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| Vallia Karaharisis died of complications from heroin withdrawal |
As a Bucks County prisoner placed on medical watch, Vallia Valene Karaharisis should have been checked on 64 times — once every seven to eight minutes by a fellow inmate or a guard — during the overnight hours of Sept. 28, 2013.
Instead, written records suggest she was observed only 13 times over roughly 10 hours, an apparent violation of the prison's Watch and Observation policy. The last contact she allegedly had with a guard came nearly four hours before she was found dead as a result of complications from sudden heroin withdrawal. But there is no record that a conversation took place during that contact, according to testimony.
Those and other details contained in deposition testimony and recent court documents involving a lawsuit filed by Karaharisis' mother last year suggests that lax oversight existed in a Bucks County prison program that pays inmates to watch over other inmates who are sick, suicidal or a security issue. Those documents provide details the county previously denied this news organization in a Right to Know request about the program.
“The prison had a custom of noncompliance with the (inmate watch) policy and failed to provide adequate supervision and training regarding the policy,” according to attorney Jonathan Feinberg, who represents Karaharisis' mother, Loretta Lopez.
Bucks County is one of only a handful of prisons or detention centers in Pennsylvania — and the only one in the Philadelphia region — that uses inmate monitors to help watch over sick and suicidal inmates to ensure that they get help as quickly as possible if their condition deteriorates. No federal standards exist for such monitoring programs, and the little data that is available shows the practice varies widely depending on local jurisdictions and agency policies. The closest county jail to Bucks County using inmate monitors is Lehigh County, but those inmates do not watch prisoners detoxing from drugs or alcohol.
Bucks County has acknowledged in related court documents that corrections staff and inmate monitors failed to properly follow watch procedure during the shifts immediately before Karaharisis, who was jailed on a probation violation, was found dead. However, they deny the lapses reflected widespread failure to follow the protocol, any lack of adequate corrections officer training, or that the delayed monitoring contributed to her death.
A medical assistant conducting detox check rounds discovered Karaharisis dead at 8:15 a.m. on Sept. 29, 2013. She was in rigor mortis, cold to the touch, and her hands, fingers and legs above her calf were blue, according to testimony from medical staff and corrections officers. In humans, the onset of rigor mortis generally occurs 4 to 6 hours after death and reaches maximum stiffness after 12 hours, according to Dr. David Fowler, Maryland's chief medical examiner and president of the National Association of Medical Examiners.
“Not only is there a complete lack of evidence to demonstrate that Karaharisis was in ‘medical distress’ during the overnight shift of Sept. 28, 2013, the conduct of the individual county defendants in failing to monitor Karaharisis every 15 minutes, instead of every 30 minutes, does not constitute deliberate indifference to her serious illness," the county said in an Oct. 6 motion to dismiss the lawsuit. The suit names the county, three corrections officers and PrimeCare Medical Inc., the prison's medical services provider, as defendants.
Yet hundreds of pages of deposition testimony from corrections officers, prison employees and inmates contained in a court motion opposing the county’s request to dismiss the lawsuit provide new insight into the inmate monitoring protocol, including:
- While the county has used inmate monitors, who are paid $3 for an eight-hour shift and often referred as "babysitters" by prison employees, for at least 30 years, according to a county official, a lieutenant assigned to the prison’s officer training division testified that the watch and observation procedures weren't written until 2003.
- One of Karaharisis’ cellmates, who testified that she worked as an inmate monitor, stated she believed the inmate monitors — not the corrections officers — observed inmates on watch protocol. County policy requires both to make observations.
- Corrections employees testified they were aware that inmate monitors sometimes incorrectly filled out monitoring forms, which are used to communicate with corrections staff about the updated needs of an inmate in mental or medical distress.
- Corrections officers and senior prison staff testified they did not know what happened to the completed inmate monitor forms after they were forwarded to the corrections mental health unit.
- None of the corrections officers responsible for Karaharisis during the shifts before her death were disciplined or retrained on the watch protocols after her death, according to testimony including from the officers involved. The suit also alleges that a lack of consequences for officers who didn't follow watch protocol was not unusual.
- Superior officers failed to flag Karaharisis' inmate monitor forms as out of compliance with county policy and procedure. Supervisors are responsible for reviewing the forms after they are turned in by corrections officers.
In an emailed response to this new organization, Bucks County Commissioner Diane Marseglia said inmate monitoring policies were in place prior to 2003. She declined further comment on the case, and other county officials could not be reached for comment.
WHO IS WATCHING
Karaharisis, 29, of Philadelphia, was the first of two prison inmates to die while under medical watch and assigned inmate monitoring since 2013. Six months after her death, Marlene Yarnall, 49, of Bensalem, also died of cardiac arrest in March 2014, during heroin detoxification three days after she was incarcerated on a probation violation. Yarnall’s family has also filed a federal wrongful death suit, which is still winding its way through the federal system.
The Karaharsis suit contends that had the county properly trained and supervised inmate monitors and corrections officers to follow the county protocol, the severity of her daughter's medical distress would have been noticed and she would have received prompt medical intervention. It also alleges that PrimeCare employees failed to follow company detox protocol, and provide Karaharisis adequate medical care and supervision.
Prison employees testified in depositions that case managers at the prison are responsible for selecting inmate monitors and reviewing the written job instructions with them before they are assigned a watch shift, Deputy Warden Lillian Budd testified. Inmate monitors are not formally trained to oversee other inmates on watch.
Inmate monitors are generally assigned to observe up to eight inmates during a regular watch shift. The job requires them to observe and record the behavior of the inmates they watch on a form using the codes that include eating, sleeping, toilet, shower, talking, in the cell, out of the cell and “other," Budd said.
