February 27, 2005
Private Health Care in Jails Can Be a Death Sentence
By PAUL von ZIELBAUERrian Tetrault was 44 when he was led into a
dim county jail cell in upstate New York in 2001, charged with taking
some skis and other items from his ex-wife's home. A former nuclear
scientist who had struggled with Parkinson's disease, he began to
die almost immediately, and state investigators would later discover
why: The jail's medical director had cut off all but a few of the
32 pills he needed each day to quell his tremors.
Over the next 10 days, Mr. Tetrault slid into a stupor, soaked in
his own sweat and urine. But he never saw the jail doctor again,
and the nurses dismissed him as a faker. After his heart finally
stopped, investigators said, correction officers at the Schenectady
jail doctored records to make it appear he had been released before
Two months later, Victoria Williams Smith, the mother of a teenage
boy, was booked into another upstate jail, in Dutchess County, charged
with smuggling drugs to her husband in prison. She, too, had only
10 days to live after she began complaining of chest pains. She
phoned friends in desperation: The medical director would not prescribe
anything more potent than Bengay or the arthritis medicine she had
brought with her, investigators said. A nurse scorned her pleas
to be hospitalized as a ploy to get drugs. When at last an ambulance
was called, Ms. Smith was on the floor of her cell, shaking from
a heart attack that would kill her within the hour. She was 35.
In these two harrowing deaths, state investigators concluded, the
culprit was a for-profit corporation, Prison Health Services, that
had moved aggressively into New York State in the last decade, winning
jail contracts worth hundreds of millions of dollars with an enticing
sales pitch: Take the messy and expensive job of providing medical
care from overmatched government officials, and give it to an experienced
nationwide outfit that could recruit doctors, battle lawsuits and
keep costs down.
A yearlong examination of Prison Health by The New York Times reveals
repeated instances of medical care that has been flawed and sometimes
lethal. The company's performance around the nation has provoked
criticism from judges and sheriffs, lawsuits from inmates' families
and whistle-blowers, and condemnations by federal, state and local
authorities. The company has paid millions of dollars in fines and
In the two deaths, and eight others across upstate New York, state
investigators say they kept discovering the same failings: medical
staffs trimmed to the bone, doctors underqualified or out of reach,
nurses doing tasks beyond their training, prescription drugs withheld,
patient records unread and employee misconduct unpunished.
Not surprisingly, Prison Health, which is based outside Nashville,
is no longer working in most of those upstate jails. But it is hardly
out of work. Despite a tarnished record, Prison Health has sold
its promise of lower costs and better care, and become the biggest
for-profit company providing medical care in jails and prisons.
It has amassed 86 contracts in 28 states, and now cares for 237,000
inmates, or about one in every 10 people behind bars.
Prison Health Services says that any lapses that have occurred are
far outnumbered by its successes, and that many cities and states
have been pleased with its work. Company executives dispute the
state's findings in the upstate deaths, saying their policy is never
to deny necessary medical care.
And they say that many complaints - from litigious inmates, disgruntled
employees and overzealous investigators - simply come with the hugely
challenging work they have taken on.
"What we do," said Michael Catalano, the company chairman,
"is provide a public health service that many others are unable
or unwilling to do."
The examination of Prison Health also reveals a company that is
very much a creature of a growing phenomenon: the privatization
of jail and prison health care. As governments try to shed the burden
of soaring medical costs - driven by the exploding problems of AIDS
and mental illness among inmates - this field has become a $2 billion-a-year
It is an intensely competitive world populated by a handful of companies,
each striving to find enough doctors and nurses for a demanding
and sometimes dangerous job. The companies, overseen by local governments
with limited choices and money, regularly move from jail to jail,
and scandal to scandal - often disliked but always needed.
Perhaps the most striking example of Prison Health's ability to
prosper amid its set of troubles unfolded in New York State. Despite
disappointed customers and official investigations in Florida and
Pennsylvania, the company still managed to win its largest contract
ever in 2000, when New York City agreed to pay it $254 million over
three years to provide care at the correctional labyrinth on Rikers
The city, in fact, just renewed that deal in January for another
three years - despite the deaths upstate, and a chorus of criticism
over Prison Health's work at Rikers, where employees and government
monitors have complained of staff shortages and delays in drugs
and treatments for H.I.V. and mental illnesses. A rash of suicides
in 2003 prompted a scramble by officials to fill serious gaps in
care and oversight.
Along the way, though, Prison Health has acquired at least one tenacious
adversary. The State Commission of Correction, appointed by the
governor to investigate every death in jail, has moved over the
last several years from polite recommendations to bitter denunciations,
frustrated by what it says is the company's refusal to admit and
address deadly mistakes.
The commission has faulted company policies, or mistakes and misconduct
by its employees, in 23 deaths of inmates in the city and six upstate
counties. Fifteen times in the last four years, it has recommended
that the state discipline Prison Health doctors and nurses.
And since 2001, the commission, along with the State Education Department,
which regulates the practice of medicine, has urged Attorney General
Eliot Spitzer to halt the company's operations in New York, saying
that Prison Health lacks any legal authority to practice medicine
because business executives are in charge. New York, like many other
states, requires that for-profit corporations providing medical
services be owned and controlled by doctors, to keep business calculations
from driving medical decisions.
Prison Health says its work in New York is legal because it has
set up two corporations headed by doctors to run medical care. But
state investigators have called those corporations shams.
Elsewhere, Prison Health did not go that far, until questioned by
The Times. Now it says it is creating doctor-run corporations in
11 other states with similar laws, including New Jersey and California.
"Had we realized this would be a question, we would have addressed
it earlier," said Mr. Catalano, the company's chairman. "We
have nothing to hide here."
