“Give me answers!” Melissa Welch shouts, arching her back and aiming her voice toward the flat facade of the Pima County Adult Detention Complex. 

Two months earlier, inside that jail, guards repeatedly shocked her little brother, Wade Welch, with a taser. Minutes later, he died.

“Give me answers! Give me answers!” she screams again. Her voice gone hoarse. Her eyes wide. Unblinking.

Standing outside the jail on Oct. 16, Melissa wants to know who will be held responsible for Wade’s death and what the Pima County Sheriff’s Department is doing about it. She wants to know why at least 28 people have died in the jail since 2020 and what will change in time to stop another death. 

She arches back again and screams.

With nine deaths this year, four in just the last two months family members and friends of those who have died, as well as concerned community members, are demanding justice.

In 2021, the year Sheriff Chris Nanos took office for the second time, 10 people died in the jail. That’s more than three times the national rate as of 2019, the last year for which national statistics from the Bureau of Justice Statistics are available. Nanos also served as sheriff when he was appointed to the role from 2015 until 2016.

Editor’s Note: Since publication two more people have died inside the Pima County jail as of Jan. 10. Sheriff Chris Nanos wrote a Dec. 5 memo to the Pima County Board of Supervisors saying that conditions at the jail are in a “full-blown crisis” and the inmate population has reached a “life-threatening level.” He sent a memo to the supervisors on Dec. 27 stating that 49 people have died inside the Pima jail since 2017.

Melissa Welch marches down Fourth Avenue holding a sign demanding justice for her brother Wade Welch during an Aug. 27, 2022 protest in downtown Tucson. Wade died after repeatedly being shocked by guards at the Pima County jail. His death has been ruled a homicide by the medical examiner. Credit: Michael McKisson

Arizona Luminaria compiled accounts from No Jail Deaths, a local advocacy organization, lawsuits filed by family members, and past news reports to calculate this estimated total number of deaths since 2020. Officials with the Pima County Sheriff’s Department did not dispute the number when provided the data.

The last minutes of Wade’s 37 years of life are captured in edited body-camera video footage released to the public in late August by the Pima Regional Critical Incident Team. The standoff begins at about 7:30 p.m. as guards are attempting to transfer Wade into another housing unit. He resists. The following is a summary of the video, highlighting moments of interaction between Wade and the guards. 

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Wade is clearly distraught, saying something, but the first minutes of the video has no audio. Guards try restraining Wade as they corral him into the jail cell. 

A guard points the taser at him and pulls the trigger.

“Why are you guys doing this to me?” Wade shouts.

As the altercation moves from the cell into the hallway, the frames show a team of Pima County jail guards swarming Wade, some piling on top of him, while at least one guard repeatedly tases him. 

When aimed at a person’s body, a police-issued taser can emit more than 1,000 volts of electricity. 

Guards pin Wade down, ignoring his pleas.

Wade calls out: “I need to go to the hospital. I can’t breathe. Help.” 

A guard orders him to get on his stomach. A guard tases him. He arches back, writhing and screaming. His pants are pulled down as a guard again presses the taser into him and shocks him. Wade’s words are hard to hear as guards order him to stay on his stomach and stop moving his legs.

Still on the ground with guards on top of him, Wade says: “Help me, help me, please. I have a heart condition.”

Guards order him to put his hands behind his back. “You’re killing me,” Wade says. “You’re killing me.” 

Several guards wait by the stairs, watching.

A guard says, “I got cuffs.” One guard standing over the team still on the floor coaches his colleagues to start talking: “Communicate, guys.” 

Some guards busy themselves searching for the long conductive taser wires, collecting darts from the concrete-walled jail cell. Some are keeping Wade pinned to the ground as he gasps, and gasps for air.

Guards place a white spit hood on Wade’s head.

As they lift Wade off the ground, one guard says, “Something’s wrong with him.” Other guards are still concerned with taser darts: “Anymore? There’s one on his leg. Did you get the one on his leg?” 

Wade’s screams fade to moans. 

Wade’s hands are cuffed behind his back. Guards move him downstairs and begin pushing him into a restraint chair. 

A guard presses the taser against Wade’s right upper leg and shocks him again, and then again. Wade screams and guards can be heard saying, “Relax. Stop resisting.” Within seconds after that wave of electric voltage, Wade seems to lose consciousness, and guards call for medics. 

A guard orders others to keep the white spit hood over Wade’s face. He isn’t moving when a quieter voice says, “Breathe.” Several guards are saying expletives, when the unknown quiet voice is heard again: “Stay awake.”

Wade is limp when guards release him from the restraint. They roll his body over, his wrists still handcuffed and underneath him on the hard floor

Finally, they pull the hood off his face, blurred in the edited body-camera video footage.

One guard says, “Do you want handcuffs off? There’s a pulse.” Another guard says, “He’s faking his ass off.”

At least a dozen guards stand nearby watching as Wade dies.

The video is a window into whether guards working for the Pima County Sheriff’s Department — the Arizona law-enforcement agency overseeing a skyrocketing number of jail deaths —  violated their own regulations.

Those policies include a “duty to intervene” to “prevent the use of excessive force.” The department’s safety regulations for tasers also outline how to protect people who are already in restraints: A taser should not normally be used, for example, on people who “are handcuffed, unless they are physically violent and otherwise uncontrollable.”

Deaths in the Pima County jail 2022

Pedro Xavier Martinez Palacios Jr., 24, Jan 14, overdose

Sylvestre Inzunza, 18, Feb 2, overdose

Alejandro Romo, 42, May 13, unclear cause of death, possible overdose

Jonathan Leary, 33, July 5, apparent suicide

Wade Welch, 37, Aug 16, homicide

Terrance Salazar, 30, Oct 3, unclear cause of death, possible overdose

Benjamin White, 41, Oct 6, unclear cause of death, possible overdose

Hugh Gillespie Burford, 50, Nov 15, apparent suicide

Amin Shaheed Muhammad Ali, 40, apparent suicide

In the weeks and months before his death, Wade had been hearing voices and feeling increasingly paranoid. “He needed help,” Melissa says, remembering her little brother Wade. 

