King County Ombudsman's Office
FINDINGS AND RECOMMENDATIONS

King County
Respondent: Public Health-Seattle & King County,
Jail Health Services
Ombudsman Case No. 2007-01436
April 15, 2008

CONTENTS

Executive Summary. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . ..

2

Allegation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

2

Investigative Authority . . . '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

3

Procedural History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Summary of Key Facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

4

Expert Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

5

Ombudsman Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

8

Recommendations & Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

8

: . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

Appendix A

Report of Dean Dellinger, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

Appendix B

Report of Lori S. Kohler, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

Appendix C

Response of Public Health-Seattle & King County. . . . . . . . . . . . . . . . . . ..

Appendix 0

Chronology

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 2 of9

EXECUTIVE SUMMARY
Lynn Dale Iszley was booked into the King County Correctional Facility on July 16,
2007, and soon began exhibiting symptoms consistent with alcohol and heroin
withdrawal. Mr. Iszley's symptoms worsened in the early morning of July 18, and his
condition deteriorated until his death in the early morning of July 19. The cause of
1
death was acute peritonitis due to a perforated ulcer.
Corrections officers, who are employed by the Department of Adult and Juvenile
Detention, appear to have acted appropriately and commendably by responding to Mr.
Iszley's condition in a timely and professional manner.
However, based on our independent review of the record and on the opinion of our
expert consultants who reviewed Mr. Iszley's medical records, we find that Jail Health
Services (JHS), a division of Public Health-Seattle & King County (DPH), failed to
provide Mr. Iszley with the medical care he needed. Based on his symptoms, JHS
providers should have, but failed to, recognize that Mr. Iszley was suffering from an
acute illness other than withdrawal. Mr. Iszley should have received intravenous fluids
and been transported to a hospital emergency room on July 18, 2007. Mr. Iszley might
have survived had JHS taken these actions.
This Office transmitted its preliminary findings to DPH along with recommendations for
improvements. We recommended that JHS review the actions of each JHS employee
involved in Mr. Iszley's care, evaluate whether discipline is appropriate, and take steps
to ensure that the mistakes made in Mr. Iszley's care are not repeated. We provided
DPH with an opportunity to respond to our preliminary findings and recommendations.
DPH elected not to respond to our findings, but responded to our recommendations by
describing JHS' ongoing efforts to improve its systems of care.

ALLEGATION
At the request of the deceased's next of kin, this Office investigated whether Lynn Dale
Iszley received adequate medical care while he was in custody at the King County
Correctional Facility.

Peritonitis is an infection of the lining of the inner abdominal wall.
http://www.mayoclinic.com/health/peritonitis/DS00990•. accessed online, March 13, 2008.

1

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 3 of9

INVESTIGATIVE AUTHORITY
The King County Ombudsman's Office was created by the voters of King County in the
County Home Rule Charter of 1968 and operates as an independent office within the
legislative branch of King County government. The Office is authorized.to investigate
the administrative conduct of King County agencies in response to complaints received
from the public, or on its own initiative. 2 The Office promotes public confidence in King
County government by responding to issues in an impartial, efficient and timely manner.

PROCEDURAL HISTORY
This investigation commenced on July 19, 2007, when this Office received a telephone
call from a concerned King County resident regarding an alleged inmate death that
morning at the King County Correctional Facility (KCCF).3 After confirming the death of
inmate Lynn Dale Iszley, and the cause of death, this Office sought and obtained
relevant investigative records from the Seattle Police Department. Following an internal
investigation by the King County Department of Adult & Juvenile Detention (DAJD), this
Office obtained and reviewed the complete, uriredacted DAJD investigative file, which
contains command reviews of the incident, officer reports, deck logs, and other relevant
records.
This Office met with Mr. Iszley's mother, who filed a formal complaint seeking an
evaluation of the medical care her son received at KCCF. Mr. Iszley's mother also
signed a release of information form allowing this Office full access to Mr. Iszley's
medical records from Harborview Medical Center (HMC), Jail Health Services (JHS),
and the King County Medical Examiner's Office. After reviewing all of the above-noted
records, this Office sought expert review of Mr. Iszley's medical records from Dean
Dellinger, M.D., and Lori Kohler, M.D. Their reports are attached to this report as
Appendices Band C, respectively.
King County Code (KCC) section 2.52. In addition, the Ombudsman's Office investigates alleged
violations of the King County Employee Code of Ethics (KCC 3.04) and the Lobbyist Disclosure code
(KCC 1.07), and reports of improper governmental action under the Whistleblower Protection Code (KCC
3.42).
2

3 The telephone call was from the mother of a King County Correctional Facility (KCCF) inmate who said

her son told her another inmate, whom corrections officers had allegedly assaUlted the night before, had
died that morning. This Office relayed these allegations to KCCF staff members, the Seattle Police
Department (SPD), and the King County Medical Examiner's Office. Later on July 19, 2007, this Office
spoke with the pathologist who performed the autopsy on Lynn Dale Iszley. The pathologist stated that
Mr. Iszley had died a natural death and that there is no evidence to support the allegation that Mr. Iszley
had been assaulted. SPD's investigation supports that conclusion. This Office's independent review of
the record in this case, including medical records, inmate witness statements, and corrections officers'
reports, also supports that conclusion.

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 4 of 9

Based on Dr. Dellinger's report, which was completed on February 22, 2008, this Office
transmitted preliminary findings to the director of Public Health-Seattle and King
County (DPH), on March 14, 2008, and requested a response by April 11, 2008. Dr.
Kohler completed her report on March 25, 2008, and this Office transmitted it to DPH
that same day. As Dr. Kohler's findings are substantially consistent with Dr. Dellinger's,
this Office requested that DPH honor the April 11 reply deadline. This Office received
DPH's response to our preliminary findings on April 11, 2008. These final Findings and
Recommendations follow.
Senior Deputy Ombudsman Jon Stier led this Office's investigation into Mr. Iszley's
death, with assistance and oversight from King County Ombudsman Amy Calderwood,
and with assistance from other Ombudsman's Office staff members.

SUMMARY OF KEY FACTS
This Office has produced a chronology of events which is attached to this report as
Appendix A. We provide this summary for the reader's convenience.
Mr. Iszley was arrested on the afternoon of July 15, 2007. Before he was booked, a
JHS employee conducted a medical screening of Mr. Iszley. The screening noted
bleeding on Mr. Iszley's right wrist, and skin sores on his buttocks and legs. Booking
was deferred, and Mr. Iszley was taken to HMC, where he was diagnosed with
abscesses and prescribed Bactrim, an antibiotic. Mr. Iszley was then transported back
to KCCF and booked very early in the morning on July 16, 2007.
Mr. Iszley told JHS staff that he used heroin and alcohol daily. On the evening of July
16, Mr. Iszley appeared to be experiencing opiate withdrawals, and had been vomiting.
JHS staff provided him with medication intended to help stop the vomiting.
A JHS physician evaluated Mr. Iszley on the morning of July 17. Mr. Iszley had open
and scabbed wounds on his right buttock and calf. The physician diagnosed Mr. Iszley
with alcohol and opiate withdrawal, and ordered antibiotics for the open wounds.
In the early morning of July 18, Mr. Iszley pressed the emergency call button in his
housing unit. A corrections officer responded, and found Mr. Iszley curled on his bunk.
Mr. Iszley said, "I think my liver exploded," and reported "kicking alcohol." A corrections
officer made a medical status II call,4 and a JHS staff member soon arrived. Mr. Iszley
complained of abdominal pain "like never before," including pain when lying on his right

A Medical Status II call is appropriate for a "[p]otentiallife-endangering medical problem and/or inmate
unable to be moved". JHS Operating Procedure J-E-08(3).

