Watchdog report: Questions persist over jail health care
Amid inmate complaints and mixed official reports, sheriff cites improvement.
By Christina Jewett and Dorothy Korber -- Bee Staff Writers
Published 2:15 am PST Sunday, December 18, 2005
Story appeared on Page A1 of The Bee
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Anthony Jose Gonzales entered the Sacramento Main Jail last year with 10 fingers. He left with nine.
During the week after his arrest for drug possession, a splinter in his middle right finger became infected. He asked - then begged - for medical attention as the finger swelled to twice its normal size, turned green and oozed pus, he says. Jail and court documents corroborate his account.

Gonzales, 39, signed up for sick call, but no doctor saw him. He tried to show guards the wound, he says, but was rebuffed. To ease the pain, he resorted to plunging his throbbing hand into the cold water of his cell toilet.

It finally took a judge's order last Dec. 6 to get Gonzales immediate medical care. But it came too late. A week later, the finger had to be amputated.

"I came in like this," Gonzales said, spreading the fingers on his good left hand during a recent jailhouse interview. His injured right hand, with its uneven stump, rested on the stainless steel ledge of the visiting booth.

Gonzales' case is symptomatic of issues raised by a Bee investigation into health care at the Main Jail. They cover a broad medical spectrum: patients' access to care, record keeping, drug management, staff accountability. The problems have been laid out repeatedly in inspections and reports since the jail lost its medical accreditation in 2001.

Sheriff Lou Blanas says medical care at the jail improved after his department took over Correctional Health Services from the county coroner in 2003. In a letter to The Bee, Blanas expressed pride in "the existing conditions in our correctional health system" and noted that he has increased the jail medical staff.

Blanas cited a December 2003 inspection he described as glowing. Indeed, county health inspectors did praise the sheriff: "Overall, since reorganization of the health services under the Sheriff's Department administration, considerable progress has been made in the review and revision of policies and procedures as well as frequent, documented interdisciplinary administrative meetings."

On the next page of the report, however, the inspectors criticized the jail for making inmates wait up to three days for a "face-to-face opportunity" to see a doctor or nurse. They said the outdated pharmacy system is "inherently subject to human error." And they noted that jail nurses continue to collect forensic evidence for prosecutors, a procedure that is barred by state regulations.

Year after year, other inspections have touched on similar concerns. The impact was illustrated in medical records, court filings and internal jail communications reviewed by The Bee, as well as in interviews with current and former jail doctors and nurses, civil rights lawyers, experts in correctional health care, and inmates and their families.

One key document is a report by an evaluator for the Institute for Medical Quality, brought in by the Sheriff's Department to determine whether its health care met national accreditation standards. The 2003 report found an array of shortcomings that would prevent the jail from earning the voluntary medical accreditation achieved by about half the jails in California.

Nearly three years later, Sacramento officials say accreditation is a goal they still are pursuing.

Dr. Wayne Thom, a UC Davis physician who also worked part-time at the downtown jail last year, called the problems there entrenched. Thom described a health care system where "it's not my job" too frequently was the response to a request for help from an inmate or a doctor.

"Basically, it's compartmentalized and there's no feeling that patient care is paramount," Thom said. "If something is not directly your responsibility, you're not likely to help a patient. There's no camaraderie, sharing of workload nor sharing of knowledge for the overriding goal of patient care."

Such allegations raise a fundamental question: Who makes medical decisions in a custody setting, the doctors or the jailers? The answer depends on whom you ask.

Who's in charge is in dispute
The deputies call the shots, according to Dr. Neil Flynn, a physician at the UC Davis medical school who treats HIV/AIDS patients from the jail.

"I find the jail medical system is lax," Flynn said. "It's OK to make you suffer, to allow lapses of your medications. It's focused on being punitive. And the deputies have an overriding say on how patients are treated."

The doctors are in charge, according to John O'Shaughnessy, chief of Correctional Health Services for the Sheriff's Department.

"I think we do an amazing job," O'Shaughnessy said during a meeting between jail administrators and Bee reporters. "This population doesn't have a history of taking care of themselves."

O'Shaughnessy spoke of the challenges of providing individual care in a jail that houses about 2,300 and annually books about 53,000, many with long-term addictions to drugs or alcohol. Jail inmates are a medically challenging population, some of them already chronically ill, who may get health care only while in custody.

Gonzales, who is homeless and a methamphetamine user, learned he was diabetic while hospitalized for the amputation.

