In the fall of 2011, as he was hauled off to jail, Aaron Persin was nursing a small scratch on his forearm.

At first, nobody seemed to notice the injury. It was so minor that, in his initial screening at the Oahu Community Correctional Center, Persin was given a clean bill of health — albeit with a history of gout and high blood pressure.

But Persin’s wound was infected: In a matter of days, it triggered a septic shock that put him on life support in the emergency room at The Queen’s Medical Center.

Persin survived, but the infection took a heavy toll: All of his fingers and both feet had to be amputated.

To critics, Persin’s experience is a case study in poor medical care behind bars — a persistent problem that puts the state’s taxpayers on the hook for millions in malpractice lawsuits.

Indeed, in October, the state reached a $7.2 million settlement with Persin to compensate for damages. A few months later, it also agreed to pay $625,000 to a family of another inmate whose kidney disease went untreated for months before he was found dead in his cell at the Halawa Correctional Facility.

To sign off on the payments, state lawmakers are now considering House Bill 2279, an appropriations measure that’s waiting for a vote on the Senate floor.

State Sen. Will Espero, vice chair of the Senate Public Safety Committee, says the Hawaii Department of Public Safety needs to learn from what happened to Persin and prevent similar incidents from occurring in the future.

“I’m appalled that we had to pay millions due to our own neglect,” Espero said. “We can’t keep doing this.”

Homeless With An Open Container

Persin’s troubles began with a seemingly trivial offense: A police officer found the 30-year-old, who was homeless and sleeping out of his car at Kapiolani Park, with an open container of alcohol.

Persin, who had outstanding warrants for skipping court on traffic violations, was arrested on the spot. Unable to post bail, he was then taken to OCCC.

Four days later, on Oct. 4, 2011, Persin came down with flu-like symptoms.

According to the court records, Persin had a fever — as high as 103 degrees — and suffered from headache, rapid heart rate and a stomachache. OCCC’s nurses gave him Tylenol and two liters of water before sending him back to his cell.

But Persin returned to the infirmary in the afternoon, complaining of dizziness and blurry vision. The nurses gave him another dose of Tylenol, but it didn’t help much, so they kept him at the infirmary overnight. They also consulted OCCC’s on-call physician, Dr. Sisar Paderes, who ordered a blood test to be done the next morning.

When his blood was being drawn, Persin pointed to an open wound on his forearm, which the court records say started as an “abrasion” he sustained while resisting the arrest. The nurses noted that it had pus and was “warm in the surrounding tissue.” Paderes, who examined Persin in person later that morning, also noticed an infection in his throat.

Paderes prescribed a broad-spectrum antibiotic called Ciprofloxacin and sent Persin back to his cell. But, less than 12 hours later, a guard took him back to the infirmary — he was too sick to stand up for a head count.

Shortly afterward, Persin’s test results came back, showing that he was suffering from kidney failure and sepsis — severe blood infection. He was eventually taken to Queen’s, where he soon went into septic shock.

The doctors put Persin on life support and administered medications to fight his declining blood pressure. The treatment kept his vital organs functioning, but it cut off blood circulation to his extremities and caused gangrene in his feet and fingers — which led to the amputations a few weeks later.

Richard Turbin, the personal-injury lawyer who represented Persin, says his client went back to his home state of Indiana after the surgery to live with his parents and recuperate. But he has since returned to Hawaii and now uses prosthetic legs to get around.

“He doesn’t have slippery snow to worry about in the winter here,” Turbin said.

Medical Missteps

Persin declined to comment for this story, but Turbin says a number of missteps by OCCC officials led to his client’s amputations.

For one thing, Turbin says, a timely diagnosis and treatment could have kept Persin’s infection at bay.

“The worst thing is that the nurse suspected the septicemia long before he was send to ER,” Turbin said. “If there’s any suspicion that a guy has a sepsis, he’s got to go right to the hospital, and you need to get a team on him right away. If they had done that, the odds were he would have been fine. He would’ve recovered.”

Turbin says OCCC officials also took more than 90 minutes to transport Persin to the hospital, which is less than 3.5 miles away, because they chose to wait for the jail’s vehicle to be available, rather than calling for an ambulance.

“It’s possible that, if they called an ambulance instead, he wouldn’t have lost his hands and feet,” Turbin said.

Turbin says what happened to Persin is not an isolated incident, noting that he hears from four or five inmates a month complaining about poor medical care.

“It’s possible that, if they called an ambulance instead, he wouldn’t have lost his hands and feet.” — Richard Turbin, attorney

“These problems go on and on and on, year after year,” Turbin said. “The prison officials — they don’t get it. They don’t make sufficient efforts to repair the problem, and it’s not going away.”

For their part, Wesley Mun, administrator of the Department of Public Safety’s Health Care Division, and Medical Director Michael Hegmann declined to comment on Persin’s case with Civil Beat.

But, in response to Espero’s inquiries, Mun and Hegmann put together a report in February, specifying the corrective steps that the department has taken since 2011.

The report listed eight separate steps, including the adoption of an electronic patient tracking system and two software reference programs for physicians and nurses, as well as revamped training for nurses to “enhance vigilance” and make them “more proactive and preventative than reactive.”

The steps also included a practice known as “the principle of ‘when in doubt.'” This practice, which calls for erring on the side of treatment, is aimed at encouraging physicians and nurses to be proactive in dealing with potential emergencies and not to hesitate to send inmates to the emergency room.

But, according to Toni Schwartz, public safety spokeswoman, this policy has been in place for about 15 years — long before Persin’s case.

Still, Mun says he is confident that the department now has a solid system in place to provide reliable medical care to inmates.

“As we keep these things in place … and continue to monitor what needs to be enhanced, I think they’ll have a great potential to decrease the bad outcomes,” Mun said.

Too Few Nurses And Doctors

But Turbin says he doesn’t expect major improvements until the department addresses its medical staff shortages.

As of Feb. 16, 40 of the Heath Care Division’s 144 nursing positions were vacant — nearly 28 percent. The rate was lower for the 80 nursing positions not assigned to mental health or dental care, but 13 of the positions — or 16 percent — were still vacant.

The department also had a vacancy for one of the five full-time primary-care physician positions overseeing the state’s eight prisons and jails.

“It’s simple. We just need more doctors and nurses,” Turbin said. “Unless they fill those positions, another inmate is going to be victimized again. It’s just a question of when.”

“If we don’t pay now, we might end up paying later because of inadequate care and negligence in health care.” — Sen. Will Espero

To be sure, medical staff shortages aren’t unique to Hawaii: Nationwide, many correctional systems have long been grappling with it.

In March, for instance, the U.S. Justice Department’s inspector general found that the Federal Bureau of Prisons had a vacancy rate of about 17 percent for its 3,871 health services positions. At 12 of the 97 Bureau of Prisons facilities, the rate was at 29 percent or higher.

But Mun told Civil Beat that the department is trying to address the issue. Its funding request to the Legislature includes an additional $160,000, so that the base annual salary of $170,000 could be increased to $200,000 for primary-care physicians and $220,000 for psychiatrists.

Espero supports the increase. “We just need to make the necessary appropriations to make certain that inmates do receive the care that they’re supposed to get,” he said. “If we don’t pay now, we might end up paying later because of inadequate care and negligence in health care.”

Espero says he might also introduce a bill next year to have an independent auditor look into the performance of the department’s medical care.

“We need to stay on top of the department, and it might take an independent eye to go in there to make certain that the changes needed are being made,” Espero said.