Inmates called her Red, for the thick auburn hair her beloved older sister once painstakingly curled.
Smart as a whip at 9, Donna Pickelsimer was troubled in her teens, struggling with alcohol in her 20s and at 52, a convict, sentenced to 15 years behind bars.
Under the care of Florida's newly privatized prison health system, she didn't last four.
Handing off prison inmate medical care to for-profit companies was designed to deliver tens of millions of dollars in taxpayer savings beginning in 2012.
But for inmates, it has come with cold-blooded consequences, a Palm Beach Post investigation found.
Just months after all medical care in state prisons was privatized, the count of inmate deaths spiked to a 10-year high in January and continued at a record pace through July.
Doctors have expressed alarm. The number of seriously ill prisoners sent for outside hospital care is on track to drop by 47 percent from 2012, the last year for which the state handled medical care. Inmates say prescription painkillers are abruptly replaced with over-the-counter drugs such as ibuprofen.
Pickelsimer's undiagnosed lung cancer was treated with Tylenol and warm compresses.
Serving time for manslaughter, "Donna did something wrong, and she went to prison to pay for what she did," said Pickelsimer's sister, Beverly Clancy. "But she was not sentenced to death."
Following weeks of questions from The Post about inmate deaths, Florida's Department of Corrections took action late Friday, warning prison health provider Corizon Inc. that its $1 billion contract was at risk if things didn't improve.
"The level of care continues to fall below the contractually required standard," wrote DOC Secretary Michael Crews. Problems, noted Crews, had begun almost as soon as Corizon took over inmate care for the vast majority of state prisoners.
"We are currently in the process of evaluating Secretary Crews' concerns, and will work in a spirit of collaboration to address them," said Corizon spokeswoman Susan Morgenstern.
"Corizon works hard every day to deliver quality care to our patients," she added. "We take that responsibility very seriously."
Only dollars and cents
Forking over millions of dollars to pay for inmate health care never has been politically popular. And when Gov. Rick Scott, a former hospital conglomerate executive, campaigned in 2010 on saving tax dollars by turning over prison medical care to for-profit companies, lawmakers embraced the idea.
In 2012, the state inked inmate health care contracts totaling $1.3 billion with two companies: Wexford Health Sources for care at nine major prisons and Corizon Inc. for approximately 44. In addition, the companies care for inmates at prison annexes, work release centers and two centers for new inmates -- roughly 100,000 prisoners in all.
Brenda V. Smith, a law professor at American University who has studied women's health in prisons, doesn't oppose privatization. But, she says: "There's a sort of ignorance oftentimes at the policy level about what these changes mean. All they are looking at is dollars and cents.
"You have to be concerned about how you are getting these cheap rates."
No state is under a legal obligation to provide inmates with excellent medical care.
They are, however, legally bound to provide adequate care by the U.S. Constitution's ban on cruel and unusual punishment.
"I admit I was one of those saying, 'Hey, they're in prison, they can't expect a lot,'" said Sandra Bustin, whose nephew was given over-the-counter painkillers such as Aleve for bone cancer. "But even basic care was missing."
In fact, inmate deaths are sharply up, according to state-supplied mortality data.
Data analyzed by The Post excluded deaths from homicides and accidents. Included are deaths from natural causes, such as disease and infection, as well as suicides and deaths in which the cause is listed by the state Department of Corrections as "pending."
Suicide, a tiny portion of the deaths in all years, is considered a medical issue, as psychiatric care is part of the private companies' health care contracts. The "pending" category, which occurs most frequently in 2014, is almost always determined to be a death from natural causes, 15 years of prisoner death records show.
Among the The Post's findings:
- In January, roughly 100 days after medical privatization was fully phased in, the monthly inmate death count shot to a 10-year high of 36.
- Inmate deaths for the first seven months of this year totaled 206, also a 10-year high when compared with the first seven months of any other year and an 18.4 percent increase from the first seven months of 2012, when the state handled medical care.
- When the state was in charge of all or most medical care, the monthly count of inmate deaths reached or topped 30 a total of 15 times in 10 years. That includes one year where the monthly death count hit 30 twice and topped 30 twice. This year, deaths topped 30 a total of four times in just seven months.
- At the current rate of deaths, 2014 will have about 5 percent more deaths than the 313 recorded in 2012, the previous high.
