Two days before Terry West died at the El Paso County jail, he complained to a nurse of chest pain.
She told him he'd slept on his arm wrong and needed to stretch.
In the hour before West died, he screamed for help and vomited blood.
A nearby medical staffer walked away.
Inmates who knew West say the jail’s health care staff witnessed warning signs before he died June 27th, according to investigation records The Gazette obtained from Colorado Springs police and the Sheriff's Office.
A gastric ulcer — an ailment commonly treated with over-the-counter medications — turned lethal when it eroded the wall of the 57-year-old's stomach and hemorrhaged, an autopsy shows.
West's death and another inmate, who killed herself weeks earlier, again call into question the quality of care that those behind bars receive from the jail's for-profit medical contractor, Armor Correctional Health Services.
The company denies any culpability, saying its employees "followed all medically prescribed protocols." The deaths were "not the result of any action or inaction" by its staff, Armor said.
County officials, meanwhile, will soon choose a new provider after concluding that past lapses by Armor have endangered inmates' lives.
The Sheriff's Office "has absolutely no concerns" with how jail staff handled West or the woman who completed suicide, according to Detentions Bureau Chief Clif Northam.
But the investigative documents raise questions about whether authorities went far enough to determine what went wrong before each inmate died or if either could have been saved.
"You have the death of a citizen. Every stone should be unturned," said Erik Heipt, a civil rights attorney who specializes in jail deaths, after reviewing the details of the June suicide.
Documents kept confidential
The Sheriff's Office reviewed the circumstances of each death and concluded further investigation was not "warranted or appropriate," Northam said in a statement, provided to The Gazette by a spokeswoman.
The agency provided The Gazette with more than 70 pages of reports related to the deaths in response to a Colorado open records request.
When The Gazette sought further documentation, the Sheriff's Office stated that it had no internal files that assessed whether jail staff properly handled the deaths, but weeks later acknowledged that there are additional records.
Northam said a "critical incident review" is conducted within 30 days of an in-custody death, in which sheriff's investigators examine all records associated with the case and present their analysis at a debrief attended by everyone who was involved. "We look at the pros and cons, if any, with the purpose of discovering any issues that could have helped us prevent the incident and what, if anything, we could have done differently or better," he said.
Sgt. Deborah Mynatt, the spokeswoman, later clarified her first response: The Sheriff's Office has additional written materials associated with the reviews but won't release them, she said. Those documents are considered "work-product and/or attorney-client privileged materials" and are exempt from disclosure under the state's open records laws, Mynatt said in an email.
The agency also declined a request by The Gazette for an interview with jail officials familiar with the investigations.
Describing West's symptoms
Inmates told investigators that West complained about his health problems routinely in the six days he spent at the jail before a hemorrhaging stomach ulcer killed him, according to more records from Colorado Springs police.
One inmate, who witnessed the exchange between West and the nurse who suggested he stretch, said West was treated like "a piece of sh*t" when he raised concerns about his health.
West, who was homeless, was being held on charges including driving under the influence of drugs and criminal impersonation. He was in a wheelchair.
A day before he died, inmate Ray Warren recognized a symptom of the ailment that would kill West.
Warren told investigators he knew something was wrong when he saw black stool in the toilet while trying to help West in the bathroom. He tried to tell the medical staff who arrived to assist West, but they told him to leave, so he relayed the information to a deputy, he said.
West again complained of chest pain, records show. It was another symptom of the ulcer, which was near his esophagus, according to the autopsy report by the El Paso County Coroner's Office.
A nurse then assessed West, initially concerned that he had a heart issue. But his vitals were fine and an electrocardiogram screening showed nothing abnormal, the nurse told investigators.
Hours before his death, West told another inmate that he wasn't feeling well and believed jail staff had given him the wrong medication.
A third symptom — bloody vomit — came the morning West died, when inmates say he yelled for help as another nurse was making her rounds with a medicine cart.
Deputy Derek Barr had just helped West to the bathroom when the inmate threw up, the jailer reported to investigators. Barr called the medical wing when he saw the blood. The nurse proceeded with her rounds, he said.
A struggle with deputies
Barr wheeled West into the jail's medical section about 3:50 a.m., about 10 minutes after the deputy first made contact with West in the ward, records show.
There, West began acting erratically, according to multiple accounts.
He slid out of his wheelchair and onto the floor, commenting on how cool the ground was. When he refused to get up, Barr and another deputy lifted him back into the chair.
