As soon as I saw the autopsy report I knew something was missing. 

If Joseph Zarate was an inmate of Pima County jail, then why had the 29-year-old’s March 25 death not been counted as an in-custody death? Why hadn’t press releases gone out from the Pima County Sheriff’s Department to inform the public that another person died? 

In April, Joseph’s godmother was the first person to show me the autopsy report. The same day I heard from her, I reached out to the Pima County Office of the Medical Examiner. They quickly confirmed the autopsy report I had seen was conducted and written by their office. They then gave me both the original and an amended report that, notably, did not refer to Joseph as an inmate. 

That amended April 24 autopsy report erases from the public record the examiner’s notes documenting Joseph’s deteriorating health in the jail and any proof of him having been in the jail when guards transported him to the hospital, where he died.

A few days after officials sent me the new report, Pima County Medical Examiner, Dr. Gregory Hess, called me to explain that his office had verified with the sheriff’s department that Joseph was no longer officially an inmate in the jail when he died, which is why his office amended the autopsy report and deleted the words: “29-year-old inmate.” 

During that call, Hess also said that the county medical examiner’s office would be rolling out a new public system tracking jail-related deaths, or what they are officially calling custodial agency related deaths.

The purpose is to not only track the deaths of people who are in jail, but also those who have been released within 30 days, excluding deaths unrelated to a person’s time spent in custody. Hess said the action follows similar steps by the Maricopa County Office of the Medical Examiner, which began counting custodial agency related deaths in early 2023. 

The new system was rolled out in May, utilizing a digital dashboard that previously only tracked in-custody and police-related deaths in the county. The greater transparency meant that the county tracked both pre- and post-custody deaths, paving the way for the medical examiner to count these deaths in the total tabulations and for the public to review this information online. 

Hess told me that the standard system for tracking, counting and publicly reporting deaths related to incarceration is outdated and doesn’t provide the full picture of how and why incarcerated people are dying. The medical examiner said he had 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 jail.

Hess said he was 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 said, to understand why people “die after recently being released from prison, from stuff like overdoses.”

However, in recent months the dashboard, accessed through the Pima County Data Dashboards & Reports website, stopped showing the new information. Currently, it only lists in-custody deaths. Arizona Luminaria asked about the reversal and Hess referred questions to his supervisor Deputy County Administrator Dr. Francisco Garcia.

Garcia told me on Aug. 8 that the county is in discussions with the sheriff’s department and the medical examiner’s office to find the right way to count deaths related to a person’s time spent in custody. Garcia did not provide a timeline for when the county would return to offering the public information about pre- and post-custody deaths. 

What the new system ultimately showed was that there have been many more deaths related to the jail in the last two years than previously known. In fact, under the updated system of classification, Arizona Luminaria reported that the Pima County medical examiner’s office had identified another 11 jail-related deaths — for a total of 23 people who died in 2022.

As Arizona Luminaria seeks to understand why people keep dying in the jail, we want to hear from you.

If you or your loved one has experience in Pima County jail, if you have tips, concerns, questions or comments, reach out to us at You can contact me directly at or on Twitter at @jbwashing.

Protestors follow committee members outside the Pima County Courthouse after the final Blue Ribbon Jail Commission was abruptly adjourned following disruptions by the protestors on Thursday, Aug. 10, 2023. Credit: Michael McKisson

Community wants accountability

The Pima County jail is increasingly reaching a point of tension, fear and calls for action in Southern Arizona communities. At a July 25 Pima County Board of Supervisors meeting, at least seven people stood up during the call to audience session to address the high rate of deaths in the jail. Those community members also opposed the proposal to build a new, and much bigger, jail. 

Two days later, the county’s Blue Ribbon Commission assessing whether or not the new jail should be built had their next to last meeting. About a dozen community members showed up, asking questions about and casting doubt on the idea of building a new facility. That doubt was more loudly expressed at an Aug. 10 commission meeting. 

At a press conference organized by No Jail Deaths before the meeting, Rosanne Inzunza — whose 18-year-old son Sylvestre died of an overdose in the jail in 2022 — spoke out.

“Please, we don’t need a new jail,” Rosanne said. “Let’s use that money for medical care, for more staff. A new jail isn’t going to fix the problem.” 

The meeting itself lasted only about four minutes. Commission members shut it down, saying that they could not hold a productive meeting while community members – seeking to make their message heard after the press conference – entered the room chanting and playing music. 