“Instead, they killed him,” she says. 

Wade was pronounced dead on Aug. 16, at 8:13 p.m., according to the autopsy report, minutes after he was last shocked by the guards and 37 minutes after the beginning of the video released to the public. 

The Pima County Office of the Medical Examiner has ruled Wade’s death a homicide, according to an Aug. 30 autopsy report shared by Wade’s family, and subsequently independently obtained by Arizona Luminaria through a public records request. 

As of Nov. 22, no charges have been brought against any of the officers involved, according to the Pima County Attorney’s Office. The case is still being investigated by the Pima Regional Critical Incident Team, PRCIT, according to a statement Pima County Attorney Laura Conover shared on Oct. 25. The multi-agency investigative team released a statement on Aug. 17 that while they were “activated to conduct the investigation,” the Tucson Police Department will be the “lead investigating agency.”

The overwhelming majority of jails in the United States don’t have any deaths in a given year, or, at most, one or two. With an average annual death rate of nearly 10 a year, critics say there is something seriously wrong at the Pima County jail.

Twenty-eight deaths since 2020 may also be an undercount. Families and advocates told Arizona Luminaria that there have been deaths at the jail that have gone unreported.

Nationally, according to a Sept. 20, 2022 U.S. Senate hearing and a Government Accountability Office report, nearly 1,000 deaths in state and local prisons and jails were not reported to the Department of Justice, as required by law.  

Many of the people who live, or die, in the Pima County jail are not guilty. Most of the people detained in jails are pre-trial detainees, meaning that they have not been convicted of any crimes, and remain innocent. However, some people convicted to sentences of less than a year do their time in jail instead of prison. 

While the majority of people held in the Pima County Detention Center, located on the west side of Tucson on West Silverlake Road, spend a few days or a few weeks inside, there are inmates who can remain detained for a year or more as they await the duration of their trials. People who can afford it pay bonds and are released to await their trials while outside. Those who can’t afford to pay, stay in jail. 

Jails should be safe for people detained before or during their trials, before any of them have a criminal conviction, said Andrea Armstrong, a professor at Loyola University in New Orleans and a national expert on jail and prison conditions.

“Death seems like a particularly egregious punishment when there hasn’t been a ruling in someone’s case,” she said.

Protestors regroup at a streetcar stop on Fourth Avenue in Tucson Ariz. on Aug. 27, 2022. The protest was organized by the group No Jail Deaths. Credit: Michael McKisson

‘Pima County’s death trap’

After months of increasingly loud criticism of the Pima County Sheriff’s Department, which runs the jail, some critics are now also calling for the jail to be shut down. 

Mourners and critics have marched, held vigils — including the Oct. 16 protest decrying “Pima County’s Death Trap,” as a flier for the event put it — formed groups such as No Jail Deaths, and demanded investigations and transparency. Now they are calling for the resignation of Sheriff Nanos.

The organization’s demands include: “Fire all officers responsible” and “Close the Pima County Jail.”

Joining the chorus of critics are two former employees of the jail who spoke to Arizona Luminaria asking to remain anonymous, as they fear retaliation.  Their identities and their work experience were reviewed through former work identification cards and pay stubs.

Collectively, the former employees have more than five years of experience working in the jail, covering a period over the last decade and including when Nanos was sheriff. For clarity and to protect their identities, Arizona Luminaria is referring to the whistleblowers who worked at the jail as Former Employee 1 and Former Employee 2.

Arizona Luminaria also spoke with four people who have been detained inside the jail. 

One of them, Paul Gutierrez, described the conditions when he was inside the jail in 2017. “It’s inhumane in there. You have no idea, man,” he said.

The deaths and the first-hand testimonies of people formerly incarcerated, as well as from the two former employees, paint a grim picture of what’s happening behind the jail walls as two more people died in November.

Former Employee 1 called the jail:  “An unconstitutional hole.” Former Employee 2 said they saw: A “very dark” place.

Together, with former inmates, they detailed instances of extreme medical neglect, guards severely beating inmates, systemic failures of oversight, a culture of brutality and anti-inmate animus among the guards, as well as cover-ups of potentially wrongful deaths.

“Where does the buck stop?” Former Employee 1 asks. “It ultimately stops at the county, at the sheriff, and nothing is being done to make things better.”

When asked in an October interview with Arizona Luminaria if the conditions inside the jail were clean and safe, Nanos put it simply: “It’s horrendous.” While referring to leaky pipes, graffiti on the walls, and the general state of sanitation, he said there are also problems with drugs and understaffing.

Nanos said that his response to COVID-19 was unpopular among some of his supporters but necessary to save lives. He continued a quarantine process that was begun before he took office, and required staff to be vaccinated against the virus. He also expressed sympathy for the grieving families and claimed ultimate responsibility for the conditions in the jail.

Nanos did not respond to allegations made by the former employees. Nor, citing the ongoing investigation, did he respond to questions regarding Wade Welch’s death.

Questions unanswered

The Pima Regional Critical Incident Team, a multi-agency team of investigators from law enforcement agencies throughout Pima County, is tasked with looking into serious use-of-force incidents, such as when someone dies or is injured during contact with law enforcement. 

Nanos explained the importance of the regional investigative team that was created after the national civil unrest in 2020, following Minneapolis police officers murdering George Floyd. 

“The PRCIT is something I created with all the regional chiefs,” Nanos told Arizona Luminaria. “I trust that my people, my team, would do an investigation on themselves 100%. But that’s not really the best way to do it, right?” 

At a news conference shortly after the creation of PRCIT, Nanos said, “Transparency is really just that. It talks about our openness and our willingness to be honest with not just those that work within our organizations, but those we serve, particularly our community.”

The team is currently investigating Wade’s death.

