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Arizona prison health care trial: Psychiatrist’s assessment of system at odds with prisoners' testimony

Arizona Republic

Sandra Day O'Connor U.S. Courthouse in Phoenix

The landmark trial Jensen v. Shinn began Nov. 1 in Phoenix, the latest chapter in an almost decade-long struggle to determine whether Arizona’s prisoners are getting the basic health care they are entitled to under the law.

The federal trial pits Arizona against the people held in its prisons, who argue in a class-action lawsuit that the medical services they receive are so poor, they constitute cruel and unusual punishment.

The state’s health care contractor, Centurion, is the latest in a string of companies that have failed to pass muster with the courts.

Here's the latest:

Nov. 19: Psychiatrist’s rosy assessment of health care system at odds with prisoner testimony

Who testified: Dr. Joseph Penn

Dr. Penn is a correctional psychiatrist who manages health care in Texas prisons. He was called as a witness by the defendants. He reviewed health care records and conducted tours to assess the quality of care provided in Arizona prisons.

What did he say?

Penn told the court he believed there is appropriate, adequate access to medical care, mental health care and medications in state prisons.
He acknowledged there was a “breakdown” in the system that led to a prisoner suicide he reviewed.
Penn told the court prison health care staff work with patients to create treatment plans.
Penn said it’s hard to find psychologists to work in the prisons.
He believes the prison offers more access to counseling than is available to the general public.
Penn said he did not find any evidence in the prison health care system of people recording information or making health care decisions that were beyond their scope of practice or licensure.
He claimed patients can reach out to a statewide administrator to ask for medicine that is not provided in the Centurion formulary.
Penn told the court he believed security staff attempted to call mental health staff to talk with a patient before using pepper spray on them, but they are not always available.
Penn said the Arizona prison suicide rate, or the number of suicides per 100,000 prisoners, is low compared to other states.

Cross-examination

Dr. Penn said he charges $8,000 a day to testify in out-of-state cases.
After spending the morning speaking glowingly of the National Commission on Correctional Health Care accreditation standards, which he called the “Rolls Royce” of standards, Dr. Penn admitted that he was the board chair of the NCCHC until November 1, 2021.
Arizona pays NCCHC to be reviewed and accredited and then pays yearly fees to maintain the accreditation.
Dr. Penn said Centurion gives financial support for NCCHC conferences and provides grant funding for the NCCHC. Centurion is Arizona's privatized prison health care contractor.
Plaintiff attorneys read from notes made by Dr. Penn’s consultant, who had reviewed incarcerated patient medical records. Those notes included the following statements: “Died by suicide by hanging. Ambulance team refused to go to patient’s location due to policy and he was brought to medical on a gurney.” “Waiting almost 3 weeks to have psychotic complaints addressed.” “On suicide watch 6/21/19-7/8/19 but saw no psychiatric provider until 7/18/19.”
Judge Silver asked Dr. Penn if he thought it was appropriate that the patient had not been seen by a psychiatric provider. He said that it could be the patient was seen by a mental health worker with a lower level of training and licensure.

Why it matters

Dr. Penn spoke very enthusiastically about the state of health care in Arizona prisons and the accreditation organization by which they are judged. But he later admitted to previously working for that organization less than three weeks ago.

— Jimmy Jenkins

Nov. 18: Judge questions use of force on seriously mentally ill prisoner

Who testified: Jeffrey Van Winkle

Van Winkle is the warden of the Florence state prison who oversees operations of maximum custody units. He was called as a witness by the defendants.

What did they say?

In response to the settlement agreement in 2014, he said the prisons put recreation enclosures into maximum custody units, gave prisoners more access to programming and made the windows in the cell doors larger.
Van Winkle said that prisoners in maximum custody have varying amounts of out-of-cell time, access to programming and recreation. The highest custody levels are not guaranteed time out of their cells.
Van Winkle said the prison operates in 12-hour shifts to help with staffing deficiencies.
He said a pest control service regularly sprays the prisons, but “we do have issues with bugs — we live in farmland out in Florence.” He noted that this summer has been the worst in 22 years. He said they try to “eradicate bugs the best we can.”
He said prisoners often complain about food portions.
Van Winkle said Dustin Brislan, an incarcerated person who previously testified, made hundreds of complaints about staff retaliation against him through a prisoner hotline. Van Winkle said investigations did not find any merit to those complaints.

Cross-examination

Judge Silver asked Van Winkle about the repeated use of force on Rahim Muhammad, an incarcerated person who previously testified about his mental health care treatment in the prisons. Prison staff used pepper spray on Muhammad and shot pepper balls at him more than 40 times, many times while he was committing acts of self-harm. Van Winkle said it is the security staff’s job to keep a prisoner from harming themselves, and chemical spray is a tool they use to stop that behavior. “Obviously it wasn’t working,” Judge Silver said. “Did you go back and tell anyone it wasn’t working?” Van Winkle said he discussed the problem with Centurion staff every day. “They are well aware of it,” he said.
Van Winkle said self-harm incidents are spontaneous, so they don’t always have mental health staff available to treat the prisoner.
Van Winkle said Muhammad’s self-harming behavior was a “spontaneous event,” despite acknowledging it had happened at roughly the same time every day.
Plaintiff attorneys showed Van Winkle prison records that indicated classes and programming had been canceled for days at a time.
Van Winkle said Florence has been understaffed since he began working there in 2016.
Despite out-of-cell time being canceled for prisoners, Van Winkle confirmed the Department was still reporting the hours in compliance records submitted to federal court as though the prisoners had actually been able to leave their cells.
Van Winkle told the judge the Department believes they can count canceled out-of-cell time as compliant with the settlement agreement stipulation if the time was canceled due to staffing shortages.
He said that necessary signatures were missing from documents attesting that prisoners declined to go to recreation.

