This story is supported by a grant from the Fund for Investigative Journalism.

Joseph Zarate was in Block 1S, Cell 20 of the Pima County jail when a medical worker checked on the 29-year-old who had been detained for 46 days. They found him lying naked on his back on a bunk without a mattress near a toilet filled with brown water. His knees were up in the air. Dried feces was smeared on the bunk, as well as on his hands and buttocks.

Joseph gave the NaphCare worker a thumbs-up and said, “I’m not suicidal. I need my Methadone.” That was March 20, 2023. The next day, Joseph’s heart stopped beating.

The details documenting the last moments of Joseph’s life come from his mother, Denise Mills. She says she found a stack of jail medical records stashed inside a bag with her son’s belongings at the hospital shortly after he died. She showed the jail records and hospital medical reports that are described in this story to Arizona Luminaria.

For weeks inside the jail, Joseph had been alternating between accepting and refusing his medications, including ones prescribed for nausea and vomiting, diarrhea, cramping, psychosis, as well as acetaminophen for pain. 

Joseph Zarate, right, in a photo provided by his mother, Denise Mills. Credit: Joseph's family

Most days Joseph took his Aripiprazole, a drug often used to manage bipolar disorder. But for the final five days he was in jail he refused the medicine, according to medical records. 

NaphCare and non-NaphCare medical workers kept a detailed log of his drug administration history. 

At 7:15 p.m. on March 20, after swearing he was not a threat to himself, Joseph pleaded for medical help. “I want a Sgt up here taking care of me. I need my meds. I need some gatorade,” he said, according to medical records.

“Pt hands and legs appear to be trembling as he speaks with this writer,” the records state.

A box documenting whether a medical worker took Joseph’s vital signs during the visit is left unchecked. A box designating him as “Level of Care 2” is checked, as opposed to “Level of Care 1.” Other details include Joseph’s date of birth, Hispanic race, age and booking date.

In a May 17 emailed statement NaphCare said the company’s “mission is to improve and save lives. We aim to ensure that every patient we treat within the Pima County Detention Center receives community standard of care.”

A part of a mental-health assessment record for Joseph Zarate where Arizona Luminaria has redacted medical workers’ names.

For weeks, Denise says that the jail staff was telling her that her son was refusing her visits.

“I knew something was wrong,” she says. “He would never refuse his meds or my visits. Something was going on.”

Sometime after 1:45 p.m. on March 21, the day after the medical worker found Joseph covered in his own feces and pleading for help, and more than a month of incarceration at Pima County jail, Tucson City Court Judge Lisa Surhio orders Joseph released.

Joseph “will be transferred to the hospital if released,” court records state.

Pima County Sheriff’s Department officers did not take Joseph directly to the hospital as mandated at the March 21 hearing, according to court and medical records.

Instead, officers transported him to the Crisis Response Center, a 24/7 mental-health center run by Connections Health Solutions. The center is inside the same complex as Banner University Medical Center South and serves patients with behavioral health issues or who are struggling with substance abuse. 

The center declined to take Joseph, according to Banner South medical records. Officers then took him to the emergency room at Banner South. Just after 10 p.m., with sheriff’s officers still by his side, he went into cardiac arrest.

Four days later, Joseph died.

Among the list of past medical problems Banner South doctors listed for Joseph was bipolar 1 disorder, chronic pain, depression and drug addiction.

A spokesperson for Connections Health Solutions, on behalf of the crisis center, sent Luminaria an emailed statement regarding questions about why they turned Joseph away.

“All individuals brought to a Connections crisis center complete an intake evaluation that includes a general medical assessment by our nursing and medical professionals. If those professionals determine that the individual is suffering from a medical emergency, it is our policy to send the individual to a medical emergency room for immediate medical evaluation and treatment.”

This year, so far, there have been two deaths in the jail publicly reported by the sheriff’s department. Joseph is not counted among them.

The initial autopsy report signed by the Pima County Office of the Medical Examiner on April 12 referred to Joseph as a “29-year-old inmate” and includes information on his condition in the jail. That report was later amended, re-signed on April 24 and erases from the public record Joseph’s history in the jail and his status as an inmate. According to the Pima County Chief Medical Examiner Gregory Hess, at the time of his death, Joseph was no longer in official custody of the sheriff’s department. Luminaria obtained the original and amended public records from the medical examiner’s office. 

The amended report refers to Joseph as a “hospitalized 29-year-old.”

Hess says the medical examiner’s office amended the report after noticing that their count of in-custody deaths differed from that of the sheriff’s department. After which, Hess says, the medical examiner’s office checked with sheriff’s department officials who confirmed that Joseph had been discharged from custody by the time he died.

As of May 19, Sheriff Chris Nanos, the sheriff’s department communications officials, the Pima County Attorney’s Office and County Attorney Laura Conover have not responded to Luminaria’s specific questions to confirm whether law enforcement officers had officially released Joseph from custody and if so, to clarify the legal process behind his release. They also have not responded to requests for the county policies outlining the process for releasing people after they’ve been arrested and booked in the jail to include in this story so the public would have access to information about their rights.

