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

On Jan. 28, 2022 — one day after 18-year-old Sylvestre Inzunza was locked up in Pima County jail — guards found him unresponsive in his cell. He’d swallowed two blue pills, overdosing on fentanyl inside the jail. Staff pumped nine doses of Narcan into him and transported him to the hospital.

Within five hours, guards took him back to the jail.

Four days later, on Feb. 1, guard Saul Montano arrived to work a 3-11 p.m. shift. Montano later told a review board that Sylvestre had “the appearance of not being very well cared for.”

Montano said Sylvestre looked “unkempt.” The teen “looked like a detoxer.”

The newly-hired guard learned during his long shift that he would have to work a double. He would be on duty for about another 8 hours, until 7 a.m. the next day. Montano later said that working doubles that stretched over 16 hours was something he had to do “all the time” at the understaffed jail.

That night, Montano was responsible for keeping track of 63 people in the jail. Between 10-11 p.m. — at the close of his first shift — Montano violated sheriff’s department policies and left his position, according to public records.

Sylvestre Inzunza, 18. Photo courtesy of his family.

Another guard while delivering breakfast — at about 5 a.m. on Feb. 2 — saw that Sylvestre was not moving. The teenager had overdosed — again inside the jail — on fentanyl. The Tucson Fire Department arrived a few minutes later, finding that Sylvestre “had been dead for an undetermined period of time.”

The accounts of Sylvestre’s last days are based on a March 16, 2022 “Death Review” report conducted by the sheriff’s department and incident reports obtained by Arizona Luminaria through public records requests, as well as court records.

Health care in the jail — including medically-supervised opioid withdrawal management for drugs like fentanyl — is run by NaphCare, an Alabama-based company.

The death review did not specify the nature of Montano’s discipline for his “failure to comply with policy and procedure,” nor did it state NaphCare’s role in providing medical care for Sylvestre. In Pima County’s own medical-care audit of the jail the month that Sylvestre died, officials found that NaphCare was severely understaffed and had failed to provide drug treatment to almost all of the people who needed it.

Citing an ongoing lawsuit, the sheriff’s department did not answer questions about Sylvestre’s medical care or whether Montano still works at the jail. Only one of five elected members of the Pima County Board of Supervisors answered questions about NaphCare’s failing standards of medical care for people who are incarcerated at the jail. 

Families, former workers, attorneys, incarcerated people and civic leaders are increasingly concerned that the silence surrounding abuses at the jail signal a grim pattern of secrecy from an array of elected Pima County officials in the largely Democrat-controlled region.

Amid widespread legal complaints against NaphCare, the county hired the for-profit company in 2021 to manage an estimated $63 million contract. That decision came after the county replaced the previous health care provider, Centurion, when officials canceled the agreement following a breach of contract.

Perhaps the most telling signal that something is seriously wrong at Pima County jail comes from the county’s own audits.

The audits are among the county’s few oversight measures to track medical care for incarcerated people. Many of the people in the jail can’t afford to pay for bail. The overwhelming majority of them have yet to face any criminal charges before judge or jury.

Arizona Luminaria reporters reviewed 20 months of audits by the Pima County Behavioral Health department that track NaphCare’s contractual, legal and ethical responsibilities. The audits are public records and shed light on chronic understaffing and persistent failures to meet standards of medical care for people in detention.

The county board of supervisors are elected to manage public policy in the region, including jail oversight.

Between February 2022 and April 2023, the county’s behavioral health department penalized NaphCare more than $3.1 million for understaffing and failing to provide contractually-obligated health care.

The county pays NaphCare about $1.2 million per month. That number has varied depending on the extent of the financial penalties the county imposes.

Despite their own findings, senior officials with the county’s behavioral health department recently told Arizona Luminaria that they are satisfied with NaphCare’s performance.

“The County takes all allegations of substandard care seriously and investigates each and every allegation,” wrote Paula Perrera, the behavioral health director, in a July 26 email to Arizona Luminaria. “None of the deaths were related to substandard healthcare so any such characterization is misplaced and incorrect.” 

At least eight of the in-custody deaths over the past two years — during NaphCare’s tenure as health provider — were related to drug overdose or complications with withdrawal. Joseph Zarate spent 46 days in the jail earlier this year. He was suffering from diarrhea, nausea and pleading for Gatorade in the jail before he died, according to medical records.

In March, the day after a medical worker found Zarate covered in his own feces and pleading for help, the 29-year-old went into cardiac arrest. He died four days later. The official cause of death was sepsis. 

Amid the repeated financial penalties and persistent complaints of inadequate medical care, Pima County Behavioral Health has repeatedly declined requests for in-person interviews, insisting on answering questions only via email. 

“I am not inclined to grant an interview,” Perrera wrote. 

Luminaria sent repeated requests for comment, including questions about health care the company provides for people in the jail, to a NaphCare spokesperson and to the CEO Bradford McLane. No one from the company responded.

Previously, NaphCare has told Arizona Luminaria that 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.”

Dying in the jail 

In a lengthy 2020 investigative report — prior to Pima County officials contracting with NaphCare for medical care — the Reuters news agency found that jails where NaphCare provided health care had the highest death rates in the nation over a three-year period.

