HARRIS COUNTY, Texas (KTRK) -- Sarah Borchgrevink said her brother told her he was worried about his diabetes after turning himself in on a DWI charge at the Harris County Jail last year.
"I believe he was very cold. I believe that he was mismanaged. I believe it was the weekend and that something very dark and very, very, very sad happened," Borchgrevink told 13 Investigates in November.
On Thursday, 13 Investigates confirmed her brother, 28-year-old Matthew Shelton, was the inmate at the center of a non-compliance notice issued to the jail for violating state standards and not providing insulin and blood pressure medication to an inmate who later died.
Shelton died of diabetic ketoacidosis on March 27, five days after arriving at the jail.
Borchgrevink shared a photo of the belongings Shelton had with him when he arrived at the jail. The pictures show Shelton had the insulin and needles needed to treat his diabetes. But based on his high insulin levels, Borchgrevink told us last year that she didn't think he received it.
"There's a stigma against people who have endured any kind of issues that require perseverance, such as homelessness or dysfunctional backgrounds, or a lot of reasons why people find themselves in jail," Borchgrevink said on Thursday. "Despite the person's behavior or the cause of being in jail, nobody per their civil rights is allowed to be denied medication, and he went in with his medication."
The latest non-compliance notice for the jail confirmed Shelton didn't receive blood pressure medication or insulin ordered by jail physicians.
The notice from the state, dated Dec. 19, 2022, says, "Documentation reviewed after a custodial death revealed that while insulin was reviewed, ordered, and provided while the inmate was at intake, it was not reviewed, ordered, and provided once the inmate was housed."
The letter also states, "Documentation reviewed after a custodial death revealed that daily orders were written for the inmate to receive KOP (Keep on Person) blood pressure medication. However, this order was not filled, nor was this medication provided once this inmate was housed."
Borchgrevink said her brother always successfully managed his diabetes, even through times of homelessness, so when he told her he wasn't receiving it in jail, she started making calls and demanding answers from the jail.
"I became concerned when I no longer heard from him. That was unlike Matthew. When he did call and told me he wasn't receiving medical care, that's when it became not just a worry but an actual emergency, to which we never were able to get in hold of an actual human being," Borchgrevink said.
In a statement responding to the notice, the Harris County Sheriff's Office told 13 Investigates, "Harris Health has implemented measures to address the issues raised by the jail commission and to raise the level of health care service they provide in the jail."
HCSO previously said the Harris Health System "assumed responsibility for jail healthcare on March 1, 2022."
Anytime an inmate dies at a county jail, it has to be reported to the Texas Commission on Jail Standards.
"What Texas Commission on Jail Standards does after a custodial death is review relevant records, and information that they request from the jail related to the minimum standards at the time that the person was detained," Gabriela Barahona, a program associate with Texas Jail Project, said. "That could include whether or not observation checks were being performed in the areas in which the death occurred. It could include documentation that prescription medications were being administered. It could confirm where in the housing (unit) the inmate was before the death occurred."
The TCJS is an oversight agency responsible for ensuring jails comply with state standards.
Barahona said the agency cannot investigate criminal activity and has few enforcement options available to force corrective measures.
"The unfortunate reality is there is very little enforcement that the commission can do. What needs to happen is continued public pressure on the county commissioners to reprioritize and realign our budget and spending with prevention instead of punishment. To halt hiring, freeze hiring pending an internal review of HR practices, internal investigations," she said.
Barahona said this latest notice of noncompliance is significant.
"This special report took extraordinary measures to specifically name the failure and inaction of jail staff as it related to the medical care of people that went on to die in the jail," she said. "In our experience, the Texas Commission on Jail Standards has not gone so far as to name jail staff behavior related to medical care or death, so I think this is an extraordinary step meant to demonstrate how culpable and how responsible sheriff's office and jail staff (have) been in denying folks care that they are legally entitled to and have been ordered by doctors to receive."
Last year, 28 inmates died in HCSO's custody, including 25 who were under the jail's care.
Prior to this latest letter of non-compliance related to Shelton's death, the jail was already under scrutiny for its failure to book all inmates within 48 hours.
As of Wednesday, there were 10,082 inmates at the Harris County Jail and another 866 outsourced to facilities in Louisiana and West Texas due to a lack of space locally.
This week, the jail's top leader resigned, citing some of the challenges during his two years at the jail, including "a large felony case backlog which lead to overcrowding and outsourcing."
"While my time here has been one of mixed emotions, HCSO has some of the most amazing people I have ever had the privilege of meeting and working with. A large percentage of the staff here go above and beyond on a daily basis to protect each other, our inmates, and the general public," Harris County Jail Assistant Chief of Detentions Shannon Herklotz said in his resignation letter. "While I pushed myself to new limits, the results were not always what I/we expected. I have no regrets, and there is very little I would change. However, I feel that you and Chief (Deputy Mike) Lee want to move in a new direction, and I do not feel as (if) I have a place in that vision."
Before joining the jail in 2021, Herklotz spent decades working for the state commission on jail standards.
"(His resignation) raises a lot of questions for community members for who will fulfill that role given his unique background in inspecting jails and even leading jails (through) remedial orders and then compliance," Barahona said.
In the meantime, families like Borchgrevink are still fighting for answers.
"Although this notice of non-compliance is long overdue, our family is grateful for every little step toward justice for Matthew and all the inmates that have needlessly suffered due to overcrowding practices at the Harris County Jail," she said.
Borchgrevink said that her brother had at least five family members and friends advocating for him, calling and visiting the jail to make sure he was receiving proper medication and care.
She's worried about the inmates whose family members might not know they're in jail, or who don't have friends or family who can advocate on their behalf or navigate the "multi-faceted bureaucracy" at the jail.
"For it to happen to somebody when we are actively trying to avoid it because we know what the worst outcome could have been and we were not able to save Matthew lets me know that it's a very dire circumstance and there are things happening - whether it's protocol, accountability, I don't know what's in there other than the overcrowding issues," Borchgrevink said.
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