It is now clear, though, that including Joseph, there have been six additional Pima County jail-related deaths so far this year. That means the new tally of deaths in 2023 has quadrupled, increasing from two to eight. 

This new death count is the result of Hess deciding that his medical examiner’s office will soon be overhauling its policies and begin tracking and counting deaths that occur within 30 days of release from jails and prisons, excluding those that are unrelated to a person’s time spent in custody.

The medical examiner’s office is also going back to review 2022 records and has identified another 12 jail-related deaths — twice the previously reported number — for a total of 24 people who died.

With the change in categorization, the Pima County medical examiner’s office is counting an additional 18 deaths related to the jail so far. That means there were at least 32 people who died in the jail or shortly after being released from the jail in 2022 and 2023.

Jail-related deaths are now more than twice as high as previously reported.

Dying in a custodial gray area

The original autopsy report signed on April 12 states in the “circumstances of death” section that Joseph’s health was declining in the jail and starts with the following sentence: “This 29-year-old inmate was reportedly less communicative over a two-week period and was transported to the hospital for medical clearance, when he became unresponsive with PEA arrest in triage.” PEA stands for pulseless electrical activity and is a medical condition characterized by unresponsiveness and impalpable pulse.

The amended autopsy report signed 12 days later removes from the public record any history of Joseph being in the jail. It deletes the original first sentence and changes the circumstances of death section to start with this sentence: “This hospitalized 29-year-old was diagnosed with an upper gastrointestinal hemorrhage (melena and anemia with hemoglobin of 6.4 g/dL), group A streptococcus & staphylococcus aureus (MSSA) bacteremia with septic shock, constipation, cavitary lung lesion, non-bleeding duodenal ulcer, duodenitis and anoxic brain injury.”

The cause of death is listed as “complications of bacteremia with sepsis,” which is more commonly known as a staph infection and is treatable with antibiotics. Medical signs of the infection include skin infections, fever, muscle and joint pain and nausea, vomiting, abdominal pain, diarrhea and dehydration. Joseph was suffering from diarrhea, nausea and pleading for Gatorade in the jail before he died, according to medical records.

Arizona law mandates that officials report the death of any person who has been arrested and is in the custody of a law enforcement agency to the local medical examiner’s office.

“It’s sort of a check in the system to make sure the government isn’t willy-nilly killing people and then trying to cover it up,” Hess says.

But the system for tracking, counting and publicly reporting deaths related to incarceration is outdated and doesn’t provide the full picture of how and why incarcerated people are dying, he says.

“The tools most offices like ours have historically used to claim this group is in custody or not. Now, that’s a little bit of a problem, because when do you define in custody and what are you not defining people as in custody?” he says.

Hess says he read recent news reports of people in jail and prisons not getting the medical or mental health care they need.

It is the legal responsibility of the sheriff’s department, as mandated by the U.S. Supreme Court, to provide health services to people detained in the Pima County jail.

Hess says he’s seeing more interest from concerned public officials and community members about people dying while in the process of being taken into custody. There’s also a growing movement, he says, to understand why people “die after recently being released from prison, from stuff like overdoses.”

“Should they have been given Narcan on the way out the door?” he asks.

Joseph is one among the dozens of people locally, and many more nationally, whose jail-related deaths go unreported by law-enforcement officials charged with caring for incarcerated men, women and children. 

Not reporting out-of-custody deaths to the public is perfectly legal. It’s a loophole lawmakers have not addressed, say criminal justice experts, that paves the way for civil and human rights violations of people locked up inside U.S. jails and prisons.

But questions about Joseph’s rights — and whether he was still in the custody of the Pima County Sheriff’s Department and should have legally been counted in the state and federally mandated number of incarcerated people dying — are even more complex.

“So if a death is classified based solely on where the person is located at the moment of death, that is problematic for at least a couple of reasons,” says David Fathi, Director of the American Civil Liberties Union National Prison Project.

“One, it obscures what might be relevant history. Where was the person 24 hours before his death? What was going on with him at that time?” he says.

“The second problem is that it creates a perverse incentive for jails and other carceral facilities to dump desperately-ill patients when they’re on their deathbed. And unfortunately, jails and similar facilities strategically releasing people just before they die to avoid reporting requirements, to avoid investigations, to make their numbers look better, is unfortunately a familiar phenomenon.”

Was Joseph still in the custody of Pima County jail officers?

“One of the traditional legal tests for whether a person is in custody is whether a reasonable person would have felt free to leave. And if this person was in a squad car being driven by deputies, I would say he probably wasn’t free to leave,” Fathi says.

Pima County sheriff’s officers transported Joseph from the jail and were still with him at the hospital in a law enforcement waiting room when he fell unconscious and medical staff issued a code blue to try and save his life, according to Banner South medical records

A partial scan of one of Joseph Zarate’s medical records where medical workers’ names have been redacted by Arizona Luminaria.