Lawsuits against NaphCare in Pima County and across the nation continue to add up, including a wrongful-death action involving a jail in Spokane, Wash. That case led to a $27 million jury verdict against the company in 2022.

In Pima County, people incarcerated at the jail continue to die at alarming rates. Most recently, on Aug. 1, 41-year-old Joel Loya died in the jail. He was designated for supervised medical care to manage detoxification symptoms, according to a sheriff’s department press release from the same day. So far, in 2023, 13 people have died either in custody or shortly after being released.

In 2022, at least 12 people died in Pima County jail. That’s a per capita mortality rate over four times the national average as of 2019, and higher than New York City’s notorious Rikers Island jail, which saw 19 deaths in 2022. The population of Rikers Island currently hovers slightly below 6,000. The population of Pima County jail is nearly 1,900. 

The Pima County Medical Examiner office has since reviewed 2022 records and has identified another 11 jail-related deaths for a total of 23 people who died that year.

Late last year, following Luminaria investigations into deaths at the jail, the county medical examiner overhauled practices to better track medical care at the jail and count deaths of formerly incarcerated people who die shortly after being released from detention.

In a July 26 email, Perrera told Arizona Luminaria that she disputes findings that Pima County jail, as compared to other jails, has an above-average number of deaths. Perrera did not provide any reason for disputing the numbers.

Pima County Sheriff Chris Nanos also has repeatedly denied that the jail has an above average number of deaths.

Multiple professional statisticians specializing in jails and prisons have confirmed Arizona Luminaria’s calculations of the death rate.

Families whose loved ones have died at the jail have called for oversight to save lives. They’ve also called for closing the jail.

In February 2022, the month that Sylvestre died after overdosing two times within five days, Pima County’s audits found that NaphCare had “appropriately managed” only one of the 22 people inside who were undergoing withdrawal. The audit did not provide names of those who lacked medical care.

That same month, the county gave NaphCare a score of 5%, or five on a scale of 100, for dealing with withdrawals. The county’s thresholds for meeting care typically target a score of at least 90%. For managing withdrawal symptoms, it’s 95%. The county penalized NaphCare more than $175,000 for understaffing, and another $8,000 for failures to provide medical care or notify the county when their patients needed hospitalization.

In emails obtained by Arizona Luminaria through a public records request, Pima County officials expressed concern over NaphCare’s legal history. Gary Fennema, a Pima County employee who restores people to competency to stand trial, flagged an article published in Spokane that detailed a history of lawsuits against NaphCare.

Fennema also referenced a news report from a public radio station in Boston, writing in a May 1, 2023 email: “One of my favorite parts is: ‘Both Correct Care Solutions and NaphCare have boasted in marketing materials or bids that they’ve never lost a legal case. But behind the scenes, they have settled lawsuits totaling millions of dollars, according to court records and news reports.’”

Terri Rahner, Pima County’s Behavioral Health Restoration to Competency Manager, replied to Fennema on the same day: “All these companies are liars in the RFP stage. It’s just blatant.”

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Inzunza lawsuit: “Deliberately indifferent”

NaphCare, the for-profit firm that provides health care to more than 100,000 prisoners in 32 states, has been operating in the Pima County jail since September 2021.

Arizona Luminaria requested all county audits of NaphCare, and was provided records from September 2021 through April 2023. The records show that the county has been aware of consistent understaffing and persistent failures of NaphCare to meet its contractual obligations.

Under the county contract — a three-year term, beginning in 2022 — the company is “mandated to provide quality medical and mental health services” to people detained in the jail.

The jail remains accredited by the National Commission on Correctional Health. Yet, Arizona Luminaria’s review of county audits and statements from former jail employees and people who have been incarcerated, raise questions about conditions, especially regarding staffing and medical care.

NaphCare’s contract with the county specifies that financial consequences should be imposed on the company for not meeting performance indicators specifying standards of medical care.

In October 2022, the county hit NaphCare with its largest financial penalty since the company took over medical care, withholding $366,000 from its expected monthly payout of $1.5 million — docking it nearly 25%. 

Attorneys for Sylvestre’s family allege in a federal wrongful-death lawsuit — their latest complaint was filed in March — that officials charged with caring for incarcerated people at the jail were “deliberately indifferent” and “grossly negligent” of the risks that Sylvestre faced because of his drug use.

The facility failed to safely detox incarcerated people and safeguard them from obtaining illegal drugs inside the jail, according to the lawsuit. The family’s lawsuit on behalf of the 18-year-old argues that the jail was dangerously low on workers serving as guards.

Pima County, Sheriff Nanos, NaphCare, and four guards, including Montano, are named as defendants. Arizona Luminaria reached out to Montano by email and social media. He did not respond.

Similar allegations are repeated in a barrage of other lawsuits — at least 40 — filed against an array of officials legally responsible for caring for people detained at the jail, including the county, the sheriff’s department and NaphCare. 

Pima County itself has repeatedly raised similar issues in its audits of the jail, as the facility has faced persistent complaints from civic and community leaders about how faltering medical care contributes to the deaths of incarcerated people.

