US jails are outsourcing medical care — and the death toll is rising

SAVANNAH, Georgia — Matthew Loflin was coughing up blood, struggling to breathe and losing consciousness in his cell while awaiting trial on drug-possession charges in this historic Southern city.

“I need to go to the hospital,” he told his mother in a jailhouse phone call. “I’m gonna die in here.”

It was March 28, 2014, and his seven weeks at the Chatham County Detention Center had been a blur of blackouts and racing heartbeats.

The jail’s senior medical staff – Dr. Charles Pugh and two well-credentialed nurses – agreed he needed hospitalization. But the move was opposed by a senior manager at their employer, Corizon Health Inc, which held a multi-million dollar contract to manage the jail’s healthcare, according to court records and former medical staff.

When Loflin’s X-ray showed a suspicious spot in his chest on April 7, Pugh tried another plan: He sent Loflin to a cardiologist, believing the specialist would want him hospitalized. After a quick exam, the cardiologist sent him straight to the hospital, but it was too late. Loflin, 32, deteriorated quickly, suffering irreversible brain damage. He died April 24.

His death was the second in two months that Pugh and nurses Betty Riner and Lynne Williams considered preventable, internal jail memos and emails produced in litigation show. That August, the trio met with the sheriff and accused Corizon of prioritizing profits over lives.

Corizon fired all three, triggering a wrongful termination lawsuit settled on confidential terms. The plaintiffs agreed not to discuss their allegations.

Reuters corroborated their claims about faulty care at the jail in this city of antebellum homes and moss-covered oaks. The story of deadly neglect was assembled through previously unreported whistleblower testimony, thousands of court and police documents, interviews with more than a dozen former medical and jail staff, and confidential monitor reports.

In the last years of Corizon’s watch from 2014 to 2016, prescription drugs went missing, patients deemed gravely ill by medical staff were denied hospitalization, mentally ill inmates went untreated and records were falsified, Reuters found. Weeks passed with no doctor on site, leaving care to nurses and video calls with doctors. The jail’s 400 mentally ill inmates, nearly a quarter of its population, were treated by a sole psychiatrist. Corizon said it put patient care first and told its staff to hospitalize inmates when needed.

Yet an inmate died from a treatable heart condition after his doctor’s requests for hospitalization were denied. A guard was crippled by an inmate who hadn’t gotten her meds. Another inmate died from a blood clot in his leg 32 hours after he crawled across the floor begging to go to the hospital.

The Savannah jail’s breakdowns speak to a national trend. More than 60% of America’s top jails now hire private companies to deliver inmates’ medical care, Reuters found, and that shift has taken a toll: more dead.

A Reuters review of deaths in more than 500 jails found that, from 2016 to 2018, those relying on one of the five leading jail healthcare contractors had higher death rates than facilities where medical services are run by government agencies. The analysis assessed deaths from illness and medical conditions, suicide, and the acute effects of drugs and alcohol.

Jails with publicly managed medical services, usually run by the sheriff’s office or local health department, had an average of 12.8 deaths per 10,000 inmates in that time. Jails with healthcare provided by one of the five companies had an additional 2.3 to 7.4 annual deaths per 10,000 inmates. The death rates were 18% to 58% higher, depending upon the company.

The Reuters review is the most definitive examination to date revealing the risks that have emerged as hundreds of jails have embraced the multi-billion dollar correctional healthcare industry and its promises of quality care and controlled costs. It is part of a larger Reuters examination finding that two-thirds of dead inmates, including Loflin, never got their day in court for the alleged offenses on which they were held.

Corizon, among the nation’s biggest correctional healthcare companies, now manages care for some 116,000 prisoners in state and county facilities at more than 140 locations in 15 states.

In an interview, Corizon Chief Executive James Hyman said jail death rates alone were not a valid indicator of “the quality of performance … in what is a very complex population set.” He said the Reuters findings did not take into account the challenges of providing care to two distinct groups of inmates: Those who stay less than a month in jail and those who cannot afford bail or are serving post-conviction sentences.

