
made a request to see a doctor.
The exact time Ms. Slater spent in the restraint chair, while in the jail’s custody for nine
(9) hours, is not well documented. No removal is documented in the morning report.
The application of protective restraints indicates a removal was done at 2:00 a.m. The
morning report and application of protective restraints document indicates Ms. Slater was
placed in the restraint chair again at 3:21 a.m. and not removed again until 8:22 a.m. for
her video court appearance. Ms. Slater spent a minimum of seven (7) hours in the
restraint chair, five (5) of those hours consecutively.
Analysis and Conclusions
Sickle Cell Disease
According to the Sickle Cell Information Center by the Georgia Comprehensive Sickle
Cell Center at Grady Health System, Atlanta, Georgia, “pain is one of the most common
and distressing symptoms that sickle cell patients have.” Sickle cell disease, also known
as sickle cell anemia, is a hereditary problem that causes a type of faulty hemoglobin in
red blood cells. Hemoglobin carries oxygen in the blood. The disease causes some red
blood cells to be sickle-shaped. As a result, this can stop or slow blood flow to parts of
the body, causing less oxygen to reach these areas. Someone with sickle cell disease
would be experiencing pain when the red blood cells are not able to carry oxygen to
tissues. Pain can begin suddenly and last several hours to several days. The pain can be
throbbing, sharp, dull or stabbing. Pain medications are recommended for treatment.
Both prescribed (opiates) and over- the- counter medications (acetaminophen, ibuprofen
or aspirin) are recognized appropriate for acute pain management. There is no cure for
this disease.

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Severe pain is the most common of the sickle cell disease emergencies (acute sickle cell
crises). According to an article by author John R. Krimm, Associate Professor,
Department of Emergency Medicine, Albert Einstein University, four patterns of an acute
sickle cell crisis are now recognizable. They are as follows:
•
•
•
•

Bone crisis: An acute or sudden pain in a bone can occur, usually in an arm or leg.
The area may be tender.
Acute chest syndrome: Sudden acute chest pain with coughing up of blood can
occur. Low-grade fevers can be present. The person is usually short of breath. If a
cough is present, it often is nonproductive.
Abdominal crisis: The pain associated with the abdominal crisis of sickle cell disease
is constant and sudden. It becomes unrelenting. The pain may or may not be
localized to any one area of the abdomen.
Joint crisis: Acute and painful joint crisis may develop without a significant
traumatic history. Its focus is either a single joint or in multiple joints. Often the
connecting bony parts of the joint are painful. Range of motion is often restricted
because of pain.

Emergency hospital care is recommended by Dr. Krimm when there is uncontrollable
pain even with the use of narcotics, continued loss of fluid (vomiting), uncontrollable
fever, chest pain or shortness of breath, severe abdominal pain.
References
1. The International Association of Sickle Cell Nurses and Physician Assistants is an
organization of heath care providers involved in improving the care of the sickle
cell patient. For further information contact: IASCNPA, Box 3939, Duke University
Medical Center, Durham, N.C. 27710. http://www.scinfo.org/prod05.htm
2. eMedicine Health, Emergency Care & Consumer Health Sickle Cell Crisis
Overview Author: John R Krimm, DO, FAAEM, Associate Professor, Department
of Emergency Medicine, Albert Einstein University. Retrieved June 14, 2006, from
http://www.emedicinehealth.com/sickle_cell_crisis/page13_em.htm.
Medical Assessment and Treatment by Jail Staff
To assess Ms. Slater’s complaints, the Ombudsman reviewed Iowa’s “Jail Standards,”
which are in rules promulgated by the Iowa Department of Corrections (DOC) that apply
to all jail facilities in Iowa. The Ombudsman spoke to Ms. Oostenryk, Risk Manager for
Scott County, who provided the requested documentation, including, the jail’s morning
report, dated January 26, application of protective restraints for inmate Slater, incident
reports, commitment summary report, prisoner intake sheet, support service memo,
correctional health medical file, restraint chair policy and a one (1) hour DVD labeled
“booking chairing,” dated January 26. The Ombudsman obtained from the restraint chair
manufacturer, AEDEC International, Inc., their operational instructions for law
enforcement and photographs of the restraint equipment. [Appendix A]