But in one report after another, the state commission has exposed
what it says is the dangerous way Prison Health has operated.
One investigation found that the doctor overseeing care in several
upstate jails in 2001 - continually overruling the doctors there,
and refusing drugs and treatments - was not even licensed to practice
in New York State. He did the job, the commission found, by telephone
- from Washington.
The commission's gravest findings have involved deaths on the company's
watch, mostly of people who had not been convicted of anything.
Candy Brown, a 46-year-old Rochester woman jailed in 2000 on a parole
violation, died when her withdrawal from heroin went untreated for
two days as she lay in her own vomit and excrement in the Monroe
County Jail, moaning and crying for help. But nurses did not call
a doctor or even clean her off, investigators said. Her fellow inmates
took pity and washed her face; some guards took it on themselves
to ease her into a shower and a final change of clothes.
Scott Mayo Jr. was only a few minutes old in 2001 when guards fished
him out of a toilet in the maternity unit of Albany County Jail.
It was the guards, investigators said, who found a faint pulse in
the premature baby and worked fiercely to keep his heart beating
as a nurse stood by, offering little help.
"We're a jail," the nurse told state officials after the
infant died. "There's no equipment for a fetus. Or a newborn."
In at least one death report, the commission took the opportunity
to voice a broad indictment of the company. Frederick C. Lamy, chairman
of the commission's medical review board, denounced Prison Health,
or P.H.S. as it widely known, as "reckless and unprincipled
in its corporate pursuits, irrespective of patient care."
"The lack of credentials, lack of training, shocking incompetence
and outright misconduct" of the doctors and nurses in the case
was "emblematic of P.H.S. Inc.'s conduct as a business corporation,
holding itself out as a medical care provider while seemingly bereft
of any quality control."
In its review of Prison Health's work, The Times interviewed government
regulators, law enforcement officials and legal and medical specialists,
including current and former company employees. The review included
thousands of pages of public and internal company documents, state
and city records, and every New York State report on deaths under
the company's care.
The examination shows that in many parts of the country, including
counties in New Jersey and Florida, Prison Health has become a mainstay,
satisfying officials by paring expenses and marshaling medical staffs
without the rules and union issues that constrain government efforts.
But elsewhere, it has hopscotched from place to place, largely unscathed
by accusations that in cutting costs, it has cut corners.
Georgia, which hired Prison Health in 1995, replaced the company
two years later, complaining that it had understaffed prison clinics.
Similar complaints led Maine to end its contract in 2003. In Alabama,
one prison has only two doctors for more than 2,200 prisoners; one
AIDS specialist, before she left this month, called staffing "skeletal"
and said she sometimes lacked even soap to wash her hands between
In Philadelphia's jails, state and federal court monitors in the
late 1990's told of potentially dangerous delays and gaps in treatment
and medication for inmates under Prison Health, which nonetheless
went on in 2000 to win a contract not far away in the Baltimore
City Detention Center. There, two years later, the federal Department
of Justice reported that better care might have prevented four inmate
deaths. One guard, it said, complained that she had to fight nurses
to get sick inmates examined.
Such stories can be heard around the country. In Las Vegas, after
an H.I.V.-positive inmate died in 2002, nurses and public defenders
said the county jail's medical director had refused medications
for AIDS and mental illness, calling inmates junkies.
In Indiana, Barbara Logan, a former Prison Health administrator
who filed a whistleblower suit last year, said in an interview that
the pharmacy at her state prison was so poorly stocked that nurses
often had to run out to CVS to refill routine prescriptions for
diabetes and high blood pressure.
Before Prison Health even started in Georgia, there had been several
inmate deaths in neighboring Florida that cost the company three
county contracts, millions of dollars in settlements - and an apology
for its part in the 1994 death of 46-year-old Diane Nelson. Jailed
in Pinellas County on charges that she had slapped her teenage daughter,
Ms. Nelson suffered a heart attack after nurses failed for two days
to order the heart medication her private doctor had prescribed.
As she collapsed, a nurse told her, "Stop the theatrics."
The same nurse, in a deposition, also admitted that she had joked
to the jail staff, "We save money because we skip the ambulance
and bring them right to the morgue."
A Tough Business: Taking On Headaches, and Creating Some, Too
Few jobs are harder to get right than tending to the health of inmates,
who are sicker and more dependent on alcohol and drugs than people
outside. AIDS and hepatitis have torn through cellblocks, and mental
illness is a mushrooming problem. In the last decade, state and
local government spending for inmate health care has tripled nationwide,
to roughly $5 billion a year.
Qualified doctors and nurses are difficult to find, as jails are
hardly the most prestigious or best-paying places to work. The potential
costs of failure, though, are high - because most inmates will eventually
be let out, along with any disease or mental illness that went untreated.
For decades the task fell to state and local governments that typically
lacked resources or expertise, acting in sometimes conflicting roles
as punisher and medical protector. Often, the results were tragic.
Three skeletons dug up at an Arkansas penal farm in 1968 led to
the uncovering of a monstrous system in which a prison hospital
served as torture chamber and a doctor as chief tormentor. The 1971
uprising at Attica state prison in upstate New York, which was sparked
in part by complaints about health care, left 43 inmates and guards
dead. The debacle unleashed a flood of prisoner lawsuits that culminated
in a 1976 United States Supreme Court decision declaring that governments
must provide adequate medical care in jails and prisons.
But where governments saw a burden, others spotted an opportunity.
Two years after the ruling, a Delaware nurse named Doyle Moore founded
Prison Health, pioneering a for-profit medical-care industry that
offered local officials a grand solution: hand off the headache.