In Savannah, Corizon was eventually replaced by another contractor amid a series of deaths. Corizon said it never sacrificed care for profits. “I would not have operated in or stayed in that kind of environment,” said Dr. Calvin Johnson, the Tennessee company’s chief medical officer from 2014 to 2016.

Hyman said Corizon’s statisticians did not believe the variance in death rates for jails contracting with Corizon was “statistically significant.” While every jail death is “significant,” the company disputed Reuters’ methodology and “resulting assumptions.”

Many factors can contribute to a jail’s mortality rate, such as the overall health of its population and the size of its budget, and it is impossible to account for all such variables with publicly available data. But even after adjusting for the size of the jail and the area’s mortality rate, Reuters and two independent statisticians still found statistically significant disparities between jails with publicly provided medical care and those with healthcare managed by one of the top contractors.

An industry rises

Until the 1970s, jail healthcare was minimal. Most lockups offered little more than first aid, a 1972 American Medical Association survey found.

Then, in 1976, the U.S. Supreme Court ruled that “deliberate indifference” to an inmate’s medical needs amounts to “unnecessary and wanton infliction of pain,” violating the Eighth Amendment. Inmates began suing, and in the 1980s the correctional healthcare industry emerged.

The industry expanded through the 1990s and early 2000s as a push to deinstitutionalize the mentally ill spurred the closure of mental health hospitals – sending many former patients to the streets, and then jail.

By 2010, nearly half the U.S. jails surveyed by Reuters had turned to privatized medical care. By 2018, 62% got privatized services.

Today, a handful of companies dominate the jail healthcare business: Wellpath Holdings Inc, NaphCare Inc, Corizon, PrimeCare Medical Inc, and Armor Correctional Health Services Inc. The largest, Wellpath, is owned by a private equity firm. An investment firm owns Corizon. NaphCare, PrimeCare and Armor are privately owned.

“It makes sense to have someone whose specialty is to come in and take care of inmates,” said Chatham County Commissioner Helen Stone. “Saving money,” she said, is key.

Many sheriffs have embraced the chance to shed the headaches of managing their own medical operations. “It is a package deal and everything is done for you,” said Captain Jessica Pete, whose facility, the St. Louis County Jail in Duluth, Minnesota, hired regional contractor MEnD Correctional Care in 2012. “We are getting fantastic care.”

Yet even as the industry’s reach expanded, no large-scale studies have been conducted to assess privatization’s impact on inmate mortality. To answer that question, Reuters surveyed 523 jails for healthcare and death data from 2008 to 2019. It explored all U.S. jails with 750 or more inmates, plus the 10 largest jails in nearly every state.

From 2010 to 2015, death rates were generally similar in jails using the big healthcare contractors and those with publicly managed care.

But from 2016 to 2018, the most recent year for which comprehensive statistics are available, the death rates diverged. Jails using the major companies had 691 fatalities among an average total population of 138,000 inmates in that three-year span. By contrast, jails using publicly managed care had 587 fatalities while caring for more than 152,000 inmates.

To be sure, some publicly run systems suffer high death rates. But on balance, Reuters found, death rates are higher when healthcare is in the hands of private industry.

Overall, facilities with care managed by the biggest jail medical providers had 17 deaths per 10,000 inmates, compared to 13 deaths in publicly-run units.

Contracts with private providers sometimes lack quantified standards for care, Reuters found, such as staffing requirements or protocols for inmate health evaluations or hospitalizations. Such problems can occur in publicly run systems, but they aren’t locked into contracts or dependent upon profits.

Size can also play a role. Big jurisdictions are more likely to have publicly managed inmate care under the aegis of a health department, Reuters found. Small to midsize counties, often operating with tight budgets, are more likely to hire private firms.