Nurses’ hospital notes on March 22 are a window into Joseph’s life, death and whose custody he was in. It also offers a loose timeline of what happened to Joseph after he went from pleading for medical help in the jail to waiting for deputies to transport him, and then, only after being declined by a mental health center, to waiting in a hospital emergency room.

The report states: “Patient was in law enforcement waiting room and law enforcement called me to discuss the patient’s petition status. When I arrived at the waiting room I spoke with the officers about the status of the petition along with the case manger. They notified me that they originally brought the patient to the CRC but the CRC declined the patient. The reason for coming to the emergency department was because the patient was on petition for court ordered treatment but had no medical complaints. I informed the psych nurse that there was a new patient that needed to be triaged but we were both in the middle of dealing with other situations. Later I received a call from the psych ED nurse stating the patient was not breathing. I rushed to the law enforcement waiting room and found the patient unconscious and unresponsive. I checked for a pulse and immediately began CPR. A code blue was sent out and help arrived and we arranged to get the patient on the stretcher and moved into a room.”

A final emergency room report by doctors for “patient care initiated: 3/21/23” at 10:09 p.m. sheds more light on the status of Joseph’s custody and medical condition leading up to his death.

The report states: “Patient was brought in by correctional officers from Pima County jail in which they originally went to the CRC however were sent here for medical clearance. Pima County officers state that while in the triage area, they noticed the patient to start having dyssynchronous breath in which he collapsed without a pulse.”

Denise showed her son’s “inmate personal property receipt” to a Luminaria reporter. The document includes Joseph’s name, booking number and a February 2023 date. The lines titled “signature of inmate,” which Joseph was supposed to sign when entering the jail and upon receiving his property after leaving, are blank. The only signature on the document is from an officer, verifying that Joseph had property being held by the Pima County Sheriff’s Department that can be claimed within 30 days following his release.

42 days in Pima County jail: ‘Not doing well’

On Feb. 7, days after Joseph was booked into the jail, a judge set his bond for $1,250. On that same day, his video conference with the judge was canceled for unspecified reasons. A hearing in the “Mental Health Court,” which Joseph could attend in person or by video, was set for March 9. 

On March 9, a Tucson City court document obtained via a public records request by Luminaria, states that Joseph “could not attend today’s hearing because he was uncooperative.” The documents also state that Joseph had been taking medications for more than a month and that he was housed in a mental health unit in the jail. Joseph’s mother, Denise, advocated for her son to go to a “residential substance use treatment” center. His public defender, was looking for residential treatment options for Joseph, according to the records.

Five days later, on March 14, a court document explains why Joseph didn’t attend a video court hearing though he remained incarcerated at Pima County jail: “Defendant is not doing well today and is not going to be seen. Defendant is partially med compliant.”

The March 14 records also state that defense attorneys argued for Joseph’s release “based on the fact that he has been in for 40 days.” Though his felony charge had been dropped, the prosecutor objected, “based on concerns about community safety” and a desire for “more of a plan in place for his treatment.” 

In bold text, the records state that Judge Surhio “requests that La Frontera, go to meet with the defendant in jail.” La Frontera is a medical provider that offers behavioral health services and treatment for substance abuse and serious mental illness.

Plans to request court ordered treatment for Joseph also are noted and if released, Joseph would be sent to the Crisis Response Center. (In Arizona, courts can order behavioral or mental health treatment under Title 36 laws aimed at providing critical care when a person “as a result of mental disorder, is a danger to self or to others or has a persistent or acute disability or a grave disability.”)

Surhio states at the March 14 hearing, “I am denying release at this time.”

The next court hearing is set for March 16.

Again, while Joseph remains in custody at the jail, records document his absence from his own March 16 public court proceedings and show his medical condition. A single sentence echoes the status of Joseph’s health two days earlier: “Defendant is not doing well today and is not going to be seen.”

The defense, again, argues for Joseph’s release, “based on the fact he has been in for 42 days.”

The March 16 records also state that if released, Joseph would go to the Crisis Response Center for treatment. Again, the prosecutor objected to Joseph’s release “based on concerns about community safety.”

These records also show that the county attorney’s office — per Community Bridges, Inc., a behavioral health, addiction, transitional housing provider — would file a Title 36 petition, an involuntary process for evaluation, care, and treatment of persons with a mental health disorder.

At the March 16 hearing, while Joseph was in a jail cell, not well enough to attend his own hearing, the records also show that Joseph’s public defender told the court that they “may be filing a Rule 11 petition.” That petition starts the process of evaluating whether someone in the justice system is competent to stand trial.

If Joseph had been found incompetent during his time in jail, officials would have been charged with ensuring that he receive an array of health and psychological treatment services to help restore him to competency. 

On March 21, during a hearing scheduled for 1:45 p.m., it is unclear from the court documents if Joseph was present via video. The records state that he was refusing medication. Denise requested that her son be released for treatment.

On that day, the prosecutor did not object, and Judge Surhio orders Joseph “released on his own recognizance.” She set a pretrial hearing for April 27. 

