U.S. Department of Justice
Federal Bureau of Prisons

Washington, D.C. 20534

MEMORANDUM FOR REGIONAL DIRECTOR NORTHEAST REGION

FROM:



Medical Director

SUBJECT: Multi-Level Mortality Chart Review Consultant's Comments

The Office of Quality Management, Health Services Division, conducts reviews of all inmate deaths through the multi-level mortality review process as part of the Bureau of Prisons’ quality improvement function. Following this review, a consultant, M.D., provides her independent analysis of the medical records of the inmates who have died during the year. She conducted a review on September 19, 2019.

Five mortality cases were reviewed from your region. Four cases demonstrated appropriate care. One case from your region had quality of care or risk management issues identified. This case from your region will require a corrective action response.

- EPSTEIN, Jeffrey, #76318-054 died on 8/10/2019 at MCC New York.

o Quality of care or risk management issues at MCC New York.

Please see the attachment for further information. If you have any questions or concerns, please do not hesitate to contact me or have your staff contact Chief, Office of Quality Management, Health Services Division, at (202)514-2136.

Attachments

EFTA00040957

## External Reviews

Review Date: 9/19/2019

## Northeast Region

Regional Director:

| Devens FMC |
| :--- | :--- |

This markdown representation preserves the original layout, including headings, paragraphs, and table formatting.

<table><thead><tr><th>FLUKER</th><th>Roy</th><th>40533-424</th><th>Male</th><th>Age 64</th><th>DOD</th><th>6/18/2019</th></tr></thead><tbody><tr><td>No Findings</td><td colspan="2">Expected Death? Yes</td><td>Manner</td><td>Natural Causes</td><td></td><td></td></tr><tr><td>Death Category</td><td>Cardiac</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Death Cause</td><td>Congestive heart failure</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

<table><thead><tr><th>PHILLIPS</th><th>Charles</th><th>02952-000</th><th>Male</th><td>Age 68</td><td>DOD</td><td>5/13/2019</td></tr></thead><tbody><tr><td>No Findings</td><td colspan="2">Expected Death? Yes</td><td colspan="4">Manner Natural Causes</td></tr><tr><td>Death Category</td><td colspan="2">Cardiac</td><td></td><td></td><td></td><td></td></tr><tr><td>Death Cause</td><td colspan="2">Heart failure</td><td></td><td></td><td></td><td></td></tr></tbody></table>



Elkton FCI


<table><thead><tr><th>GARLING</th><th>Lee</th><th>41184-039</th><th>Male</th><td>Age 78</td><td>DOD</td><td>5/6/2019</td></tr></thead><tbody><tr><td>No Findings</td><td colspan="2">Expected Death? Yes</td><td colspan="2">Manner Natural Causes</td><td></td><td></td></tr><tr><td>Death Category</td><td colspan="2">Pulmonary</td><td></td><td></td><td></td><td></td></tr><tr><td>Death Cause</td><td colspan="2">Pneumonia, unspecified</td><td></td><td></td><td></td><td></td></tr></tbody></table>

Loretto FCI

<table><thead><tr><th>HORNBAKER</th><th>Anthony</th><th>38954-068</th><th>Male</th><td>Age 60</td><td>DOD</td><td>6/28/2019</td></tr></thead><tbody><tr><td>No Findings</td><td>Expected Death?</td><td>No</td><td>Manner</td><td>Natural Causes</td><td></td><td></td></tr><tr><td>Death Category</td><td>Cardiac</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Death Cause</td><td colspan="6">Atherosclerotic cardiovascular disease, so described</td></tr></tbody></table>

New York MCC

<table><thead><tr><th>EPSTEIN</th><th>Jeffrey</th><th>76318-054</th><th>Male</th><td>Age 66</td><td>DOD</td><td>8/10/2019</td></tr></thead><tbody><tr><td>No Findings</td><td>Expected Death?</td><td>No</td><td>Manner</td><td>Suicide</td><td></td><td></td></tr><tr><td>Death Category</td><td>Hanging</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Death Cause</td><td colspan="6">Intentional self-harm (suicide) by hanging, strangulation, and suffocation</td></tr></tbody></table>

Mr. Epstein was a 66-year-old male with a history of obstructive sleep apnea, hypertriglyceridemia, L4-L5 stenosis, and no past mental health history. On 7/23/2019, at 2:00 am, Mr. Epstein was placed on suicide watch for 31 hours and 5 minutes due to abrasion found on the lower anterior surface of his neck area. On 7/24/2019, he was taken off suicide watch and was placed on psychological observation. On 7/30/2019, he was removed from psychological observation and placed in the Special Housing Unit where he was housed with a cell mate. On 8/8/2019, he was seen by Psychology Services and denied any suicidal ideation, intention or plan. On 8/10/2019, at 6:33 a.m., Special Housing Unit staff found Mr. Epstein unresponsive in his cell and attempted to wake him. A medical emergency was called and CPR was initiated by Special Housing Unit staff. At 6:35 a.m., medical staff responded and continued CPR, the AED was applied, and EMS was called. The EMS arrived at 6:45 a.m. and ACLS protocol was initiated by the EMS. No pulse found, no shock was advised and the inmate was prepared for transport to local hospital. He was pronounced dead at 7:36 am by the ER Physician.



EFTA00040958


Consultant Comments: There were quality of care issues identified in this case. However, these issues did not contribute to directly Mr. Epstein’s cause of death.

Review roles and responsibilities of staff responsible for inspecting, testing and maintenance of AED units at each location at your institution. This is considered life support equipment requiring implementation of a process that assures that the AED is available and accessible to all staff in the event of a life threatening emergency. In addition, the Health Service staff should be added to the group/committee convene to conduct the Psychological Reconstruction review for suicide. Adding the Health Services staff not only provides clarification of medical response but more importantly strengthen the review to identify risk management issues and corrective actions.

Recommendations: The Health Services leadership needs to develop a protocol and put procedure in place for monitoring AEDs throughout the institution. The QI Staff should monitor this in the quarterly Governing Body meeting. The institution, Regional and Central Office leadership will look into adding an appropriate Health Service staff member to all Psychology Suicide Reconstruction cases. The Clinical Director, HSA and the Quality Improvement staff need to develop a corrective action plan and provide necessary training to all staff involved to disseminate these expectations. Please submit the corrective action plan along with training sign-in sheet to the HSD/Quality Management~@bop.gov mailbox and carbon-copying the respective Regional Director, RHSA, and RIOP within 45 days of the Warden’s receipt of this notification.

EFTA00040959