However, in a May 9 filing, Democrat Pima County Attorney Laura Conover wrote that claims that jail staff’s actions, including Montano’s, had anything to do with Inzunza’s death, are “entirely speculative.” 

“Low staffing allegations,” Conover wrote, “fail to plausibly allege a direct causal link between an alleged custom and a constitutional violation suffered by Inzunza.”

On April 18, the county attorney’s office asked a judge to throw out the Inzunza family’s lawsuit. The motion states that the jail only had sporadic staffing shortages due to COVID-19, that those shortages can’t be linked to Inzunza’s death and that the county can’t be held responsible for the allegedly negligent actions of a single employee. Since that filing, lawyers for both the county and Inzunza’s family have argued on technical grounds for and against dismissal. As of Aug. 7, the judge has not issued a ruling.

Despite that argument, Sheriff Chris Nanos himself has raised warnings about the jail, citing a 30% decrease in officers, mandatory 16-hour shifts — such as Montano was forced to work the day Sylvestre died — and “staff falling asleep on duty.”

In a December 2022 letter to the Pima County Board of Supervisors, Nanos said the facility faced a “full-blown crisis,” was perilously jammed with prisoners and that support staffing was “critically low.” Nanos urged county supervisors to give jail staff a raise, which the supervisors approved. He also argued for building a new jail, which could cost taxpayers as much as $380 million. 

Pima County jail, on Tucson’s west side, holds nearly 1,900 people in a sprawling complex built four decades ago. Sylvestre was among those who are often detained at the jail while awaiting trial because they cannot afford to pay bail. The 18-year-old’s family couldn’t pay a $50,000 bail for his arrest on an aggravated assault charge.

He is also among 38 men and women who have died since the beginning of 2022 while behind bars there or shortly after being freed, according to the Pima County Medical Examiner records as of early August. Experts say deaths that occur soon after an incarcerated person’s release are a warning sign of a weakness in care by a facility. Of the deaths, 21 were drug-related and at least six people died by suicide. 

The contract also stipulates that NaphCare “must demonstrate a good faith effort to reduce turnover in the health care positions by maintaining competitive salaries and benefit plans and utilizing local and national recruitment resources to maintain appropriate staffing levels.” 

However, audits indicate that NaphCare has not fully staffed health care positions in the jail for a single month since the company began operating.

Pima County Sheriff Chris Nanos talks with Frances Guzman, the mother of Cruz Patino Jr. who died in the jail, at a meeting of a commission formed to study building a new facility. Credit: John Washington

Nanos: “The sad consequence”

In his December letter, Nanos said that understaffing has led to his guards being unable to complete their duties.

“Completing timely rounds is nearly impossible and the sad consequence is increased risk of suicide attempts, inmate violence and an increase in drug abuse,” Nanos wrote.

In June, county supervisors expressed dismay that the sheriff’s department went more than $3.3 million over budget last fiscal year. Most of that excess went to pay guards overtime. In a July 10 letter to the supervisors, Nanos wrote, “I simply ask: am I over budget, or am I underfunded?”

In lawsuits, plaintiffs echo the sheriff’s complaint about insufficient staffing. At least five wrongful death lawsuits point to understaffing being a key part of the problem. The Inzunza lawsuit says that the jail last year had 130 fewer guards on duty than its recommended staffing level — almost 30% under proper levels. 

In a July 21 email to Arizona Luminaria, in response to detailed questions about medical care and other issues in the jail, Nanos said that while “staffing levels have improved” — over the last two years — “the inmate population continues to rise.” The sheriff said he could not speak on certain issues because of pending litigation. In remarks about the crisis, Nanos did highlight the poor condition of the jail and that the staffing has increased from 300 in 2021 to 400 in 2023.

“Should your county jail house those suffering from mental health?” Nanos wrote in the email. “Those suffering from addiction? If so, then I’m going to need a significantly different facility than we currently have.”

According to estimates made by the county’s Blue Ribbon Commission studying options for a new jail, the detention facility’s population could reach as high as about 2,750 incarcerated people by 2024, a 50% increase from today.

Nanos said he is eager for the commission to determine whether there is a need for a new jail. At recent county meetings, community members have repeatedly expressed their fierce resistance to spending hundreds of millions of dollars to build a new jail.

The chart above shows the amount of money Pima County deducted from its monthly payment to NaphCare between February 2022 and April 2023. The reductions are for staffing shortages and failing to meet certain health care and business performance standards. The data to make this graph was obtained from monthly audits of NaphCare provided to Arizona Luminaria by Pima County Behavioral Health. Credit: Reia Li

“What are they doing to fix it?”

Mariah Inzunza, 21, is Sylvestre’s older sister. She laments that responsible parties in the jail — NaphCare, the county, the sheriff’s department — have failed to keep incarcerated people, including her brother, safe. 

“The nurses, the sheriff — everybody working in there — what are they doing?” she said. “The amount of times I see on the news that someone else died in Pima County jail — what are they doing to fix it?”

She is a plaintiff in her brother’s federal wrongful-death lawsuit.

Inzunza said when she first heard that her brother had died, she didn’t believe it. It took her weeks to even come to terms.

“I convinced myself that it wasn’t him,” she said. “I thought they made a mistake.”

