Health Care

Locked out of care: Brain fungus death points to extensive problems in Kansas prisons

For months, Marques Davis complained of headaches and muscle weakness at the Kansas prison where he was incarcerated.

But employees for the prison’s private health care contractor, Corizon Health, repeatedly ignored his pleas for help — until he was bedridden in the infirmary, so disoriented that he was soiling himself and drinking his own urine, according to a lawsuit filed by his mother. What Corizon staff missed: a fungal infection of his brain that soon killed him.

The Star reviewed Corizon oversight records for the 3.5 years surrounding Davis’ death and found that though his illness might have been unusual, the lack of medical attention was not.

The Star’s analysis of Corizon’s performance documents from July 2015 through December 2018 — hundreds of pages of raw data obtained through open records requests — found that almost a third of the time the company fell short of contract requirements for treating inmates who said they were sick.

Records for those 42 months show:

Inmates regularly complained three, four and in one case five times of the same ailment without being allowed to see a doctor or mid-level practitioner like a physician’s assistant or advanced practice nurse — a violation of the company’s contract.

Almost 20 percent of Kansas’ 10,000 inmates are on psychotropic medications, but several prisons went months without reporting any hours worked by psychiatrists to oversee those prescriptions.

The state levied about $1 million in performance-based penalties against Corizon, and an additional $6.4 million for falling short on staffing requirements, particularly for psychiatrists.

“It’s showing a clear and consistent pattern of delaying, postponing or not providing necessary medical treatment,” said Leland Dempsey, the Kansas City-based lawyer for Davis’ mother, Shermaine Walker, who is suing Corizon. “That’s what this is showing (and) that’s what our whole lawsuit is about.”

The records were available only because Kansas, unlike most states, has an independent third party watching over its inmate health care contractor. Every month, as part of the state’s contract with Corizon, a team of experts at the University of Kansas Medical Center reviews a sample of health care records at Kansas’ prisons.

Marques Davis died at 27 of a fungal brain infection while a prisoner at Hutchinson Correctional Facility. File photo

Corizon’s contract with Kansas pays about $70 million to $80 million a year, depending on the prison population.

“I would hope the people of Kansas and their representatives would have a strong interest in whether that $70 million (a year) is being well spent and whether they were getting their money’s worth,” said Eric Balaban, a senior staff attorney with the American Civil Liberties Union’s National Prison Project.

He said the fines levied against Corizon don’t appear to be enough of a deterrent for contract violations.

“Corizon is simply writing off the liquidated damages they’re having to pay as the cost of doing business with the state without doing anything meaningful to improve,” Balaban said.

Most prisoners get released at some point. When they aren’t properly cared for while inside, Balaban said, taxpayers often have to pay twice: once to Corizon and again when former inmates who are uninsured or on public programs like Medicare and Medicaid show up at hospitals because of conditions that were allowed to fester while they were incarcerated.

Balaban also said prisoners have a constitutional right to reasonable medical care, and failing to provide it can expose not only the company but the state to litigation when things go wrong. Beyond that, he said denying needed care is inhumane.

It’s good that Kansas is tracking Corizon’s performance and docking it some pay for non-compliance, he said, but if that non-compliance persists for years, as it has in Kansas, the state either needs to stiffen its penalties or find a new contractor.

Now state officials say they are planning to give Corizon one more year to improve its performance before they explore other options.

Corizon spokeswoman Eve Hutcherson said via email that the company stands by the care it provides in Kansas, adding that over the last five years no court rulings or settlements related to that care have gone against the company or the Kansas Department of Corrections.

“The Davis case involves ongoing litigation and is moving through the court system,” Hutcherson said. “As such, we cannot comment on particulars, but we will defend our care strongly in court.”

Lamont McIntyre did not think the care Corizon provided was adequate.

McIntyre spent more than 20 years at prisons in Hutchinson and Lansing for a crime he didn’t commit before he was exonerated and released in 2017. He said it was not unusual for inmates who wanted care to struggle to get it.

“I knew a guy who had a hernia that looked like two twin babies in his stomach and they kept saying there’s nothing wrong with him,” McIntyre said. “If you can still talk and still breathe you’re OK. They make sure you’re just well enough to do time.”

McIntyre, who lives in Kansas City, Kansas, said he experienced it firsthand.

While in prison he developed a knotty growth on the top of his foot that became so painful he had to order a larger shoe. He said he sought help several times, to no avail.

“You keep going back and they don’t believe your ailment,” McIntyre said. “They think everybody is trying to con.”