Why it matters

Van Winkle’s testimony further confirmed that state prisons are chronically understaffed. Echoing testimony from a different warden, Van Winkle told the court about discrepancies between actual out-of-cell time being offered to prisoners and what the staff records as out-of-cell time. Judge Silver seemed skeptical of the prisons’ repeated use of pepper spray on Rahim Muhammad.

Arizona Department of Corrections Medical Director Grant Phillips’ testimony was cut off at the end of the day. His testimony will resume on Friday.

— Jimmy Jenkins

Nov. 17: Prison health care workers confirm low staffing levels

Who testified: Dr. Bobbie Pennington-Stallcup

Stallcup is a psychologist and a mental health program director for the Arizona Department of Corrections. She was called to testify by the defendants.

What did they say?

Stallcup monitors contract requirements with Centurion and ensures DOC practices are in line with national standards.
She also monitors compliance with court-ordered mental health performance benchmarks.
Stallcup reviews cases of incarcerated people who died by suicide to see if the deaths could have been prevented.
After noting an increase in self-harm incidents, Stallcup said she developed programming to reduce the behavior among incarcerated people.
When incarcerated people arrive at a prison, Stallcup said they are given a mental health intake screening to address their needs.
Stallcup said they have increased the number of residential treatment beds, which can provide better mental health care.
Stallcup told the court the prison health care system develops a treatment plan for incarcerated patients to address their specific symptoms.
Corrections officers are provided with suicide prevention training, according to Stallcup. She said staff members who work in specialized mental health units receive three additional days of training.

Cross-examination

Mental health workers at the Eyman complex told Stallcup there was not enough staff to do their jobs properly and she said she was concerned about it.
Stallcup expressed concern that Centurion had not fully staffed the health care contract at several prisons.
During her employment, Stallcup said there has never been a time when all of the mental health staff positions were completely filled.
Stallcup said Centurion provided her with staffing reports that were inaccurate and did not represent the actual number of full-time employees working in the prisons.

The standout quote

“Staffing is critical. You can have the best plans on Earth, but it doesn’t matter if you don’t have the staff to carry them out.”

Why it matters

Stallcup’s experience and position in the prison health care system give her a valuable perspective, and her testimony made clear that she was concerned about overall staffing levels and the quality of care being provided to patients.

Who testified: Dr. Elijah Jordan

Jordan is the Yuma prison medical director for Centurion. He was called to testify by the defendants.

What did they say?

Jordan said there is one full-time doctor on-site at the Yuma prison.
He told the court that prisoners are submitting more health needs requests now that they are able to do so with a tablet.
Jordan said they treat a lot of patients with diabetes and high blood pressure, as well as cancer.
He said there is a backlog for patients who need to see a GI specialist.
Jordan said the pandemic impacted them at Yuma “dearly,” making it more difficult for patients to access nurses and doctors.
Jordan said they have nurses translate for patients who speak other languages.

Cross-examination

Jordan said he worked as the acting medical director at the Winslow prison at the same time he was the medical director at Yuma.
He said Yuma is not equipped to handle a patient who needs acute care, and that they do not have an in-patient facility.
Jordan said nurses were not using the correct assessment tools with patients.

Why it matters

Jordan admitted he was the medical director of two different prisons at the same time, furthering the case made by plaintiffs that the health care system is understaffed, and it is causing harm to incarcerated patients.

Warden Jeffrey Van Winkle’s testimony was cut off at the end of the day, so he will continue on Thursday.

— Jimmy Jenkins

Nov. 16: Corrections director claims prisoners have better access to care than he does

Who testified: David Shinn

Shinn is the director of the Arizona Department of Corrections. He is a named defendant, and he was the first witness to testify for the defense.

What did he say?

Shinn told the court he believes the prison health care system provides greater access to care than services that are available to people in the community.
Shinn described corrections as a “challenging business.”
Shinn testified that running the Arizona prison system was “by far one of the most challenging assignments I have ever had” in a professional career that he began as a corrections officer in 1991. But Shinn said he had a “tremendous willingness to achieve success and make the lives of the men and women in our custody better.”
When asked what he had done to increase the quality of health care in the prisons, Shinn pointed to the addition of staff to the state’s health care monitoring bureau, which oversees the state’s contract with Centurion of Arizona.
Despite its history of performance failures in Arizona, Shinn spoke glowingly of Centurion, saying it had done “an extraordinary job” in general, and specifically during the COVID-19 pandemic.
Shinn said Centurion’s management of the pandemic response had produced “exceptional results,” citing a 99% recovery rate among infected prisoners.
Of Centurion, Shinn said: “There is virtually nothing we will not do to help them succeed.” But when asked how the director was holding the company accountable to live up to its contractual obligations, he had no answers.

Cross-examination

Shinn admitted that shortages of corrections officers and health care staff were impacting the delivery of care, but he said he was focused on total systemic improvements, instead of individual facilities.
Shinn said health care costs for the department had nearly doubled since the privatization of services more than a decade ago, while the prison population has declined. He said the state currently spends approximately $7,700 per prisoner, per year on health care.
Shinn confirmed that some prisons have nearly 50% staff vacancy rates, which affects the provision of health care.
Shinn told the court he believes being incarcerated in an Arizona prison was one of the safest places to be during the pandemic: “I believe it’s been proven and evidence based — yes.”