As she spoke of her brother, she steered the conversation away from his death and toward memories of his life and what she misses about him.  

“He was really, really kind,” she said. “He treated everyone the same, with respect, no matter what. Even if it wasn’t reciprocated.” 

Sylvestre was a competitive Golden Gloves boxer with an intense focus, but also was “constantly telling jokes, making people laugh.” 

She shared a bedroom with her little brother when they were kids. He would often sing to her in the darkness, making up songs and telling her stories.

Grace periods for accountability

In an August 2021 memorandum to the Pima County Board of Supervisors touting the hiring of NaphCare, then-county administrator Chuck Huckleberry wrote that the NaphCare contract provides the “accountability the County demands.” 

He cited the use of performance indicators, staffing requirements and the “availability of financial consequences should the County’s expectations not be met.”

From the signing of the contract in September 2021 through January 2022, the county granted NaphCare a grace period, during which it did not impose any penalties. Since then, the average monthly deduction from the county’s payment to NaphCare, from February 2022 through April 2023, was more than $210,000.

Not meeting staffing requirements to provide health care for people detained in the jail has potentially dangerous secondary effects not captured in the county’s audits, former NaphCare workers told Arizona Luminaria. 

Three former workers told Arizona Luminaria that despite observing incarcerated people regularly being denied care and medications, NaphCare staff would state in jail medical records that they had responded in a timely manner. The staffing shortages created a dangerous work culture, contributing to a pressure to rush systems of care.

Arizona Luminaria asked Linda Everett, the county’s program manager for correctional health, if she could verify the reports from former NaphCare employees and people in the jail that medical staff responded too slowly to requests for aid or medicine.

“Medical, mental health and dental professionals are licensed practitioners and as such, follow their individual Standards of Practice,” Everett wrote in a March 6 email. “Part of these Standards are to maintain accurate medical records.”

Everett added: “Please know that our office investigates each and every complaint regarding patient care and if the complaint is substantiated we require our vendor to rectify the situation.”

She chose not to call the cuts in Pima County payments to NaphCare for health care a penalty.

“Rather, it is the manner through which the county ensures it is not paying for services that were not received,” Everett wrote.

NaphCare wants break from financial “penalties”

On March 6, NaphCare’s CEO, McLane, wrote to Perrera, the behavioral health director, asking that the county cut the company a break for not meeting medical care standards in the contract.

“We respectfully request that Pima County consider applying a discount to calculated monthly penalties and credits,” McLane wrote in an email obtained by Arizona Luminaria through a public records request.

McLane’s reasoning for the financial break included that the county had failed to credit his firm for work done out of its corporate headquarters in Birmingham, Alabama.

Perrera told Arizona Luminaria that the county denied McLane’s request.

As the problems with medical care have endured, Arizona Luminaria’s examination of the county’s oversight of NaphCare reveals that the private medical care company is falling short of standards outlined in the $62 million dollar contract approved by the Pima County Board of Supervisors.

The contract is up for renewal in September 2025. The county can terminate the contract at any time, without notification, if it finds NaphCare fails to correct chronic deficiencies.

Explaining the contract

The contract states that Pima County “has a legal responsibility to provide health services for individuals held in detention.”

The county “has established certain clinical standards (“Minimum Performance Indicators”) related to evaluating the quality of health care provided to patients.” NaphCare must “cooperate fully with the monthly audit of these Performance Indicators,” as well as “meet or exceed the threshold levels.”

Failure to meet the performance indicators “will result in Liquidated Damages,” the contract states. A detailed chart establishes specific dollar amounts for “Financial Consequences of not Meeting Business Requirement.”

For example, the financial penalty is $5,000 per occurrence each time NaphCare does not notify the county’s Behavioral Health Director and Correctional Health Quality Management Team “of a death or serious adverse event within 24 hours.”

The county may notify NaphCare “regarding chronic deficiencies in its performance or operations,” after which the company “must conduct a multidisciplinary analysis of all deficiencies and submit a formal” corrective action plan within two weeks. 

The county can terminate its contract with NaphCare “at the County’s sole discretion,” should NaphCare fail to correct deficiencies.

Between September 2021 and April 2023, the county audited NaphCare eight times to see whether it was conducting immediate mental-health evaluations to identify people at high risk of suicide. In seven of those eight audits, the county found the company to be in violation. At least six of the in-custody deaths since NaphCare took over medical care in the jail were ruled suicides. 

In the same eight audits, the county reviewed NaphCare’s performance providing treatment to incarcerated people with mental health issues. The company fell short each time.

The county also found that for six out of seven months NaphCare did not meet standards for delivering people their previously prescribed medications as required under contract.

The contract mandates that for NaphCare to meet standards the company must deliver prescribed medications within 24 hours of booking to at least 90% of patients. In September 2022, for example, NaphCare fell short of meeting health care standards, when three of 10 people did not receive their prescribed medications.

Another performance check looked at how quickly NaphCare screened incarcerated people for health issues. When the contract first went into effect in 2021, the county mandated a standard of medical care requiring NaphCare to screen incarcerated people within two hours of their booking.

After a year of NaphCare failing to meet that standard, in 2022 the behavioral health department loosened the benchmark, giving NaphCare twice as much time to complete the screenings.

