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Erick Thomas lay in his bunk moaning in pain, too weak to make the night's final count at Stillwater prison.
Alerted by guards, two nurses gave him a 10-minute exam and concluded he was merely suffering from a muscle spasm near his neck. One wrote "Faker!" in her shift report before going home for the night.
By midnight, Thomas was writhing on the floor of his cell. The next morning, he was found paralyzed, drenched in urine and near death. After an ambulance rushed him to Regions Hospital in St. Paul, doctors discovered a blood clot pressing on nerves atop his spine. He underwent emergency surgery and a week later, at age 30, had to learn to walk all over again.
"I felt like they were trying to kill me," Thomas said. "No human being should be treated like that."
Thomas' ordeal last March is just one in a series of cases, outlined in court records and internal documents, in which Minnesota prison inmates in distress have been denied medical care -- with dangerous and sometimes deadly results.
Since 2000, at least nine prisoners have died after medical care was denied or delayed by corrections staff, a Star Tribune investigation has found, and another 21 have suffered serious or critical injury.
The state Department of Corrections and its staff have been held liable for nearly $1.8 million in wrongful death and negligence cases, court papers show. In addition, at least six nurses have been disciplined for countermanding doctors' orders, giving false statements or denying emergency care, and one surrendered her license to the state Board of Nursing after its investigators found she denied care to inmates in eight separate cases.
Just last month, a jury in Washington County awarded an inmate more than $1 million after finding negligence on the part of Dr. Stephen Craane, a contract physician at the prison in Oak Park Heights. The inmate, Stanley Riley, was suffering from what turned out to be cancer and had written a series of pleading notes to prison officials. One read: "I assure you that I am not a malingerer. I only want to be healthy again."
Jane Eskelson, who recently retired after more than 20 years as a corrections officer and witnessed the death of one inmate, said the medical staff was often overworked.
"Stuff got dropped, they were apathetic and angry," Eskelson said. "You're just plain worn out at the end."
Corrections Commissioner Tom Roy and his two top medical administrators declined to be interviewed for this story. The agency issued a statement saying prisoners receive medical services that meet the "community standard" of care required by law, and that its managed-care philosophy is a responsible approach widely used in American medicine.
"Quality assurance issues are endemic to the health care industry as a whole," the statement said. "Our health care providers, like others, are constantly working to improve the quality of care we provide that is responsible to taxpayers."
Offenders in state prisons and county jails are the only Americans with a constitutional right to health care -- the result of a 1976 U.S. Supreme Court ruling which found them to be "vulnerable" adults. Because they are completely dependent on their guardians, the court said they are entitled to medical care comparable to that received by the general public in their community.
To provide that care in Minnesota prisons, while controlling the system's ever-rising medical costs, the state Department of Corrections has contracted since 1998 with Corizon Inc., a private, for-profit corporation based in Tennessee. The firm, formerly known as Correctional Medical Services, is the nation's biggest prison health care company, holding contracts with 31 state and local prison systems.
Although state officials are ultimately responsible for inmate care, Corizon's contract grants it broad authority over day-to-day prison medical operations. Corizon hires prison doctors; establishes the list of approved prescription drugs; determines doctors' daily caseloads, and oversees the use of such outside services as ambulances and medical specialists. Prison nurses are state employees, but they work in a command structure with Corizon doctors and physician assistants at the top.
Working for a fixed annual fee -- $28 million last year -- Corizon has an incentive to maintain strict cost control.
A review of Corizon's state contract shows how lean the operation can be. Doctors employed by Corizon leave their prison clinics after 4 p.m. and do not work weekends. Prison nurses generally finish their last shifts by 11 p.m. Except for the prisons at Oak Park Heights and Faribault, which hold inmates with complicated medical conditions, Minnesota prisons have no overnight medical staff, and clinics are closed.
While on duty, the physicians face daunting caseloads. At the prison in Stillwater, for example, a lone doctor and his small nursing team are responsible for the care of 1,600 offenders -- seeing at least 40 prisoners per day while also keeping charts and writing prescriptions, according to two longtime employees.
Corizon officials declined to respond to questions submitted by the Star Tribune. Instead, a company representative wrote: "Corizon's current coverage meets the need to provide the community standard of care. Corizon is committed to delivering services in a safe, efficient, cost-effective manner. Our employees work hard day in and day out to deliver quality health care to these patients and we are proud of the job they do."
Medical records and court documents show that Corizon's employees sometimes chafe at the company's guidelines. In a 2005 court deposition, Craane said Corizon officials overruled his decision to refer an ailing prisoner to a gastroenterologist. The prisoner, who had stomach cancer, later died from complications resulting in part from the delay of care, according to two corrections sources with direct knowledge of his case. Craane later learned that he could override his superiors, and did, but by then critical weeks had passed.
In another case, an inmate named Ezzy Pratt died without proper pain management for cancer, according to two medical staff familiar with the case. A Corizon physician refused to approve an ambulance trip to a hospital, they said, even though nurses told their superiors they were not equipped to handle the case.