The standout quote

“They often have greater access to care than I do as a private citizen,” Shinn said of the people in Arizona state prisons.

Why it matters

In the past, the Department of Corrections has attempted to deflect blame onto its health care contractor. Yet, despite years of continued performance failures, Shinn praised the efforts of its current contractor, Centurion.

Better care? Arizona Corrections director claims prisoners have better access to health care than he does

Who testified: Larry Gann

Gann is an assistant director at the Department of Corrections, where he monitors the department’s contract for health services in the prisons.

What did he say?

Gann told the court that the department has developed a traveling troubleshooting team that looks at performance measures that different prisons are struggling to meet to help them come into compliance.
He found that each facility had different processes for achieving court-ordered performance measures and said he has been working to implement a more unified system.
Gann said 64% of prisoners in Arizona state prisons are on some kind of medication.
In fiscal year 2021, Gann said there were 302,000 health needs requests submitted from Arizona state prisons. He said this number increased after the department suspended co-pays during the pandemic.
Gann said it has been difficult to find off-site specialty care providers for the department to work with.
Every prison is laid out differently, which Gann said makes it difficult to establish one staffing model for all of the health care facilities.
Gann said it has been difficult to maintain staffing numbers because the prisons are competing with other health care sectors in Arizona as well as with higher-paying offers from other states.
Gann told the court that Centurion has paid $17 million in sanctions and $4 million in staffing offsets since the beginning of its contract with the Department of Corrections. The sanctions are for failing performance benchmarks, and the offsets are used to repay the state for unfilled contract positions.

Cross-examination

Gann acknowledged that the Centurion contract has never been fully staffed.
Despite being in charge of monitoring the contract, Gann said he cannot track the number of full-time health care employees working in the prisons.
Gann said the department relies on Centurion to determine how many health care staff members are needed
When there isn’t enough health care staff, Gann said people start cutting corners and it can impact proper documentation practices.
Gann said the Tucson and Yuma prisons have serious staffing problems and were recently forced to cancel opportunities for prisoners to see a nurse.
He found some prisons were not properly distributing insulin to diabetic patients.
Gann said he is unable to reconcile staffing reports provided by Centurion with payroll records to monitor its contract compliance.

The standout quote:

Gann said he is “not a fan of Centurion’s staffing tracking.”

Why it matters

Gann is in charge of making sure taxpayers are getting their money’s worth out of the prison health care contract, but he testified that he was unable to verify numbers provided by Centurion to hold the company accountable.

— Jimmy Jenkins

Nov. 15: Deputy warden testimony casts doubt on DOC records

Who testified: Deputy Warden Lori Stickley

Stickley is a Deputy Warden at the Eyman prison complex, SMU-1, which houses prisoners in the highest custody level. She was called as a witness by the plaintiffs.

What did they say?

Stickley confirmed the Department of Corrections policy of keeping prisoners sentenced to life in prison at the maximum custody level for two years, regardless of their disciplinary record.
When prisoners are reclassified, and given a new custody level, Stickley testified they are not always given notice of the change, or if the level remained the same.
Stickley testified that critical security staffing positions are often vacant, and the health care system is short staffed, resulting in the cancelation of recreation time and programming for seriously mentally ill people.
The prison is so understaffed, Stickley said they changed the rules so that officers only were required to conduct wellness checks on prisoners once every hour.
Stickley confirmed that her staff was recording prisoners receiving “out of cell time” when they had not actually been allowed to come out of their cells.
Plaintiff attorneys showed Stickley records that indicated prisoners at SMU-1 didn’t receive access to showers and recreation for days at a time. She could not explain records that indicated prisoners had gone for four days without being served dinner.

Cross-examination

Stickley said some inmates are housed at SMU-1 for their own protection in what is called “protective custody.”
Stickley told the court programming was often canceled because Centurion did not have enough staff.

Why it matters

Stickley’s testimony that the prisons were falsely reporting out-of-cell time was a damning admission that casts doubt on the validity of all other prisoner movement records presented by the Department.

Who testified: Deputy Warden Anthony Coleman

Coleman is the Deputy Warden of the Rast Unit at the Lewis Prison, which houses high custody level prisoners. Coleman was called as a witness by the plaintiffs.

What did they say?

Coleman confirmed that some prisoners are transitioned back and forth so much between mental health watch and maximum custody that they are known as “frequent flyers.”
Coleman told the court that there is no Department of Corrections policy that prevents severely mentally ill people from being held in maximum custody.
Plaintiff attorneys asked Coleman to confirm records of people who were reclassified to lower custody levels, but kept in maximum custody. Coleman said this happens due to a lack of lower-custody beds at the unit. He said sometimes people spend days or even weeks waiting on a lower custody bed to open up for them to move into.
Coleman reviewed records that showed the prison was recording prisoners as refusing recreation, but not getting their signature as proof of the refusal. Instead, only one correctional officer, instead of the two that are required, signed the refusal for the prisoner.
Plaintiff attorneys showed Coleman documentation indicating prisoners did not receive dinner for several days in a row.

Cross-examination

Coleman said he is unable to do anything about the lack of lower custody level beds which keeps some prisoners in higher custody levels.
Coleman told the court he believed the problem was poor documentation, not prison employees failing to do their jobs.

Why it matters

Coleman could not explain discrepancies in log sheets and reports he was provided from the Rast unit, calling into question the integrity of the Department’s documentation process.

— Jimmy Jenkins

Nov. 10: Medical expert describes 'shockingly poor' care

Who testified: Dr. Todd Wilcox

Wilcox formerly worked in health care in the Maricopa County jails. He has been the Salt Lake County Jail medical director for the past 26 years, and provides expert testimony in correctional health care litigation. Wilcox is a witness for the plaintiffs. His testimony began Tuesday and lasted through Wednesday.

