How a Health Care Company’s Practices Endangered Patients in Jails

NORMAN, Oklahoma — Two days after Thanksgiving in 2022, Shannon Hanchett walked into an AT&T retailer for a brand new cellphone, and ended up in handcuffs.

Hanchett ran the Cookie Cottage, a well-liked bakery on this school city, the place she made treats named for locations throughout the state, from Stilwell Strawberry to Lawton Lemon. However currently, her psychological well being appeared to be fraying. She was falling behind on orders. Her marriage was crumbling. And the 38-year-old mom of two had picked fights with household and pals.

All of it detonated that day within the AT&T retailer. Workers phoned police after Hanchett started pacing, ranting and calling 911. Physique digital camera footage exhibits an officer from the Norman Police Division speaking to her for a number of minutes, then tackling, handcuffing and arresting her for misusing the emergency line.

Like so many individuals experiencing psychological well being crises within the U.S., Hanchett landed not in a psychiatric hospital, however in a county jail. In her case, it was Norman’s Cleveland County Detention Heart, which contracts with a for-profit firm to supply medical care: Flip Key Well being Clinics.

And for Hanchett, that’s the place issues received even worse.

As native jails have morphed into among the largest psychological well being remedy amenities within the U.S., many counties have outsourced medical care to non-public firms that promise to comprise rising prices. Flip Key is without doubt one of the quickest rising in the course of the nation.

At the very least 50 individuals who had been below Flip Key’s care died through the previous decade, an investigation by The Marshall Challenge and The Frontier discovered. Our reporting unearthed firm insurance policies and practices which have endangered folks in jail — particularly these with psychological sickness.

In dozens of instances, Flip Key workers didn’t ship folks to the hospital after they had been in disaster, catatonic or refusing to eat or drink. The corporate staffed psychological well being and different medical positions with low-level nursing assistants educated to carry out primary duties like taking important indicators, however to not diagnose or assess medical circumstances.

Medical docs and extra advanced-level nurses working for Flip Key continuously consulted over the cellphone for a restricted variety of hours per week as a substitute of constructing in-person visits, in accordance with authorities data and paperwork obtained by way of lawsuits.

Till final yr, the corporate typically restricted the sorts of medicines it could present folks in jail, not giving them long-acting psychiatric medicine and prescriptions they’d acquired earlier than their arrests.

We obtained data from sheriffs who raised issues in regards to the firm not offering the right medicines for folks in jail with psychological sickness. “I’ve been instructed that Flip Key doesn’t prescribe these sorts of medicines,” one Texas sheriff wrote in a 2022 e mail. “That is inflicting a cascade of issues not just for their security and well-being, however for the workers and facility as nicely.”

Flip Key officers declined interview requests for this story. In response to written questions, the corporate issued a press release from its medical director, Dr. William Cooper: “Flip Key’s aim is to supply the very best degree of care pursuant to the shopper’s funds. … The corporate continues to increase due to the standard of the care supplied.” He added that Flip Secret’s “continually working to construct on the standard of care it offers.”

To look at the corporate’s practices, we obtained data, together with inner paperwork and emails between firm leaders and public officers, in practically 70 counties throughout Oklahoma, Texas, Arkansas, Louisiana, Colorado, Kansas and Montana. We additionally reviewed greater than 100 lawsuits involving jail deaths and accidents. Many had been dismissed for not assembly authorized hurdles required for civil rights lawsuits: Plaintiffs should show that the corporate wasn’t simply negligent, however confirmed “deliberate indifference” to sufferers’ medical wants, amongst different necessities. Some fits resulted in settlements, lots of which had been confidential, and practically two dozen fits stay pending.

A girl in Colorado died after a bag of medicine she’d hidden in her physique burst, whereas a Flip Key nurse allegedly dismissed her signs and refused to name an ambulance. A person in Arkansas died after medical workers didn’t give him remedy to forestall lethal signs of alcohol withdrawal and didn’t name an ambulance till he grew to become unresponsive. One other man in Arkansas died after medical data present he wasn’t given the seizure remedy he wanted, and he was strapped to a restraint chair and lined with a spit hood.