“A Title 36 petition is pending, so he will be transferred to the hospital if released,” according to the March 21 court records.

At some point later in the afternoon or evening of March 21 — less than 24 hours after Joseph was found by health-care workers in his cell pleading for medical help and naked with dried feces smeared on his body and mattress-less bunk near a diarrhea-filled toilet — Pima County Sheriff’s Department officers did not take Joseph directly to the hospital as mandated at the hearing, according to court records.

Instead, officers took Joseph to the Crisis Response Center, according to medical records.

After the mental-health center declined to take him, jail officers took the 29-year-old to the hospital emergency room for “medical clearance,” where Joseph went into cardiac arrest and later died, according to health-care records.

It is standard policy, for nurses to evaluate if anyone brought to the center “is suffering from a medical emergency” and “send the individual to a medical emergency room for immediate medical evaluation and treatment,” according to a statement on behalf of the Crisis Response Center.

On March 24, and as recently as April 27, more than a month after Joseph’s death, records show that court officials are still scheduling trial hearings for him. Joseph is scheduled to appear at a hearing in front of Judge Surhio on May 25. 

On May 19, a Luminaria reporter spoke briefly with the prosecutor in Joseph’s case. They declined to comment.

For-profit health care

NaphCare is the Alabama-based for-profit private company contracted by the county to provide medical care in the jail. They have been subject to complaints of medical neglect and understaffing since the Pima County Board of Supervisors approved a contract for the company of up to $62.9 million in 2021.

More than a dozen inmates, and other sources, have spoken with Arizona Luminaria about chronic deficiencies with medical care in the jail. Care also frequently depends on the correctional officers, or guards, who work for the sheriff’s department. Those guards frequently block access to medical care, according to the incarcerated people Luminaria spoke with.

Paul Gutierrez has described the conditions from when he was incarcerated at the jail in 2017.

“It’s inhumane in there. You have no idea, man,” he said in a 2022 interview with Luminaria, adding that medical neglect is one of the more common complaints about the jail. 

“You literally have to be dying to get attention,” he said.

“Any type of delay and diagnosis, delay in triaging and escalation of care will often, unfortunately, lead to poor health outcomes,” said Dr. Elena Jimenez-Gutierrez, a medical expert and member of Physicians for Human Rights, in a recent interview with Luminaria about legal and ethical standards of health care for incarcerated people. Jimenez-Gutierrez has experience attending to patients in and out of carceral settings.

And such delays, “might mean complications, depending on the disease, to different organs, amputation, loss of some dexterity, loss of some vision or or hearing. It could also mean death and very serious illnesses,” she said.

Regarding questions about Joseph’s medical crisis and how people inside the jail are cared for when they aren’t taking their medication, NaphCare wrote: “All patients have the right to refuse medication. When a patient refuses treatment, our policy is to educate the patient on their treatment and encourage medication compliance. All NaphCare policies and procedures are designed to follow industry standards set by the National Commission on Correctional Health Care (NCCHC).”

Citing the confidentiality of medical records and the county’s ownership of them, NaphCare did not provide any of Joseph’s records.

In an April 14 emailed response to a detailed list of questions and requests for responses to claims about inadequate medical care in the jail, NaphCare said: “All patients have access daily to directly request medical care. Registered Nurses (RNs) review the requests twice a day and triage for follow-up by the appropriate provider. Emergent requests are addressed immediately.”

Despite repeated attempts to speak with the sheriff’s department communications office and Sheriff Nanos about Joseph’s death, they provided no comment. 

Along with the sheriff’s department and other Pima County agencies and officials, NaphCare faces multiple lawsuits from family members of incarcerated people who have died. 

The county’s own monthly audits have found that NaphCare has consistently failed to provide adequate and timely care to the people detained in the jail. 

In seven out of seven months — including as recently as January 2023 —that the Behavioral Health Department assessed whether or not “patients undergoing withdrawal are appropriately managed,” NaphCare failed to meet the performance indicator, according to audits conducted by the county and provided in an email to Arizona Luminaria by health department officials. 

The county agency administers the medical service contract and audits contractors providing medical care, such as NaphCare, and designates financial penalties for failing to meet requirements of the contract.

Pima County isn’t the only place where NaphCare has faced serious criticisms and lawsuits. 

In Washington state in 2022, NaphCare was hit with a $27 million dollar verdict for its role in the death of someone in the Spokane County Jail. Similar troubles go back as far as 2003, when an Alabama state audit charged NaphCare with supplying “dangerous and extremely poor quality health care” in a state prison.

In an October 2022 interview with Luminaria, Nanos said his department investigates every death and he’s working to prevent future deaths.

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

In a Dec. 5 memo to the Pima County Board of Supervisors, following Luminaria’s November reporting on the deadly conditions at the jail, Nanos cited a “full-blown crisis” in the jail. “This crisis has no embellishments,” he wrote. “As some of you have seen firsthand, it is real, it is urgent, it worsens and remains untenable.”

