Mount Holly, New Jersey- Nurses at the Burlington County Jail were found negligent in the death of Jerome Lozzia, an inmate at the facility in 2014. A nurse with over 20 years of experience wrote a report of her findings.
Nurses and other jail employees attempted to cover up their negligent actions by altering formal documentation of Lozzia's care while in their custody.
The nurses did not abide by Standards of Practice and nursing protocols, and they ignored standard operating procedures of the jail.
Helen Strasko, a Licensed Practical Nurse reviewed and evaluated the case and will be the expert witness against BJC and the companies that provide the medical care for the facility were Lozzia died.
Investigations surrounding the death of Lozzia revealed that the jail was unsanitary and the health care was unsatisfactory.
The coroner's report deemed the death to be a result of natural causes. But Physicians and other medical professionals have said that the death could have been avoided with adequate medical intervention.
“The prosecutor’s office should reopen the investigations of the death,” said Robert Fuggi, the attorney representing Iozzia’s estate during an interview last week. “Somebody should be held criminally responsible.”
In the months prior to Lozzia's death, he wrote letters to his fiancee explaining the conditions at the jail and all the suffering he experienced in the months leading up to his death. This was also evident in his medical records.
“Animals in a veterinary clinic are treated better than he was,” Fuggi said. “Whether someone is in jail or in a hospital, they deserve to be treated with dignity. They treated him like an animal.”
The family of Lozzia has filed a $25 million dollar lawsuit against the Department of Corrections in New Jersey and all the medical staff involved in his care. The family is also suing the state of New Jersey.
The State of New Jersey lawsuit has been dropped because a judge ruled that there is a 90-day period for tort claim notices required by law and the suit was filed after the 90-day period.
“Even some well-educated people don’t know about these strict requirements to file a tort claim notice,” Fuggi said. “It’s kinda unfair. Pemberton police got out on a technicality.”
Inmate Lozzia was arrested for stealing his fiancee's car and suffered from substance abuse.
When police found Lozzia with the car he was arrested, but not before he was pepper sprayed for fighting with police during the arrest.
Capsaicin, the chemical in pepper spray is dangerous to inhale and can even cause death if an individual is overexposed.
According to the arrest documents, he was pepper sprayed after he ran “directly into a chain link fence,” and that the spray “had little to no effect” on him. But Lozzia continued to resist arrest despite being sprayed.
The court documents claim the Officer Edward sprayed "excessive" amounts of pepper spray on the inmate when Lozzia was already on the ground.
The documents also allege that the inmate was immobile and “suffered heart palpitations, chest pain and shortness of breath” as a result of an “excessive use of pepper spray,”
Lozzia suffered from atrial fibrillation( A-Fib) following a pulmonary vein isolation in 2006. The top chambers of his heart occasionally beat out of sequence with the bottom chambers.
Lozzio was in A-Fib when he was admitted to Lourdes Emergency Department at Deborah Heart and Lung Center. He was on the Electrophysiology floor that specializes in treating patients with abnormal heart rhythms.
On Nov 19 Lozzia was released from the hospital after receiving a pacemaker implant and he was noted to be in stable condition. His discharge instructions included the following: "If you develop a fever, chills, pain, drainage or discharge from the pacemaker site, you must come back to the hospital.”
He was scheduled for three follow-up appointments, but he was not taken to any of them.
According to Strasko, “It was imperative to ensure he kept the clinic appointments,”
According to the letters, he sent to his fiancee, he told her that he had informed the medical staff about his heart condition, but was ignored.
In a letter to his fiancee on Dec. 30, he said: “Call my mom and tell her they are gonna let me sit here forever . And are not taking care of my heart. Got my meds all messed up. And still, no follow-up visit to adjust my pacemaker.”
On Jan 25 he said: “This thing in my chest is really starting to bother me. Need to get out of here to go back to Deborah hospital to get this adjusted, but they won’t send me back.”
The medical staff's failure to acknowledge Lozzia's need for medical attention violated standards of nursing care and the jail's standard rules and regulations which state that inmates have the right to have their healthcare needs met regardless of the time of day.
In nurse Strasko’s report, she outlines the care that Lozzia should have received: He should have been discharged from the hospital with a cardiac monitor. This would have alerted nurses that there was a problem with his heart rhythm prior to Lozzia falling and becoming unconscious,
The autopsy report showed there were no medications in Lozzia's system, even though Sotalol was prescribed prior to discharge from the hospital, to treat an irregular heartbeat, and Eliquis to reduce blood clots. There was no notation in the chart to explain why these medications had not been administered.
According to the report, “Once administered, these medications should have shown up on the laboratory tests,"
On medical forms provided by the jail, there are two signatures that appear to be from the deceased refusing medical treatment, but the lawsuit by his family alleges that the signatures are forged.
Lozzia's vital signs were not recorded, although medical staff claim that the inmate refused vital sign checks. But this is contrary to the letters that he sent to his family members about requesting medical treatment but not receiving any.
“Why would he be refusing these important vital sign checks?” the report says. “There’s no documentation that shows why he was refusing these particular vital sign checks and is inconsistent with his requests for care and treatment. This gives rise to whether [jail medical documents] were altered or changed along with the nurses notes.”
Lozzia's autopsy report documents that he had a tooth extraction, but was never given antibiotics to prevent infection. subsequently, his mouth became infected and the infection spread to his right lung.
According to the autopsy“tan pus” was noted in the “subcutaneous pocket” containing his pacemaker, and “an early fibrinous empyema” surrounded his right lung. "Clumps of fibrinous clot” surrounded all three pacemaker leads.
The cause of death listed by the coroner was a combination of pneumonia/empyema/sepsis. According to an expert witness, these were all due to negligence, especially the prescribed medications that were not administered.
According to Strasko’s report Lozzia was exhibiting signs of sepsis because he was unable to walk around without assistance,
“The fact Mr. Iozzia needed assistance to walk around demonstrated a change in his physical status and was not further investigated by jail or nursing staff,” the report states.
Strasko also suggested that Lozzia's diet should have been changed to a more heart-healthy diet and not one filled with high levels of sodium, This would have contributed to the edema in the body and around the heart.
When Lozzia began refusing to eat this should have sent a red-flag to medical staff, indicated that his mental and physical status were on the decline and this should have been documented and examined further by staff.
“Refusal to eat signals not feeling well and the slowing down of the gastrointestinal tract’s digestion of food,” the report says. “Burlington County Jail staff and Nurse Evans, LPN were negligent in the care and treatment of Mr. Iozzia resulting in his death.”
Lozzia collapsed in his jail cell while brushing his teeth on the morning of Feb 25. The nurse who responded to the report by a corrections officer said she found him lying in a supine position in a pool of water. Because of the water on the cell floor, Nurse Evans was unable to
use an automated external defibrillator (AED) to shock the inmate's heart and restart the rhythm.
“Rapid defibrillation is the single most important factor in determining the survival of a person,” According to the expert witness. “The failure to move Mr. Iozzia to a safer area and employ the AED device to restart his heart directly contributed to his death.”