“If PRCIT brings forward evidence of criminal activity, the Pima County Attorney will review what happened and make decisions about whether the evidence available shows beyond a reasonable doubt that an individual or individuals should be criminally charged,” Pima County Attorney Laura Conover said. “Our office remains involved with PRCIT as the investigation continues and I am being kept apprised as the case develops.” 

Conover did not respond to questions about the medical examiner ruling Wade’s death a homicide. 

Protestors march past a Tucson Police Department vehicle in downtown Tucson on Aug. 27, 2022. The march was organized by the group No Jail Deaths. Credit: Michael McKisson

There were at least seven guards shown in the body-camera video footage actively restraining Wade. In addition to the seven “focused correction officers” there were thirteen other “correction officers,” three nurses and 31 inmates who were “eyewitnesses,” according to an Aug. 31 Pima County Sheriff’s Department incident report obtained by Arizona Luminaria via a public records request.

Former Employee 1 pointed to numerous instances in the video of Wade’s death when they think guards’ actions escalated the situation, including: not closing the door when he was backed into an empty cell, or tasing him when he was already partially restrained. 

The Aug. 31 incident report also states that Wade was “in handcuffs” and “that he continued to resist and was arching his back” as guards tased him again. 

Another incident report, also from the Pima County Sheriff’s Department and dated Aug. 31, states that Wade was at least partially restrained: “Once the inmate was secure,” the guard “returned to his desk…” the report reads.

Jail policies outline safety regulations for when Pima County jail officers or guards are banned from using tasers on people in their care.

“TASERs and OC [a form of pepper spray] shall only be authorized for use on restrained inmates when a CO [correctional officer, or guard] is being injured, assaulted, is in reasonable fear for their safety or the safety of others from a restrained inmate,” according to jail policies lawyer Amy Hernández shared with Arizona Luminaria.

Hernández, who is representing the Welch family in their lawsuit against the sheriff’s department, said she obtained the policies through a public records request. She said officials with the county records department told her the policies are current as of at least May 31, 2021.

The sheriff’s department did not respond to Arizona Luminaria’s emailed questions about their taser policies. During an in-person interview in October with Nanos and Arizona Luminaria, the sheriff said he would not comment on Wade’s death, citing the ongoing investigation. Officials did provide jail policies that they said are current. However, those policies did not include the detailed safety regulations outlining when Pima County jail guards are allowed to use a taser on a person in custody.

Arizona Luminaria reviewed the Pima County Sheriff’s Department online policies from the past year. The regulations dated June of 2022 outline steps to guide guards in protecting the lives of people inside the jail. 

Tasers “shall not be used” when a person “is not actively physically resisting” and when they pose “no immediate threat of violence to self or others.”

Any guard, referred to as “member” in jail policies, participating or watching has a duty to intervene and “report when they reasonably believe another member is using, or about to use, force that is in violation of these policies. Members shall intercede to prevent the use of excessive force, if such intercession can be done safely and reasonably.”

When Melissa, Wade’s sister, saw the body-camera video footage she recognized her brother needing help. She couldn’t bring herself to watch its entirety. He had been hearing voices, she says in an interview with Arizona Luminaria, and thought that people were out to get him. 

“He wasn’t a threat to anyone,” she says.

Melissa isn’t the only one who is looking for answers.

“I haven’t heard from anyone.”

Rosanne Inzunza’s teenage son Sylvestre Inzunza, whom the family fondly called “Fatty,” died of an overdose in the Pima County jail in February 2021. He was 18. The day of Sylvestre’s death, two police detectives told Rosanne her son had died. She says in an Oct. 19 interview with Arizona Luminaria that they also told her at the time they were opening an investigation into his death.

Protestors march north on Fourth Avenue in Tucson, Ariz. on Aug. 27, 2022. The march was organized by No Jail Deaths. Credit: Michael McKisson

Officials with the sheriff’s department responded on Nov. 3 to questions about the investigation into Inzunza’s death, saying: “The case is closed, a panel was conducted.” 

A sheriff’s department spokesperson, Tyler Legg, wrote that: “For any further details, you will need to submit a formal FOIA request.” Arizona Luminaria filed a public records request for additional information about the panel’s conclusions on Nov. 4, and as of Nov. 21 still has no response from the sheriff’s department.

“The only communication I had was when they came to tell me that he had passed on and then I haven’t heard from anyone,” Rosanne says.

“I guess you would also assume that we wouldn’t have to reach out, that they would reach out to offer condolences,” says Shawn Lopez, a close friend of both Rosanne and Fatty. “They haven’t.” 

The family says that as of Nov. 6, they haven’t heard anything from Nanos.

Nanos, when asked in a late October interview about contacting families, told Arizona Luminaria, “I have an obligation to not just those families who lost loved ones, but also to this agency and this county.” He added that, “they always have my condolences. ” 

“I just believe it’s inappropriate for the sheriff or any elected official to reach out to a family who’s lost a loved one to say he’s sorry,” he said.

Rosanne, however, isn’t just looking for a kind word. She wants to know what happened to her son. In the year before Sylvestre died, at least three other people in the jail — Justin Crook, Jacob Miranda, and Pedro Xavier Martinez-Palacios — died of drug overdoses. According to a lawsuit filed in federal court against the sheriff’s department in early November on behalf of Sylvestre’s family, three additional inmates, ​​Weldon Ellis, Cruz Patino, and William Omegar Jr., all died in the jail under circumstances that suggest drug overdoses. As of Nov. 21, the federal docket shows there have been no additional filings. 

Within one day of being booked into jail a guard found Sylvestre lying in his cell, pale, sweating profusely, and unresponsive, according to the family’s lawsuit. Both medical personnel and guards responded and administered nine doses of Narcan, a drug that rapidly halts the effects of overdose. Sylvestre was transported to St. Mary’s Hospital for further treatment. Within 24 hours, he was back in jail, detained in Pod 2-Delta, the portion of the jail designated for inmates in detox protocol. He was put in a cell alone. Three days later, on Feb. 2, he overdosed again. Again, it was fentanyl. The second time, he died.