4

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 5 of9

side. He was sweating and writhing. After examining Mr. Iszley, the responding JHS .
staff member cleared him to remain in his housing unit.
Later on the morning of July 18, a nurse was called to Mr. Iszley's housing unit. The
nurse found Mr. Iszley lying on the floor, sweating, with tremors, and complaining of .
vomiting, nausea, and inability to eat or drink. The nurse notified a JHS physician, who
ordered Mr. Iszley transported to the jail clinic. The physician's notes, entered later that
morning, record that Mr. Iszley's symptoms were increasing, and that Mr. Iszley was
dehydrated. The physician ordered vital signs three times daily, rehydration fluids, and
observation in detox housing within the jail infirmary. Mr. Iszley's records show a low
blood-oxygen saturation rate in the morning and low blood pressure in the afternoon.
His infirmary admission note states that he denied voiding his bladder since the morning
of July 15. He was administered 400mg of Motrin.
.
Mr. Iszley complained of rib pain, chest pain, and pain in general during the night of July
18 and/or early morning of July 19. During medication pass on the early morning of July
19, Mr. Iszley stumbled when he tried to stand. Two other inmates helped him to the
floor. Mr. Iszley did not eat his breakfast.
Shortly after 7:00 a.m. on July 19, a corrections officer attempted to wake Mr. Iszley, but
he did not respond. The officer called a nurse, who also could not wake Mr. Iszley. The
officer made a medical status III cal1. 5 JHS personnel arrived and attempted to revive
Mr. Iszley. Mr. Iszley was declared deceased at 7:50 a.m. An autopsy conducted by
the King County Medical Examiner's Office concluded that Mr. Iszley died of acute
peritonitis due to perforated duodenal ulcer. 6

EXPERT REVIEW

This Office obtained review of Mr. Iszley's medical records from two physicians who
practice and teach outside of the Seattle area. Each possesses experience and
expertise specifically relevant to Mr. Iszley's medical care.
Dean Dellinger, M.D., was certified by the American Board of Internal Medicine in 1995,
and serves as an Assistant Professor of Medicine in the Internal Medicine Division of
Oregon Health and Science University in Portland, Oregon. Lori S. Kohler, M.D., an
expert in correctional health, is Professor of Clinical Family and Community Medicine at
A Medical Status III call is appropriate for a "[c]ritical, life-threatening emergency." JHS Operating
Procedure J-E-:-8(4).

5

6 Mr. Iszley's mother, and a friend of Mr. Iszley's interviewed by this Office, stated that Mr. Iszley knew he
was suffering from an ulcer, and had obtained treatment for it from medical providers. However, Mr.
Iszley's records do not contain any indication that he told corrections staff or jail health staff about the
ulcer.
.

- - _.--_ _-_

__

_-----_ . .

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 6 of9

the University of California, San Francisco, and serves as Director of the Correctional
Medicine Consultation Network. 7
Prior to this case, this Office had no relationship with either Dr. Dellinger or Dr. Kohler,
and neither of them knew that the other was reViewing Mr. Iszley's medical records. Dr.
Dellinger's report is attached to this report as Appendix 8. Dr. Kohler's report is
attached as Appendix C.
Overall, Dr. Dellinger identified the following problems with the care that JHS provided
to Mr. Iszley:
•
•
•
•
•
•
•
•
•

JHS staff initially failed to document that they continued Mr. Iszley's antibiotic
prescribed by HMC.
Monitoring vital signs twice per day was not consistent with hospital practice.
Documentation of patient history was limited.
Abdominal pain and lack of voiding were not specifically noted as negatives or
positives in MD history.
Chart contains no documentation of evening vital signs.
More careful evaluation of hydration status would have been appropriate.
Full orthostatic vital signs were not taken during July 18 medical status II call.
Low oxygen saturation level noted on the morning of July 18, if accurate,
required more urgent evaluation.
Tachycardia (heart rate above 100 beats per minute) such as that experienced
by Mr. Iszley is associated with acute illness as well as dehydration and
withdrawal, but JHS did not transport Mr. Iszley to the emergency room.

Dr. Dellinger stated his opinion that "the patient should have been transferred to the
emergency room by mid afternoon of 7/18/08 (sic)". In this regard, Dr. Dellinger wrote,
In Mr. Iszley's case the severity of the pain and the fact that he localized his
abdominal pain should have raised concerns earlier for another source of his
abdominal pain after his evaluation early 7/18/07. Neither of [the JHS
physician's] evaluations on the 18th listed any alternative causes for the
abdominal pain, such as gastritis, ulcer, pancreatitis-all of which are more likely
in the setting of alcohol abuse.

7 The Correctional Medicine Consultation Network (CMCN) is a program of the Department of Family
and Community Medicine at the University of California, San Francisco, in collaboration with the
California Department of Corrections and Rehabilitation (CDCR). CMCN's mission is to improve the
quality of healthcare, the dignity, and the quality of life of inmates in California prisons, through,
among other things, peer education and professional development for CDCR clinicians, assessment
of care and consultation for high risk patients, and evaluation of medical care delivery systems.
http://www.ucsf.edu/cmcn/index.html. accessed online, April?, 2008.

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 7 of 9

Regarding Mr. Iszley's apparent worsening dehydration on the morning of July 18, Dr.
8
Dellinger noted that Mr. Iszley's records reflect thatfull orthostatic vital signs were not
taken during the medical status II call. This was not consistent with the relevant
standard of care, according to Dr. Dellinger. He further stated that Mr. Iszley's report of
not voiding his bladder for three days,
would suggest severe dehydration and possible renal failure. These signs of
dehydration, and especially the lack of voiding in the face of 2 days of
antiemetics[9] should have warranted-at the least-IV hydration and closer
monitoring.... [Mr. Iszley's] low BPs and persistent tachycardia[101 are
concerning for worsening dehydration and other more acute illness.... the
standard of care would have been starting IV fluids at gam or at the latest 1pmand had vital signs repeated every 2-3 hours.
While Dr. Dellinger could not identify the exact time when Mr. Iszley's ulcer perforated,
h
"the most likely time would have been early on the morning of the 1i [when he]
complained of the most severe abdominal pain." Dr. Dellinger concluded that while Mr.
Iszley's substance abuse history would have reduced his chance of survival, "Mr.
Iszley's chance of survival would have been significantly improved if he had been
diagnosed with perforation within 12..24 hours of the event" and Mr. Iszley "likely would
have benefited" from transfer to a hospital emergency room on July 18.
Dr. Kohler's findings are consistent with those of Dr. Dellinger. Dr. Kohler wrote,
It is obvious from reading the records that his [Mr. Iszley's] was not a case of the
usual withdrawal syndromes from etoh [alcohol] and heroin.... This patient had
an 'acute abdomen' and should have been transferred to an emergency room
where prompt surgical evaluation most likely would have saved his life. JHS did
not respond appropriately to multiple signs and symptoms that should have
prompted immediate transfer to a higher level of care.
Dr. Kohler's report specifically criticized JHS for keeping incomplete patient records,
failing to perform various tests indicated by Mr. Iszley's symptoms, and failing to take
appropriate action based on the information JHS had.

Orthostatic vital signs are "serial measurements of blood pressure and pulse taken with the patient in
supine, sitting, and standing positions .... n http://enw.org/Research-Orthostatic.htm, accessed online,
March 12, 2008.
8

9Antiemetics are drugs that prevent vomiting. http://www.britannica.com/eb/topic-27951/antiemetic.
accessed online, March 13, 2008.
10 Tachycardia is a heart rate above 100 beats per minute.
http://www.mayoclinic.com/health/tachycardia/DS00929. accessed online, March 13,2008.

