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Missed doses of medication. Urgent health request slips left to collect dust in drawers. The health care crisis in Maricopa County's troubled jails is worsening.

New internal documents obtained by Phoenix New Times illuminate the toll that understaffing has taken on the health services in the county's jails. In the fall, New Times found, Maricopa County tapped a group of consultants to investigate its correctional health system. They uncovered serious failures.

The resulting 84-page "Correctional Health Services workplace environment assessment," which New Times obtained, shows that over a three-month period, from September through November, auditors documented nearly 40 occasions in which nursing staff failed to provide any medication to an entire jail. Health needs requests that, according to policy, must receive a response within 24 hours, were regularly left unattended for far longer periods — sometimes for weeks.

Furthermore, wound care, changing bandages, and tending to open sores and cuts was skipped for days at a time.

Experts told New Times the findings could have an adverse impact on patient health. The findings also could expose the county to lawsuits and threaten the jails' accreditation status, the consultants noted.

The issues "might not seem particularly life-threatening, but they absolutely have been," said Ricky Camplain, an epidemiologist and assistant professor at Northern Arizona University who focuses on health in prisons and jails. Medical conditions are common among people in custody, and that would make it "extremely dangerous," Camplain said, to miss a dose of medication.

The six jails in Maricopa County are run by the Maricopa County Sheriff's Office, which is headed by county sheriff Paul Penzone and custody chief Barry Roska. But health care in the jails is managed by another branch of the county, Correctional Health Services, which operates outside the jurisdiction of the sheriff.

In written responses to detailed questions from New Times, Assistant County Manager Lee Ann Bohn said that this spring, the county has taken action in response to the "clinical concerns" identified in the report, which was finalized in February. Most of the recommendations suggested by consultants are being implemented, Bohn wrote.

She said the county has increased correctional nurse salaries by 14 percent and restructured CHS leadership. As a result, Bohn claimed, the county has seen a "consistent decline" in the issues identified in the report. "CHS's goal has always been to provide exceptional care to patients," she wrote. "While the report helped us pinpoint areas to improve, we are not aware of any adverse medical outcomes tied to the concerns identified in the report."

After New Times contacted each member of the county board of supervisors, a county spokesperson said they would not grant interviews or comment for the story. Bill Gates, the board's chairman, did not reply to several written questions in lieu of an interview.

The body that accredits CHS, the National Commission on Correctional Health Care, did not respond to questions about issues at the Maricopa County jails and their accreditation status. Per policy, NCCHC does not comment on specific jail systems or cases, according to the organization's website.

On any given day, there are typically 6,100 people in custody in Maricopa County's jails. Many of them have not been convicted of a crime and are merely awaiting trial. The rest are serving short sentences — typically shorter than a year — for minor offenses, or waiting to be sentenced.

Despite this, jail is not always a temporary place. There are people in the jail system who have been there for years — a decade, even — awaiting trial in complex cases. For these people, CHS can serve as their only source of health care for years.

As in most jails and prisons, medical issues run rampant. According to figures published by CHS on its website, around 23 percent of people in Maricopa County's jails have chronic illnesses — diabetes, hypertension, heart disease. Another 16 percent suffer from a "significant" mental illness, though it's unclear how the county defines this. Among the 6,100 or so inmates, the county also says it conducts around 400 checks each day for people experiencing withdrawal from drug or alcohol abuse. It's not clear how often any given person in withdrawal gets checked.

Medical care in Maricopa County's jails has long been troubled. Court cases over the years have helped shed light on lapses in the medical system, including one lawsuit waged by the American Civil Liberties Union that spanned four decades. The lawsuit, Graves v. Arpaio, dealt with deficiencies across the jails and health system. It focused, though, on mental health care in the jails, which one expert testified suffered "many serious problems."

The Graves case began in 1977, when three men in the county jails brought a suit that alleged myriad issues: overcrowding, poor diet, and harsh, dangerous conditions. By the 1990s, the jails' failing mental health care was a key focus of the suit.

The case dragged on for decades, continually revived as new laws were passed relating to prison conditions and as plaintiffs complained the jails were — still — failing to reach the bare minimum standard of care. Until 2019, the jails were still subject to ongoing court oversight due to the case.

"County and CHS leadership are pleased they were able to meet the expectations of Judge [Neil] Wake in September 2019 to conclude the Graves lawsuit," Bohn wrote of this history.