“How did he get those drugs?” Rosanne asks. She lets the question linger, and then offers a possible answer, “It was the COs,” short for correctional officers, or guards.

The lawsuit filed over Sylvestre’s death, argues that the sheriff’s department has “struggled to maintain constitutionally minimal staffing levels” in the jail, alleging that they were understaffed by as many as 105 guards. 

“We cannot effectively run the facility at the low staffing levels,” Correction Sergeant Thomas Frazier said in a Dec. 2021 KOLD 13 News story.

The family’s attorney says that as of Nov. 21, they have received no information about the investigation. Rosanne said she has tried multiple times to reach out to the sheriff’s office and the Tucson Police Department, but, nine months later, has received neither answer nor update. 

Nanos, in response to questions in late October about guards taking drugs into the jail, told Arizona Luminaria he was looking into the issue. He also said that while he has to “be cautious of the civil liberties and rights of the inmates, shouldn’t I be just as cautious of the civil liberty rights of my employees?”

Nanos said he worries that searching guards for contraband, such as for weapons or drugs, could be interpreted as infringing on guards’ civil rights.

Balancing these responsibilities is possible. It’s happening at other jails in the Southwest and across the U.S.

“Courts have upheld the broad authority of jail and prison administrators to search any person (visitor, staff, contractor, or arrested or sentenced persons) entering the facility as consistent with the administrator’s obligation to maintain a safe and secure environment,” said Armstrong, the national prison and jail expert. 

She explained that, more broadly, employers can place conditions for employment, including non-invasive searches, on employees, as long as they are broadly applied and don’t target a particular group of people.

Armstrong pointed out that Texas has a code that requires prisons and jails to search both inmates and employees. “For the protection of jail personnel and inmates,” the code states: “Any items brought into the security perimeter of the facility by anyone should be searched for contraband” (stress added). “There shall be regular and irregular searches of the entire facility area for contraband.”

Cruz Patino Jr’s mother Frances Guzman, left, and stepfather Allan Monge lead a protest demanding justice for inmates who died while in custody at the Pima County Jail during a march in downtown Tucson on Aug. 27, 2022. The protest was organized by No Jail Deaths. Credit: Michael McKisson

“It’s horrific”

About 1,200 people died in jails across the nation in 2019, the most recent year for which statistics are available, according to the Bureau of Justice Statistics. That’s more than a 5% increase from 2018 (1,138 deaths), a 33% increase from 2000 (903) and a 2019 rate of 167 deaths per 100,000 inmates. 

In the Pima County jail, with 10 deaths in 2021, the rate was nearly 619 deaths per capita for every 100,000 inmates, according to Arizona Luminaria’s own calculation using the total number of deaths cited in news reports and the average daily jail population, which is currently just under 1,900. That’s more than three times the national rate as of 2019, the last year for which national statistics from the Bureau of Justice Statistics are available. 

Arizona Luminaria provided the number of 10 deaths in 2021 to officials with the sheriff’s department, who did not dispute the number. Two independent statisticians, both of whom focus on prisons and jails research, also confirmed Arizona Luminaria’s calculations for the jail’s outsized deaths compared to other jails.

Following the same methodology used by the Bureau of Justice, the mortality rate in Pima County jail in the last two years is more than twice as high as the national average. Per 100,000 people, the mortality rate at Pima County Jail over the last two years is nearly 500.

In the approximately 3,000 jails across the United States, 77% of them typically have no jail deaths in a calendar year, according to the Bureau of Justice Statistics. Around 15% of jails will have a single death in a year. It is in the remaining less than 10% of jails — such as Arizona’s Pima County jail — where, overwhelmingly, people die. 

“One death is bad enough,” Nanos said. “It should never be accepted. It’s horrific. It is.”

Nanos focused on a longer period of time, saying that there was precedent for the current death rate in the jail, though his claims were disputed by whistleblowers, who spoke with Arizona Luminaria, as well as by previous reporting.

“What nobody seems to understand is that you could go back 20 years, 30 years, 40 years, and the average number of deaths in that jail is eight per year,” he said. “So, in two years, can I have 17?”

With another two deaths in November, that number is now at least 19.

According to research from Reuters, looking at jail deaths in Arizona, only one other year (2018) since 2009 saw as many as eight deaths in Pima County jail. On average, the number of people who died in the jail from 2009 to 2019 was three. Along with national statistics collected by the Bureau of Justice Statistics, the Reuters data only goes up to 2019. 

Though advocates have raised concerns of deaths going unreported by officials, there were at least nine deaths in 2020, 10 in 2021 and there have been nine reported deaths so far in 2022 in the Pima County jail, according to past news reports and the lawsuit filed by Inzunza’s sister.

Despite repeated requests for clarification, the sheriff’s department did not offer evidence of a historical average of eight deaths a year. The two former employees also disputed Nanos’ numbers, telling Arizona Luminaria that the annual number of deaths in the jail was lower than the eight per year that the sheriff cited as a historical average.

Nanos also disputed the calculation of the annual per capita death toll in the jail, claiming that the death rate was significantly lower than the national and state averages. 

The difference in calculation appears to be that Nanos divided the total number of deaths by the total number of bookings rather than the average daily jail population. Because the total number of bookings doesn’t accurately portray the number of hours a person actually spends in jail — some spend only a couple of hours, some spend months or years — the Bureau of Justice Statistics uses the average daily population to determine a more representative number. Following the nationally determined methodology, Pima County jail has a per capita death rate of more than three times the 2019 national average.

Samuel Sinyangwe, a data scientist and founder of Police Scorecard, reviewed Arizona Luminaria’s calculations and said, “In short, I think you calculated the rates correctly and don’t understand why the sheriff is taking issue with the data.”  

