The Cypress Creek juvenile detention center should strongly reenforce some safety messages to its staff, the Department of Juvenile Justice's inspector general says after investigating the death of a 17-year-old inmate last year.
+ Staffers should be "instructed on a recurring basis the importance of calling 911 immediately if a situation appears to be life threatening," the report says.
A guard found Willie Lawrence Durden III cold and unresponsive in his cell, but 20 minutes passed before staffers called 911.
The guard said he initially thought Durden was playing a prank.
An autopsy showed Durden died of natural causes from a heart abnormality. His body showed no sign of abuse. A toxicology screen was negative for drugs.
+ Cypress should continue its quarterly first aid drills for staffers, with special emphasis on cases like this one, where an inmate is found "down and unresponsive."
+ The state should consider buying automated external defibrillators and training staffers to use them at Cypress Creek and all juvenile correctional facilities.
These machines can shock the heart back into rhythm. Such a machine was not used for Durden, though a guard did perform CPR while awaiting paramedics.
Last month, the state reported that Durden died of natural causes related to ventricular arrhythmia, which is an abnormal electrical conduction that prevents the heart from pumping blood.
The arrhythmia was caused by a thickening of the walls of the heart and an enlargement of the size of the chambers.
That information came from the medical examiner. The inspector general reviewed the performance of G4S Youth Services LLC, the company that operates Cypress Creek on the state's behalf.
The inspector general's office, whose report was released Thursday, interviewed guards, reviewed surveillance tapes and examined official accounts of what happened Oct. 13 at the facility, which houses high-risk juvenile offenders.
Durden showed no health problems and seemed fine during his time at Cypress Creek. There were no problems Oct. 12 and early Oct. 13, guards and fellow inmates told investigators.
At 4:08 a.m., guard Josephus Johnson paused at Durden's cell, the surveillance tape showed. Johnson said Durden had not moved since the last bed check.
The guard opened the door, called Durden, shook him, but got no response. The inmate was cold and had a faint pulse, if any, Johnson told investigators.
"Johnson stated he wished he had immediately started CPR," the report says. "But he was unsure if (Durden) was playing games, as other youth in the past have played."
He called for a supervisor but didn't convey any possible emergency, the report said. John Esteves arrived at 4:18 a.m. He told investigators he yelled Durden's name, shook him, but got no response. He couldn't detect a pulse.
Esteves called for another employee, Matthew Yuhas. He arrived at 4:28 a.m., the tape showed. He couldn't detect a pulse and started CPR.
At 4:30 a.m., 911 was called.
Paramedics entered the cell area at 4:44 a.m. Durden was declared dead on arrival at Citrus Memorial Health System.
Times staff writer Abbie Vansickle contributed to this report.