“You’ve got counties being greedy, not wanting to spend money on medical care, and companies saying, ‘We can do this, we can do it cheaper for you,’” said Dr. Robert Greifinger, former chief medical officer for the New York State Department of Correctional Services. “How do companies achieve those economies? Part of it is being stingy with care.”

An exorcism in Oklahoma

Jails where NaphCare and Armor operated had the highest death rates in the three-year period – 20.2 and 18.8 deaths per 10,000 inmates, respectively. Rates for the other companies were 16 for Corizon, 15.9 for Wellpath, 15.1 for PrimeCare.

NaphCare said it “has never compromised patient care for profit and we never will.” In an interview, CEO Brad McLane said his family-owned company shields itself from pressure from outside investors as it operates in counties with “the biggest challenges,” such as opioid outbreaks.

Jails often hire contractors when they hit a crisis, and comparing death rates in those facilities to other jails is “apples to oranges,” said Wellpath President Kip Hallman. “We’re sort of like firemen,” he added, saying Wellpath typically boosts staffing and spending on inmate care.

PrimeCare Medical said it often takes over for government agencies. “In every one we have been informed that we provide a more comprehensive and better healthcare system,” said CEO Thomas J. Weber.

The Oklahoma County Jail, which had been under Justice Department monitoring since 2009 amid concerns over overcrowding and lax inmate supervision, was among those served by Armor.

From 2009 to 2018, 54 inmates under Armor’s medical and mental health care there died from medical conditions, suicide or addictions.

In one case, the sheriff barred an Armor nurse for allegedly attempting an “exorcism” on an inmate suffering a fatal methamphetamine overdose. The nurse denied the accusation and filed an ongoing lawsuit against the sheriff and Armor for defamation and wrongful termination.

Armor said its health services “meet or exceed” industry standards.

“What statistics can’t explain, and many in the public do not know, is that the first day ‘behind bars’ for most of our patients is the first time they receive essential medications, medical care, and behavioral healthcare,” Armor wrote. Inmates bring “incomparably unique healthcare challenges.”

Some industry adversaries say companies have an incentive to cut costs. “It is a one to one, dollar to dollar, relationship between denying care and profit,” said Savannah lawyer Will Claiborne, who represented Loflin’s family in a lawsuit against the jail and Corizon that settled last year.

In 2011, Corizon’s predecessor company spent about $113,000 a month sending inmates to the hospital, or more than $1.3 million a year, including ambulance fees, financial records disclosed in litigation show. The next year, under Corizon, the cost shrunk by about 53%, records show. With fewer inmates sent out for care, Corizon’s jail profit margin soared – from 14.6% in 2011 to 21.5% in 2012 and 24.2% in 2013. Reuters did not have access to annual data in later years.

For 2013 and 2014 combined, Corizon paid a total $1.5 million for outside medical services involving 333 inmates at the Savannah jail, including more than 400 ER visits, the company said. “Any suggestion that we routinely deny care that may require outside services is simply not based in fact.”

The county had opened a new jail infirmary, Corizon added, so “there was an expectation from the client” that hospital visits would decline.

An overwhelmed psychiatrist

The Chatham County Detention Center is 600,000 square feet of beige concrete filled with 1,500 to 1,800 inmates. Circled with razor wire and tucked between a busy parkway and a forested patch of swampland, it’s a world apart from the oak-lined streets of historic Savannah miles away.

Corizon’s predecessor company, Prison Health Services, won the contract in 1992. Two decades later, Corizon was earning $5 million a year when then-Sheriff Al St. Lawrence sought an official seal of approval from the Medical Association of Georgia.

“I want that accreditation,” St. Lawrence, who died in 2015, told a jail manager. To get it, the jail had to show that new inmates got timely access to medications.

Psychiatrist George Hall, 84, struggled to keep pace. Nurses said they wrote prescription renewals themselves and put them on Hall’s desk to be signed without the doctor seeing the inmate, a prohibited practice under Georgia law for many psychotropic drugs and controlled medications.