Jacob Kang-Brown, senior research fellow at Vera Institute of Justice, also corroborated the calculations, finding a per capita mortality rate at Pima County jail in 2021 of 619.

“Oh, you’ll be alright.”

The families of those who have died see comments about eight deaths a year, which Nanos has made repeatedly, as callous and dismissive. 

“Maybe if your own son died, Nanos, you would know what it feels like,” Domenique Miranda yelled out at the Oct. 16 vigil. Her son, Jacob, died in October 2021 of a fentanyl overdose.

Nanos said his department looks into every death. “Am I doing everything?” he asked, in regard to preventing future deaths. “I’m trying.”

David Fathi, director of American Civil Liberties Union’s National Prison Project, said that with such an excess of deaths in a single jail, you can usually point to something going wrong. 

“The most important single thing to do” — to prevent deaths — “is immediate and adequate health and mental health screening.” 

That should entail looking into an inmate’s health and mental health history, adding that “suicide preventions are extremely important,” Fathi said.

According to the former employees and inmates Arizona Luminaria interviewed, such medical checks inside the jail are cursory, if conducted at all.

Medical neglect is one of the more common complaints about the jail. “You literally have to be dying to get attention,” Gutierrez, the formerly incarcerated man, said. “You can be on the floor and barely breathing and a cop will laugh at you, say, ‘Oh, you’ll be alright,’ and walk away.”

Medical service in the jail is contracted out to a private company, NaphCare, which is headquartered in Alabama. According to the county’s Sept. 2021 contract with NaphCare, the medical providers “will follow appropriate detoxification procedures for all patients who demonstrate a need for the service after being housed.” An Oct 1, 2021 contract with the county also states that there shall be at least four Licensed Practical Nurses, or LPNs, to staff detox units “24 hours a day, seven days a week.” 

The contract says NaphCare will provide “in house Medication Assisted Treatment to opioid dependent patients.” NaphCare is compensated by the county at a maximum of $62.9 million for the contract term from Oct. 1, 2021 until Sept. 30, 2025.

NaphCare took over health care services in the jail in Oct. of 2021, after the previous vendor, Centurion Detention Health Services, was found to have committed “a material breach of their contract,” according to an August 2021 memo from Director of Pima County Behavioral Health, Paula Perrera, to former county administrator, Chuck Huckelberry.

NaphCare’s CEO, Brad McLane, responded to Arizona Luminaria in an email statement to a series of questions, including regarding allegations of medical neglect, detox protocols and how inmates are screened for their medical history or risk of suicide.

“NaphCare’s mission is to improve and save lives,” McLane said. “We aim to ensure that every patient we treat within the Pima County Detention Center receives a community standard of care to support a healthy return to their community.” 

In response specifically to screening incoming inmates, McLane said that every person coming into the jail is thoroughly screened and that treatment, if necessary, is immediately initiated. “We are committed to providing compassionate, comprehensive and proactive health care for every patient. All patients have access daily to directly request medical care,” McLane said.

McLane said the company created and implemented “advanced protocols for safely managing patients through drug and alcohol withdrawal” and follows “specific protocols for caring for patients at risk of withdrawal from opioids, alcohol and benzodiazepines.” 

Every person booked into the jail is asked specific questions about alcohol and drug use to determine risk of withdrawal, McLane said. They also use urine drug screens to identify the substances that people are using and “provide for regular assessment, monitoring and treatment (e.g. medications, supplements) specific to the substance or substances that present the risk of withdrawal.” 

NaphCare staff, McLane said, are “aggressive in using nasal Narcan — the drug that reverses opioid overdoses — and our staff have prevented many overdoses and saved many lives in the Pima County Detention Center.” 

A NaphCare spokesperson said they believe they have saved the lives of 38 people since taking over care at the jail. “Each of these patients experienced a suspected opiate overdose while in custody and were given one or more doses of Narcan by NaphCare medical staff before being sent to the emergency room,” McLane said. 

At least 38 other inmates in 13 months have almost died in the Pima County jail. That’s what advocates and people formerly detained in the jail say has been missed when only counting the deaths. 

Handwritten notes from a person recently detained in Pima County jail obtained by Arizona Luminaria and redacted to remove sensitive names and dates. Left: “Pima County Death Row” and “No regard for human life – old fashion guard vs. inmates mentality.” Right: “Officer ‘ ___’ asked for two inmates to keep an eye on the third inmate nearly unconscious from Fent withdrawals. Mentioned this happened to him 2 weeks prior same cell 2D03 and his instructions because he can’t call his death is to provide CPR until medics arrive. ‘It looked like coca-cola coming from his mouth & nose.'”

“It’s Not My Problem”

Inmates aren’t the only ones wanting to escape the dire conditions inside the Pima County jail. 

Former Employee 2 told Arizona Luminaria that they quit because of the “ugly, ugly atmosphere” inside. The former employee did not want to be named due to fears of retaliation and the “toxic” work culture that made them fear their bosses. Arizona Luminaria reviewed pay stubs and communication between officials at the Pima County jail and the former employee to confirm they worked there during the period described. 

An Arizona Luminaria reporter also reached out to the union that represents the jail guards, by phone and email, to ask for comment or responses to the various allegations. They did not respond.

Former Employee 2 recalls seeing one man booked into the jail who seemed to be going through an overdose. He was throwing up and dry-heaving, really clammy, and was there on a drug charge, they said.

One of the guards, when Former Employee 2 pointed out that the man needed help and wasn’t getting it, “Just shrugged, and said, ‘It’s not my problem.’”

“There’s a whole not-my-problem environment” in the jail, they say. “Employees were constantly mistreated, horrendously spoken down to. It’s a really toxic, toxic place.”

Former Employee 2 described another situation about a woman who seemed to be having a severe mental health breakdown while being held in a cell with a large window. The cell is designated to monitor people who potentially pose a danger to themselves, they said. The woman had stripped completely naked and was screaming and shaking.

