Two new federal civil rights lawsuits filed in March shed light on how the privatization of jail medical care may pose a specific threat to inmates with drug dependencies.

In Alabama, Whitney Elizabeth Foster sued medical contractor Advanced Correctional Healthcare (ACH) for withholding her prescription methadone, Xanax, and blood pressure medication, causing her to suffer multiple strokes, seizures, and worsening withdrawal, which resulted in irreversible brain damage.

In Indiana, the estate of deceased inmate Tammy Perez sued ACH for forcing her to withdraw from a serious heroin addiction without proper assistance. She was so violently ill she couldn’t keep down her prescribed medication for an adrenal gland disorder she had since birth. When jail officials grew tired of cleaning up after Perez’s vomiting and diarrhea, an ACH doctor ordered her moved to an isolated cell, where she died hours before anyone found her.

A 2010 report from the National Center on Addiction and Substance Abuse at Columbia University found that, as jail populations in the United States grew over the past few decades, the proportion of inmates who are substance-involved increased dramatically. By 2006, 84.7% of all inmates were substance-involved.

The report notes that, despite there being a “substantial body of professional standards […] developed for providing addiction treatment in prisons and jails,” there are “no mechanisms […] in place to ensure the use of existing scientific guidelines and professional standards.”

In jails that that are increasingly overcrowded, underfunded, and face mounting inmate medical costs, decisions are easily guided by fiscal expediency over basic principles of medical care.

As previously reported by Shadowproof, ACH and other for-profit medical providers win contracts not by promising the highest quality care or most comprehensive services, but by underbidding the competition to provide services at the lowest rates. These rates are often derived by looking at how much a county was previously paying for healthcare and choosing a number below that. ACH then covers all medical expenses for inmates up to a cap, after which the county would be responsible for the cost.

WHITNEY ELIZABETH FOSTER

Around the time Whitney Foster was arrested, she was twenty-eight years old and lived with her parents and her newborn child. Foster was clean for months, attended a methadone clinic and took prescription anxiety medication Xanax. She had a history of drug abuse. She took 80mg of methadone each day and previously suffered from withdrawal.

On April 4, 2014, a routine traffic stop revealed Foster had an outstanding warrant for possession of drug paraphernalia from six years prior. Officers arrested her, and she was admitted to the Madison County Jail in Huntsville, Alabama.

Advanced Correctional Healthcare was under contract to provide medical, dental, and mental health services to Madison County inmates. The company, the county, and the sheriff negotiated an agreement in which ACH would pay up to $200,00 in medical costs each quarter, any costs after which the county would have to pay. However, if ACH’s costs totaled less than $200,000 per quarter, the company would get to keep the difference as profit.

County officials were happy with this arrangement for a while, repeatedly renewing ACH’s contract while citing its ability to contain costs.

Chief Deputy Steve Morrison explained the importance of this to a local CNN affiliate, saying “We had an inmate that had some type of illness from all the psychotropic drugs that he’d been taking throughout his lifetime. He was in a coma for a long time, and it was almost $300,000 for him. Now when you get just one of those out of a thousand inmates, that can really cripple your budget.”

By turning to for-profit contractors for more affordable medical care,  the lawsuit contends the county has created “a financial incentive to control outside medical costs, which in turn has led ACH to delay and deny referrals to outside providers.”

Foster was entirely dependent on the jail to give her access to her methadone and blood pressure medication. She should have been labeled a “high risk inmate” during intake at the jail, and her treatment should have been familiar to jail medical staff anywhere, given the objectively high number of inmates who suffer from alcohol and drug addiction.

But at Madison County, nurses noted in her file that she was taking daily doses of methadone and that someone needed to “verify” her medication with the clinic. There is no indication anyone ever followed-up. Foster’s medications were withheld.

Foster’s health quickly declined in the days that followed. One day after her incarceration, nurses recorded elevated blood pressure. Two days after, she was experiencing stomach cramps and anxiety, for which she was given vistaril and dicyclomine (two medications that treat symptoms of nausea, vomiting, anxiety and irritable bowel syndrome) as per “protocol for withdrawal patients.”

