David Stojcevski died in the Macomb County Jail on June 27, 2014. He was serving a 30-day sentence for failing to pay fines related to traffic offenses.
At the time, Stojcevski was undergoing medical treatment for chronic substance abuse problems. He did not receive his prescribed medications while in jail. In his autopsy report, the county medical examiner listed his cause of death as “acute withdrawal” from those prescription drugs, resulting in severe dehydration and seizures.
After news of Stojcevski’s death broke in 2015—along with jail video monitoring footage that showed every minute of his excruciating final days—the FBI opened a preliminary investigation into whether the Macomb County jail and its medical care contractor, Correct Care Solutions, showed “deliberate indifference” that led to Stojcevski’s death.
After reviewing the findings of that months-long investigation, then-Detroit U.S. Attorney Barbara McQuade “determined that the evidence does not support a federal criminal civil rights prosecution." Her office closed the case in September 2016.
"The federal criminal civil rights statutes that we enforce carry a very high burden of proof that cannot be met in this case,” McQuade wrote in a letter to Stojcevski’s family. “Specifically, the available evidence is insufficient to prove beyond a reasonable doubt that the deputies and medical personnel who were responsible for the care of your son acted with the requisite criminal intent."
That legal determination aside, FBI witness interviews and other investigation reports obtained by Michigan Radio raise some serious red flags about how Stojcevski’s case was handled--both before and after his death.
Here are some of the FBI’s most noteworthy findings:
Most jail medical staff believed Stojcevski was faking symptoms such as seizures for “secondary gain.”
That phrase is repeated in a number of interviews with corrections officers, nurses, mental health evaluators, and the jail’s own doctor.
After observing Stojcevski inside the jail’s mental health unit, Dr. Lawrence Sherman wrote that Stojcevski was not having seizures as reported, and that his symptoms were most likely “a poor attempt to feign one.” Sherman recommended Stojcevski remain in the mental health unit without seizure precautions. Mental health staff also reported suspicions that Stojcevski was faking his symptoms in order to get medication.
But a correctional health care expert the FBI interviewed reached a different conclusion.
Dr. Robert Greifinger reviewed the Stojcevski investigation documents. He found that Stojcevski informed medical staff that he had been taking the benzodiazepines Xanax and Klonopin before he was sent to jail. Greifinger says medical staff should have started him on a withdrawal protocol for those drugs, which can be fatal if not treated. He also believed the severity of Stojcevski’s dehydration and weight loss should have raised alarms.
But Greifinger says the medical staff simply “documented” Stojcevski’s condition, and despite “serious medical need…made the choice not to treat him.” The FBI report goes on to say:
“Dr. Greifinger stated if this was a civil proceeding, he would say that Stojcevski died because of deliberate indifference to his medical needs by the staff at the jail…this was a preventable death.
Dr. Greifinger advised that any good doctor who saw the patient, and the patient showed the symptoms of hallucinations and tremors, would say there was a medical emergency and have the patient sent to the hospital.”
Medical and mental health staff were repeatedly informed of Stojcevski’s evident hallucinations and other strange behavior.
One nurse, Vicky Bertram, helped respond to an emergency call about Stojcevski. She reported that “he told all the nurses in the cell he was taking Xanax, and he told them that all of his organs but 10% of his heart was removed and his arms shredded a couple days ago.” But his vital signs appeared normal, and nurses reported this was not unusual behavior in the mental health unit.
Bertram believed the nurses should inform Dr. Sherman about Stojcevski taking Xanax, but says she was told he already knew that. So Bertram did not include that information in her report, but later “admitted she should have put it in the report.”
That kind of omission was not an isolated incident.
Sloppy record-keeping and missing medical reports.
Again and again, the FBI found that jail and medical staff either did not keep complete records of their interactions with Stojcevski, and in some cases kept no records at all.
One witness reported that nurses made several unscheduled checks on Stojcevski and gave him water, but “these visits by the nurses were not documented.”
Another nurse reported checking on Stojcevski after a corrections deputy asked her to. She found his vitals to be normal and was not overly-disturbed by his behavior, noting “it was not unusual for inmates in the Mental Health section to lay on the floor and not move around much.” The nurse admits she didn’t “chart” the visit, and “only did it as a favor to the Corrections deputy.”
Dr. Lawrence Sherman also admitted to record-keeping errors. Sherman told a jail administrator he had seen Stojcevski on June 17, but his medical note documenting the visit was dated June 23. Sherman called this “an oversight on his part,” and “stated he just forgot to write the note.”
A hasty “mortality review” and reports of destroyed evidence.
After Stojcevski’s death, jail administrators and Correct Care Solutions staff gathered for a routine review into an inmate death. The jail’s Health Services Administrator, David Arft, says he found out there that some documentation was lacking. “Arft stated the medical staff saw and talked to Stojcevski but did not always document these interactions,” the FBI reported.
Furthermore, Arft reported that the mortality review:
“…consisted of reviewing all medical and mental health charts and discussion to look for improvements that need to be done. The review was conducted before receiving the autopsy report. After the meeting all material from the meeting was destroyed and no meeting minutes were maintained. Arft stated the mortality review believed Stojcevski died from a heart arrhythmia and did not feel any changes needed to be made to procedures.”
Arft acknowledged some jail medical policies were later changed, and staff received additional training. But he insisted that was not a result of Stojcevski’s death.
Nurse Monica Cueny was also present at the mortality review. Cueny reported “she was told what happened in the meeting room stayed in the meeting room, and does not believe minutes were taken of the meeting. After the meeting, all the records reviewed were collected and Cueny believed they were destroyed.”
Access to those records and witnesses at the meeting have become key battle points in the Stojcevski family’s federal civil rights lawsuit over David’s death. After requests for access were denied, the family’s lawyers asked the judge to compel Correct Care Solutions to turn them over. The judge granted that request in August of this year.
But Macomb County objected to the order, and filed its own motion to block it. On October 12, the plaintiffs filed their own counter-objection. In the meantime, the court has extended the deadline for the fact-finding portion of the case until December.
What does this mean for the case moving forward?
After reviewing the FBI findings, the U.S. Attorney’s office declined to file criminal charges or further investigate Stojcevski’s case. And a 2015 Michigan ACLU request that the U.S. Justice Department’s Civil Rights Division conduct its own investigation went nowhere.
So as far as federal law enforcement is concerned, the Stojcevski case is closed. However, the FBI’s findings could prove crucial to the family’s civil rights lawsuit. There’s a different legal standard in civil cases: plaintiffs only need to prove that some combination of “gross negligence, deliberate indifference, and willful disregard” played a role in causing death.
That’s still not an easy bar to clear, but the FBI reports give the Stojcevski family some significant ammunition. They’ve added allegations to their case, accusing the county and Correct Care Solutions of “falsifying documents or failing to complete documentation,” leaving gaps in the record that directly affected the chain of events leading up to David’s death.
For its part, Macomb County continues to fight the case vigorously. Both County Executive Mark Hackel and Sheriff Anthony Wickersham say there’s no fundamental problem at the jail, and that few corrective actions or policy and personnel changes are necessary--even as 18 people have died there since 2012.
There have been some changes though, including one big one: Wickersham says, and Michigan Radio has confirmed, that Correct Care Solutions seems to be “erring on the side of caution more” these days.
While the jail’s inmate population has stayed more or less the same in the past few years, just 174 inmates went to hospital emergency rooms in 2012. By 2016, that number had more than doubled to 407.