By May 2014, a year before Hall died, some 120 inmates were on a waiting list for medical or psychiatric consults, three former workers said.

One was Sheena Burton, arrested May 3, 2014, for missing court on a traffic charge. She said she suffered from bipolar disorder, depression and multiple personality disorder, and told nurses she took the antipsychotic drug Zyprexa. She wasn’t given medication, jail records show. On May 12, she became violent. Deputies strapped her into a restraint chair.

Nurse Riner put Burton, then 28, on a computer list of patients waiting to see the psychiatrist for medication. Days later, Riner discovered Burton’s name wasn’t on the list. Riner later testified that colleagues told her names were deleted from the list so the backlog wouldn’t undermine the jail’s accreditation. Corizon denied any deletions and declined further comment.

Soon, Burton’s emotions were “like a firecracker,” she said in an interview. One day, she stopped at a water fountain when a guard, Wendy Smoot-Lee, ordered her back in line. Tensions escalated: The women, each more than 200 pounds, tumbled to the floor in a brawl.

Smoot-Lee suffered nerve damage requiring back surgery. “My whole life is changed,” she said. Unable to stand without a cane or a walker, she lives on workers’ compensation.

She sued Corizon for negligence in its handling of Burton’s healthcare, an allegation the company denies. She also sued Burton for causing her physical harm, but told Reuters, “It wasn’t her fault. She needed her medication.” Burton admits punching Smoot-Lee, but blames the jail for denying her medication. The cases are pending.

Showdown, firings, death

The Savannah caregivers who protested to Corizon declined to discuss events in the jail, but Riner spoke to Reuters about her career. “These people need you. They’re forgotten,” she said. She had a master’s degree, a decade’s experience, and credentials as an “advanced practice nurse.”

Soon after starting, she described feeling pressure to avoid hospitalizing sick inmates and instead treat them in the jail’s infirmary. At orientation in 2014, she testified, Corizon regional medical director Scott Kennedy told her, “It costs too much money to send people out.” She added, “They would ask me not to prescribe medications that I felt like were necessary.”

Kennedy acknowledged in testimony in the Loflin case that Corizon preferred inmates remain at the jail to control costs. But he added, “If someone needs to be in the hospital, I want them to be there, and I don’t care what it costs.” Kennedy did not respond to interview requests.

The nursing director at the time lacked the credentials required by state law to oversee registered nurses, according to court records and medical staff. Inmate screenings and distribution of meds were often handled by nursing assistants, not nurses as required by state law, said former Corizon workers. Corizon declined to discuss the credentials of specific staff.

The breakdowns rattled Dr. Pugh and Nurse Riner. Riner turned to jail administrator Thomas Gilberg, vowing to resign. “The medical isn’t up to standards,” she said, according to Gilberg. He relayed her concerns to Sheriff St. Lawrence. That month, August 2014, St. Lawrence nominated Corizon’s top jail manager for a Medical Association of Georgia award.

On August 26, Pugh, Riner and another senior nurse, Lynne Williams, met the sheriff. They accused Corizon of “corruption” and “unethical practices,” according to notes taken by Chief Deputy Roy Harris and reviewed by Reuters. They said another inmate’s suicide on Easter Sunday might have been prevented. Pugh said Corizon “pushed some things under (the) rug” to secure the Medical Association of Georgia accreditation, according to Harris’s notes and testimony by the jail’s Compliance Manager, Melissa Kohne, who also attended the meeting.

“Corizon said, ‘this is Pugh wanting to stir up trouble,’” Harris told Reuters.

Three weeks later, Riner was fired “for going outside the chain of command” by complaining to the sheriff, an internal jail memo said. Pugh was fired for allegedly failing to work scheduled hours, which he denied. Williams was fired, also for allegedly going outside the chain of command.

The day Pugh was let go, September 24, 2014, was the last day Donald Johnson received the regular blood pressure checks for his hypertension.

