Report: Inmate at Salem prison died from flu due to neglect, ignorance of mental illness, dementia

Whitney Woodworth
Statesman Journal

Michael Barton spent his last day in Oregon State Penitentiary too sick to stand and too weak to drink water from a glass, surrounded in his cell by uneaten meals. 

By the next day, on Feb. 6, 2018, the 54-year-old Medford man was dead, having been rushed to the hospital for surgery. After four liters of MRSA-infected fluid were drained from his chest cavity, Barton went into multi-system organ failure and was pronounced dead at 7:31 p.m.

His painful, prolonged death could have been avoided, according to a recently released report from Disability Rights Oregon, a non-profit that advocates for the civil rights of people with disabilities.  

"DRO’s investigation of the circumstances that led to Mr. Barton’s death led us to conclude that he died because of negligence," Disability Rights Oregon staff attorney Joel Greenberg said in the report released Monday. "One medical provider after another failed to consider the impact of his mental illness and obvious dementia when called to assess his medical condition and complaints."

Michael Barton, 54, died in 2018.

A Department of Corrections investigation into Barton's care questioned preventative measures taken, staff response and whether he had appropriate housing and care.

Greenberg told the Statesman Journal that Barton's death is a symbol of a larger problem with how prison staff care for inmates with mental illness and dementia.

"Our belief is that what this case illustrates is a systemic issue that, in this case, produced the most tragic result possible," he said. 

He died from a treatable disease because he was neglected, disrespected and not believed, he added. 

"There will be other Michael Bartons unless ODOC changes a culture that allows its nurses to see patients with cognitive and mental health disabilities as less than human," Greenberg said in the report. 

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Prison officials dispute report

Oregon Department of Corrections officials declined to comment on the findings, citing its policy of withholding comment on pending or potential litigation. 

"The department will need time to fully review and assess the findings and determine any appropriate action," corrections spokeswoman Betty Bernt said. "We look forward to our continued partnership with Disability Rights Oregon in ensuring the safety and wellbeing of all adults in DOC custody."

In a letter to Greenberg, Oregon Department of Corrections director Colette Peters said Barton's death "profoundly and personally concerned and affected several of his peers and neighbors, as well as ODOC staff."

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She said she welcomes DRO's review of Barton's medical care but was disappointed that the organization only gave the prison a single business day to review the investigative report and respond to inaccuracies before releasing it to the media.

Peters said she also does not believe it is a fair or completely accurate review. She said her department identified significant factual inaccuracies in the report, most likely stemming from DRO's limited sources and an incomplete understanding of Barton's medical records. 

The DRO report said witnesses reported prison officials responded to Barton's death in a "hush-hush" manner. Media and the public were not notified of his death through the prison's typical notification process. 

History of mental illness

According to the report and prison records, Barton had a history of mental illness and had shown significant signs of dementia in the 17 months preceding his death. He was sentenced to prison in 2017 for robbing a bank and fleeing a police officer. Greenberg said signs of Barton's mental illness and dementia can even be seen in his botched robbery of a Medford bank.

Barton told his attorney he decided to rob the bank because he had run out of his psychotropic medications and had no money to pay for more. His attorney described the video of the robbery, showing Barton waiting "politely" in the bank while employees collected money and called police. 

"She further described how he walked out of the bank with little apparent understanding that he would be pursued while holding a red bank bag full of money," Greenberg said. 

After five months in prison, Barton was transferred to a special unit at the Salem prison to get special assistance from inmate helpers and mental health clinicians. He routinely struggled with simple tasks like how to open his unlocked cell door and getting water from his sink, according to the report. 

Tall concrete walls with guard towers surround the Oregon State Penitentiary, the state's only maximum-security prison, along State Street in Salem. Photographed on Wednesday, March 23, 2016.

Flu leads to organ failure

In January 2018, Barton began experiencing flu-like symptoms. 

"He was seen by a number of nurses and medical providers who ignored his increasingly panicked requests to be admitted to the infirmary," Greenberg said.

Barton cried and begged, saying he got dizzy drinking the water in his cell. Still, staff refused to admit him.

One provider was allegedly overheard stating, "I don’t want him in my infirmary where he can make other people sick.”

Greenberg said staff continued to misinterpret Barton's inability to understand or follow directions as malingering. 