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 8 of9

OMBUDSMAN FINDINGS
This office makes findings based on a preponderance of the evidence standard of proof.
A preponderance of the evidence means we are persuaded, considering all the
available evidence, that the facts at issue are more likely true than not true.
While corrections officers appear to have responded promptly and appropriately to Mr.
Iszley's medical condition, based on our review of the complete DAJD investigative file,
Mr. Iszley's medical and autopsy records, and the analyses provided by Drs. Dellinger
and Kohler, this Office finds that JHS failed to provide Mr. Iszley with the medical care
he needed while he was in custody at KCCF. Mr. Iszley was observed suffering from
severe localized abdominal pain and other intense symptoms on the morning of July 18,
2007, and yet he was initially cleared to remain in his general population housing unit.
He was later transferred to the infirmary, but the anti-vomiting medications and attempts
at oral hydration were not working. Moreover, Mr. Iszley's vital signs, including
persistent tachycardia, and his overall deteriorating condition, indicated the possibility of
acute illness. JHS should have transferred Mr. Iszleyto the emergency room on July
18. JHS's failure to do so may have contributed to Mr. Iszley's death.
We note that symptoms of perforated ulcer and peritonitis may overlap with those of
opiate and alcohol withdrawal, thereby complicating diagnosis in cases such as Mr.
Iszley's. Lay observers might initially assume that withdrawal symptoms would fully
mask the symptoms of acute illness present here. However, as Dr. Dellinger's and Dr.
Kohler's reviews establish, professionally-trained medical providers should have
recognized and acted on Mr. Iszley's symptoms that indicated the presence of illness.
more acute than withdrawal.

RECOMMENDATIONS AND CONCLUSION
While this Office's investigation focused on determining the appropriateness of the
medical care that JHS provided to Mr. Iszley, in our preliminary report to DPH we also
recommended that in response to Mr. Iszley's death, JHS should review the actions of
each JHS employee involved with Mr. Iszley's care, and evaluate whether to discipline
employees found to have violated relevant medical standards of care, or those who
otherwise deviated from applicable protocols.
We also recommended that JHS undertake a comprehensive review of how it responds
to inmates in severe pain, how it determines whether to transport patients to the
emergency room, and how it evaluates patients for acute illness when those patients
suffer from complicating symptoms such as those associated with alcohol and heroin
withdrawal. We further recommended that JHS assess its basic care protocols, such as
documentation of continued dosing of medicines prescribed by HMC providers, and the
number of times per day vital signs are checked. Finally, we recommended that JHS

King County Ombudsman's Office
Findings & Recommendations
Ombudsman Case No. 2007-01436
April 15, 2008
Page 9 of9

further assess its quality improvement program to ensure adequate continuity of care
and that apparent lapses in care are detected before, rather than merely after,
catastrophic results.
While DPH's response does not address the specifics of Mr. Iszley's case or this
Office's findings, DPH did discuss its ongoing efforts to improve JHS systems of care.
(See Appendix D to this report.) It is unclear from DPH's response whether all of the
stated improvements were initiated following Mr. Iszley's death. However, Mr. Iszley's
death may have been preventable, and this Office therefore urges JHS to ensure that its
review of this case is complete and, where necessary, to fully institute reforms that will
ensure that future patients receive the medical care they need while in King County
custody. We look forward to learning more about DPH's efforts to improve in the future.

Ombudsman Case No. 2007-01436

APPENDIX A

King County Ombudsman's Office
Ombudsman Case No. 2007-01436

King County
APPENDIX A

CHRONOLOGY

DATEITIME
EVENT
7/19/07
Autopsy commenced. Cause of death: acute peritonitis
11:00 am
due to perforated duodenal ulcer. Manner of death
classified as natural.

SOURCE/NOTES
King County Medical Examiner
Autopsy Report, signed 9/10/07
by Associate Medical Examiner;
Certificate of Death

JHS personnel conduct debriefing in medication room.

Memorandum from Sgt. 1
(SIUlCIU) to KCCF Commander,
dated August 22, 2007

Iszley pronounced deceased.

Jail Incident Report, dated
7/19/07, by Officer G. Vigil;
Memorandum from Sgt. 1
(SIU/CIU) to KCCF Commander,
dated August 22,2007.

7/19/07
7:46am

Life saving measures stopped per direction .of Medic
One personnel.

Jail Incident Report, dated
7/19/07, by Officer 2;
Memorandum from Sgt. 1
(SIUlCIU) to KCCF Commander,
dated August 22,2007.

7/19/07
7:37 am

SFD/Medic One personnel on scene. CPR continues.

Jail Incident Report, dated
7/19/07, by Officer 2;
Memorandum from Sgt. 1
(SIU/CIU) to KCCF Commander,
dated August 22,2007.

7/19/07
7:347:47 am

Other inmates from Iszley infirmary tank interviewed by
DAJD: Inmate 1 said Iszley began to fall during
breakfast med pass, & Inmate 1 caught Iszley & helped
him to the floor; Inmate 2 said he helped lower Iszley to
his mattresS & that Iszley had been complaining of rib
pain; Inmate 3 said Iszley could not get up and had
been complaining of chest pain and pain in general;
Inmate 4 said Iszley was not eating.

Memorandum from Sgt. 1
(SIU/CIU) to KCCF Commander,
dated August 22, 2007.

7/19/07
7:27 am

JHS doctors and nurses arrive on scene and assist
CPR. Other inmates relocated.

Jail Incident Report, dated
7/19/07, by Officer 2;
Memorandum from Sgt. 1
(SIUlCIU) to KCCF Commander,
dated August 22, 2007.

7/19/07
8:00 am

7/19/07
7:50 am

.

King County Ombudsman'S Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 2 of 8

7/19/07
7:05-7:26
am

Iszley not responding when name called for detox
treatment. Officer attempts to wake Iszley without
success. Officer requests assistance of nurse as it
appears Iszley not breathing. Nurse responds·
immediately. Officer calls medical status 3.

"On 7/19/071 (C/O [2]) was assigned to work the
Infirmary 1 position. At 0630 I entered J Dorm to
perform the initial headcount and security check. All
inmates were alive and accounted for at this time. I
conducted the next security check at 0700 and again all
inmates were alive and accounted for. At 0705, RN
Flor asked for the detoxers to come out for their
treatments. At 0706, I entered J Dorm again to bring
out some of the detoxers. At this time, five came out to
see the nurse. The next group would come out when
the first five were finished. At 0724, I entered J dorm to
bring out the last five detoxers. 11M Iszley, Lynn BA
207030519 was not responding when I called his name.
As I approached him, he was on his mattress laying on
his right side uncovered by his blanket. I then went to
shake him to see if I could get him to wake up and he
was still uncooperative. I looked at his chest and I
could not tell if he was breathing or not. I exited the
tank and asked RN [Nurse 1] to come check him out.
We entered the tank and RN [Nurse 1] tried to awaken
him but was also unsuccessful. At 0726 I called Central
Control via radio and requested a Medical Status 3.... n

Memorandum from Sgt. 1
(SIU/CIU) to KCCF Commander,
dated August 22, 2007; Deck
Log, 7/19/07. NOTE: "Nurse [1]
and Provider [] on deck."
Jail Incident Report, dated
7/19/07, by Officer 2

7/19/07
5:15 am

Breakfast served in infirmary. Iszley does not eat.

Memorandum from Sgt. 1
(SIUlCIU) to KCCF Commander,
dated August 22,2007.

7/19/07
5:00-5:15
am

During morning medication pass, Izsley attempts to
stand but stumbles. Two inmates catch & assist Izsley
to the floor, where his mattress is. Iszley previously
complaining of rib pain according to inmate witness.
Inmate said Iszley could not get up and had been
complaining ofchest pain and pain in general. Inmate
said Iszley was not eating.