Johnson, 68, arrested a month earlier on Medicaid fraud charges, had a history of chronic hypertension and diabetes. Pugh checked him on September 16 and ordered his blood pressure to be monitored three times weekly. His last blood pressure check came eight days later, records show.

On November 13 at 5:31 p.m., a deputy found Johnson in distress. A nurse couldn’t find a pulse, and he was pronounced dead at the hospital. Official cause: hardening and narrowing of coronary arteries, often linked to high blood pressure. He was never convicted of the charges.

“It’s not a day that goes by that I don’t think about how he may have suffered,” his daughter, Rochon Johnson Small, said in an interview.

A family lawsuit alleged the company was deliberately indifferent to Johnson’s serious medical needs, but the case was dismissed because the statute of limitations had expired. “This case went to court and was dismissed without finding of liability for Corizon,” the company said.

‘I want to die’

On New Year’s 2015, Matthew Ajibade arrived on charges of battery and resisting arrest. Police told jail deputies Ajibade was a “49,” code for a mentally disturbed person. An arresting officer wanted to take him to a hospital for a mental health check, but was overruled by a supervisor.

Ajibade, 21, attended Savannah College of Art and Design. Three years earlier, he had suffered a mental breakdown in Los Angeles, when police found him in the middle of a road. He took medication for bipolar disorder.

Booked four hours after his arrest, Ajibade refused to return to his cell. Three deputies wrestled him to the ground, and a sergeant attempted to shock him with a Taser. Ajibade grabbed it and tried to stun the deputies, toppling the sergeant. Deputies punched and kicked Ajibade, then cuffed his hands behind his back, shackled his legs and carried him to a cell where they put him in a restraint chair and covered his head in a spit mask.

“I want to die!” Ajibade yelled, kicking and squirming.

Deputy Jason Kenny pressed a Taser against Ajibade’s thigh and squeezed the trigger. Ajibade screamed. “Stop kicking. You’re going to get it again,” the deputy said. He stunned him twice more, Kenny later testified.

When he stopped, Ajibade’s skin was “hot to the touch,” said Kenny.

A deputy called Corizon nurse Gregory Brown, on the job less than two weeks, at 11:47 p.m. Brown was out of the cell in 51 seconds, jail records show. Brown later testified he wasn’t trained on how to check inmates in a restraint chair. He didn’t assess Ajibade’s respiration, blood pressure, pulse or airway. He said he didn’t know Ajibade had been punched, kicked or stunned with a Taser.

For 100 minutes, no one checked on Ajibade. When senior officer Maxine Evans looked in his cell at 1:30 a.m., he was dead.

The jail’s policy requires checks every 15 minutes for inmates in restraint chairs. An internal jail investigation found that Evans’ “restraint log” – signed by Brown – was falsified to show multiple checks before 1:30 a.m.

A jury convicted Kenny of cruelty to an inmate, Evans of perjury and public records fraud, and Brown of making a false statement. Involuntary manslaughter charges were dismissed against all. Kenny got a one-month sentence, Evans probation and Brown a three-year suspended sentence. Each declined to comment.

Begging for care

After Ajibade’s death, jail Compliance Manager Kohne begged the county to end Corizon’s contract.

“I’m scared to death somebody is going to die over something stupid that Corizon is going to do,” she told the Georgia Bureau of Investigation in an April 2016 interview. Jail officials, she said, had become “skeptical” of Corizon after it dismissed the doctor and two nurses. Kohne did not respond to interview requests.

Ajibade’s death prompted an audit by the Medical Association of Georgia, which found information missing from files, breakdowns in inmate screening, and misuse of restraint chairs. A lawsuit by Ajibade’s family was settled.

The accrediting agency put the jail on probation for about nine months, and Chatham County hired experts to inspect the jail and Corizon’s contract. On August 4, 2015, a monitor warned the sheriff that jail healthcare “wasn’t at even constitutional levels,” Kohne testified. Monitor RJS Justice Services did not respond to requests for comment.