The regular watch protocol calls for inmates to be observed every 15 minutes, but watch tours are supposed to be staggered so that an inmate is actually observed every seven to eight minutes by an inmate monitor or a corrections officer, according to Budd’s testimony. Both inmate monitors and corrections officers are supposed to record each observation on the inmate monitor forms, and the officer initials both observations, Budd testified.
Inmate monitors and corrections officers fill out separate forms and must use new forms for each shift under a change implemented last year, according to testimony. In 2013, though, monitors and correction officers used the same monitor form, which contained 64 spaces for observations, according to a training supervisor's testimony. Corrections staff also now sign inmates’ monitor forms every 15 minutes, whereas before it was sometimes signed sporadically throughout a shift, according to testimony.
However, in its Oct. 6 motion, the county denied the watch policy requires observations to be “noted and initialed on the inmate monitor form every 7-8 minutes.” The county also denied that regular watch procedures require that correction officers write their observations of inmates on the form; rather, they are required only to initial the form that includes the notations from the inmate monitor.
JUDGMENT CALL
The inmate monitor assigned to Karaharisis for the 10 p.m. to 6 a.m. shift starting Sept. 28 testified Karaharisis appeared to be experiencing what she considered a “normal” detox when she observed her early in the shift, describing her as “up and down getting sick.”
The monitor testified she made observations at 1 a.m. and 2 a.m. She added that Karaharisis stated she was not “OK,” but she also did not want a corrections officer called. At 2 a.m., after Karaharisis said she still wasn't "OK," the monitor said she brought Karaharisis water because she worried she was dehydrated and appeared to be "progressively getting a little bit worse," she said.
Around 2:15 a.m. on Sep. 29, 2013, the monitor testified, she checked on Karaharisis, who appeared to be sleeping in bed with her body facing the wall. One of Karaharisis’ cellmates also testified that she believed Karaharisis was in her bed around 2 a.m.
The monitor also testified that, when she worked overnight on a regular inmate watch, the locked cell doors prevented her from observing an inmate up close. Instead she pressed her face against the cell window with her hands cupped around her face to observe an inmate. Another option was to turn on the cell lights, but she was reluctant to do because it upset sleeping cellmates.
“I have 20/20 vision. I can see into the cell, but it’s not a clear picture,” she added. “I can see outlines of bodies in a bed, but you know, I could not tell you what they were doing. ... I don’t understand the whole process, because how am I supposed to know if somebody is breathing?”
For the remainder of the shift, the monitor testified that every time she checked on Karaharisis, the inmate was in the same position facing the wall.
But the monitor's testimony contradicts what was written on the inmate monitor form she turned in, according to testimony. The sheet contained only eight identical entries that Karaharsis was asleep the entire eight hours starting at 10 p.m., according to deposition testimony. The monitor also testified it wasn’t the first time she failed to write down observations.
“I would check on (inmates) obviously, but I would never write down what they’re doing if they’re sleeping,” she said.
Other deposition testimony suggests that incorrect or incomplete inmate monitor forms were not an anomaly.
Frank Bochenek, described in court documents as a prison “chief investigator,” testified that he saw “multiple” inmate monitor forms that were incomplete or contained only eight recorded observations during an eight-hour shift rather than the combined 64 checks required from both inmate monitors and correction officers.
“I’m going to say not all of (the monitor sheets) were filled out on every line. Some of them would be filled out in this type of format showing one entry with a line down, (indicating the behavior didn’t change),” Bochenek said, according to deposition testimony.
Corrections officer Rebecca Mitchell, who worked the 6 a.m. to 2 p.m. shift on Sept. 29, 2013, on Karaharisis’ cellblock, testified that she was aware that inmate monitors sometimes filled out monitor forms at the start of their shifts with “predicted” observations.
“If they see them inside the cell, they assume that’s … where they (are) at, like, for the next 15 minutes and they will write it down even though they didn’t get up to observe the inmate at that time,” Mitchell testified. “I’m not going to say all the time (it happens). You might have some that we call lazy, that don’t want to do the whole thing. But then there’s some that’s on all the time. So we stress to them, this is what your job duties are.”
Two of the three corrections officers on duty when Karaharisis died testified that they observed inmates on regular watch protocol every 30 minutes; one testified that she knew the protocol required an officer or inmate monitor to stagger tours so observations were done every seven to eight minutes. All three officers testified that they did not know they were required to write down their observations.
Corrections officer Kristin Spadaro acknowledged in her testimony that the inmate monitor form for Karaharisis that she approved had only eight written entries and she initialed under “staff” portion of the form only five times. But she insisted that Karaharisis was observed more often than that overnight on Sept. 28-29. The county contends that an activity log shows Spadaro and other officers toured the module at least 15 times throughout the night.
Spadaro testified that she spoke to Karaharisis around 4 or 4:30 a.m. on Sept. 29 while doing her inmate watch tour and Karaharisis had no complaints. “I’m good. I’m still breathing,” she allegedly said, according to the officer's testimony.
According to court documents, though, Spadaro did not write on the inmate monitor sheet that the conversation took place.
Feinberg, the attorney representing Karaharisis' mother, alleges the conversation wasn't documented because it never took place.
"Had Spadaro actually monitored Ms. Karaharisis every 15 minutes as required by BCCF's Watch and Observation protocol, she would have seen these symptoms of Ms. Karaharisis' serious medical need and could have called for medical intervention," Feinberg wrote in court documents. "While Spadaro claims to have spoken with Karaharisis at approximately 4 a.m. or 4:30 a.m., her claim is belied by both documentary and testimonial evidence."
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