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The correctional health medical file indicates on January 25, in booking, a nurse inquired
about Ms. Slater’s medical history and treating physician. Ms. Slater’s pharmacy was
called to verify her medications. The health care notes, entered at midnight on January
25 by the nurse, states that she was “called to booking re: an inmate with sickle cell.”
The nurse described Ms. Slater as “on the floor rocking back and forth” and “minimally
cooperative.” She was reported to be yelling that she had sickle cell and needed
medications and a doctor. Ms. Slater was removed from the booking area and taken to
the carpeted video court room.
The nurse telephoned their physician and medication orders were received to provide Ms.
Slater 100 mg. tablet PO Q6hours of Tramadol HCL (generic for the listed Ultram on the
doctor’s orders). However, the Ombudsman is concerned that the health care notes did
not document the following information in relation to the initial physician consultation:
(1) what information the nurse provided to the physician about Ms. Slater’s medical
history, verified medications or her condition.
(2) their discussion about any possible emergency medical care plans or needs.
(3) evidence that the nurse checked Ms. Slater’s pain intensity or vital signs, including
her temperature for a fever. If Ms. Slater had both severe pain and a fever, her
condition could have required the attention of a physician immediately.
Ms. Slater initially refused the pain medication prescribed for her. She can be heard on
the “booking chairing” DVD saying that she was unfamiliar with the drug prescribed and
concerned about the consequences of taking an unknown medication. The health care
notes indicate Ms. Slater was told “this is what Dr. ordered to treat your pain.” Given
Ms. Slater’s medical condition and prescribed pain medications her treating physician
had her taking for pain management, it appears reasonable that she would have some
hesitation and basic questions about an unknown medication being prescribed for her.
There is no account of the nurse or jail staff providing Ms. Slater with any substantive
information about the unfamiliar medication or why the doctor prescribed this medication
instead of the known prescribed medications. The American Corrections Association
(ACA) standards requires that inmates are to be afforded the same level of consent as in
any community medical facility for the specific type of treatment involved. [Guidelines
for the Development of Policies and Procedures: Adult Local Detention Facilities,
American Corrections Association, March 1992]. While the Scott County Jail is not
required to satisfy the ACA standards, medical services staff should have provided Ms.
Slater more information about the prescribed medication and explained why she could
not have her own medications brought to the jail. See White v. Napoleon, 897 F.2d 103
(3d Cir. 1990), holding “prisoners have a right to such information as is reasonably
necessary to make an informed decision to accept or reject proposed treatment…” The
right to medical information, including mental health related information has also been
recognized in the Ninth Circuit. Also, the National Commission on Correctional Health
Care has taken the position that there is a “need for informed consent, which includes
material facts as to the nature, consequences, and risks of proposed treatment,
alternatives, and risks, if the treatment is not undertaken.” [Inmates’ Right to Refuse

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Treatment Requires Information on Treatment, Correctional Law Reporter, Volume
XVIII No.3, October /November 2006].
The Ombudsman is also concerned that the nurse did not further consult with the
physician about the use of the restraint chair and hard restraints on Ms. Slater, who was
claiming to be in pain from an acute sickle cell crisis. Following Ms. Slater’s initial
placement in the restraint chair, she was not examined by a nurse again until 8:10 a.m. or
eight hours later.
After the initial telephone call for physician orders, there is no account a nurse or jail
staff seeking a second physician consultation. This is concerning because the morning
report at 8:22 a.m. states: “Inmate in a lot of pain due to sickle cell.” According to jail
documents, at the time of Ms. Slater’s release, at 9:16 a.m. on January 26, she indicated
to the nurse that she could not walk. At Ms. Slater’s request, an ambulance was called
and she was taken to a local hospital emergency room.
It must also be noted that the subsequent nursing notes indicate Ms. Slater was asked
“why she refused all attempts for pain medication through the night….” This question
implies facts that are in conflict with the “booking chairing” DVD. Ms. Slater can be
seen accepting her pain medications from the jail staff approximately one hour after she
is placed in the restraint chair.
The DOC has promulgated rules found in the Iowa Administrative Code that apply to all
jail facilities in Iowa. Rule 201—50.15 states:
201—50.15(356,356A) Medical services. The jail administrator shall establish
a written policy and procedure to ensure that prisoners have the opportunity to
receive necessary medical attention for the prisoners’ objectively serious
medical and dental needs which are known to the jail staff. A serious medical
need is one that has been diagnosed by a physician as requiring treatment
or is one that is so obvious that even a lay person would easily recognize the
necessity for a physician’s attention. (emphasis added). The plan shall include
a procedure for emergency care. Responsibility for the costs of medical services
and products remains that of the prisoner. However, no prisoner will be denied
necessary medical services, dental service, medicine or prostheses because of a
lack of ability to pay. Medical and dental prostheses shall be provided only for
the serious medical needs of the prisoner, as determined by a licensed health
care professional. Cosmetic or elective procedures need not be provided.
50.15(1) Medical resources. Each jail shall have a designated licensed
physician, licensed osteopathic physician or medical resource, such as a hospital
or clinic staffed by licensed physicians or licensed osteopathic physicians,
designated for the medical supervision, care and treatment of prisoners as
deemed necessary and appropriate. Medical resources shall be available on a
24-hour basis. (emphasis added).
IAC 11/23/05