About 40 percent of all inmate medical care in America is now contracted
to for-profit companies, led by Prison Health, its closest rival,
Correctional Medical Services, and four or five others. Though the
remaining 60 percent of inmate care is still supplied by governments,
most often by their Health Departments, that number has been shrinking
as medical expenses soar.
A few big-city hospitals and other nonprofit enterprises have stepped
into the fray, and while not perfect themselves, have performed
the best by many accounts, bringing a sense of mission to the work.
But that care usually costs more than governments want to spend,
and most hospitals are neither equipped nor motivated to enter a
jail or prison, where profit margins linger in the single digits.
In this world, where governments are limited in their choices, a
half-dozen for-profit companies jockey to underbid each other and
promise the biggest savings.
"It's almost like a game of attrition, where the companies
will take bids for amounts that you just can't do it," said
Dr. Michael Puisis, a national expert and editor of "Clinical
Practice in Correctional Medicine," an anthology of articles
by doctors. "They figure out how to make money after they get
Businesses with the most dubious track records can survive, and
thrive. When cost-trimming cuts into the quality of care, harming
inmates and prompting lawsuits and investigations, governments often
see no alternatives but to keep the company, or hire another, then
another when that one fails - a revolving-door process that sometimes
ends with governments rehiring the company they fired years earlier.
Prison Health has mastered the game. When its mistakes have become
public, the company has quietly settled lawsuits and nimbly brokered
its exits by quickly resigning, thus preserving its marketable claim
that it has never been let go for cause.
Even dissatisfied government clients can be reluctant to discuss
their complaints openly, or share them with other counties or states.
Some fear being exposed to lawsuits and criticism; others worry
that the company dropped this year may return next year as the only
bidder for the job. Or, as some former Prison Health customers discovered
to their dismay, the new company they hire may be bought by the
company they fired.
"You've got the professionals dealing with amateurs,"
said Dr. Ronald Shansky, a former medical director for the Illinois
prison system. He said most sheriffs and jailers were not sophisticated
enough about medicine to know what to demand for their money until
things go wrong. Local laws requiring that contracts be regularly
put out for bid - and go to the lowest bidder - can force officials
to switch providers constantly, disrupting care and demoralizing
Yet once they turn jail medicine over to an outside enterprise,
governments rarely go back to providing it themselves. "It's
like an article of faith that private is better," Dr. Shansky
said, even though a 1997 study comparing government and for-profit
prison care, commissioned by the Michigan Department of Corrections,
found little difference in cost or quality.
On this playing field, Prison Health has prevailed by thinking big,
buying up competitors and creating a nationwide pharmacy to supply
its operations. Its revenues have risen in the last decade to an
estimated $690 million last year from $110 million in 1994, and
its stock has leapt to $27.46 a share - its closing price on Friday
- from a split-adjusted price of $3.33.
But day by day, Prison Health - like all of its competitors - faces
the most basic challenge: finding people to do the job. For openings
in Philadelphia last year, it advertised on a Web page called the
Job Resource. "Psychiatrists - Feel shackled to an unsatisfying
job? Discover correctional medicine!" said one ad. A Las Vegas
posting urged, "Come do some time with us!"
Those who Prison Health hires wind up responsible for the legion
of people locked up every day. When the doors shut behind them,
the care those prisoners get is shuttered from public view. Deaths
behind bars provoke scant outcry.
But if the public has little information about inmates, and not
much inclination to care, it may have even less sympathy for the
notion that they should die for want of medical attention.
Cutting a Lifeline: For Parkinson's Patient, a Countdown to Death
Four days into his stay at the Schenectady County Jail, it all began
to come apart for Brian Richard Tetrault. He could no longer walk
the four steps from his bunk to the door of Cell 22, in A-block,
where a nurse was waiting with his small ration of pills.
Since his arrest, the state commission said, he had been denied
most of the medication he had used for a decade to control his Parkinson's
disease and psychological problems. The medical staff knew about
his ailments from the day he arrived, soft-spoken and clutching
a plastic pill organizer; they even phoned his doctor for his charts.
But the jail's medical director took him off all but two of his
seven medications, and nurses concluded that the new inmate was
more uncooperative than ill, state investigators said. Mr. Tetrault,
a former nuclear scientist at the nearby Knolls Atomic Power Laboratory,
had only seven days left before an agonizing death that investigators
would label "physician induced."
He had grown up in the Albany suburbs, a hunter and amateur mechanic
with a gift for mathematics. He joined the Navy, and spent a year
on classified missions in a nuclear submarine. By 1990, he had a
wife and two sons, a house on a lake and his pick of good-paying
jobs in nuclear engineering.
But try as he did to ignore its slow trespass, Parkinson's ruined
everything. His sister Barbara first noticed how his hand shook
during a game of pinochle. By 1995, Mr. Tetrault was popping prescription
Sinemet tablets every two hours to counter the loss of dopamine,
a brain chemical vital to muscle function. Every day became a battle
with dyskinesia, the drug-induced tremors common to Parkinson's
"He'd call it 'disky,' " said Larry Broderick, a high
school friend. "He'd say, 'I'm getting disky.' "
By 2001, the disease had destroyed Mr. Tetrault's marriage and estranged
his two teenage sons. His ex-wife, Eileen, had obtained an order
of protection as he grew increasingly depressed and angry. That
Nov. 10, he stormed into her home while she was away and snatched
some items - skis and a push broom - before the police arrived and
charged him with burglary and harassment.
His mistreatment began that day, according to the state commission.
Without seeing Mr. Tetrault, the jail's medical director, Dr. W.
J. Duke Dufresne, prescribed Sinemet and an anti-ulcer drug, but
none of the other five medications for his Parkinson's, pain and
On his second day in jail, Mr. Tetrault saw Dr. Dufresne, the only
physician for the jail's 300 or so inmates. In a brief visit, the
commission said, the doctor reduced even the Sinemet. As for the
mental health drugs, Dr. Dufresne later told investigators that
only a psychiatrist should prescribe them.