Any number of factors can push mortality rates higher, such as an influx of older inmates, pointed out DOC spokeswoman Jessica Cary. And, said Cary, when DOC handled medical care in 2012, more inmates died than in 2013, when private companies gradually assumed care for all inmates.
"This is a snapshot in time," she said. "While we are continuing to monitor the number of deaths and their causes very closely, another year or more of information is needed to identify a trend."
Some deaths are expected: Age 50 is considered elderly among inmates, the result of little or no health care prior to prison.
"Many of our patients have not had access to health care before they see us and are already suffering from addiction, mental issues and chronic conditions such as diabetes and hypertension," said Morgenstern, a spokeswoman for Corizon. "We are not always able to restore them to full health again."
However, Crews' Sept. 26 letter to Corizon makes clear the agency expressed concerns about shortcomings in medical care, nursing, mental health and administration fewer than 90 days into the company's contract.
Repeated meetings have yet to fix the problems, Crews wrote, and now, the state is considering financial penalties. Payment will be withheld for each prison where Corizon fails to meet 80 percent of auditing standards. If a prison fails multiple audits, Corizon may have that facility cut from its contract.
Different suits, same complaints
Even as the state was quietly meeting with Corizon last year, inmates and doctors were voicing concerns.
Three private-practice doctors outside the Florida prison system agreed to speak with The Post anonymously. All expressed worry -- and anger -- with changes.
It wasn't a perfect system when the state was in charge, said one, but now: "We order surgery and they don't come in. They are dying before they get to surgery."
At Memorial Hospital in Jacksonville, a once-busy ward designed to house more than two dozen prison inmates now holds as few as three or four a day, doctors say.
State numbers confirm the sharp dropoff: In the first eight months of this year, Corizon and Wexford sent just 1,009 inmates to outside hospitals. At that pace, the number of inmates referred to hospitals this year will plunge 47 percent from 2012, when DOC handled health care.
George Horn is among those waiting for surgery. The Columbia Correctional inmate was left with space where his right hip joint should be, according to his federal lawsuit. Horn's artificial hip joint was surgically removed in early 2013, one of three surgeries needed to treat an infection. Wexford first approved but later denied an operation to replace the bone, leaving Horn, who has six years left on an 11-year burglary sentence, without a hip joint.
Horn said he recently was told he would get another surgical consult, 11 months after the surgery was originally planned.
Tylenol for nerve pain
The Post reviewed more than 350 federal lawsuits brought by a Florida jail or prison inmate between 2004 and 2014 against Wexford or Corizon, as well as those filed against Corizon's predecessors, Correctional Medical Services and Prison Health Services. Prison Health Services provided care at the Palm Beach County Jail from 2002 to 2004 but lost a bid for a new contract following reports of withheld psychiatric medicine, an outbreak of an infectious disease and inmate deaths that triggered lawsuits.
"In our litigious society, people file lawsuits for many reasons of their own," said Corizon's Morgenstern. "I can tell you that the majority of lawsuits filed against us are dismissed or resolved before they ever go to court."
However, lawsuits alleging serious medical complaints tended to describe the same types of problems: fewer consults or treatment by outside specialists; Tylenol and ibuprofen prescribed for overwhelming pain; and medication abruptly changed or withdrawn.
For instance, several Florida inmates previously prescribed Neurontin for pain say in court suits that they have been switched abruptly to over-the-counter painkillers such as Tylenol. Neurontin is a non-narcotic anti-seizure medication used to treat nerve pain.
A 60-year-old Florida inmate diagnosed with rheumatoid and osteoarthritis, bursitis, fibromyalgia, tendinitis, a dislocated shoulder and ruptured disks said he took Neurontin and another painkiller, Tramadol, for 10 years. Corizon's prison medical director stopped the Tramadol and cut the Neurontin dosage in half, the inmate said. Acting as his own lawyer, he sued -- not for money, but to get his medicine.
Separately, an inmate with a narrowing of spaces in the spine said state doctors prescribed Neurontin for three years to treat related nerve pain. "All that changed in November 2013," he said, after Corizon began providing care. "I was told that the Aleve they gave me to replace the Neurontin I was on was the only thing I was going to get."