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The preliminary medical staff/nurse at the Scott County Jail did take a number of
appropriate actions. A medical history was done at booking, which included asking Ms.
Slater about her medical condition, allergies, prescribed medications and her treating
physician’s name. A pharmacy was called to verify Ms. Slater’s prescribed medication.
A physician was consulted. Orders were received and implemented for medication.
Medical records were maintained to document that Ms. Slater received medical care and
that the nurse had monitored the initial placement and restraint settings.
Nevertheless, based on the Ombudsman’s review of the factual circumstances and the
DOC rule, it is believed that Ms. Slater’s condition could qualify as a serious medical
need pursuant to the above cited rule and may have required more physician attention.
As such, it is undetermined whether the Scott County Jail provided adequate medical
assessment and treatment for Ms. Slater’s medical condition on January 26. The
Ombudsman believes reasonable minds could look at the same evidence and reach
different determinations about this issue. In part, the Ombudsman found the medical
documentation insufficient to reach any other determination without the assistance of a
medical expert. The Ombudsman felt certain additional action could have been taken by
the medical staff to assess and treat her condition and the medical records maintained
could be improved to provide more substantive information on an inmate’s condition.
Especially when the situation requires a physician to be contacted for orders.
The Iowa Nurses’ Association (INA) takes the position that medical documentation
should be “timely, objective and defensive to avoid facing a lawsuit or licensing board
disciplinary action.” The type of charting and protocols to use can be dependent on the
setting which the practice takes place. However, there are key elements recognized by
professional standards for nurses, such as, charting clinically significant changes in the
patient’s condition. To do this, the patient’s baseline from which the changes may be
measured would be required. The INA states a nurse should “record the facts of what
you see, hear, smell, and touch, in an objective manner as possible. Record the
information timely. Chart chronologically. Use flow sheets to record routine cares. Be
sure to include time/date in your documentation of medical visits. Consultations and
discussions about concerns with medical orders and directions.” [Iowa Nurses
Association. Defensive Documentation and the Law: Iowa Department of Corrections.
Retrieved December 26, 2006, from http://www.iowanurses.org/defense.htm]
The Ombudsman does not substantiate, however, the complaint that the medical and jail
staff showed deliberate indifference to Ms. Slater’s condition and medical needs. In
reaching this conclusion, a wide variety of additional medical information was reviewed
on the topics of sickle cell, sickle cell crisis, sickle cell symptoms, sickle cell crisis
treatment and medications. The Ombudsman also reviewed Ms. Slater’s historical
medical records and the treatment records following her release from the Scott County
Jail.
For Ms. Slater to succeed on her claim that the jail was deliberately indifferent, she will
need to show “(1) she suffered from a serious medical condition, (2) the jail staff knew of
the condition, and (3) the jail staff deliberately disregarded the condition.” Kitchen v.

8

Miller, 343 F. Supp.2d 820, 823 (E.D.Mo. 2004). Also see, Dulany v. Carnahan, 132
F.3d 1234, 1239 (8th Cir.1997) holding that “to show deliberate indifference, a prisoner
must demonstrate that he suffered objectively serious medical needs, and the officials
actually knew of but deliberately disregarded those needs.”
Use of Excessive Force by Jail Staff
Restraint Chair Time
DOC rule 201—50.13(2) requires the following:
201—50.13 (2) Security and control. The jail administrator shall develop and
implement written policies and procedures for the jail which provide for the
control of prisoners and for the safety of the public and the jail staff. The policy
and procedures shall include:
f. Restraint devices. The jail administrator shall have a written policy on restraint
devices. Restraint devices shall not be applied as punishment. Restraint devices
shall be used only when a prisoner is a threat to self or others or jeopardizes jail
security. There shall be defined circumstances under which supervisory approval
is needed prior to application of restraints. Restraint devices shall not be
applied for more time than is necessary to alleviate the condition requiring
the use of the restraint device. While restrained, prisoners shall be either
clothed or covered in a manner that maximizes prisoner privacy…[emphasis
added]
The Scott County Sheriff’s Office Restraint Chair Policy (Policy) states:
Under no circumstance will restraints be left in place for more than four (4)
hours without authorization form the Corrections Division Captain. Such
authorization will be documented by the duty supervisor on the Application of
Protective Restraints form to include date and time.
The AEDEC International, Inc. operational warning for law enforcement states:
In most circumstances, the prisoner should not be retained in the chair for over a
four-hour period. If it becomes necessary to restrain the prisoner for a longer
period of time, approval from the watch commander should be obtained with the
appropriate medical staff review…If it becomes necessary to hold the prisoner
handcuffed to the rear in the chair for an extended period of time (excess of an
hour), the prisoner should be released from the metal cuffs and re-cuffed to each
side of the chair with the optional soft restraints provided by AEDEC…It is
recommended that the optional PRO-STRAINT lower back support be used
when the prisoner is soft cuffed to the sides of the chair for a period of more
than three hours.