Memorandum from Sgt. 1
(SIUlCIU) to KCCF Commander,
dated August 22, 2007.

7/18/07 7/19/07
night

"... none of the subjects [inmates] reported any
disturbances or other problems in the cell during the
night. There was mention that Mr. Iszley had
complained about 'not feeling well"'.

SPD Follow-Up Report, dated
7/25/07, by SPD Homicide Sgt.

"On Wednesday night, July 18, 2007, I was assigned to
the Infirmary. I do remember inmate Iszley, Lynn - SA
207030519 as being housed in J Dorm. He came to
the door of J Dorm as required during medication pass
to receive his medication. He was given a shot by the
medication nurse. Throughout the night as I was doing
my security checks he was awake and asked me

Officers Report, dated 7/24/07,
by Officer 3; Infirmary
Security/Surveillance Log, dated
7/19/07

King County Ombudsman's Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 3 of8
7/18/07 7/19/07
night
(continued)

questions. He said I looked familiar and what high
school did I go to. He asked if there was a temporary
release for him in the computer, everytime I got to J
Dorm he would ask me a question. During the morning
medication pass he got up to ask for medication, he
stumbled and was helped back to his bunk. The
medical nurse alerted the R.N. who at that time went to
J-Dorm and checked to see if he was alright. I gave
him a breakfast tray at his bed and he looked up at me
and said thank you. The last I saw of inmate Iszley was
at my last security check at 0600hrs."

7/18/07
3:35 pm

Diagnosis/Problem: Polysub abuse, dehyd
P[ulse?] 126/142
BP 103/80 102179
Temp 98'
AlO c/o n/v/d ped IL 0 trembling

Multiple Treatment Form Infirmary, signed by [?] 2547E .

7/18/07
2:12 pm

Started meds: Motrin 400 mg tabs: 1 tab oral(po) QID,
KOP T.O. [JHS physician]

Infirmary Admission Note 7/18/07
13:16

7/18/07
1:16 pm

BP 81/63 (standing) 99/69 (sitting)
Pulse 135 (standing) 135 (sitting)
Temp 97.8 (oral)
Appearance: "brought from med. Status II 9th floor,
weak, shaky, demanding, with several clo's, sitting on
the floor clo back pain."
Heart: tachycardic
Abdomen: cramping, tender on palpation
Back: Most LBP with inc tenderness to light palpation
Genitourinary: denies voiding since sund. 07/15/07 on
AM

Infirmary Admission Note 7118/07
13:16

7/18/07
10:03 am

"Dehydration first observed"

Infirmary Admission Note 7/18/07
13:16, signed by [Nurse 1], RN

7/18/07
9:50-9:55
am

Iszley transferred to Infirmary Housing Unit "Detox" tank· DAJD Deck Log for 7/18/07;
Memorandum from Sg1. 1
(SIUlCIU) to KCCF Commander,
dated August 22, 2007.

7/18/07
9:44 am

BP 133169 (supine) 105/69 (sitting)
Pulse 95 (supine) 86 (sitting)
Temp 95.8 (L ear)
S0286%
Medicatons:
Pepto-Bismol262 mg, 2 tabs oral(po) QID OTC as
need
Phenergan 25 mg, 2 tabs oral(po) TID SD only
Promethazine HCL 25mg/ml, intra-muse
Septra DS 800-160mg, 1 tab oral(po) BID
Sl;Ibjeetive: "severe cramping, aching, dizziness and
weakness, continued NNID wlo relief with meds since
yesterday. "
Obiective: Pale, weak, in WIC, writhing. Abdomen soft,

Medical Provider Progress Note
7/18/079:44 am, signed by JHS
physician.
Meds ordered by [Nurse 2],
ARNP.

King County Ombudsman's Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 4 of8

7/18/07
9:44 am
(continued)

diffuse tenderness, ? active BS. Neurologic: + - tremor.
Skin: cool, sticky, no change from 7/17/07.
Assessment and Plan: Opiate WID - Increased Sxs
without relief, now dehydrated. Will move to 7W Obs
for [incr.] management. rio EtOH WID - Doubt
dominate contributor to current presentation and last
drink 4 days ago per pt.
Procedures ordered: Rehydration fluid Q shift:
dehydration
Procedures ordered: EM - 99213 - EST -15 minutesEPF, EPF, L: rule out opiate withdrawal, dehydration,
alcohol withdrawal, etoh, detox, TRANSFER TO 7W
NON-INFIRMARY STATUS: Dehydration VITAL SIGNS
- BID X3 Days: Dehydration, rule out opiate withdrawal

7/18/07
9:10 am

BP 110190 (sitting)
Pulse 108 (sitting)
Temp 96.7 (L ear)
Resp 18/min

Nursing Progress Note, 7/18/07
9: 10 am, signed by [Nurse 3], RN

7118/07
8:50 am

Triage [Nurse 3] "called to pts cell, to find pt laying on
the floor and extremely diaphoretic and tremulous Was
not able to sit up without assistance, pt clo not being
able to drink or eat, and emisis and nausea Vs at this
time were taken, and med notified Dr. [JHS physician],
gave vo; TO BRING PT VIA WHEEL CHAIR TO BE
SEEN NOW IN CLINIC, pt was transferred by officer
and RN 571 WAS FILLED OUT"

Medical Provider Progress Note
7/18/07 9:44 am.
Nursing Progress Note, 7/18/07
9:10 am, signed by [Nurse 3], RN

"On 7/18/07, I was assigned as the second Triage
Officer conducting my duties on the ninth floor, when
C.O. 4, who was assigned to South 9, requested the
triage team presence, to please come to his wing and
see a very sick Inmate, who was named Iszley. The
assigned ninth floor nurse was [Nurse 3] and she took
Inmate Iszley vitals, did a medical assessment, called
the clinic and talked to the medical provider. [Nurse 3]
then requested me to go, retrieve a wheelchair and
transport this Inmate to the clinic per Dr. [JHS
physician]. I complied, the nurse and myself escorted
Inmate Iszley to the clinic, where he was admitted into
the infirmary for medical observation on that day."

7/18/07
6:28 am

BP 120180 (supine)
Pulse 60
Resp 18/min
S: Seen on Med Stat II. clo abdominal pain "like never
before." Admits withdrawing from heroin. Hurts to lie on
Rside.
0: 11M sweating, doubled over lying in bed. Abdomen
soft, nondistended. RLQ tenderness and RCVA
tenderness. See vs. Pupils 4-5 mm. Receiving meds for
heroin wid and abx.
A: Abdominal pain probably due to heroin wid
P: report to day shift RN to follow-up in triage.

Officer Report, dated 7/19/07, by
Officer 5

Nursing Progress Note, signed
by [Nurse 4], RN

King County Ombudsman's Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 5 of 8
"Inmate Iszley, Lynn (B/A# 207030519) pushed the
Lower-D dayroom button. I looked down to see him
curled up on his bunk by the door. I asked him what
was wrong. He moaned and said 'I think my liver
exploded.' I called floor control with that information
and a medical status II was called at 0440 hours.
Officers [7] and [8] arrived immediately, followed by
Sergeant [3] and Officers [9] and [10]. Nurse Cynthia
arrived at 0443 hours. Inmate Iszley was evaluated
and cleared to stay in Lower-D. The medical status II
was cleared at 0448 hours. n

DAJD Deck Log for 7/18/07,9
South.

"... I found 11M Iszley laying on his bunk writhing in
pain and moaning loudly. I asked him what was
happening and his (sic) said it 'felt like his liver
exploded' (sic) and wanted to go to the hospital. When
JHS arrived, they examined him and took vital signs.
All tests were within acceptable ranges. JHS [Nurse 9]
said he remembered 11M Iszley from ITR and said he
was withdrawing from heroin and alcohol. The inmate
confirmed that he was still 'kicking alcohol', but that he
was over his heroin withdrawal. JHS determined to
refer 11M Iszley to the clinic for further testing but
allowed him to remain in his current housing. The code
was cleared at 0449 hours."