What did they say?

Wilcox testified about a report he submitted to the court that gave specific case study examples of what he called “shockingly poor” health care.
He based his findings on interviews with people incarcerated in state prisons and a review of medical records.
Wilcox told the court about a 30-year-old incarcerated man who experienced significant delays in care. After alerting health care staff to a lump on his testicle, the man’s diagnosis and treatment were delayed for months. Wilcox said health care staff failed to recognize the tumor, lost the patient's records, and misinterpreted test results. After surgery to remove a tumor, and a cancer diagnosis, the patient was not sent back to the hospital for a follow-up examination. The cancer spread to the man’s stomach and eventually killed him.
Wilcox told the court the death was "shockingly preventable" because "testicular cancer is one of the most successfully treated cancers that is out there. If done in a timely fashion, the death rate is extraordinarily low."
According to Wilcox’s review of records, he found the prison health care system was not learning from its mistakes: “There should have been substantial discipline — there should have been an intervention.”
"The errors made were catastrophic. These are egregious errors. And the response was not directed in any way to implement change that would prevent it from happening again."
Wilcox said the Arizona prison health care electronic records system is extremely challenging to use and the clinical data he reviewed was “scattered” and difficult to navigate.
According to his review, Wilcox said nurses have been empowered to make decisions about access to care in the prison health care system, which is contrary to the way the system should work. He said nurses lack the training and licensure to be making such decisions: “The nurse ends up being the final decision maker for requesting a provider visit — that is inappropriate. It creates barriers. And it’s outside the legal scope of a nurse’s practice.”
“Can you imagine in the community, if you schedule an appointment with your doctor, and you’re met in the lobby by the nurse who does an assessment on you and sends you home? And you’re not allowed to see your doctor? That just doesn’t exist in the scope of health care anywhere.”
Wilcox described another patient who requested treatment for severe pain for weeks and had to call for an emergency medical response three times before he was finally given adequate care. The patient lost sensation to the right side of his body, lost control of his bladder, and couldn’t walk. When he was eventually seen by an outside provider, the patient was taken to emergency surgery for a significant neurological injury. The man required two months of recovery in the prison infirmary.

The standout quote

“The system is terrible. If you have higher end medical needs, you are at serious risk for harm and, in some instances, death.”

Cross-examination

Defendant attorneys stressed that Wilcox’s experience with correctional health care is predominantly working in jails, not prisons.
Attorneys for the state said the department and its health care provider are requesting proposals for a new records management system for prison health care that would improve upon the current system, which plaintiff witnesses like Wilcox have criticized.
Defendant attorneys questioned the randomness of the medical patients Wilcox interviewed and focused on in his report.
Wilcox was questioned about whether he had interviewed enough patients to determine whether the problems he identified were truly systemic.

Why it matters

Wilcox said the cases he evaluated exemplified the harm caused to the plaintiffs by significant delays in the provision of care. He told the court he believed understaffing was a factor in the poor standard of care.

— Jimmy Jenkins

Nov. 8: Incarcerated people say correctional officers encouraged them to commit self-harm

Who testified: Jason Johnson

Johnson is a witness for the plaintiffs incarcerated at the Eyman prison. He is classified as seriously mentally ill and diagnosed with depression.

What did they say?

“Some days I get really low and it’s hard to pick myself back up.”
Johnson said he was in a mental health unit where he was getting adequate treatment, but was then transferred to a higher custody prison for disciplinary reasons: “I don’t think it's fair – you shouldn’t be taken away from something that was working. I need all the mental health therapy I can get. I’m trying to keep from coming back to prison.”
Johnson said programming, recreation and showers are frequently canceled due to "staffing shortages." He said he is forced to bathe in his sink in his cell.
When therapy is provided, Johnson said it is usually only offered at the front of a cell, with no privacy: “You don’t want to talk about your feelings or your family. You don’t want to put vulnerable information out there because other prisoners start calling you a sissy and it makes you uncomfortable.”
Johnson told the court about a process known as "Kickstarting" in which officers and sometimes even mental health staff "push their buttons" and "take advantage of their triggers."
He testified officers mistreat "very low functioning" people held in isolation, call prisoners names, pepper spray them, and twist prisoners’ arms until they scream.
Johnson said the prison frequently "runs out of trash bags" for two to three days, so he is forced to try to flush uneaten food and garbage down the toilet to prevent mice and roaches from overrunning his cell.
Johnson works as a porter cleaning other prisoners' cells. He said he is constantly cleaning pools of blood and feces from isolation units. He said many severely mentally ill prisoners become so filthy they are taken away by officers and their clothing is cut off their bodies.
Johnson said he has only been outside for recreation once in the past five months.

The standout quote

"I heard officers encouraging self-harming behaviors. I have seen officers taunt inmates into self-harm. They will get into an argument with an inmate, then empty a whole can of pepper spray on them, go into the cell and rough them up more."

Cross-examination

When defendant attorneys showed Johnson documents indicating he had been out more frequently, Johnson testified under oath, repeatedly, that his signature had been forged and the documents were falsified.

Why it matters

Johnson accused the state of falsifying movement logs and he testified that placing him in a more restrictive housing situation was harmful to his mental health.

Who testified: Dustin Brislan

Brislan is a named plaintiff and testified from the Tucson prison.

What did they say?

