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 For twelve days, she didn't eat.  She vomited 
 and defecated uncontrollably.  Staffers at
 Orange County 
Jail Did Little To Help Her.
 

 Henry Pierson Curtis of The Sentinel Staff

What if she had been your daughter?  How many people have to die before we admit the truth?  Are we a nation that has come to care only about ourselves? 

Susan Bennett died in the Orange County Jail while nurses and guards watched. The once-bubbly Orlando Homemaker arrived healthy last March but ended up lying naked and motionless in her own waste.

For 12 days, she vomited and defecated uncontrollably.  -  Guards occasionally carried her on a mattress to the showers.  Nurses jotted notes about the smell. The medical staff kept documenting that Bennett was fine right up until a guard pointed out she was dead. Then, rather than try to resuscitate her, the nurses on duty argued over who was Bennett's official caretaker at that moment, accord-ing to county records.

So far, three jail nurses have been fired because of the incident. - - Five other nurses who took care of Bennett resigned before a county investigation of her death ended.

However, not one supervisor at the jail has been disciplined.

On Friday, Bennett's husband and two adult sons filed a wrongful death lawsuit in U.S. District Court against Orange County and a list of corrections workers who dealt with her in jail.

The suit, which seeks $10 million in damages, is based almost entirely on the county's own findings of incompetence and indifference to the dying woman.

, 'She would have been better off in a cage in the Sanford zoo. They wouldn't have allowed this to happen to one of their animals," said former State Attorney Bob Eagan, one of the lawyers representing the woman's family.

Bennett, 42, landed in jail March 5, 1997, after her second arrest on a charge of trying to pass a forged prescription at a pharmacy. A former toll collector on the East-West Expressway and teachers aide at Kaley Elementary School, she had become addicted to prescription painkillers five years earlier when the family business failed and her husband of 25 years was diagnosed with kidney cancer.

A state-certified methadone program had failed to curb her cravings for hydro-codone, a narcotic marketed under the names Lorcet and  Lortabs.  - Records show she told jail workers that she took methadone once every day  and  two other prescribed drugs - one to help her sleep and another for depression.

 'I would like help to get back in control of my life," she told the Deputy Sheriff who arrested her.

The jail made Bennett quit all three drugs cold turkey.  This happened despite repeated attempts by her Husband and Her Attorney to alert County and all officials of the risks to her health and of her increasingly bizarre behavior.



Only two days after entering the jail, her family alleges, Bennett started on a downward spiral from her combination of drugs.  - - Familiar to experts, it's a progression from erratic behavior to vomiting and diarrhea to listlessness and finally death. - Nevertheless, a staff doctor said Bennett was physically healthy after being told by a mental-health worker that Bennett was withdrawing from methadone, records show.  -The doctor ordered a psychiatric evaluation.  -So guards kept Bennett under 24-hour observation in a special cell, records show.

Bennett never saw a psychiatrist partly because her medical chart couldn't be found for more than a week, the staff admitted afterward.

The only medical treatment Bennett may have received was a single dose of milk of magnesia, but the nurse who recalled it did not record it on the chart, records show. That is a violation of jail policy, which requires that any inmate who vomits continually to be treated by a doctor.


 The jail made Bennett quit all three drugs     
 cold turkey.  The only medical treatment  
 Bennett received was a single dose of 
 Milk Of Magnesia.
  
 Jail policy requires any inmate who vomits
 constantly  to be treated by a Doctor. 
 
 She never saw a Psychiatrist because her
  Medical Chart couldn't be found.
  Guilty or Not Guilty?   Not Guilty...

Bennett might have gotten help early on. The day after her arrest, her family arranged with Circuit Judge Reginald Whitehead to let her go home. - When asked why she wasn't released, jail officials replied that she could not leave until  she submitted to an Interview with a worker in the Home - Confinement Program.

A Home - Confinement Officer who tried to Interview Bennett on March 11 told County Investigators that Bennett was disoriented and confused and could not comprehend that the worker was trying to help her to go home.

Because she could not answer questions, Bennett went nowhere. Bennett's husband, Gary, 50, expressed alarm to a jail official after he visited his wife, who was brought to him in a wheelchair. He feared she'd had a stroke, the county report says.

She did not eat in the "twelve days"  it took for her to die, nurse notes indicate. No one took action as the previously talkative woman began grunting unintelli-gently and playing with her feces.

Because she wasn't talking, the jail staff described her as obstinate, records show. 

An autopsy showed Bennett died of a heart attack brought on by malnutrition and an electrolyte imbalance - the result of untreated vomiting and diarrhea. Her cell smelled of urine, and her body was covered with bruises, cuts  and feces, officials said.

The Orange County Medical Examiner said the time of death was about 3 p.m. on March 16, 1997.

At 4:50 p.m. that day, guards summoned a nurse to Bennett's cell because she wouldn't respond. The guards were worried because hours earlier Bennett had been making a strange snoring sound that nurses said was not significant, records show.