Other medical cases reviewed by The Bee are similarly complex: HIV-positive inmates who require complicated drug cocktails, epileptics with special housing needs, disabled patients whose walkers and wheelchairs could be used as weapons.

Rewards in jailhouse health care are numerous, said Dr. Sandra Hand, the facility's medical director.

"It's a very fulfilling job - you're dealing with a population at need and at risk," Hand said. "This population doesn't get care outside. We can take people in really disadvantaged situations and help them."

But others say medical treatment at the jail is not only substandard but sometimes harmful. Those expressing concern about inmate care range from public defenders who speak out in court to doctors from area hospitals.

Anthony Gonzales finally got treatment for his infected finger when his lawyer, public defender Kelsey Johnson, pointed it out at a Superior Court hearing: "Your honor, before we begin," she told the judge, "I'd like the court to note Mr. Gonzales' finger. It's swollen to about twice the size. It is seriously infected."

"I can see it," responded Judge Michael P. Kenny, according to court records. He ordered immediate care for the finger.

Another inmate's medical care prompted public defender Linda Parisi to forgo a trial and ask for immediate sentencing to state prison - to get her client, Nou Thao, access to better medical care. While awaiting trial for killing her husband, the ailing Thao had spent months in the jail infirmary recovering from self-inflicted wounds.

At a hearing last year, Parisi told the judge she believed a jury might well acquit Thao as a victim of battered women's syndrome. Even so, Parisi said, Thao's "medical needs will be better met in the (state) Department of Corrections, so we are asking for immediate judgment and sentencing."

Thao pleaded no contest to voluntary manslaughter.

Dr. Neil Flynn wrote to the Sacramento NAACP last year, offering his expertise free as an advocate for better health care at the jail. His letter describes an AIDS/HIV patient, Jackie Zachary, who died Sept. 9, 2003, after spending two weeks in the jail infirmary with fever, difficulty breathing, weakness and weight loss.

Zachary should have been transferred to the hospital sooner, Flynn argued, writing that "it is quite possible that medical care in the jail did not meet minimum standards of care and contributed greatly to his death."

Although it was not the case for Zachary, Flynn in an interview also criticized the jail for not ensuring that HIV-positive inmates consistently receive their medications; interruption of those medications can lead to drug-resistant infections and death. Flynn described such interruptions as common at the jail.

"A sentence of jail time should not also be a death sentence," he wrote in his letter.

Hand disagreed with Flynn's view. "We rarely run into any difficulties in getting medications continued for HIV patients," she said.

Inmates file county claims
Individual cases help frame the medical issues at the county jail.

Peter Bruno Heines, an epileptic inmate, alleged in a lawsuit that his repeated request for a bottom bunk was ignored. He fell head first from the top bunk during a seizure, fracturing his foot and spraining his hand, according to court documents.

Heines, then 40 and in jail on a burglary charge, sued the county over the Jan. 8, 2004, incident and received a settlement in July that cost taxpayers $16,290.

"His injuries could not have been a surprise to anyone at the Sacramento County Main Jail, given that jail medical staff explicitly noted that he needed to be placed in a ... bottom bunk on three separate occasions within 48 hours of his fall because of his medical needs," Heines' suit states.

In its court response, the county made a sweeping denial of all charges then settled eight months later.

As in other individual inmate cases raised by The Bee, jail supervisors cited patient confidentiality when asked about Heines. However, talking generally about the situation, Chief Deputy Bill Kelly - who oversees the jail - said inmates decide who gets which bunk.

"We have no control once they go in their cells," Kelly said. "Disputes about where they sleep are worked out in the cell."

Heines' lawsuit began as one of 90 claims filed against the county since 2000 by Main Jail inmates. The claims allege lack of medical care, improper care or negligence.

Sacramento County has closed 55 of the claims - rejecting most of them as unfounded - while another 35 await resolution, according to the county Risk Management Office.

The total cost to taxpayers so far is more than $216,000, but only $20,000 of that was paid out for actual injuries - in four cases.

The Sheriff's Department points to that tally as an indication that Correctional Health is doing a good job.

"This figure reflects a statistic many medical care facilities would envy and sets a new high standard for Correctional Health facilities of comparable size," said sheriff's spokesman R.L. Davis in an e-mail to The Bee.

But civil rights attorneys contend that the number of successful cases reflects just a fraction of the potential cases that cross their desks.

The cases are very difficult to pursue, said Sacramento lawyer Mark Merin, who handled a class-action lawsuit challenging jail strip searches. That case settled for up to $14 million, the largest settlement in the history of the Sheriff's Department.