At a March 17 public meeting, Nanos told county officials that “We’re making a mistake,” referring to the county’s detention of people with mental health issues. “That [care] should be handled by healthcare professionals,” he said.

“The carceral environment can be inherently damaging to mental health by removing people from society and eliminating meaning and purpose from their lives,” according to Prison Policy Institute, a non-profit, non-partisan research organization that focuses on incarceration. “On top of that, the appalling conditions common in prisons and jails — such as overcrowding, solitary confinement, and routine exposure to violence — can have further negative effects.”

When deaths aren’t counted

Nationally, lawmakers are calling for more widespread public information on jail and prison deaths. This year, Arizona’s two largest county agencies, with populations of more than 5.5 million, are taking actions to ensure the lives and deaths of people like Joseph are investigated and counted. Criminal justice experts are calling the steps long overdue, unprecedented and vital to understanding the deadly effects of incarceration. 

It also could help speed up state or federal oversight and intervention at jails with excessive deaths. 

Hess calls the new classification “custodial-agency related deaths.” He says that his office would not count people who died in unrelated circumstances, such as car accidents. Hess says the action follows similar steps by the Maricopa County Office of the Medical Examiner.

Calculating mortality rate

The Bureau of Justice Statistics, which tracks mortality rates in jails and prisons across the country, calculates the death rate by tallying the number of deaths in a given year and dividing by the inmate average daily population (ADP), and then multiplying by 100,000. The ADP for jails is defined as the average daily number of inmates held in a jail jurisdiction during a calendar year, from January 1 through December 31.
The ADP is used instead of the total number of bookings to account for the high turnover rate and the constantly fluctuating population in local jails. According to a 2021 report, “the ADP is a better indicator of the number of days per year that an inmate is exposed to the risk of death. Jail populations have a much higher turnover than prison populations. Mean length of stay is about 26 days in local jails, compared to 2 years in state prisons.”

In 2022, Pima County counted 12 deaths in the jail, an estimated per capita mortality rate, or 667 for every 100,000 incarcerated persons — more than four times the national rate as of 2019, the last year for which national data from the Bureau of Justice Statistics are available. For a more recent perspective, that’s twice as high as the per capita mortality rate for incarcerated people at notoriously violent Rikers Island jails. In 2022, 19 people died at the New York jails, or at local hospitals.

Local news organizations nationwide have recently been individually reporting on increases in jail deaths.

In 2013, Congress passed the federal Death in Custody Reporting Act (DCRA) which requires states to report deaths in state and local correctional facilities. But, as detailed in a U.S. Senate Committee Hearing in September 2022, “despite a clear charge from Congress to determine who is dying in prisons and jails across the country, where they are dying, and why they are dying, the Department of Justice is failing to do so.”

Arizona law also requires law enforcement officers to report deaths that occur in prisons or jails.

Still, nearly 1,000 deaths in state and local prisons and jails have gone unreported because there’s no enforcement of reporting, according to a 2022 U.S. Government Accountability Office report.

“I think it’s fair to say it would certainly be a fuller picture if DCRA also applied to people who had recently been released from custody,” said Fathi, the ACLU jails, prisons and human rights expert. “I would certainly think you would want to look at people, not only people who die unquestionably in custody, but people who die shortly after release or during the process of release.”

Families of people who died in Pima County jail, joining a chorus of critics across the country, are calling for major reforms and increased transparency to curtail suffering and death in the jail. Local officials also want answers. 

Following Arizona Luminaria’s reporting on the outsized mortality rate at the jail, council member Lane Santa Cruz attended an April 19 community panel on the deadly conditions and crisis at the Pima County Adult Detention Center. Luminaria hosted the panel that included criminal justice experts and loved ones of people who died at the jail. 

Santa Cruz brought concerns raised by community members to the council.

On May 2, the Tucson City Council held a special study session, saying that the local government funds the bulk of arrests in Pima County. Tucson Mayor Regina Romero said she wants to see a report from the county that includes details about staffing levels, the state of medical care, and what the jail is doing to prevent suicide and overdose deaths.

The city council voted unanimously to ask county leaders for information about “the intake and care of detainees at the jail, including any information relating to recent inmate deaths.”

“I want to make sure that when we are putting people at the Pima County jail that we’re not sending our city residents to die at the facility,” Santa Cruz said. “I think we have a responsibility to look into why these deaths are happening.”

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Santa Cruz represents residents of Ward 1, where the jail is located. She listened to Frances Guzman, a mother who spoke at the panel about how her son, Cruz Patino Jr., died inside the Pima County jail. Guzman said she thought her child might recover and turn his life around after going to jail.

“We have Latino moms who are OK with their kids going into custody, thinking that’s going to be the wake-up call that they need to get sober or clean, and that it ends up in a tragedy,” Santa Cruz said in a Luminaria interview after the study session.