Despite being in such a state for at least a couple of hours, she received no help, Former Employee 2 said. “They’re not trained to help,” they said, referring to the guards.

“They just see them as criminals,” Former Employee 2 said, describing guards regularly laughing at inmates going through mental health crises.

 “The whole place wasn’t very professional,” they said. 

Former Employee 2 also said: “There’s a lot of prejudice, there is a lot of bias” inside the jail. They recall one of the jail officials saying, “If they have three last names” — erroneously referring to Hispanic people — “you have to call the Border Patrol.”

Jail guards sometimes don’t offer phone calls to people who only speak Spanish, they said.

“The tone of voice is definitely different with Black or Brown inmates,” they said. “It’s worse.”

Former Employee 1, who worked in the jail for years, said the environment “is like walking back into the 1950s. Whites back Whites, Blacks back Blacks, and Hispanics back Hispanics.”

“You become the jail,” Former Employee 2 said of working there — and why they decided to leave. “How do you even know yourself anymore? The atmosphere is suffocating.”

Responding to allegations of a toxic work environment, Nanos said that “when you talk about morale and how the place has become toxic, some of that toxicity, if that’s the right word, is from within the facility itself because it’s deteriorated so badly. And that’s management’s problem. That falls on me. So now I need to do something about it. I need to come up with policies and procedures and look at our staff and find out who’s there and what are they doing and how can we better them and get them to see their role differently than they do.”

He added, “It’s a struggle. It’s a challenge. We know that we’ve got a lot of work ahead, but we still do it.”

Another woman formerly detained in the jail described near identical situations. Still in her 20s, and having gone in and out of the jail for years, she said that she has straightened herself out and found steady work. She was detained in the jail both previous to and during Nanos’ tenure. 

She also spoke on the condition of anonymity, explaining that she was so disturbed by the conduct of some of the officers inside that she feared they would come after her on the outside if she spoke. Arizona Luminaria reviewed their name and corroborated that they were in the jail.

“There was a guy who was sick, obviously, seriously sick, and asking for help, and the guard just said, ‘Go fuck yourself.’” When one person was overdosing and “practically foaming at the mouth,” a guard said “just let it happen,” according to the formerly detained woman.

In 2021, at least one woman was among those who died in the jail. Inmates are separated, with about 300 women compared to over 1,500 men held in different units.

Some inmates needing medical care, she said, would simply never be brought to the infirmary. “The COs would be beating them up constantly and sending them to the hole,” she said, using slang for a solitary confinement cell.

Gutierrez, who was formerly detained in Pima County jail — spending 278 days inside, according to his own count — further substantiated such claims. “I was harassed, I was not fed on multiple occasions. I was even hit by a cop there.”

Arizona Luminaria corroborated the basic facts of Gutierrez’s case, including the allegations of abuse, with his former attorney. The sheriff’s department did not respond to questions about Gutierrez’s allegations.

“They failed him”

Frances Guzman is another mother whose son, Cruz Patino Jr., died inside the jail. She knew he had been using drugs, and hoped the wake-up call of jail would help get him clean.

“I prayed to God for my son to get arrested so he could get better. But you have to be careful what you pray for,” she says.

Cruz Patino Jr’s younger brother carries a signs commemorating his older brother’s death during a protest organized by the group No Jail Deaths in downtown Tucson on Aug. 27, 2022. Credit: Michael McKisson

At 22 years old, Cruz died on Aug. 3, 2021, of necrotizing pneumonia, which can be a symptom of drug overdose. “The manner of death is natural,” the autopsy report reads.

Frances, however, questions what’s natural about medical neglect, and blames jail officials for his death.

“They failed to do their job,” she says. “If they had been better trained, they would have taken my son to the hospital. His life would have been spared.”

Officials with the sheriff’s department said in early November that they cannot respond to specific questions about the case due to legal concerns since attorneys for Frances have filed a lawsuit, amended in late October, about her son’s death. 

The lawsuit alleges that Sheriff Nanos, along with the co-defendant, the former medical care provider for the jail, Centurion Detention Health Services, was negligent in their duties, failing “to properly assess, administer and supervise care” to her son, resulting in his death.

 In a response filing on Oct. 27, attorneys representing the sheriff state that Nanos denies many of the allegations made by the family, including that corrections officers were negligent in their “duty to provide for the health, safety and welfare of their inmate.”   

Cruz had become addicted to opiates after, years earlier, enduring a bad car accident, Frances says. He struggled with the pain and got into trouble with the law. When he was arrested, he was booked into the Pima County jail and put on “detox protocol.”

Frances said a person who was incarcerated with her son reached out to her and told her about the dire shape Cruz was in. 

“If an inmate can see he clearly needs medical attention,” she says, “then why don’t these professionals?”

Frances has become a local leader in calling out the deadly conditions at the jail. She’s offered support and an ear to others who have lost loved ones in the jail.

“I get motivated off the pain,” Frances says, “to fight so another mother doesn’t have to go through this.”

She also questions how drugs got into the jail. “The guards need to go through the same protocols as the inmates,” she says.

A protestor holds a sign commemorating Cruz Patino Jr who died while in custody at the Pima County Jail. Credit: John Washington

Good Ol’ Boys v “Care Bears”

Another mother, CC, was at the Oct. 16 protest and vigil outside Pima County Detention Center with her two daughters. All three of them held signs commemorating the lives lost inside the jail. 

CC’s son was nearby, too, but inside the jail. She is scared that her son could be another number, another death. She only shared her initials due to fear of retaliation against her son.

CC says her son was detoxing when, earlier this year, he first was booked into the jail.

“He was really struggling and wasn’t getting help in there. His bunkies were keeping him alive,” she says, referring to her son’s cell mates looking out for him.

“I came” — to the vigil — “to let other families know, to let the community know how dangerous it is in there,” she says. “It should be safe. It shouldn’t be a death sentence to go to jail.”

“You’re not just damaging a family, you’re damaging a community,” Frances says, describing the impact of jail deaths.