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As his condition worsened, Barton became unable to leave his bunk to get water. Nurses checked in on him without taking vitals or entering his cell — allegedly a common practice at the prison. From their vantage point at the doorway, they were unable to recognize Barton's semi-comatose state, greying skin, swollen limbs and emaciated body, according to the report. 

The inmate helpers who visited Barton became increasingly concerned. His meal trays lay untouched on the floor of his cell, and he even needed help lifting his head to sip water for his medication. 

This alarmed one witness to the extent that he made a series of requests on Feb. 4, 2018, to get Barton urgent medical attention. The witness said they were told Barton could wait until his scheduled appointment the following morning. 

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When an inmate helper arrived to take Barton to his appointment the next day, he could not sit up. The helper had to lift him into the wheelchair and only made it a few steps before Barton's head flopped to one side. He lost consciousness and emptied his bladder. The inmate helper screamed for help and staff responded with a "man down" code.

He never regained consciousness and died the next day. 

The medical examiner did not perform an autopsy. The prison's chief medical officer concluded that Barton died from Influenza B, which led to MRSA empyema, which led to sepsis, which led to severe septic shock, which led to cardiopulmonary arrests, multisystem organ failure and severe anoxic brain injury. 

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Prison reviews death

Following Barton's death, DOC launched an investigation into his care. An unsigned report stated:

"(We) did not recognize that his patient was critically ill."

ODOC physician Reed Paulson's case review questioned eight out of 14 aspects of Barton's medical care, including preventative measures taken, staff response and whether Barton had appropriate housing and care. 

His review ended with the recommendation to increase medical staffing to appropriate levels to reduce unnecessary "mental fatigue and numbing."

"It is clearly demonstrated in this case that the fault does not lie in one person’s mistake, but rather highlights system failure that has affected many staff," he wrote. 

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Disability Rights Oregon officials agreed that Barton's death illustrated a system failure but argued that there should be fault attributed to individual actors. 

"Indeed, it is our belief that the conduct of the nurses who responded to Mr. Barton’s cell during the last days of his life was surely negligent, if not deliberately indifferent, to the harms that ended his life," Greenberg said.

Two witnesses, an inmate helper and a DOC employee, contacted Disability Rights Oregon with concerns about Barton's treatment and care. His death "deeply disturbed" many of the people working in his unit, according to the report. One witness recalled seeing a correctional officer break down in tears after learning of his death. 

Those who provided information said theywere concerned about retaliation from prison officials but felt they needed to speak up about the events leading to Feb. 6, 2018. 

Family members learned of Barton's death from a friend's Facebook post reading "Michael Barton RIP." They did not learn about the circumstances of Barton's death until DRO contacted them in June 2019. 

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"They are very concerned and hopeful that some substantive changes will be made so that this kind of thing doesn't happen again," Greenberg said. "They were quite adamant we use Mr. Barton's name. They thought it was important that he be recognized as a person with a name and a family rather than someone with a pseudonym."

Disability Rights Oregon officials are calling on the Oregon Department of Corrections to hire an independent prison health expert to review the investigations of Mr. Barton’s death, identify the factors that contributed to this loss of life, and recommend necessary changes to policies and practices.

They also are calling for the expert to issue a public report on the level of medical care provided to inmates with mental illness and developmental disabilities as preparation for helping ODOC implement needed changes within one year of the report’s publication. 

Peters said she did not believe the facts supported DRO's conclusion that the prison was negligent and fosters a negative culture. Peters also said she was deeply troubled by the organization's decision to include quotations from DOC's peer-review process in its report.  She invited DRO to meet with medical staff to discuss Barton's care. 

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Greenberg said the organization wants to see changes and help inform the prison on the circumstances of Barton's death. 

"The reason we wrote the report and the reason we are making it public is not to embarrass the Department of Corrections but to provide them with some information that they did not have," he said.

"We are hoping that culture and whatever created it, whatever contributed to it, can be reformed and changed for the better, and we hope to work with the Department of Corrections in the future to make sure that that happens." 

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For questions, comments and news tips, email reporter Whitney Woodworth at wmwoodwort@statesmanjournal.com, call 503-399-6884 or follow on Twitter @wmwoodworth