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Who’s responsible? Accountability questions remain after Denver County jailhouse death

Unanswered questions about accountability linger a year after a man died in Denver’s downtown detention center, after several days of begging for medical care as he experienced chest pains, trouble breathing, nausea and losing his ability to swallow medication.

Medical staff repeatedly sent him back to his cell even as fellow inmates and sheriff’s department officials noticed his deteriorating condition and tried to get him care in the days leading up to his death.

Since Leroy Taylor died in February 2022, those concerned with his death say they have gotten little clarity about steps Denver Health took to investigate. That, they say, highlights a troubling lack of a clear chain of accountability in the relationship between Denver Health and the Denver County Sheriff’s Department in circumstances such as a potentially preventable death.

The foggy picture has resulted from a combination of a limited obligation by Denver Health to produce records under the Colorado Open Records Act and an agreement between the agency and the Denver Sheriff’s Department for health care in the jails that those concerned about Taylor’s death say has led to little transparency and accountability.

The agencies’ legal obligations to each other appear to be so loose that a year later, Denver’s Department of Public Safety hasn’t received any investigative report from Denver Health.  The city’s civilian board for law enforcement oversight has struggled to get information about actions taken by the agency in light of concerns that Taylor’s worsening health was not taken seriously by medical staff.

Nicholas Lutz, an attorney for Leroy Taylor’s family with the civil rights firm Rathod Mohamedbhai, said the relationship between the agencies allows each to shed responsibility by pointing fingers at each other. It’s not clear at any point whether one has oversight over the other, he said.

“He went back and forth five times to medical. It was DSD folks who were advocating for him to get medical treatment. He was getting sent out there and sent right back. And that’s how he perished.”

Taylor, 71, died on Feb. 9, 2022 in the Van Cise-Simonet Detention Center — about two weeks before the end of a 90-day sentence — after his public defender requested his emergency release because of what appeared to be severe COVID-19 symptoms. He had been in jail since November 2021 serving a sentence for probation violations stemming from third-degree assault and protection order violation cases in 2015 and 2016.

He had been diagnosed with COVID in mid-January. In the days leading up to his death, Taylor complained of chest pains, struggled with shortness of breath and had gone to see medical staff twice the day he died, cleared both times to return to his cell. In his last hours, a sheriff’s deputy noticed he had blue hands and feet, struggled to walk and other inmates had to help him use the bathroom. Fellow detainees raised alarms about Taylor’s condition, and at least two deputy sheriffs alerted their superior officers and nurses working in the jail, according to a supplemental report produced by the Denver Police Department.

Taylor collapsed shortly after 4 p.m., according to the report.

A voicemail Taylor left for his public defender on Feb. 7 captured him begging for her to help get him released to see his own doctor, saying he had been sick for 10 days and didn’t feel any better. He promised to finish his sentence afterward.

“I need to get out of here before I die. … I feel like I’m dying in here.”

He called his sister the next day, saying he had worsened. He had had diarrhea for 14 hours and couldn’t eat, Taylor told her. When she asked him how his chest felt, he told her: “It’s hurting. Everything is hurting.”

An autopsy included a negative test for COVID, and instead named pulmonary emphysema and chronic renal failure as two contributing factors to his death — though at least one other contributor is redacted from the autopsy report. Signs of drugs or alcohol did not show up in a toxicology screening.

The medical examiner’s office ruled Taylor died of natural causes.

His death prompted three investigations: By the police department, Denver Health and the city’s Public Integrity Division — a civilian branch of the Department of Public Safety responsible for internal affairs investigations of the sheriff’s department.

Investigations opened into death of elderly man in Denver jail

The investigation by the Public Integrity Division found none of the sheriff’s department’s policies were violated, according to a letter produced in September 2022 from the Administrative Investigations Unit, which houses the division.

But a year after Taylor died, the chair of Denver’s Citizen Oversight Board, a civilian law enforcement watchdog body, said the board has gotten little clarity about any investigation by Denver Health or actions they took as a result of Taylor’s death.

