Great Falls jail death leads to $1M payout to inmate’s family

The family of a central Montana jail inmate who died in 2018 accepted a $1 million payout this summer after the man suffered a series of seizures and staff failed to follow protocol.

Inmate Roger Lee Wells, 64, died at the Cascade County Detention Center on March 10, 2018, after suffering nine seizures during a period of roughly two-and-a-half hours.

The policy at the Great Falls jail was to transport an inmate to the hospital after his or her second seizure, according to a report by the Division of Criminal Investigation on Wells’ death.

Instead, the on-call nurse kept Wells in a padded single cell for periodic observation.

The nurse and jail staff were unaware, then, that Wells was repeatedly lapsing into seizures during the moments between checks, until he was found unresponsive. Wells’ seizures were recorded on video.

An investigation by the Division of Criminal Investigation found that while some nurses who worked at the facility knew to transport an inmate after the second seizure, the one on call that morning did not.

In July, Wells’ surviving family was paid $1 million by the insurance carrier for Planned Parenthood of Montana. The organization, known for its reproductive health services, has the contract to provide general medical services at the Cascade County jail and was responsible for the payment under an indemnity agreement with the county.

Planned Parenthood, the county and the jail admitted no liability as part of the settlement. The Wells estate agreed to release the parties from future claims.

Seizures missed between checks

Wells, arrested on a domestic violence charge, had been held in the jail for seven days when he died. He was housed in a crowded “'dorm-style' medical/geriatric pod” where inmates weren’t deemed a danger to others, according to the DCI report. Wells and three other inmates slept on bedding on the floor, according to the state’s report.

Wells had a seizure disorder and sent multiple written requests for his medication but never received it.

It was the job of medical staff to read through new medical care requests each day, record them and respond. Their goal was to have a response sent to the inmate within 48 hours.

None of Wells’ written requests received a response, according to the DCI report, although investigators would later learn medical staff acted on a verbal request and ordered the medication, but that it did not arrive in time.

Wells' family members also attempted to bring his medication to the jail for him but were turned away by jail staff, according to family members who spoke to investigators.

Sheriff Jesse Slaughter said he could not comment on the allegations because he worked for a different agency at the time and took office in January. Slaughter did say current protocol is for jail staff to accept such drop-offs and refer them to medical staff for review.

Wells had his first seizure around 3 a.m. in the dorm-style pod. Another inmate in the pod, Kevin Moore, told a DCI investigator it looked like Wells might have bitten his tongue in half.

Jailers then moved Wells to a padded observation room, but in the process, he had another seizure. Once at the padded single cell, he had a third seizure, which ended around the time the on-call nurse arrived to assist.

The on-call nurse instituted a plan of checking on Wells every five minutes, and later extended that to every 15 minutes when Wells was seen sleeping and snoring and no problems were observed.

“She understood the primary nursing protocol for patients with seizures to be observation and stated the seizures would be followed by exhaustion,” the DCI report states.

Jailers performed most of the checks, while the nurse performed some as well.

While Wells' first seizure that morning was witnessed by inmates, and jail staff witnessed his second and third seizures, the remaining six took place in moments between the periodic checks, according to an activity log the DCI investigator took based on jail video.

The nursing supervisor told investigators that the nurse on call the morning Wells died should be credited for at least getting Wells’ medication to the jail.

“…(I)f not for (the nurse) keying on and responding to Wells’ verbal request for his anti-seizure medication while she was doing her rounds, his prescription would not have been ordered and sent to the jail,” the report states.

The prescription arrived the day Wells died, the report noted.

Demand letter answered

The $1 million settlement was entered into in response to a demand letter sent by Colin Gerstner, the Billings attorney representing Wells’ estate. No lawsuit was filed.

Tanis Holm, general counsel for Planned Parenthood of Montana, declined to comment on the settlement or answer questions about whether the incident resulted in any employee discipline, training or other corrective action.

“This is supposed to be a confidential settlement agreement,” Holm said. “And I’m just not going to comment on it.”

The on-call nurse has an active registered nurse license with the state Board of Nursing, with no discipline listed.

Wells’ death was the first of two at the jail that week. Inmate Leland Bennett, 23, was taken to the hospital around the same hour that Wells had his first seizure. Bennett was taken by ambulance after trying to hang himself and died the next day at the hospital.

Months later, in July, Cascade County saw a jail riot by 14 inmates that lasted four hours. No injuries were reported, but the event was estimated to have caused $22,000 in damage to the building.

The riot came days after then-Sheriff Bob Edwards said the county would no longer book certain non-violent or misdemeanor offenders because the jail was over capacity by about 170 inmates. Edwards said he was concerned about staff and inmate safety under the strain.

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