Five Examples Of Serious Medical Malpractice In Arizona Prisons

An ongoing lawsuit filed in the United States District Court District of Arizona cites many examples of serious and deadly medical malpractice events that have occurred in Arizona prisons.

Lung Cancer

A 69-year-old man died from metastatic lung cancer that first went undetected and then was ignored for years. Multiple red flags should have alerted the prison medical staff to his possible cancer diagnosis but were overlooked. Once clearcut imaging plainly established the diagnosis, the prison healthcare staff repeatedly reviewed the information but failed to act on it. As he “slowly and agonizingly deteriorated,” staff failed to provide him with critical pain management. “He died a horrific and painful death as a result.”

An expert who reveiewed the care (lack of care) provided to the prisoner stated, “I am appalled by a system that allows this level of sustained incompetence and cruelty, and fails to take decisive action to determine the causes of these myriad and horrific breakdowns and to ensure that the people involved in this case do not continue to practice medicine with such dangerous departures from the standard of care.”

Liver Fibrosis

A 60-year-old man who had severe liver fibrosis resulting from hepatitis C, repeatedly informed medical staff of his urgent health concerns and, with no physician-level oversight, died as a result of a severe upper gastrointestinal bleed due to portal hypertension secondary to liver scarring. The prisoner was a patient who was “followed” in the chronic care clinic but that clinic failed to understand his underlying medical conditions and did nothing to identify, diagnose, or treat his increasing hepatic insufficiency and complications of cirrhosis. An expert stated: “This is a classic example of the situation where a patient is seen by a nurse practitioner, a chronic care clinic encounter is completed, but the quality of the encounter is so poor that it completely misses the primary medical problem and completely fails to address his serious healthcare needs … Neither NP Johnson nor any of the RNs realized that the medication [he] was prescribed was killing him … The medication that healthcare staff gave [him] is absolutely contraindicated for people with serious liver disease, and they increased his dose as he became sicker and sicker, until he died – tragically but predictably – of a massive hemorrhage. In addition, none of the standard preventative measures were implemented which could have prevented his massive GI bleed. This was entirely avoidable.”

Gastrointestinal Bleed/Testicular Cancer

A 30-year-old prisoner “presented at least three times with obvious signs and symptoms of serious gastrointestinal bleeding on 5/27/21, and twice on 5/30/21, and was inadequately evaluated and treated every time. The care he received was shockingly poor. It took five days to get him to the hospital, when it should have been obvious to any competent physician that he was having a very serious gastrointestinal bleed and needed an emergency department evaluation immediately. [He] suffered needlessly in the days leading to his untimely death due to the extreme incompetence of medical staff … Once at the hospital, it was found that [he] had a widely metastatic tumor and metastasis to the stomach that were causing the gastrointestinal bleeding.”

An expert who reviewed the young man’s health care at the prison stated, “[His] case is particularly tragic because it is so familiar. In my 2016 declaration (Doc. 1539 at 6-8), I described the cases of three young men who were also all housed at ASPC-Tucson, and who also all received terrible treatment for their testicular cancer.”

Multiple Sclerosis

“Kendall Johnson (189644) received care from a physician and an NP over a period of years, and her case tragically illustrates a pattern of grossly deficient care, failure to utilize a differential diagnosis, and substantial confirmation bias by the clinicians (i.e., the tendency to process information by looking for, or interpreting, information that is consistent with one’s existing beliefs). Ms. Johnson ultimately received a very delayed diagnosis of multiple sclerosis and her treatment was so delayed that the disease progressed irreversibly to the point that she now lives in the ASPC-Perryville Special Needs Unit and requires almost full care for her activities of daily living.”

Spinal Abscess

A 44-year-old prisoner with severe “neck pain” “described his problem clearly and he reported it to medical staff numerous times for almost a month. It is axiomatic that any time a patient presents with a new onset of severe pain coupled with neurological disability they have to be worked up fully for the problem. If they had taken his reports seriously, and attempted to identify the source of the problem instead of simply temporarily treating the pain, medical staff could have caught and treated it early, before it compressed his spine so much that it caused permanent damage. The medical documentation also is poor, rudimentary, and incomplete, with no documentation of a proper neurological exam. Testing for reflexes and assessing for clonus are simple and important tests to identify issues with the central nervous system. This is basic clinical practice that all providers are trained to do – but all [his] providers failed him.”

The expert stated: “These five case studies illustrate several common failings of the healthcare delivery system in Arizona prisons that I observed repeatedly in patient files, including nurses practicing outside the scope of their licenses, nurses performing inadequate assessments and failing to refer patients to providers, providers failing to develop and test differential diagnoses to evaluate the cause of symptoms, providers failing to do basic physical exams, minimal or no involvement of a physician in the care for complex patients, failure to provide adequate pain management to end-stage cancer patients, and unreasonable delays in specialty care, all of which can lead (and, as the examples above show, has led) to unnecessary suffering, permanent harm and death.”


If you or a loved one were injured due to deliberate indifference or the lack of appropriate medical care while incarcerated in a prison, jail, or other correctional facility in Arizona or in another U.S. state, you should promptly seek the legal advice of a local medical malpractice lawyer in your state who handles prisoner/inmate medical malpractice claims and may investigate your claim and represent you, if appropriate.

Visit our website or call us toll-free in the United States at 800-295-3959 to be connected with prisoner rights lawyers in your state who may assist you.

Turn to us when you don’t know where to turn.

This entry was posted on Monday, December 20th, 2021 at 5:26 am. Both comments and pings are currently closed.


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