Flip Key declined to reply to questions regarding these incidents.

Medical care in jails could be difficult and expensive, stated Dr. Anne Spaulding, founding father of the Heart for the Well being of Incarcerated Individuals at Emory College in Atlanta. Most individuals in jails are there awaiting trial, and plenty of arrive with advanced wants — some are in drug withdrawal or experiencing psychological well being crises; others want costly remedies similar to HIV medicine, insulin or dialysis.

Jail operators have a constitutional obligation to provide vital medical care, regardless of the sickness, she stated. “Whenever you lock the door of a jail or jail cell, you’re stopping the individual from going out and looking for well being care elsewhere,” she stated. “So it’s a must to present it.”

However there are not any nationwide requirements for what constitutes vital medical remedy in jail, and federal courts are break up over what degree of care is satisfactory, particularly for folks awaiting trial. Near half of individuals in jail have acquired a analysis of a serious psychological sickness, in accordance with authorities knowledge final compiled in 2017, and two-thirds endure from substance abuse. Girls, the fastest-growing group of individuals in jails, have even greater charges of psychological well being and habit issues.

Some, like Hanchett, have undiagnosed psychiatric points and had been arrested after public episodes. It took 10 days after she was put in jail earlier than a physician consulted on Hanchett’s care. Flip Key’s major psychiatrist prescribed antipsychotic capsules and famous Hanchett didn’t reply to questions. Medical workers recorded her signs as “extreme — having a marked affect on the inmate’s skill to perform satisfactorily within the present outpatient setting.”

By then she had been mendacity on the ground of an empty cell for days, largely bare, dehydrated and in deep psychosis, data present. The licensed sensible nurse on the jail consulted with an off-site Flip Key nurse practitioner, who stated to present Hanchett some Gatorade, in accordance with jail data. Her pulse was weakening, her blood stress dropping — she couldn’t rise up or gown herself.

A nurse reported listening to Hanchett saying: “They’ll kill me.”

As the inhabitants of individuals it handled in jails doubled over a span of six years to greater than 20,000, data present Flip Key had 4 docs, three psychiatrists and 10 nurse practitioners on workers. Some oversaw care at a number of jails in numerous states.

Flip Key has staffed its jails with largely licensed sensible nurses or licensed medical assistants, in accordance with depositions and inner paperwork. These employees can get licensed with a yr or much less of education and are educated to carry out primary duties like checking pulse charges, to not assess medical circumstances. In 2020, a contract monitor for the Tulsa County Sheriff’s Workplace complained in an e mail that the corporate was utilizing low-level personnel to fill the position of psychological well being technicians, which raised “questions if inmates are really being serviced accordingly.” The sheriff’s workplace declined to remark for this story.

In its assertion, Flip Key stated it “maintains an on-call staff that has docs, nurses, and psychological healthcare suppliers who can be found 24 hours a day, each day of the yr.”

However in most of the instances we examined, the on-the-ground employees failed to acknowledge extreme well being issues, and didn’t search counsel from docs and extra senior nurses who consulted remotely.

The outcomes had been typically deadly, as within the case of Marconia Kessee. He lived out and in of lodge rooms and struggled with extreme psychological sickness, stated his uncle, Michael Washington. In 2018, Kessee went to a hospital for assist and ended up in jail in Norman. Police physique digital camera video exhibits Kessee stumbling and falling after officers ordered him to stroll throughout the road to a homeless shelter — so the officers arrested him for trespassing.

On the county jail, a licensed sensible nurse working for Flip Key didn’t acknowledge that Kessee was overdosing on methamphetamine and prescribed drugs, as a substitute accusing him of faking signs that included seizures, in accordance with a lawsuit filed by his household. The nurse and jailers left Kessee alone in a cell.

Inside two hours, he was useless of an overdose. He was 35.

