The system failed
Toolbox
Published: March 9, 2010
The death of Ashley Ellis has many lessons for us.
She was the 23-year-old woman who died last August two days after she entered prison in Swanton on 30-day sentence for a traffic offense. A story in Sunday's Herald provided a detailed accounting of the failure of medical personnel to provide the medication Ellis needed as treatment for complications from anorexia. Without her pills she died in her cell.
Health care inside Vermont's prisons was contracted out to a Tennessee-based company called Prison Health Service. Soon after Ellis's death the company announced it would not seek to renew its contract, and the state turned to a different company, Correct Care Solutions.
One of the problems contributing to the failure to care properly for Ellis was the fragmentation of responsibility in the corrections system that mirrors the fragmentation of the health care system as a whole. The account of personnel who failed to get the message, or failed to pick up the needed medications, is all too similar to stories of bureaucratic bungling, inattention and lack of coordination encountered every day by people outside of prison.
Step by step the system failed Ellis, and the steps included these:
Ellis's doctors faxed her records to a doctor in the Corrections Department's health services. This was two days before Ellis was to report to prison.
The Corrections doctor faxed Ellis's records to a nurse at the prison.
The next day the nurse e-mailed a regional director of Prison Health Service in California. By the end of the day the regional director authorized the nurse to order Ellis's medication. But the nurse did not do so because it was the end of the day.
The next day — the day Ellis was to arrive — the nurse handling Ellis's case had to fill in for another nurse, and so another day went by without anyone ordering Ellis's medication.
The next day a different nurse found Ellis's chart on her desk, and she ordered the medication. But she found that the prison did not have it in stock, so she ordered it from a pharmacy in St. Albans. She left a message with a nurse on the night shift to pick it up on her way to work.
The night shift nurse didn't listen to her messages until the next day, and so she arrived at work in the evening without the medication, and the pharmacy was soon closed.
The next morning Ellis died.
What this boils down to is that a day was lost because the nurse at the prison needed to clear her order with a company director in California. The next day a shortage of personnel caused the nurse to neglect her duty when she failed to order medication. Not having ordered the medication, the nurses didn't know it wasn't available and would have to be ordered from the local pharmacy. A failure of communication about picking up the medication delayed its arrival another day.
How often have ordinary people seeking ordinary health care outside of prison fallen victim to the delays — often lasting weeks or months — of insurance companies and caregivers in receiving authorization and then communicating among themselves? Our fragmented, unwieldy system causes thousands of deaths each year.
There is another lesson in the Ellis case. And that is that private enterprise is no guarantee of efficiency. When it comes to health care, private companies have an incentive to cut corners or to skimp on personnel. They are in business to make a profit. The welfare of Ashley Ellis got lost in the shuffle, not through malice but from inattention and lack of accountability.
Corrections Commissior Andrew Pallito has ascribed Ellis's death to human failure. But it's not enough to write off the system's failure as the mistakes of individuals. Individuals made mistakes, but the system failed, too. Ashley Ellis needed her medication to be there when she arrived. People placed the rigmarole of the system above her needs. It is a failure with which millions in America are familiar.
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