MEMORANDUM

To: Tyree D. Jones, Sheriff, Hinds County

Via: Jarratt Taylor, Undersheriff, Hinds County, Latasha Holmes, Chief Deputy,
Hinds County, Wendell France, Federal Receiver, John Hall, Attorney, Hinds
County

From: Anthony Simon, Jail Administrator, Hinds C o u n t y ~

Date: July 31, 2025

Re: Formal Complaint: Concerns Regarding Clinical Practices, Emergency Response,

and Professional Conduct of Medical Contractor

This memorandum serves as a fonnal complaint regarding a series of seriou s concerns identified
during and following the July 30, 2025, mortality review, particularly as they relate to the
contracted medical provider' s clinical decision-mak ing, emergency response protocols,
documentation practices, and professional engagement. These concerns are submitted for fom1al
review and consideration of conective action , with the intent of improving patient outcomes and
ensuring alignment with established cotTectional healthcare standards.

I. Identification Discrepancy - .J. Rohinson

A significant patient identification eJTor occtmed during the July 7, 2025, incident, in which a
detainee was etToneously documented as "M . Robinson .. when, in fact, the individual receiving
care was ··J . Robinson.·· While it is acknowledged that contributing facto rs included the absence
of wristbands and lack of access to detainee photographs. such limitations do not negate the
obligation to implement and uphold robust patient identification procedures, pa1iicularly in high-
risk environments such as coJTectional settings.

In light of this event, clarification is requested regarding the following :

Does the cunent cl inical practice adher0 to National Commission on Correctional Health
Care (NCCHC) :;tand ards, \Vhich requ ire verit1catit)n uF two uniq ue idcnti fiers (e.g., full name
and date of birth) prior to the provision of medical treatment or administration o f medication?
• In the absence of wri stbands. is verbal identity confi nnation (i.e .. name, date of bi1ih,
housing unit) a standardized procedure when the patient is conscious?

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 • Would the medical team support the implementation of a real-time photograph access tool
within the Electronic Medical Record (EMR) or, alternatively, an integrated system linking
housing rosters with booking photographs as a temporary ve1ification measure?

Recommended Preventive Strategy:

To mitigate clinical, ethical, and legal risks associated with misidentification, it is recommended
that the facility implement a three-point identity ve1ification protocol, consisting of:
1. Verbal confinnation by the detainee (when conscious)
2. Housing unit roster or classification cross-check
3. Photo ID confirmation through EMR or intake records

This layered verification approach should be embedded as standard practice for all emergency
and non-emergency medical encounters.

2. Medical Response and Documentation - Clincy Case (July 9, 2025)

Documentation provided for the July 9, 2025, incident indicates that only three emergency
medical calls were formally recorded . However, based on observations by facility staff, as many
as nine detainees exhibited symptoms consistent with stimulant or opioid toxicity during this
same time. Only one detainee, Clincy, was documented as unresponsive, and no naloxone
(Narcan) was administered.

This discrepancy necessitates the fo llowing clarifications:

• Are there corresponding nursing notes or EMR entries for the evaluations of detainees
Anderson, Russell, and Johnson? If not, were these assessments conducted infonnally, and if so,
what is the justification for the lack of documentation?
Were vital signs, oxygen saturation levels, or neurological assessments conducted and
recorded for these individuals, regardless of the decision not to administer Narcan?
• Was the clinical decision not to administer Narcan to Clincy suppo1ied by documented
indicators, and has this determination been reviewed and fonnally approved by the facility's
Medical Director, Dr. Martin?

In accordance with guidance from both the NCCHC and the Centers for Disease Control and
Prevention (CDC), any presentation involving altered mental status, depressed respirations, or
unresponsiveness, particularly in group exposure scenarios should prompt immediate
consideration for Narcan administration.

Furthennore, all detainees evaluated during such incidents sho uld be fonnally documented in the
EMR, regardless of whether treatment is rendered, to ensure transparency, continuity of care, and
compliance with clinical standards.

3. Narcan Use, Clinical Communication, and Protocol Standardization

We acknowledge and appreciate the clarification regarding the statement, --J Na rcan e1'e1yone,--
made during the mo1iality review by t\-urse Practitioner (:-JP) Singleton. As a licensed Family
Nurse Practitioner (FNP) \11.: ith substantial clinical experience, To clarify, Singleton·s statement,
••When thev are dropping like/lies. I Na rcan all o/thcm • referring specifi cally to the July 9

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incident, was reflective of her personal protocol and professional judgment under conditions of
apparent group exposure and urgency.