Brislan provided the names of more than 10 officers he accused of taunting him and encouraging him to self-harm, a tactic known in the prisons as “kickstarting.”
"Kickstarting is where an officer or mental health staff push your buttons - they know your triggers - and get you to react. It happened many times."
Brislan said he would often cut himself with rust from the isolation cells while on constant suicide watch, while correctional officers were watching and encouraging him to do so. He said the officer would watch him and not act to stop him.
"The officers actually encourage me to cut myself. They say they want to see how bad I can get. They heard stories about me and wanted to see how seriously I could hurt myself. They know exactly how serious I am. There's a lot of them that do it."
Like previous testimony from incarcerated people with severe mental illness, Brislan told the court officers used force against him while on constant suicide watch. He said they used several cans of pepper spray which he called "foggers."
Brislan described the use of pepper spray on him while on suicide watch in isolation units: "It turns the whole room orange. It gets on your skin and it feels like a bad sunburn for hours."
Brislan told the court he was testifying as a named plaintiff despite a fear of retaliation.

The standout quote

"I am a voice for other people who can't defend themselves. I feel that I need to speak up for those who don’t know their rights. I feel obligated as a human being to do this."

Cross-examination

Brislan told attorneys for the state he is now, after years of substandard care, finally getting weekly individual and group therapy: "But I want to know - why did it take so long? I'm so mentally bad right now - I'm drowning."
He said while the current therapy he’s receiving is the best he’s ever experienced, prison staff has repeatedly threatened to take away his mental health treatment if he testified against the state.
“I'm at the edge of a pit right now - it's a place I've been before. And they're threatening to take my therapy away again because I'm testifying. I'm terrified."

Why it matters

Brislan is another example of an incarcerated person who said they have struggled for years to get the proper mental health care to keep them from harming themselves. Brislan gave specific names of prison staff who he said encouraged him to harm himself, which would run completely against the stated goals of the Department of Corrections.

Who testified: Martin Horn

Horn is a former jail and prison administrator who now works as a litigation consultant. He was a witness for the plaintiffs.

What did they say?

Horn submitted declarations to the court about the security classification system in Arizona prisons. He said he based his work on prison tours, prisoner interviews, and reviewing videos and documents.
“There were an awful lot of people in restrictive housing in Arizona prisons. The policies and procedures governing the system are difficult to follow, complex and convoluted.”
Horn said the conditions he observed were “harsh and severe and inconsistent with what the profession believes is the appropriate standard of care.”
Horn told the court the Arizona Department of Corrections doesn’t know how long prisoners spend in the most restrictive custody levels, which posed a problem: “If you can’t measure it, you can't manage it.”
Horn testified there are no policies keeping seriously mentally ill people out of the highest custody level, maximum custody, even though isolation poses a specific risk to that population.
Horn said Arizona prisons calculate custody levels based on many factors including crimes committed, previous history, escape history, disciplinary records and the severity of the sentence. The prisons then come up with a score for a prisoner, and the higher the score, the higher the custody level they are assigned.
But Horn said many prisoners' custody levels are “overridden” using factors that were already considered, which he said leads to “overclassification.”
Horn’s review found that while prisoners’ custody levels are periodically reviewed, the prisoners are often not told the results, nor given a chance to appeal decisions, keeping them at high custody levels for long periods of time.
“If they don’t tell you you have a right to appeal, you’re probably not going to appeal.”
Horn found a Department practice of keeping prisoners sentenced to life in maximum custody for their first two years of incarceration was “an unnecessary waste of resources for no good reason.”
Horn reviewed cases of prisoners who had been held in maximum custody for nine and 10 years without any disciplinary infractions.
Horn found some prison units had recorded periods of time where 80% or more of the maximum custody population had “refused” outside recreation, which led him to believe the prison staff was improperly recording the refusals.
Horn reviewed videos of maximum custody prisoners on suicide watch being pepper-sprayed by correctional officers, which he said was “painful to watch.”
“This is a situation where a counselor or mental health professional could have been called before the chemical spray was applied. As with any use of force, I think it should be the last resort.”

The standout quote

“Prisons are very expensive public resources. They have a profound impact on the people who live there and the rest of society. We have to pay attention to how we use those resources - especially in Arizona, where we are suffering from a staffing shortage.”

Why it matters

While Horn touched on many of the same issues as previous experts who have testified, plaintiff attorneys said his experience as a correctional expert was essential to understanding the flaws of the custody system in Arizona prisons.

Horn’s testimony was cut off for the day, and his cross examination will continue on Tuesday.

— Jimmy Jenkins

Nov. 5: Deputy warden says no limits for isolation in prison

Dr. Stefanie Platt

Platt is a witness for the plaintiffs and a psychologist. Platt worked as Centurion’s Regional Director of Mental Health for Arizona.

What did they say?

Platt said current mental health staffing levels are not enough to meet court-ordered performance benchmarks, nor enough to provide adequate levels of care.
Platt worked as a high-level administrator for Centurion and for Corizon, the former healthcare provider for Arizona prisons. She said there was never a time during her employment for either company when the contracted mental health positions were fully staffed.
Platt said there was a discussion in late 2020 about hiring additional staff to specifically deal with rising numbers of self-harm incidents in the prison, but Centurion never hired the extra staff.
She gave several examples where correctional officers reacted inappropriately to mentally ill patients. Platt said they should be given special training to deal with that population. She said correctional officers working constant suicide watch don't receive any special training.
Platt talked about the role of behavioral health techs, a position that is tasked with a wide variety of duties, and how they have few requirements for education or training. She said the techs do things like walk the units conducting wellness checks and run therapy groups.
Platt said she was part of a mortality review committee that looks at deaths and suicides in prisons to see what went wrong. She said that while the committee makes recommendations, there is no way to follow up and check to see if they are implemented.