DAJD Supervisors Incident
Report, 7/18/07, by Sgt. 2.

·0442....Medical Status 2, 9 South LD. 11M Iszley, Lynn
(07-30519) says he felt like his "liver exploded". 11M
Iszley is kicking alcohol and heroin. JHS examined 11M
Iszley and cleared him to remain in his current location.
.
IT# 07-1093. SgI. [2]."

DAJD Roster Notes for 7/17/07

"... When I asked what was wrong he was moaning
and said "I think my liver exploded." ... At 0442 hours
Sergeant [3] arrived along with Officers [9], [10] and
[Nurse 10] and [Nurse 9]. [Nurse 4] arrived at 0443 .
hours. Inmate Iszley was evaluated and cleared to
remain in lower-d."

Jail Incident Report, dated
7/18/07, by Officer 6

7/17/07
1:30- 4:00
pm

Izsley in court re criminal charges.

Memorandum from SgI. 1
(SIUlCIU) to KCCF Commander,
dated August 22,2007.

7/17/07
10:57 am

BP 128/70 (sitting)
Pulse 72
Temp 98 (oral)
Resp 16/min
Meds: Phenergan 25 mg, 2 tabs oral(po) TID single dos
Promethazine HCL 25mg intramusc as dir
SUBJECTIVE:Chief Complaint: 47 year-old male with
complaint of abscesses, NNID 2' heroin wId. History: R
buttock, B calves abscesses x 1 mo, not in shooting
sites per pI. Also 3 gmld IVDU, last hit - yesterday.
States drinking 1 qtld vodka until yesterday. Active
problems: open wounds on R buttock, Bilat Les. Heroin

Medical Provider Progress Note,
7/17/0710:57 am, signed by
[JHS physician], MD

7/18/07
4:39 -4:49
am

King County Ombudsman's Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 6 of 8

7/17/07
10:57 am
(continued)

7/17/07
10:25 am

7/17/07
8:45 am

7/17/07
8:00 am

wid.
OBJECTIVE: appearance WDIWN, in NAD. Alert,
aware, cooperative, irritable. Nose + sniffles. Lungs
clear. Abdomen soft, uncomfortable, Active BS.
Musculoskeletal FROM; wlo CCE, pulses equal. Skin:
Open, moist, tender, mildly flared wound along dimpled
and distorted scar R buttock, with thick brown D/C.
Small open, moist wounds Bilat posterolateral upper
calves, with crusting but no active D/C. Healed? wound
L posterolateral calf. Closed, scabbed, small linear
wound R upper lateral calf.
ASSESSMENT & PLAN: Opiate wid - with symptoms.
Will [incL] management. RIO EtOH wid - no obvious
acute findings, has VIS checks ordered. R buttock
wound - With ?purulent DIC noted, minimal flare,
located in old scarring. OK empiric Rx awaiting ROI
review. B cald wounds - Healing wlo complication.
Procedures ordered: EM - 99213 - EST -15 minutesEPF, EPF, L: alcohol withdrawal, etoh, detox, rule out
opiate withdrawal, wound open buttock.
Started meds: Septra OS 800-160mg, 1 tabs oral(po)
BID; Pepto Bismol262 mg tabs, 2 tabs oral(po) OlD
OTC
Wounds redressed. Continue current management plan
BP 128170
Pulse 72
Temp 98 (oral)
Resp 16/min
<eds: Phenergan 25 mg; Promethazine HCL 25 mg
S: States, "I am in withdrawals from heroin and I have.
nausea and I can't keep anything down. n Requesting
above previous meds-states they helped a tot.
0: Slight hand tremors bilat hands, VSS. Given nutria
boost packet
A: Poss heroin withdrawal
P: Ref to provider for new orders. VS BID to continue x3
days. Advised to report or re-kite if sIs worsen.
Instruction given for increasing fluids, slowly.

Nurse Note: Triage, signed by
[Nurse 5], RN.

BP 128170 .
Pulse 72
T98
R 16

Medical Kite - JHS response by
[Nurse 5], RN

Pt complained of "withdrawals - still can't keep water
down"

Medical Kite submitted by pt

King County Ombudsman's Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 7 of 8

7/17/07
12:58 am

BP 110/72 (sitting)
Pulse 86 (sitting)
Resp 18/min
Meds: Phenergan 25 mg, 2 tabs oral(po) TID single d.
Promethazine HCl 25 mg intra-musc as directed, vo
from [Nurse 6], ARNP
S: at 12:15 am, 7/17, inmate clo vomiting, saying he is
detoxing.
0: vis 142nO, p81. dry heaves. alox3
A: Heroin withdrawal, not ETOH wid.
P: instructed to KITE in AM. Increase fluids.

Nursing Progress Note, signed
by [Nurse 7], RN

7/16/07
9:27 pm

BP 110172 (sitting)
Pulse 86 (sitting)
Resp 18
S: Seen in treatment room. 1M reports "kicking heroin"
vomiting all day
0: VS - see above. 1M actively vomiting.
A: Opiate WD
P: VO from [Nurse 6], ARNP for Phenergan 25 mg 1M
x1 then 50 mg PO x 3 days.
Started Meds: Phenergan 25 nig tabs 2 tabs oral(po)
TID single dose
Promethazine HCL 25 mg intra-musc as directed x 1Sd
now

Nursing Treatment Sheet, signed
by [Nurse 8], RN

7/16/07
5:26 am

BP 121183
Pulse 74
Temp 96.4 (l ear)
Resp 16
S0299%
Initial observation: bleeding, injury, sores, observable
pain.
Medical History: Skin sores or infection-mult abscesses;
hepatitis.
Substance abuse: daily alcohol, seizures, hallucinations
when stops drinking or using; currently using; daily drug
use: heroin 3 grms qd, last used 12-14 hours.
Prescrip meds: Soma.
ETOH Eval: Vodka 32-48 oz qd, time since last drink:
12-14 hrs; history of wldrawal symptoms: seizures,
shakes.
Cooperative, alert.
Housing Recommendation: Gen Pop

JHS Receiving Screening Form,
signed by [Nurse 9], RN

7/16/07
4:56-5:05
am

Iszley moved to receiving area (S09LD) of jail

Memorandum from Sgt. 1
(SIUlCIU) to KCCF Commander,
dated August 22, 2007.

7116/07
12:25 am

Booked at King County Jail (VUCSA, Disord Cond,
Obstructing)

JILS printout 7/20107

King County Ombudsman's Office
Ombudsman Case No. 2007-01436
Appendix A: Chronology
Page 8 of 8

Transported by: SPD
BP 109/67
Pulse 78
Resp 16
History & Findings: multiple abcesses + chills/sweats. 0
NN.+D.
Diagnosis: Abscesses
Discharge Meds: Bactrim

HarboNiew Medical CenterEmergency Notes

Cleansed abscesses, referred to HarboNiew for eva!.

DAJD Arrestee Medical
Clearance Report

Izsley declined at jail: Bleeding R wrist, diabetes, skin
sores, seizures, daily alcohol, heroin today.

DAJD Deferral Screening,

7/15/07
unknown

EMTcontact
Meds: Bactrim
S: 47 yr old male call to SPD north to cut of handcuff.
0: Pt states he has MRSA. Ulcers on rt buttocks both
legs. Pt states he has drug resistant MRSA, not
compliant wi meds or medicare
A: Pt needs no further med assist. No exam.
P: Leave wi SPD to trans to jail.