Former Employee 1, who worked in the jail for years, described at length the culture that guards and staff adhere to. They said it was a “good ol’ boys’ club,” in which undertaking the most basic acts of humanity toward the inmates can get you pejoratively labeled as a “hug-a-thug” or a “care bear.”

You can get labeled a “care bear,” they explained, for the simple act of giving an inmate toilet paper when they request it.

They described how guards regularly fail to conduct their “rounds” — basic safety checks. And then the sergeants who oversee entry-level guards, the former employee explained, frequently sign off on uncompleted tasks, including the rounds.

The lack of oversight became so prevalent at times that the safety and sanitation sheets that sergeants are supposed to sign off on were frequently mere photocopies of the completed forms, the former staffer explained.

“There’s no real inspection done. They just print out the forms and sign them,” Former Employee 1 said.

That example is one of a myriad of rules that are flouted at the jail, according to both former employees. The lack of effective oversight, Former Employee 1 described, “and the complete autonomy of a housing officer or a sergeant creates the opportunity for officers not to do their job as they were supposed to do.”

They said that even in the training academy, the teachers tell incoming guards that there are rules that simply are not enforced.

Former Employee 1 described an instance they witnessed in which a female inmate was on “detox protocol,” coming off some hard drugs, and was complaining to a guard that she couldn’t breathe and was having an issue with her heart. Instead of helping, they said, the guard slammed the door in the inmate’s face and told her to “fuck off.”

After the inmate passed out, the officer told her she was faking it and gave her a sternum rub — a painful method to test consciousness. The guard was doing the procedure in a punitive manner, the employee said, and they told her to stop.

“I was labeled a hug-a-thug after that. But I reported it anyway. Nothing was done except I got a bad reputation,” they said.

A common response from guards to an inmate saying they can’t breathe is: “Well, you’re fucking talking,” they said.

Such dismissiveness, they claimed, is part of the “pervasive mentality” of the jail. They described a number of other instances of severe abuse, cover-ups, and high-ranking officials’ flippant attitude to reports of misconduct.

“A particularly toxic or combative culture leads to predictable results,” Armstrong said. “In some jail cultures, people in custody are treated as if they have been found guilty and are less deserving of treatment and more deserving of punishment.”

Overall, Former Employee 1 described an “us vs them” mentality between the guards and the inmates.  

Gutierrez said some of the guards push the gangs, pitting inmates against each other. “This one guard, he was taunting me, man, trying to get me to hit him, just to laugh at me.”

Fathi, of the ACLU, said jails have problems with some guards dehumanizing inmates.

When Wade had already lost consciousness after being violently manhandled by more than half a dozen guards and repeatedly tased, he was laid flat on the ground, unmoving. As one guard searched for a pulse, another guard said: “He’s faking his ass off.”

“The us vs. them, antagonistic attitude is very common,” Fathi, of the ACLU, said. “There is often a hostile, oppositional, skeptical attitude toward jail detainees.”

“It’s particularly dangerous when it comes to staff thinking someone is faking a medical emergency,” Fathi said. 

Protestors march past vehicles on Congress in Downtown Tucson on Aug. 27, 2022. The march was organized by the group No Jail Deaths. Credit: Michael McKisson

Official silence

Wade’s sister Melissa and her family have reached out to the Pima County Sheriff’s Department multiple times, she says, but haven’t heard back. 

“Not one call back. Not a sorry. Not nothing,” she says.

When asked about families of people who have died in the jail he oversees reaching out to him, Nanos said he hasn’t heard from anybody. 

“Not once,” he said. “And my number is out there, I give it to everybody. I don’t turn down interviews.” 

How the disconnect between Nanos and the families saying that they have repeatedly called on the public official in charge of the jail and keeping people inside it safe happened is unclear.

For now, the families of the dead are focused on justice, answers, and making sure the Tucson community is safe. 

“I want the community to know that we need to stand up,” Melissa says. “That it’s a bigger problem than just the jail.”

Arizona Luminaria reached out by email and/or phone to all five Pima County Board of Supervisors to ask for responses about the deaths and allegations of dangerous conditions inside the jail. None of the elected officials responded.

Fathi said that public pressure and scrutiny can help mitigate the worst abuses in jails. So, he said, can simply reducing the population. 

“The fact that a man in jail died when he could have been home on a $1,000 bond is horrifically tragic,” he said of Wade’s case. “The vast majority of people in jails are there because they are poor. If they could afford to post bail, they wouldn’t be there.”

Armstrong offered some ways local jails and communities can curtail abuses and deaths. 

One is to enhance the authority of the sheriff to release someone. Typically, only serious medical issues allow the sheriff to release an inmate to the hospital. But, in concert with a judge, some sheriffs in other states have been granted authority to release people to hospitals, shelters, or mental health institutes where they can seek care.

In a number of cities and counties, including Marion County, Ohio, court orders permit the release of some detainees to avoid overcrowding. According to one study, “The jail relied on this authority on a daily basis.”

Armstrong also said community-based oversight can help “identify systemic gaps that produce insecure institutions.”

A new civilian oversight board was established in 2021, though only publicly announced in April of 2022, to, among other tasks, “hold the department accountable to its constituents.” Dr. Damond Holt, who was chairperson, said in early November that he was no longer part of the board. Advocates with No Jail Deaths said that as of mid-November the board had not publicly commented on deaths in the jail. 

One of the members of the civilian oversight board, Joseph Delgado, told Arizona Luminaria on Nov. 15 that they are aware of the poor conditions in the jail and the issue “is one of our top priorities.” Arizona Luminaria also reached out to the chair of the committee for further elaboration and to other members, but received no response.

Protestors gather outside the Pima County Detention Center on Oct. 16, 2022 demanding justice for their loved ones who died while in the jail. Credit: John Washington

“Justice for my son”

Wade liked to fish.

