Dying Behind Bars

In ‘‘Dying Behind Bars,” Leonora LaPeter of the Savannah Morning News uncovered the troubling shortcomings of privatized health care in the county’s jails. The series made a solid link between the poor quality of medical care and privatization, showing that inmates’ health had been sacrificed for low costs and higher profits — with little regulation or oversight.

 

Ronald Smith hanged himself with a bed sheet. James Scott’s life ended because of a duodenal ulcer. And Alfonzo Roberson died either of an aneurysm or a blood clot, although experts can’t agree.

All three were one time inmates at the Chatham County, Georgia Sheriff’s Complex. Their families blame inadequate medical care at the jail for the loss of their loved ones. They filed wrongful death lawsuits against the county and the private company — Prison Health Services (PHS) — that provides health care at the jail.

“Why didn’t they listen to him and give him medical assistance?” asked Lula Roberson, Alfonzo Roberson’s grandmother, a year after the 19-year-old became sick in his jail cell and died. “Don’t let them just lay there and die like an animal without just listening to them.”

But county commissioners didn’t talk about these lawsuits once during a yearlong public discussion of who should provide health care at the jail. The county asked for bids last summer as the end of PHS’s contract approached.

In fact, county officials said they were happy with the service provided by the for-profit, publicly traded PHS, one of the two largest private correctional health care companies in the country. They only chose a smaller private company, Correctional Healthcare Services (CHS), because it was the low bidder. (The county and the two companies are currently in court to decide whether the selection was proper.)

But these lawsuits and others around the country question whether proper health care for prisoners also should be at issue when private companies are considered. Consider that PHS, the current provider, has been the subject of more than 20 federal lawsuits by inmates in the past five years in southern Georgia alone. Some of those lawsuits came from inmates in the state prison system, a contract that PHS lost in 1997 after a year and a half on the job.

Inmate medical lawsuits against the county jail range in seriousness from an inmate’s contention that inadequate care left him with a permanent shoulder injury to another’s complaint that he wasn’t being supplied enough colostomy bags.

Jean Byassee, general counsel for the Tennessee-based company, said she is not surprised by the large volume of lawsuits. “These folks have a good familiarity with the justice system, they may have access to a law library and a lot of time on their hands,” Byassee said. “And they’re the only folks in America guaranteed health care. So a lot of factors contribute to us getting a lot of lawsuits.”

PHS is the subject of multiple lawsuits across the country. Inmates and their families have sued the company a number of times for inadequate medical care, including deaths and injuries they say could have been prevented. The smaller CHS also has been named in a number of claims, including a class-action lawsuit filed last April in Fulton County, alleging the company neglected its AIDS-infected inmates and contributed to a public health crisis.

Health care is one area where inmates are the most vulnerable. Those who end up in jail tend to be sicker than average but less inclined to seek medical care, experts say.

As more and more jails opt out of the health care business and turn to these private managed care companies for inmate health care, those who represent the interests of inmates worry that the companies’ need to make a profit will come at the expense of inmates.

The trend comes at a time when overcrowded prisons and jails strain to provide the most basic services to inmates. “I have to say that the idea that health care is going to the lowest bidder doesn’t make those of us who are not in jail comfortable,” said Debbie Seagraves, executive director of the American Civil Liberties Union in Atlanta. “Certainly because someone is in jail doesn’t mean they deserve to die because of a lack of health care.”

 

Dying in Jail

At 17, Ronald Smith had problems. He suffered from dyslexia and an “organic mental disorder” that left him with a mental disability, court documents show. He attended a rehabilitation center in the mountains of western Virginia and sought training in auto body work.

But in October 1995, a staff member at the center found a tin can fashioned into a marijuana pipe in his dorm room. He blamed it on his roommate, but both boys were suspended. Then Smith and a friend broke into Smith’s grandparents’ house and took two pistols that supposedly belonged to Smith. They went to the other boy’s mountain cabin and shot the pistols.

The break-in drew the attention of police. So Smith and his friend hid the pistols, hot-wired a car, and headed for Florida, where the other boy had family. Smith called his mother several times as he headed south on the highway and she, in turn, called the highway patrol. Smith was apprehended in Chatham County and placed in the county jail. His cohort, a 16-year-old, ended up in the county’s juvenile facility.