The quote

“Mental health staff at the vast majority of the prisons expressed concerns about the volume of their workload. Their morale was generally low. People said they felt overworked and undervalued."

Cross-examination

Defendant attorneys brought up a number of improvements Platt was able to implement during her employment, including the creation of a suicide prevention committee and the introduction of a training program to teach de-escalation tactics.
Defendant attorneys said Centurion was providing a new recruitment incentive to deal with understaffing.
Defendant attorneys said additional training is in fact offered to officers who work with mentally ill prisoners

Why it matters

Platt’s testimony continued the narrative that all aspects of the Arizona prison health care system are understaffed, and prisoners are being harmed as a result.

Deputy Warden Travis Scott

Scott is a Deputy Warden at the Browning Unit, a maximum custody unit with around 700 people on average, at the Eyman prison. He oversees many incarcerated people held in the highest level security classifications.

What did they say?

Scott testified over the course of several days. He spoke about his experience running a unit that has been the topic of previous testimony regarding the use of isolation and solitary confinement.
Scott told the court there are no formal limits on the amount of time people spend in isolation and restrictive custody settings, and there are no precautions taken or exceptions made when placing a mentally ill person into maximum custody.
He said there are several different types of custody levels and steps within those levels that incarcerated people are assigned based on multiple factors. He said there are instances where prisoners are unable to lower their custody level even if they are displaying good behavior.
Scott said his team conducts a step review process for every person in maximum custody every week, reviewing prisoner behavior and disciplinary records, but said no one takes notes.
Scott said the DOC does not track how long people spend on average in maximum custody, or how long they are on each step.
Scott confirmed that one prisoner had been in max custody for 10 years even though he had no disciplinary infractions during that time.
Scott confirmed several instances when his staff had failed to perform temperature checks of cells, take prisoners to recreation, and had not allowed them to shower. He said every time a prisoner leaves their cell, they must be strip-searched.

The quote

Scott told the court there were instances when one night-shift officer was assigned to six control rooms at one time, leaving hundreds of inmates completely unmonitored.

Cross-examination

Scott told defendant attorneys that in many instances prisoners placed in restrictive housing have committed severe assaults on staff or other prisoners.
Defendant attorneys had Scott clarify the differences between enhanced security and restrictive housing, which he said are both used for safety purposes.
Scott said it was important for prisoners to have out-of-cell time and access to programming: “It helps decrease tension among the inmates. It makes the prison a safer place to work. It makes the inmates less agitated and keeps them occupied."

Why does it matter?

Scott oversees a prison that houses many of the prisoners in Arizona living in the most severely restricted conditions, which plaintiff attorneys say causes them harm.
Scott testified to critical understaffing in the prisons, which he said impacted the ability to provide mentally ill prisoners with programming.

— Jimmy Jenkins

Nov. 4: Who testified on Day 4 of the trial

Dr. Craig Haney

Haney is a witness for the plaintiffs. He is a professor of psychology at the University of California, Santa Cruz, who studies the impact of solitary confinement and isolation in prisons. Haney was a lead researcher on the Stanford Prison Experiment.

What did they say?

Haney called Arizona’s extensive use of solitary confinement and isolation “very harsh” and “among the most severe in the country.”
Haney said mentally ill patients are especially at risk when subjected to isolation.
Haney told the court that human beings are “wired to connect. Our connections with others provide us with a sense of identity; a sense of self."
“Isolated confinement is painful and it causes suffering. It can be damaging, irreversible and life-threatening because it can lead to self-harm and suicide.” He said that more than half of the suicides he reviewed from 2015 to 2021 took place in isolation housing units.
Haney testified about recent tours of Arizona prisons and described isolation units at the Lewis and Eyman prisons with no windows and solid steel doors that prevent prisoners from communicating. He said prisoners live in these cells "more or less around the clock." He documented that prisoners living in isolation at the Eyman prison had made "peanut butter traps" to catch roaches and rats in their cells.
Haney described cages that prisoners are locked in while wearing restraints during sessions with mental health counselors at Eyman prison. He said prisoners often decline counseling sessions because they don't want to be locked in the cage.
Haney said prisoners refer to the brief mental health care encounters they receive as “drive-bys.” They told him counselors will often quickly pass their cell and ask for a thumbs up instead of spending time evaluating them.
He said he spoke to juveniles committed to the Department of Corrections. They told him they had not been allowed to go outside for recreation for three weeks: "The Arizona Department of Corrections' isolations practices create a very substantial risk of harm to juveniles ... One told me he couldn't sleep, another told me all he does is sleep. This is taking enormous risks with a young person's psychological well-being."
Haney testified that most prisoners held in isolation units are not given much recreation time. When they are, it's usually in a small concrete block pen.
Haney said Arizona should adopt limits on the amount of time prisoners can be held in isolation. He found that many incarcerated people had been held in isolation for months or even years.
Haney said prisoners who are seriously mentally ill, juveniles or pregnant should be completely excluded from isolation practices except in only emergency situations.

The quote

"Prisoners in isolation sometimes tell me they are not sure if they exist anymore because they haven’t had any contact with others."

Cross-examination

Defendant attorneys accused Haney of conflating custody classification levels and detention status levels in his discussion of conditions in the prisons.
When attorneys asked Haney about the Stanford Prison Experiment, he said the study would not be done today because it would be deemed unethical.
Defendant attorneys claimed the number of prisoners held in maximum custody has declined in recent years and faulted Haney for not reviewing that data.
Defendant attorneys said prisoners in isolation can watch TV, use tablets and purchase commissary items, and they disputed the amount of out-of-cell time prisoners are given.

