On Feb. 12, Mustaffa Jackson, a 25-year-old paraplegic African American, was found lying face down in his cell at the George W. Hill Correctional Facility in Delaware County. Clad in an adult diaper, Jackson was alone in a cell strewn with new and used catheters. Efforts to revive him failed, but chest compressions didn’t even start until five minutes after Jackson was found in this condition. He not only died alone, but his death was painful, according to medical authorities.

A month later, the county said Jackson died of “delayed homicide” and offered no other information or additional depth to its original explanation.

Broad + Liberty fought a months-long open records battle to obtain Jackson’s autopsy, a battle won only because of a ruling handed down by the Commonwealth Court in a separate case from Allegheny County while Broad + Liberty’s open records appeal was still pending with the Pennsylvania Office of Open Records.

The autopsy sheds new light on Jackson’s death, but it only raises more questions.

READ MORE — Wally Nunn: Delaware County Council, are you happy with your prison now?

Mustaffa Jackson died from urosepsis, a fact the county concealed for months. The new information raises serious concerns about Jackson’s level of care while in custody, even though it does not completely refute the county’s earlier explanation.

Urosepsis is a condition in which an “untreated urinary tract infection (UTI) spreads to your kidney.” While urosepsis can be fatal, it can also be easily treated in the majority of cases with antibiotics but typically requires prompt intervention. “Your survival rate will decrease by eight percent each hour antibiotics are delayed after the first six hours” of having urosepsis, according to WebMD.com. Deaths due to sepsis are almost always painful for hours or days.

One month after Jackson’s death, a Delaware County spokeswoman gave the longest explanation the government would ever provide, totaling eighteen words: “The Manner of Death is homicide. The homicide is a delayed homicide from complications from a previous gunshot.”

That closely tracks the opinion from the autopsy, which says Jackon “died as a result of urosepsis due to paraplegia due to a gunshot wound.”

Mustaffa Jackson appears to have been shot sometime in 2019, which left him a paraplegic and in a wheelchair, although Broad + Liberty lacks independent verification of that fact. As a result of that condition, he would have normally needed to use a catheter to urinate, and catheter use can often cause urinary tract infections.

Given that Jackson’s paraplegia was a result of being shot and that his infection was most likely due to his frequent catheterization because of the paraplegia, it’s not incorrect to say his death was a delayed homicide. However, in subsequent inquiries over a number of months, county officials concealed the urosepsis, never disclosing or offering up that fact. Urosepsis may have been a consequence of the shooting but can usually be controlled with proper medication. Was Jackson, who was not being housed in the prison’s medical unit, receiving proper medical care?

Another prison document, obtained through a Right-to-Know request, shows chest compressions were not begun by responding personnel until five minutes after he was discovered.

With the new information from the autopsy in hand, Broad + Liberty addressed a new set of questions to the county.

“The County is not releasing any further information due to HIPAA privacy rights and due to this being an active criminal investigation,” spokeswoman Adrienne Marofsky said in response.

This was an otherwise healthy 25-year-old.

In January, a month before his death, Jackson had a violent encounter with medical staff.

“Jackson was complaining that the medical staff refused to give him more medication than he was ordered. It was explained to l/P Jackson that medical staff was only allowed to provide him with the prescription that was ordered,” an internal email said. “[Incarcertated person] Jackson eventually took his medication. Officer Herbin and Sgt. Serody attempted to return l/P Jackson to his assigned cell via wheelchair. At this time, l/P Jackson threw a left elbow at Officer Herbin, hitting her in the abdomen. l/P Jackson then threw himself to the floor to prevent himself from being escorted to his cell.”

Jackson’s death in February came about a month before the county was preparing to celebrate the one-year anniversary of the government taking full management control of the prison after being privately managed for three decades.

When that management handover was complete, the county named Laura Williams as its new warden.

Although her education was primarily in psychology, Williams previously served as the chief deputy warden of health care services at the troubled Allegheny County Jail. That disparity in education often generated pointed criticism from former colleagues.

Janet Bunts, who quit as the health services administrator at AJC, said Williams was an obstacle.

“Specifically, Bunts said that Chief Deputy Warden Laura Williams, who has no background in medicine, would not allow her to do her job,” TribLive.com reported in December 2020.

“She’s very micromanaging and controlling,” Bunts was quoted as saying about Williams. Williams did not respond to the paper’s request for a response.

Another article from the same time echoed the same concerns, but from a different source.

“Other former employees questioned why supervisors without medical training, such as Williams and Deputy Health Services Administrator Ashley Brinkman, are allowed to override the decisions of staff with medical training,” a report from PublicSource said. “‘How is that possible that none of them have a medical background but they’re still medical management for the jail?’ asked Sara McClung, a former medical assistant who said she was terminated in May for arriving late to work.”

