BOULDER COUNTY, Colo. — A 22-year-old at the Boulder County Jail, who had staph bacteremia and was repeatedly denied proper care for about a month, died after staff "didn’t even do the bare minimum to treat him," according to a lawsuit filed Friday.
Holland, Holland Edwards & Grossman filed it on behalf of Avery James Borkovec's brother and uncle, who represent Borkovec's estate.
Borkovec had been arrested in September 2022 and during his time at the Boulder County Jail, had staphylococcus aureus bacteremia ( or staph bacteremia), endocarditis, and sepsis, which are all easily treatable conditions. However, he was never provided appropriate care and suffered from "an entirely preventable, protracted, and excruciatingly painful death," the law firm said.
The lawsuit named the following defendants:
- Turn Key Health Clinics, LLC
- Bryan Reichert, doctor with Turn Key
- Chantel Trevizo, licensed practical nurse with Turn Key
- Nely Moreno-Santacruz, licensed practical nurse with Turn Key
- City and County of Broomfield
- Enea Hempelmann, chief of police for the City and County of Broomfield
- Board of County Commissioners of Boulder County
- Boulder County Sheriff Curtis Johnson
- Maxim Healthcare Staffing Services, Inc.
- Blake Morrow, with Maxim Healthcare Staffing Services
- Shonda High, licensed practical nurse with Maxim Healthcare Staffing Services
- Alexis Henderson, registered nurse with the Boulder County Jail
- Tiffany Jones, employee with the Boulder County Jail
- Deyanira Martinez, registered nurse with the Boulder County Jail
- Mel Parker, dental assistant with the Boulder County Jail
- Kaela Seeburger, employee with the Boulder County Jail
- Jack Markling, registered nurse with the Boulder County Jail
- Jennifer Samuels, nurse practitioner with the Boulder County Jail
- Charles Robert Davis, doctor with the Boulder County Jail
Borkovec had been arrested on Sept. 29, 2022 on charges of trespassing and previous failure to appear warrants, and was initially held at the Broomfield Detention Center. There, staff with Turn Key Health Clinics, LLC, a private correctional health care company, learned that he had staph bacteremia — a bacterial infection of the bloodstream that can be deadly if not addressed — and had been treated at Good Samaritan Hospital a few days prior.
"Even though they knew Avery’s recent lab results showed he had bacteremia, and despite knowing and that he was exhibiting clear signs and symptoms of a serious bacterial infection, Turn Key medical staff recklessly chose not to send him to the hospital or even start him on antibiotics," the law firm said.
The lawsuit reads that Dr. Bryan Reichert with Turn Key "baselessly" claimed that the blood cultures showing Borkovec's elevated white blood count were "contaminated," and said the man was "not experiencing 'true bacteremia.'"
"Defendant Reichert knows that it is impossible to rule out proven bacteremia on lab tests without any further testing, and that when it comes to bacteremia and sepsis, time is of the essence," the lawsuit reads. "He nonetheless chose to ignore the obvious danger posed by Mr. Borkovec’s lab results and deprive him of the benefit of a diagnosis... Dr. Reichert admittedly already knew that Mr. Borkovec needed to go to the emergency room, but chose to deny that care."
About a week later, on Oct. 7, 2022, Borkovec was transferred to the Boulder County Jail "due to population issues" at the Broomfield facility, the lawsuit said.
None of Borkovec's conditions — which the lawsuit said included "an elevated (white blood count), positive blood cultures, a persistently high pulse, ongoing signs of infection" — were reported to medical staff at the Boulder County Jail.
"Turn Key workers’ conscious choice not to convey this information to Boulder was a complete and total dereliction of their gatekeeping duties," the lawsuit reads. "They simply handed off this known-to-be seriously ill patient without any regard for his future care needs, despite knowing that without antibiotic treatment he was likely to develop sepsis and suffer serious injury or death."
During intake, Borkovec told a nurse that he did not have any breathing problems, ulcers or dental problems. Borkovec said he had used heroin intravenously four times daily and his last use was two weeks prior. IV drug use is common in all jails, including Broomfield and Boulder, the lawsuit reads. Bacterial infections are also frequent amid users.
Over the next 26 days, Borkovec became more and more sick. Over that time period, he had reported "recent IV drug use, severe back pain and tightness, severe pain and soreness throughout his body, inability to sleep, vomiting, coughing, extreme tooth pain, migraines, anxiety, significant weight loss, and fatigue for weeks," the lawsuit reads.