At that point, about two hours after the estimated time of death, her mattress and bunk were' 'covered with loose watery stool mixed with urine," a nurse  who described the scene wrote.

The nurse placed an ammonia inhalant under the inmate's nose. But Bennett did not respond. The nurse wrote that Bennett was resisting them."Inmate held her breath. Inmate refused to communicate verbally. Unable to obtain VS[ vital signs) due to inmate," the nurse wrote. "No distress noted at this time.  - -  No treatment warranted or done.


County Chairman Linda Chapin acknowledged Friday that jail workers made numerous errors.

'I have been very saddened and distressed over what happened. I think it is very clear that we had policies and procedures in place that should have prevented this," Chapin said. "I think that the fact eight people have lost their jobs over this is indicative of our concern. "

But Attorneys for Bennett's family said, " Senior Officials in the Jail's Medical, Mental-Health and Home-Confinement Departments are as responsible for Bennett's death as the workers who were fired or resigned. All are named as Defendants in the Lawsuit,  along with Several Guards,  a few Mental-Health Workers and the Nurses who were fired or resigned."

'"Think about it - those who were left twisting in the wind were all underlings," said attorney E. Clay Parker, whom Eagan brought into the case.

The County's Internal Investigation of the Death ended October 17 when officials received an 85-page Report stamped " Confidential." It included fourteen pages  dedicated to violations of county jail policy.

Two of the nurses who were fired, later wrote in protest, that Jail Supervisors had ordered them to keep quiet about what happened in cell 6B at the Main Jail, where Bennett died.

'I truly think it was a cover-up. Like I say, we were the expendable ones," nurse Angela M. Baxter said Saturday. "Because the family is suing, county officials wanted to have like a good-faith thing to show to the family,  " Yes, we did take some action."

Baxter and Sharon Carter, also a nurse who was fired, said their Supervisor, a Registered Nurse, should have been punished because they worked under her direction. They said their firing was a smoke screen because no one in the Jail Administration or any of the guards were disciplined.

The county said Baxter and Carter failed to perform assigned duties. They forgot to document their work and to report Bennett's deteriorating condition.  - - - The nurses said the findings were wrong and that officials misled them into believing nothing would happen to them.

A third nurse who lost her job was accused of the same violations as Carter and Baxter, plus lying to investigators and violating the Nurse Practice Act that calls for competent care. She could not be reached for comment Saturday.

The county and the Bennetts failed earlier this month to settle the dispute out of court. Instead of filing in State Court, where damages in a wrongful-death action would be capped at $200,000, the family chose to  seek  unlimited  damages  in federal court.  They are accusing the county of civil-rights violations and cruel and unusual punishment.

" First and foremost, they are seeking reform in the sense they do not want to see
what happened to Mrs. Bennett ever happen to anyone else who has the misfortune of faIling ilI or having a psychological problem in the jail," Parker said.

" Secondly, they are, of course, seeking damages for what might be most charitably referenced as gross neglect."


Bennett's death is the first inmate fatality,  in at least ten years,  to result in the discipline of a jail employee. In the past ten years, - forty - one prisoners have died in jail or after being transferred to a hospital, according to jail records.

Orange County's Jail has a reputation as one of the best-run jails in the country. The county spends $78.7 miIIion a year on its Corrections Budget, including $5.9 million for a 93-member Medical and Mental-Health staff. - It is one of eighty -six accredited by the American Corrections Association out of 3,400 nationwide.

Jail spokesman Allen Moore said new safeguards are in place to ensure that a death like Bennett's does not happen again. Those include making nurses and Mental-Health workers conduct rounds together to make sure they  do share information about Inmates. That did not happen in Bennett's case, the county found. Drug-treatment workers say Bennett's experience in Jail was not unique, however.

Pat Robertson of the Central Florida Treatment Center, a Methadone Program on West Colonial Drive, said some of her clients, also have been forced, as she was to withdraw cold turkey when sent to the jail.

The jail does not have facilities to dispense methadone.  Pat said, "My  clients  do complain that the jail's staff leaves their vomiting and diarrhea untreated."

'That's just inhumane as far as we're concerned," said Robertson, a Registered nurse. -  "I've heard that over and over again that it takes three days to see a nurse."

Baxter and Carter said, " Lack of Treatment is a common experience for sick Inmates. "They usually wait weeks and weeks for them to be seen. - - It's not uncommon," Carter said.

Reference:  The Orlando Sentinel  March 1997 Archive
                  Henry Pierson Curtis of The Sentinel Staff 


"What can I say?"  It sickens me every time I read about Susan Bennett.  She did not deserve such a terrible death.  I am sure we have a lot of you that will say, she should have left the medication alone.  Who are you to judge her?  Who are you to judge her actions?  Have you walked a mile in her  shoes?   Today we have a lot of people that have all the answers.   I believe, today, as the Pharisees of old was called, "self-righteous hypocrites" would define them perfectly. 

Compiled and Edited By:  Deborah Shrira, RPH, CMA      25 March 2006 

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