Nine months later, Jimmie Lee Alexander, 60, jailed for missing a court date and receiving stolen property, complained to guards about throbbing pain in his right knee and hip. He asked to go to the hospital.

A nurse prescribed a painkiller. Later that night, Alexander crawled to the middle of his wing’s floor, vomited and pleaded again for help. The nurse phoned Corizon’s medical director, Guy Augustin, who recommended keeping the inmate under close watch at the jail, records show.

The next day, Augustin did not check Alexander until 2:45 p.m. Concerned by the coldness of Alexander’s right leg, Augustin ordered him to the hospital with deputies, not an ambulance. It took more than an hour to arrange his ride and another hour to reach the ER. Doctors removed a massive blood clot that choked off Alexander’s thigh. Early the next morning, Alexander suffered a heart attack and died. He was unconvicted of his charges. A family lawsuit described his leg as gangrenous.

A judge dismissed the lawsuit against the sheriff, nurses and Corizon but ruled the ongoing case could proceed against Augustin and two jailers, who all deny wrongdoing. In court filings, Corizon and the doctor said they “met or exceeded” standards of care. Augustin declined comment.

Two months after Alexander’s death, Corizon’s contract ended. At midnight July 31, 2016, the keys to the infirmary were passed to another contractor. Sheriff John Wilcher, who took over that March, said his “first goal” was to change healthcare contractors. “They just weren’t the type of medical people I wanted here,” he told Reuters.

Corizon’s troubles didn’t end there. Alameda County, California, one of the nation’s biggest jail systems, dropped Corizon later that year. Seven months later, the company lost its contract in Indiana’s prison system.

The company went through a series of shake-ups: a new chief executive officer in 2015, a new chief financial officer in 2016, a recapitalization under new investors and another new CEO in 2017, and a deal to eliminate more than $100 million in debt in 2018.

In November 2018, Corizon agreed to pay $3.7 million to settle the case of a man whose family claimed he died from inadequate medical care while detoxing from opioids in a Colorado jail. A month later, it was ordered to pay $10 million in a lawsuit over the death of a female inmate detoxing from heroin in Oregon.

Then Corizon lost a $189 million contract with Arizona’s state prison system.

Contracts often “move around the industry,” said Hyman, who became CEO in 2019. “We got beat in competition and that was my competitors across the street,” he said. “They underbid us.” Corizon stresses quality care, he said. “You make more money if they are healthy. If they get sick,” he said, “you’re going to have a problem with the contract.”

One inmate in Corizon’s care was Wade Jones, 40, a businessman accused of stealing golf balls, food and alcohol at a store in Walker, Michigan, in April 2018. A judge sentenced Jones to five days in jail for retail theft, a misdemeanor, at the Kent County Correctional Facility.

That night, a deputy twice alerted Corizon medical staff that Jones was showing alcohol withdrawal symptoms, jail records show. The next day, he complained of tremors, anxiety and nausea. Surveillance video showed Jones picking at his skin, pacing and beating the walls, according to a wrongful death lawsuit his family filed.

The next morning, he was sent to the infirmary at 6 a.m. and placed in an observation cell. By 7:30 a.m., he had passed out on a toilet. When a nurse checked on him eight minutes later, he was unresponsive.

Corizon staff began chest compressions and tried to administer oxygen, but the tank was empty or broken, the lawsuit said. Surveillance video showed a Corizon nurse struggling to operate a defibrillator on Jones, the family said in its lawsuit. The battery was low and it powered off without delivering a shock, the suit said. Jones went into cardiac arrest and then a coma, dying on May 2. While in jail, he never saw a doctor, jail logs show.

Corizon called the allegations “absolutely, categorically false” and said it plans “to vigorously defend this case.”

This year, holding company the Flacks Group acquired Corizon, keeping Hyman on as CEO. He said the sale moved Corizon from the world of private equity ownership where stakeholders have “to constantly get money from investors” to one where the focus is to “think long term.”