The following three times the county reviewed NaphCare’s performance on providing health screening for people in the jail — under the newly relaxed standards — the company still failed each time.

Perrera said that the county lowered the screening standard to be in line with the National Commission on Correctional Health Care. She said that they had initially set the standard at two hours as “an incentive for Naphcare” to be “consistent with the County’s desire to provide quality care in the most prompt manner.”

The correctional health care commission has stated that ideally the screening is “conducted within minutes of an inmate’s arrival. However, a good rule of thumb is that it should occur no more than two to four hours after admission.”

An article about the standards on the commission’s website outlines how delays can harm incarcerated people.

“Administrators should consider the risks of not knowing an inmate’s medical condition (e.g., suicidal ideation, prescription medications, communicable illness symptoms, drug and alcohol use and/or withdrawal symptoms) when designing the intake and receiving screening process,” the article states. “Staff need to get an idea of inmates’ urgent health needs, identify and meet any known or easily identifiable needs that require medical intervention, and identify and isolate inmates who may be contagious.”

This chart shows the number of months that Pima County found NaphCare in violation of certain performance indicators from February 2022 to April 2023. Arizona Luminaria edited the descriptions of the performance indicators for clarity. Pima County’s monthly audits did not check for each performance indicator each month. The data to make this graph was compiled from monthly audits of NaphCare provided to Arizona Luminaria by Pima County Behavioral Health. Credit: Reia Li

County puts NaphCare on corrective action plans

Matt Heinz, the only county supervisor who responded to requests for comment about NaphCare’s performance, characterized the county’s reliance on the company after firing the last health care provider as “banging our heads against a brick wall.”

“We’re never going to get to a place where the correctional system is doing what we want by just repeating the same stuff and expecting a different outcome,” Heinz said.

We won’t keep people safe “until we start to look at the correctional system as truly a place of rehab and reeducation,” he said, “instead of just grad school for additional criminal activity and dehumanizing punitive living situation.”

​​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 its own health care and behavioral health in the jail, so they do not rely on a private, for-profit contractor, such as NaphCare.

People in jail should expect the same health care people outside of jail have access to, he said, calling for “reimagining the whole system.”

Under the county policy, behavioral health officials also can impose a reform plan. NaphCare’s contract stipulates that the “county may notify contractor regarding chronic deficiencies in its performance or operations.”

In June of 2022, the county imposed three “corrective action plans” tied to accessing care, initial health screenings and withdrawal and detox protocols, according to a chart the behavioral health department provided Arizona Luminaria in July.

The chart notes, for example, that “detox rounds are not completed every eight hours… as clinically indicated.” The chart’s assessment also notes that staff had not been checking to see if the medications they were administering were working and that multiple staff meetings and trainings to correct the problem, as well as bringing in outside experts, “have been ineffective.” 

The county’s proposed correction was for “corporate leadership” to provide “in-depth education and training,” as well as assigning registered nurses, rather than medical staff with less training, to the units. The county also established that the detox nurse “now lives on the detox units.” 

By the county’s own standard, the corrective action plan has been failing. In all of the county’s five subsequent audits — starting in August 2022 and as recently as March — NaphCare did not meet the performance standard for patients undergoing withdrawal being properly managed.

Another corrective action plan was implemented to address problems with access to care, with the county noting that in at least one case a “patient was punished for seeking health care services.” 

The action plan included identifying which nurses were responding to sick call requests by giving them individual logins for the online system, as well as providing “education around access to care and deliberate indifference.” 

Less than two months after the county imposed the June 2022 corrective action plan, nurses had individual logins and staff received education. By July 21, 2022, the county behavioral department said NaphCare had fixed the problem. However, Arizona Luminaria obtained 111 grievances from a single month, March 2022, about medical care, many of which claimed that sick call requests were being ignored.

In one such request, filed on March 23, someone in the jail writes, “I have sent at least 5 requests saying my medication is screwed up AGAIN and have got no answer, no call to medical, no nothing. I need my heart medication before I have another heart attack that would be 100% preventable had they listened to anyone of my requests and got me my medications.”

The chart from the behavioral health department details county corrective action plans with an August 2022 “target date to achieve compliance goal.” The chart shared with Arizona Luminaria is incomplete. It notes that correction plans started on June 1, 2022, and includes two additional updates and audit findings from June and and July 2022. However, the last update and audit findings, as well as the “date compliance goal achieved,” that follow are blank.

Perrera did not respond to questions about why the chart was incomplete or if her department has continued monitoring the implementation, effectiveness and compliance.

Ranit Mishori is a physician and senior medical advisor for Physicians for Human Rights, a research and advocacy group based in New York. Mishori said in an interview that it served little purpose for jails to conduct audits without repercussions. 

“Essentially, the audits are a good way of monitoring and oversight,” she said. “But if nobody is taking any action based on these audit outcomes, then you know that it’s not going to go anywhere.”

Explaining that it’s a constitutional right to have access to reasonable medical care in jails and prisons, Mishori said, “There are so many reasons why one’s care can be delayed or denied, and that can lead to catastrophic health outcomes and death.”