In response to the lawsuit, the nurse stated he hadn’t been educated on overdoses and wasn’t certified to find out if somebody was experiencing one. Flip Key’s medical director agreed — and conceded that with out such information, the nurse was unlikely to ask a higher-up for assist.

In a confidential settlement, Flip Key settled the case for an undisclosed quantity final yr. The corporate didn’t reply to questions on Kessee’s demise.

September Daybreak Bottoms for The Marshall Challenge

From the start, Flip Key has asserted that it might present high quality care to folks in jails at a decrease price.

The week after Cleveland County Sheriff Joe Lester took workplace in 2009, a bookkeeper introduced him a stack of unpaid payments from the native hospital and well being clinics. It added as much as about $1 million in medical debt for treating jail detainees, Lester stated later in a court docket deposition. The division’s complete funds for the yr was half-spent, and the sheriff’s workplace was getting assortment calls.

“When anyone goes to the hospital, whether or not it’s a headache or what, it’s a giant expense,” Lester stated.

Hospitalizations additionally pressure jail staffing as a result of a deputy typically stays with the detainee till they return to jail.

Lester reached out to Jon Echols, who ran an organization that supplied well being care personnel to native nursing properties. The county awarded his firm a contract to supply 24-hour nursing personnel on the jail.

The corporate completed the primary three months of the contract below funds and despatched only one individual to the hospital by ambulance, Echols instructed county officers in 2009, in accordance with an area newspaper report. He and his enterprise companions fashioned the corporate that might change into Flip Key Well being Clinics.

Echols received a seat within the Oklahoma Home of Representatives in 2012. A Republican, he now serves as Home majority ground chief. In March, we requested Flip Key company leaders for an interview, together with Echols, who was nonetheless listed as the corporate’s president and founder. He didn’t reply, however his title and picture have since been faraway from the corporate’s web site. His most up-to-date monetary disclosure, filed in Might with the Oklahoma Ethics Fee, exhibits he retained a “non-controlling minority possession curiosity” within the firm, and acquired a wage by way of 2023.

Flip Key has since expanded right into a multimillion-dollar firm with contracts to supply medical take care of greater than 75 jails — and 23,000 folks — in 10 states.

At first, many of the jails the place Flip Key operated had been lockups in small counties. However in 2016, the corporate received its largest contract, in Tulsa, after the native sheriff modified the bidding necessities, permitting the corporate to qualify. On the time, Echols instructed The Frontier: “I wished a good alternative. … There’s little doubt that I requested that we be capable to bid.” Flip Key promised to cowl as much as $500,000 a yr in exterior medical prices, together with hospitalizations; the county would pay for something over that quantity.

Flip Key later boasted to potential shoppers that it lowered emergency transfers in Tulsa by 77% and the variety of days prisoners spent within the hospital by 35% inside just a few months.

The corporate went on to get the contract for the troubled county jail in Oklahoma Metropolis, the state’s largest, on comparable phrases.

In its assertion, Flip Key’s medical director stated the corporate tries to cut back medical prices by offering remedy earlier than emergency care is required. The corporate added that it “hardly ever, if ever,” reduces staffing when it wins a brand new contract.

Christa Sullivan was jailed in Oklahoma Metropolis in 2020 after she suffered delusions, heard voices and attacked her husband with a knife. It was the primary time the 64-year-old grandmother and navy spouse had ever been incarcerated.

She instructed the jail workers she had been identified with nervousness, schizophrenia, insomnia, a coronary heart situation, excessive ldl cholesterol, hypertension and fatty liver illness, data present. She reported a historical past of suicide makes an attempt and hallucinations. She had been prescribed medicines, together with the anti-anxiety drug Ativan.

Sullivan was placed on the prolonged state waitlist for individuals who want remedy as a result of they aren’t competent to face trial. Flip Key was in control of her care whereas she waited.

Inside just a few days of her arrest, Sullivan tried to kill herself by chopping her wrists, data present. She went on to aim suicide quite a few instances, attempting to drown herself in a rest room and to strangle herself with an grownup diaper.

