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Report points to deputies, medical contractor in Ortiz death 

click to enlarge Eliezer Tirado-Ortiz died Sept. 7 at the El Paso County Criminal Justice Center. - COURTESY EL PASO COUNTY SHERIFF’S OFFICE
  • Courtesy El Paso County Sheriff’s Office
  • Eliezer Tirado-Ortiz died Sept. 7 at the El Paso County Criminal Justice Center.
In the 90 minutes before Eliezer Tirado-Ortiz died on Sept. 7 in the El Paso County Criminal Justice Center, he thrashed, sweated profusely, complained of chest pain and demonstrated confusion. He also admitted to sheriff’s deputies he’d taken heroin and methamphetamine.

But despite several deputies realizing the 40-year-old Ortiz was under the influence of drugs, they struck him several times and failed to provide medical care for “excited delirium,” a condition associated with people who die in law enforcement custody, according to a report of the incident obtained by the Indy through an open records request.

Unfortunately for Ortiz, “Law enforcement did not appear to comprehend or piece together the symptoms of distress that all deputies noticed in one fashion or the other,” 10th Judicial District Deputy District Attorney Robert Toole noted in his March 16, 10-page report.

Moreover, Toole’s account notes that a jail nurse “did not have much interaction with Mr. Ortiz,” although she was the apparent primary caregiver when he was brought to the jail. That nurse, Montie Baxley, also was named in a “notice of concern” sent by the Sheriff’s Office to the contractor, Armor Correctional Health Services Inc., of Miami, last fall, citing the Ortiz incident and another event in July 2017 in which Baxley “did not take charge” of the situation.

The 10th District, in Pueblo, agreed to review the Colorado Springs Police Department’s investigation due to a possible conflict of interest by the 4th Judicial District Attorney’s Office in Colorado Springs. Pueblo prosecutors found jail staffers’ actions fell short of the standard required to warrant charges of criminal negligent homicide and noted the coroner said Ortiz died as the result of “heroin and methamphetamine intoxication associated with necessary physical restraint by law enforcement.”

But Toole notes that six deputies who had direct interactions with Ortiz failed to recognize repeated signals of medical distress and admitted they aren’t trained to identify and respond to such cases. The Sheriff’s Office declined to comment, citing pending litigation. (A local law firm has filed a notice of claim, a precursor to a lawsuit, regarding Ortiz’s death.)

Armor, the jail’s contractor, declined to comment on the DA’s report, but asserted it’s committed to providing quality care.

On the day Ortiz died, deputies were called to a disturbance in the 2800 block of South Circle Drive at 10:48 a.m. Witnesses reported Ortiz was acting hyper, odd and violent. Four deputies responded. “It was clear to the deputies that Mr. Ortiz was under the influence,” Toole’s report says.

One asked Ortiz if he’d like to have a medical evaluation. He at first refused but then agreed. Two deputies decided he could receive medical treatment at the jail, just two minutes away. Ortiz’s behavior was erratic — at one point he lay down in a flower bed and threw flowers — and inside the patrol car, he banged his head against the window and was “generally being hyper-active,” Toole’s report said. He also was sweating profusely, despite a deputy turning up the air conditioning.

About an hour after the initial call, at 11:44 a.m., deputies arrested Ortiz for possession of heroin after finding a can containing heroin residue. Video of the jail incident begins at 12:05 p.m. in the sally port where deputies have difficulty getting Ortiz out of the car. One deputy said Ortiz complained of feeling sick and “would make sounds like he was hurt without anybody touching him.”

Shortly, Baxley comes into the sally port but doesn’t tend to Ortiz.

A minute or two later, inside the jail, Ortiz screams in discomfort. “Mr. Ortiz is placed face first into the back wall of the cell,” the report says, as two deputies restrain him and a third pats him down. This spanned about 20 seconds before deputies “guide[d] Mr. Ortiz to the ground onto his stomach.”

The video, released to the Indy by the Sheriff’s Office on May 25, shows up to six deputies dealt with Ortiz at one time after he was placed in the cell. They pulled him onto the cell floor and struggled to get a suicide gown on him.

The video also shows several deputies trying to restrain him and putting their weight on top of him while he’s face down. While attempting to place a “spit mask” on Ortiz, a deputy struck him in the shoulder and then “administered a knee to his side,” Toole’s report said. Ortiz is kneed a second time as well, the video shows. Deputies kept Ortiz on his stomach for about 10 minutes.

Baxley then goes into the cell and checks the “capillary refills,” a fingernail test done to determine dehydration and amount of blood flow to tissue, and checks his pulse on his wrist, a reading she deems normal, the report says. Other than that, Toole notes, Baxley, “did not have much interaction with Mr. Ortiz.”

At 12:18 p.m., more than 10 minutes after he’s placed on his stomach, deputies try to move Ortiz onto his side. He immediately rolls back onto his stomach and deputies leave the cell. A minute later, when the deputies return, he’s face down.

Deputies then take turns giving him chest compressions for about 10
minutes, the video shows. Baxley, meantime, did very little.

Excited delirium, triggered by use of stimulant drugs such as methamphetamine, or mental illness, wasn’t mentioned in the CSPD’s May 11 press release outlining events that led to Ortiz’s death.

A Western Journal of Medicine article published in 2011 states that symptoms of the condition include agitation, fear, panic, shouting, violence, hyperactivity, sudden cessation of struggle, respiratory arrest and death.

“Given the violent and unpredictable nature of [excited delirium] victims, rapid sedation is likely essential to positive outcomes,” the article says. Though certain drugs have been shown to be effective in reducing victims’ agitation, they require 10 to 15 minutes for sedation, and those experiencing excited delirium “may not have minutes to spare as they continue to struggle against law enforcement or physical restraints in a state of hyperthermia and metabolic
acidosis,” the article says.