"Suing the jail when there's a medical problem is almost impossible," Merin said. "The problem is you have someone who doesn't have inherent credibility dealing with people who have badges, and it's one against many."

Hernandez Palomino, an immigration detainee, was forcibly removed from his wheelchair on Sept. 18, 2004, after he argued with guards about his need for the device. A jail physician had discontinued both the chair and a neck brace, according to a deputy's incident report obtained by The Bee.

Three deputies assisted in "removing the wheelchair from Palomino" by twisting his wrists behind him and putting him on his back in his bunk, the report says. Palomino also was ordered to undergo discipline for insubordination.

Hours later, nursing supervisor Carolyn Buonauro told The Bee she found the 37-year-old inmate crying in his bed, desperate to use the toilet. She tested his legs and found them useless - atrophied and without sensation.

"He was pitiful," Buonauro said. "I know you don't always want to believe everything inmates say, but he was telling the truth. I told the deputy to get him a wheelchair."

She also got Palomino's discipline canceled, she said.

The jail's pre-accreditation review cites a similar case and notes that denying a disabled patient a wheelchair could conflict with federal law. It suggests that the medical director should be the only one authorized "to deny any appliance necessary to assist in the activities of daily living."

Whether or not a patient gets a wheelchair is up to doctors, not deputies, said O'Shaughnessy, the health services chief. "Medical autonomy is the line in the sand that we don't let (custody staff) step over," he said. "They don't have medical degrees, and we won't listen to them on medical questions."

'Continuity of care' an issue
Among the criticisms in the jail's pre-accreditation review is a failure to provide "continuity of care" from arrival at the facility to discharge. "The health records documented sporadic care, rather than a system of care," the report states.

Flaws in the jail's system of dispensing drugs also were detailed in the pre-accreditation review, as well as in reports filed by county health inspectors in late 2003 and by the Sacramento County grand jury in 2004.

The issue took on dramatic overtones during a hearing in Sacramento federal court Oct. 5. Transcripts show that inmate Jesse Sanders Jr. suffered a grand mal seizure in the courtroom moments after his attorney told the judge that Sanders had not received proper medication while in the downtown jail.

Sanders, 46, was in court that Wednesday for a pretrial hearing on weapons and drug charges. His lawyer, Charles Bloodgood, had just described his client's condition after nearly three months in jail: "I am very concerned about his health. ... He is not getting his meds. He looks bad."

When Sanders fell to the floor in convulsions, Judge Edward J. Garcia called for a recess. After paramedics removed Sanders from the courtroom, Garcia asked for a full report on the inmate's medical condition.

"It would be horrible if the defendant were to suffer a seizure such as we saw this morning in the presence of the jury," the judge said.

A month later Bloodgood made his report to the judge, relaying information from a jail doctor, Asa Hambly. In court, Bloodgood said Hambly told him he had originally given Sanders his accustomed dosage of anti-seizure medicine, but "someone changed the prescription and dropped it down."

Sheriff's spokesman Davis said there would be no comment since Sanders' criminal case is a matter of pending litigation.

Inmate Ricky Kirk, in jail on a domestic violence charge in 2004, had cut his hand at the time of his arrest. The wound was cleaned and covered with a dressing when Kirk entered the jail but then left untreated for three and a half days - despite his repeated requests for care and an order by jail medical staff that it should be cleaned and redressed daily - according to UC Davis medical records and his pending federal lawsuit against the Sheriff's Department.

Eventually his "grossly infected right palm" required three surgeries over a week's time to dredge skin and muscle from his arm and necessitated a large skin graft from his thigh, according to medical records.

Interviewed at home, Kirk said he signed up for jail sick call three times but was never seen. The wound, discolored and foul-smelling, finally caught the attention of a guard who notified medical staff, according to Kirk.

"Regardless of what I was arrested for, I'm there with an injury, pleading for treatment," Kirk said, displaying a scar stretching from his wrist to his elbow. "Their responsibility was to treat my hand."

Kirk, 39, filed a civil rights lawsuit in Sacramento federal court alleging that his constitutional rights were violated. That suit cites a benchmark 1976 Supreme Court case, Estelle v. Gamble, which held that "deliberate indifference" to a prisoner's medical needs violates the Eighth Amendment's prohibition against cruel and unusual punishment.