Sullivan repeatedly requested for Ativan, the drug she’d been taking earlier than jail. She was instructed it wasn’t on Flip Key’s authorised checklist, often known as a formulary, in accordance with her medical data.

In its assertion, the corporate stated it displays Ativan and different “managed substances which are addictive and liable to abuse and use as illicit forex in a correctional setting,” and added that entry to these medicines is “intently moderated.”

Sullivan had been in jail for greater than six months when she confronted a physician about her entry to Ativan in January 2021. He wrote in his notes: “As I method her cell, I see she is strolling round bare. Not presently screaming. I greet her and she or he tells me ‘You lied to me. You might have Ativan right here. A nurse instructed me.’ I counsel her once more that Ativan isn’t on the psychiatric formulary.”

As a substitute, data present, docs on the jail injected her a number of instances with the antipsychotic Haldol, which was on the corporate’s checklist of authorised medicine.

Sullivan was typically in deep psychosis, data present. She developed stress sores from mendacity bare on the ground. Medical exams famous she was “at extraordinarily excessive threat for problems together with sudden demise.”

However she wasn’t taken to a hospital for practically a yr. Then, twice in a single week, she was despatched to the emergency room to be handled for dehydration, kidney points and accidents to her head and again — after which promptly returned to jail. After Sullivan’s return, a physician famous that she was displaying extreme indicators of “failure to thrive, at excessive threat for poor end result.” Medical data notice she’d misplaced virtually 30 kilos since her preliminary reserving, and that she was allergic to Haldol — the drug Flip Key had been injecting her with. A psychiatrist lastly prescribed her Ativan on March 25, 2021, data present.

On April 13, 2021, she was discovered useless in her cell. The health worker labeled her reason behind demise “undetermined.” An investigation by the Oklahoma State Division of Well being discovered the jail didn’t present Sullivan satisfactory care, in violation of state requirements. A spokeswoman for the Well being Division stated it referred the case to the native district lawyer’s workplace for prison investigation. Nobody was charged.

A spokesperson for the Oklahoma County district lawyer’s workplace stated that Sullivan’s demise occurred below a earlier administration, and the workplace didn’t have data in regards to the determination to not file costs.

A lawsuit filed by Sullivan’s household alleges Flip Key repeatedly confirmed “deliberate indifference” to her situation and refused to switch her to a hospital as a result of the corporate didn’t need to bear the fee for remedy. Flip Key has denied the allegations and contended in its response to the lawsuit that Sullivan’s remedy was “cheap and inside the relevant requirements of care.” The case is scheduled for trial subsequent yr.

After a suicide contained in the Oklahoma County Detention Heart in December 2021, the identical psychiatrist who’d handled Sullivan, Dr. Gabriel Cuka, emailed an entreaty to native public defenders, giving them an inventory of 18 “inmates who want inpatient psychiatric stabilization that exceeds the capability” of the jail, data present.

“Principally, these people want pressured lengthy performing injectable antipsychotic brokers,” he wrote in an e mail. “I’m not saying that these inmates are incompetent within the Oklahoma authorized sense of the time period. These inmates are very sick and in some instances dying.”

Cuka not works for Flip Key and is a defendant within the Sullivan household’s lawsuit. He declined to remark. In court docket filings, Cuka has denied allegations that he under-prescribed any remedy or that Sullivan’s psychological well being worsened below his care.

Related issues cropped up at different jails served by Flip Key. An analysis accomplished by psychological well being specialists for the jails in Smith County, Texas, famous that detainees couldn’t get long-acting injectable antipsychotic medicine and the formulary restricted entry to medicine they’d been prescribed earlier than being jailed.

A sheriff’s division e mail we obtained exhibits Smith County waited weeks in early 2023 to get orders for pressured remedy for folks with extreme psychological sickness as a result of the corporate’s major psychiatrist was out of the workplace. At the very least one individual died by suicide within the jail throughout that point interval, data present.