Consistent staffing problems: “It was dangerous”

The Inzunza lawsuit claims that in February 2022, the month of his death, there was a severe staffing shortage in the jail, with 335 guards keeping watch on up to 1,700 people — or “25 percent fewer corrections officers than what was considered to be fully staffed.” 

Nationally, according to the National Institute of Corrections, there is no standard guard-to-inmate ratio, as proper ratios must be determined on a facility-by-facility basis. 

Understaffing has been the most consistent problem with NaphCare. Every month, the company understaffed the jail by hundreds of total hours, according to the audits. The same month that Sylvestre died, the county deducted about $176,000 from its payment to NaphCare due to staffing shortages.

How we reported this story

Arizona Luminaria reporters reviewed 20 months of audits by the Pima County Behavioral Department, basing its calculations of staffing shortages on the county’s review of NaphCare’s monthly invoices for health services from September 2021 through April 2023. A review of docked payments was based on county-reported financial penalties — for “failures to achieve staffing commitment” and falling short of performance standards — in a payment summary contained in audits.

There were inconsistencies in how the county tracked staffing hours, as some specific positions were tracked some months and not others. Arizona Luminaria reached out to county officials repeatedly asking for an interview to better understand the audits. Those requests were denied.

The month Sylvestre died, the licensed practical nurse chronic care coordinator position was understaffed by 168 hours. The two physicians assistant positions, focused on sick call requests, were understaffed by more than 130 hours.

NaphCare’s substance abuse counselor is a position that should be staffed full time, or 168 hours for the month of October, according to the contract. Instead audits show that a substance abuse counselor did not work in the jail at all in October 2022.

That same month, Terrance Salazar and Benjamin Willhite died, both of overdoses, according to medical examiner’s reports reviewed by Arizona Luminaria. 

October 2022 was the worst month on record for NaphCare based on penalties for staffing shortages, according to audits from February 2022 to April 2023. Hundreds of hours were understaffed for medical care positions, including for Registered Nurse Supervisor (271 hours short), Licensed Practical Nurse (2,463 hours short), Psychiatric Nurse Practitioner (114 hours short), and Psychiatric Registered Nurse (653 hours short).

The same month, the county looked at NaphCare’s performance with regard to whether “patients undergoing withdrawal are appropriately managed.” The county gave them a score of 7%, or 7 out of 100.

In the three months (December 2021, and January and May of 2022) that the county assessed staffing levels for the detox unit, it was always found to be understaffed. 

In December 2021, for example, the detox unit was understaffed by 33 hours.

This chart shows the difference between the hours contracted in NaphCare’s agreement with Pima County and the actual hours in time cards at Pima County jail in October 2022. The data to make this graph was obtained from the October 2022 audit of NaphCare provided to Arizona Luminaria by Pima County Behavioral Health. Credit: Reia Li

Heinz, the county supervisor, was aware of the persistent staffing failures. “I prefer to keep everything in house,” he said, referencing providing health care in the jail from the county instead of outsourcing it to a private company. 

“We have to keep them,” he said, referring to people in the jail, “safe and secure and have the proper health care.” He added: “I don’t like the idea of outsourcing anything.”

Five former NaphCare employees who spoke to Arizona Luminaria all cited low staffing levels as a grave concern. They also said that their training was minimal and that a shortage of expert staff made their jobs even more difficult.

The former employees spoke to Arizona Luminaria on condition of anonymity, as they weren’t authorized to speak on behalf of the company. Luminaria confirmed their former employment by reviewing pay stubs and employment contracts.

One former medical employee said in February 2023 that staff had received “no formal orientation.” In their first weeks of working in the jail, the worker later recounted, “I felt like I was missing a lot.” They added: “Little things can turn critical if you aren’t careful. I know stuff was missed.” 

“There was no orientation,” another former NaphCare worker said also in February 2023. “They put you on the floor with another nurse, and that was supposed to be your orientation. But when you’re working with someone who doesn’t have time to breathe, they don’t have a lot of time for teaching.”

Summarizing the impact of staffing shortages, the worker said: “It was dangerous.”

Mishori, with Physicians for Human Rights, said a lack of training, as well as a lack of experience, for health care workers in jails can lead to problems.

“There’s a lot of decision-making that may not be taking place because of inadequate training,” she said.

“People in jails and prisons are the most marginalized in our communities and very vulnerable. And they rarely have a voice,” she said  “Oftentimes the power struggles between them and whatever authorities are in the jail — whether it’s the medical staff or their correctional officers — can lead to a lot of misunderstanding and ultimately to devastating consequences.”

Many lawsuits

When Sylvestre was booked into jail in January 2022, the teenager was stripped of his clothes and given a full-body scan to detect any hidden items and prevent banned materials from entering the facility.

Nonetheless, in his mere six days behind bars, Inzunza twice obtained fentanyl, surviving the initial overdose — not the second. Fentanyl is an illegal synthetic opioid 50 times stronger than heroin.

Between those two overdoses, jail guards for a time “inadvertently moved” Inzunza back with the general population, according to a March 16 sheriff’s department report obtained through a public records request.  

When jail guards recognized that mistake, they moved Inzunza back to a special “observation/quarantine” pod.  