9

The documents provided for my review did not indicate a Corrections Division Captain
authorized Ms. Slater to be left in restraints for more than four (4) hours. The application
of protective restraints indicated Ms. Slater was in the restraint chair from 12:15 a.m. to
2:00 a.m. and again at 3:21 a.m. to 8:22 a.m. In total, Ms. Slater was in a restraint chair a
minimum of seven (7) of the nine (9) hours she was held in jail.
In subsequent requests for document to Ms. Oostenryk, the jail was unable to provide
verification that the jail staff had complied with the above Iowa law or internal restraint
chair policy. The Ombudsman was informed that there was no additional evidence,
including pictures, videotapes or DVDs, to confirm Ms. Slater’s total time placed in the
restraint chair or that her condition required the use of restraint devices for more than six
hours.
After reviewing all the collected information, the Ombudsman concludes the jail staff’s
treatment of Ms. Slater in the restraint chair was contrary to law and inconsistent with jail
policy and the manufacturer’s operational warning. The Ombudsman substantiated her
complaint that the jail staff used excessive force by keeping her longer than necessary in
a restraint chair, with her hands cuffed behind her back.
Handcuffs (doublelocked) Behind the Back / Hard Restraint
Scott County’s policy regarding the use of the restraint chair requires handcuffs
(doublelocked) behind the back and shackles (doublelocked) to be applied to the inmate
before placing the inmate into the restraint chair. The policy also states:
It is desirable to place the inmate’s hand in the soft restraints immediately, but if
not possible, the inmate should be left handcuffed behind the back while in the
chair. At 15 minute intervals the handcuffs must be checked.
Once the inmate is non-combative, remove the handcuffs and secure the wrists
into the soft side restraints using the follow method as a guideline….
According to Ms. Slater, she was held in hard restraints / handcuffs (doublelocked)
behind the back when placed in the restraint chair. She also alleged she was left alone
for long periods of time and not allowed to use the toilet, forcing her to urinate in the
restraint chair.
The typed application of protective restraints indicates hard restraints were applied. The
one (1) hour DVD showed only the use of hard restraints. The Ombudsman noted a
handwritten and initialed comment on the typed application. Following the initialed
comment the handwritten words “SOFT RESTRAINTS” appear. There is no indication
when these words were added to the Application or by whom. Health care notes prepared
on January 25 indicated the use of hard restraints were used and checked.
After reviewing the one (1) hour “booking chairing” DVD, dated January 26, the
Ombudsman determined that the jail staff’s treatment of Ms. Slater was contrary to law

10

and inconsistent with jail policy. The Ombudsman observed no attempt to place Ms.
Slater in soft restraints at any time. Upon placing Ms. Slater into the chair, she can be
heard asking the jail staff to not cuff her hands behind her back because she has sickle
cell. This request is often repeated over the next hour.
After placing Ms. Slater in the restraint chair, her handcuffs were checked only once
during the hour. The DVD shows there was a problem with the right shoulder/arm
restraint staying locked into place on Ms. Slater. Jail staff attempted to lock this restraint
into place again 30 minutes after placing her in the restraint chair. While in the room her
handcuffs were checked at this time.
After being in the restraint chair for fifty-four (54) minutes, one hand was uncuffed for
medication for less than three minutes. Despite Ms. Slater’s compliance with taking the
prescribed medications and non-combative demeanor at the time, a less restrictive
manner of restraint was not used.
No other documentation was provided to verify if or when the supervisory staff inspected
Ms. Slater’s restraints when placed in the restraint chair. The health care notes provided
indicate only one restraint check by a nurse was done at midnight on January 25.
The Ombudsman substantiates Ms. Slater’s complaint that the use of the restraint chair
and the type of cuffing used caused considerable pain and exacerbated her sickle cell
symptoms.
Recommendations
Based on the findings and conclusions of the Ombudsman, the following
recommendations are made:
1. Review and modify Scott County written policy on the use of the jail’s restraint
chair to address the issues identified in this report. In addition, the policy should
incorporate other best practices. The new policy should:
•

Whenever doing so does not jeopardize staff safety, an inmate should be
warned in advance before the staff uses force as described in the Scott County
Sheriff’s Office Restraint Chair Policy.