Jason Weger, the sheriff of Eastland County, Texas, who wrote a 2022 e mail elevating issues about entry to medicines, instructed an area psychological well being authority: “I’m rising increasingly involved in regards to the inmates not receiving the right medical consideration they want. Particularly in terms of the psychological well being folks we’re housing.” Weger declined to remark.

Flip Key didn’t reply to questions in regards to the emails from Smith and Eastland counties, however the firm stated it at all times has workers accessible.

In mid-2023, The Marshall Challenge and The Frontier obtained a replica of Flip Key’s formulary checklist after being denied copies quite a few instances by way of open data requests. Round that very same time, the corporate stopped utilizing it, data present. Dr. Jason Beaman, a forensic psychiatrist at Oklahoma State College who reviewed the formulary, instructed us it was lacking a key drug for folks with schizophrenia in addition to many more recent, dearer long-acting injectable antipsychotic medicine.

When Eusebio Castillo Rodriguez was locked up within the Union County, Arkansas, jail on a DWI cost in June 2022, his documented signs of alcohol withdrawal — a standard drawback in jails — went untreated for greater than 5 days, in accordance with a lawsuit filed by his household. Most remedy protocols embody a prescription for a drugs to forestall lethal seizures or alcohol withdrawal delirium. As a substitute, a Flip Key physician consulting over the cellphone prescribed a blood stress drug, data present.

The household’s lawyer employed Dr. Thomas Fowlkes, a correctional medication specialist who continuously testifies on behalf of jail well being care contractors, to evaluate Rodriguez’s remedy. In his report, he wrote that Flip Key’s protocols and remedy had been “far under the usual of care.”

When Rodriguez’s situation grew to become dire, jail medical workers first tried to move him to an area hospital in a deputy’s automobile, data present — an ambulance was known as after he grew to become unresponsive. The hospital life-flighted him to a bigger hospital in Little Rock, the place he died days later, data present.

Fowlkes wrote: The jail workers “meant for Mr. Rodriguez to be merely dumped off on the hospital with no obvious concern for his wellbeing and with out taking any accountability for the intense medical situation which developed immediately because of their lack of medical care.”

In among the bigger counties the place Flip Key had contracts, our evaluation of economic knowledge confirmed jails paid for added costs for issues similar to COVID-19 assessments and sensors designed to enhance well being monitoring.

Counties additionally paid for lab assessments and prescribed drugs when these prices had been excluded from the contracts or exceeded a threshold. In Smith County, Texas, over the three-year interval we examined, the jail paid an extra $1 million to Flip Key past the quantity for base medical providers — largely as a result of funds for sure medicines. The corporate stated in its assertion that counties by no means paid greater than the contract required.

The corporate cultivated shut relationships with regulation enforcement. At conferences in Arkansas, Texas, Kansas and Colorado, Flip Key raffled off searching gear together with crossbows and knives to sheriffs and deputies, in accordance with social media posts. It handled shoppers to steak dinners and delivered packages of smoked bacon for Christmas, in accordance with emails we obtained.

Personal fairness corporations have taken an curiosity in Flip Key’s progress: Gladstone Capital Company invested $11 million within the firm in 2021 by way of secured loans, data present. The Dallas-based non-public fairness group Trive Capital acquired a majority stake in Flip Key by 2019, in accordance with court docket filings and interviews. Neither agency responded to requests for remark.

The corporate stated in bid paperwork that its income grew a mean of 87% a yr between 2014 and 2019. However as Flip Key has grown, so has the variety of lawsuits alleging its care led to deaths and accidents.

In July 2023, a federal decide in Colorado denied the corporate’s request to dismiss a lawsuit that accused a Flip Key nurse at a jail north of Denver of refusing to name an ambulance for a girl she believed was “performing a idiot.” In actual fact, Amy Lynn Cross was foaming on the mouth earlier than she died of drug toxicity.

Flip Key canceled its contract with Weld County final December.