Seattle Fire Department Medical
Incident Report, signed by SFD
ID# 1240

7/15/07
3:05 pm

Iszley arrested next to Cowen Park in Seattle.

DAJD Superform

7/15/07

7:00 pm7/16/07
12:00 am

7/15/07

6:30 pm
7/15/07

5:44 pm

Ombudsman Case No. 2007-01436

APPENDIX B

APPENDIXB
Review of Medical Records in Ombudsman Case No. 2007-01436
Completed 2/22/08
Dear Mr. Stier,
I have reviewed the records you have sent me regarding the death of King County inmate
Lynn Dale Iszley. These records included your offices data review and summary, the
Harborview ED records, and the Jail Health Services records including RN and MD
progress notes, vital signs and med administration records. I also reviewed the autopsy
report. I have done a narrative summary of the records, followed by a summary. If you
have any questions about my, review please contact me.
Sincerely,
1'h- J2z- -iZe.. tU .......
Dean Dellinger, MD
Assistant Professor of Medicine
OHSU
Portland, OR

Narrative Review:

Mr. Iszley was admitted to Jail Health Services after an eval in the Harborview
ER for small lower extremity and buttock abscesses on 7/15/07. There he appears to
have been appropriately treated and started on TMP/SMZ, a good antibiotic choiCe for a
patient at risk for MRSA.
The jail staff didn't document that they continued this antibiotic, intially.
Otherwise, his initial evaluation by jail staff the morning of 7116/07 was reasonable. His
vital signs were stable. He reported past ETOH withdraWal associated seizures. His self
reported last use ofETOH and heroin were noted as 12-14 hours prior to admission. His
ER blood alcohol level of .13 was consistent with this.. Need for wound dressing
changes and vital signs BID were noted. He was reevaluated by RN at 21 :26
complaining of vomiting all day. Vital signs were stable and antiemetic given.
On 7117/07 he was reevaluated by RN at lam. Vital signs were stable. He was
still complaining of vomiting, dry heaving in office. Told to increase fluids. RN and Dr.
_eval at 10:2Sam - vital signs stable. Patient cOmplaining of nausea and stated
.•
antiemetic was helping but stated "I can't keep anything down".
Tremors and sniffling were noted, typical withdrawal symptoms. Patient was
showing signs of opiate withdrawal more than ETOH withdrawal, but his history of
ETOH withdrawal seizure would suggest potential formore serious ETOH withdrawal.
In the hospital we monitor patients in ETOH withdrawal with more frequent vitals than
twice daily, and monitoring tools that include other symptoms of withdrawal are
available and may be usedfor both types of withdrawal.

Dr. •examined wounds and restarted the antibiotic recommended by ER
7/15/07. Patient history documented waS limited. Abdominal pain and lack of voiding
were not specifically noted as negatives or positives in MD hx. Abdominal exam was
"uncomfortable" but active bowel sounds and lack of rigidity reassuring. Twice daily
vital signs continued but I couldn't find documentation. ofevening vitals. More careful
evaluation of hydration status would have bee~ appropriate, such as documenting fluid
intake, voiding, and physical findings such as looking at oral mucosa and performing .
orthostatics to assess for dehydration. If patient was showing signs of dehydration he
should have been observed more closely and IV fluid hydration considered if unable to
adequate hydrate orally.
.
was called to
Next patient contact RN eval 7/18/08 4:43am when
patient's cell by corrections officer to assess abdominal pain. (The deck log states 5
officers saw the patient and a medical status II was called and that the RN saw patient
briefly and cleared to stay in cell. RN note entered 6:28am but deck log states RN
arrived at 4:43am. Patient described pain "like never before" and worse with lying on
right side. Patient was lying in bed doubled over and diaphoretic. Blood pressure and
heart rate were taken supine and sitting, but not standing so not full orthostatics. Patient
was afebrile. RN exam noted abdomen soft, but with RLQ and ReVA tenderness.
Assessment was abdominal pain due to heroin withdrawal. Plan was for patient to
follow up in triage ~rt to day shift RN.
.
. Triage R N , . . - was then called by corrections officer to patient's cell at
8:50am to assess patient for severe abdominal pain. Patient found"lying on floor of cell,
diaphoretic and unable to sit up without assistance. Vital signs were repeated supine
and sitting and HR(heart rate) 108 sitting vs. 60 supine. BP(blood pressure) dropped
from 120 to I 10 with sitting. MD was notified and he gave verbal order for patient to be
taken by w . "air to infirmary immediately.
"
.
"
. evaluated patient at 9:44am. Repeat vitals were 105/69 HR 86 sitting
"
Dr.
~d 133/69HR ~5 supine. Oxygen saturation_owt 86%, no~al resl?ir~ti~? r~port~d..
HIstOry was copIed from RN assessment. Dr.
noted patient "wnthmg WIth dIffuse
abdominal tenderness and "?active bowel soun s. Assessment was opiate withdrawal.
The oxygen saturation of 86% is concerning but it was commented on in the note. If this
9)Cyg~n saturation was"accurate, it would be evidence of severe illness, and would require
uigentevaluation. (It issomewhat puzzling; b/cthe next two readings taken 4 and 6
hours after were both normal.)
"
." ""
D r . _ reevaluated patient at 1:16pm and noted c/o ofabdominal pain, n/v x2,
days, diarr~eling "very dehydrated". Also c/o of "mid and low back pain 10/10
" secondary to slip on wet floor." MD noted "denies voiding since Sunday 7/15/07 am".
Sitting BP 99169 HR 135, standing 81/63 HR 135. Oxygen saturation 100%. On exam
noted abdominal tenderness and low backtendemess: Assessment was polysubstance
"withdrawals. Twice daily vitals were continued "and antiemetics arid presumably oral
rehydratoin. Ibuprofen for pain.
"
Medical record ends with vital signs at 3:35pm: oxygen saturation 97%, sitting
BP 103/80 HR 126, standing BP 103/80 HR 142. Patient HR was high and increased
with standing. Both are concerning findings. HR> 100 is tachycardia and associated
.with dehydration and acute illness as well as withdrawal. HR increases> I0-20 and/or
BF drops of 10-20 suggest orthostasis - consistent with dehydration.

RN,.

Corrections 'officers' notes report patient was asking questions and was able to
stand for llledication pass and that he was given a shot by RN. In the morning at 5am he
stumbled dj..lring med pass and was helped back to bunk. RN was alerted and reportedly
checked on patient. Patient was reporting pain to fellow irunates. CO reported last
~eeing patient at 6am. Next CO reported on his security checks at 6:30am and 7:00am.all
irunates were "alive and accounted for". At 7:24am patient, Iszley, did not respond to
name call and was found unresponsive on exam. Medical team called and unsuccessful
resuscitation attempts beguIL
Summary:
Medical treatment ofpatients in opiate (and etoh) withdrawal is complicated by
the symptoms and signs of withdrawal which include elevated I-{R, abdominal pain,
diaphoresis,· nausea/vomiting, diarrhea, shakiness, and mental status changes.
Nonetheless, in Mr. Iszley's case the severity of the pain and the fact that he localized his
abdominal pain should have raised concerns earlier for another source of his abdominal
~ain after his eVal~ationearly 7/18/07. N:ither ~fDr. •' ev~l~ations on the 18~ .
lIsted any alternative causes for the abdommal pam, such as gastntIs, ulcer, pancreatItIs all of which are more likely in the setting of alcohol abuse. .
The other concerning issue was the patient's apparent worsening dehydration
despite antiemetics and oral rehydration. He was orthostatic the morning of 7/18 with a
>40 point increase In HR vdth sitting: Though the HR didn't rise when these were
.repeated at 9am, the blood pressure dropped almost 30 pOInts - again suggestive of
dehydration. Some argue the reliability of orthostatic vital signs in the assessment of
fluid status, but they are still the standard of care. The patient also reported not voiding
in 3 days would suggest severe dehydration and possible r-enal failure. These signs of
dehydration, and especially the lack of v~iding in the face of2 days of antiemetics should
have warrante~ -:- at theleast - IV hydration and closer monitoring.
~

'.
.