But no one ever arranged for Mr. Tetrault to see the jail psychiatrist,
the commission said. And never again did he see Dr. Dufresne, who
told investigators he had believed that Mr. Tetrault was merely
feeling the typical ups and downs of Parkinson's; he had planned
to check on him in three months.
Mr. Tetrault had only days. On his fourth day in jail, medical records
show, he grew increasingly "disky" and belligerent, as
his body withdrew from the medications that had sustained him for
years. On the sixth day, he lay in his bunk, steeped in his own
urine and unable to move. "Continues to be manipulative,"
a nurse wrote.
On the seventh day, the commission said, nurses continued to look
in on him, chronicle his deterioration and do little about it. "Inmate
remains very stiff," one wrote. "Head arched back, sweating
profusely," another noted. A third nurse forced him to walk
to the jail clinic, though he could barely move.
On the eighth day, alerted by a nurse's phone call, Dr. Dufresne
ordered Mr. Tetrault hospitalized. At Ellis Hospital in Schenectady,
emergency-room doctors diagnosed the ravages of his untreated Parkinson's.
"I suspect, in the prison setting, he was not getting his full
dose of medication as needed," wrote Dr. Richard B. Brooks.
There was not much the hospital could do. On the 10th day, Mr. Tetrault
went into septic shock. On the 11th, he died.
The state commission ultimately referred Dr. Dufresne to the State
Board for Professional Medical Conduct for what it alleged was "grossly
inadequate" care, urged Prison Health to fire him and asked
the county to fire Prison Health.
The commission found that Dr. Dufresne had never given Mr. Tetrault
a physical examination; and nurses had transcribed the doctor's
orders incorrectly, reducing even the Sinemet.
The medical conduct board has taken no action against Dr. Dufresne.
The company, in its lawyer's response to the commission, disputed
virtually all of the commission's findings, saying that Mr. Tetrault
sometimes resisted taking his medication, and that he was well able
to move when he wanted. The company's internal one-page review of
Mr. Tetrault's care passed no judgment on the doctor or the nurses.
But it did recommend six minor changes, like keeping medical records
in chronological order. Dr. Dufresne, who is now the company's regional
medical director for upstate jails, did not return calls seeking
Richard D. Wright, the president and chief executive of Prison Health,
would not discuss details of the case, citing a lawsuit by Mr. Tetrault's
son Zachary. He said that over all, Schenectady County "was
extremely pleased with the work of the company."
But the county moved to fire Prison Health the day after the commission's
report was made public last June. "We were going to terminate
them for cause," said Chris Gardner, the county attorney. "But
they approached us and we mutually agreed to terminate the relationship."
The humiliation of Mr. Tetrault did not end with his passing, or
with Prison Health, the commission said. On the day he died, Nov.
20, 2001, sheriff's officials altered records to change the time
of his release from custody, in the early evening, to 2:45 p.m.
- 10 minutes before he was pronounced dead, the commission said.
The Sheriff's Department denied the charge, and said it had done
nothing untoward in trying to formally release Mr. Tetrault.
But the commission said the time change allowed the department to
avoid an investigation, at least for a while. Commissioners learned
of Mr. Tetrault's death by reading a newspaper article about Zachary's
lawsuit, 20 months later.
The Revolving Door: After Trouble in Florida, Moving On, and Up
If Schenectady County was learning hard lessons about Prison Health,
it was old news in South Florida, where several counties had tangled,
and re-tangled, with the company years earlier.
By the time Pinellas County hired Prison Health in 1992, the company
was hitting its stride. Fourteen years after its founding, it had
established a wide beachhead in the state, and had just begun a
nationwide push that by the end of the decade would put it in the
three biggest cities of the Northeast and the prison systems of
entire states. A year earlier, the company began selling stock under
the name of a holding company, America Service Group.
But for Pinellas, halfway down Florida's Gulf Coast, things were
Everett S. Rice, who was sheriff then, said that Prison Health understaffed
the county jail in Clearwater. The company seemed reluctant, he
said, to send seriously ill inmates to hospitals, which could cost
it thousands of dollars a day. Inmates were regularly showing up
in court incompetent to stand trial, said Bob Dillinger, the county
public defender, because they were not getting their psychiatric
The sheriff's office learned that even the most basic care had to
be spelled out in the contract. When one inmate died after a delay
in calling for help, Mr. Rice said, the agreement was rewritten
to require that Prison Health call 911 at a specific time after
the start of a medical emergency.
Then, in March 1994, came the death of Diane Nelson, who collapsed
of a heart attack in front of the nurse whose words would echo in
news reports: "We save money because we skip the ambulance."
Saving money was the reason the county had hired Prison Health.
Pinellas was actually on its second round with the company, having
first enlisted it in 1986 because of worries about the ballooning
costs of the county's own jail health care. When the contract went
back out for bid three years later, Pinellas switched to a cheaper
competitor; three years after that, Prison Health bid the lowest
and retook the job.
But Mr. Rice said the bidding process never turned up a whisper
of criticism about Prison Health, or any of its competitors. "Every
time we'd be up for renewal, we'd talk to the other counties and
institutions, and surprisingly, most of them had glowing reports,"
In the end, the deal with Prison Health "probably saved a little
money," Mr. Rice said, but the human and political costs were
too high. "I thought if I'm going to get the blame for this,
I'm going to bring it back inside," he said.
The county did that in April 1995, going back into the business
of jail medical care. Three months later, an hour's drive to the
east, rural Polk County - which had hired Prison Health the same
year as Pinellas - broke off with the company after three inmate
deaths that cost Polk taxpayers thousands of dollars in settlements.
