Key Points: 

• Federal judge orders prison health care receivership

• Court finds persistent unconstitutional medical failures

• Receiver to overhaul Arizona prison system

After nearly a decade and a half of litigation, a federal judge has cleared the way for a court-ordered takeover of medical and mental health care at the Arizona Department of Corrections, Rehabilitation and Reentry, citing chronic, persistent constitutional violations.

The order will effectively take the health care system out of the state’s hands and place it under the care of a third party to address and alleviate insufficient staffing and health care delivery. 

“Plainly, only the imposition of the extraordinary can bring an end to this litigation and the reasons it was brought,” Judge Roslyn Silver wrote. “An end to unconstitutional preventable suicides. An end to unconstitutional preventable deaths. An end to unconstitutional failures to treat those in severe pain. The Motion for a Receiver will be granted.”

The class-action lawsuit came to the court in 2012, claiming inadequate medical, dental and mental health care, excessive isolation and insufficient conditions. 

Two years later, the parties reached a settlement agreement detailing 103 required health care and maximum custody improvements, approved by the court in 2015. 

Over the next six years, the court would field twelve motions to enforce the agreement. The department would be held in contempt twice and ordered to pay millions in fines for failure to comply with the stipulation. 

The court then rescinded the settlement agreement and initiated a fifteen-day bench trial in 2022 as well as a preliminary, then permanent, injunction identifying “persistent, unconstitutional” conduct within Arizona’s corrections facilities. 

“The Court identified the overarching failures in the delivery of healthcare as seriously insufficient staffing, inappropriate use of nurses beyond the scope of their licensure, failure to manage complex patients or employ a differential diagnosis approach, substantially inadequate mental health treatment, and a deficient electronic health care record system,” Silver wrote. “All these critical deficiencies were found to exist at every one of Defendants’ complexes, rendering the healthcare delivery systemically unconstitutional.” 

Since the final order in April 2023, the department has been under the keen watch of both court monitors and the plaintiffs, with accounts of insufficient medical and correctional staff persisting, and monitors ultimately finding patient care to be “wholly inadequate.” 

In one example, poor mental health treatment led to suicides. In another case, one inmate was found to have spent “fifteen minutes banging his head on a wall,” requiring emergency services. 

More broadly, observers found correctional facilities suffered from a variety of health care staffing issues. Nurses and nurse practitioners filled in for physicians, health care staff failed to diagnose serious and sometimes fatal diseases and conditions, and delays in patient care and the administration of medications remained frequent in facilities. 

Plaintiffs then asked the court to appoint a receiver, a court-ordered takeover of all health care systems housed in the Department of Corrections. 

The department asked the court for more patience, claiming a receivership would be premature less than two years after the injunction, two years into the contract with NaphCare and under the purview of current director Ryan Thornell. 

In mulling a receivership, the court must consider whether there is “grave and immediate” harm to the plaintiffs, whether all other remedies have been exhausted, a lack of leadership, repeated failure to implement change, wasted resources, and continued confrontation and delay in response to pushes for compliance. 

And, a judge must weigh whether a receiver is likely to provide a “relatively quick and efficient remedy.”

In weighing these factors, Silver relied on court monitor reports. She noted the department had initially been receptive to meeting with and accepting monitors’ recommendations. 

But communication lines began to break down, with the department rejecting or ignoring monitors’ recommendations and then claiming that their credibility and qualifications failed to comply with federal rules. 

“Either the Defendants are amnestic, or duplicitous, or both,” Silver wrote. “The Monitors’ reports are thorough, amply supported, and their reasoning is fully explained. Defendants’ contentions to the contrary border on bad faith.”

Silver starts with harm to the plaintiffs, noting that monitors found the department noncompliant with 131 of the 154 health care benchmarks. 

“(T)hese violations were not then, and are not now, abstract. They are brought to life—or death—by the individuals who experienced profound delays in receiving treatment or who failed to receive treatment at all,” Silver wrote. 

She then turns to mortality review, which she called “appalling in their illustration of the callous, inhumane indifference displayed on a regular basis.” And she claimed the department failed to identify or correct problems in care. 

One patient with a stroke and seizure disorder had his antiseizure medication discontinued. He died shortly after. 

Another patient’s recommended one week follow-up appointment for a heart condition wasn’t scheduled until more than two months later, at which point he had been dead for a month. 

A third had developed lung cancer. It was not diagnosed until it metastasized to his brain. The man needed a critical surgery “within minutes to hours,” and defendants took no action on the recommendation until two days later.

The list goes on, with reported failure to timely and properly examine, diagnose and refer people for care. 

“Defendants have shown a complete inability or unwillingness, or both, to recognize and correct their failures, exacerbating the grave and continuing threat of harm and actual harm suffered by inmates,” Silver wrote. 

Silver went on to find several instances of attempted compelled compliance, failure to respond or make improvements in line with monitors’ recommendations. She noted a lack of leadership and efforts to undermine the monitors.

As for the contention that the receiver would be a waste of money, Silver pointed out that, despite spending more than $1 billion per year and millions toward inmate health care, the department “have proven completely incapable of reaching constitutional compliance, resulting in more than a decade of litigation without appreciable effect on the provision of healthcare.”

She found it has been more than enough time, both since the dawn of litigation and the most recent permanent injunction in 2023, to get in line. 

The order requires the parties to each submit five receiver candidates within 60 days and to submit proposals on the scope of duties, powers and authorities of the receiver within 30 days. 

Corene Kendrick, deputy director of the American Civil Liberties Union National Prison Project, has been working on the case since the investigative phase in 2011. 

“Over the past 15 years, I would say we’re well into the hundreds of people who have passed away due to deficiencies in the medical care or the mental health care,” Kendrick said. 

John Fabricius, director of Praxis Initiative, reflected on his time incarcerated, before and while the class action is underway. He reflected on watching people die, lose limbs, go blind and commit suicide.

“All preventable,” Fabricus said. 

Fabricius called the order “historic.” Kendrick called it “significant” and “rare.” And in turning to the next steps, the hope is to push for streamlined hiring of vital health care personnel and to correct the system writ large. 

She notes the need, too, to push to cut a state law requiring the department to use private health care contractors, given the failure of about four companies over the past twelve years. 

The Arizona Department of Corrections did not respond to a request for comment. 

Gov. Katie Hobbs said she was “disappointed” in this decision, which fails to recognize the immense strides” of the department and that her office had “inherited a decade of neglect and mismanagement.”

“My administration has consistently made improvements, and we have worked in good faith to do so,” Hobbs said.