1-2 Page 1 of 3 FEATHER ASSOCIATES, LLC LEGAL NUISE CONSULTANT TO: Shayla Maatuka Dodd Maatuka 303 Mattis Ave, Suite 201 Champaign, IL 61821 Date: November 30, 2016 RE: TOYA FRAZIER Dear Ms. lVlaatuka: have had a nursing license in the State of Illinois since 1982 and a physician assistant license (both national certification and in the State of Illinois} since 1996. I currently work in an urgent care setting as a physician assistant. have worked in multiple clinical settings as both a Registered Nurse and a Physician Assistant. lam familiar with the standard of care for a nurse in the state of Illinois. The standard of care for both nursing as well as physician assistant is a national standard and is, therefore, the same in all states. A copy of my Curriculum Vitae is attached as Exhibit i have been asked to render an opinion on the standard of care and ?treatment or lack of treatment" at the Champaign County Satellite Jail (CCSJ) on 11/30/15-12/1/15 when Toya Frazier was an inmate. have reviewed the records of Toya Frazier totaling 328 pages. have reviewed the following material: a FOIA Investigative Report 0 Champaign County Coroner Report 0 Champaign County Necropsy Report 0 Death Certificate . Promise Health Records Facts on the case: Toya Frazier arrived at the court house on 11/30/15 at 0845 am to turn herself in. She was then transported to the Champaign County Satellite Jail (CCSJ) on 11/30/15 at 1026 am via the Sheriff's Department. Toya Frazier had been sentenced to IDOC and was being temporarily held at the CCSJ. Toya Frazier had multiple medical problems including: Hypertension, Morbid obesity, Insomnia, Gastroesophageal reflux disease (GERD), Joint pain of lower extremities, along standing polysubstance abuse history. Toya?s medication list included: Triamterene 25, Zolpidem 10 QHS, Omeprazole 20mg BID, Cyclobenzaprine 10mg QHS, Gabapentin 300mg QHS, Ranitidine 150mg BID, Trazodone 100mg QHS, and Seroquel 100mg QHS. (Taken from Promise Health Records 7/25/15). 1 EXHIBIT 1-2 Page 2 of 3 a FEATHER ASSOCIATES, LLC LEGAL NURSE CONSULTANT Interesting, she also had multiple drug allergies listed, one of them being HCL {Benadry ). Toya Frazier was placed on medical watch by the CCSJ staff for heroin addiction. During the early morning hours of 12/1/15, Toya Frazier started screaming with severe abdominal pain. CCSJ Staff did not send the patient for medical treatment, instead moved Toya to solitary confinement, so not to disturb the other cellmates. At approximately 5:11 pm on 12/1/15 a correctional officer noted that inmate Toya Frazier had not eaten her evening meal. Upon further checking, the correction officer found Toya Frazier to be unresponsive. 911 was called. was initiated. EMS transported Ms. Frazier to Carle Hospital where she was pronounced dead at 5:46 pm. In the Emergency Department the following medications were found in Toya Frazier?s sock: 3 Trazadone 100mg, 8 Aleve PM, 1 Advil PM. The Coroner?s report showed the cause of death to be toxicity and misuse. According to the records: 11/30/15 0845 AM Toya Frazier arrived at court house to turn self in. 1026 AM Toya Frazier arrives at Champaign County Satellite Jail. 1121 AM Moved to Cell F2 1845 PM Jessica Burgener escorts Toya Frazier to shower room, does complete strip search, inspects clothing, cane and knee brace 1900 PM Toya Frazier placed in Cell H4 12/01/15 0250 AM Toya Frazier moved to cell H1 by herself. Complaining of abdominal pain. Moved to solitary confinement, so she wouldn?t disturb her cellmates. According to Officer Warren, Frazier continued to bang on cell door and would say "Help me?. 0705 AM Message sent for nurse to see Toya Frazier. (Email sent by Officer Matthew to medical staff stating "Inmate Frazier stomach hurts due to Heroin withdraw. Can you see her at your earliest convenience?) 0730 AM Officer Warren stopped in and advised Nurse Kemp about Frazier?s abdominal pain Frazier requesting to see the nurse. 1130 AM Nurse Cecile Kemp took Vitals and did a COWS score on Frazier. Frazier COWS score was 7, so they contacted the physician to start the withdraw protocol. Frazier was given lmodium for diarrhea, Meclizine for nausea, and Tylenol for body aches. She was put on medical watch. 1415 PM Beth Novak (nurse) spoke to Toya Frazier 1550 PM Camera shows last movement noted of Toya Frazier 1643 PM Food tray delivered to Toya Frazier 1711 PM Correction officer finds Toya Frazier unresponsive 1713 PM 911 Call made 1717 PM Arrow ambulance responds to Champaign County Satellite Jail 2 1-2 Page 3 of 3 FEATHER a ASSOCIATES, LLC LEGAL NURSE CONSULTANT 1746 PM Time of death Carle Hospital. Pronounced by Valerie Pollard MD In conclusion: Based on my report as above, it is my opinion that Toya Frazier?s "care/or lack of care" was below the standard of care while she was in-custody at Champaign County Satellite Jail on November 30 - December 1, 2015. This lack of treatment, resulted in a preventable death that was caused by overdosing on 0 Failure to adequately search Toya Frazier for pills on her person. (How did Toya Frazier have multiple medications in her possession at the time of her death?) Failure to completely assess patient. (How where did Toya Frazier get the medications to over-dose with? Was she not searched appropriately? How did the CCJS staff not see her taking the medications?) 0 Failure to completely assess, perform interventions, and appropriately refer Toya Frazier to the Emergency Department with abdominal pain. Sending her to the ER could have possibly prevented her overdose, which resulted in her untimely death. Toya Frazier started complaining of severe abdominal pain at 2 AM, instead of sending her for medical attention, she was put in solitary. A nurse did not see Tora Frazier until 11:30 AM (8.5 hours after her complaint of pain). 0 Failure to properly assess Toya Frazier every 13 minutes as CCJS have documented on their records. According to the camera, the last movement seen was 3:50 PM on 12/1/15, however Toya Frazier was not found unresponsive until 1711 (1 hour 21 minutes later). Did the person that delivered the food tray at 4:43 PM not speak or make any contact with Toya Frazier? Yet the staff has documented assessing her every 13 minutes. I reserve the right to amend/or supplement this report, if necessary. Sincerely, Lisa Feather RN PA-C Lisa K. Feather, RN BSN PA-C MPAS