"There were instances where we would actually send somebody
to the hospital by ambulance because P.H.S. wouldn't do so,"
said David Bergdoll, counsel to the Polk County Sheriff's office.
Since 1992, at least 15 inmates have died in 11 Florida jails in
cases where Prison Health appears to have provided inadequate care,
according to documents and interviews with state and county officials.
As it grew, Prison Health proved adept at ingratiating itself with
local politicians, hiring lobbyists and contributing to campaigns
for sheriff. Under a promise of immunity from prosecution, the nurse
who founded the company, Mr. Moore, testified at a 1993 Florida
corruption trial that he had paid the Broward County Republican
chairman $5,000 a month - "basically extortion," he said
- to keep the contract there and in neighboring Palm Beach County.
Some counties say Prison Health has done good work and saved taxpayers
money. In Tampa, the medical bill at the Hillsborough County Jail
fell to $1.2 million, from $1.8 million in 1982, the year Prison
Health replaced the county's medical operation, said Col. David
M. Parrish, who runs the jail.
There have been other costs. Last year, the company dismissed a
nurse and reprimanded two others after an inmate's baby died; the
mother, Kimberly Grey, said in a federal lawsuit that although she
had been leaking amniotic fluid for five days, nurses refused to
examine her until she gave birth over a cell toilet.
But Colonel Parrish said that mistakes, and second-guessing, were
part of the job, no matter who does it. "Anybody who is in
the health care business for inmates is going to get blasted because
inmates have nothing better to do than complain and sue and find
somebody who is going to make a big stink about nothing," he
Certainly, a litany of complaints followed as Prison Health expanded
across the nation. In Philadelphia, a 1999 federal court monitor's
report warned that the company's failure to segregate inmates who
were suffering from tuberculosis posed "a public health emergency."
Pregnant inmates, it said, were not routinely tested or counseled
for H.I.V., endangering their babies.
Dr. Robert Cohen, a state court monitor, said in an interview that
Philadelphia doctors "actually encouraged women to refuse pelvic
Prison Health still works in Philadelphia, where officials have
persistently prodded it to improve care. Like many governments,
the city has moved from a fixed-cost contract in which the company's
profit comes out of whatever it does not spend to one that covers
most medical costs and pays Prison Health a management fee.
When other governments have shown less patience, Prison Health has
survived, and even grown, by buying rivals like Correctional Health
Services, of Verona, N.J. In 1999, its biggest purchase, EMSA Government
Services, brought with it contracts with dozens of prisons and jails.
Back in Florida, the purchase brought some unwelcome déjà
vu to Polk County, which thought it was through with Prison Health
when it hired EMSA. When Prison Health bought EMSA, Polk officials
soon replaced it yet again.
"P.H.S. was the lowest bidder, but we didn't accept their bid,"
said Mr. Bergdoll, the sheriff's counsel. "That should tell
you something." Since then, he said, the number of lawsuits
has fallen so sharply that the county's insurer lowered its premiums.
The EMSA purchase also brought Prison Health back to Broward County,
Fla., which had dropped it years earlier because it had been unhappy
with the medical care. Two years after its return, three state judges
noticed the phenomenon that had played out in Pinellas - a parade
of inmates showing up in court incoherent - and ordered the company
to stop withholding psychiatric drugs.
"My impression was that it was money," Judge Susan Lebow
said in an interview. "The doctors were under corporate direction
to not continue the medications."
Prison Health denies it gave any such order. The Broward sheriff
would not comment on the company, which the county replaced again
But the revolving door of for-profit health care spins on. Last
December, Broward hired Armor Correctional Health Services, a company
formed just a few weeks earlier by a familiar figure: Doyle Moore,
the nurse who founded Prison Health.
A Jailhouse Birth: Chaos on a Cell Floor as a Baby Is Discovered
It could not have been much worse. A newborn baby lay in a pool
of blood on the floor of the Albany County Jail. At least four adults
were there: the mother, a registered nurse and two correction officers
who struggled to save the tiny boy. But the nurse looked on passively,
tending to the dazed mother, convinced that little could be done,
state records show.
The baby, who was named Scott Mayo Jr., died two days later.
The mistreatment and missed chances to help the young mother, Aja
Venny, began soon after her arrival 11 days earlier, investigators
said. A 22-year-old secretary and community-college student from
the Bronx, she knew she had done something stupid: taken a ride
with a drug dealer she knew from her neighborhood. When a state
trooper pulled them over, she stuffed his small bags of drugs into
She was booked into jail on Aug. 30, 2001, nearly six months pregnant.
The medical staff made an appointment with an obstetrician it paid
to visit every two weeks, but Ms. Venny never saw him, state investigators
said; nurses ordered her files from a Bronx women's clinic, but
never received them. The one concession to her condition, it seems,
was her assignment to the maternity unit, a six-bunk cell with a
toilet cordoned off by a white curtain.
On Sept. 9, Ms. Venny awoke before dawn with excruciating cramps.
Another inmate told the guard that Ms. Venny was about to give birth.
After two calls to the nursing supervisor, Donna Hunt, a jail sergeant
sent an officer to fetch her immediately.
When she arrived at 7:15 a.m., Ms. Hunt found Ms. Venny sitting
on the toilet crying and "blood everywhere," she told
investigators. She cleaned off and consoled the inmate, and told
the officers to call an ambulance. She said later that she assumed
that Ms. Venny had miscarried and saw no reason to check the toilet.
But ambulance technicians, on the phone with the sergeant, asked
if there was a baby. Guards looked in the toilet and discovered
the infant, still in his placental sac. Officer Dave Verrelli scooped
him out using a red biohazard waste bag and laid him on a towel
on the cell floor as Nurse Hunt watched.
