The staff at the Somerset County Jail did not follow jail policies as an inmate hyperventilated, apparently tried to choke on his own saliva, became unresponsive and ultimately died in his cell in 2014, according to a report from the Maine Department of Corrections.

Meanwhile, nearly two years after Joseph Daoust’s May 28, 2014, death at the jail in East Madison, the Office of the Maine Attorney General continues to conduct a criminal investigation into the case.

The report by the corrections department, completed in June 2014 and released last week to the Morning Sentinel after a Freedom of Access Act request, shows that there were “several areas of failure to assess and operationalize emergency medical services response” by jail personnel as Daoust died.

The report specifically says that the jail did not call a “code blue” to indicate there was a medical emergency when Daoust was found unresponsive, that on-duty staff did not make an attempt to see if Daoust had a pulse or was breathing before he was removed from his cell in handcuffs, and that the staff waited for an on-call nurse to arrive from her home to conduct a medical assessment “before initiating life-sustaining actions” and contacting an emergency medical services unit.

The report recommends a review of jail control logs and requirements to establish a better time frame for events.

Earlier this month, the county settled a lawsuit brought by Daoust’s girlfriend, Pamela Swett, in connection with the death.

The Department of Corrections report was based on a review of jail videos, inmate files, jail unit logs and incident reports, along with other documents from the jail.

The lawsuit was more detailed in specifics, including a cause of death for Daoust, while the report “strictly focuses on jail operations,” said Jody Breton, deputy commissioner of the department.

Breton said in an email last week the report is not a basis for criminal charges.

“If deficiencies are discovered, the report will require a corrective action response by the jail within a prescribed time limit,” Breton wrote.

Somerset County Sheriff Dale Lancaster, who was not sheriff when Daoust died, said in a written statement Tuesday that as a result of Daoust’s death, the sheriff’s office reviewed medical policies and provided the correctional staff with additional first aid and CPR training.

It’s not clear whether any jail personnel were disciplined after Daoust died.

Breton said disciplinary action for jail employees who do not follow policies is determined by the sheriff’s office, not the Department of Corrections.

Lancaster said he could offer only limited comments on personnel matters, but that “following our internal review there have been staffing reassignments and some employees who are no longer employed by Somerset County.” He cautioned that people should not “draw any conclusions regarding adverse employment actions that were taken by this administration. Individuals leave employment for a myriad of reasons.”

Tim Feeley, a spokesman for the attorney general’s office, said it is standard for the attorney general to review inmate deaths and that the Daoust case is still under investigation. He would not comment on how long it typically takes for the attorney general’s office to review inmate death cases, and said there was no information readily available about whether any past reviews of other inmate deaths in Maine have resulted in criminal charges.

Maine State Police have denied a request by the Morning Sentinel for a copy of the state police investigation report of Daoust’s death, saying release of the report would “interfere with criminal law enforcement proceedings.”

“It is always a tragedy when an individual dies while incarcerated,” Lancaster wrote. “It is emotionally hard for the families and it is emotionally difficult for the correctional staff. Once a death has occurred it is incumbent upon the sheriff and the jail administration to evaluate and assess jail operations.”

“In this particular case, Somerset County Jail policies were in place to deal with this medical emergency,” he said. “These policies were approved by the State of Maine Department of Corrections.”

The report, however, points out that while jail personnel didn’t violate state and federal corrections governing standards, the investigation “reveals several areas of failures to assess and operationalize emergency medical services response.”

FINAL HOURS

The report paints a grim picture of Daoust’s final days in the East Madison jail, where he was being held as a pretrial detainee from Franklin County on two charges of drug trafficking and one count of criminal threatening.

Dauost was admitted to the jail May 14 and didn’t have “significant behavioral problems” until the second week of his incarceration, when he began destroying property and disobeying staff directives.

“His behavior became increasingly more acting-out” and he was placed in administrative segregation.

A May 27 review by “mental health personnel” described him as “volatile, very unpredictable” and recommended “full restrictions stay in place.”

That night, the report says, Daoust was not following staff orders, refusing to wear a security gown and “engaged in repetitive attempts to hyperventilate.” The report says that as the night progressed, he continued to hyperventilate and also “began to develop large amounts of saliva in his mouth to ‘inhale and cause self-harm.’ ”

Written logs show that Gerard Bussell, a corrections officer at the jail, checked on Daoust at 1:48 a.m. May 28 and recorded that Daoust was no longer responding to him and “I could no longer determine if inmate Daoust as living, breathing flesh (sic).”

While he called other staff members to help, ultimately adding up to five officers, the logs and other jail information didn’t record accurate times for when the on-duty nurse was called or when an ambulance was called, the report says.

Jail personnel didn’t announce a code blue, which is used to identify a medical emergency, during the time when they found Daoust unresponsive on the floor of his cell. According to jail policy, it is protocol that the death of an inmate is treated as an emergency situation, the report says.

Bussell’s logs say Daoust was handcuffed, shackled, put in a wheelchair and taken to the admissions unit to be put on a diagnostic machine, which measures oxygen levels, pulse, temperature and blood pressure.

“At no time during this process do video tapes display … any attempts to determine that Joseph Daoust was ‘living or breathing’ while on the floor in his room,” the report says.

The report says “it should be noted” that when the on-call nurse was contacted at home, she was told the jail may have “had a medical emergency or ‘it may be more than that.'”

The video, written reports and other documents did not provide a consistent time for when Daoust’s body was found.

The report also states that an exact time when Bussell realized that Daoust was dead can’t be pinpointed. He was pronounced dead at 2:46 a.m.

LAWSUIT DETAIL

The lawsuit, which included sworn testimony from a number of people involved with Daoust as well as his autopsy report, is more detailed than the Department of Corrections report.

While the report, for instance, lists “method of death” as unknown, the lawsuit filed by Swett, reported on Jan. 28 in the Morning Sentinel, contended that Daoust suffered a pulmonary hemorrhage – bleeding in the lungs – after he was pepper-sprayed by jail staff. Daoust was pepper-sprayed twice in the days leading up to his death, according to the lawsuit, after his medication was changed and he began to behave aggressively.

The report doesn’t mention the pepper spray or other disciplinary measures taken against Daoust during his last days, aside from the segregation.

The lawsuit also notes Bussell checked on Daoust about every 15 minutes over a two-hour period in which he saw that Daoust was hyperventilating and lying on the floor.

The suit also said that Daoust was having respiratory problems for about two hours. While jail personnel checked on him at least six times during that period, they did not call for medical attention or enter Daoust’s cell to check on his well-being, the lawsuit said.

The report also does not address a concern brought up in the lawsuit, that Daoust was not wearing a blood pressure cuff and that while he was wearing a pulse oximeter on his hand, it was not being used correctly. It states, rather, that no attempts were made to help Daoust before the on-call nurse arrived.

Swett’s lawsuit, filed in April in U.S. District Court in Bangor, names then-Sheriff Barry DeLong and four corrections officers and states that the sheriff’s office denied Daoust the medical attention he needed and failed to get him mental and medical care while officers watched him die for nearly two hours.

Swett and her son with Daoust got a settlement of $850,000 from the county and bank fund of $550,000 to be set up for their son.

While Lancaster couldn’t comment on the lawuit, in his response to the corrections report Tuesday, he said that the review the department took of its medical policies after the death, in additional to its annual overall police review, “confirmed that all involved policies are sound and in keeping with all applicable state and federal standards.”

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