The lawsuit contends protocol also discourages any attempt to manage an inmates withdrawal outside of the jail, regardless of the severity of their symptoms, “to avoid the costs associated with hospitalization.”

Her blood pressure climbed by the day, and having had a family history of elevated blood pressure, Foster was familiar with the symptoms. She began to lodge grievances and complain that she was not allowed to see a doctor, and was denied her medications. The complaint notes instead of calling a doctor, nurses “turned the air conditioning to 55 degrees, only issued her a plastic sheet, and kept her from buying sweat pants/sweat shirt in the commissary.”

Foster allegedly had to fill water bottles with hot tap water and place them under her arms to keep warm.

On April 17, Foster filed a sick call request for a migrane that she said began around the time of her arrest. Her speech deteriorated, and she had limited control of her body. She could not keep from biting her tongue. Nurses believed she was faking these medical problems.

Jail officers, who may have noticed Foster’s deteriorating condition, were discouraged from acting by ACH’s policy of universal deference to medical staff. All inmate grievances and medical slips were directed to medical staff, and corrections officers were trained to “punt” inmate requests to ACH at all times.

Officers were trained “not to contact emergency personnel even if there” was a “medical emergency.” According to the lawsuit, officers who acted unilaterally to request emergency services in the past were disciplined.

Foster’s family, which noticed her slurred speech during phone calls home, asked the jail for information on her medical condition but “got nowhere.” Nurses and officers reportedly told Foster to tell her mother to “quit calling here or you’re going to have some problems.”

On April 18, Foster managed to complain so much that jail officials relented and brought her to the clinic, where her elevated blood pressure and other symptoms were treated with ibuprofen. ACH Doctor Arthur Williams, who was responsible for Foster’s care as the Madison County site physician, signed off on the plan, noting her blood pressure was “elevated but not as bad as the nurse said it was yesterday.”

She was placed on a “blood pressure list,” which meant her blood pressure would be “watched” for three days. An entry was missing for one of the days she was on the list.

A series of strokes and seizures started on April 21 and escalated in severity with time. That day, Foster’s cellmate called for medical assistance because she was “shaking and sweating.” Foster told the nurse that strokes ran in her family, and she was brought to the medical observation unit. Her blood pressure was very high, and she was described as “slightly lethargic” and said to be “slurring words.” She was harassed and ridiculed, as she suffered more strokes and seizures.

Yet, for the first time, Foster was provided medication to help her cope with her methadone withdrawal, and she was moved to a medical cell. Two hours later, a nurse checked on her and placed a call to Dr. Williams. Seventeen days after entering the jail, she was prescribed Atenolol for her blood pressure and Clonidine for methadone withdrawal.

By this point, Foster was too weak to even sign her own name. She was too weak to use the phone and couldn’t remember her charge code, which allowed her to pay for calls. Another inmate used her own charge code to help Foster call her mother, who couldn’t understand anything her daughter was saying, besides, “Mom I’m gonna die.”

In the background, Foster’s mother believes she heard nurses and/or officers say “quit calling your mother.”

At the commissary, Foster was found laying on the ground. When other inmates called the nurses for help, one of the nurses “arrived and told Whitney to ‘get the fuck up.’ Then this nurse began picking her up and dropping her while continuing to say ‘get the fuck up’ over and over.'” Nurses and officers then put Foster in a shower because she had urinated on herself.

Soon after, an inmate requested emergency assistance for Foster, who was “twitching” in her bunk. When officers arrived,  she told them she was hurting all over her body and her muscles were tensing. They helped her into a wheelchair and brought her back to the medical unit, where nurses recorded high blood pressure and pulse rate. Foster kept sliding out of her wheelchair and had to be helped back into her seat. She was so sick that officers left her uncuffed.

The next day, a nurse found Foster “lying on the floor with her upper body under the bed.” She told the nurse she could not “get out,” and when the nurse tried to help her, she kept crawling on her back going under the bed.” Foster heard the nurse say “there is nothing I can do with her, take her to the fucking hospital.”