,

Repeated vital signs at 1 pm showed tachy:c~dia to 135 and hypotension with.
BP<IOO sitting. At 3pm the HR was 126 sitting aindi42 standing with BPs just over
100. These low BPs and persistent tachycardia are concerning for worsening dehydration
or other more acute illness. If related to heroin withdrawal this tachycardia should have .
appeared earlieiprobably after 24hours from last use, not at >72 hours, and neither heroin
or eroh withdrawal present with hypotension unless -the patient is dehydrated or otherwise
ill. With his vital ~igns and his report of not voiding >48hours, the standard olcare
would have beenstWting IV fluids at 9am or at the latest 1pm - and had vital signs
repeated every 2-3 hours.
Based on the character of his abdominal pain, the issue of dehydration, and .
. persistent ta~hycardia. it is my opinion that the patient should have been transferred to the
emergency room by mid afternoon of 7/18/08. The jail infirmary could have started IV
fluids and monitored him more closely at 1pm, and iihe didn'1 improve significantly
within a few hours they could have transferred him to the ER. It is likely that he would
have benefitted from a transf~r during the afterno~m of the the 18 th •

I read a historical review ofperforated peptic ulcers in a surgicaljournal from
2000. They reported a range of 5-18% mortality for patients under the age of 50. Nonlethal complications ranged from 10% to just oVer 40% for wound infections, other
intraabdominal and extra-abdominal complications. Morbidity and mortality increased
with time after perforation, particularly at >12 hours. At >24 hours mortality increased
7-8 fold and complication rate 3 fold: I would estimate >=50% chance ofsurvival ifhe
had been evaluated in the ER within 12-24 hours of the event.
.

One confounding factoris Mr. Iszley's substance abuse history. Substance abuse
and withdrawal alter vital signs increasing heart rate and increasing blood pressure, and
alcohol withdrawal increases morbidity and in some cases mortality of comorbid
conditions. The confusion associated with withdrawal also makes it more difficult to
evaluate patient's medically. Mr. Iszley reported alcohol and heroin abuse, but his
autopsy toxin screen also showed benzodiazepines and cocaine as well. If anything, his
substance abuse history would reduce hisch?Ilce of survivaL Nonetheless, Mr. Iszley's
chance of survival would have been sigilificantly improved, ifhe had been diagnosed with
perforation within 12-24 hours ofthe event.

.
I don't think it is possible to know when Mr. Iszlt~y's perforation occurred, but the
.most likely time would have been early on the morning of the 17th • This is when he
complained of the most severe abdominal pain, and soon after complained of severe back
pain which is associated with perforated ulcers and in SQme cases peritonitis inflammation Qf the abdominal lining. The autopsy report detailed a anterior ulcer With
perforation, though posterior ulcers are more likely associated with back pain. The
2500ml of feculent material was probably not present when the staff at the jail examined.
his abdomen the morning and early afternoon of 7/18/07. That would have been
associated with a likely rigid, distended abdomen and other signs of peritonitis. It most
likely leaked out over a period of some hours, dUring the early hours of 7/19 and some
after Mr. Iszley expired.

Ombudsman Case No. 2007-01436

APPENDIX C

APPENDIXC

Stier, Jon
From:

Kohler, Lori [LKohler@fcm.ucsf.edu]

Sent:

Monday, March 24, 200811:21 PM

To:

Stier, Jon

Subject: RE: Reviewof Deceased Inmate Moo Recs
Hello- my general impressions are not good. There are a number of issues, not the least of which is the charting
and the missing data. It is obvious from reading the records that his was not a case of the. usual withdrawal
syndromes from etoh and heroin. This patient was in extreme pain and he was repeatedly. ignored. I see no
record of an exam by a physician, no repeat labs-a total bilirubin of 6.5 needs to be addressed, especially in the
case of severe abdominal pain- there was no assessment for a GI bleed-no questions, no reytal or stool guaiac .
test, no cbc, there are multiple notes that indicate this patient was suffering from extreme pain, multiple abnormal
vital signs were ignored, there is a question on 7/18 of whether bowel sounds are present- this'should have·
.triggered further work up. On the same note, the postural vital signs indicate orthostatic hypotension that was
ignored, skin was noted to be cool-all ofthese sign's suggest a potentially serious and grave condition but the
plan was to move t07W for observation and hydration and give Imodium. Upon admission to the infirmary the
patient was given ibuprofen- itlthe setting of severe abdominal pain this is clearly inappropriate. .
This patient had an 'acute abdomen' and should have been transferred to an emergency room where prompt
surgical evaluation most likely would have saved his life. JHS did not respond appropriately to multiple signs and
symptoms that should have prompted immediate ·transfer to a higher leve.1 of care. the treatments giv.en were
meant to stop his diarrhea but given that he had feculent material in his peritoneum, he must have suffered from a
rupture of his gut and the use of Imodium and Pepto-Bismol may have exacerbated his condition.
From an outside observer perspective is appears to me that they let this man suffer and did nothing. It is unlikely
that they would tolerate this kind of agony in a friend or family member and his misery is quite obvious. I am
happy to discuss any further details with you. I hope this helps and I apologize for taking so long.. Lori
Lori Kohler, MD
Professor of Clinical Family and Community Medicine
.
University. of California, San Francisco
Director, Correctional Medicine Consultation Network
1940 Bryant Street
Box #1308
San Francisco, CA 94110
Office
(415) 476-2041
Voicemail
476-2040
FAX
476-2207
Adminstrative Assistant
Quieter Russ
476-2152
Family Health Center
995 Potrero Avenue, Ward 85
San Francisco, CA 94110
Patient Appointments
Nancy Lopez 476-2041'
Email: Ikohler@fcm.ucsf.edu

3/25/2008

Ombudsman Case No. 2007-01436

APPENDIX D

. Office of the Director
401 Fifth Avenue, Suite 1300
Seattle, WA 98104-1818
206-263-8801
TIY Relay: 711

Fax 206-296-0166

Public Healthl:tfl
Seattle & King County

W

www.kingcounty.gov/health

April 11, 2008

KING COUNTY OMBUDSMAN
OFFICE OF CITIZEN COMPLAINTS

TO:

Amy Calderwood, Ombudsman-Director
Jon Stier, Senior Deputy Ombudsman·

FROM:

David Fleming, M.D., Director & Health Officer
Via: Benjamin Leifer,. Chief Administrative Officer

RE:

Response to Ombudsman Case No. 2007-01436

\~ ~
~~ r ~

This letter responds to your memorandum of March 14,2008, regarding Lynn Dale Iszley,
Ombudsman Case No. 2007-01436. Thank you for requesting our comments regarding an
investigation conducted by your office in the death of Mr. Iszley.
While no health care system can completely eliminate the risk of adverse outcomes, we are
committed to providing the best quality system of care in Jail Health Services. Health care
orgariizations recognize that sad outcomes do occur, and health care providers regret the loss
of any patient. Jail Health Services takes very seriously its responsibility for ensuring that
systems of care are appropriate to treat illness and to systematically decrease the risk of
adverse outcomes for the patients they serve.
While recognizing the tragic nature of Mr. Iszley's death, it is also important to recognize
. ongoing efforts to improve systems of care in Jail Health Services. A key method of
improving systems of medical care, which includes preventing risks of errors, is the Jail
Health Services Quality Improvement (QI) -Program. While specific QI reviews cannot be
disclosed here (the information is protected and confidential under RCW 43.70.510 and
Chapter 246-50 WAC), Jail Health Services is committed to providing the best quality system
of care and actively uses its QI program as one means of monitoring quality of care.
Components of the QI Program include Critical Incident Reviews (which evaluate actions of
each employee involved in the care of a given patient, as well as review of applicable
policies/procedures, training, and equipment) and a Morbidity and Mortality review (this is
typically referred to as "M&M" in health care organizations.) At M&M reviews, providers
discuss in a step-by-step method each critical decision point in the clinical process of care.