During an admission interview with a PHS nurse, Smith said he had considered shooting himself three days prior to his arrest. According to legal documents filed in U.S. District Court, those words should have provided Smith with mental health attention.

Instead, the intake form was lost. The PHS nurse said he gave the form to the booking desk. The sergeant there said he never received it. So Smith was moved to the general population. A day later, Smith was placed on cell restriction after another prisoner mistakenly told jail officials he thought he’d testified against Smith’s brother.

Smith spoke with his mother, who was trying to get her car fixed to come to Savannah. He told her he was depressed and could not live in jail. Smith’s mother, Sharon Ann Clark, called a mental health counselor at the jail and left messages expressing concern about her son.

On November 15, 1996, Smith inquired four times why he was on lockdown, but could not get an answer. Later that morning, officers found him hanging from a bed sheet that had been wrapped around a vent over the toilet in his cell.

Jail officials conducted an internal investigation and determined that no procedures had been violated during Smith’s incarceration. Still, the county has filed a cross-claim against PHS, alleging that the health care company’s workers failed to notify the county about Smith’s condition.

County jail officials say that the lockdown was to protect Smith, not punish him, court documents show. They said he was able to call both his mother and aunt a number of times, and he was checked regularly by corrections officers, who had no knowledge that he posed a risk to himself.

But Smith’s mother, Clark, and her lawyer, Eugene Brooks, view it differently. Although federal court rules bar them from discussing the case while it is pending, legal documents outline a $2 million claim that officials at the jail were both negligent and deliberately indifferent to Smith’s needs.

They accuse the jail and its health care workers of failing to follow its own policies or train its personnel properly. They say Smith did not get the mental health treatment that he should have gotten immediately.

But Brooks, the lawyer, has a tough road ahead of him. The Supreme Court ruled in a 1976 case that inmates have a constitutional right to medical care, but they must show that jail officials were “deliberately indifferent” to a serious medical need.

Brooks believes the higher standard is unfair. It’s hard to prove that jail workers deliberately failed to care for inmates, because those who have all the information that might corroborate the claim have a vested interest in making sure that inmates and their lawyers don’t have access to it. “You can get bad care in prison and it’s fine, and I’m not sure if that’s appropriate,” Brooks said.

 

Prisons, Privatization, and Concerns Grow

More than 2 million people are now incarcerated across the United States, a 500 percent increase in the last 25 years. Prison experts say no wonder medical care standards have plummeted.

But conditions are nothing like they were in the early part of this century, when prisoners were used in medical experiments and even subjected to torture.

In the 1970s, more attention was focused on prison conditions. The American Medical Association developed standards for health care that eventually spun off into an organization known as the National Commission on Correctional Health Care. Today, it accredits jails and prisons on a voluntary basis for a fee.

A 1976 Supreme Court decision in the case of a Texas inmate with back problems further set the standards. Prisons and jails were required constitutionally to provide adequate medical care.

Enter the private correctional managed care companies. They offered states and local governments a cheaper alternative at a time when diseases became more complicated and prison medical costs skyrocketed. Industry analysts say these companies now represent some 25 percent of the $3.75 billion spent nationwide on correctional health care.

Chatham County’s jail hired its own medical staff until 1992, when it awarded a contract to Prison Health Services. Jail officials say it has saved them thousands of dollars and makes sense for the prisoners too.

“For me to go out and hire nurses and manage nurses, I don’t have that kind of training or ability,” said Gary Blake, then the jail’s administrator. “We’re much better off getting professionals to provide those services.”

But some question whether privatized health care is the way to go. The companies may offer to do it better, but they actually may skimp on staffing and services, leaving inmates vulnerable, prison experts said.

“Everybody’s fear in this area is that there will be lessened accountability somehow and because services are for profit, prisoners will be in some sense neglected in order to increase profit margins,” said Craig Haney, a professor of psychology and law at the University of California at Santa Cruz. “I think there’s evidence of it happening and evidence of it not happening in other cases.”

Haney and others are concerned the private companies will come in and initially provide a high standard of care but later begin cost-cutting practices that maximize profit but harm inmates.

“There’s a built-in conflict of interest because the private health care provider is trying to make as much money as it can for its stockholders,” said Stephen Bright, director of the Southern Center for Human Rights in Atlanta. “So if inmates need something, the temptation is to not give them expensive medicine because it cuts into profit.”