"I knew that there was probably nothing we could do for this
fetus," she told investigators.
Officer Verrelli detected a slight pulse. "What should I do
now?" he frantically asked the nurse, who told him to cut open
the sac. Officer Verrelli cut it, removed the baby and uncoiled
the umbilical cord from its neck. Ms. Hunt confirmed that there
was a faint heartbeat, investigators said, but did nothing to get
the baby breathing in the quarter-hour before ambulance workers
arrived and administered oxygen.
At the hospital, the boy was placed on a ventilator, his heart pumping
but his temperature too low to be measured. On his third day of
life, he died.
The State Board of Regents found that three Prison Health nurses,
including Ms. Hunt, had failed to care properly for Ms. Venny or
her baby. Each nurse was placed on a year's probation and fined
$500. The State Commission of Correction did not say whether anyone
might have saved the child, but it emphasized that Ms. Hunt did
not take basic steps to help. She did not return calls seeking comment.
The commission also found more deep-seated failures: a disorganized
staff and prenatal training for nurses that consisted of e-mail
messages with instructions copied from a university Web site.
Prison Health's lawyers defended Nurse Hunt - saying she found the
child in the toilet, but was pushed aside by guards - and accused
the commission of ignoring "inconvenient facts."
Ms. Venny, who completed a six-month boot-camp prison program after
her son's death, now lives in the Bronx with her husband, Scott,
and their 20-month-old daughter, Skye. The ashes of Scott Jr. are
kept in a golden urn in the bedroom.
"I know what I was doing was wrong," she said. But still,
"I can't find a reason why a baby had to die."
Connecting the Deaths: A Pattern Emerges, and a Battle Begins
It was late 2000 when state investigators began to notice something
strange. Reviewing deaths that had occurred in jails in upstate
New York, they were not struck by the number or even the grim details
of the cases, which they routinely examined as employees of the
State Commission of Correction. Something else was wrong.
Working out of a cluttered office in Albany, the three commissioners
and a six-member medical review board noticed that low-level employees
were doing work normally done by better-credentialed people. Nurses
without the proper qualifications, they said, were making medical
decisions and pronouncing patients dead.
In Rochester, where Candy Brown had died that September, pleading
for help as she withdrew from heroin, investigators found that one
of the nurses responsible for her had been suspended by the state
three times for negligent care.
In that case and others, commission members said, the people offering
the most help and compassion were guards and inmates. And the company,
it turned out, was always the same: Prison Health.
"Our sense was that what we were dealing with was not clinical
problems but business practices," said James E. Lawrence, the
commission's director of operations.
It was the start of a long fight to get the company to change its
ways, and when that failed, to get other officials in Albany to
step in. Four years later, the commission has been stymied on both
Mr. Lawrence said Prison Health seemed unfamiliar with New York's
tradition of regulated health care, "and dismissive of it."
When the agency sought out those in charge, it would often be routed
to lawyers or executives at the company's headquarters in Brentwood,
Tenn., who bristled at the suggestion that they were answerable
to New York State regulators. "The rules were not of any consequence,"
Mr. Lawrence said.
Prison Health entered New York in 1985 as medical provider for the
Dutchess County Jail. Orange and Broome Counties hired the company
for a few years, but ended those contracts in the 1990's.
By late 2000, when the company began to attract the state commission's
notice, it had signed contracts with Schenectady, Ulster, Monroe
and Albany Counties. The Albany jail superintendent at the time
called the company "a godsend."
The commission called it a disaster. "Grossly and flagrantly
inadequate," for instance, was its verdict on the care given
Prison Health, in turn, challenged the commission's authority, and
even sued over its report on one inmate's treatment, saying the
panel had acted maliciously. The suit was dismissed on its merits.
Dr. Carl J. Keldie, the corporation's medical director, said the
commission seemed to make up its mind before an investigation and
then overstate its case in reports. "The tone, the timbre,
the language is egregious," he said. Company executives said
the commission has refused to meet and try to reconcile their differences.
The commission in 2001 moved beyond the specific criticisms in its
reports to sound a general alarm. Asking state education officials
to investigate, it said Prison Health was allowing "dangerously
substandard medicine" by hiring doctors and nurses with questionable
A month later, spurred by the commission, the Department of Education
alerted the state attorney general that the company was operating
illegally in New York by not having doctors in charge of medical
care. "Nobody really noticed that they weren't licensed,"
one commission doctor said of Prison Health's presence in New York.
In the three years since, nothing has come of either complaint.
The only agency with the power to enforce the state law - the attorney
general's office - finally replied last October, telling the commission
to resolve the matter on its own. In a heated exchange of letters,
an assistant attorney general, Ronda C. Lustman, scolded the commission
for refusing to meet with executives.
The company says that it is acting legally because it has set up
local corporations with doctors in charge. But there is abundant
evidence, state investigators say, that those corporations are shams.
For example, Dr. Trevor Parks is listed as the sole shareholder
of P.H.S. Medical Services P.C., which the company says provides
all medical care at Rikers Island, free of any influence from Prison
Health executives. But investigators say that when they interviewed
him, he had little idea of his role, or his corporation's.
Moreover, records show that Dr. Parks's corporation went out of
business in July, for nonpayment of taxes and fees. After The Times
pointed that out to company executives in December, Prison Health
paid the money. Dr. Parks did not respond to phone calls and e-mail
If frustration mounted at the commission, a sense of impending trouble
was growing at the jail in Albany County, where the commission said
doctors' decisions on inmate treatment were being overruled by a
regional medical director in Washington who was not licensed to
practice in New York.