Attorneys for the Sheriff's Department responded to the suit in a court document, denying the bulk of Kirk's claims and saying his "carelessness and negligence" contributed to his injury. The response also says sheriff's officials acted in good faith and therefore had some immunity from the claims.

Kirk's lawyer, Sacramento attorney Stewart Katz, has handled multiple cases involving medical and psychiatric care at the Main Jail. Katz described the attitude of jail staff as callous, a point he also made in his current federal suit against the jail on behalf of three inmates who committed suicide.

"There's an institutional bias toward letting people suffer," Katz said in an interview. "Their mantra is 'We're not running a hotel,' to which my response is, 'You're not running a kennel.' "

In-custody health care has the same goal as medicine practiced anywhere else, countered Shelley Jordan, director of nursing at the jail.

"Nursing is not concerned with whatever crime (the inmate) is accused of," she said. "Our position is they are patients. Our position is to provide care."

The Kirk lawsuit alleges the jail has "a custom, practice or policy of poor wound care, which results in serious injuries and amputations."

Director defends wound care
Three amputations in 2004 - Anthony Gonzales lost a finger and two other inmates lost toes - alarmed nursing supervisor Buonauro, who started working at the Main Jail in the summer of 2002.

She recalls thinking: "People are getting their fingers and toes cut off. What's going on?" She asked her supervisors, she said, but felt their responses focused more on legal liability than health care.

"They didn't want to hear about problems," she said. "Meanwhile, the nurses kept coming to me and saying that things weren't right, so I would look at the patient and look at the chart and send an e-mail about problems I saw."

Hand, the jail medical director, defended the facility's protocol for treating wounds to The Bee. "Our policy is to provide wound care to the standard of what is given anywhere," she said.

Buonauro said she pushed for answers up the chain of command. In time, she took her concerns to top administrators in the Sheriff's Department, she said. On Jan. 5, she also met with members of the sheriff's Community Advisory Board.

"The things I brought to their attention could have been fixed on the spot," she said, "but I learned that if you try to address a problem, you are considered a problem."

Sacramento City Councilwoman Sandy Sheedy was among the advisory board members who met with Buonauro. Sheedy said the nurse's concerns struck her as a personnel matter, thus out of the board's purview.

Sheriff's officials opened an internal affairs investigation into Buonauro's allegations of medical wrongdoing and retaliation. The department's summary of the probe says sheriff's investigators did not have the "necessary training, expertise, experience or education" to look into the medical issues she raised.

The investigation denied Buonauro's claim of discourteous treatment from deputies. It also noted that she was "boisterous and disruptive" in relaying her concerns about medical management.

Buonauro left the jail in February on a stress disability in a still-pending worker's compensation case. She said she was frustrated and worried about payback for her whistle-blowing and has since found another nursing job.

Many of the issues voiced by Buonauro had been raised two years earlier in the pre-accreditation report. At the jail's invitation, Rebecca Craig toured the facility to document problems that needed correction before hosting a full accreditation team.

Craig wrote a pointed summary of what she saw during her three-day visit: Nurses were confused. Medical records were hard to find. An inmate who was "actively suicidal" was not referred to mental health staff.

Craig found that nurses' files noted that inmates needed follow-up care - but there was no indication the patient was seen again. She described the coordination of services as problematic, though she did report, based on her interviews, that the custody staff was being careful not to interfere with medical decisions.

Craig, who has changed jobs since evaluating the jail, declined to elaborate on her findings.

Although accreditation of jail health services is not mandatory, experts in correctional medicine said it provides some safety net in case of a lawsuit. It helps the medical unit prove it abides by the Eighth Amendment and is not guilty of "deliberate indifference," said Paul Persons, a Chico-based lawyer who has sued 20 county jails across the state on civil rights grounds.

"Actually, I think accreditation sets somewhat minimal standards which should be met anyway," Persons said.

Correctional Health chief O'Shaughnessy said he plans to seek accreditation, but two issues stand in the way.

The first relates to the jail's pharmacy, where nurses still pour pills out of bulk bottles and keep records by pen and paper. Craig's report calls the jail's pharmacy system "inadequate" and notes that it is the medical unit's main source of grievances.

O'Shaughnessy said the staff is looking into modernizing and computerizing the pharmacy.

The second reason the jail has not sought accreditation, he said, is that jail nurses still collect blood and DNA samples from patients that are used as evidence by prosecutors.

Though once a common practice in jail clinics, Sacramento is the last large jail in California where nurses who provide health care also collect forensic evidence. Craig calls the practice inappropriate.