Under former longtime Maricopa County Sheriff Joe Arpaio, record keeping of medications and mental health issues was "inadequate," according to one 2010 opinion by two U.S. Ninth Circuit Court of Appeals judges in the Graves case. "Sheriff Arpaio does not know which pretrial detainees are taking which medications," the judges found. As a result, inmates on psychotropic meds, for example, were being kept in unsafe conditions.

Legal trouble has not subsided in the years since Graves ended and Arpaio left, court records show. The ACLU has brought another ongoing court battle against the county, alleging it failed to properly protect jail inmates from COVID-19. The county declined to comment on that suit, citing pending litigation.

In 2020, Pedro Esquivel sued the county over an incident in September 2019, claiming he was forced to walk barefoot across hot asphalt on a 106-degree day after being booked at the jail. CHS, according to the complaint in the suit, did not provide Esquivel treatment for the resulting abscess. The infection then spread from his foot. He was hospitalized "repeatedly," after being released, and has "undergone surgical amputations and skin graft procedures," the complaint alleged. It appears Esquivel was never charged with a crime.

In legal pleadings, attorneys for the county denied any negligence had caused his injuries, and claimed that staff had acted in accordance with policy. Last year, though, the suit was settled for an undisclosed amount.

Two other recent lawsuits raised similar claims. One, filed in April in Maricopa County Superior Court, alleges that a man who was clearly ill was not provided medical care for a serious bacterial infection and a rare, life-threatening form of Valley fever — until he was found unconscious in his cell. He was in a coma for two weeks as a result.

The other lawsuit, from 2020, documents the March 2019 case of a man with a heart infection who was given only Tylenol and a "big glass of water" for his symptoms. After a month without treatment, he died in jail.

The county has not yet filed a response in court to claims in the first lawsuit. In the second lawsuit, the county did not contest most of the claims by the man's family about his death, though it denied liability. In fall 2021, all parties mutually agreed to dismiss the case. Details about a settlement are unclear from federal court records.

Calbert Gillett, a spokesperson for the sheriff's office, wrote that the agency would not comment on pending litigation. Gillett did not reply to other questions for this story, including questions about lawsuits that have been settled.

Phoenix Fire Department data shows that emergency services responded 28 times so far this year to the 200 block of Fourth Avenue, where the Fourth Avenue Jail is located. Five times, the fire department was called for a hanging, three times because someone was unconscious, and twice to treat someone who had stopped breathing.

These calls are common, years of fire department data show. No other year for which data is available, back to 2014, indicated there were more than two or three calls for a hanging in the same period, however.

According to documents and multiple sources within MCSO and CHS, the quality of health care has worsened further since the onset of the pandemic in 2020. This is hardly a surprise. Over the last two years, the county jails have suffered from serious understaffing, as New Times has previously reported.

Prior reports by New Times showed that the jails had implemented new emergency protocols as a result of the understaffing. People in custody say that lockdowns, resulting from too few detention officers on shift, are frequent. These lockdowns are referenced in the new documents obtained by New Times. On two occasions, the lockdowns prevented medications from being distributed, auditors found.

The understaffing has taken a toll on correctional health as well.

"The project team considers Maricopa County to be operating under crisis standards of care at the time of our assessment," the consultants wrote of this understaffing. "While the county has been aggressively working to mitigate any effect these shortages will have on operations ... there is only so much CHS can do given these exceptional challenges."

Over the last year, 400 out of Correctional Health Services' 512 total positions have typically been filled at any given time. According to the most recent figures provided by the county, 394 positions at CHS are currently filled. That's approximately a 23 percent vacancy rate, a slight improvement over the vacancy level the consultants identified at the end of November, which was around 26 percent.

Last October, Maricopa County commissioned a "workplace environment assessment" of CHS, in response to "growing concerns regarding staff levels and reports of missed medication passes," the county said. Chandler-based government consulting firm 65th North Group was contracted to carry out the assessment.

The resulting report, which was released on February 13, focused, in large part, on coping with severe understaffing. It provided several dozen recommendations for how to improve operations, including restructuring CHS's leadership, upping employee pay, and formalizing protocols for reporting failures in health care.

The report also provides a window into how seriously CHS's operations have been impacted.

On May 3, 2021, Diane Smith submitted a grievance to the medical staff at the Estrella Jail, the county women's jail where Smith is in custody.

"No medications for the evening were administered to any inmate in A-300," wrote Smith, a former nurse, referring to the section of the jail where Smith stayed. Smith, 53, faces murder charges in the shooting of her husband, who she claims she believed was an intruder. She has not yet gone to trial.