•

Whenever practical, staff of the same gender will be involved in use of force
applications, so that at least one employee of the same gender is present to
observe the incident.

•

Establish procedures which include staff training and annual review of the
policy and restraint applications for staff likely to be involved in use of force
incidents.

11

•

Give an offender the opportunity to be released from the restraints in order to
eat and to use the toilet.

•

If a physician has been consulted on an inmate’s medical condition prior to
the use of force applications, determine if the physician should also be
consulted about the use of force applications and how long the medical staff
should monitor the condition of the inmate to ensure no conflict with the
inmate’s medical condition, doctor’s orders and use of force application.

•

Have improved documentation for the assessments made on type of restraints
used, when restraints are checked, removed or changed, the decision to use
restraints for more than four (4) hours, and the Corrections Division Captain’s
authorizations.

•

Develop improved safeguards against accusations of improper use of force,
including videotaping or making a DVD of the entire use-of-force incident.
Clear guidance should be provided to jail staff to ensure they know who
makes the decision to videotape, who checks the equipment to ensure it is
operating properly, how often recording checks are made and how long tapes
or DVDs are stored.

2. Review policies to ensure jail staff is provided with instructions for securing
medical services in the event of a medical emergency, consistent with community
standards of health care, on a 24 hour basis. There should be no reluctance to
refer an inmate with a suspected serious medical need to a physician, regardless of
the time they come into the jail’s custody.
3. Have the jail physician review Ms. Slater’s correctional health medical records for
the sheriff, jail administrator and risk manager to determine if they satisfy the
existing standards established for clinical recordkeeping. Develop and improve
consultative records, examination forms, progress notes and summaries to
safeguard against accusations of improper medical assessment and treatment.

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Appendix A, Page 1 of 3

MANUFACTURER'S WARNING 2/1
OFFICERS SHOULD BE INSTRUCTED HOW TO PROPERLY OPERATE THE
PRO-STRAINT®CHAIR PRIOR TO USING IT.

The "0" ring handle musl w puaed lllaJohl back from 11a retainar to make lhe cinching mochal\ialn ~unction po-operty. 0o not Jell< llandlu
~ u R may caus.<Wnage 10 lhe retaine<.
STAT!MI!NT OF PURPOSE
The purpoM of lhe PRO.STAAINT411 VIOitnt Prioon.r Chair is to~ law .nfo<cementand corrKIIoMI ollloela wilh 1lle &afNI, most
hUmane, and leUI peychoiOglcally Ire~ system for rutrolni!>g violent. out-ot-control pritoners. It is tnMnt to be emplOyed u a
.....,._ and cornlo<Uble rKtralnl when ~ 1o suspected thAt a P<i- mlght dO n.rm to himsellln.tMII or fellow pl!eO<\ers or guards. It
may W ueed In eilher a c:onvenlionel or aalety eel. It Ia en~ us.n.IIOOI lor f11Sil"ainiog Clr\lg or &lc:cl~Q..,_ prieoner3 when
apec1a1 ptiCOIUiiona aro 1\Mded to auure that tile prilon<l(s aJtway Is dowed. The ptlsoner'a IO!W ia h.td upright to p - Q'loking on
1'111 ~ e><pedorato. The cn.ir may be used in Ins aecure arau to lf\l\afiCa const...,t ot>aervallon or a dupondent ~'· The chllr ta
""'"*"''toW an~ ol punitllmeo'lt and lhould not W ueed u such.
·
IMPORTANT
ln. prisoner may w restraint In the chair In !WO diNorent position a: one, with lhe prisoner hanclcuNid to tho rear. and two, with lhe ··
Jl<lson*r 10ft ou11ed 10 th& oidN o1 the cl\llt. White lho prlsonar II handcuffed behind the back whh oonvantfonal molal handcuffs,
a.oslemal'f ptOC&Uiiona lhould bo tal<on to make cerlaln lhe ~ doe& not incur ~ due to Wnpaired circ.Milon and ex.c6SIIve
ptouv,.. to thO wr~ lrorn overly tight hllldcufts. &:Ira ~ II\OUid bo hlkan to I.SS\Iro P'CPOf ciiQJiation wh&n tMitUllng an
porwoo. In addltlona to chook!J>g circulation In lho orma 111d legs, look lor signa ol reduced clroulation uodlr tlla knH wlloro tlla
Cllalr mMII 1110 log. To OQUe)ize the pre.. botwHn the bunocke and lags tor pneonars wtlh ohe<ttr legS t1w dO not rneh the tloor,
olighlly ....,,,_ the h..r of foot ol the prioonor from the 1loo< with a AEOEC tool t40vator (RC I 530) or other non...u-.1 attacnod pladonn.
In most~. the priiOMIShOuld not bo reWnecl ln thO Cllalr lot ovor a lOUt~ period. U• bec<>rMs -.art to ruua.in the
pt~soner lor a lOnger period ol ~me. approval from the ,.arch commander should bt 06Wnad wnn the appropr1att modieal 1taH review.
The p~ ahould bo monitored at regullt intarvaJJ, consistent ,..th dopertmental rNtraint policy. Standard operating procadurH on the
. - of !he Cllalr be speclric a~s can bo obt&ined from 1lle laC(Oiy l1jlOO requut. They are - ' to bo exampl.s. Pluse aclapt your
SOP$ 10 tilt lpoclftc lawo and court ~die~& in )OUt rNpoC!iW Slatt. If k llecorMo noc:ossary to 1'1010 ttl& prisoner ~ad 10 the " " ' in
lhlchllr lor an extended po~od ol time (o•cesa ol111 hour). the prieontr should be ritlaased from !he metal cuna and r~ed 10 each
liCit of the chair wiU't the optional soh restraints providad by AEOEC. Appmpriate restra,nts by Other manut~C~urere may also be used. It
I& r~ lhat lila optional PRO.STRAJNT lowor back suPPOrt ba used whlll the prisoner Is soft cuffed to the lidOS ollhe ct1&i< lor
a period ol mote lhln 11\tM hours. To~~. a/Ways kHp 1lle tap boK lighL