The doctor, Akin Ayeni, said in an interview that he never overruled
any doctor there. But a former medical director at the jail said
she quit in April 2001 because she felt the company's policies,
and Dr. Ayeni's decisions, were dangerous.
"I told my staff, 'I know it's only a matter of time before
they kill someone,' " she said, asking that her name not be
used because she feared retribution. "I knew there was going
to be a death. I could feel it."
In the six months after she left, two people died and a third was
seriously injured after poor treatment by Prison Health, the state
commission found; the dead included Aja Venny's newborn son.
The county and the company parted ways six months later, said Thomas
J. Wigger, the jail superintendent, because he was unsatisfied with
the quality of care.
One by one, other counties have followed suit. Ulster County, for
example, caught Prison Health overbilling it for thousands of dollars
of nurse hours and switched to another company in 2001. The company,
for its part, said it lost most of the upstate contracts to competitors
who had underbid them. Strangely, it said it had no record of working
in Orange County, even though the state commission faulted the company
in two inmate deaths, in 1989 and 1990.
Last October, Schenectady County dropped Prison Health after the
death of Mr. Tetrault, the inmate with Parkinson's disease. The
jail director, Maj. Robert Elwell, said in an interview that the
medical director, Dr. Dufresne, had discouraged treatment for anything
but the most urgent problems. "When you're dealing with a for-profit
corporation, those are the types of decisions that get made,"
Major Elwell said.
The company's only remaining outpost in upstate New York is Dutchess
County. "I believe they are a good company," said David
W. Rugar, the county jail administrator. "It's just an intense
thing to do, when you provide medical services."
Indeed, just days before it renewed its deal with Prison Health
in 2002, the jail had an intense experience that would cost the
company's medical director there his job.
Cries From the Heart: Despite Days of Agony, 'Nobody Will Help Me'
When they cleaned out Cell 6 in Unit 10 on Feb. 16, 2002, workers
at the Dutchess County Jail found a letter that Victoria Williams
Smith had written to her husband.
"My chest is tight & burns, my arms are numb," it
said. "I been to the nurse about five times & no body will
help me. I need to get out of this jail. It feels like I'm having
a stroke, no bull."
Actually, it was a heart attack, and it had killed Ms. Smith a few
hours earlier at the age of 35. The letter was just one in a skein
of increasingly panicked pleas for help during her last 10 days
Ms. Smith was born in Brooklyn, but settled in North Carolina with
her second husband, Justin Smith. They married in 1997, shortly
after he was sent to a prison in Dutchess County for attempted robbery.
She shipped him canned food that he could sell for cash, and in
January 2002 drove to the prison for what friends said was a visit
allowed to married couples.
The reunion was called off by state troopers, who were waiting at
the prison to search her. They found about seven ounces of heroin
clearly intended for her husband to use or sell, state records show.
Thirteen days passed, state investigators said, before Ms. Smith
was examined by a doctor: Vidyadhara A. Kagali, the part-time medical
director at the jail in Poughkeepsie, who worked only on Wednesday
and Friday evenings even though he was responsible for about 300
She could have hoped for better. Dr. Kagali, who was board certified
only as a pathologist, had never treated patients in a hospital
and had "limited knowledge of his responsibilities as jail
medical director," according to commission records.
On Feb. 6, when she began to complain of chest pains and numbness,
Dr. Kagali told her she was suffering from inflamed cartilage in
her chest, and had her continue taking the Vioxx arthritis medication
that friends in North Carolina mailed to her.
The next day, after Ms. Smith was found crying in pain in her cell,
an electrocardiogram revealed abnormalities in her heart. But Dr.
Kagali, notified by a nurse, did not see her, according to the state
commission. On her third day in jail, records show, a second EKG
showed the same heart problem, but the doctor still did not see
On the seventh day, a nurse turned to the jail's part-time psychiatrist
for help in easing Ms. Smith's chest pain and labored breathing.
Without seeing her, he prescribed a drug for intestinal problems.
On the eighth day, Dr. Kagali saw Ms. Smith; he ordered a spinal
X-ray and recommended Bengay.
Two days later, in tears, she phoned her North Carolina friends,
Chris and Marjorie Bowers, three times. "She said these people
would not help her at all," Ms. Bowers said.
In the early morning of Feb. 16, Ms. Smith's untreated heart ailment
became an emergency, according to jail records and sworn statements
from nurses and guards. Around 4:30 a.m., a guard found her rocking
on her bunk, clutching her chest, and called Barbara Light, the
registered nurse on duty.
Ms. Light concluded that Ms. Smith was having an anxiety attack
- even though, the commission said, the nurse had never seen the
inmate's medical record.
A half-hour later, Ms. Smith, weeping, told the guard she wanted
to go to a hospital - a plea Nurse Light dismissed as an attempt
to get drugs. Minutes after that, the guard placed a frantic third
call to the nurse, who arrived to find the inmate on the floor,
shaking. An ambulance rushed Ms. Smith to Vassar Brothers Medical
Center, where she died in less than an hour.
The state commission, in its report, seemed hardly to know where
to begin to catalog the failures.
It urged that Dr. Kagali be fired for "gross incompetence,"
and referred Ms. Light to state regulators for discipline. State
health authorities eventually suspended the doctor's license for
six months, but have not taken action against Ms. Light. Neither
she nor Dr. Kagali would comment.
The company's confidential review of Ms. Smith's death found no
fault with her treatment, but recommended that its staff offer grief
counseling to colleagues and inmates after future jail deaths.
In a letter to the commission, Prison Health defended Ms. Light
and Dr. Kagali. It said that over Ms. Smith's five weeks in jail
the doctor had seen her numerous times and provided medications,
knee braces and even an extra mattress for her arthritis. Ms. Smith
had no known history of heart disease, the company said, and any
suggestion that her death could have been prevented was "20-20
The letter was signed by Dr. Dufresne, whom the commission would
later blame for Brian Tetrault's death.
