Doctor suspended over Beltrami County Jail death

A Minnesota doctor has been indefinitely suspended by the state medical board for care lapses that led to the death of a Beltrami County Jail inmate in 2018.

The Minnesota Board of Medical Practice this month suspended Dr. Todd Leonard's medical license effective March 1 for "a careless disregard for the health, welfare, and safety of his patient."

Hardel Sherrell had been in the county jail nine days when he died. After becoming ill with numbness and pain in his chest and lower limbs, he was placed under the care of Leonard and the staff of MEnD Correctional Care, which provides contracted medical services to county jails.

"[Sherrell] entered the county jail on August 24, 2018, a vibrant, seemingly healthy 27-year-old man," the board said. "He was carried from that same jail nine days later to be laid to rest, after having endured days of suffering, begging those responsible for his care — medical providers and correction officers alike — for help that never came."

Del Shea Perry, Sherrell's mother, began advocating for the health and safety of incarcerated people after her son's death.

"I am elated. Although it has been three-plus years and mentally hard on me, I know that we have a long way yet to go," Perry said Wednesday. "But this is definitely a step in the right direction."

Last summer, the Minnesota Legislature passed a law in Sherrell's name that set new standards for mental health, suicide prevention and other health policies.

Leonard is the owner and president of MEnD and at the time was the chief medical officer for the company. Although he never met Sherrell, the board said he had a duty, as the doctor in charge, to make sure that Sherrell was receiving proper medical attention from MEnD's health care workers.

"I am profoundly saddened and disappointed by the Minnesota Board's decision. This death was a tragedy, but to my core I believe our care was appropriate, especially given the incredibly rare nature of this patient's condition," Leonard said in a statement Wednesday.

"This incident has been investigated extensively by the Board, through the legal process and other means; each of those investigations documented the steps we took to properly evaluate the patient's condition, to recommend a course of treatment, and to follow up as appropriate. For reasons I still struggle to understand, these facts were not persuasive to the Board."

An MEnD employee had recommended that Sherrell be transferred to a hospital emergency room, but the jail administrator initially vetoed the move. Jail employees thought Sherrell was faking his symptoms in an effort to escape, the board's order noted. Leonard should have insisted on the transfer, the board said.

"But instead of calling the administrator himself to insist that the Patient receive necessary medical care, Respondent yielded to the administrator's will and discretion," the board said, referring to Leonard. "In making this choice, Respondent abdicated his duty to protect his patient to a person without any apparent medical knowledge or training, and he put the interests of the facility and his company ahead of his patient's wellbeing."

After another MEnD employee intervened, Sherrell was evaluated at a hospital. A doctor there said the causes of Sherrell's symptoms were unclear, but he should get medical attention if they worsened.

Although Sherrell later became incontinent and developed slurred speech and facial drooping, he was never sent back to the hospital.

One medical expert hired by the board said Sherrell most likely died of respiratory failure caused by Guillain-Barre syndrome, a rare autoimmune disorder that affects the nervous system. Another expert said Leonard's behavior and lack of action did not meet the standards of care and "created unnecessary danger to the Patient's life, health, or safety," according to the board order.

While a doctor hired by Leonard's legal team said Leonard met the standard of care, an administrative law judge ruled that a state expert's "assessments and conclusions were better reasoned and more consistent with the evidence contained in the hearing record."

Leonard requested that the Office of Administrative Hearings review the case. After hearings last summer, Administrative Law Judge Ann C. O'Reilly recommended that the board impose "significant and appropriate discipline."

"A tragedy like this should never have occurred," O'Reilly wrote. "And it must never be allowed to happen again."

The FBI is reviewing the case for possible criminal charges.

A wrongful-death lawsuit filed by Perry in federal court in 2019 is pending, and she said any award would be used to benefit Sherrell's three daughters, ages 6, 8 and 10.

"They have been devastated and they are going to require a lot of mental health services when they get older," Perry said. "It is just going to be hard for them."

The board fined Leonard $30,000. He can petition the board for reinstatement of his license six months after the suspension takes effect.

Leonard noted that MEnD was not sanctioned and the company continues to provide health care services.

"While I disagree with many of the board's findings, I respect the board's process and its authority in this matter," he said. "Accordingly, while I am working to resume my practice, I will remain actively involved in the business aspects of MEnD."