While in Allegheny County, Williams was named in several lawsuits filed against the prison.

READ MORE — ‘It’s personal’ says lawmaker spearheading police safety effort

Her tenure as warden in Delaware County likewise got off to a rocky start.

Within the first ten months of government management, the George W. Hill Correctional Facility witnessed three suicides — a tally not seen in any single year dating back at least to 2015.

Also in that first year of government management, the jail accidentally released the wrong inmate, and a terrible homicide was recorded in which one inmate strangled his cellmate.

All this has come while the facility’s budget is rapidly expanding.

“In 2019, the prison budget was just over $48 million. By the end of 2022 — a year that included nine months of government management — the prison budget climbed to $55.7 million,” Broad + Liberty reported in March.

To further understand the significance of the autopsy, Broad + Liberty obtained comments from one pathologist and an emergency physician.

“When we take away somebody’s freedom, their liberty, when we incarcerate them, they no longer have the ability to manage, to try to get care for themselves. And we — society — assume the duty to take care of that person,” said Frank Speidel, a Chester County emergency physician with over four decades of experience who once ran for coroner but lost.

“That doesn’t mean everything we do has to be perfect because even good physicians with the best of intentions sometimes make bad choices that have bad results. It’s an imperfect situation in an imperfect world,” Speidel continued. “Yet, having said that, we have a duty to make sure we treat and optimize the life process of a patient, of a person who is in our custody. If somebody passes [away] in custody, I think we owe it to ourselves to make sure that it wasn’t from neglect, but it was from the disease process.”

The other doctor who provided comment did so anonymously because he is currently employed as a coroner/medical examiner at another government and is not authorized to speak on issues outside his jurisdiction.

Both agreed that Dr. Khalil Wardak’s autopsy raised more questions than answers.

“It would have been beneficial for Dr. Wardak to acquire the [medical records] from when Mr. Jackson was shot in order to specify where he was shot, how many times he was shot, whether any bullet(s) or bullet fragments remained in the body and where, and what injuries were sustained,” the anonymous doctor said.

“Please note that no x-rays of the body were conducted, so how can we be assured that there was or was not a bullet remaining from the prior incident in Mr. Jackson’s body that was of evidentiary value and needed to be retrieved?” that doctor continued. “In addition, review of the [medical records], particularly from the past year and, more significantly, from the past two to three months [in which Mustaffa Jackson was in custody] would have been beneficial to address what specific clinical challenges Mr. Jackson had been experiencing, and whether any of those clinical challenges required hospitalization and follow-up.”

If somebody passes [away] in custody, I think we owe it to ourselves to make sure that it wasn’t from neglect.

Speidel mostly agreed with that sentiment but offered caveats.

“[Dr. Wardak] may have had all the patient’s clinical records in the last three, four weeks of [Jackson’s] life. He may have access to all his medical records while he was incarcerated. He may have reviewed those and come to the conclusion that everything was done as it should be to optimize the patient’s life expectancy,” Speidel said.

But to reach that point of thinking, you’d have to use what’s called an assumption of normalcy — if the inspecting doctor doesn’t mention a particular thing, the reader should assume it’s normal. Whether or not you can apply the assumption of normalcy is more difficult to determine than whether a doctor has possession of a deceased individual’s medical records.

The second doctor also took issue with a lack of description of the outside condition of Jackson’s body.

“Dr. Wardak’s external examination is woefully inadequate, as 90 percent of a forensic autopsy examination is predicated on the external exam, supported and corroborated by the internal examination of the organs and tissues,” he said.

“I am completely befuddled by the cursory nature of the exam and the absence of imaging studies/radiology,” that doctor added.

Speidel, likewise, believes the autopsy needed more depth.

“This was an otherwise healthy 25-year-old. I don’t know whether it happened to him with him being sick for five days and then he passes in his cell, or was he sick for just twelve hours and passed? I’d like to know the difference. I think our community, our society, needs to know the difference.”

Melissa Melewsky, in-house counsel with the Pennsylvania News Media Association, said the medical records leading up to Jackson’s death are not likely to be obtained by a Right-to-Know request because of health privacy laws, particularly HIPAA. The only way those records might be obtained is through Jackson’s next of kin, any of whom Broad + Liberty has not been able to positively locate.

Editor’s note: Jackson’s autopsy cost $500 in fees paid to the Delaware County Medical Examiner’s office. If you value this kind of in-depth journalism, please make a donation to help defray that expense.

Todd Shepherd is Broad + Liberty’s chief investigative reporter. Send him tips at tshepherd@broadandliberty.com, or use his encrypted email at shepherdreports@protonmail.com. @shepherdreports