The backdrop is an alarming rate of deaths that continues in the jail. From 2022 through September 2023, at least 39 men and women have died inside the jail or shortly after being freed, according to records from the Pima County Office of the Medical Examiner.

Numbers of reported deaths at the jail have varied. Reasons for that include: inconsistent reporting by the sheriff’s department; the effort by Hess, the Pima County medical examiner, to scrutinize deaths and count people who died shortly after being released; and families who have said there are more deaths than officials are publicly disclosing.

Despite these grim statistics and what Pima County Sheriff Chris Nanos has himself described as a “full-blown crisis,” the jail largely remains shrouded by unanswered questions. 

Why are so many people dying? What is being done about it? What more can be done?

Joseph Zarate’s story

Questions remained about what happened to Joseph.

First: Why did he die? And even if he had officially been discharged from the jail, if Joseph was still in the presence of sheriff deputies who had transported him to the hospital, why wasn’t he still officially in law enforcement’s custody?

Joseph Zarate, right Credit: Joseph's family

Medical records showed that deputies were still with Joseph in the hospital in a law enforcement waiting room. They were still with him when his heart stopped and medical staff issued a code blue to try and save his life.

I asked criminal justice experts to weigh in. They had questions, too.

“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,” said David Fathi, Director of the American Civil Liberties Union National Prison Project.

And why exactly had Joseph been removed from the jail? 

I set out to find those answers.

I could not have dug into this reporting if Joseph’s grieving mother, Denise Mills, hadn’t trusted me with her son’s story. And if someone hadn’t left her with documents that provided rare insight into a jail system that lawyers in wrongful death suits and county officials say is often cloaked in secrecy.

Denise, like many mothers and families I’ve spoken with, said she wants justice served and an end to the deaths at Pima County jail.

She said Joseph’s medical records from his time in jail had been slipped into her son’s property bag that had traveled with him to the hospital. We don’t know who put those papers into his bag, but they contained the kinds of records for which I had been asking the jail and the jail’s for-profit medical provider, NaphCare, for months — to no avail.

Joseph’s medical records shed light on a wider systemic problem that the public needed to know more about. The pages of notes by NaphCare and other workers were a unique window into the daily struggles of someone locked up and struggling to get help with mental health and other medical needs in the jail.

The first of many medical documents we reviewed described Joseph as desperate and pleading for help behind bars.

On March 20, the day before his release, a medical worker noted in his file: “Pt [patient] is observed lying naked on his back, on a bare bunk. Pt has no mattress or gown. Pt also has smeared, dried feces on his buttocks, hands, and bunk. Cell toilet appears to have brown water in it. Pt gives this writer a thumbs up and says, ‘I’m not suicidal. I need my Methadone. I want a Sgt [sergeant] up here taking care of me.’” 

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

In total, Joseph spent 42 days in Pima County jail.

Neither Joseph’s mom nor the medical examiner knew why Joseph had been released from jail. And the sheriff’s department and the county attorney weren’t answering specific questions about Joseph. Had there been signs that Denise’s son was on the brink of an inevitable medical emergency or death? Had a judge ordered Joseph released? 

Prior to publication, we went to Tucson City Court to try to access public records about Joseph’s case. The problem was, however, that a clerk told us that response times on our public records requests would be anywhere from one day to three weeks. So I went knocking on doors, trying to see if we could expedite the process.

I heard a lot of: sorry, no. Hours before publication, I tried once more. And with some help from a court supervisor, we were able to get the records I’d requested. I photographed them and sent them to my editor. We started reviewing them so I could summarize what I was finding.

The judge, we learned, had repeatedly refused to release Joseph, though his felony charge had been dropped. Prosecutors argued that Joseph should stay in the jail due to “concerns about community safety.” Court records showed, despite being held inside the jail, the reason Joseph was not able to show up to his own court dates via video was that, according to jail staff, he was “not doing well.” Using nearly identical language, the jail twice reported to the court that Joseph was unwell.

Until March 21, Joseph remained in the jail on the judge’s orders. That day, the court held another hearing. Denise asked that her son be released for treatment. The judge agreed. Instead of taking Joseph “to the hospital if released,” as court records stated, Sheriff’s Department officers took Joseph to the Crisis Response Center. Only when the mental health center’s staff declined to take him, did officers then take Joseph for “medical clearance” to a hospital, according to health-care records.