In December of 2022, Arizona Luminaria requested dozens of records about medical care from NaphCare, including policy and regulations regarding mental and medical health requests (commonly referred to as kites); policy and regulations related to staffing, including staffing requirements per unit, detox unit, overnight, and overtime; as well as medical or mental health requests submitted by incarcerated people in the jail; among other records. In January, Luminaria made a mirror request to the Pima County Sheriff’s Department seeking records about medical care in the jail.

Attorneys working with Luminaria on the public records request have since sent correspondence urging both entities to respond to the request. While NaphCare responded by providing limited records pertaining to policy and staffing, they did not provide any medical or mental health requests submitted by incarcerated people, nor response times to the inmates’ requests.

On Jan. 11, Deputy County Attorney Sean Holguin wrote in an email, “Regarding your request for NaphCare records/documents, NaphCare is a private entity and not a department of Pima County. Consequently, the Pima County Sheriff’s Department cannot provide you with the records/documents you have requested, to the extent they exist.”

In a Feb. 27 letter, NaphCare cited confidentiality of medical records and stated that “even if medical records were public and not entirely confidential, the County maintains ownership of the records and NaphCare is prohibited from disclosing these records unilaterally.” 

On May 5, Holguin wrote again that the Pima County Sheriff’s Department is not the custodian of several categories of records Luminaria requested pertaining to NaphCare. Holguin added that the county would work with the Pima County Department of Behavioral Health to obtain records in their custody that are releasable under Arizona public records laws. The Pima County Adult Detention Complex is also continuing to search for additional records, he wrote.

Pima County’s contract with NaphCare, approved by the board of supervisors in 2021, states: “The County is the sole owner of health records for all adult and remanded juvenile patients at the PCADC.” NaphCare’s contract also requires the for-profit medical provider to “keep and maintain proper and complete books, records and accounts, which will be open at all reasonable times for inspection and audit by duly authorized representatives of the County.”

As of May 19, the sheriff’s department has not provided any records in response to this request. 

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Using a loophole

Michele Deitch, an expert on jail and prison deaths, says just because it’s perfectly legal not to report the deaths of incarcerated people recently released from custody, doesn’t mean it’s right.

“It is quite common for jails to use this loophole” to avoid reporting deaths, she says. 

Pima County “is not the first jail to figure out that if they release someone who might die they don’t have to report the death,” says Deitch, who is also the director of the Prison and Jail Innovation Lab at the University of Texas at Austin.

Currently, according to federal law, jails and prisons do not have to report any deaths of people who are not in their custody even if their deaths may be related to their treatment while in custody, she says. Deitch isn’t aware of any state laws in the nation that require reporting people outside of custody either.

“From the agency’s standpoint, it’s not their problem anymore,” Deitch says. “But it should be. Not reporting these deaths is a way to skirt the reporting requirement.” 

She says that because of the loophole, “you miss a lot of systemic stuff that’s going on.”

She says Pima and Maricopa counties’ medical examiners are taking a “very unusual” step in trying to count post-release deaths. She called their effort “impressive.”

The goal is better understanding of incarceration’s immediate and long-term effects on people — how a stint in jail can turn into a death sentence.

For Denise, and other family members advocating for change, it’s a step toward justice — knowing that their loved one’s life counts, how they died matters and who should be held responsible.

“Patterns in custodial deaths can tell us a lot about the internal operations of the jail,” says Andrea Armstrong, a professor at Loyola University in New Orleans and a national expert on jail and prison conditions. “If deaths are not counted or analyzed because the time of death occurred at the hospital, rather than the jail, then our understanding of the jail’s operations is incomplete and limits our ability to prevent future deaths.”

Luminaria reached out to Arizona House Democratic leader Andrés Cano, of Tucson, and Sen. Juan Mendez, D-Tempe, for comment on the intent of state statutes mandating law enforcement’s duties to report deaths tied to a person’s time and care in jail.

Cano did not respond. A spokesperson for Mendez said that the senator would ask legislative staff to begin looking into the matter. 

Jail-related death 

Joseph had been in and out of jail for years. In January 2021, according to Pima County Superior Court public records, he was deemed incompetent to stand trial and was sent to the jail to be restored to competency. 

Records do not show if his competency was considered to be restored or not, but by February of this year, Joseph was back in jail, according to court records. 

Joseph is at least the second person to die after a court ordered jail officials to provide the medical care and services needed to restore them to competency.

A former guard at the jail spoke to Arizona Luminaria about Yunan Tutu, a 26-year-old with mental health issues who had been in and out of jail. After being arrested in June of 2022, Tutu was deemed incompetent to stand for trial. For six months, he waited in jail.

When a doctor checked on Tutu two weeks after Christmas, he was reportedly refusing food. By January 10, 2023 he was dead.

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That was less than a month before Joseph was back in jail, and less than three months before sheriff deputies first took him to the mental health center and ultimately to the emergency room.

While waiting in the triage section of the Banner South emergency room, with sheriff’s officers seeking “medical clearance” for him, Joseph stopped breathing, according to medical records. 

A nurse rushed in and began CPR. Joseph was repeatedly shocked using an external defibrillator. After his heart started beating again, he was intubated. Later that night, a doctor told Denise that her son was brain dead. 