O'Shaughnessy said his department is exploring contracting out for this service.

Access to sick call criticized
Authority over the jail's medical system has changed hands several times. The Sheriff's Department controlled it until 1982, when then-Sheriff Duane Lowe relinquished it to other county officials. After the jail lost its medical accreditation in 2001, the county coroner took over the health program.

A year later, Sheriff Blanas pushed for authority over Correctional Health, which the supervisors granted him in January 2003. "I can't have accountability without control," Blanas said at the time.

Chief O'Shaughnessy has held his post four years; Medical Director Hand for three years. Both worked under the coroner and shifted to the sheriff.

Impetus for that move came amid criticism and finger-pointing over seven jail suicides in 2002. In the 2000-2002 period, the Sacramento jail's suicide rate was the highest among California's 11 largest jails - nearly four times that of Los Angeles County - according to the federal Bureau of Justice Statistics.

Another problem on the coroner's watch, according to a county health inspection, was limited inmate access to medical care during sick call - when doctors and nurses see patients who sign up in advance.

Since regaining authority over Correctional Health Services, Blanas said in his letter to The Bee, its staffing has increased by 34.5 positions, to a total of 159.5 positions. The correctional health budget also increased during that period, from $28 million in 2002 to its current $32 million.

Blanas also pointed to the June 2004 county grand jury report, saying that it "gave the medical systems a clean bill of health."

That report, issued in the aftermath of the spate of suicides, said there had been improvement in lines of communication between health workers and guards. It also praised the staffing increases and the creation of a Suicide Prevention Task Force.

Despite the changes, four inmate suicides have occurred in 2005.

Sick call problems also were found to persist in the the December 2003 county inspection. It said that while inmates' access to non-emergency care had improved, they sometimes waited three days for the urgency of their complaint to be assessed.

The pre-accreditation report, written shortly after the sheriff took over Correctional Health, noted that clinic staffers were afraid to go into cellblocks to sign up inmates and that deputies sometimes directed inmates to handle the sick-call signup lists.

In interviews, former jail health staffers told The Bee that patients were simply crossed off the list if a doctor did not have time to see them all.

Maryann Save, a registered nurse who worked at the jail on a contract basis for eight months last year, said a patient might miss several sick calls in a row because his name was on the bottom of the list.

"Say someone had a serious infection," Save said. "I would put him on the list to see the doctor. Then I'd be off a day or two, I'd come back and he wouldn't have been seen. I'd go and look and his name would be crossed off the list."

The sheer numbers of patients sometimes dictate who is seen and who is not, jail administrators say.

"On any given day, we have more people who want to be seen than we can see," said Jordan, the nursing director. "People are sicker now, and we are dealing with more complex care."

Inmates often treated off-site
Infirmaries at many other jails in California manage to see inmates at sick call much more often, according to a Bee analysis of data from the state Department of Corrections and Rehabilitation.

Across California last year, the data show, each inmate saw a medical professional during sick call an average of 3.7 times every four weeks - almost once a week. The average rate for Sacramento County's jail facilities was about once every six weeks.

O'Shaughnessy said the comparative sick-call statistics surprised him and speculated that Sacramento's jails may use different counting methods.

On the other hand, Sacramento's jails are much more likely than other jails to send inmates out for medical care, according to the 2004 state data. Sacramento County transported patients offsite more than 7,000 times that year. For the size of the jail population, Sacramento's rate of off-site transfers was three times the state average and the highest in California.

There are financial implications for sending so many patients away for care, said Persons, the civil rights attorney.

"If they're outsourcing at three times the normal average, that's expensive," he said.

The daily rate for sending an inmate to UC Davis Medical Center is $6,386, O'Shaughnessy said. That compares to $2,070 a day at San Joaquin General Hospital in Stockton, a 50-mile trip from the jail. O'Shaughnessy instructs his staff to use the cheaper Stockton facility except for pregnancies, cardiac care and 911 crises.

O'Shaughnessy attributed the higher rate of sending patients out for care to a more conservative medical philosophy - and a desire to avoid legal problems down the road.

"If they need it, we send them out," he said. "It's costly but a good practice medically."

Some jail health workers suggested another explanation: Inadequate or sporadic treatment can lead a treatable problem to deteriorate and sometimes trigger a trip to the hospital - as it apparently did in the case of Anthony Gonzales' infected finger.

"These things can evolve in a very short period of time," said Thom, the UC Davis physician who worked briefly at the jail last year. "The infection can lead to compartment syndrome and necrosis. Infections of upper and lower extremities, if not managed carefully, can get worse quickly and lead to amputation."