Midnight phone call
Overnight medical care has become a particular sore point with prison guards and other staff. Between dusk and dawn, one on-call Corizon doctor covers the entire state, dispensing advice by telephone.
One night in June 2010, a 27-year-old Rush City inmate named Xavius Scullark-Johnson suffered a series of seizures into the evening. The nurse who examined him did not contact the on-call physician and went home. Late that night, with Scullark-Johnson still ailing, a prison guard contacted the on-call service. The physician, relying on the guard's descriptions, finally called for an ambulance. But a nurse arriving on the morning shift overruled the doctor's order and canceled the ambulance run, citing system protocols. The emergency crew was called back to the prison within hours, but Johnson had suffered another seizure and died.
A corrections spokesman said in a statement that phone access to a physician at night is "not only adequate for the needs of the DOC health system; this is a common practice for clinics that meet the needs of many Minnesotans who live in rural communities."
Court testimony shows that at least one of those on-call physicians thought his job was merely to renew prescriptions, not recommend treatment. Dr. Khin Aye said in a sworn deposition: "Actually, I was not there to make a diagnosis." Aye, who no longer works for Corizon, also said the on-call physicians did not keep medical records when called about inmates.
Minnesota isn't the only state where doctors and advocates have criticized Corizon.
In a federal lawsuit in Idaho last year, a physician appointed by the judge to review Corizon's performance issued a scathing report, concluding that terminally ill patients were not fed or cleaned properly.
But the court's expert, Dr. Marc Stern, also observed that public officials are ultimately responsible for inmate care.
"[Corizon] wants to provide care in the least expensive ways possible," Stern said in an interview. "That company is not going to volunteer to give things it can't afford just to help out. So, first and foremost, this issue falls on the shoulders of the public officials. In Minnesota, I would ask, 'Do they hold the vendor's feet to the fire?'"
A Corizon spokesman said an independent professional review of the Idaho case found its performance to be in "substantial compliance" with industry standards.
Public records and internal e-mails also describe cases in which medical staff refused to respond to inmates in distress. In August, for example, the Minnesota Board of Nursing found that a corrections nurse, Thaloyce Minkens-Strader, denied or delayed care to inmates eight times between 2007 and 2011. In one emergency, the board found, she refused to respond to a prisoner because she was on her dinner break. On another occasion, the board said, she refused to care for a patient because she was near the end of her shift and feared having to work late. She was suspended for eight days in total, then eventually surrendered her nursing license and retired.
A second nurse, Betty Judd, was disciplined twice for withholding care from inmates, including one with chest pain and trouble breathing. "It is very disturbing that in such a short period of time you were involved in another incident [of] poor decision-making that involved failure to treat an offender," her discipline letter said.
The deaths of two prisoners in 2000 were the first hints of trouble with Minnesota's private-contracting arrangement.
In late March of that year, a Stillwater inmate named Gregory Jennings went to the prison clinic complaining of blurred vision and symptoms of diabetes, medical records show. Clinic staff scheduled him to see an optometrist. When he returned seven days later for that visit, he was suffering from dizziness, a dry throat and headaches. The optometrist noted that he should be checked for diabetes, but no one made an appointment with a doctor or ran a diabetes check. By the next day Jennings was in a wheelchair, eyes rolled upward and his speech slurred.
"States has pain everywhere," a nurse wrote in his chart. Prison officials called an ambulance, but by the time Jennings arrived at a local hospital, he had lapsed into a coma and was diagnosed with Type 2 diabetes. Two days later, Jennings was dead at age 30. The department settled out of court for $150,000.
Eight months later, at the state's juvenile facility in Red Wing, 17-year-old Michael Howard complained for four days of excruciating pain in his head and neck, court records show. A nurse gave Howard a few ibuprofen tablets, told him to use an ice pack and noted that he could see a doctor. Records show she didn't check his vitals or call her superiors. The next night, alone and unmonitored, the teenager died of a brain hemorrhage.
Dr. Lawrence Lockman, a pediatric neuroscientist at the University of Minnesota, reviewed the case at the time and concluded that the direct cause of Howard's death "was the failure to follow the most basic standard of care ... a doctor's treatment which likely would have saved his life."
'Tell it to medical'
Jane Eskelson is haunted to this day by the death of an inmate at the Shakopee women's prison in 2003. Brenda Jones arrived to begin a 33-month sentence, her breathing so labored that she could barely move. Jones told prison officials she was ill, but they replied, "Tell it to medical," prison records show. No one called a doctor.
That afternoon Eskelson arrived at work and saw Jones nude and groaning in her cell. She and a colleague began to trade e-mails.
"New one sounds like a caged animal," she wrote. "Even medical refusing to see her."
Her colleague responded: "Don't they have to see new intakes?"
Eskelson: "This new one on bed naked -- no one cares."
A half-hour later, she found Jones dead from a pulmonary embolism.
"The breakdown was medical," Eskelson said recently. "She died alone. I feel like a coward. I should have raised holy hell."
Paul McEnroe • 612-673-1745