The Washington County Sheriff's Office has never experienced a string of inmate deaths quite like the one it's seen in the past two months.
The agency says that it usually only sees one death at the county jail in a year at most. This year, there have been three — and all since April.
The trend mirrors a larger statewide and national increase in in-custody deaths, and it's also dredged up issues previously identified in the county's jail health care systems.
On April 17, 23-year-old Bryce Bybee was found unresponsive in his cell during routine morning checks by jail deputies. First aid efforts could not revive him.
On May 24, 35-year-old Crystal Leuenberger died in jail custody less than 24 hours after she was arrested on suspicion of violating her probation.
Most recently, 51-year-old Ronald Ferguson was found unresponsive by jail deputies on June 1, before he had finished the intake process. Deputies noticed he wasn't breathing when they checked on him in the holding area.
On all three cases, the State Medical Examiner's Office has completed an autopsy, but no cause of death has been made public for any of these inmates.
When Pamplin Media Group asked what the holdup is in releasing that information, a spokesperson responded via email that they were "pending further testing."
In all three cases, the Washington County Major Crimes Team, made up of law enforcement from various agencies throughout the county, and overseen by the District Attorney's Office, is conducting an investigation.
However, the Washington County Sheriff's Office also stated that it is seeking a separate outside agency to investigate Ferguson's death. The agency says it is still in the process of identifying one.
For Bybee's death, the Sheriff's Office said it was also asking the Beaverton Police Department to conduct an independent investigation.
The last time three inmates died in a single year was in 2011, though police say they were not in a short span like this. Before this string of inmate deaths, the next most-recent in-custody death at the jail was over a year ago, in May 2021.
There were no in-custody deaths at the Washington County Jail in 2020.
The episode mirrors a larger national and statewide trend of increased in-custody deaths.
In 2021, Street Roots published a report that detailed a spike in deaths at Oregon prisons, pointing to inadequate healthcare systems in place inside of detention centers.
In 2019, Oregon Public Broadcasting, in partnership with Northwest News Network and KUOW, published a piece that showed a large increase in inmate suicides and deaths related to illness. That report also showed that larger national data show increases in fatalities at county jails and state prisons alike.
Local news reports from Seattle to Atlanta have highlighted similar upticks in in-custody deaths over the past five years.
History of neglect
Washington County has seen high-profile issues with its jail healthcare services, which have been contracted out to private firms since 1998.
In 2014, the Washington County Auditor's Office analyzed the jail's healthcare services following increases in service costs and significant overruns on the budget.
That audit found that the county did not adequately monitor its contractor, Corizon Health — formerly Prison Health Services — to ensure that it had enough staff on-site to provide adequate care to inmates.
In several instances, the audit found that the contractor was not meeting minimum staffing requirements laid out by the contract. But this was partly due to the county allowing flexibility in staffing levels that "was inappropriate for a contract of this nature," the 2014 audit report stated.
This understaffing led to more referrals of inmates to outside hospitals, pharmacies and other medical providers, further increasing costs, the audit showed. All the while, there was no mechanism in place to monitor these charges or enforce staffing levels, leading to skyrocketing costs.
The audit shows that from the 2007 through 2010 fiscal years, the total costs of running the jail's health services was over budget by several hundred thousand dollars. For external referrals and pharmacy costs alone, expenses grew from $400,000 in 2007 to over $1.8 million by the 2013 fiscal year.
The audit also found that Corizon Health was often substituting less qualified and less highly paid staff in some cases, "thereby increasing its profits at county expense," the report states. The county departments who were supposed to oversee the service provider did not properly monitor these trends, according to the audit.
The county has contracted with other healthcare providers since then, and the auditor's office conducted follow-up reports in 2015, 2016 and 2018.
At last check, the county had implemented most of the 27 recommendations made by the auditing staff to shore up these issues with the contract administration and oversight.
Those that were not implemented, according to the 2018 report, include a requirement to develop minimum staffing requirements for the jail's medical staff and providing a contract that allows the county the authority to require minimum staffing at that level.
In general, the audit and follow-up reports repeatedly highlighted a problem with allowing for-profit companies to operate inside of jails without oversight.
"A for-profit corporation's need to demonstrate that it can provide services at a lower cost than government, while realizing a profit, creates a natural tension between cost-control and healthcare objectives," the report states. "As a result, strong oversight by the government is essential to ensure that the vendor complies with its contractual obligation to provide adequate care."
The county currently contracts with NaphCare, an Alabama-based company that provides jail health services across the country. It was awarded the contract on June 1, after Washington County's previous contract with Correction Health Partners expired.
NaphCare was previously contracted by the county from 2015 to 2018.
Lack of records
While all this shakeup was going on, another high-profile death at the jail made national headlines. Madaline Pitkin, 26, died while in custody at the Washington County Jail in 2014 after repeatedly seeking medical treatment for drug withdrawal symptoms.
Her family sued the county and Corizon and were awarded a $10 million settlement in 2018.
Sgt. Daniel DiPietro, a spokesperson for the Washington County Sheriff's Office, pointed out that the jail is accredited and routinely inspected by outside agencies, including the National Commission on Correctional Healthcare, which reaccredited the jail on April 6.
The county health department, district attorney and court security inspections are all also regularly conducted, "as a proactive measure to ensure we operate the safest jail possible," DiPietro said.
As for these latest deaths, the agency declined to comment, citing open investigations.
"The jail and WCSO take all (adult in custody) deaths seriously, and each incident has unique factors to be determined on a case-by-case basis," DiPietro said in a written statement. "For the recent deaths, those matters are still under investigation, which, once concluded, will be able to provide better insight to the jail on further factors, if any, to be taken into consideration to ensure the health and safety of AICs."
The spate of deaths has also revealed a lack of readily available data on deaths at county jails, both locally and across the state.
Until 2019, the Washington County Jail reported all in-custody deaths to the U.S. Department of Justice. In 2020, however, the Bureau of Justice Statistics program that tracked this data was defunded.
There is no comparable state agency that tracks jail deaths — only those reported at state prisons and federal penitentiaries through the Oregon Department of Corrections. That left the Washington County Sheriff's Office with no agency to which it must report in-custody deaths.
Since last year, the job of tracking inmate deaths has been taken up by the Oregon State Sheriff's Association.
An official with the association told Pamplin Media Group it does not have enough years' worth of data to answer the question of whether there has been a statewide increase in deaths, or whether Washington County's in-custody deaths are higher than average. However, the association is lobbying the Oregon Legislature to make pretrial detainees eligible for Medicaid waivers if they need care while in custody.
"Oregon sheriffs take the care of adults in their custody very seriously," executive director Jason Myers said. "OSSA has long advocated for a Medicaid waiver for pretrial detainees and is currently on a legislative workgroup that will be making recommendations to the Legislature on jail healthcare and funding for these services."
Editor's note: An earlier version of this story misstated the year of Madaline Pitkin's death. She died in 2014. The story has been corrected.
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