Why it matters

Haney’s testimony highlighted one of the main plaintiff complaints, which is that Arizona uses isolation extensively on incarcerated people, causing specific harm to seriously mentally ill patients.

Rahim Muhammad

Muhammad is a witness for the plaintiffs and is currently incarcerated at the Tucson prison. He has been diagnosed with PTSD and schizophrenia.

What did they say?

When asked how has living in a maximum custody unit impacted his mental health, Muhammad replied: “I'm all screwed up.” He told the court the conditions he lived in were “appalling and inhumane. I feel less than.”
Muhammad told the court he has been at the highest, most restrictive custody level since 2014, despite good behavior. He said in some prisons he was only allowed to have recreation time once a week and allowed to shower twice a week.
Muhammad has spent most of his time in prison in isolation, which he says has had a negative impact on his mental health: "If I can't interact and socialize with anyone, I can't keep the voices in my head away."
Muhammad told the court he's spent more than $200 requesting mental health treatment, because Arizona prisons charge incarcerated people $4 to submit a "health needs request" to receive health care.
Testifying to the brutality of his treatment in isolation cells, Muhammad says he was pepper-sprayed more than 40 times. He accused COs of beating him, holding him down with a knee on his throat, making profane comments to him and saying things about the size of his genitalia.
Plaintiff attorneys showed the court a video where correctional officers threatened to pepper spray Muhammad if he continued to self-harm while he was on constant mental health watch: “Muhammad if you bang your head again I'm going to spray you.” The video showed the COs pepper spraying him. Muhammad said he remembered none of what transpired in that video, telling the court he was "blacked out" and "very distraught."
Plaintiff attorneys presented another video of a different incident where correctional officers shot Muhammad with pepper balls at very close range through the food slot of his constant watch cell after ordering him to stop harming himself. In the video, Muhammad tells the officers that voices in his head tell him he has to hurt himself to prevent someone from raping his daughter. The officer responds: “You are choosing to bang your head against the wall. We will keep shooting you. We will gas you every day. These are behavioral choices you are making."

The quote

"I hear voices that tell me to hurt myself and hurt others. I have aggression issues. I see things. I can’t sleep, sometimes I sleep too much.”

Cross-examination

Defense attorneys said since Muhammad has been at the Tucson prison for the past two months, he has had access to programming, recreation and counseling sessions.
Muhammad told defense attorneys he is now on medication that allows him to be more stable, but that he “had to fight to get back on it.”

Why it matters

Muhammad’s history of denial of care and the prison's repeated use of force against him reinforces the plaintiff’s accusations that extensive use of isolation has detrimental impacts on seriously mentally ill patients.

— Jimmy Jenkins

Nov. 3: Who testified on Day 3 of the trial

Dr. Pablo Stewart

Stewart is a witness for the plaintiffs. He is a psychiatrist and correctional psychiatry expert.

What did they say?

Stewart said mental health staffing numbers are “grossly inadequate” at several Arizona prisons and told the court a shortage of correctional officers is also impacting health care.
He said that many patients who had died by suicide had experienced very short mental health encounters before their death and said that a significant number of suicides occur in isolated housing units.
"I was saddened but not surprised by the descriptions and photographs of the conditions at Eyman. Memorably, this included the graffiti within the entrance to the suicide watch unit, that read, 'Don’t go suicidal. This place sucks. Please help me.'"
Stewart said he observed people on suicide watch. One such patient, despite being on constant watch, was able to remove 10 surgical staples used to close a self-inflicted wound and swallow them, causing his colostomy bag to rupture.
Stewart reviewed videos of an incarcerated person at the Eyman prison with serious mental illness. In his review, he said that staff used pepper spray or pepper balls on them for a period of 15 days in December 2020.
Stewart said he reviewed emails between prison administrators showing employees of Centurion, Arizona's prison health care contractor, approved this behavior and encouraged a prisoner to commit acts of self-harm.
On a tour of the Eyman prison, Stewart discovered a cell for seriously mentally ill patients covered with blood. "The people living in the adjacent cells reported that the previous evening, the man in that cell cut both of his arms and perhaps his legs, and hit an artery."
Stewart reviewed a case where a corrections officer told a prisoner experiencing psychosis that his self-harming behavior was a choice, and the officer threatened to tase the patient if he continued banging his head against the wall.
Echoing Tuesday’s testimony from Laura Redmond, an incarcerated woman, Stewart found there were no translators available for deaf patients, nor for Spanish-speaking patients.

The quote

“It's hard for me to adequately express how significantly mentally ill the patients I encountered are.”

Cross-examination

Defendant attorneys accused Stewart of selection bias and said previous court findings have characterized his work as speculation, containing errors. They also accused Stewart of not providing patients with a non-confidentiality warning before speaking with them, as required.
Defendant attorneys said some staffing vacancies noted by Stewart are being filled by part-time workers and overtime work.

Why it matters

Stewart’s testimony centered on a recurring theme at the trial: Arizona’s prison health care system is understaffed.
Interviews Stewart conducted with prisoners and case files he reviewed of incarcerated patients supported the plaintiffs’ claims that people in Arizona prisons are subjected to substandard levels of mental health care.
Stewart testified about the negative impacts associated with Arizona’s use of solitary confinement on seriously mentally ill prisoners.

Eyman Deputy Warden Travis Scott's testimony was cut off again and is scheduled to resume on Thursday.