Joseph Plambeck contributed reporting for this article.
Copyright 2005 The New York Times Company
February 28, 2005 07:45 AM US Eastern Timezone
America Service Group Responds to Media Coverage of Prison Health
BRENTWOOD, Tenn.--(BUSINESS WIRE)--Feb. 28, 2005--America Service
Group Inc. (NASDAQ:ASGR) released the text of a message distributed
by Chairman, President and Chief Executive Officer Michael Catalano
in response to coverage of the Company and its subsidiary, Prison
Health Services, Inc., in The New York Times. In his message, Mr.
"Some of you may have seen the recent coverage of Prison Health
Services in The New York Times. This blatantly unfair story contains
so many mischaracterizations, exaggerations and oversimplifications
that it is difficult to know how to start to set the record straight.
"The fact is that PHS doctors, nurses and other healthcare
professionals provide high quality and effective care 24-hours-a-day,
365-days-a-year, in over a million patient encounters a year, under
extremely difficult circumstances. And day after day, under these
challenging conditions, they save lives. Unfortunately, rather than
acknowledging the countless success stories we've had - stories
that can be found in every facility we work with - the reporter
chose to use only very select anecdotal information to form unfair,
misleading and inaccurate conclusions.
"PHS routinely improves the quality of healthcare in facilities
it serves. The National Commission for Correctional Health Care
(NCCHC) and American Correctional Association (ACA) have established
guidelines for correctional healthcare, and we are proud of our
track record in achieving a 100% success rate in obtaining and maintaining
accreditation by these organizations in each case where our clients
have elected to meet these standards. Jail facilities served by
PHS have received accreditation at a rate several times higher than
other jail facilities around the country.
"The positive results are clear. And while this reporter cites
a number of lawsuits against our company, the fact is that the number
of lawsuits against PHS is a fraction of the average number of lawsuits
filed by inmates in correctional facilities around the United States.
And the vast majority of cases against PHS are dismissed.
"Our clinicians treat patients with compassion, dignity and
respect. We are proud of them. We respect their professionalism
and judgment. They go through the same type of credentialing process
that is used by most community hospitals, and we know they are well
qualified to do their jobs. We also know that they will continue
their good work guided by the principle that our patients always
"It seems as if anyone who tried to present our side of the
story to this Times' reporter - or anyone who provided evidence
contradicting his view - was dismissed with no more than a minor
"In his lengthy descriptions of cases in which patients died,
the reporter gives tremendous credence to the New York State Commission
on Corrections (COC). The article barely mentions that PHS and jail
officials themselves have refuted many of the COC conclusions and
have offered evidence that contradicts them. It also ignores the
fact that many of the COC's recommendations are contrary to practices
recommended by the Institute of Medicine and the Agency for Health
Care Research and Quality.
"The suggestion that our staff operates in a reckless manner
or puts business interests ahead of patients' needs is outrageous,
repugnant and demeaning to the thousands of dedicated employees
whose commitment, competence and caring save lives in some of the
most challenging situations imaginable. They understand that good
clinical care and honesty are fundamental values of our company,
and they share those values.
"Remarkably, the Times portrays our clients, government officials
around the country, as either uncaring or incompetent individuals
who are simply being duped. The reporter's assertion that government
officials support PHS for fear of being sued is ludicrous. We believe
they do so because they recognize our outstanding record of quality
"The story discounts the possibility that our company's growth
and consistent record of contract renewal is based on merit. Perhaps
the reporter believes that private companies should not be in the
correctional healthcare business. But we, our clients and an increasing
number of corrections officials around the country obviously disagree.
The reality is that PHS provides quality care. We are dedicated
to achieving the highest standards of operational excellence, clinical
quality and client service, bearing in mind that our patients come
to us with a history of being medically underserved and with a high
incidence of infectious and chronic diseases, drug abuse and mental
"PHS is proud of the thousands of dedicated medical, dental
and mental health professionals who work tirelessly to serve a very
challenging population who are very frequently sick, violent and
plagued with mental health or drug abuse problems. We will continue
to ensure these individuals receive high quality care."
America Service Group Inc., based in Brentwood, Tennessee, is the
leading provider of correctional healthcare services in the United
States. America Service Group Inc., through its subsidiaries, provides
a wide range of healthcare and pharmacy programs to government agencies
for the medical care of inmates.
This press release may contain "forward-looking" statements
made pursuant to the safe harbor provisions of the Private Securities
Litigation Reform Act of 1995, including the Company's beliefs and
expectations of future performance, the effects of any stock split
and may be indicated by words or phrases such as "anticipate,"
"estimate," "plans," "expects," "projects,"
"should," "will," "believes" or "intends"
and similar words and phrases. As such, they involve risk and uncertainty
that actual results may differ materially from those projected in
the forward-looking statements including, without limitation, risks
related to the following: the Company's ability to retain existing
client contracts and obtain new contracts; whether or not government
agencies continue to privatize correctional healthcare services;
increased competition for new contracts and renewals of existing
contracts; the Company's ability to execute its expansion strategies;
the Company's ability to limit its exposure for catastrophic illnesses
and injuries in excess of amounts covered under contracts or insurance
coverage; the outcome of pending litigation; and the Company's dependence
on key personnel. A discussion of these important factors and assumptions
regarding the statements and risks involved is contained in the
Company's annual report on Form 10-K and other filings with the
Securities and Exchange Commission. These forward-looking statements
are made as of the date of this release. The Company assumes no
obligations to update or revise them or provide reasons why actual
results may differ.
America Service Group Inc.
Michael Catalano or Michael W. Taylor, 615-373-3100