West appeared to become irritated, kicking his legs and punching himself in the face. He stood up from his chair and threw himself backward into a wall, then came to the ground, rolling around flailing his arms and legs, jail staff told investigators.
The nurse who assessed West a day earlier was standing by with another medical staff member. She reported that she couldn't examine West because he was moving wildly.
Barr tried to hold West's legs, struggling to put shackles on, while another deputy held his arms and secured handcuffs. West ignored commands to be still, Barr said.
The struggle lasted 60 to 90 seconds, Barr estimated. At least once, West asked for help in a hoarse voice, the deputy said.
West abruptly became still as soon as the handcuffs were on.
Jail staff released the restraints and tried unsuccessfully to resuscitate him. 911 was called.
West died about 4:33 a.m., the Sheriff's Office reported.
West "never indicated abdominal pain to any Armor clinician" or provided "any medical information or history indicating he was at risk of a gastric ulcer," the company's chief medical officer, Dr. Jimmy Fernandez, said in a statement provided to The Gazette by a spokeswoman.
"With no patient report, or documented history of abdominal pain and no other reason to suspect abdominal ailments, there was no way to know about or predict Mr. West’s condition," Fernandez said.
Colorado Springs police wrapped up their investigation of the case in September after the Coroner's Office attributed West's death to the ulcer.
The Police Department reviewed the death at the Sheriff's Office's request because use of force was involved. Police don't investigate civil liability, said spokesman Lt. Jim Sokolik.
West was seen by the jail's medical staff "multiple times," a CSPD investigator wrote. His death "was not the result of any potential criminal activity" on the deputies' part. Police didn't investigate the past medical calls, according to the report.
"I find that highly troubling," said Heipt, the civil rights attorney, who is not connected to the case but reviewed the death investigation documents at The Gazette's request. "Obviously, Armor or its employees could be culpable even if the Sheriff’s (Office) isn’t."
Heipt's Seattle-based firm won a $4.25 million settlement for the estate of John Patrick Walter, who died of prescription drug withdrawal at the Fremont County jail in 2014.
"I certainly see some red flags and potential signs of neglect and even deliberate indifference by medical staff," he said. "This man was clearly experiencing a life-threatening medical emergency. … I’d like to know why he wasn’t rushed to the hospital, or why an ambulance wasn't immediately called to the scene when he was screaming in pain and vomiting blood."
A messy divorce
Armor is one of a handful of companies that dominate the correctional health care industry which have faced claims of putting profit ahead of patients. Similar to other private providers, the Miami-based company has been accused of neglecting inmates at jails across the country.
Its contract with El Paso County was renewable for two more years. But the company's CEO told Sheriff Bill Elder in a May letter that it will cut ties with the county at the end of 2019 because the relationship has been "irreversibly damaged."
Elder has said he'd already decided to end the deal, worth roughly $7.5 million annually.
In an April notice to the contractor, the county said that blunders by Armor staff had left an inmate without vital medications and led to an outbreak of hepatitis A that infected several people.
Armor has said it spent hundreds of thousands of dollars to fix problems with the facility's medical system after the previous contractor, Correct Care Solutions, left a backlog of medical requests and other tasks when it departed in 2017.
A decision on the new provider is expected in the coming weeks, county officials have said.
'It had to be Terry'
Inmates who spoke to Colorado Springs police about West also aired concerns about Armor staff ignoring other medical complaints.
Armor has said that its employees are charged with providing care in a difficult environment.
Staff depend on what patients tell them, Fernandez said. Inmates might be under the influence of alcohol or drugs when they are screened, which can complicate things. They might also refuse to sign forms that allow the jail's health care team to request their medical records from outside providers, he said.
"As with any health care, the services we provide are based on cooperation and information provided to us by the patient," Fernandez said.
Northam, the Detentions Bureau chief, said West was "seriously ill" before he was booked into the jail and "was quickly identified by Armor's medical personnel as someone needing special attention due to chronic care needs."
Patient confidentiality laws limit the information authorities can release about an inmate's medical history.
A man who was a friend of West before he died said he was a diabetic. Others described West as having slow speech and sudden, jerky body movements or convulsions.
His risk of developing a gastric ulcer was high because of cirrhosis of the liver and a history of tobacco use, according to the Coroner's Office.
West had been incarcerated at the jail before, said West's friend, Kasper Reger.
Reger met West at the food pantry at Mount Calvary Lutheran Church, where he works. West often got into trouble with drugs — particularly meth, he said.
But Reger had tried to help, providing him with cars and places to stay. West often called him "Dad."
West called the church from jail June 24. Everything was going to be OK, he told Reger, and that he hoped to see him soon.