In bids submitted to officers in Larimer County in northern Colorado in 2022, Flip Key officers stated the corporate had settled solely 13 lawsuits, most of them “for nuisance worth and for strategic profit to our shoppers … a file we’re keen to place up in opposition to any of our rivals.”

The corporate didn’t reply questions on ongoing lawsuits or settlements. In its assertion, the medical director stated the corporate “trusts in its front-line healthcare suppliers, it values enter from its correctional companions, and Flip Key investigates sentinel occasions and incorporates classes realized to enhance outcomes.”

However a number of jails have ended their contracts with Flip Key over its degree of care. Garfield County, Colorado, did so in June 2023 after Sheriff Lou Vallario stated he decided the corporate wasn’t offering sufficient nurses and psychological well being staffing.

Ouachita County, in southern Arkansas, ended its contract with Flip Key after simply six months, partially as a result of the corporate wasn’t offering many in-person visits from medical suppliers, stated Robert McAdoo, the county government.

In September 2023, officers in Smith County, Texas, additionally opted to not renew Flip Key’s contract. As a substitute, the jail will use an area hospital system for medical and psychiatric care.

It should price more cash, however having in-person visits from a psychiatrist to deal with folks with extreme psychological sickness is value it, stated Neal Franklin, the county’s chief government.

“I do know they’ve truly handled this particular person and seen them with their very own eyes and talked on to them,” he stated.

Shannon Hanchett’s pals known as her The Cookie Queen. Her small store in Norman offered out of cookies practically each day.

Bethney Grove grew to become shut with Hanchett by way of Fb posts about baking. The primary time they met in individual, Hanchett shocked Grove with a classic beehive cookie jar embellished with bumblebees — Grove’s favourite image.

“She did every part 1,000% — whether or not it was chuckle, inform a joke, get mad, advocate for one thing,” Grove stated.

She stated she had assumed that after the post-Thanksgiving encounter with police, Hanchett had been taken to a hospital or psychiatric facility — not locked in jail.

Hanchett’s household stated they didn’t need to publish her $1,000 bond as a result of they feared that if she had been launched with out remedy, she may harm herself or another person.

4 days after her arrest, her uncle, a lawyer, wrote a letter asking a county decide to subject an emergency order to switch her to an area hospital.

“As a household we’re extraordinarily involved about Shannon staying in jail together with her present psychological well being points that may proceed to worsen with out remedy,” Michael Schade wrote. A listening to on her case was nonetheless two weeks away.

Shortly after midnight on Dec. 8, Hanchett was discovered useless in her cell. The psychological well being analysis Hanchett’s household had pleaded for was scheduled to happen eight hours after her lifeless physique was found.

In accordance with an post-mortem, Hanchett’s demise was attributable to problems from a coronary heart defect, with contributing components together with psychosis “with auditory and visible hallucinations” and dehydration.

In January, her widower, Daniel Hanchett, sued Flip Key and Cleveland County on behalf of his sons.

“She was a really loving mom and the boys had been her largest precedence in life,” he stated.

Flip Key has requested a decide to dismiss the case. In its filings, legal professionals for Flip Key and its workers wrote that the case didn’t meet an evidentiary hurdle displaying “an pointless and wanton infliction of ache” or that it was “repugnant to the conscience of mankind.”

As within the case of Marconia Kessee, Shannon Hanchett’s jail cell was video monitored. The footage stays below a protecting order in federal court docket, so it isn’t public. However her household’s lawyer, Daniel Smolen, stated she was locked in a cell with no sink, mattress or rest room for greater than every week.

“After they lastly eliminated her from her cell, they discovered her bare and so dehydrated that she couldn’t even stand. As a substitute of calling an ambulance, they dragged her limp, bare physique by the arms down an extended, concrete ground,” he stated. Hours earlier than Hanchett died, Smolen stated, nurses didn’t present her satisfactory care. “As a substitute, they mocked and laughed at her.”

Information present three months after Hanchett’s demise, Cleveland County renewed Flip Key’s contract.