u,..

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Scott County Reply
WILLIAM E. DAVIS
COUNTY ATTORNEY
Scott County Courthouse
400 West Fourth Street
Davenport, Iowa 52801-1187
Telephone: (563) 326-8600
Facsimile Transmission (563) 326-8763

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Scott County

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Theodore J. Priester. Assistant County Attorney (563) 326-8239

June 1, 2007
VIA FAX AND ORDINARY MAIL
William P. Angrick II
Citizen's Aide/Ombudsman
Ola Babcock Miller Building
1112 East Grand Avenue
Des Moines, Iowa 50319
Re: Lillian Slater Investigative Report
Dear Mr. Angrick:
Please be advised that I am an Assistant Scott County Attorney who has been assigned
to the above referenced matter. I have conferred with Scott County's Risk Manager, Rhonda
Oostenryk, concerning this matter and I have had an opportunity to review your Investigative
Report along with other documentation from the Scott County Jail. My initial reaction to your
office's Report was that it appeared to be premised largely on the allegations of Ms. Slater
herself, with very little input from other persons. including the Jail personnel who may have had
direct knowledge of the factual circumstances. The Report appears to presuppose the
credibility of Ms. Slater without taking into full consideration the actual circumstances of her
condition and aggressive behavior when she was booked into the Jail in the late evening of
January 25, 2006. In the section of the Report referred to as "Background", it is surprising that
there is no mention of her intoxication, which I would presume would be of great importance in
not only determining the level of her credibility, but also the extent of her memory with regard to
the factual circumstances occurring during the nine (9) hours of her incarceration. In the
courtroom, intoxication is typically considered grounds for impeachment, and the fact that there
is no mention of intoxication in the Report strongly suggests that undue weight has been given
to Ms. Slater's "recollected " allegations.
I am also concerned that the Report contains only "text book" references to sickle cell
disease, with no apparent direct consultation or input from a physician or other medical expert.
The Jail physician, Scott C. Ludwig, M.D., was apparently not contacted during the course of the
investigation which is also surprising given his critical role as the physician in charge of medical
care at the Jail. After your Report was received, the Scott County Risk Manager, Rhonda
Oostenryk, did contact Dr. Ludwig, and asked that he provide a written statement concerning
Ms. Slater's condition , and I am enclosing herewith a letterfrom Dr. Ludwig dated May 15, 2007.
Said letter takes issue with certain conclusions in the Report, and importantly, Dr. Ludwig

