Medical care in Illinois prisons remains “extremely poor” and conditions leading to preventable deaths have worsened since a court-appointed team of experts first assessed the state’s prison health program.

Attorneys from the American Civil Liberties Union of Illinois and the Uptown People’s Law Center challenged the systemic problems with health care in state facilities in 2013.

The United States District Court for the Northern District of Illinois ordered an expert to evaluate the services, and that report was released in 2015.

Following the report, the court certified the complaint as a class action lawsuit, allowing the attorneys to represent the interests of all prisoners failed or harmed by negligence in the Illinois Department of Corrections’ (IDOC) health program.

The federal court requested a second report by a medical investigation team. That report was released on November 14, and it concluded examples of “preventable morbidity and mortality” seemed worse than what was initially uncovered by the first evaluation.

“The vendor, Wexford, fails to hire properly credentialed and privileged physicians,” the report states. “This appears to be a major factor in preventable morbidity and mortality and significantly increases risk of harm to patients within the IDOC. This results from ineffective governance.”

It adds, “Wexford and the IDOC fail to monitor physician care in a manner that protects patient safety. There is no meaningful monitoring of nurse quality of care. If care is provided, it is presumed to be adequate when, in fact, it may not be adequate.”

There were 33 death records reviewed. Of those records, “73 episodes of grossly and flagrantly unacceptable care” were found.

“For a few record reviews, there was a repetitive pattern of inappropriate care,” the report notes. “This type of care is so egregious that it would typically result in a peer review for possible reduction of privileges or referral to licensing boards for evaluation of sanction of their license. These are serious errors.”

One patient had “diabetes, decompensated cirrhosis, and an unknown skin condition.” She had a fever, hypotension, and swelling around the eyes. She developed sepsis, which is a life-threatening illness that is caused by an infection. She needed to go to a hospital, however, without any diagnosis, the patient was “treated” with “oral Bactrim, pushing fluids [to combat dehydration], and Tylenol with infirmary admission by phone consultation.”

It was not until two days later that the patient was referred by a doctor to the hospital. “When the patient returned from the hospital there was no report and it was not clear that staff knew what occurred. The day the patient returned from the hospital, she vomited dark red emesis [vomit] and was hypotensive.”

“The only order was to ‘continue present management,'” the report adds. “The patient had repeated episodes (four) of bloody emesis during the night. The doctor was called at home but took no action. In the morning and when the patient was in shock, the doctor obtained a ‘do not resuscitate’ (DNR) order from the patient. Her barely legible signature did not match her typical signature, and the signature appeared to have been obtained under duress.”

Because of the DNR order that she was apparently coerced into signing, the hospital could not intervene when the patient was sent there for treatment. She died from “bleeding varices”—a complication of her cirrhosis.

Neutropenia is a low white blood cell count. When low, this can be a sign that someone has an HIV infection. It should prompt a test, but a 46 year-old man had neutropenia for more than three years and was never appropriately evaluated. He also suffered from fevers and an altered mental state for more than a year. Still, doctors did not appropriately evaluate him.

“The patient had confusion and was incontinent without recognizing that it was inappropriate, yet evaluation for serious central nervous system disorder was not done,” according to the report. “The doctor, who was a surgeon, inappropriately believed that the patient had lupus, a collagen vascular disorder, which was an incompetent diagnosis and unquestionably related to his lack of primary care training.”

It was not until a year later that a rheumatologist saw this man and confirmed he likely did not have lupus. That did not affect how doctors treated him. He remained in general population, and though he had trouble moving, he was given an “assistive device” and no further diagnosis was done.

“The doctor took virtually no history and performed virtually no examinations for extended periods of time,” the report states. “The patient was mistakenly given methotrexate, a medication that can lower white counts. Eventually the patient was unable to walk and was given a wheelchair.”

The patient developed severe hypoxemia, which is a low concentration of oxygen in the blood; hypotension; and tachycardia, which is an abnormally rapid heart rate. Doctors sent him to the hospital, where “septic shock and HIV infection were diagnosed. He died in the hospital with an AIDS-related central nervous system disorder and disseminated systemic infection, never having been appropriately evaluated at the prison for his problem.”

He had “multiple pustular lesions on his left leg, right foot, right hip, penis, and abrasions on the hip and shoulder, none of which were recognized at the prison. The patient also had severe unrecognized malnutrition.”

“We incidentally note that this patient was evaluated at least twice on annual examinations and had risk factors for HIV infection (blood transfusions, multiple sexual partners, and a sexually transmitted disease), and yet was never offered HIV testing,” the report declares.

There was a 66 year-old black man with a “history of hypertension, high blood lipids, diabetes, asthma, and chronic kidney disease.” He was a smoker and had a heightened risk of heart disease or stroke and was not receiving proper medication. He had “repeated episodes of shortness of breath with exertion” but was never tested appropriately.

When he had chest pain and elevated blood pressure, it was likely that he had angina, which is reduced blood flow to the heart. The doctor increased his blood pressure medication and told him he would “need a cardiac treadmill after he paroled.”

“This was indifferent, as work-up of the angina should not be delayed until the patient paroled,” the report concludes. Ten weeks later, his condition worsened, and he died.

Yet another patient, a 24 year-old with a mental illness, swallowed two plastic sporks. A correctional officer watched him ingest the sporks. A doctor ordered an x-ray, which was not likely to show the sporks. So, naturally, the x-rays were “normal.”

“About two and a half months later, a nurse practitioner evaluated the patient,” according to the report. The young man had lost 33 pounds. The nurse practitioner failed to notice.

The patient informed the nurse practitioner that he “swallowed a spork a long time ago and needed it removed.” This was noted, but no action was taken. He eventually lost 54 pounds and had “repeated episodes of abdominal pain with an inability to eat without pain, nausea, and diarrhea.” He was found “unresponsive,” sent to a hospital, and died.

“On autopsy, the two swallowed sporks were found [to have] caused esophageal perforation, which was the cause of death.”

Wexford put together death summaries for all of the deaths. They were completed by physicians, who were responsible for the care of the patients. None of the reviews identified any problems, “even when grossly and flagrantly unacceptable care was provided.”

The Illinois Department of Corrections has contracted Wexford for about 20 years. In the most recent contract signed in 2011, a Wexford medical director has the responsibility of reporting “deficiencies” to the health care unit administrator (HCUA). Yet, this medical director is employed by Wexford. “Clinical monitoring is self-monitoring by the vendor, rather than independent monitoring by IDOC.”

“The only monitoring of clinical performance of the physicians is Wexford peer review, in which Wexford physicians monitor other Wexford physicians. Many of these physicians are unqualified to practice primary care medicine,” the report adds.

“Contract monitoring reports” show “no one is monitoring clinical care, particularly physician care.” This makes accountability nearly impossible.

What the second report recommended is that all deaths be reviewed by an independent physician. There should be no “vendor physicians” determining whether negligence occurred when a patient dies.