Four days later, on March 25, doctors removed the breathing machine from Joseph and he died.

Confusion about whether or not Joseph was an inmate of the sheriff’s department carries over into how his death should be categorized, and speaks to a gray area in in-custody death classifications. 

All of which is part of the reason why the Pima County medical examiner’s office is revamping the way they count and classify deaths related to people who have been in the custody of law enforcement agencies. 

They will begin counting what Hess is calling “Custodial Related Agency Deaths,” or CARDs. That means they will track both pre- and post-custody deaths and count these total deaths in their tabulations. 

That information will be publicly available in the medical examiner’s dashboard, which tracks in-custody and police-related deaths in the county.

Pima County Chief Medical Examiner Gregory Hess

Hess says that in the next couple months they will update the dashboard to account for the new system for tracking jail-related deaths.

“We need new verbiage,” Hess says. The current system of classifications “doesn’t adequately represent stuff that may have happened to people in prison,” he says. “We need better words.”

Will Joseph’s death fall into the new category? “Absolutely,” Hess says.

The new dashboard won’t include names or other personal information, such as the hospital where people died, like the Arizona Department of Corrections’ public inmate death notification system does. But some of that information will be available to the public upon request, Hess says.

Officials respond

The mounting call for action includes members of the Pima County Board of Supervisors.

“We mourn and regret these deaths and the county administration, at the Board of Supervisors’ direction, has a commission studying jail conditions and how to improve them,” board of supervisors Chair Adelita Grijalva said in an emailed statement. 

Grijalva was referring to the Pima County Adult Detention Center Blue Ribbon Commission, which the county launched in January to study the need and feasibility of building a new jail. Costs for the new facility are estimated to reach as high as $380 million. The commission has met twice so far, and has until August to make a recommendation. 

“It should be noted,” Grijalva said, “that some of the jail detainees enter the system with existing severe, often untreated, health issues. We understand that this is a serious concern for our entire community.”

Pima County Board of Supervisors Chair Adelita Grijalva

In an interview with Luminaria discussing the crisis at the jail, Pima County Supervisor Matt Heinz called the new numbers of jail-related deaths “staggering and upsetting,” saying that the board needs to make it a “priority to do a deeper dive on this and figure out why this is happening.” 

“Do we need to talk to NaphCare?” he asks. “We need to address these to understand completely each and every one of these cases.” 

Heinz is a longtime physician at University of Arizona and Tucson Medical Center who has worked for the White House leading federal health-care reform. In April, Heinz said that he is open to looking at the county managing their own health care and behavioral health in the jail, so they do not rely on a private, for-profit contractor, such as NaphCare.

On May 10, Pima County Attorney Laura Conover told Luminaria the medical examiner had “not personally informed me of this new consideration” of jail-related deaths but that her office would look into the issue. Two days later, after consulting with the medical examiner, Conover sent an emailed statement, referencing the new tracking and counting of jail-related deaths: 

“These stats will be incredibly helpful to me as I continue to advocate that alternatives to jail for treatment are safer, healthier, and more cost-effective,” she wrote. 

Conover’s office represents the sheriff’s department in some lawsuits and is charged with reviewing certain deaths at the Pima County jail, including the case of Wade Welch who died on Aug. 16, 2022 after guards repeatedly shocked him with a taser

The medical examiner’s office ruled Welch’s death a homicide. For months, Welch’s family has called for justice and pleaded for the results of the investigation launched in August into his death

In November, Conover told Luminaria that she’s staying updated on the case and if the law-enforcement officials investigating Welch’s death report “evidence of criminal activity,” the Pima County attorney’s office “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.”

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

Not counting deaths

The effects of incarceration don’t end upon release, Hess says.

“There is an admitted gray area when coding deaths as in-custody or not,” Hess wrote in an email. “Jails tend to draw the line on if they have paperwork officially discharging an inmate from custody prior to their death, or not.” 

Medical examiners “tend to be a bit more inclusive in including deaths as in-custody if a chain of events started in-custody but the death may occur in a hospital setting (for example) and the person may no longer be officially in-custody.” 

Pima County is not the only jurisdiction trying to clarify this gray area. A 2017 study by the National Association of Medical Examiners starts by stating the complexity of determining what constitutes an in-custody death.

“The defining and tracking of any category of death requires a standard definition, consistent criteria for diagnosis, and a reliable way of reporting,” the report says. “The public health approach requires a clear mechanism for capturing death data in order to predict the health of a community as well as establish programs and policy that may be able to decrease mortality and morbidity within the affected community.” 

Hess stressed the difficulty in navigating through the ambiguity, which is why Pima County is adding more nuance to the dichotomy of in-custody or not in-custody. 