With sheriff’s officers still by his side Joseph went into cardiac arrest, and died within days at the hospital.

After reviewing countless medical and court records, we published on the afternoon of Friday, May 19, less than two months after Joseph had died. That same day, I spoke briefly with the prosecutor in Joseph’s case. They declined to comment.

The following day, Saturday May 20, 38-year-old Louis A. Williams was rushed from the jail to a nearby hospital. He would die four days later. On Sunday, May 21, Caleb Kenowski was found unresponsive in his cell in the jail, and later declared dead.

Read more

Dangerous health care

After publishing our first investigation into the jail last November, more and more people, including former inmates and former jail staff members, started reaching out. People have contacted me from jail scared of what will happen to them behind bars if they get sick. Worried family members have reached out to ask how they can protect their loved ones. And there’s the growing list of calls and emails from loved ones whose son, daughter or spouse died at the jail.

One tip was repeated enough to become an urgent refrain: look into the health care situation. 

As we began digging into health care in the jail, we realized that the county was already doing the same. 

The Pima County Behavioral Health department had been conducting monthly audits of the out-of-state, for-profit, health-care company, NaphCare. The audits, provided by the behavioral health department, looked at staffing levels and a host of other contractually-required performance standards, assessing whether or not NaphCare was doing all they were mandated to do to provide adequate health care to people in the jail.

We asked for the audits from the county, after receiving 15 of them, we began combing through well over 100 pages of charts and detailed information. We built spreadsheets to track dozens of different data points that we were interested in investigating. 

Some findings immediately jumped out at us, including the high monthly financial penalties — nearly a quarter million dollars a month, on average — that the county was imposing on NaphCare. The audits showed the company was consistently failing to meet contractual standards for medical care. But when I asked the officials with the behavioral health department who oversee the contract to walk through what we were seeing, I was repeatedly rebuffed. 

“I am not inclined to grant an interview,” Paula Perrera, the director of the behavioral health department, wrote to me. Her department answered some questions via email. But the lack of transparency made it difficult to explain to the public why the county was satisfied with NaphCare’s performance despite the audits showing chronic staffing shortages and persistent failures to meet contractually required performance standards.

Pima County officials themselves expressed concerns about NaphCare in emails obtained by Arizona Luminaria through a public records request.

Gary Fennema, a Pima County employee who helps restore people to competency to stand trial, flagged 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 that same day, saying: “All these companies are liars in the RFP stage. It’s just blatant.”

Combing through lawsuits

Another angle to this story is the lawsuits. Using the federal court document search engine, Public Access to Court Electronic Records, commonly referred to as PACER, a team of five reporters, including myself, read through more than 40 separate lawsuits that have been filed against the county, the sheriff’s department, or NaphCare, to try to tease out patterns. Currently, PACER costs 10 cents for every page journalists access during research.

Throughout the reporting, it’s been a team effort. Two interns, Reia Li and Teressa Enriquez, as well as Arizona Luminaria’s co-founder and operations executive Becky Pallack, helped build the graphs and comb through the lawsuits.

An outside editor, Craig McCoy, working with The Fund for Investigative Journalism, read through early drafts and helped us wrap our heads around those dozens of lawsuits and the big picture problems at the jail.

Expert story visioning, editing, copy-editing and fact-checking were provided by co-founders Dianna Náñez and Irene McKisson. And vital legal reviews and representation came from David Bodney and Matt Kelley, of the law firm of Ballard Spahr LLP.

Previously, through a public records request we had obtained 111 health-care related grievances filed by people held in the jail. All of those grievances were from March 2023, the same month Joseph died. 

One such grievance, submitted on March 2, 2023, began: “I’ve put in several mental health request and still haven’t been seen. I’ve been in here since 01/23/2023 and I still have not been seen by the provider or started my medication regiment that works for me. I’m now exhausting my administrative remittance. Next will be law suits.”

The grievances revealed people were consistently describing suffering from persistent delays in receiving medication and medical attention. Again, the records pointed to the problem being systemic.

I’ve made numerous other records requests to NaphCare and the Pima County Sheriff’s Department that we hope will shed further light on why people continue to to suffer and die in the jail. I have made numerous requests to see the inside of the jail and will continue to ask public officials to share their perspectives on the crisis.