Dr. Williams came to assess Foster and determined she had to be sent to the Huntsville Hospital emergency room “due to signs of a stroke.”

The jail incident report notes that “Nurse Mbi informed [officers] that the transportation of [Foster] to the emergency room was a non-emergency situation”—a decision that would help the jail avoid the cost of emergency transportation. Officers “handcuffed and shackled [Foster] and escorted [her] by wheelchair to the booking area and [she] was transported to the Huntsville Hospital Emergency Room.”

Upon arrival at the emergency room, Foster was blind and partially paralyzed, and looked like she had been beaten. She was hospitalized for three weeks and diagnosed with Posterior Reversible Encephalopathy Syndrome, but the condition is no longer “reversible.”

Foster has regained some use of her arms and legs, but the numerous strokes and seizures she suffered for days at the jail have left her with permanent neurological deficits and cortical blindness.

“Whitney’s eyes are perfect,” the lawsuit states, “but her brain can no longer interpret the images. Whitney can only appreciate light out of the top half of her eyes but not to her right. What she can ‘see’ out of the top half, however, exceeds the standards for being legally blind.”

“Morever, what little Whitney can perceive will always be ‘upside down and inside out,’ meaning she has no depth perception and what she perceives to be to her right is really to her left, and vice versa.”

Foster is not the only victim of the care provided by ACH and Dr. Williams at the Madison County Jail. In fact, Dr. Williams was involved in a number of heinous inmate deaths at the jail just a few months after he treated Foster.

In October 2014, Alabama news outlets reported the story of 19 year old Tanyatta Woods, who had been arrested for stealing Star Wars DVDs from a Walmart and for using a counterfeit $100 bill. Dr. Williams and the jail’s nurses failed to treat a wound on Woods’ foot, which became gangrenous and caused him to hallucinate and lose his ability to communicate. Woods died shortly after.

Thirty year old Tanisha Jefferson died of bowel obstruction as a patient of Dr. Williams. A federal lawsuit charged Dr. Williams with “[misrepresenting] her condition in his note, among other things, completely omitting Jefferson’s alarming symptoms, including her severe and worsening abdominal pain, lack of appetite (for days), rectal pain and vomiting.” Williams had simply treated her with laxatives.

Nikki Listau died after enduring seizures and alcohol withdrawal. Dr. Williams and other jail and medical staff ignored her rapidly deteriorating condition until she was found one day “naked on the floor of her cell, rambling incoherently.” She later died and an autopsy found she had suffered broken ribs and a broken leg. Dr. Williams attempted to have a lawsuit brought against him by Listau’s estate dismissed, but a court rebuffed him.

In the end, a disagreement over who would pay for Dr. Williams’ lawsuits sunk ACH’s contract in Madison County. ACH reversed course six months after news of the lawsuits broke and opposed the provisions in prior agreements that insured and indemnified the county against legal claims.

The company refused to sign its contract renewal so long as it had to cover legal costs, and the county council voted to end the agreement. Six months after that, Sheriff Dorning sued ACH because an insurer refused to cover the costs from Dr. Williams’ lawsuits, footing ACH with the bill. The Sheriff was attempting to force ACH to cover those costs.

After ACH’s contract with Madison County ended, another private jail medical contractor, Southern Health Partners, took over for $300,000 less.

No county officials have initiated significant investigations into these cases, and there is no record the county or sheriff requested ACH make changes to their policies and procedures.

TAMMY PEREZ

In Indiana, 34 year old Tammy Perez died in the Morgan County Jail after spending four days behind bars. Perez had been sentenced to 40 days in jail with an option to complete a sentence in drug rehabilitation, if available. She was admitted to the jail with heroin still in her system.

Perez suffered from an adrenal gland disorder since birth and needed a daily dose of dexamethasone to take the place of her non-functioning glands. Her mother, Sheryl, personally brought her daughter’s medications to the jail and met with medical staff about her treatment. Her mother repeatedly explained the care regimen and stressed its importance, which medical staff said they understood.