Who is in the jail

  • More than 80% of people detained were being held while awaiting trial, according to data from 2011-2014, collected by the MacArthur Foundation.
  • According to 2014 data, most were detained for failures to appear in court; misdemeanor charges; or lower-level felony charges.
  • People of color were over-incarcerated — 9.6% of Black people were being held pretrial, while they only made up 3.3% of the county’s total population, according to 2014 data.
  • In 2020, that trend had gotten worse. According to the Vera Project, Black inmates made up 14% of the jail population and only 4% of the county’s total population.
  • In 2014, 40.7% of Hispanic people were being held pretrial, while they made up only 35% of the county’s total population.
  • In 2020, Hispanic people made up 46% of the jail population and only 40% of the county’s total population.
  • Native Americans represented 6.75% of the pretrial population, while they made up 2.4% of the county’s total population.
  • In 2020, Native Americans made up 5% of the jail population and only 2% of the county’s total population.
  • 8% of Native Americans were held in jail on failure to appear charges.

While the medical examiner is required under state law to provide death investigations and certify death certificates, Hess says the office isn’t required to report any jail death. However, he says, some counties, Pima included, do publicly report certain deaths. Through annual reports and the online public-facing dashboard, the Pima County medical examiner tracks both in-custody and police-related deaths.

The Pima County medical examiner’s office only knows that a person who died was in or had recently been in custody if they were informed by the law-enforcement custodial agency or a separate reporting party, which they then independently confirm, Hess says.

It makes sense for Pima County to align with Maricopa County, which instituted a similar reclassification process at the beginning of 2023, Hess says. The Maricopa County medical examiner’s office said that they recently began counting custodial agency-related deaths, and like Pima County defines post-custody as within 30 days of release. 

Jared Keenan, legal director for ACLU Arizona, says the danger of not tracking post-custody deaths is that the number of people who die only in custody can be misleading.

Though states are required by law to report in-custody deaths to the Department of Justice, the DOJ “has not developed a detailed implementation plan that includes metrics and corresponding performance targets for determining state compliance, or roles and responsibilities for taking corrective action” when states do not comply, according to the 2022 GAO report.

Currently, according to federal law, the death of any person in the custody of a law enforcement agency must be reported to the Arizona Criminal Justice Commission

Law enforcement agencies are required to report deaths on a quarterly basis via an online portal managed by the commission. Andrew LeFevre, the executive director of the commission, explained that his office then reports that data to the DOJ’s Bureau of Justice Assistance. 

“I know there’s been some talk about potentially the feds doing some kind of open records search periodically and then identifying that down into the individual states for us to have something to compare it to,” LeFevre says, about potential accountability if agencies are not properly reporting deaths. 

He says that though to date there have been no penalties issued to law enforcement agencies, the DOJ could withhold federal grant money from local law enforcement.

Hess says they are still reviewing other cases, so the number of people who died shortly after being in the care of the Pima County Sheriff’s Department could further increase from the 18 additional deaths in 2022 and 2023.

He added that the reason they are changing their system to include jail-related deaths is because of the growing community concern: “People (public health, media, law enforcement groups) are interested in different subsets of deaths.” 

The public agency has “the bandwidth to provide more granular reporting,” he says. ”So why not?

The two urns of Denise Mills’ two sons Credit: John Washington

Mia Burcham is a member of No Jail Deaths, a community organization founded by family members of people who died in the jail. Mothers and other loved ones have held vigils and protests at the jail, as well as spoken at public meetings about the deadly conditions and crisis at the jail.

“It’s particularly concerning that it’s hard for families to seek accountability. Both the sheriff and the county attorney have repeatedly passed the buck about deaths,” she says. “No one is taking responsibility for people in the jail.”

Burcham says No Jail Deaths is working to “make the situation more visible. A lot of local politicians seem to be trying to shuffle the problem into the dark. We’re focused on building community.”

She adds that there have been hopeful developments recently with local officials “at least paying lip service to the problem,” and No Jail Deaths hopes to help push this “to becoming an issue that is disturbing to a critical mass of people.”

‘I’m doing it for justice’

Denise sits on her sofa in her small apartment on the south side of Tucson. 

Between jaw-trembling prayers, she says, “Anything I do here, I’m doing for them, for all the people who have passed. I’m doing it for justice.” 

Denise’s words echo those of the mothers calling on elected officials and the criminal justice system for change. For many moms whose children died in the jail or within days of being released from the jail, it is a mission of love. Alone in her apartment, Denise thinks about how medical workers and the sheriff’s officers failed her Joseph in the jail. 

“I don’t know what they did to him in there, but they didn’t keep him safe,” she says. “They didn’t treat him right.”

In front of Denise, on a small glass-top table amid rosaries, a Virgen de Guadalupe candle, and a cookie for sweetness, stand two urns. One for Joseph. One for his younger brother, who died of alcohol poisoning just over a year before Joseph died.


Editor: Dianna M. Náñez Copy Editor: Irene McKisson Research and fact check: Becky Pallack Visuals: Michael McKisson Legal Representation: Ballard Spahr LLP, David Bodney and Matt Kelley

Corrections and Clarifications: An earlier version of this article misstated the cause of death for Joseph’s younger brother. It has been updated to correct that Joseph’s younger brother died of alcohol poisoning.

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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...