Report Finds Gruesome Medical Malpractice and Death in Arizona Prisons

"A system that allows this level of sustained incompetence and cruelty... is morally bankrupt," a doctor wrote after investigating medical neglect in Arizona prisons.


A paraplegic man was left to physically deteriorate until his penis had to be amputated. A man with undiagnosed, untreated lung cancer lost 90 pounds and died "slowly and agonizingly" without pain medication. A woman's multiple sclerosis was ignored and misdiagnosed until she was left, at age 36, nearly completely paralyzed.

Arizona's prison system is on trial once again in a long-running civil lawsuit over claims of medical neglect, including the examples above, and a doctor's testimony in the case paints a stomach-churning picture of unnecessary suffering, malpractice, and death behind prison walls.

In an expert witness report filed last week in the lawsuit, Tod Wilcox, medical director of the Salt Lake County Jail System, describes several cases of preventable deaths that he says were offensive to him as a medical professional and showed that Arizona prisons put incarcerated people at unacceptable risks of harm.

"A system that allows this level of sustained incompetence and cruelty, and fails to take decisive action to determine the causes of these myriad and horrific breakdowns and to ensure that the people involved in this case are thoroughly retrained and/or separated from service," Wilcox writes, "is morally bankrupt."

Wilcox's report found that the poor quality of nursing inside Arizona prisons continues to put incarcerated people "at an unreasonable and substantial risk of serious harm."

As Reason has reported, medical neglect is widespread in American prisons and jails, despite the Eighth Amendment's supposed guarantee of basic medical care, hygiene, and living conditions. 

The American Civil Liberties Union of Arizona and several law firms have been litigating the case since 2012. The federal class-action lawsuit, filed against the Arizona Department of Corrections, Rehabilitation, and Reentry (ADCRR), followed media investigations and persistent allegations of fatally inadequate medical care by the department's medical provider.

The ADCRR agreed to settle the lawsuit in 2015 by taking steps to improve medical care inside its prisons. But since then, the ACLU and several other law firms have repeatedly accused the ADCRR of failing to abide by the settlement agreement, and federal judges have agreed.

A federal magistrate judge fined the ADCRR $1.4 million in 2018. Judge Roslyn Silver of the U.S. District Court for the District of Arizona held the department in contempt this February and fined it another $1.1 million for failing to meet the benchmarks for proper medical care. Silver also rescinded the settlement agreement, forcing the ADCRR back into court, where a civil trial began last week.

The ACLU argues that the lack of medical and mental health care constitute cruel and unusual punishment under the Eighth Amendment.

"It falls very, very short of the constitutional standard," says Corene Kendrick, deputy director of the ACLU's National Prison Project. "The bar is pretty low. It's not like they're entitled to a Mayo Clinic level of medical care. We're just talking about basic, fundamental stuff. Unfortunately our experts are finding that, systematically, they fall short."

Kendall Johnson, one of several incarcerated witnesses in the trial, testified last week via video conference from the special needs unit where she is now confined due to advanced multiple sclerosis.

According to Wilcox's report, it took three years after Johnson first reported numbness in her feet and legs before she was correctly diagnosed. In the meantime, she progressively weakened and lost the ability to walk. Johnson testified last week that she wrote letters asking for help until she couldn't, then had other inmates write on her behalf. She eventually had to resort to paying other inmates to feed her, she said.

After she was diagnosed, it took another year for Johnson to start receiving appropriate medication, but by that time the disease had irreversibly progressed, leaving her "profoundly disabled," Wilcox writes. The best she can look forward to is maintaining the ability to speak and swallow for some time.

Johnson testified that she spends her days now watching TV and "counting the ceiling tiles," the Arizona Republic reported.

Wilcox describes another case where an incarcerated man, whose name is redacted from the report, died "horrific and painful death" from lung cancer. Staff overlooked, ignored, and failed to act on obvious signs of cancer, including drastic weight loss.

"A grown man who has lost 90 pounds from his baseline is a medical crisis that demands an explanation," Wilcox writes. 

Instead, in response to the man's complaints of severe throat pain and weight loss, a nurse practitioner told him to "eat slow and cut food in small pieces."

Even the man's end-of-life care, after he was finally diagnosed with lung cancer, was substandard, Wilcox says. For two months, the man received only Tylenol #3 pills for pain, which in addition to being inadequate for pain management was "malpractice," Wilcox writes, because the man could barely swallow and had already had life-threatening gastrointestinal bleeding from anti-inflammatory drugs. He eventually received morphine, but only sporadically.

Wilcox says the patient's "end of life care does not conform to any standard of care for palliative or hospice care. His cachetic body was racked with pain, and he wasted away with no reasonable assistance from medical science in the form of comfort or compassionate pain control."

In another case, Wilcox describes a paraplegic man who has open sores on his buttocks and scrotum from sliding from his broken wheelchair onto a toilet, as well as having to frequently sit in his own waste. Prison officials allowed his condition to deteriorate until his penis had to be amputated.

According to Wilcox's report, Centurion, the ADCRR's contracted medical care provider, won't even give the man moistened wipes to keep himself clean.

"The amazing thing is that the provider wants to deny him some very inexpensive wipes and Centurion runs the risk of having him develop infections and skin breakdown which would cost phenomenally more money to address through hospital stays and plastic surgery," Wilcox writes. "The priorities here just make no logical sense."

Wilcox's report concluded that the main problem with the ADCRR's healthcare system is the quality of nursing.

"By design, healthcare decisions in [Arizona prisons] are pushed down to the lowest possible level—nurses who are practicing poorly and far outside the scope of their licenses," Wilcox writes. "There is a clear pattern of failure by nurses to complete an adequate nursing assessment, take patient reports seriously, recognize dangerous symptoms, and elevate concerns to Providers."

Even if the ADCRR had complied with the rules of the settlement agreement, Wilcox writes, incarcerated people would still be at serious risk of harm "because when they did see providers and nurses, those clinicians often exercised poor clinical judgment and failed to provide clinical care that meets community standards for such care."

A spokesperson for the ADCRR declined to comment, citing the pending litigation.