El Paso County jail death remains a mystery

El Paso County Jail (Gazette file photo)

The estate of a woman who killed herself while incarcerated at the El Paso County jail last summer has threatened the county with a multimillion dollar lawsuit, saying her death was caused by the “deliberate indifference” of the Sheriff’s Office and the “negligence” of its former health care contractor.

The claimants, including the estate of 36-year-old Holly Peck, are demanding $10 million in damages from the county and inmate medical provider Armor Correctional Health Services, Colorado Springs-based attorney Josh Tolini wrote in a Dec. 2 letter to the county.

Peck, who was arrested on May 28 on suspicion of violating probation for identity theft, was found unconscious in a cell with a bed sheet around her neck on June 4 and later died at a local hospital.

She had five children and suffered from bipolar disorder, her mother, Denise Willing, previously told The Gazette.

“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,” said Willing, who hired Tolini after her daughter’s death.

A Sheriff’s Office spokeswoman declined to comment on the claim letter, saying the agency does not comment on pending litigation.

Detentions Bureau Chief Clif Northam has said the agency conducted a thorough review of Peck’s death and “has absolutely no concerns” with how jail staff handled the incident.

Miami-based Armor previously told The Gazette that Peck’s death was “not the result of any action or inaction” by its staff and that its employees “followed all medically prescribed protocols.”

The county Coroner’s Office deemed her death a suicide. She died of brain damage from lack of oxygen, according to the autopsy report.

But Tolini wrote in the letter that jail security and medical staff were to blame for the “willful and wanton wrongful death for this pretrial detainee.” Those involved included jailers who decided where Peck would be housed and medical workers who were assigned to monitor and evaluate her, he wrote.

“There doesn’t seem to be anything from (the Sherriff’s Office) to determine why this happened and how we can prevent this from happening again,” Tolini said.

The death of Peck and another inmate, who died of a hemorrhaging gastric ulcer weeks later after repeatedly complaining about his health, highlighted concerns about the quality of care during Armor’s tenure at the jail.

Last spring, the family of a woman who died after a jail stint in 2018 threatened to sue the county and contractor for $5 million, saying she would be alive if medical and security staff hadn’t “abandoned her in the middle of a medical crisis.”

In November, a 32-year-old man died after he was found hanging in his cell.

The latest legal threat comes as another health care provider, Tennessee-based Wellpath, takes over at the jail under a one-year, nearly $8.7 million contract that began this month. Meanwhile, Sheriff Bill Elder is working on an overhaul of the jail’s medical model that would put the care of inmates in the hands of local providers, instead of corporate correctional giants.

The tumultuous relationship between Armor and the Sheriff’s Office ended at the close of 2019, after the company’s CEO told Elder the multimillion dollar deal had soured beyond repair.

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,” Armor’s chief medical officer, Dr. Jimmy Fernandez, has said.

A deputy found Peck during a routine inmate check that happened every 15 minutes, the Sheriff’s Office has reported.

She regained a pulse once paramedics arrived and was put on life support at the hospital, where she died five days later.

In the roughly 20 minutes that elapsed from when Peck was found in her cell to when she was loaded into an ambulance, there were signs of dysfunction as jail security and medical staff tried to resuscitate her, according to records provided to The Gazette by the Sheriff’s Office.

They failed to utilize a neck brace to protect her from further injury, even as her head was adjusted to open her airway to supply oxygen.

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, the Sheriff’s Office investigation shows.

A nurse later told a sheriff’s investigator that Peck was in an awkward position, with her head nearly under the bed, so there was no room to put on the collar.

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.

In Peck’s case, it’s unlikely the missing neck brace or AED slip-up made a difference in whether she lived, said John Everlove, an emergency medical services expert who previously reviewed highlights of the suicide investigation at The Gazette’s request. However, the response appeared inconsistent with best practices, Everlove has said.

Load comments