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"completely disagree(s) and with any conclusion that Ms. Slater's condition required evaluation
at the hospital or that she was in any significant danger from her sickle cell SC disease at the
time of her incarceration". Said letter also states that "(T)he nurse had evaluated her condition
and reported findings and behavior much more consistent with intox icated agitation as
opposed to a sickle cell pain crisis." Dr. Ludwig also reports that after Ms. Slater was released
from incarceration the following morning, Ms. Slater asked to be taken to Genesis Medical
Center where "there was no mention of a Sickle Cell crisis and she received no treatment for
that complaint". Furthermore, Ms. Slater made statements at the hospital that she had been
assaulted by correctional staff and failed to menhon anything about her sickle cell condition. Her
statements at the hospital clearly belie her complaints to your office that her sickle cell condition
had been ignored by Jail staff. Additionally, Dr. Ludwig reports that x-rays were taken of her
w rist and ribs with the diagnosis of soft tissue contusions which diagnosis would be consistent
for a person who may have been acting with extreme agitation requiring the use of a restraint
chair. Importantly, Dr. Ludwig explains that "(P)atients with sickle cell pain crisis remain still
d ue to the fact that excessive movement worsens their pain". With Dr. Ludwig's letter, there are
now three salient reasons to call into question Ms. Slater's credibility: the symptomology of sick
cell illness, her intoxication, and of course, her obvious personal bias.
The foregoing discussion should not be taken as an outright rejection of the conclusions
or recommendations in the Report pertaining to the restricted use of the restraint chair. As
everyone is well aware, the restraint chair should only be used as a last resort for those inmates
that are found to be physically aggressive and out-of-control, whereby its use is required to
prevent injury to the inmate and to the jail staff. The "bullet-point" recommendations in the
Report emphasizing restrictions on the use of the restraint chair in many respects already
mirrors the policies that have been adopted and implemented in the Jail for many years.
However, said recommendations seNe as a strong reminder that Jail staff will need to engage in
regular ongoing training regarding the use of the restraint chair, and any deviation from the strict
policies and procedures regardin9 such use will not be tolerated. Sheriff Dennis Conard has
acknowledged and agreed to abide by the recommendations in th e Report in this respect. If the
underlying purpose of the Report is to underscore the importance of following strict procedures
w ith regard to the use restraint chair, such purpose has been fulf illed by the Sheriff's
concurrence in the Report's recommendations. It is my understanding that the Jail
Administrator, Major Tebbitts, has already implemented additional training pursuant to your
Report.
In conclusion, Scott County takes exception to the complaints of Ms. Slater that her sickle
cell condition had been ignored or otherwise inappropriately handled. It has not been disputed
that Ms. Slater presented herself at the jail in a highly intoxicated and agitated state. It now
appears that her complaint about her sickle cell condition may have been an exaggerated and
opportunistic ruse to seek remedial action through your office. Ironically, had Ms. Slater not
been placed in the restraint chair on the evening of January 25, 2006, she might have suffered
more serious physical injuries to herself or others given her high level of intoxication and
agitation. Scott County urges your office not to publish the Report. If you were to do so, your
office would in effect amplify Ms. Slater's disputed allegations that even if proven, would not rise
to the standard of "deliberate indifference" as your office has already acknowledged.
Additionally, it is the County's position that the publication of the Report would seNe no public
purpose whatsoever. The Sheriff has accepted the recommendations of the Report and he

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acknowledges that every effort will be made to follow the recommendations in the future. Scott
County has always taken great pains to maintain the highest standards with regard to matters of
jail administration. At this very moment. contractors are in the final stages of completion of a
new Scott County Jail Facility pursuant to a ten-year long effort, two public referendums, and the
expenditure of funds in excess of twenty-nine million dollars. Scott County understands well the
importance of its public function in the building and maintaining of a state-of-jail facility for the
safety and well-being of its citizens as well as the safety and well--being of the inmates.
Please contact me if you require any further information or input. Your consideration of
the foregoing matters will be greatly appreciated.

Sincerely,
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C.. .

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Theodore J. Priester
Assistant County Attorney

cc: Dennis Conard, Sheriff
Rhonda Oostenryk, Risk Manager

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May 15,2007

Rhonda Oostenryk, Risk Manager
Scott C01mty
428 West~m Avenue
Davenport, Iowa 5280 l

Dear Ms. Oostenryk;
This lener is in response to your inquiry regarding the care received by Lillian Slater
during her stay at the Scan County Jail January 26, 2006. I have reviewed the
Ombudsman report filed April 3, 2007 and the related documents for the Scott County
Jail including written statements by the nursing personnel and correctional officers.
Furthermore I must state that I am aware ofMs:. Slater's medical condition and medical
care provided to her as a result of the fact that I am employed as an emergency physician
at Genesis Medical in Davenport Iowa where she has often received medical care,
including the day after her incarceration.
I remember the contact made by the nurse the night Ms Slater was initially placed in
custody. The nurse had evaluated her condition and reported fin.dings and behavior much
more consistent with intoxicated agitation as opposed to a sickle cell pain crisis. The
in.mates was physically and emotionally agitated, too uncooperative to obtain a complete
set of vital signs, and cleariy not in acute physical distress. Patients with sickle cell pain
crisis remain still due to the fact that excessive movement worsens their pain. None the
less I offered Ms. Slater the only pain medication available at the jail and instructed the
nurse to make sure I was contacted it her physical condition deteriorated. My plan was to
send her to the hospital if there were signs of problems. I received no further call.s and
apparently Ms. Slater finally settled down. I completely disagree with any conclusion that
Ms. Slater's condition required evaluation at the hospital or that she was in any
significant danger from her sickle cell SC disease at the time of her incarceration. I feel
confident that the evaluation provided by the nurse on duty was ade(!uate and accurate in
giving me the information I need to make a dec:ision regaruing Ms. Slater' s treatment.
The contemporaneous nursing documentation could have been more substantial but
subsequent documentation explains to my satisfaction what transpired.

