Death in Prison: How Health Care Fails the Men and Women Behind Bars

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Photo by Criminal Defense Network via Flickr.

Death rates are rising in America’s prisons even as prison populations slowly shrink, after a generation of explosive growth.

While the number of prisoners crept down, the national death toll behind bars rose 15 percent from 2006 to 2016, to 4,100, according to a Bureau of Justice Statistics report released in February.

While many of the dead may be elderly lifers, about a third of prisoners who die inside are under 55.

Medical issues accounted for 89 percent of the 677 prisoner deaths recorded in Washington state from 2001 to 2019. The coronavirus is expected to cause a spike in deaths, as prisons everywhere in the U.S. struggle to contain the virus.

A series of deaths at one Washington prison has prompted lawmakers to reconsider how the legislature monitors state prisons, despite Washington Department of Corrections (WDOC) suggestions that more oversight is unnecessary.

Washington state Sen. Jeannie Darneille

“It’s an afterthought for the department to engage legislators on deaths,” says State Sen. Jeannie Darneille (D-Tacoma).

At present, she added, accountability “really has not happened in any substantial way.”

While the WDOC contends it investigates every inmate death, those inquiries aren’t regularly shared outside the department. Darneille said she and other legislators receive little insight into why inmates die or what changes prison system administrators make to correct errors.

 ‘A Black Box’

When a prisoner dies, the results of internal death investigations are rarely shared outside the department. Lawmakers and bereaved family members are often left guessing.

Attorney Ed Budge, who for two decades has represented inmates and their families, described prison as a “black box.” Prison administrators control the flow of information and can hamstring lawyers’ efforts to investigate inmates’ claims. Bereaved family members are shut out.

“The overarching concern for most clients is to learn what happened,” the Seattle attorney said.

“People want answers. People want to know why their loved one died and whether something should have been done.”

Secrecy breeds “wives’ tales and urban legends” that find fertile ground among prisoners.

Inmates, in the view of ex-WDOC prisoner Johnny Cachero, are not treated as human beings. Medical care, he said, is almost impossible to get and rarely worth the $4 copay charged prisoners earning at most about $55 a month.

The results are often horrifying.

In an interview, Cachero recalled an inmate dying of tuberculosis in his cell. Another man, a diabetic whose foot had grown necrotic, went into surgery only to have the wrong foot partially amputated; surgeons wound up redoing the surgery on the correct leg.

“He came in walking,” Cachero said. “And he left with half a foot and no leg.”

Cachero’s experience with medical treatment in custody was, he said, typical. He has an inflammatory skin condition, plaque psoriasis, which he describes as “human mange.” It’s intermittent and treatable with a high-strength steroid ointment.

Though he had been prescribed the cream for much of his life, medical staff refused to issue him a tube. He said he was left scratching at “open and festering” wounds for weeks before the nurses relented. Many other prisoners, he said, had it worse.

“If you’re a stand-up, old-school, knock-around guy, you’re not afraid of anything,” he said. But “to really be sick in prison, it’s a scary thing. …

“For men like us, the biggest failure is to die in prison.”

At Their Mercy

When prisoners get sick, they basically have to ask prison staff for help and, if it doesn’t come, keep asking and hope for the best.

“You have zero power to get your own health care. Zero power to see doctors. Zero power to get your own medications,” said Budge, the Seattle attorney.

“And if the people who are running the [facility] decide that they’re not going to help you … you’re pretty much at their mercy.”

Prison system administrators alone decide how to ration that mercy. Unlike hospitals, which must be accredited to bill Medicare or Medicaid, correctional health systems need not seek outside accreditation because they only bill themselves.

While the state Department of Health licenses prison medical workers, efforts to prompt Health Department investigations of in-prison practices haven’t amounted to much, said Rachael Seevers, an attorney with Disability Rights Washington who advocates for people held in state institutions.


A Department of Corrections medical bag lies on the floor inside a cell at Stafford Creek Corrections Center in Aberdeen after an incarcerated man confined there died by suicide in 2014. The man, who had a documented history of mental illness, had been released from suicide watch days before. Photo courtesy Washington Department of Corrections

Although about half the calls Seevers receives from prisoners relate to medical care, her office rarely pursues those claims.

“Honestly, we no longer take very many medical cases because it ends badly every time,” Seevers said. “It’s been really hard to effect change.”

The prison system faces about 4,100 official complaints related to healthcare from prisoners each year, hundreds of which lead to administrative claims and lawsuits. But Seevers and others said plenty of valid complaints go unheard.

The Department of Corrections does at times conduct lengthy investigations after prisoners die.

Reviews provided to Crosscut following a public records request included hundreds of pages of witness statements, investigators’ reports and photographs. Suicides, homicides and accidental deaths receive the most scrutiny.

However, the scope of investigation into medical deaths remains unclear. Addressing the Legislature earlier this year, Corrections Department Chief Medical Officer Dr. Sara Kariko assured senators that the department does “review every single death that occurs, whether that’s an unexpected death or an expected death.”

When asked, the department declined to share the results of its recently created medical and mortality review efforts, describing the programs as too new. A public disclosure request for records related to those investigations remains outstanding.

In-house audits routinely give Corrections Department prisons top marks. The medical services division at the Monroe Correctional Complex received a clean bill of health from department auditors in 2017 at the same time prisoners there were dying under circumstances now under investigation by state health authorities.

Speaking at the Legislature in January, Mary Jo Currey, then the assistant secretary leading the Corrections Department’s health services division, walked a Senate committee led by Sen. Darneille through new department efforts to address failures of care and inmate deaths.

Darneille had introduced legislation that would for the first time require the department to regularly report the circumstances of inmate deaths to the Legislature and create an independent body to review deaths and near fatal incidents involving incarcerated people.

State law sets similar frameworks for bureaucracies managing the state psychiatric hospitals and child welfare system. Although it houses far more people than any other state agency, no similar oversight exists for the prison system.

Arguing for her bill in a lightly attended hearing that drew a dozen or so justice reform activists and a smattering of government workers, Darneille suggested that the state has a responsibility “to learn from those deaths and to honor the people who have died, in the sense that we don’t just go on without recognizing that our system can and should change.”

Pledge to Continue

Darneille’s oversight bill did not proceed to a floor vote during the winter’s short legislative session. She said she is “quite certain” she and her colleagues will be coming back with legislation on the matter when the Legislature reconvenes.

Budge, the Seattle attorney, noted that other states, including Texas, have independent commissions that review deaths in prisons and jails. They can be effective, he said, in ensuring inmates survive their sentences and that families of those who don’t know why their loved ones died.

“I’m not here to say that people who are in prison deserve a higher level of care than people on the outside,” Budge said. “All I’m saying is that when a society makes a choice to lock somebody up, then you’re making a choice to provide for their basic needs.

“And that includes basic, competent medical care.”

Cachero, the former inmate, said he has little faith that the Department of Corrections will protect prisoners or begin to reform itself. If change comes, he said, it will arrive “bill after bill,” as the Legislature fixes what he describes as a cruel, white supremacist penal system.

Lev Pulkkinen

Levi Pulkkinnen

“I know that all of my brothers are suffering inside, and they are scared,” he said. “I’m not saying, ‘Oh, you poor criminals.’ Not that at all. But we’re people. We’re fathers and brothers, uncles and sons and all the rest of that.

“And if the system is what it’s supposed to be, then everybody gets a chance.”

This is a condensed and slightly edited version of a story published this month in Crosscut. The full version can be accessed here. Crosscut staffer Levi Pulkkinnen is a 2020 John Jay Justice Reporting Fellow. The first two parts of his series, as well as podcasts, are available here.

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