Experts who study prisons said other factors contribute to inmates not always receiving the best of care: Salaries for prison medical workers are low, so the field sometimes attracts more unqualified personnel; working in prisons is no easy task; correctional health care workers can become hardened and distrustful of inmates. Some even begin to think that all inmates with health problems are lying get out of work or to get access to drugs.

“That kind of callousness and inability to separate a true illness from a not-so-serious illness is what gets health care people in trouble,” said Michael S. Vaughn, an associate professor of criminal justice at Georgia State University. “Pretty soon everyone they see is a dirt bag or scum bag — the whole class of people is bad. They paint them all with a big, broad brush.” This stereotyping can be understandable, Vaughn said, but health care workers should make an effort to be the compassionate side of prison life.

Private companies that provide the care maintain they do provide good care. At the Chatham County jail, for instance, PHS officials say they have kept the jail accredited with National Commission on Correctional Health Care since they arrived in 1992. Jail and PHS officials said this accreditation is proof that the county jail offers adequate medical care.

The National Commission on Correctional Health Care sends a survey team into a prison or jail only at the request of officials who run the facilities. It accredits 500 of the 3,000 jails and prisons across the country. It was last at Chatham County’s jail in 1996 and is due to visit it this year.

Georgia chooses to provide no state oversight.

But Robert Cullen, an Atlanta lawyer who has represented thousands of inmates in civil rights litigation during the last two decades, said many of the accreditations are not worth the paper they are written on. “In several cases in Florida, Georgia and Alabama, I’ve seen places accredited by them and then within days or a couple of weeks, a judge would enter an order finding the health care provided was unconstitutional,” said Cullen, who has also served as a court-appointed monitor in Florida prisons.

Edward Harrison, president of the accreditation group, pointed out that deaths occur in jail just as medical malpractice occurs in the free world. An entire industry shouldn’t be condemned, he said, for the actions of the few. “Our accreditations are very valuable . . . and have been used to make improvements to jail health care hundreds and hundreds of times,” Harrison said. “It makes a very positive difference.”

The accreditation team that surveyed the Chatham County jail in 1996 found the jail’s clinic well equipped and organized. It found the facility up to snuff on more than three dozen of its standards, but it knocked the jail on a few standards related to health assessments, medical records, and mental health evaluations.

“The surveyors found at least half of the mental health evaluations were not completed, routinely missing important observations of the inmate that would help to identify certain critical situations such as depression,” the report said.

The national organization does not require a minimum staffing level at the jail, although it will consider staffing if problems surface, Harrison said.

 

Staffing a Key

Alfonzo Roberson had headaches. Bad ones. And lots of them. He asked for headache medicine at least seven times, and possibly as many as ten times, during his nearly three-month stay at the Chatham County jail in the late summer and fall of 1997.

In jail on charges of forgery and theft by receiving stolen property, Roberson received Tylenol five times. He asked for stronger medication on a number of occasions, specifying Motrin on a medical request form. His last two requests for headache medicine were never filled.

He died October 21, 1997, possibly of an aneurysm, although his exact cause of death is disputed in court documents. He had lost 10 pounds but only saw a physician’s assistant once — during a routine exam done 54 days after he entered the jail. Prison Health Services’ policies require a routine exam within 14 days.

“I need some Motrin for migraine headaches because the other pill don’t work,” Roberson wrote, time after time.

Lula Roberson, Roberson’s 64-year-old grandmother, realizes her grandson wasn’t perfect. He left school without graduating, worked odd jobs and seemed to be hanging out with the wrong crowd. If he did wrong, as police said he did, he deserved to be in jail, she said. But he didn’t deserve to die there. “It seems like they could have taken him to the infirmary if he was constantly asking for aspirin,” she said. “For what reason did he need aspirin, a healthy young man?”

Roberson’s daughter, Lorraine, and his father, Nash Mitchell, have sued the jail and Prison Health Services. They could not comment because the lawsuit is still pending in federal court.

Their lawyer, Sage Brown, argues in court documents the jail’s health care was below standard. Roberson’s vital signs should have been checked when he sought headache medication that many times, and he should have been referred to a doctor.

At least one medical expert hired by Brown contends Roberson probably suffered from hypertension that enlarged an existing aneurysm, causing his numerous headaches and his death.

In court documents, Brown maintains PHS’s custom of providing medical care at the lowest possible cost deprived him of adequate medical care and ultimately his life.

