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Findings and Recommendations 7 findings
F1
The CFMG assessment protocol lacks the formality and specificity to detect inmates with high risk for AWS. For example; the absence of a point system, the omission of specific awareness questions and general brevity of the assessment makes one consider the degree to which the outcome depends on the skill, working conditions and attitude of the medical staff. The lack of formality leaves too much to the subjective interpretation of the RN. A more comprehensive assessment would also enhance the County’s and the Contractor’s position with regard to contingent liability.
Related Recommendations (1)
R1
The Sheriff’s Department should require that Sonoma County Sheriff the CFMG alcohol withdrawal risk assessment procedure should be modified to more closely – F1, F2, F3, F4, F5, F6, F7 follow the CIWA-Ar including all the parameters and the rating scale in the formal procedure. Requested Responses to Findings
F2
Lack of withdrawal symptoms prior to assignment to general population housing is not a valid criterion for those inmates who may still have significant blood alcohol concentrations at the time of assessment. Blood Alcohol Concentration (BAC) or a breathalyzer test would reveal the need to closely monitor the inmate and reassess the AWS dangers when the BAC is low enough for the evaluation to be medically valid.
Related Recommendations (1)
R2
The Sheriff’s Department should require that the CFMG assessment protocol should identify California Forensic Medical Group, Inc. chronic alcoholics, who arrive intoxicated and have a medical history of AWS, as a special – F1, F2, F3, F4, F5, F6, F7 class of inmates needing closer monitoring. Reassessment of AWS risk is required when BAC concentrations drop below .1%. Required Responses to Recommendations
F3
To protect high risk inmates (as defined here), the withdrawal and detoxification protocol in use should be mandatory, as opposed to, being at the discretion of the RN. Initially, the protocol must include frequent monitoring of the inmate
Related Recommendations (1)
R3
The Sheriff’s Department should require that CFMG should monitor W class inmates at Sonoma County Sheriff least once every four hours. – R1, R2, R3, R4, R5
F4
A twice-a-day monitoring schedule is inadequate to monitor W class inmates for withdrawal symptoms. Medical checks, at four-hour intervals, are generally accepted as adequate in a hospital environment and in other detention environments.
Related Recommendations (1)
R4
The Sheriff’s Department should require that CFMG should consider the administration of widely-held medication practices to AWS Requested Responses to inmates as a seizure precaution. Recommendations
F5
If a more frequent monitoring protocol were to be initiated in the first 48 hours of incarceration, it may be possible to deliver medication to prevent the onset of AWS which would diminish the probability of potentially fatal withdrawal incidents.
Related Recommendations (1)
R5
Specific Rounds procedures should be defined and followed by COs for W class inmates until California Forensic Medical Group, Inc. CFMG reviews AWS S ris o k n a o nd m de a te C rm o in u es n t t h y a t Gran d Jury special attention is no longer necessary. The – R1, R2, R3, R4, R5 new W class procedure should require a verbal response from the inmate. Also, COs must open the cell door and/or turn on the light to elicit a response. 9
F6
The primary responsibility for the medical welfare of inmates resides with the medical staff. However, correctional officers observe inmates every half hour. With the implementation of special observation criteria, they could significantly diminish the risk to the most serious AWS candidates. (Opening the cell door and requiring a verbal response from high risk inmates may be sufficient).
No recommendations for this finding
F7
Two medical experts indicated that the high-risk inmates we identified would have benefited from blood alcohol testing prior to being placed in general population. Conclusions It is difficult to determine AWS risk. Fatal incidents can occur any time from a few hours to several days after the cessation of alcohol use. It is generally accepted that the greatest risk of life threatening events, such as seizures and delirium tremens, occurs in the first 48 hours. The CIWA-Ar protocol has a well documented track record for the assessment and treatment of AWS. Shortcuts to the CIWA–Ar save little time and can lead to catastrophically inaccurate assessments. The formal protocol takes only five (5) minutes to administer, and the result is less prone to subjective medical errors in the jail environment. There is a class of very high-risk people who can be easily identified. They are chronic alcoholics with a recent, very large intake of alcohol. They have a history of previous detoxification incidents, such as delirium tremens, and/or they have previously been given medication to mitigate their withdrawal. All of the research reviewed by the Grand Jury indicates that four-hour observation intervals, along with the recording of vital signs, are the minimum requirements for a safe alcohol detoxification. Numerous published Documents and the opinions of three independent medical experts support this. Two observations a day are not good enough. During our investigation at least one inmate died on that reduced observation schedule. Every Medical expert we interviewed expressed the opinion that deaths from AWS are completely preventable. There are relatively inexpensive procedures that can be employed to protect these inmates. Our recommendations outline what is required. If high risk inmates were temporarily housed in the Medical module (I module) there would be little impact on the added labor required to do this closer monitoring. The County should take responsibility to treat these sick inmates in an environment that is appropriate for their condition. Conclusions (continued) Inmate health is at-risk because they are being treated for AWS in a jail environment. As noted in F7, the high risk inmates that we identified, would have benefited from blood alcohol testing (BAC) prior to their assignment to general population cells. The experts we cite each stated two reasons for this. One reason was that alcohol poisoning potential (a separate life threatening problem) can be detected in a chronic alcoholic who may not exhibit symptoms that would cause a casual drunk to lose consciousness. The second reason was to validate the risk- assessment protocol. People with a high BAC will not exhibit the symptoms used to indicate AWS risk. Several hours later however, symptoms that would put them in a hospital may be undetected while they are in their cell. The Grand Jury checked these opinions with a third medical expert who supervises detention medicine in another county. He concurred, but pointed out that BAC testing was not a common practice in detention facilities, including the one he works in. Commendations The Grand Jury must commend the medical experts we interviewed. They provided extensive resource material, personal experiences, medical documentation and countless hours of their time to assist us in formulating our hypothesis and validating our conclusions. Their input was invaluable.