Physicians at the University of Southern California who authored the article propose using intramuscular ketamine, which can sedate a patient within 30 seconds to four minutes. “The use of ketamine for procedural sedation in the pediatric ED [emergency department] and rural operating rooms is popular and has a proven record of efficacy and safety.”

But sheriff’s deputies and Baxley, all of whom told investigators Ortiz’s behavior was consistent with someone high on meth, didn’t administer any medications to Ortiz, the report says. One deputy told investigators that Ortiz said he couldn’t breathe, to which the deputy told him, “No one is on your chest, sir. We’ve all gotten off of you. Uh, you can breathe.”

Says Toole’s report, “This should have signaled something might be amiss.”

Two other deputies also reported hearing Ortiz complain about his chest. “This should have been a clue of a problem,” the report says. But despite Ortiz’s complaints about difficulty breathing, one deputy “delivered blows to Mr. Ortiz within the cell,” Toole’s report says.

Referring to Ortiz’s display of symptoms of excited delirium, Toole writes, “While the forensic pathologist did not list this as the cause of death, many of the potential signs of this were present in Mr. Ortiz. ... These deputies do not appear trained in these symptoms.”

One of the deputies admitted as much, telling investigators that he and other deputies “are not really trained on that.”

Nevertheless, Toole concludes that while deputies “did not appear to comprehend or piece together the symptoms of distress that all deputies noticed in one fashion or the other... ,” Ortiz’s treatment and death “falls well short on an individual basis of the standard required for Criminally Negligent Homicide.”

click to enlarge Ortiz experienced “excited delirium.” - COURTESY EL PASO COUNTY SHERIFF’S OFFICE
  • Courtesy El Paso County Sheriff’s Office
  • Ortiz experienced “excited delirium.”
Colorado law defines criminal negligence as the failure to perceive, through a gross deviation from the standard of reasonable care, a substantial and unjustifiable risk that death will result from your conduct.

Neither the CSPD release, nor Toole’s report state an exact time when AMR ambulance service was called, but the CSPD release said AMR responded “later,” and Toole reports that “nurses brought in the oxygen and AMR was called.”

The video shows AMR arriving after deputies had been performing CPR for up to 10 minutes.
Toole’s report says AMR personnel administered three doses of naloxone, the antidote for opioid overdose.

“Nurse [Kristina] Smith noted that nothing seemed to revive him and he was flatlined,” Toole writes, calling Ortiz’s death “a tragic event.”

Citing pending litigation, the Sheriff’s Office refused to comment on deputies’ apparent lack of training cited in the report and why the jail nurse didn’t take more assertive action in providing medical care for Ortiz. The office instead referred questions to Armor, which declined to comment.

But in an Oct. 2 “Notice of concern” to Armor, the Sheriff’s Office outlined the Ortiz incident. “The intake nurse, Montie Baxley, who was first on the scene, did not take charge of the situation,” the notice said. “She had trouble setting up the oxygen tank, and in addition, she had difficulties performing CPR. It was also observed that other medical staff ... were standing around while deputies were performing CPR.” The video confirms this.

The notice also described a July 21 incident in which nurse Baxley responded to a code blue (cardiopulmonary arrest) as the charge nurse. “During this event Nurse Baxley did not take charge of the medical call,” the notice said. “She was observed walking around trying to find out what was happening but not giving directions. When the inmate was brought to Medical there was a delay on placing a C-collar on his neck and there was a delay in calling AMR for transport to Memorial Hospital.”

The notice letter goes on to say the performance of medical staff “was below required standards.”

Armor responded on Oct. 12, stating in a letter that when it took over the contract on July 15, 2017, it was met with “tremendously large numbers of task [sic] backlogged beyond anything we have ever seen.”

“The culture among most healthcare staff was laissez-faire, requiring Armor to prioritize tasks to ensure primary patient care is properly delivered,” the letter said, adding that Armor had hired more staff.

Armor also noted it organized emergency readiness training “to begin posthaste,” and brought in a certified CPR trainer after discovering that the previous vendor, Correctional Healthcare Management Inc. of Greenwood Village, had relied on online CPR training, which Armor doesn’t permit.

The National Commission on Correctional Health Care, an accrediting agency that promotes certain standards of performance, placed the Criminal Justice Center on probation on Dec. 15, based on an assessment completed a week earlier that flunked the jail on seven of 39 “essential standards.” Those included initial health assessments, oral care, nonemergency health care requests and services, emergency services, continuity and coordination of care during incarceration, suicide prevention and health records.

The jail also flunked three “important” standards, including clinical performance enhancement, which evaluates the appropriateness of services delivered by patient care clinicians, orientation for health staff, and nursing assessment protocols, which are guidelines nurses use to perform any number of duties, including the handling of prescription medications.

Probation was lifted on April 22 after the jail was deemed in compliance with all essential standards, though clinical performance enhancement, an important standard, remained subpar.

Asked to comment on the Ortiz incident, Armor says via email, “We sympathize with Mr. Tirado-Ortiz’s family for their loss. The company respects the privacy of its employees and patients, and adheres to federal HIPAA privacy laws that prohibit discussing specific patient information.”

But Armor defended its performance generally, saying, “When there is an emergency, we react quickly which at times requires ambulance services. Armor is committed to providing quality care for its patients and diligently works to ensure that every employee adheres to this.” Armor confirmed for the Indy that Baxley remains employed by Armor.

Ortiz’s family has retained the McDivitt Law Firm, which didn’t return a phone call seeking comment but has filed a notice of claim with the county and other agencies, demanding “the maximum allowed by law” in monetary damages.

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