Thom blamed what he described as "gaps and lapses in care" for ailments worsening that shouldn't. As a doctor, he said he's used to ordering certain treatments and expecting those orders to be carried out. At the jail, he said, that wasn't always the case.

"If they're dropping the ball in every phase of the game," he said, "it's hard to pinpoint who is responsible."

WHAT THE INSPECTORS SAID
The Sacramento County Main Jail is inspected periodically, and its medical unit is no exception. Here is a sampling from inspectors' reports on health care at the jail:
Institute for Medical Quality's pre-accreditation report, 2003

* " ... It appears that the (Sheriff's) Department has been extremely careful to not interfere or question medical or mental health decisions. This is commendable and speaks well regarding the current command structure."

* "At the time of my visit, I was provided a written quality improvement plan. Unfortunately, none of the staff nurses interviewed were aware of the plan or any of the studies."

* "In brief, it appeared that the nursing staff did not recognize impending delirium tremens (DT's)."

* "The director of medical records reported instances when sick call lists are not returned. ... These lists are the only proof the inmates are afforded the opportunity to request care."

* "The practice of ordering treatment without a documented reason is fraught with potential legal liabilities."

* "The health records documented sporadic care, rather than a system of care. The majority of intake medical screening that indicated the need for follow-up lacked any further notation concerning care."

* "Sacramento is the only large county facility in the state that continues to use licensed health staff employed by the department to collect forensic evidence."

* "The Sacramento system continues to rely on purchasing and pouring (medicine) from bulk containers. There is no mechanism for accountability of stock drugs."

Sacramento County Health inspection, 2003

* "Specifically, health services are demonstrating increased flexibility to address changing condition(s) in the jail."

* "Since the previous inspection, access to non-emergency sick call services appears to have improved. However, a face-to-face opportunity to determine the urgency of an inmate's complaint does not always occur on a daily basis. It is estimated that the longest waiting time is three days."

* "Although pharmacy services meet minimum standard, it has long been recognized that the size of the system and evolving industry standards, particularly as they relate to avoidance of medication administration errors, demands modernization of the system."

State Board of Corrections biennial inspection, 2004

* "Health care services have been reorganized into the Sheriff's Department, which enhances a team approach toward responding to suicide issues and allows the sheriff's staff to hold health care staff more accountable."

* "Title 15 Section 1206 requires that ... forensic medical services - including drawing of blood alcohol samples, body cavity searches, and other functions for the purpose of prosecution - shall not be performed by medical personnel responsible for providing ongoing health care to inmates. Interviews with health care and custody staff indicate that this is still occurring."

Sacramento County grand jury report on jail psychiatric services, 2004

* "In the spring of 2003, the reorganization of jail health services resulted in the transfer of management from the coroner to the sheriff. The improvement in coordination and communication between the health and custodial staff has been noted by the chief administrators and staff members, and is verified by the less frequent health care complaints made by inmates."

* "Problems are solved more rapidly because of the open lines of communication and the frequent meetings between health care and custodial staff and their administrators."

* " ... There are some serious problems with the storage of drugs and the dispensing program at the Main Jail."

Note: The Sacramento Sheriff's Department controlled jail medical services until 1982, when the responsibility was relinquished to other county officials. In December 2001, after the jail's medical accreditation lapsed, the county coroner took over authority for health service. Then, following an unprecedented seven jail suicides in 2002, Sheriff Lou Blanas took over Correctional Health Services in January 2003.

Related documents:
" Sacramento County - Main Jail inspection report, Feb. 22, 2002
" Pre-accreditation review of Sacramento County Adult Detention Facilities, Feb. 19-21, 2003
" Sacramento County - Main Jail inspection report, Dec. 5, 2003
" Letter from Dr. Neil Flynn regarding inmate Jackie Zachary, Feb. 12, 2004
" Board of Corrections inspection of Sacramento Sheriff's Department detention facilities, July 8, 2004
" Transcript related to State of California vs. Anthony Jose Gonzales, Dec. 6, 2004
" Transcript related to U.S. vs. Jesse Sanders, Jr., Oct. 5, 2005

About the writer:
The Bee's Christina Jewett can be reached at (916) 321-1201 or cjewett@sacbee.com; Dorothy Korber can be reached at (916) 321-1061 or dkorber@sacbee.com. Staff writer Phillip Reese contributed data analysis to this story.