— Jimmy Jenkins

Nov. 2: Who testified on Day 2 of the trial

Ronald Slavin

Slavin is a witness for the plaintiffs and is incarcerated at the Eyman prison. He is classified as seriously mentally ill, diagnosed with psychosis, bipolar disorder, schizophrenia, and major depression.

What did they say?

Slavin told the court he started hearing voices when he was hit in the head by a car at age 6 and has suffered from auditory hallucinations his whole life.
Slavin said he has access to counseling for just a half-hour, once a month, and has no access to mental health programming or group therapy. His repeated requests to transfer to a special unit for people with serious mental illness have been denied.
Slavin’s prison counselor suggested he “listen to a podcast” to deal with his serious mental illness.
Slavin told the court he wasn’t getting enough help to address his serious mental health issues.

The quote

“I don’t mind listening to a counselor. I don’t mind taking meds. But to a certain extent, other treatment is needed.”

Cross-examination

Slavin said he has been provided medication but he continues to hear voices and still struggles with other mental health issues.
When defendant attorneys accused Slavin of refusing treatment, he said it was because the counselors kept repeating the same ineffective advice over and over again.

Why it matters

Slavin’s attorneys say the repeated denials to be transferred to a unit for prisoners with serious mental illness, as well as the substandard care he testified to, bolster their claims.

Laura Redmond

Redmond is a witness for the plaintiffs and is incarcerated at the Perryville women’s prison. Classified as seriously mentally ill and has been diagnosed with schizophrenia and bipolar disorder.
Redmond is deaf, and her primary language is American Sign Language.

What did they say?

Redmond said she became deaf at 15 months old and is “profoundly deaf” in both ears.
She said her medical care is poor because she generally does not have access to a sign language interpreter during healthcare appointments in the prisons. This has also prevented her from getting a cochlear implant.
Redmond said she suffers from behavior issues and negative thinking and has a hard time sleeping: “I cry a lot”.
Redmond testified remotely from the Perryville prison via teleconference, but the video call dropped several times.

The quote

“I don’t understand what they’re saying to me. I’m always frustrated and I am not able to ask questions.”

Cross-examination

Defendant cited several instances in Redmond's medical record where it had been recorded that a language interpreter was provided. Redmond disputed some of the records and said she didn’t remember being provided with an interpreter in the other instances.
Redmond said some of her counseling sessions had been longer than the few minutes that she previously testified to.
Defendant attorneys said that the doctors found she might not be a good candidate for a cochlear implant because she has been deaf since childhood.

Why it matters

Plaintiff attorneys say Redmond was deprived of her right to be an active participant in her medical and mental health care.
They say the lack of interpretation services during her healthcare encounters affected her ability to receive constitutionally adequate care.

Deputy Warden Travis Scott's testimony was cut off at the end of the day and will resume Wednesday.

— Jimmy Jenkins

Nov. 1: Who testified on Day 1 of the trial

Kendall Johnson

Johnson is a witness for the plaintiffs and is incarcerated in the Perryville Women’s Prison.

What did they say?

Johnson said she entered prison at age 19 in 2004 as a healthy young woman. In 2017, she started to experience numbness in her legs and feet. She repeatedly requested medical treatment for several years as her symptoms progressed.
She experienced several falls that resulted in broken bones and eventually lost the ability to write and walk. In 2020, she was diagnosed with multiple sclerosis.
Johnson wrote health needs requests begging for proper treatment, but she didn’t get it until May 2021. She uses a wheelchair, is nearly immobile and has trouble speaking. Now Johnson is confined to a special needs medical unit at the prison.

The quote

“I tried to get help but it was like hitting my head against the wall.”

Cross-examination

Johnson said she is finally receiving medication that has helped her symptoms, but the treatment came too late.

Why it matters

Johnson’s story and allegations illustrate the continued failures plaintiffs have accused the state of, including delayed care, lack of specialty care referrals and medical neglect.

Robert Joy

Joy is a witness for the plaintiffs and an independent health care consultant. He previously conducted a staffing analysis of California prisons, and he created a staffing model for health care workers in Arizona prisons.

What did they say?

Joy testified about the model he created, which calls for many more health care workers in Arizona prisons than are employed by Centurion. “Based on my analysis, the 10 state-run prisons are understaffed.”
He described using data from the Department of Corrections, Department of Justice and other sources to estimate the actual health care needs of people in Arizona prisons.
Joy’s model divided Arizona prisoners into cohorts depending on medical need, then extrapolated those numbers out to make an estimate for the entire state prison population.
He told the court the state prison population has greater mental and physical health needs than in private prisons. He also found the proportion of patients designated seriously mentally ill in Arizona prisons is significantly lower than in other states.
Joy focused on factors specific to “justice-involved” populations to make estimations.
He found 18-20% of the prison population is held in isolation, a significantly higher portion than other prison systems. He said he also believes the state is using outdated staffing metrics from nearly a decade ago.

The quote

“It’s like a big math problem — you need to understand how many patients there are and put them in categories that help you understand the services they need.”

Cross-examination

Attorneys for the state said Joy was not a medical professional, and they took issue with the sources of the data used in his model. They called his work “inflated data” and “junk science.”

Why it matters

Several court experts have previously testified about how low staffing levels in Arizona prisons were leading to improper and delayed care. Joy’s findings and testimony bolster those claims.
The findings suggested Arizona is not accurately defining the true number of seriously mentally ill patients in state prisons.
Joy’s work indicates the current contract likely underestimates the true need for mental and physical health care services.
Arizona’s use of isolation makes providing health care even more difficult.

— Jimmy Jenkins