No recommendations for this finding
Conclusions 1
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CL1 Page 3It is difficult to determine AWS risk. Fatal incidents can occur any time from a few hours to several days after the cessation of alcohol use. It is generally accepted that the greatest risk of life threatening events, such as seizures and delirium tremens, occurs in the first 48 hours. The CIWA-Ar protocol has a well documented track record for the assessment and treatment of AWS. Shortcuts to the CIWA–Ar save little time and can lead to catastrophically inaccurate assessments. The formal protocol takes only five (5) minutes to administer, and the result is less prone to subjective medical errors in the jail environment. There is a class of very high-risk people who can be easily identified. They are chronic alcoholics with a recent, very large intake of alcohol. They have a history of previous detoxification incidents, such as delirium tremens, and/or they have previously been given medication to mitigate their withdrawal. All of the research reviewed by the Grand Jury indicates that four-hour observation intervals, along with the recording of vital signs, are the minimum requirements for a safe alcohol detoxification. Numerous published Documents and the opinions of three independent medical experts support this. Two observations a day are not good enough. During our investigation at least one inmate died on that reduced observation schedule. Every Medical expert we interviewed expressed the opinion that deaths from AWS are completely preventable. There are relatively inexpensive procedures that can be employed to protect these inmates. Our recommendations outline what is required. If high risk inmates were temporarily housed in the Medical module (I module) there would be little impact on the added labor required to do this closer monitoring. The County should take responsibility to treat these sick inmates in an environment that is appropriate for their condition. 8 Conclusions (continued) Inmate health is at-risk because they are being treated for AWS in a jail environment. As noted in F7, the high risk inmates that we identified, would have benefited from blood alcohol testing (BAC) prior to their assignment to general population cells. The experts we cite each stated two reasons for this. One reason was that alcohol poisoning potential (a separate life threatening problem) can be detected in a chronic alcoholic who may not exhibit symptoms that would cause a casual drunk to lose consciousness. The second reason was to validate the risk- assessment protocol. People with a high BAC will not exhibit the symptoms used to indicate AWS risk. Several hours later however, symptoms that would put them in a hospital may be undetected while they are in their cell. The Grand Jury checked these opinions with a third medical expert who supervises detention medicine in another county. He concurred, but pointed out that BAC testing was not a common practice in detention facilities, including the one he works in.
Commendations 1
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CM1 Page 4The Grand Jury must commend the medical experts we interviewed. They provided extensive resource material, personal experiences, medical documentation and countless hours of their time to assist us in formulating our hypothesis and validating our conclusions. Their input was invaluable. Recommendations Required Responses to Findings R1 The Sheriff’s Department should require that Sonoma County Sheriff the CFMG alcohol withdrawal risk assessment procedure should be modified to more closely – F1, F2, F3, F4, F5, F6, F7 follow the CIWA-Ar including all the parameters and the rating scale in the formal procedure. Requested Responses to Findings R2 The Sheriff’s Department should require that the CFMG assessment protocol should identify California Forensic Medical Group, Inc. chronic alcoholics, who arrive intoxicated and have a medical history of AWS, as a special – F1, F2, F3, F4, F5, F6, F7 class of inmates needing closer monitoring. Reassessment of AWS risk is required when BAC concentrations drop below .1%. Required Responses to Recommendations R3 The Sheriff’s Department should require that CFMG should monitor W class inmates at Sonoma County Sheriff least once every four hours. – R1, R2, R3, R4, R5 R4 The Sheriff’s Department should require that CFMG should consider the administration of widely-held medication practices to AWS Requested Responses to inmates as a seizure precaution.
No Responses Found 1
Government entities assigned to respond to this report. No response documents have been linked in our database.
Sonoma County Sheriff
Elected County Office