“You have a contractor who is responsible for life,” said Chair Julia Richman. “They have contractors responsible for food, right? And if the food has nails in it, and you do a report on how many nails are in the food, presumably that should go back to the organization that is contracting you. But in this case, the legal relationship is so loose that there’s no way for the city to really hold them accountable.”

The records custodian for the Department of Public Safety said in an email that so far its agencies have only received medical records on Taylor from Denver Health. Safety Director Armando Saldate told the Citizen Oversight Board in December he had not yet received a report from the agency about any investigation it conducted.

In a March 3 meeting of the board, Sheriff Elias Diggins said he personally ordered the revocation of a nurse’s access to the jail after Taylor’s death. He added he has the ability to review complaints submitted about incidents in the city’s detention facilities.

“If an incident happens in our facilities, and we believe that any person —  including Denver Health — personnel pose a risk to the safety, security or perhaps health care to folks that are in our custody, we will do everything within our authority, including removing their access immediately,” he said.

“Ultimately, the buck stops with me, and that includes the service that Denver Health provides.”

Saldate said in an email to the Denver Gazette he’s confident sheriff’s department employees responded to the situation appropriately. But Saldate agrees with the oversight board’s interest in strengthening the agreement between Denver Health and the sheriff’s department to provide more accountability.

“I am open to ideas to increase information sharing and enhance transparency with Denver Health to ensure those in our jails receive excellent care from both DSD and Denver Health staff,” he wrote.

Denver Health denied a records request by the Denver Gazette for investigative findings and any disciplinary or employment decisions based on Taylor’s death. In a follow-up email, an attorney for the agency declined to clarify whether Denver Health has provided any information beyond health records to the sheriff’s department.

“Denver Health does not have any public records responsive to your request and cannot speak to what documents the safety department has or does not have,” wrote senior assistant general counsel Judith Benton.

A spokesperson for Denver Health also did not provide any information when contacted for comment. She declined to confirm even whether Denver Health conducted an investigation following Taylor’s death.

“Denver Health appreciates our partnership with the Denver Sheriff’s Office to provide care to those in custody; however, due to pending litigation, Denver Health is unable to comment further at this time,” wrote Heather Burke in an email.

The attorneys for Taylor’s family have not filed a lawsuit.

Colorado law limits the scope of records from Denver Health considered public, hamstringing the ability to obtain information about any investigations or disciplinary actions. In September 2022, a Denver district court judge ruled that records from the agency subject to disclosure under the Colorado Open Records Act only include:

  • Resolutions and other proceedings of the board of directors
  • Board meeting minutes
  • Annual reports and financial statements
  • Certificates, contracts, and financial agreements
  • Employee salaries
  • Bonds given by officers, employees, and any other agents of the agency
  • Personnel reports, guidelines, manuals, or handbooks, aside from individual personnel files
  • The account of all money received by and sent on behalf of the agency

“It’s just such a loophole, because with any other kind of public entity, you should be able to get that type of thing,” said Jeff Roberts, executive director of the Colorado Freedom of Information Coalition.

The district court decision interpreted a 2018 law that laid out the specific list of records from Denver Health subject to CORA. Before that law passed, state statute said CORA governed the agency’s records. Senate Bill 18-149 deleted that portion, and replaced it with the list.

“They created this loophole for (Denver Health) that I wonder if they intended,” Roberts said.

Lutz said that although he gives the sheriff’s officials credit for their efforts to get Taylor medical care, he believes the loosely defined relationship between the sheriff’s department and Denver Health is intentional so the agencies can punt accountability.

The sheriff’s department has come under fire for other high-profile deaths in the jail. Michael Marshall died in 2015 after deputies forcefully restrained him during a mental health crisis and he choked on his own vomit. In 2014, Marvin Booker died when he was put in a chokehold and tased.

“I commend the officers that were trying to get Mr. Taylor out. There were a lot of good people,” Lutz said. “But the powers that be have created the situation where things like this can happen, and no one can be held accountable.”

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