Lamonte McIntyre (standing) spent 23 years in the Kansas prison system for a crime he did not commit and struggled to get medical care for a foot problem. Now free, he recently graduated from barber school and plans to become an instructor. McIntyre gives a specialty cut to customer Rivero Echols of Kansas City, Kansas. Jill Toyoshiba

Hundreds of lawsuits

As one of the nation’s largest prison health care companies, Tennessee-based Corizon has faced criticism for years alleging substandard care, from the ACLU and other organizations. A recent New Yorker piece noted that the company has been the subject of more than a thousand lawsuits in the last five years.

But the magazine also said inmates are prolific when it comes to filing lawsuits, whether they have a case or not, and it’s hard to objectively determine the quality of care Corizon provides. No large-scale studies have been done on it.

In most of the dozens of states where Corizon does business — including Missouri — there are no independent experts regularly checking the day-to-day care inmates get and penalizing the company if it doesn’t measure up.

But in Kansas, there is: The team of clinicians from KU Med reviews a sample of medical charts from a couple prisons every month and sends a report to the Kansas Department of Corrections.

By filing open records requests and paying the corrections department about $800 to fulfill them, The Star was able to get 42 months worth of documents outlining Corizon’s performance at nine Kansas prisons.

Among The Star’s findings: At Hutchinson Correctional Facility, where Davis slowly deteriorated before becoming brain dead, 251 of the 852 charts filed during those 42 months didn’t meet the standards set out in the state’s contract with Corizon.

Hutchinson sick call.JPG
A sample of the monthly sick call performance that shows how many charts the corrections department’s experts looked at, and how many complied with Corizon’s contract requirements. Kansas Department of Corrections

At about 29.5 percent, that rate of non-compliance tracked closely with Corizon’s rate throughout the Kansas prison system: 1,062 out of 3,695 charts, or about 28.7 percent, were found deficient system-wide.

Jeanny Sharp, a spokeswoman for the Kansas Department of Corrections, said the department levies fines whenever Corizon falls below 90 percent compliance in a month.

“Kansas is ahead of many states because of its oversight of its correction systems medical provider, so it is able to identify areas of opportunity for improvement in its services,” Sharp said. “The cases are reviewed in real time by objective physicians, so any possible trends are identified and remedied.”

Sharp wouldn’t say whether the current penalties are sufficient, though her boss, new Kansas Gov. Laura Kelly, has said that in general the state needs to do a better job holding contractors accountable for poor performance.

Kansas’ contract with Corizon expires at the beginning of July, but the state has options to extend it through 2023. Kelly’s administration audited Corizon’s 2018 performance after she came into office and found it lacking in several areas. Keith Bradshaw, the head of the corrections department’s finance division, told lawmakers in February that the administration was tentatively planning to extend the contract one more year, and then re-bid it if Corizon’s performance doesn’t improve.

Hutcherson said some of Corizon’s non-compliance was the result of transcription errors in inmates’ electronic health records, or delays in updating those records. She also said some was due to inmates refusing care, “which is a relatively frequent occurrence.”

She said Corizon was working on smoothing out administrative issues, and communication with the state corrections department “indicates a favorable trend on all these measures in the first two months of 2019.”

Sick call is key

The Kansas oversight documents provide a rare systemic look into the inner workings of a prison health care system.

Inmates in Kansas get physicals upon entry and periodic checkups after. Some are entered into special treatment programs for people with chronic conditions or behavioral health needs and are assessed more regularly.

But for most prisoners the daily sick call is the key gateway to medical care.

Inmates who have a health complaint put in a note with corrections officers to be seen by a Corizon nurse, and each trip to sick call costs them a $2 co-pay from their commissary funds. The nurses assess them and decide whether to refer them to a higher-level provider, like a doctor or physician assistant. Except in cases of emergency, those providers decide whether inmates’ medical condition is serious enough to require care outside the prison, like in local hospitals.

But the KU Med documents show breakdowns in that system.

An October 2015 review of charts from the El Dorado Correctional Facility showed one inmate, who was apparently diabetic, came to sick call for an insect bite on his arm. He was started on an antibiotic, but there was no followup. A week later he brought a sick call request with him when he came to pick up his insulin because his arm was showing signs of infection and he needed a note saying he was unable to work.

El Dorado MRSA.JPG
A monthly performance review from the Kansas Department of Corrections shows that an inmate’s drug-resistant infection, MRSA, went untreated. Kansas Department of Corrections

According to records, he went to sick call the next day for a swollen arm due to suspected MRSA, an antibiotic-resistant infection. But the nursing staff didn’t complete its assessment of the injury, for undisclosed reasons, and the inmate was instructed to return the next morning to have the arm examined again. Later that night he was “admitted to infirmary with complications from MRSA,” and remained there for six days.

