Clifford Farrar walked into the dayroom last December in a Washington state prison where he had been incarcerated for five months; after missing dinner hour and his daily insulin dose he collapsed into a seizure.
One witness said Farrar was “not seeming like himself.” His family believes that his blood sugar was so low that it may have caused him to be disoriented.
“I alerted guards that he was a diabetic thinking they were going to relay it to medics by radio,” one unnamed witness told Farrar’s family.
According to witnesses, about five minutes after he collapsed, guards at the Stafford Creek Corrections Center contacted medical staff. The guards dispatched a blanket code for emergencies throughout the facility. Witnesses said it took medical staff 15-20 minutes to arrive, and they showed no sign of “urgency” when they got there. He died after medical personnel failed to resuscitate him.
Atlanta Black Star examined more than 250 pages of Farrar’s prison medical records and other documents related to his Dec. 27 death.
Medical records show guards rolled Farrar on his left side and held up his neck while they waited on medical personnel. Bloody mucus streamed from his nose, and the fluids flowed underneath his neck. He was breathing at first but unresponsive, medical staff wrote.
They discovered that Farrar’s blood glucose level was dangerously low. The 51-year-old had been diagnosed with Type 1 diabetes when he was 15 and had been required to inject himself with insulin to regulate his blood sugar.
Staffers gave Farrar one dose of glucagon, a drug meant to increase blood sugar levels. They also tried to administer intravenous medication for low blood sugar, but Farrar lost his pulse and emergency responders could not resuscitate him. Medical records show his glucose level was 32, but his family believes it was lower.
The incarcerated man’s death certificate shows he died from natural causes: heart disease with diabetes, chronic lung disease and obesity. However, Farrar’s family believes he died because of the prison’s medical negligence.
“They killed him,” his sister Mary Farrar-McQueen told Atlanta Black Star.
Farrar’s family believes he would’ve still been alive if the prison did not ignore several of his pleas for medical help. An internal review of the man’s death reveals several incompetencies in Washington prisons’ health care services. Moreover, it illuminates a broader issue of negligence in the state’s prison system.
Incarcerated people have the right to adequate medical care under state and federal law. However, reports show the Washington Department of Corrections has a historical pattern of disregard for incarcerated people’s health.
Last July, the state agreed to a $3.25 million settlement to the estate of a man who died after Monroe Correctional Complex staffers failed to give him proper treatment for an open wound in his abdomen after outpatient surgery. Instead, they gave him Tylenol. His condition worsened for over a month, and he died later in a hospital from septic shock, acute pancreatitis and a perforated intestine.
A 2020 investigative report by Crosscut found that a third of people who die in Washington prisons are younger than 55 because their treatments were deemed “not medically necessary.” Medical issues were attributed to 89 percent of the 677 deaths in state prisons from 2001 to 2019, according to the report.
In February, 23 incarcerated people and one staffer received a monoclonal antibody treatment for COVID-19 instead of the vaccine in another facility. The drug was not authorized for use in the U.S. It’s unclear if those injected suffered adverse effects.
At Farrar’s facility, more people than in any other Washington prison died from coronavirus, reports show, and the state fined Stafford twice for “serious” and “willful” violations of COVID-19 policies. The state also issued an $84,400 fine against the Corrections Department in September for failure to control a tuberculosis outbreak.
Medical records show that Farrar had complications regulating his blood sugar level from when he was first transferred from jail to Stafford in July 2021 to serve time for felony charges.
Records indicate he had been using a diabetes insulin pump, a small computerized device that released small doses of the drug to control his blood sugar while in jail, but he had not been allowed to bring it to the state prison.
Farrar’s blood sugar spiked for his first several weeks in prison. He had been using the device for five years before his stint at Stafford.
“My blood sugars are extremely high and have been from the time I came to the facility,” Farrar wrote in a health service grievance on July 9. “Why do I have an average BG of 400 and no action is being taken? I am in a controlled environment with a food amount that’s also controlled. There should be not any reason why you’re not able to get my BG under 200.”
Medical staff told Farrar “insulin needs normally change” when someone transitions from county jail to prison and they planned to gradually increase his insulin as time went by and monitor his progress.
Still, Farrar’s blood sugar levels continued to spike between meals. At one point, it reached nearly 600. He also started getting vision problems. High blood sugar can damage the blood vessels in the retina, the Centers for Disease Control and Prevention says.
Farrar first requested medical staff to allow his wife to send his diabetic pump to the prison on Aug. 27, 2021. However, the request was not approved until after he suffered his first seizure from low blood sugar in mid-September. He also asked medical staff for glucose tablets in case his blood sugar level suddenly dropped.
“I am going to order a snack at night to keep in case of a drop in sugar,” the nurse practitioner wrote. “I have completed the request for your pump, so you can start using it when your family sends it in.”
Prison records show the insulin pump arrived on Sept. 29, 2021. However, 27 days later, Farrar ran out of pump supplies. His insurance company previously covered the limited supplies that his wife sent, so he asked the prison to replenish them. However, medical staff said the prison could not pay for the supplies because the pump was personal property.
Farrer collapsed again on Dec. 3, 2021, because of low blood sugar. The diabetic pump usually warned him when his glucose level dropped below 80.
Witnesses told prison staff they saw Farrer drop his meal tray and fall to his knees. Medical staff gave him glucagon, glucose gel to raise his blood sugar and 55 grams of carbohydrates, according to medical records. He was also treated for an injury to his elbow and forearm from the fall.
Farrer wrote a grievance that same day requesting the pump supplies.
“I don’t have the funds to buy the supplies,” he wrote.
Farrar died 24 days later. A DOC review of the incident found that a nurse had not been trained on emergency response procedures and equipment, suction and oxygen saturation medical devices did not function correctly, and some corrections staff did not have documented CPR training certification.
Farrar-McQueen also believes her brother had difficulty breathing because of another untreated medical condition. He had also filed several grievances for polyps in his nose that made breathing difficult for him.
“[Witnesses] talked about how these two nurses arrived, and they didn’t have anything to save my brother, and they screamed that he was diabetic,” she added. “They didn’t ask anybody for anything sweet to bring his sugar up.”
“There was nothing natural about his cause of death, and they call it natural because he had diabetes,” Farrar-McQueen continued. “And they say heart disease because he died from a heart attack, but he had diabetes, and the complications came from medical neglect. And that is not natural.”
Farrar-McQueen said she launched a campaign against medical negligence in prisons and is working on a list of demands for the DOC.
State Corrections Secretary Cheryl Strange, who took over the role as head of the prisons last year, has implemented reforms to the system’s grievance process, hired more medical staff and has prioritized “timely off-site medical visits” with the help of consultants, officials said. The state has also approved insulin pumps in its prisons for diabetic care because of Farrar’s death.