It was there that Montano, the newly-hired guard in his first weeks on the job, observed the teenager and decided he looked disheveled and possibly in withdrawal, according to the same sheriff’s department report.

Court records filed in July 2022 by attorneys for Inzunza’s family say Montano “took note of Mr. Inzunza’s weakened health condition” but “did nothing to document or alert his colleagues” — all part of a pattern of what the suit calls “systemic failures.” 

The family’s lawsuit argues that NaphCare also is responsible for “systemic failures” and was “grossly negligent.”

While NaphCare was contractually required to “provide 24/7 staffing coverage,” according to the lawsuit, “for certain critical areas in the jail, including the detox unit, there was no properly trained NaphCare employee in the unit on the morning Inzunza died. 

“NaphCare was deliberately indifferent by failing to adequately monitor Sylvestre from 4:00pm on February 1, 2022 through 5:00am on February 2, 2022,” the suit alleges.

On March 14, NaphCare’s attorneys filed a motion challenging the claim on technical grounds. Their arguments included that NaphCare could not be accused of a breach of contract because Sylvestre was not a party to the contract between the company and Pima County.

In emails obtained by Arizona Luminaria through a public records request, a senior NaphCare official referenced communication problems similar to those mentioned in the Inzunza lawsuit.   

“It was brought to my attention there are concerns ‘that collaboration and communication between custody and NaphCare staff is a barrier that is impacting patient care,’” wrote Amber Simpler, the chief psychologist for the Birmingham, Alabama-based company in a Nov. 4, 2022 email to Pima County officials.

In the past three years, the jail, the county and NaphCare have faced a rash of lawsuits filed by prisoners and their families. In all, court records show that plaintiffs have brought at least 40 federal and state suits involving the jail since 2021, alleging a range of abuses, from problems with access to mail to ignored medical issues. Most of the suits were dismissed on technical grounds.

Among the active filings, at least five lawsuits focus on the deaths of incarcerated people. Along with the Inzunza lawsuit, they include the following cases, with information current as of Aug. 7:

  • A suit brought by the mother of Jacob Miranda, 22, who died of a fentanyl overdose on Oct. 11, 2021. The suit in the state courts states that the jail’s alleged failure to provide proper care reflected “a pattern of abuse and neglect” and a “lack of appropriate staffing.” In a March 27 motion, NaphCare’s attorneys argued that intoxicated people are at least 50% responsible for their own death. On May 16, a judge denied their motion to dismiss. On May 31, NaphCare’s attorneys denied all allegations, arguing that any “alleged action or inaction by it or its employees was not the proximate cause” of Miranda’s death. On June 19, Conover, the county attorney representing Nanos, filed court records stating that Miranda was at fault for his own death.
  • A suit brought by the mother of Pedro Xavier Martinez Palacios, 24, who died of a fentanyl overdose on Jan. 14, 2022. The state complaint says the jail failed to provide proper medical care and alleged a “pattern of abuse and neglect of incapacitated and vulnerable adults.” On May 16, attorneys for NaphCare filed court records claiming Palacios was intoxicated and therefore at least partially responsible for his own death. Conover’s July 24 court filings on behalf of the county repeat that argument and state that there was “no breach of duty” in regard to Palacios.
  • A suit brought by the mother of Cruz Patino Jr., 22, who died on Aug. 3, 2021, of necrotizing pneumonia, which can be a symptom of drug overdose. Attorneys for Nanos have argued that Patino was “comparatively at fault for his own death.” A hearing to set a trial date is scheduled for July 2024.
  • A suit brought by the family of Alejandro Romo, 42, who died of an overdose of fentanyl and methamphetamine on May 13, 2022, two days after he arrived at the jail. Staffing at the time was “dangerously low,” the suit says. The case was filed in federal court on May 12 against Pima County, Nanos, and four individual guards, noting the county’s obligation to provide health care to people in the jail.

Beyond the lawsuits, NaphCare faces media scrutiny.

The 2020 Reuters investigative report stated that jails where NaphCare provided health care had the highest death rates in the nation over a three-year period. Reuters found that medical care in jails that rely on for-profit firms was consistently worse than when the government provided care. While some publicly-run systems can be seriously troubled, Reuters stressed that “death rates are higher when health care is in the hands of private industry.”

In response, NaphCare told Reuters it “has never compromised patient care for profit and we never will.” In an interview with the news agency, the firm’s chief executive officer, McLane, said his family-owned company faced no pressure from outside investors and  operated in areas with “the biggest challenges,” such as heavy opioid use.

Kathleen Maldonado poses with a photo of her son Hugh Burford and his daughters in her home in Tucson, Ariz. on July, 28, 2023.

“We thought he was safe”

Two sheriff’s department deputies came to Kathleen Maldonado’s door on the night of Nov. 15, 2022, a week before Thanksgiving, to tell her that her son, Hugh Burford, had killed himself in the jail. She didn’t believe them. 

“You must have made a mistake,” she told the deputies. “That’s impossible. He was in the infirmary.” 

Several months later, sitting at her dining room table on Tucson’s northwest side in the home she shared with her son, the mother says she’s still in denial. Maldonado says she can’t believe her 50-year-old son died four days after he was arrested for stealing toys from a Fry’s grocery store. 