They have submitted a report by an independent correctional health care consultant, Jacqueline Moore, that says PHS staff continuously violated its own policies by failing to provide medical care to Roberson. Moore pointed out that some nurses expressed concern that they did not have enough time to care for all the inmates. And the onsite PHS administrator said in a deposition that she had been told to reduce health care costs at the facility by 5 percent at a time when the number of inmates was increasing, Moore’s report said.

Moore knew something of what she was talking about. She helped found the very company she was writing about, Prison Health Services, developing it as the first contractual correctional health care company in the United States, according to her resume. She left the company after a decade in 1988 and went on to work for other correctional health care companies in high-ranking positions.

But PHS officials maintain in court documents that Roberson was treated properly and had “untrammeled access to PHS.” They point out that they responded to each of his requests by providing headache medicine, and the last two requests would have been carried out if he hadn’t died. Never did Roberson ask to see a doctor. If he had, he would have seen one.

Roberson’s family could not show the county or jail workers did anything wrong, they said. “We’ve never had a death because of medical care,” said Blake, the jail administrator. “Our contention is that the people receive excellent medical care.”

 

Lawsuits and Principles

Eleven people have died at the Chatham County Sheriff’s Complex since it opened in 1993. Blake said an internal review showed jail officials and PHS staff acted appropriately before and during each of the deaths.

Still, the three inmates’ families, who have filed lawsuits, believe otherwise. None has won so far in court. Despite hundreds of inmate lawsuits filed in Georgia against the company, Mark Trigg, PHS’s lawyer in Georgia, said the company has not lost any in the four years he’s represented it. He said 95 percent of the cases are filed by inmates who handwrite their complaints, and judges dismiss them most of the time as frivolous.

The only case Trigg has seen go to trial in Georgia was filed by the family of an inmate who died at Chatham County’s jail. James Scott died of a duodenal ulcer after being moved from the Chatham County jail to the Coastal Correctional Institute in Garden City in June 1994.

In jail on a violation of probation charge for burglary, Scott, 38, had diabetes and complained of weakness, fainting, dehydration, weight loss, and poor appetite, according to court documents.

He repeatedly requested medical care from jail officials. They repeatedly denied it, according to the lawsuit filed by his mother, Mary E. Henderson. Other inmates became so concerned for Scott that they sought assistance for him.

On May 31, 1994, the jail’s medical staff examined Scott and found him weak but allowed him to be transferred to the state prison, the suit says.

Lawyers for Scott’s mother contended he died from “a treatable illness and suffered a preventable death.”

Trigg said Henderson’s claims were frivolous, and the jury agreed. “The evidence didn’t support that allegation at all,” Trigg said. “There was evidence that he received medical care whenever necessary, and he was seen by a nurse on a frequent basis.”

A federal jury found Prison Health Services and the county not responsible for Scott’s death. Henderson did reach a settlement with Correctional Medical Services, medical provider at the state prison when Scott died, as well as a doctor who treated Scott there.

In a recent interview, Henderson said it wasn’t about the money. Even though she lost one case and settled the other, she hopes her wrongful death lawsuit highlighted conditions at the Chatham County jail and state prison.

“It was the principle, because money can’t bring him back and I loved him dearly,” said Henderson, 65. “They need to do something about the neglect of the inmates and give them more medical attention and reliable doctors.

“Even though they may have committed a crime, they are still humans and still have rights to medical services,” she added. “And they didn’t always do something wrong. They did something right in their lives.”

 

Update: The Story Today

Prison Health Services (PHS) is again the healthcare contractor at Chatham County jail. A superior court judge in Savannah decided that the County Commissioners had the authority to choose the provider — and they chose the smaller Correctional Healthcare Services (CHS). But then, last January, according to Col. McArthur Holmes, the jail administrator who replaced Gary Blake, CHS requested more money to operate and the commissioners reverted the contract back to PHS.

Along with its privatized healthcare services, security at the jail has also come under scrutiny. Last July, inmate Michael Kelly Deal, a former police officer, was found dead, hanging from the ceiling of his cell by a bed sheet. Apparently, a group of inmates feared he might reveal their plan to chisel their way out of custody.

Last year the National Commission on Correctional Health Care conducted a site visit to the jail, which is 170 inmates over capacity, and renewed its accreditation.

— Jordan Green