The

Pharmacy also has a Quality Improvement Committee, which is a subcommittee of the
JHS QI program. Its general process includes reviews of medication-related incidents,
including those involving documentation issues and documentation quality at the multiple
levels in the pharmacy/medication administration system. Revisions to medication
procedures may result from discussions at the Pharmacy Quality Improvement Committee
meetings.

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The following comments are provided in response to the preliminary recommendations
.
included in your memorandum.
Ombudsman Comment: "JHS should review the actions of eachJHS employee involved
with Mr. Iszley's care, and evaluate whether to discipline employees found to have
violated relevant medical standards of care, or those who otherwise deviated from
applicable protocols."
Jail J:Iealth Services conducted reviews of Mr. Iszlely's case within its QI Program.
Due to the confidential nature of these reviews, as referenced above, specifics are not
'described in this memorandum.
Ombudsman Comment: "This incident should also prompt JHS to. undertake a
comprehensive review of how it responds to inmates in severe pain..."
Jail Health Services already has an ongoing process in place to review and update
written guidelines for the care of a number of conditions. This work is performed by
the JHS Provider Group, which includes all medical, psychiatric, nursing, and dental
providers. The Jail All Staff References folder, located on a shared computer drive
and accessible from any computer workstation in JHS, provides immediate access to
care guidelines for any line staff member at the point of care.
These guidelines, which are organized by organ/body system, include topics such as:
treatment of withdrawal (withdrawal syndromes from various substances are covered
separately); pain management (there are separate guidelines for acute pain, chronic
non-cancer pain, and pain related to cancer and terminal illness); high blood pressure;
high cholesterol; diabetes; schizophrenia; depression; and many others. For example,
the guideline on Epilepsy/Seizure Disorders was recently updated and approved by the
JHS Provider Group. In another example of ongoing work, the JHS Provider Group
has been updating protocols for managing pain, which were initially developed in
2006. This has included a discussion of agreed-upon drugs for use to balance efficacy
and safety in a setting where most inmates suffer from medical and mental health or
chemical dependency conditions and the potential for diversion is high:
The Nursing Office also has a process to update JHS Nursing Protocols for triage and
.general nursing practice, and specific protocols have been redesigned to reflect best
practice considerations, offering structured guidance to nurses regarding appropriate
assessment and referral of the chosen conditions. These protocols take intb account
the principles of evidence-based medicine, algorithms and practice standards
developed by the JHS Provider Group and current referral processes. Each protocol
prompts appropriate medical history review, symptom analysis, and referral for further
care. Protocols developed to date include those for nursing assessment of abdominal
pain, chest pain, headache, substance withdrawal, diabetes, upper respiratory infection,
suicidality, and others.

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Ombudsman Comment: " •..JHS should review] how it determines whether to transport
patients to the emergency room.•."
Both JHS and the Department of Adult and Juvenile Detention are interested in
maximizing safety and security for all inmates and staff in King County Jailfacilities.
JHS conducts regular reviews of random samples of inmates transported from the
facility for emergency department evaluation. JHS has developed a clear decision tree
for staff to use in detennining when to transport for outside medical care of any kind,
and this tool has been shared with DAJD.
Ombudsman Comment: " ... [JHS should review] how it evaluates patients for acute illness
when those patients suffer from complicating symptoms such as those associated with
alcohol and heroin withdrawal... "
This has long been recognized as an important diagnostic area in JHS. Large numbers
of inmates show signs and symptoms of withdrawal to alcohol or opiates while
incarcerated. Many of these persons are also suffering from acute or chronic medical
problems. The evaluation of these cases is not necessarily different in the initial stages
of assessment. A thorough medical history and examination, with the generation of an
appropriate differential diagnosis supported by diagnostic testing or emergency room
evaluation, is the basis to develop an appropriate treatment plan.
Ombudsman Comment: "JHS should also assess its basic care protocols, such as
documentation of continued dosing of medicines prescribed by HMC providers ...."
In addition to the provider guidelines referenced above, the JHS Medication
Administration Manual (MAM) describes in detail procedures of nearly every aspect
of medication administration in Jail Health Services. Updates to the MAM are shared
with all staff as they occur, both in writing and in meetings of the various staff
disciplines, with major revisions accompanied by all staff face-to-face training
sessions and a required post-test on the updated MAM content. New staff are also.
oriented to the MAM, since so much of the practice involves medication management.
The most recent revision to the MAM was completed in May 2007. With the
implementation of the Electronic Health Record and 24-Hour Medication Cart Fill in
late 2007, another major revision is pending for 2008.
Ombudsman Comment: " ... [JHS should review] the nUDlber of times per day vital signs
are checked."
Medical providers may order vital sign checks outside of the InfIrmary as needed for
specifIc conditions. If these checks are ordered, then the nurses comply with the
specifIc directions outlined in the order, such as "twice a day for three days."
Vital sign checking also occurs in the InfInnary. Providers may order patients to be
admitted to the InfInnary when they need care requirillg constant nurse availability.
However, if a patient's medical condition or vital signs are unstable, this may indicate
a patient who may be considered sufficiently ill to warrant a hospital transfer.
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Ombudsman Comment: "JHS should further assess its quality improvement program to
ensure adequate continuity of care and th~lt apparent lapses in care are detected before,
rather than merely after, catastrophic results."
Consistent with QI systems commonly used in health care organizations, the JHS
Quality Improvement Program includes regular reviews of documentation of clinical
care to ensure that care provided is not only congruent with established guidelines, but
overall reflects quality clinical decision-making. Such reviews can help to detect
issues with a clinician's care that could lead to a problem, and thus are an important
part of error prevention and quality improveme"nt.
Also, review of care provided by JHS staff according to provider guidelines is further
"reviewed as an essential standard (J-E-12 Continuity of Care During Incarceration) by
the National Commission on Correctional Health Care (NCCHC):
Prevention of medical errors is also facilitated by redundancy of systems and
improved access to information. When multiple JHS staff (clinical and non-clinical)
can access information in the health record at once from varied locations, questions
regarding care can be readily answered without having to "look for the chart" or
"route the chart to the next location." Likewise, greater involvement of multiple
disciplines (providers, nurses, social workers, pharmacy staff, etc.) with access to the
same information reduces the chance of "something being missed." This difficult-toquantify quality improvement gain is one of the greatest potential benefits of the
electronic health record, and one that Jail Health Services will try to leverage as staff
become more experienced with the product and its features.
Finally, training and education of JHS staff, while always challenging in atwofacility, 24/7/365 operation, can help to raise awareness of high-risk areas of the
practice, decreasing the potential for medical errors. The 2008 training calendar
already includes Suicide Prevention, Alcohol and other Drug Dependency and
Withdrawal, and Wound Assessment and Management.

In summary, it is an unfortunate aspect in health care organizations that adverse outcomes
occur, even in the absence of medical errors. While we know that complete elimination of
adverse outcomes is impossible in any health care system, we will continue to focus our
efforts at JHS on reducing to a minimum the risk of adverse outcomes, while providing the
highest quality health care possible to the inmate-patient population.
Thank you again for giving us an opportunity to respond.

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