9 Investigates: Nurses 'did not follow their own policy' before inmate death

Video: 9 Investigates: 3 different nurses broke protocol in the days leading up to inmate's death

TAVARES, Fla. — A just-completed investigation shows an inmate’s suicide at the Lake County jail followed three different nurses failing to follow newly-implemented detox protocol.

The review of Tiffany Allen’s death was launched after 9 Investigates' Karla Ray started pushing for answers. The Lake County Sheriff’s Office is now looking to potentially dump the company that provides medical care to inmates, Armor Correctional Health Services.

Allen’s is the second death over the course of six months at the jail in which investigators believe Armor Correctional licensed practical nurses failed to provide proper care.

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The review of Allen’s suicide found three different LPNs "did not follow their own policy" and failed to properly address her withdrawal from drugs in the days before her death.

The investigation shows on July 11, the day she was booked into jail, a booking nurse stated that "Tiffany Allen was hearing voices and acting peculiar."

The next day, a nurse "administered one dose of [detox] medication to Tiffany Allen" but "did not call the doctor prior to starting Tiffany Allen on detox medications, which is a violation of Armor's policy." The information about the medication "was not entered into the system until the morning of July 15 as a late entry due to the nurse being extremely busy that day." That computer entry was made after Allen’s suicide.

Since the information was not in the system, a different nurse "discontinued Tiffany Allen's detox medication after the evening medication pass" on July 13. That nurse also failed to notify the on-staff doctor, according to the investigation.

On her third day in custody, July 14, a third nurse performed a blood pressure check on Allen. Her blood pressure was low at 88/60, but her pulse was high at 117 beats per minute. According to the investigation, "there is no documentation that the doctor was notified of her blood pressure and pulse." Allen was found hanging in her cell that day.

During the investigation into Allen’s death, a licensed mental health professional who was working at the jail told investigators "he felt that Tiffany Allen should have never went to general population, should have never been taken off the detox medicine and should have went to medical to be monitored. She told LPN Finley she was starting to withdraw from meth and heroin and was showing symptoms."

Allen’s death comes just a few months after 9 Investigates exposed the death of another inmate, James Anglin. Anglin was going through such a severe heroin withdrawal he began to vomit for hours. He had a seizure and died.

An Armor Correctional nurse refused him care at least twice in the hours before the seizure.

Armor Correctional was forced to submit an action plan after 9 Investigates exposed Anglin’s death. That plan included replacing the medical director who oversaw operations in Lake County.

The action plan noted that nurses and providers were not being properly trained to deal with people detoxing from drugs, prompting a new detox policy to be put into place. All nurses were trained individually as part of that action plan.

Armor Correctional recently lost a bid to renew a $30 million annual contract in Broward County, where a report from the American Civil Liberties Union found substandard care in a jail where at least 10 deaths were reported, including two inmates who starved to death.