Report: Medical staff waited 4 hours to get inmate to hospital

A 10-page report by the state Commission of Correction found that Hallenbeck received “shockingly substandard” care at the jail that “was deficient and absent and in sum was a preventable death had competent and timely medical care been provided to him.” His widow brought a wrongful-death lawsuit against the county last year.

Hallenbeck had a medical history that included atrial fibrillation, diabetes, hypertension, kidney failure and controlled congestive heart failure.

But the commission’s report faulted the jail for a laundry list of problems, such as failing to properly monitor a medically fragile adult — including a month-long period when the jail’s doctor was out of the country — and to account for a finding of an altered mental status and severe weakness with an associated 70-pound weigh gain.

But the commission reserved its most scathing criticism the medical staff’s action on Feb. 25, 2020, the day Hallenbeck was hospitalized.

On that day, Hallenbeck was awakened for sick call at 8 a.m. but told the officer that he was unable to stand up. With help from another individual, the officer tried to assist Hallenbeck to his feet. He was very unsteady and was told to sit down to wait for a wheelchair. He fell back on his bunk and hit his head on the wall, though he reported being uninjured, according to the report.

Hallenbeck was brought from his cell in a wheelchair and seen by Dr. Michael S. Nupuf at 8:45 a.m. 

His weight was documented as 312 pounds, “a shocking near 70 pounds gain since admission to the facility,” the commission said.

Nupuf noted on an exam form that he had severe ascites (abdominal swelling due to fluid accumulation), chronic rash on skin, reduced but clear breath sounds, chronic edema, and was mildly confused.

“I think the patient needs to be hospitalized for his chronic problems,” Nupuf recorded in his notes. “He is at risk for recurrent hospitalization. I have spoken to the undersheriff to see if the patient can be released due to his health. Will contact his cardiologist after decision is made.”

Instead of receiving emergency care, Hallenbeck was returned to the housing unit.

The commission’s report said that during an interview with commission staff, Nupuf stated that Hallenbeck did not appear acutely ill but was very weak and that the plan was to discuss with his cardiologist and treat Hallenbeck. The commission noted that there was no documentation in the record of the name of the cardiologist or any indication that the cardiologist was contacted during Hallenbeck’s incarceration.

Once Hallenbeck returned to the housing unit, his condition deteriorated.

“The Medical Review Board opines that Hallenbeck required an immediate transfer to a higher level of care when seen by Dr. M.N., as was also indicated in the clinical note, and that returning Hallenebeck to the cell in this condition was grossly negligent on the part of the physician and an act of patient abandonment,” the commission said.

Later that day, an officer returning from his morning break noticed that Hallenbeck was sitting in a wheelchair by his cell door and was not moving a great deal or talking. He reported struggling to breathe and that he was in pain. Hours later, at noon, Hallenbeck was noted to be sitting in the chair in the middle of the cell doorway.

“At that time, (it was)noted the smell of fecal matter and urine as well as coffee spilled all over the floor,” the commission said. “Hallenbeck was unaware of having incontinence.”

The officer attempted to have him go into the cell to clean up but noted he struggled to breathe and respond. Hallenbeck did manage to ask the officer when he was being sent to the hospital.

At 12:30 p.m., the officer notified a sergeant and at 12:40 p.m. Julia L. Demm, a registered nurse, entered the housing unit to see Hallenbeck. He was reported to be pale in color and short of breath. He was placed on oxygen and Demm determined he needed to go to the emergency room for an evaluation. She notified Nupuf, who agreed.

Oswego County 911 received a call for a transport at 12:51 p.m. and Menter Ambulance arrived 10 minutes later. While at Oswego Hospital, Hallenbeck underwent a paracentesis, a procedure that removes fluid from the abdomen with a needle. Hospital staff removed 3.8 liters of fluid, according to the report.

At 8:17 p.m., Hallenbeck was transported to St. Joseph’s Hospital in Syracuse for a higher level of care. He arrived at the hospital’s ICU in a pulseless electrical activity cardiac arrest. He was resuscitated and remained in the hospital in a “severe shock state.”

On Feb. 27, hospital staff removed 15.7 liters of cloudy fluid. Hallenbeck went into cardiac arrest on Feb. 28 and again on Feb. 29 but couldn’t be resuscitated.

In addition to the county, the lawsuit filed by Hallenbeck’s widow names former jail physician Nupuf, Demm, former jail administrator Michael Benjamin, Sheriff Don Hilton and Undersheriff John Toomey.

County officials have declined to comment on the case, citing the pending lawsuit.