"Mr. Borkovec was so obviously sick throughout his time at Boulder that medically untrained laypeople were aware he needed hospital-level emergent care," the lawsuit reads. "He was concerningly pale, jaundiced, thin, lethargic, and frail. He was coughing up blood, barely eating, and obviously struggling to breathe. Other inmates had been collecting his meal trays, summoning deputies to get him medical attention, and telling Boulder staff he obviously needed to go to the hospital."
Some of the other inmates called him "Casper" because of how he looked, the lawsuit reads.
Attorney Rachel Kennedy of Holland, Holland Edwards & Grossman said the healthcare staff should have sent him to a hospital so he could have received the care he "so clearly needed," but instead they "continued to blindly administer an ever-growing cocktail of ineffectual over-the-counter drugs that did nothing to treat Avery’s serious infection."
Throughout the day on Nov. 2, 2022, Borkovec asked for medical care, but did not receive any. Inmates noticed a gurgling sound when he breathed, which appeared to be a clear sign his lungs were full of liquid, the lawsuit reads.
"He continued to deteriorate, and at approximately 11:30 p.m. he was so obviously in the throes of a medical emergency that inmates who were passing by his door looked in and called for deputies to help," the lawsuit reads.
Medical staff — Nurse High and RN Martinez — evaluated him for less than seven minutes and determined he could stay at the jail. He was moved to a single-person cell. The lawsuit says Dr. Charles Robert Davis accepted the "erroneous and simplistic conclusion that Mr. Borkovec’s symptoms were caused by asthma."
"The next morning Avery stumbled out of his cell, weak, coughing, and keeled over at the waist," the law firm said. "A concerned inmate called for deputies, who called for a non-emergent medical response although Avery was clearly on the brink of death."
Those deputies, identified in the lawsuit as Deputy Gerardo Wence and Sgt. Dave Nagle, "refused to immediately summon medical workers, instead waiting until they got a verbal report of shortness of breath from Mr. Borkovec," the lawsuit reads, adding that Deputy Wence knew Borkovec had been seen by medical staff the night prior for shortness of breath. When the 22-year-old was able to verbally confirm this, Deputy Wence called for a "nonemergency medical response."
"While they waited for medical personnel to arrive, deputies repeatedly accused Avery of taking drugs, downplayed, and mocked the severity of the situation, instructing him not to 'make a mess,'" the law firm said.
When other security staff arrived, "it was immediately apparent to them that this was a serious medical emergency" and they radioed for help, a crash cart and Narcan, the document reads.
Borkovec had not taken any drugs or overdosed, the lawsuit reads.
"Medical workers and security staff nonetheless continued treating Mr. Borkovec as if he were overdosing, administering him four doses of Narcan and refusing to consider any other possible causes of this acute medical emergency despite his documented complaints of various serious symptoms for nearly a month prior," the lawsuit reads.
Shortly after the first time he was administered Narcan, he lost consciousness and began vomiting up blood, including golf-ball sized clots.
First responders were called in but despite their efforts, Borkovec died.
An autopsy conducted on Nov. 4, 2022 found that his blood and lungs contained staph bacteria and his heart was covered in lesions. His lungs were filled with bloody fluid and weighed more than double the weight of a normal post-mortem lung, the autopsy found. He also had ulcers throughout his gastrointestinal system and had experienced an acute upper gastrointestinal hemorrhage.
Staff at the Boulder County Jail measured his vital signs just three times in the 26 days he was there, the lawsuit reads.
Attorney Anna Holland Edwards said people should not die in Colorado's jails from bacterial infections.
"The prolonged and painful suffering and death of this 22-year-old from an entirely treatable infection is particularly cruel and unnecessary," she said. "The medical staff had so many opportunities to intervene and treat Avery, but chose instead to ignore his obvious crisis and the pleas of Avery and others in the jail for help.”
The lawsuit filed Friday also listed out what it called a "shameful record" of Turn Key employees providing inadequate medical care that led to inmate deaths. It included several settled and ongoing lawsuits, as well as a case where two Turn Key nurses were charged with second-degree manslaughter. In one case, Turn Key will pay a family $3 million after their loved one died of starvation and dehydration after a year of solitary confinement, the lawsuit reads.
Denver7 is committed to making a difference in our community by standing up for what's right, listening, lending a helping hand and following through on promises. See that work in action, in the videos above.