The family of a woman who died in the Josephine County Jail in 2018 filed a lawsuit last month against the county, sheriff and private medical companies responsible for her care.

On Sept. 5, 2018, Janelle Marie Butterfield hanged herself in her segregation cell.

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Butterfield's case was first reported by OPB and the Northwest News Network as part of the Booked and Buried series, which found from Jan. 1, 2008, to Dec. 31, 2018, at least 306 people died in county jails in Oregon and Washington. Of those, at least 122 died by suicide, the leading known cause of death.

Under the U.S. Constitution, correctional facilities are required to provide “adequate healthcare,” but the investigation by Northwest public media showed many deaths were because of poor and inadequate care.

Butterfield was diagnosed with schizophrenia years before her death, according to her family.

Janelle Butterfield, right, had been diagnosed with schizophrenia years before she died in the Josephine County Jail. Butterfield's mother, Connie Dence, left, says she doesn't believe the jail didn't know her daughter was ill.

Janelle Butterfield, right, had been diagnosed with schizophrenia years before she died in the Josephine County Jail. Butterfield's mother, Connie Dence, left, says she doesn't believe the jail didn't know her daughter was ill.

Courtesy of Connie Dence

“She was homeless for the last, probably six years,” Connie Dence, Butterfield’s mother, told OPB in 2019. “She just lost it.”

Dence filed the lawsuit in April. It was first reported by the Grants Pass Daily Courier.

The case alleges Butterfield’s rights under the 8th and 14th Amendments of the U.S. Constitution were violated. Those provisions grant equal protections under the law and guard against cruel and unusual punishment. The lawsuit also alleges the jail and Butterfield’s medical providers acted with negligence.

“I do not believe they had no clue that she was ill,” Dence said in 2019. “That’s a bunch of bull.”

The civil lawsuit doesn't mention a dollar amount, but raises serious allegations about the quality of health care Butterfield received.

“During her 40 days in custody, Ms. Butterfield did not see a doctor, a nurse practitioner, a physician assistant, or a nurse employed by the medical and mental health providers,” the lawsuit states. “Her antipsychotic medication was discontinued without explanation after 16 days in custody.”

The lawsuit names Sheriff Dave Daniel, as well as two private medical contractors and their providers hired to work with inmates: Options for Southern Oregon, which provide mental health services in Jackson and Josephine counties, and  Wellpath LLC, a for-profit company that provides health and mental health services to prisons and jails across the country.

Janelle Butterfield is pictured in an undated photo. In June 2011, Butterfield's condition deteriorated as she had flashes of delusion and paranoia.

Janelle Butterfield is pictured in an undated photo. In June 2011, Butterfield's condition deteriorated as she had flashes of delusion and paranoia.

Courtesy of Connie Dence

A key allegation of the lawsuit points to Wellpath’s use of licensed EMTs to check on Butterfield once per day, rather than nurses or doctors to provide care in the jail. The lawsuit references a similar case in 2013 involving the death of Donnie Ray Brown, who died of a perforated ulcer hours after he was released from the Coos County Jail.

“One of the issues in the Donnie Brown case was the use by Wellpath/CCS of people with EMT licenses to provide medical care at the Coos County Jail,” the lawsuit states. The federal judge who reviewed the case found “there is evidence that [one of the EMTs] undertook a medical professional task (diagnosing and treating Brown) without consulting a qualified physician or nurse practitioner.”

A spokesperson for Wellpath said the company doesn’t comment on active litigation, and that due to privacy laws the company can’t comment on the care provided in this case.

Options for Southern Oregon did not respond to OPB’s request for comment.

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“I prefer a no comment response at this point,” Gerry Warren, an attorney for Josephine County, wrote in an email. “The suicide death of Ms. Butterfield was unfortunate but certainly not the fault of the County.”

Starting in 2016, Butterfield was booked into the Josephine County Jail at least eight times, according to the lawsuit. Her mental illness and history was also well documented.

“A Wellpath/CCS EMT named Brian Mavity documented that Ms. Butterfield ‘is very skittish and conversations last about 10 seconds before she drifts off to some other memory flash,’” the lawsuit alleges. “Mr. Mavity also noted that Ms. Butterfield ‘was in her cell locked down because she was eating soap & cleaner in cell block 4’ and charted that he was ‘leaving a note for mental health.’”

The lawsuit describes an August 2017 booking into the county jail.

“The booking officer noted that Ms. Butterfield had tried to hurt herself or commit suicide in the previous six months – ‘tried cutting herself but did not break the skin,’” the lawsuit states.

In April 2018, an Options employee, Dr. Ki Kurtz, diagnosed Butterfield with substance induced psychosis. Though, according to the lawsuit, the doctor added symptoms could be consistent with schizophrenia or schizoaffective disorder. Kurtz started Butterfield on a drug called Abilify, an antipsychotic medication used to treat schizophrenia.

Later, another doctor who would visit Butterfield in jail weeks after any use of substances, would diagnose her as “schizophrenic, with nonsensical statements, thought blocking, suspicion, and confusion,” the lawsuit states.

In May 2018, during a stay in the jail, Wellpath medical staff gave Butterfield a 90-day prescription of Abilify. She also had prescriptions for several other similar antipsychotic medications, aimed at treating schizophrenia, seizures, and bipolar disorder.

Records obtained by OPB show on May 11, Susan Tubbs — Butterfield’s aunt — wrote an email to the Josephine County Sheriff’s Office.

“We are the family of Janelle Butterfield,” it said. “If our Janelle were just another drug user, it would be hard enough to accept. But compound that with the horrible disease of PARANOID SCHIZOPHRENIA, and you can begin to imagine what our hearts deal with on a daily basis.

“We want to thank you for realizing that Janelle has people who love her dearly,” Tubbs wrote. “We appreciate anyone who keeps our Janelle safe."

The jail never got back to Tubbs.

The last time Butterfield was booked into the Josephine County Jail was on July 27, 2018. A jail deputy led Butterfield into the jail by her hair, a technique used by corrections officers to control inmates. There’s no indication, the lawsuit states, that Butterfield saw a Wellpath medical staff member when she was booked.

An unknown person, presumably on the overnight shift, filled out a suicide questionnaire for her. OPB obtained the form through a records request.

“The person who completed the form circled ‘No’ to the question: ‘Is subject under the influence of alcohol or drugs?’” the lawsuit states. “The person who completed the form circled ‘Unusual speech or behavior’ and ‘History of mental or emotional disturbance,’ and wrote ‘EDP’ on the form. On information and belief, ‘EDP’ stands for “emotionally disturbed person.”

Janelle Butterfield was found dead in cell 408, at the Josephine County Jail, on Sept. 5, 2018. She had been in jail for 40 days.

Janelle Butterfield was found dead in cell 408, at the Josephine County Jail, on Sept. 5, 2018. She had been in jail for 40 days.

Courtesy of Oregon State Police

In early August, Butterfield refused to take her Abilify. Wellpath stopped giving her the medication on Aug. 12, 2018.

“She did not receive any type of medications during the remainder of her stay at the jail,” the lawsuit states.

After 30 days in custody, her then public defender raised concerns about her mental state, the lawsuit states. Butterfield received a recommendation to go to the Oregon State Hospital for mental health treatment so she could later stand trial.

The morning of Sept. 5, 2018, the same day as her court hearing to determine whether she would receive transfer to the psychiatric facility for care, Butterfield was found hanging from her top bunk; a bed sheet wrapped around her neck.

No one was disciplined or fired for Butterfield’s death, the lawsuit states. Both Options for Southern Oregon and Wellpath continue to provide mental health and medical services at the Josephine County Jail.

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