Hutcherson said Corizon couldn’t speak to individual cases but pointed out that doctors outside of prisons miss early symptoms of disease too.

“As with all health care providers and their patients, individuals present with symptoms that evolve with time,” she said, “and a diagnosis may evolve accordingly from the first interaction.”

Under Corizon’s care, the number of inmates diagnosed with MRSA grew from 172 in 2014 to 265 in 2016 before leveling off, according to data from the corrections department. It was 242 in the fiscal year that ended in July 2018.

Sheila Officer, who lives in the Wichita area and has worked as a community college instructor in the Kansas prison system, said she saw inmates suffer from substandard medical care, including one man at Hutchinson who got an infection after a botched tooth extraction.

“How is it that a doctor can extract your tooth and leave a piece of it in your head and then you come in a few days later and your jaw looks like the Elephant Man and (they) tell him that it’s OK, that it will go down and they give him Ibuprofen?” Officer said.

She said that a week later the man had to be taken outside the prison for care.

In another case, an inmate was scheduled for a toenail removal but it didn’t happen until after the toe developed an infection. Another inmate complaining of testicular pain got referred to a doctor, but wasn’t seen for 27 days.

That sort of violation — referrals that took more than seven days — was the most common source of non-compliance. But the KU Med team also documented instances at nearly every prison where inmates were coming to sick call repeatedly for the same complaint without getting a referral, suggesting their medical issues weren’t getting resolved.

Hutcherson said that doesn’t mean they weren’t getting necessary care. Treatment needs change as symptoms progress, she said, “and best practices rarely dictate the most aggressive intervention be utilized first.”

“Patients who submit sick call requests are evaluated by trained and licensed nurses according to established medical guidelines and utilizing approved nursing guidelines that outline whether a referral to a provider is necessary,” she said.

But the state’s contract with Corizon specifically requires that inmates be referred to a higher level health care provider “after the second complaint regarding the same health concern is made through sick call without resolution.”

The Star’s review of corrections documents found a regular pattern of inmates going to sick call three or four times for the same problem. KU Med’s September 2016 review of medical charts from the Larned Mental Health Correctional Facility found one inmate there who had been seen five times for the same symptoms without a referral.

Balaban, who works for an ACLU unit dedicated to ensuring jails and prisons comply with the Constitution, said that’s the sort of non-compliance that, if repeated enough, could prove deadly.

Marques Davis became deathly ill at the Hutchinson Correctional Facility in 2017. Bo Rader The Wichita Eagle

“A system that is broken”

All names were redacted from the documents provided to The Star, so it’s impossible to tell if Davis was one of the inmates who made multiple sick call visits without getting to see a doctor.

His mother and his lawyer say that’s what happened, but Hutcherson said “it would be a mistake to draw a comparison to patients who submit multiple sick call requests with no provider referral to the care provided to Marques Davis.

“You have received a one-sided account of his care provided by a personal injury lawyer seeking a damage claim,” Hutcherson said. “Unfortunately, due to this litigation and patient privacy laws, we are unable to provide you with facts that would show a very different perspective.”

Davis died two years ago this month at age 27. According to his mom’s lawsuit, his condition slowly deteriorated over eight months despite numerous trips to sick call, as Corizon officials failed to properly address neurological symptoms like weakness in his legs, numbness and itching in his arms and eventually dizziness and vision loss.

The suit alleges that Davis didn’t get a brain MRI until April 11, after he had become almost completely incapacitated. The scan revealed a “widespread infection” that had caused the top part of his brain to push down into the bottom part. But according to the suit, Davis still wasn’t hospitalized until the next day, when he suffered a heart attack and was rushed to Hutchinson Regional Medical Center, where he was declared brain dead.

Balaban said sick call is the one time when inmates have some measure of control over their health care.

If sick call visits aren’t resulting in appropriate referrals to doctors and then relatively prompt visits with those doctors, then “that’s a system that is broken,” he said.

“It’s (sick call) an absolutely essential aspect of every correctional medical system,” Balaban said. “If that’s not working right you’re exposing every prisoner to unreasonable risks of harm.”

Other options

Corizon was formed in 2011 with the merger of Correctional Medical Services and Prison Health Services. As Corizon has grown, it has become a lightning rod for criticism, with thousands of lawsuits filed against the company nationwide, including more than 300 in Kansas and Missouri.