In her complaint, Smith detailed "alarming side effects" she experienced from missing her heart and blood pressure medication. "Several inmates are stating that they alerted guards throughout the night of the situation, but it was not remedied," she wrote. "This infraction needs to be reported to the state." The grievance, according to the materials Smith provided to New Times, was closed with only a brief note apologizing for "any perceived unsatisfactory patient care" and a promise to bring the issue to a supervisor.

New Times provided the grievance number and other documentation of the complaint to the county, which said it could not comment on details of care for any particular patient. Federal law prevents health providers from disclosing health information without a patient's consent.

The county isn't required, according to the consultants, to report such failures to the state. But because of how muddled internal reporting is around these practices, it's not clear whether the missed medication that night was even brought to the attention of CHS leadership. Bohn claims that county leadership became aware of the broader medication issues in early October. But Smith had submitted her complaint about the issue five months earlier.

In the jails, patients with prescriptions receive medication twice a day, in the morning and evening. This is called, colloquially, "med pass." The process is often lengthy: Nurses must deliver medication to hundreds of people, and often are required to ensure that people take the medicine, checking the insides of their cheeks or crushing the pills in water and watching them drink.

Smith's account aligns with what consultants discovered in their investigation of health services in the jails. Understaffing has grown so severe, according to the report, that med passes are frequently missed, sometimes for "up to three days in a row."

"Numerous clinical staff reported in interviews that they have missed medication passes on several occasions," the consultants found. When they looked at the available data, they found that med passes were missed 38 times in the three-month period of September through November.

This means that, on these nearly 40 occasions, an entire jail did not receive prescribed medication, either in the morning or evening. One source at CHS familiar with the report and with nursing operations confirmed this, saying: It meant that "nobody, not even the critical ones, got done."

The source, like other county employees who spoke to New Times for this story, is not authorized to speak to the press, and requested anonymity for fear of retaliation.

It appears that missed medications are often kept quiet, even internally.

"Discussions with staff at a clinic revealed that they are told to document a missed medication pass in their own computer file, without forwarding that information on to anyone else," the consultants wrote. Because of this, it was "possible" that missed medications were going unreported.

Regarding the consultants' discoveries around reporting protocol, Bohn wrote: "This is inconsistent with CHS's core philosophy. Patient care concerns are expected to be reported consistently and completely."

It's not fully clear who might have known about the missed medical care before the report was commissioned in October. In the months before the report was finalized, the former CHS director, Tania Lynch, left her position. The county confirmed that Lynch resigned on December 17.

One source familiar with what occurred said the revelations about missed medication contributed to Lynch's departure. In response to questions from New Times about this allegation, the county said, "We don't discuss personnel matters."

The report raises "very serious concerns for patients," said Elizabeth Kizer, a health care administration and policy lecturer at Arizona State University and former correctional health director in Pinal County.

The regular provision of medication, Kizer said, was "very important," given that most inmates have no access to medication otherwise. It was a basic standard of correctional health care, she said.

One MCSO employee, who worked as a detention officer for many years under Arpaio before moving to an administrative role at the agency, was shocked to hear that missed med passes had grown so common.

"What possible justification could they ever have — ever — for that?" the source said. "I can't believe heads aren't rolling for that." In the past, the source recalled staying past their shift to ensure medication was distributed. "Because it's an essential thing," the source said. "It's not like — ah, the next shift will get it. No. You have to do med pass."

But one current detention officer who spoke to New Times stated that missed medications had become routine. When New Times brought up the figures referenced in the report — 38 times in three months — the officer said, "I would've thought that it was more."

At one jail, med passes were missed "once a week," estimated the officer, who maintained, "It's definitely gotten worse over the last year and a half. It's just how CHS has operated for a while."

The county disputes this, saying that in May, only one small group of people in a single jail experienced a missed medication pass — a significant improvement from the dozens of missed passes in the winter. "CHS is committed to continuous improvement with a goal of no missed passes," Bohn, the assistant county manager, wrote to New Times.

Accounts from people in custody in Maricopa County indicate that the severity of the issue differs from jail to jail — but that it has continued in recent months. In all, six people, including Smith, said they had experienced missed doses of medications at least once. Several said they had witnessed a missed dose sometime this spring.

Christopher Consales, 47, currently incarcerated in Watkins Jail awaiting trial on drug possession and money laundering charges, told New Times that he had missed medications frequently when he was at Lower Buckeye Jail, but that things had improved since being transferred. Danielle Walker, 37, who is currently at Estrella Jail, estimated she had noticed a missed med pass "20 times" in the 10 months she had been at the jail. Walker recently pleaded guilty to one count of burglary, and is awaiting sentencing.

