REPORTS POINT FINGER AT PRISON NURSES

Policy Violated In Inmate's Death, Corrections Chief Says

Madison -- In the first public accounting of Michelle Greer's death,
Corrections Secretary Jon Litscher said Wednesday that nurses at Taycheedah
Correctional Institution violated policies and should have seen the
asthmatic inmate immediately when she pleaded for help.

Litscher, testifying for two hours in a packed hearing room before the
state Assembly Corrections and the Courts Committee, said several times
there had been a "breakdown" in responding to Greer on Feb. 2.

Litscher said the call for assistance was "there in a number of places from
Michelle to appropriate staff." He said proper prison protocol for severe
asthma requires a prompt face-to-face assessment by medical staff. Litscher
said it was "clear" in his mind that Greer should have immediately been
seen by nurses. Despite screaming repeatedly that she needed medical help,
Greer was never seen by a nurse; she died on the floor of the prison dining
room.

Litscher released two reports - one from a Department of Corrections
mortality review committee, the other from an ad hoc committee he set up to
look specifically into Greer's death - outlining the miscommunication and
health care failings. The reports also revealed contradictions in the
accounts of nurses and corrections officers.

"There is a definite problem in communication between all the parties,"
says the ad hoc committee's report. "One problem . . . seems to be a
'we-they' mentality rather than one of teamwork. There also seems to be an
atmosphere of fear on the part of officers when it comes to addressing
problem areas at the (Taycheedah) Institution."

Some of the more glaring findings in the reports:

- - Policies require that when inmates are transferred from one prison to
another, their medical needs should be relayed in a phone call, and that
call documented. But Greer was transferred in January to Taycheedah, near
Fond du Lac, and no documentation exists that prison personnel "had been
notified by DCI (Dodge Correctional Institution) of inmate Greer's severe
asthma and recent exacerbations." Also, Greer was supposed to be assessed
in person when she arrived at Taycheedah. There is no documentation that
occurred.

- - A Dodge nurse reported telling an unidentified Taycheedah nurse
that Greer required a nebulizer machine to assist her breathing at Dodge.
But Greer never got (nor did she request) a nebulizer machine at
Taycheedah. Litscher said that was partly because Greer was given a
stronger asthma medication.

- - Greer was taken off the stronger medication
Jan. 28. The Health Services nursing coordinator for the prison system told
the Assembly committee Wednesday that the medication sometimes causes a
rebound effect in patients, prompting more serious attacks. But Greer still
was not given a nebulizer.

- - Policies require staff members from the prison's
Health Services Unit to bring an emergency response bag to all medical
emergencies. That did not happen when Todd Graff, the lead nurse, responded
to a report of Greer's collapse.

- - An officer and two kitchen workers who
were the first on the scene were not CPR certified and reported feeling
"helpless." A videotape of Graff working on Greer showed that he "needs
review of his technique in performing chest compressions."

- - Taycheedah
administration did not launch an immediate, extensive investigatio.
Although a cursory review was performed, it was inadequate; a security
director who pronounced staff conduct "exemplary," for example, has no
medical training. The ad hoc report said failure to conduct immediate
investigations puts the Department of Corrections "in the position of
reacting to newspaper articles."

- - Greer's inhaler has mysteriously
disappeared. A correctional officer reported giving the inhaler to Graff,
but Graff said he never got it.

- - The Health Services staffing level at
Taycheedah is roughly the same as it was when there were just 200 inmates.
Now there are about 633. That is "far from adequate," the ad hoc panel's
report says.

Litscher outlined numerous recommendations, either for changes that need to
be made or policies that need to be re-emphasized. Among them:

- - A review of emergency reporting procedures to ensure that staffers
understand their responsibilities in reporting emergencies. Litscher said
correctional officers illustrated a clear "feeling that they themselves in
cases of emergencies could not directly contact the Health Services Unit
even though there was a policy and process that says they should."

He said corrections officers felt that they would be "subject to some kind
of reprimand" if they contacted the unit themselves, even in emergencies.

- - A communication change to make sure that institution staff are aware of
inmates with chronic medical conditions.

- - Immediate review of the medical
file in the event of a medical emergency. When inmates are transferred from
one institution to another, documented communication must occur regarding
inmates with chronic health conditions.

- - A staffing analysis to assess current staffing levels.

The report by the ad hoc panel also listed recommendations.

After Wednesday's hearing, Litscher said a decision on whether to take any
disciplinary action against Taycheedah personnel would come perhaps within
two weeks. Litscher said the focus of any disciplinary action would be on
the two nurses who refused to immediately see Greer, Graff and Deborah
Federer. Asked several times whether Warden Kristine Krenke could possibly
face discipline, Litscher would say only that the focus was on the nurses,
who have been suspended.

The chairman of the Assembly panel, Rep. Scott Walker (R-Wauwatosa), said
committee members would make recommendations and added that further
hearings would be held.

Some Milwaukee ministers said the reports only bolstered their opinion that
Greer's treatment bordered on "criminal conduct." They want an inquest into
her death. Although one is sought by Milwaukee County District Attorney E.
Michael McCann, his counterpart in Fond du Lac County has not announced a
decision.

Mary Zahn of the Journal Sentinel staff contributed to this report.