Medical errors and malpractice lawsuits are common outside prisons, as well. But judges have previously found that Corizon and its predecessors were unusually slow to deliver appropriate care.

In 2012, a federal appeals court upheld a jury verdict that found that Prison Health Services had a pattern or policy of failing to send inmates outside of prisons for care unless it was an emergency, without clearly defining for its employees what constituted an emergency.

In June 2018, a federal court ruled that Arizona prison officials should be held in contempt, because even after levying $1.4 million in fines against Corizon, the company had “repeatedly and consistently failed” to meet 103 performance measures that were put in place as part of a 2014 legal settlement.

Corizon has had the exclusive rights to provide health care to the approximately 10,000 people in Kansas state prisons since October 2013, under its contract.

It’s a common arrangement. Most states have privatized their prison health care system over the last few decades, though the New Yorker story noted that four states — Texas, Georgia, New Jersey and Connecticut — have tried contracting directly with their university medical centers to provide prison health care, rather than just oversight like in Kansas.

Those arrangements have had mixed results. The Texas system has become something of a model, but Connecticut jettisoned its system last year after an audit found inmates were getting substandard care.

Experts on prison health care interviewed by The Star were split over whether privatization is a better way to provide constitutionally mandated health care to prisoners than programs run by state workers or university medical centers.

Marc Stern, a physician and professor of health services at the University of Washington, said the quality of a prison health care system depends less on how it’s set up than on how well it’s funded and what type of oversight it has.

Prisoners are generally sicker than the population at large, and yet most states allocate less per capita for their health care — about $7,000 per inmate, per year in Kansas, for example, compared to about $10,500 per person, per year in the United States as a whole.

“This is not a problem with Corizon,” Stern said. “I’ve seen this with all of the companies at one time or another, but I’ve also seen it with prisons that are self-operated. As much as I don’t like privatization of prisons, that’s not the problem.”

But Michael Hallett, a professor of criminology at the University of North Florida, said for-profit prison health care programs have a strong incentive to deny or delay costly medical care.

Most of the time, companies like Corizon are paid a flat rate, and the less they spend on care, the more they pocket.

“I think what we’ve learned is that while on the one hand privatizing prisons is fraught with challenges, privatizing medical services in the context of a prison can be deadly,” Hallett said.

Both Hallett and Stern said the KU Med team’s monthly reviews give Kansas’ system more oversight than most states.

Balaban said similar scrutiny would be in other states’ best interests. If Corizon is routinely not meeting contract obligations in Kansas, where a third party is looking over its shoulder, he said states without that oversight are “creating substantial risks” to the health of prisoners.

When those prisoners get out, their unaddressed medical problems will probably be more costly to address.

That’s something Lamonte McIntyre worries about.

He’s building a career as a barber now, which means he spends most of the day standing. But he still hasn’t gotten his foot fixed because since he got out of prison he’s been uninsured. In the meantime, the knotty growth has only become more painful.

“I’m still dealing with that right now, man,” McIntyre said. “All those years, I never got it taken care of.”


Why did The Star do this story?

The Star’s health care reporter, Andy Marso, had written about Marques Davis, an inmate at Hutchinson Correctional Facility who slowly died from a fungal infection of his brain in 2017. Marso set out to determine whether Davis’ death was a fluke or a symptom of bigger problems within the prison health care system. Read more by clicking the arrow in the upper right.

What made this story possible?

Like many states, Kansas contracts with a private company, Corizon Health, to provide its prison health care. But unlike most states, Kansas also has a group of independent medical experts who review Corizon’s performance. The records of those reviews are public.

How did The Star get the information?

The Star filed an open records request with the state’s corrections department asking for years of Corizon performance reviews. The Star paid about $800 in processing fees. Marso combed through those monthly reports and compiled databases to identify patterns and total counts of instances when Corizon did not comply with performance and staffing measures spelled out in its contract. He also interviewed academic experts and former inmates and discussed the data with a Corizon spokeswoman throughout the process.

What took so long?

It took time to organize and analyze the data, which was based on records from July 2015 through February 2018. Then, before publication, The Star filed a second records request for more recent data, through the end of 2018. After that data was added, The Star contacted Corizon again and found out that its spokeswoman was no longer with the company. The Star extended its deadline to allow her replacement time to review her responses and provide new ones.

Related stories from Kansas City Star

Kansas City Star health reporter Andy Marso was part of a Pulitzer Prize-finalist team at The Star and previously won state and regional awards at the Topeka Capital-Journal and Kansas Health Institute News Service. He has written two books, including one about his near-fatal bout with meningitis.