Multiple people in custody also said that, even when medications weren't missed, nursing staff was stretched so thin that they were forced to start delivering prescriptions in the early hours of the morning — 1 a.m. or even later.

"It's bad when they miss it, but I think it's even worse when they do it so late that it's very close to the next one," Walker said, recalling a time when the evening medication was delivered at 3 a.m., and the next dose was given just a few hours later, at 7 a.m.

The full impact of these missed medications and late doses in Maricopa County is not yet clear. But experts say it could be dangerous — and it certainly flies in the face of accreditation standards for health care in jails. In other parts of the country, inmates have died after missing a medication dose in prison, including one recent case in Oakland, California, where a man held on $2,500 bail died shortly after he missed a shot of antipsychotic meds.

"Some of the conditions that are especially prevalent among incarcerated populations really require not missing dosages of medication," said Alexander Testa, a professor at the University of Texas at San Antonio who studies public health in correctional settings.

"You get really high rates of things like HIV, hepatitis C, and you get really high rates of mental illnesses, ranging from depression to more severe forms of psychosis," Testa said. And when it came to medications like antipsychotics, Testa said, missed doses "can be really consequential," with the potential of severe side effects.

The report on Maricopa County's correctional health found other key failures as well. Requests for medical attention — which inmates can submit electronically or on paper — were being neglected for weeks, despite standards that require a response within 24 hours.

"A report from nursing staff was that numerous health needs requests were found in a desk drawer – 'weeks' after they were completed and filed by the inmate," the consultants wrote.

People in the jails pointed this out as well. Some provided numbers and timestamps of grievances to New Times documenting their experiences. People in custody describe filling out these requests, putting them in a black dropbox, then waiting for days or weeks for any response — if they get one at all.

Consales, the man incarcerated on drug charges, said it took medical staff four months to schedule an ultrasound to check for blood clots, which he is supposed to receive regularly. Kassie Garcia, 30, currently serving time at Estrella Jail for a probation violation, said she was left with a severe, untreated infection for two months after medical staff ignored her multiple requests for a sexually transmitted infection test.

"It was horrible," Garcia said of her experience. "All this time, I've been sitting with this."

These delays raise several issues, the consultants noted. For the county jails to maintain their accreditation, they must address all medical grievances in 24 hours. And, "more importantly," consultants wrote, this was needed "to reduce risk of possible medical harm coming to a patient."

The report offered approximately 75 recommendations to the county to fix these issues, which Bohn says the county is now implementing. They included: "universally applied process" for reporting missed or delayed medication passes; improved pay for correctional health staff; and restructured leadership of the department. Missed medication, the consultants said, should be brought to the attention of the director within 24 hours of any missed pass.

Kizer, the former Pinal County health director, agreed with the recommendation regarding missed doses. "The medical doctors who oversee the operation would be most aware of the acute cases where there could be troubling consequences of a missed dose," she said.

"CHS's entire executive team has been engaged in the implementation of these recommendations and progress has been reported to staff," Bohn said. She provided an email that she says she sent to staff in April, providing an update on actions the county had taken, including a new employee recognition program and improvement in the "backlog of grievances."

Kizer was skeptical of other suggestions in the report, however, including one suggesting that doctors take patients off their meds — a "medication holiday" — whenever possible, to improve efficiency of medication distribution. "I can't imagine this being a policy solution that would be applicable to the entire population on one or two days a week," she said.

The county says it has rejected this recommendation. "CHS has declined the 'medication holiday' concept as not recommended for our patient population," Bohn said.

In the time since the consultants began digging into the issues at CHS, the agency has gotten a new director: Lisa Struble, who was appointed interim director in December, after Lynch departed. In April, Struble was given the permanent position.

Struble declined an interview request for this story. A spokesperson for the county, Fields Moseley, explained that while Struble "is familiar with the report and the recommendations," an interview would "put her in a position of answering for her predecessor's decisions."

Throughout her comments to New Times, though, Bohn emphasized that Correctional Health Services has turned things around in the few short months since the release of the report. By her telling, county leadership was unaware of the medication issues until October, and has since worked tirelessly to right the ship.

If this is true, it's not yet reflected in accounts from people inside. Garcia said she had not witnessed such improvements in her months in jail this spring. She described a half dozen requests and grievances being left unanswered. All that jail staff could tell her, she said, was that they just couldn't keep up.

"That's all they tell us," she said. "'Medical is behind.'"

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