He and his family went to all the lakes in Southern Arizona, spending days casting lines and goofing around. When he was feeling good, he also liked to garden. He grew watermelons and strawberries in his mom’s yard.

Melissa says Wade desperately loved his 14-year-old son. He was also tough, Melissa described, and deeply committed to his family. She considered her brother his best friend.

“Everybody loved him. Even still, at random stores, people will recognize me and tell me how much they loved my brother,” Melissa says.

Wade’s mother, Constance Welch, sitting in a wheelchair at the Oct. 16 vigil, holds a sign that reads: “Justice for my Son!! RIP Son. Mom loves You.”

“It kills me,” Constance says. “I’m the mother of six children, 13 grandkids, three great-grandkids. There was no need for what they did to him.”

As Constance and Melissa, CC, Frances, and other family and community members chant and shout at the jail, children weave between their legs, some of them holding signs, some of them eating snacks or peering at the votive candles.

A relative of Ricardo Duran, a 32-year-old who died in Pima County Jail in 2020, says, “It’s nice to get the kids out. Let them know what’s going on.”

Yesenia, Duran’s sister-in-law, describes him as incredibly outgoing and kind. “He would always put everyone before himself,” she says. “He wanted to be there for people because he didn’t have that growing up.” Ricardo suffered through periods of homelessness beginning when he was 10 years old, Yesenia said. 

Ricardo left behind two children, a 16-year-old daughter and a 13-year-old son. He died in the Pima County jail on Father’s Day.

At the October vigil, among the supportive honks from passing cars, the kids blasting air horns, and Tupac and Bone Thugs-N-Harmony playing out of a portable speaker, the most persistent sound is simple: “No more deaths! No more deaths!”

Joining the chant is CC’s youngest daughter, not yet a teenager. She knows her big brother is locked inside the jail. Still alive. She’s holding a poster with a photo of someone else’s brother, Sylvestre — his mugshot, the last photo of him alive. Below are the words written in thick blue permanent marker: “NANOS I died in your hands!!! Why!!!”

As Arizona Luminaria continues to investigate the deadly conditions inside Pima County jail, please reach out to reporter John Washington, jwashington@azluminaria.org, for information and tips.

Corrections and clarifications: An earlier version of this article misspelled the first name of Rosanne Inzunza. Rosanne is the accurate spelling.

Arizona Luminaria reviewed criminal justice reform studies that offer recommendations and best practices for making jails and prisons safer and more humane.

Perhaps the best way to address the dangers in the jail is simply keeping people out of it. 

As Armstrong suggested, other counties and jurisdictions in the United States have given broader leeway to sheriffs, courts, and prosecutors to allow people to await trial outside of detention or not press charges in the first place, especially for non-violent offenses or the use or possession of drugs. 

For a few months beginning in late 2021, Pima County was not charging people for minor drug offenses, but began doing so again in March of this year.

A 2016 report from Vera focused on reducing the jail population in Oklahoma City by creating alternatives to jail, especially for those suffering from mental health and addiction challenges. Substantive oversight and accountability is also key. 

Partnerships with business and civic organizations united the community in calls for change in Oklahoma City.

“We commend the Greater Oklahoma City Chamber of Commerce for  recognizing that jail misuse is an issue for the entire community — one that will not be solved by simply building a bigger jail,” said Vera President Nicholas Turner. “The leadership the Chamber has shown is unusual and should be a national model.”

While experts highlight best practices for criminal-justice reform at Oklahoma City jails, shifting toward more humane and safe facilities remains a struggle.

People inside the Oklahoma City jails are still suffering, with recent cases of extreme violence and pastors and activists calling for the jail’s leadership to resign. There were 14 deaths in the jail as of Sept. 2022.

Another Vera report about Wayne County, Michigan, which includes Detroit, focused on serious problems at the county jail, including overcrowding and abuse. The report, in part, outlines ways to decrease the jail population, including reducing arrests, increasing pretrial releases and ending the criminalization of civil violations such as for suspended licenses, registrations, or lack of insurance. Recommendations also highlight the value of increasing diversion programs, sending people for mental health care instead of cramming them into jail.  

The report stresses the need for non-carceral alternative responses to criminal activity, noting that national studies have found that incarceration actually increases crimes.

“Incarceration may increase the likelihood that an individual will use violence by making it harder for them to meet their economic needs, isolating them from their communities and the prosocial connections within them, exposing individuals to more trauma and violence while inside, and enhancing feelings of shame,” the report states.

Experts are torn on the solutions to the significant challenges facing jails in Pima County and across the country.

“While jails officials said they needed basic infrastructure improvements and more staff, some prisoner advocates point out that more lenient bail policies could help ensure fewer people stay behind bars when they don’t have money to pay for their freedom,” states a report from The Marshall Project, a nonprofit newsroom focused on criminal justice reporting.

Prison Policy Initiative, a nonprofit that advocates for criminal-justice reform, lists “winnable criminal justice reforms for 2023,” including a number of ways to reduce the number of people entering the “revolving doors” of jails and prisons. They include decriminalizing or reclassifying offenses, making citations rather than arrests the default, and instituting grace periods for missed court appointments. Among the biggest reforms recommended would be to entirely decriminalize drugs, poverty, sex work, and homelessness.

Another major impediment to making jails less deadly is accessing clear data. The Bureau of Justice Statistics currently only has data on jail deaths up until 2019. A case in point is the dispute about mortality rates in Pima County Jail. 

Michele Deitch, a law professor at the University of Texas at Austin who studies jails and prisons, told The Marshall Project, “We literally do not have the means to assess the safety or dangerousness of a facility in any comparative way.”

Wayne County is trying to address that with a real-time “dashboard,” a publicly accessible portal that shows current jail population, breaks that down by demographic, and also shows, for example, how many current inmates are receiving or in need of mental health care. 

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John Washington is an investigative journalist based in Tucson with a focus on immigration and borders, as well as criminal justice and literature. His first book, "The Dispossessed: A Story of Asylum...