But after she left, medical staff did not give Perez her medication, and she was made to suffer from severe withdrawal. She was so violently sick she was unable to hold down any food or water, much less any medication.

Perez became “incoherent and critically ill,” according to the complaint. She repeatedly soiled herself with vomit and feces because she was unable to control her body functions.

Her cellmates repeatedly notified jail and medical staff, who did nothing more than shower her off and dress her, whereupon she would vomit and defecate on herself again.

At a certain point, officers told Perez they weren’t going to take her to the shower anymore. ACH Dr. Ronald Everson, according to officers, ordered her moved to an isolated cell where they left her in her soiled clothing, instead of having her taken to the hospital.

After Dr. Everson placed Perez in a cell by herself, her dehydration worsened, and her eyes visibly sunk into her head. She vomited her medications as soon as she took them. Other inmates urged staff to take her to the hospital, but they ignored their pleas. One officer told Perez to “stop being a drama queen.”

Four days after her arrest, an officer was bringing another arrestee into the jail when he noticed Perez’s name on the whiteboard outside a single cell in the receiving area. He slid open the cover of the door and found her dead on the floor.

The officer summoned jail and medical staff, who documented that Perez had been dead for so long that she was cold to the touch, and rigormortis had begun to set in. Her diminished health and the “physical stress caused by her condition, including the lack of medication and hydration, contributed to the development of a heart arrhythmia, resulting in death.”

“Had Ms. Perez been provided adequate care,” the lawsuit concludes, “her death would have been prevented.”

It was not the first time that Everson was implicated in human rights abuses.

In 2013, Donnay Marcum, who was awaiting charges on drug manufacturing and possession, sued Everson for denying his dialysis treatment three days a week. As Marcum’s legs swelled and his blood pressure increased, Everson refused to send him offsite. He treated him with some medication for blood pressure and advised him to lay down and have a nurse ice his legs.

Marcum’s condition worsened and a week later, instead of having emergency services transport him to the hospital, he was “taken by police or members of the Jail’s staff to Pattie A. Clay Regional Medical center, where he was found to be in end-stage renal failure.” He was “unresponsive and was in [emergency] need of dialysis.” The Richmond Register noted Marcum was released and had not returned to the facility.

Dr. Everson is also licensed to practice medicine in Kentucky as well, where he was briefly appointed to be the Acting Prison Medical Director in 2011 at the same time he held the position of regional medical director for Correct Care Integrated Health.

CCIH operates in four Kentucky facilities at a cost of $104 million over two years. These are the same facilities for which Everson was supposed to coordinate and oversee medical care as the state’s Acting Prison Medical Director. His salary for this public sector job was paid exclusively by CCIH.

GAMING THE SYSTEM

ACH controls costs by understaffing facilities, often with personnel that lack the appropriate skills and training, and favoring policies that substitute costly off-site, emergency and specialized healthcare, with only that which can be provided by nurses, who occasionally consult with doctors over telephone. Known as “circuit riders,” the doctors often have questionable records, yet can be responsible for the care of thousands of inmates at a time. Because of their high volume of patients, they rarely spend more than a few minutes considering treatment for each case, sometimes never seeing their patients in person.

The company routinely refuses to administer psychotropic drugs and disregards treatment regimens imposed by inmates’ personal physicians prior to their incarceration. ACH officials broadly classify medical needs as “elective” to avoid treating conditions they deem to be beyond the purview of constitutional protections against cruel and unusual punishment.

ACH mandates all jail staff defer to medical decisions made by the company’s personnel, even in emergencies. ACH typically provides insurance for the county and indemnifies officials from legal liability from medical claims, so long as they completely submit to the judgement of medical staff.

These policies work as advertised, suppressing costs, limiting legal liability for jail staff and reducing taxpayer spending on correctional healthcare. Local governments and law enforcement agencies are, in most cases, pleased with the results, since these are the express reasons for privatizing services in the first place, and the contracts are often renewed year after year.

While all inmates with medical needs stand to suffer from such arrangements made to privatize jail medical services, those who are drug dependent—either from addiction, a physician-managed treatment regimen, or both—face a unique risk of serious injury or death.