Sangamon County jail death highlights grisly record of Dr. Stephen Cullinan
Sangamon County taxpayers will pay the family of a deceased inmate $60,000 to settle a lawsuit filed by the family of Maurice Burris, who died a horrific death in 2007 due to a perforated ulcer that went untreated in the county jail.
But Dr. Stephen A. Cullinan, the Peoria physician whose alleged indifference to Burris’ suffering prompted a separate settlement this month between himself and Burris’ relatives, remains free to practice medicine, despite a history of malpractice lawsuits and a $10,000 fine levied in Michigan in 2009 by authorities who say that the doctor skimped on medication.
In addition, Cullinan, who could not be reached for comment, settled a malpractice case in Sangamon County last year for $130,000, according to the website of the Illinois Department of Professional Regulation. Just what case that might be is difficult to determine amid the thicket of lawsuits filed against Cullinan and his Peoria-based company, Health Professionals, Ltd., which provides medical services in more than 100 correctional facilities in several states.
Included in the cases is a lawsuit filed by Jason Waggener, who had a history of seizures when he was arrested in 2007 and taken to the Macoupin County jail in Carlinville, where he had a seizure that resulted in a broken ankle and lacerations to his head. An emergency room physician told Cullinan that Waggener needed to see an orthopedic surgeon and offered to make a referral so that he could be immediately evaluated, according to court documents. Instead, Cullinan ordered Waggener back to jail.
Cullinan didn’t call in an orthopedist or a psychiatrist, according to court documents, and Waggener, delusional, took off his splint, walked around and sat Indian-style in his cell. Two days after he was returned to the jail, a nurse called Cullinan to report that Waggener was hallucinating, paranoid and walking without his splint. But Cullinan didn’t examine Waggener, nor did he call an ambulance, according to the lawsuit. The next morning, jailers found Waggener psychotic and sitting in a pool of blood in his cell, suffering from a compound fracture to his lower leg, which appeared gangrenous. Doctors ultimately amputated below the knee.
Court records show that both Cullinan and Macoupin County settled the case last year, but Sheriff John Albrecht didn’t sound concerned during a brief telephone interview.
Albrecht, a defendant in the case, said that he didn’t know how much the county paid to settle the case and that Cullinan’s company is still providing medical care in the Macoupin County jail, albeit under a different name. He said that he has no concerns about Cullinan’s abilities and believes that the doctor is still treating inmates.
“As far as I know, he does,” Albrecht said.
“We’ve had good experience with him.”
By contrast, the Sangamon County sheriff’s office terminated its contract with Cullinan and HPL in 2008, nine months after Burris died from an ulcer that went untreated until it was too late.
Burris began feeling stomach pains on Dec. 2, 2007, one week after he was booked into the jail, according to court documents. He had a pulse of 142, twice the normal rate, and a respiration rate of 48 breaths per minute; the normal rate is fewer than 20 breaths per minute.
He was vomiting and sweating, with a stomach hard to the touch, according to a July opinion in the lawsuit written by U.S. District Court Judge Sue E. Myerscough. Cullinan told a nurse at the jail that Burris would be fine, according to the judge’s opinion.
Cullinan examined Burris the next day and ordered a urine test. Surveillance video showed that he didn’t eat and made several trips to a sink, where he either vomited or had dry heaves, Myerscough wrote. On the next day, the third since pain began, Burris told a guard that he had a bleeding ulcer. His pulse rate was 138, with a respiration rate of 44 and a temperature of 95 degrees. Cullinan ordered a blood test, but a nurse told the doctor she couldn’t draw blood because she didn’t have supplies, according to court documents.
“Dr. Cullinan informed (the nurse) that Decedent would be fine and not to worry about it,” the judge wrote in her opinion.
Three hours later, video showed that Burris collapsed on the floor of his cell, but no one noticed, the judge wrote. For the next hour, he repeatedly fell onto his bed or collapsed on the floor before jailers responded and a nurse summoned an ambulance. By then, Burris had suffered a fatal brain injury caused by lack of oxygen, the judge wrote. He died eight days later.
“The case before him was so simple and the errors so egregious, that Dr. Cullinan’s acts and omissions go beyond mere malpractice,” wrote Dr. Marc Stern, former medical director for the state Department of Corrections in Washington State and now on the faculty of the University of Washington Public School of Health, in a memo written for the plaintiff’s lawyers. “In my opinion, the behavior Dr. Cullinan exhibited went beyond an error of knowledge – it was an error of attitude; it demonstrates the attitude of someone who did not care.”
In an interview, Stern said doctors are generally successful at saving lives if perforated ulcers are promptly treated. Burris, he said, was likely in “significant discomfort” while his condition deteriorated in the jail, and the care provided by Cullinan was below standard.
“I would say this is at the bottom level of what I would expect, and what I would hope, looking around the country,” Stern said.
Problems with Cullinan’s care date to at least 2004, when Anthony Snyder was rushed from the Franklin County jail in southern Illinois to an emergency room. He died three days later from pneumonia, a death the coroner said “was 100 percent preventable,” according to media accounts. In addition to pneumonia, Snyder, who was 36 and died after six months in the jail, had extensive bedsores, according to a 2004 story by the Associated Press.
“I’d venture to say this person had lain around for months,” Cape Girardeau County (Mo.) coroner Mike Hurst told a reporter.
In the subsequent lawsuit against Cullinan and the Franklin County sheriff, attorneys for Snyder’s family say that the doctor told the doomed man, who was incoherent and drooling, that he was faking symptoms on the day he was rushed to a hospital.
R. Courtney Hughes, attorney for Snyder’s family, said that the case was settled, but declined further comment, saying that settlement terms are confidential. Sheriff Donald Jones, who has been Franklin County’s top cop for about a year, says he recalls the case. HPL still holds the contract for medical care in the Franklin County jail, Jones said.
Neither HPL nor Correctional Health Care Companies, the firm’s parent company, could be reached for comment.
Concerns have been raised outside Illinois.
In 2009, the state board of medicine in Michigan fined Cullinan $10,000 for denying psychotropic drugs to two inmates who suffered from schizophrenia and other mental disorders. According to Michigan investigators, Cullinan cut back on dosages prescribed by a psychiatrist without speaking with the psychiatrist, reviewing charts or examining the inmates.