“I keep waiting for him to walk in that door,” she says, flicking a glance at the afternoon sun burning through the door’s metal screen.

According to a sheriff’s department press release from Nov. 16, 2022, Burford tied his socks together and hanged himself in the jail’s infirmary. Officials provided few other details about his death.

One former NaphCare worker told Arizona Luminaria the challenges of working in the infirmary, and how sometimes a single nurse was left alone to manage all of the medical cases. The designed capacity for the infirmary is about 20 people, they said, but sometimes there can be almost twice that many patients crammed into the medical unit. The former employee said that they had only recently been licensed. 

“I’ve only had a little bit of medical training. So I knew how to do it, but I was by myself trying to handle all that,” they said. “It was very overwhelming.”

Photos obtained by Arizona Luminaria through a records request to the sheriff’s department show Burford’s body sprawled on a floor and partially covered by a black blanket. The infirmary cell was in disarray. Emergency medical paraphernalia strewn about. 

A photo of a bed in the infirmary cell at the Pima County jail where Hugh Burford was found dead. Credit: Pima County

A mattress on the floor is covered in a crumpled blanket, a plastic spoon, two orange plastic sandals, and what seems to be food waste. Next to the mattress are crumpled paper bags, papers, miscellaneous trash, and a few toilet paper rolls. 

In another photo, yellow non-slip socks are knotted over the waist-high door between the toilet and the sink. Those are the socks the sheriff’s department said Burford used to hang himself.

The sheriff’s department says Hugh Burford hanged himself with yellow socks. Credit: Pima County

“We thought he was safe,” Maldonado says, sitting in her dining room, clenching her jaw. “He was in the infirmary. And to be honest with you, they are not safe. I expect as a taxpayer in this community and in this state, that if anybody, not just my son, but any single person should be in our facilities, these community facilities should be safe.” 

She’s hired an attorney to file a lawsuit against the sheriff’s department, county and NaphCare.

Her son became addicted to opioids after hurting his back years earlier while working at Home Depot, Maldonado says. His reliance on pain killers began with a percocet prescription and developed to buying percocet on the street and then to smoking the drug. 

The pain from the back injury never went away, his mother says, and neither did his struggle with addiction. 

Burford had graduated from COPE, a program to address substance abuse. By the summer of 2022 he had been clean for a year. Maldonado says he relapsed and had fentanyl on him when he was arrested in November. 

Police recommended burglary charges — a Nerf gun, a Hot Wheel set, some Star Wars items were all taken from the grocery store, according to a Marana Police Department report obtained through a public records request filed by Arizona Luminaria. 

Burford told police he meant to sell the toys for drugs, hoping to make about $30 dollars, according to the same police report.

Burford called his mother from the jail on Nov. 11, 2022 and told her he had been taken to the hospital after having multiple seizures. After a short hospital stay, his mother says, he was taken back to the jail and placed in the infirmary.

“Hugh was decent, gentle, and calm,” Maldonado says. “He was a great guy. He has three grandchildren, the youngest of whom was born just two weeks after he died.” 

Kathleen Maldonado shows off a photo of her son Hugh Burford at his job in her home in Tucson, Ariz. on July, 28, 2023.

Burford worked as a landscaper for the Amphitheater school district. He collected belt buckles, ball caps and key chains. His mother said she tried desperately to find a drug treatment program that could effectively help her son.

“I called Dr. Phil, everybody I could think of,” she says. In-patient treatment centers charged tens of thousands of dollars. She says she could not afford that. 

Maldonado’s son called the day before he died. She remembers the last thing he said: “Mom, get me out of here.”

In November 2022, the month that Burford died, despite being contractually required to staff a substance abuse counselor at least 40 hours per week, the position was left vacant.

That same month, the county’s audit found the facility was short the equivalent of more than five licensed practical nurses or emergency medical technicians and lacked a contractual nurse supervisor as well.

The county audit for November reviewed whether “Patients undergoing withdrawal are appropriately managed.” Officials with the behavioral health department gave NaphCare a 0% score.

The county’s audit found that not one of the 26 people who needed medically-supervised withdrawal management was provided it that month, according to the county audit. Burford was not the only person in the jail to die by suicide that month. Five days later, Amin Shaheed Muhammad Ali also hanged himself.

The county penalized NaphCare $209,316 the month that Burford and Ali died.  

“Had we known that there had been 20-some-odd deaths in that jail,” Burford’s mom says, “we’d have gone down and beat the doors down and dragged him out of there.”

Her gaze — unblinking as she stares at the door — is knowing. Her son is gone.


Editors: Dianna M. Náñez, Irene McKisson Research/Contributors: Craig McCoy, Becky Pallack, Reia Li, Teressa Enriquez Visuals: Michael McKisson Legal representation: Ballard Spahr LLP, David Bodney and Matt Kelley

Clarification: An earlier version of this story undercounted the jail-related deaths in 2023 based on the Pima County Medical Examiner’s database. As of Aug. 9, 2023, 15 people have died either in custody or shortly after being released. The medical examiner has now reviewed 2022 records and has identified another 11 jail-related deaths for a total of 23 people who died that year.

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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...