Reger saw a TV news report a few days later on the death of a jail inmate.
"Right away, I said, 'It had to be Terry.'"
'A joke' of an investigation
On June 4, 36-year-old Holly Peck was discovered hanging from the ladder of a bunk bed in a county jail cell.
A deputy found her during a routine inmate check that happened every 15 minutes, the Sheriff's Office has said.
She regained a pulse once paramedics arrived and was put on life support at a local hospital, where she died five days later.
Peck had five children and suffered from bipolar disorder, said her mother, Denise Willing.
Years ago, Peck had signed the children's custody over to her mother while battling drug addiction, Willing told The Gazette. But she'd been mostly drug-free for the past six years, her mother said.
Days before Peck was booked into jail, she attended the high school graduation of her 19-year-old daughter, the eldest of her children, Willing said.
"She was there for her graduation. Happy as a lark. As proud of her as she could possibly be. And then June 4, she’s technically dead," Willing said. "Holly wasn’t the type of person that was going to leave her children and me just up in the air with a whole bunch of questions and no reason for it."
Peck was arrested on May 28 on suspicion of a probation violation for identity theft, according to the Sheriff's Office.
The Coroner's Office deemed her death a suicide. She died because her brain was damaged due to lack of oxygen, according to the autopsy report.
When Peck entered the jail, neither jail security nor health care staff had "justifiable cause to place Peck under observation" to safeguard against self-harm, according to Armor.
"Ms. Peck presented no behavioral health warning signs upon intake and evaluation; nor did her responses to established psychiatric assessment protocols trigger a suicide-watch order," Fernandez said.
The Sheriff's Office's 22-page incident report regarding Peck's death primarily focused on how authorities responded once the woman was found.
"On some level, it was a joke," Heipt said after reviewing the report. "Whenever there’s a jail suicide, the first question that should come to our mind is whether the suicide was preventable. There was nothing in those 22 pages that addressed this very fundamental issue."
Colorado Springs-based attorney Josh Tolini, who's now representing the mother of the deceased woman, echoed that sentiment, saying the investigation appeared "incredibly minimal."
"This is a horrible tragedy where a mother of five apparently took (her) own life in the jail," Tolini said. "(There) doesn’t appear to be any effort to figure out what went wrong here, how did this occur, and what can we do to prevent this from happening again."
Before the ambulance arrived
In the roughly 20 minutes that elapsed from when Peck was found in her cell to when she was loaded into an ambulance and taken to the hospital, there were signs of dysfunction as jail security and medical staff tried to resuscitate her, records show.
They failed to utilize a neck brace to protect her from further injury, even as her head was adjusted to open her airway while trying to supply oxygen with CPR and and a mask.
Her neck remained exposed as two jailers pulled her out of the cell by her ankles and lifted her onto a backboard when paramedics arrived, according to the Sheriff's Office investigation.
A nurse later told a sheriff's investigator that the woman's body was in an awkward position, with her head nearly under the bed, so there was no room to put on the collar.
Fernandez said interrupting CPR to secure the brace would have been "potentially harmful."
Jail staff also grabbed an automated external defibrillator, a device that's used to restore a normal heart rhythm after cardiac arrest. But the attachments needed to use the device didn't fit, so they had to wait a few more minutes as a staff member grabbed a second one, the records show.
Though there was a delay in placing an AED on the woman, it wasn't used for its primary function — trying to reset a heart rate with a shock — because the machine suggested that no shock was required.
Given past missteps by Armor staff that were documented by the county two years ago, there are "really significant risks" with the contractor, said John Everlove, an emergency medical services expert who reviewed highlights of the suicide investigation.
In a 2017 letter to Armor, the county cited two more botched emergency responses. During both instances, the lead nurse "did not take charge of the situation," the county's Contracts and Procurement Division manager wrote. In one case, there was a delay in putting a neck brace on the patient and calling an ambulance. On the other occasion, the nurse struggled to set up the oxygen tank and perform CPR, the notice says.
In Peck's case, it's unlikely that the missing neck brace or AED slip up made a difference in whether she lived or died; however, the response appeared inconsistent with best practices, said Everlove, who works as a paramedic in Southern California.
"The standard of care for prehospital medicine is based on risk analysis, not based on definitive outcomes," he said. "We live in a world where we are trying to do the best that we can for the patients based on what we believe is wrong with them."
Peck's mother's attorney, too, expressed concerns about the potential stumbles at a time when minutes could've mattered.
"This is life and death that we’re talking about," said Tolini.