In contrast, Nurse Laird expressed that she would not have administered Narcan under the same
circumstances. While both practitioners are fully credentialed and entitled to exercise clinical
discretion, such opposing viewpoints within the same clinical team underscore the urgent need
for unified emergency response protocols.

It is also noted that following NP Singleton's evidence-based contiibution to the discussion,

Nurse Laird stated, albeit jokingly, that she would not attend any future meetings. While the tone
may have been infonnal, such comments are inappropriate in the context of a mortality review
and suggest a dismissive stance toward multidisciplinary engagement. Professional collaboration
is critical, particularly when reviewing events involving detainees deaths .

Fmiher, during the review, when I recommended that Narcan be administered in unresponsive
cases based on the facility's recent overdose trends, both Health Services Administrator (HSA)
Jackson and Nurse Laird stated they would not follow such a recommendation, despite
simultaneously acknowledging that Narcan presents no clinical hann if administered
unnecessarily. This resistance to a life-preserving precaution, especially in a setting where
overdoses have become increasingly prevalent, raises significant concern regarding alignment
wi th best practices and responsiveness to emergent trends .

It is also important to highlight that not all nursing personnel appear to be adequately trained in
Narcan administration, which presents a direct risk to detainee safety and institutional li ability.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA),
World Health Organization (WHO), and National Institute on Drng Abuse (NIDA), Narcan is
clinically safe, even when administered to individuals not experiencing an opioid overdose. Its
use in suspected.cases of unresponsiveness, parti cularly in correctional environments, is a
recognized standard of care and should be applied consistently through the use of a defined
protocol.

Proposed Protocol Enhancements:

• Ensure Narcan is accessible in all housing units and that custody staff are trained and
authorized to administer it in emergency scenarios .
• Implement a facili ty-wide standardized emergency response algorithm for suspected
overdoses:
l . Assess for responsiveness and respiratory effo1i
2. Initiate emergency medical code and notify medical personnel
3. Administer Narcan
4. Begin CPR (cardiopulmonary resuscitation) 1f indicated
5. Document all assessments, decisions, and interventions
Require that medical personnel document both the rationale for administration and non-
administration of Narcan in all cases invol ving unrespo nsiveness or suspected overdose.

This protocol would reduce ambiguity and ensure consistency across clinical responses .

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. l

4. Professional Conduct During the Review

We want to acknowledge HSA Jackson·s comments concerning the tone of the .July 30, 2025,
mortality review. However, it is impo1i ant to cl arify that the meeting remained professional,
orderly, and consistent with the purpose and expectations of a fonnal post-incident review.

All questions raised during the review were procedural and clinically relevant, designed to
clarify treatment timelines, document clinical rationale, and identify potential areas for
improvement. These questions were neither perso nal nor accusatory.

That said, it was observed and should be noted, that when members of the review team,
including myself, posed reasonable and necessary inquiries, both HSA Jackson and other
members of the medical staff became visibly defensive and, at times, appeared offended. While
such conversations can be uncom fortable, they are essential in ensuri ng transparency,
accountability, and improved care delivery.

It is the responsibility of all professional parties to appro ach mortality reviews with openness,
objectivity, and a shared commitment to pati ent safety. Professionalism is reflected not only in
how questions are asked, but in how they are received.

This memorandum is submitted as a fonnal complaint regarding the medical contractor's current
deficiencies in emergency preparedness, inconsistency in clinical decision-making,
documentation lapses, and unprofessional conduct dming fonnal review. These concerns must be
addressed urgently, given the ir potenti al impact on detainee health outcomes and institutional
liability.

We respectfully request:
• A review of Narcan training and profic iency for all medical personnel;
Implementation of a standardized overdose response protocol;
Reaffinnation of expectations regarding profes sio nal conduct in collaborative review
settings;
Submission of all outstanding documentation rel ated to the July 7 and 9 , 2025, incident,
including nursing notes, EMR entries, and physician reviews, by close of business, Thursday,
.July 3 1, 2025.

'Ne remain committed to cross-departmental collaboration and continuous improvement.

However, the gravity of these matters requires timel y co1Tective measures to ensure alignment
with clinical standards and the protection of those in our custody.

Best regards,

Major Anthony Simon

Jail Administrator

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