There are still a lot of questions to answer, and even more to ask. And because our community has made it clear they want accountability and more in-depth reporting about the jail, we’ll keep asking.

Tips, comments, concerns — please reach out to us

With drug addiction gripping our communities. With housing out of reach for thousands. With untreated mental health challenges proliferating. And with few alternatives to incarceration. Will the jail continue to be a place where the most marginalized and vulnerable members of our community are sent? 

Without systemic changes, will people in the jail continue to languish, suffer, and sometimes die?

We at Arizona Luminaria will continue to listen, dig, expose, and shine a light on stories of people who have died in the jail and on people seeking solutions, action, justice, and more than anything — an end to the deaths.

We will continue seeking accountability and transparency from officials charged with caring for the lives of people incarcerated at Pima County jail.

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

Deaths in the Pima County jail


  • Pedro Martinez Palacios, 24, in-custody, died Jan. 14, fentanyl intoxication
  • Sylvestre Inzunza, 18, in-custody, Feb. 2, fentanyl intoxication
  • Brian Chuchill, 41, post-custody, Feb. 4, fentanyl and methamphetamine intoxication
  • Robert Durbin, 67, post-custody, Feb. 11, complications of COVID-19
  • Gabriel Aguilar, 21, post-custody, April 14, fentanyl intoxication
  • Glenda Estrada, 55, post-custody, April 29, undetermined
  • Rosemarie Rivera, 33, post-custody, May 7, fentanyl intoxication
  • Alejandro Romo Jr., 42, in-custody, May 13, fentanyl and methamphetamine intoxication
  • Jonathan Leary, 33, in-custody, July 5, suicide
  • Steven Whinery, 28, post-custody, Aug. 11, fentanyl intoxication
  • Wade Welch, 37, in-custody, Aug. 16, homicide
  • Michael Sfraga, 56, post-custody, Aug. 20, complications of recent blunt impact
  • Avery Frederico, 27, post-custody, Aug. 31, withdrawal complications
  • Terrance Salazar, 30, in-custody, Oct. 3, withdrawal complications
  • Matthew Kmetz, 41, post-custody, Oct. 3, fentanyl intoxication
  • Benjamin Willhite, 41, in-custody, Oct. 6, complications with fentanyl and methamphetamine withdrawal
  • Wayne Brady, 63, post-custody, Oct. 8, bilateral pulmonary emboli
  • Janell Jenkins, 41, post-custody, Oct. 29, heroin and methamphetamine intoxication
  • Daniel Rodriguez, 39, post-custody, Nov. 2, fentanyl and alcohol intoxication
  • Hugh Burford, 50, in-custody, Nov. 15, suicide
  • Amin Shaheed Muhammad Ali, 40, in-custody, Nov. 20, suicide
  • Robet Tsalabounis, 38, in-custody, Dec. 16, peritonitis (complications with swallowing utensils)
  • Emanuel Santizo-Perez, 24, post-custody, Dec. 20, fentanyl intoxication


  • Yunan Tutu, 26, in-custody, Jan. 10, hyponatremia
  • Jose Octavio Flores, 61, in-custody, Jan. 23, cardiovascular disease (he had recently suffered gunshot wounds)
  • Rachel Valcarce, 40, post-custody, Feb. 24, fentanyl and methamphetamine intoxication
  • Jesus Cruz, 38, post-custody, March 25, fentanyl and methamphetamine intoxication
  • Joseph Zarate, 29, post-custody, March 25, sepsis
  • Victor Dagnino, 27, post-custody, March 26, fentanyl intoxication
  • Louie Sanchez, 33, post-custody, April 27, fentanyl intoxication
  • Caleb Kenowski, 22, in-custody, May 21, fentanyl and methamphetamine intoxication
  • Christopher Dillon, 40, post-custody, May 22, fentanyl intoxication
  • Louis Williams, 38, in-custody, May 25, suicide
  • Michael Potenzieri, 42, post-custody, June 3, suicide
  • Jennifer Valenzuela, 24, in-custody, June 27, fentanyl and methamphetamine intoxication
  • Michael McDonald, 39, post-custody, June 29, fentanyl and methamphetamine intoxication
  • David Pruitt-Richardson, 25, post-custody, July 31, suicide
  • Joel Loya, 41, in-custody, Aug. 1, withdrawal complications
  • Casey Krizan, 40, in-custody, Sept. 3, cause of death is under investigation

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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...