When the inmate asked why, the doctor wrote first that the drug was no longer approved; when the inmate persisted, the physician changed the explanation, writing that the inmate no longer met criteria for getting the drug.
One blind prisoner who has trouble walking was prescribed orthopedic shoes in 2008, legal documents show. Such shoes can retail for as little as $99. DOC regularly filled his prescription beginning in 2009. This year, when it was time to replace the shoes, Corizon's doctor refused, the inmate said in written grievances filed at the prison.
In another case, an inmate's leg prosthesis was taken from him by state guards. The amputee was given crutches. Corizon authorized a new prosthesis-- the inmate's $10,000 device was lost -- but in a federal suit, the inmate says five months lapsed before it was delivered. All the while, the muscle in what remained of his leg was withering.
When the inmate did get the device, it wasn't fitted, said Randall Berg, executive director of the Florida Justice Institute, a legal advocacy group. As a result, "The stump became raw and infected and finally after some pressure from us they gave him antibiotics," he said.
Federal law bars the state, Corizon and Wexford from discussing an inmate's health.
However, DOC's Cary pointed out that the state employs 17 monitors to watchdog medical care. "When there is a charge of inadequate care, each is personally reviewed and if care is found inappropriate we direct the provider to take corrective action," she said.
In incidents involving Wexford, said company spokeswoman Wendelyn Pekich, "We are confident we and our employees acted appropriately. For those instances still pending, we believe further investigation will demonstrate and prove the lack of any wrongdoing or negligence."
Determining whether medical care is appropriate and necessary is a key component of containing medical costs. And Corizon's bid for Florida business emphasized the successes of its own cost containment strategies with a series of dramatic cuts: In Maine in 2011, Corizon wrote, "We have developed a new working definition of 'medically necessary care,'" which cut visits to health care providers outside the prison by 30 percent.
In New Mexico, a new system of monitoring psychiatric drug prescriptions slashed monthly costs from $180,000 in 2007 to less than $30,000 in 2011, an estimated taxpayer savings of $2.1 million a year.
University of California Professor of Economics Kelly Bedard, who has researched inmate mortality, said that drops in prescriptions and hospital visits aren't necessarily a sign companies are skimping.
"You can overtreat," she said. For instance, the state may have over-prescribed psychiatric drugs. Fewer ER visits may mean a company is improving preventive care.
Fewer outside consults might mean that mobile X-ray and ultrasound services are being brought to the prison. "Making quality specialty and diagnostic services available within the prison facilities reduces the need for inmate patients to travel to community hospitals," points out Wexford's Pekich. That's what Corizon did in Arkansas.
But Bedard's research on 1990s-era mortality rates also found deaths rose slightly in prisons where care is provided by private companies, "and that leads to a whole host of questions."
The same year Maine and Corizon redefined "medically necessary care," a state-ordered review of the contract with Corizon found that about half of prescription records reviewed were missing information. State prison officials were concerned that prisoners were getting the wrong medications. Staff training was lacking.
In Idaho, where psychiatric drug use dropped by 13 percent in 2011 and prisons had one of the lowest rates of inmate hospitalization in the country, a 2012 report by a court-ordered monitor was so critical of Corizon's care at one prison that the state sought to keep it sealed.
The cost of not getting health care right can wipe out taxpayer savings: States are usually sued right along with the health care companies, and inmate lawsuits rack up a state's legal defense bills.
Equally problematic is that federal judges overseeing class-action cases can seize oversight from the state and dictate details of care. That's what happened in Florida in 1972, when a prisoner's handwritten lawsuit prompted federal judges to oversee Florida inmate health care for the next two decades.
The substandard health care at the heart of that case was provided by the state, not private companies. However, William Sheppard, a Jacksonville attorney who represented the inmates, said that about eight of every 10 inmate letters to his law firm allege substandard medical services under the privatized system.
Sheppard doesn't doubt the companies are saving the state money. But, he says, cases like Pickelsimer's exact another price: "How much does it cost your soul to watch these people die?"
Staff writer Kavya Sukumar contributed to this story.
Award-winning prison reporting
Palm Beach Post investigative reporter Pat Beall won the 2014 Hillman Foundation award, a national investigative journalism award. Her eight-month multipart series, "Private Prisons: Profits, Politics, Pain," linked a nationwide pattern of human rights abuses to corporate cost-cutting.