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The next morning upon her release Ms. Slater stated she had no transportation and
asked jail staff to call an ambulance to give her a ride. She was taken to Genesis Medical
Center where her chief complaint was that she was assaulted by correctional staff and
injured as a result. There was no menti on of a sickle cell crisis and she received no
treatment for that complaint. X-rays were taken of her wrist and ribs with not bony injury
identified and she was discharged from the emergency department after a brief stay \\ith
the diagnosis of soft tissue contusions.
My recommendations regarding this matter are to continue to pursue 24n nursing
staff at the jail in order to provide round the clock nursing care and evaluation and to
mak<: further ..:fforts to ens~ th11t full and C<)mplete contemporaneous documentatio n of
oursiug cvalu;,tiolls aJtd care arc recorded. lJnfoctunately we h.ave to routinely deal with
belligerent and agitated inmali!S at the jail who in some ca~cs al.~ suffer from S<:>ious
medical problems. It will always be a challenge lo provide a safe and secure cnvirvt\IHcnl
for tl:\cm and to ensure !hey receive timely and proper medical care. We stand dedicated
to maiutaining that standard.

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Ombudsman’s Comments to Reply

Scott County’s reply to this report is disappointing. In his letter on behalf of the Scott
County Jail, Assistant County Attorney Theodore Priester attempts to put the focus on
whether Ms. Slater actually had an acute crisis episode of her illness by raising an
“intoxication” claim, rather than face up to the facts that in its application of the restraint
chair, the Scott County Jail failed to follow its own policy and the manufacturer’s
recommendations. Restraint chairs can be effective tools for custodial authorities to use
to control unruly persons, but their application must be humane, legal, medically
appropriate, and within policies and guidelines. It is of significant concern to the
Ombudsman when an authority like the Scott County Jail does not appear to accept its
responsibilities in this regard. [Note: The Ombudsman has concerns about inappropriate
use of restraint chairs and restraint boards and is currently investigating allegations of
misapplication of restraint equipment by other entities.]
Scott County objects to the report’s failure to mention Ms. Slater had intoxicated
agitation as opposed to experiencing sickle cell crisis. The Ombudsman did not include
this information in the report because it assumes facts not documented nor recorded by
the Scott County Jail correctional or medical staff. There is no reference to Ms. Slater
being intoxicated in any of the following documents: the jail’s morning report,
application of protective restraints for inmate Slater, incident reports, commitment
summary report, prisoner intake sheet, support service memo, Ms. Slater’s correctional
health medical file, and the one (1) hour DVD labeled “booking chairing,” dated January
26.
Assistant County Attorney Priester and Scott C. Ludwig, M.D., also asserted that Ms.
Slater’s reported medical crisis was not credible because after she was released from
custody and went to Genesis Medical Center (Genesis), “there was not mention of a
Sickle Cell Crisis and she received no treatment for that complaint.”
Confidential emergency medical records from Genesis, authorized for release by Ms.
Slater and reviewed by the Ombudsman, dated 1/26/2007, confirm her complaint to be
Sickle Cell Crisis. Ms. Slater also reported to the emergency room medical staff that
“she was put on jail last night and reportedly she went into a sickle cell that she had pain
all over. She reportedly curled herself because og [sic] the pain and a jailer reportedly
tried to straighten position by putting his knees on her thighs while she was handcuffed
whith [sic] her hands behind her back”.
Finally, Scott County suggests that the Ombudsman gave undue weight to Ms. Slater’s
“recollected” allegations. The Ombudsman summarized Ms. Slater’s complaints but
gave little mention or reliance to Ms. Slater’s recollected testimony. The bulk of the
information and evidence gathered and relied upon was from the jail’s own records
(referenced above). The Ombudsman also considered general medical information on
Sickle Cell Disease and information about the restraint chair, including the operational
instructions, from the chair manufacturer, AEDEC International, Inc.

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