JACKSONVILLE, Fla. — On Dec. 15, 2023, Brian Tracey, an individual held at the St. Johns County Detention Center, did not receive the medical attention he needed to survive while under the care of Armor Health of St. Johns County LLC.
“Brian Tracey lay naked and unable to breathe on the floor of the medical ward at the St. Johns County Detention Center,” reports ProPublica.
Tracey’s girlfriend waited outside, anticipating his release. Instead, she was told by a deputy and chaplain that Tracey had died.
The medical staff of Armor Health of St. Johns County LLC, the jail’s health provider, said Tracey “was showing flu-like symptoms and suffered from chronic obstructive pulmonary disease, a lung condition that makes it difficult to breathe,” according to ProPublica. The county sheriff’s office described Tracey’s behavior during the days and hours leading up to his death, noting that “Tracey had passed out and appeared confused.”
Two retired jail commanders and two medical doctors with “extensive knowledge of jail treatment,” according to ProPublica, “determined that Tracey should have been hospitalized based on the symptoms he showed at the jail, which were later determined by an autopsy to be caused by pneumonia with COVID-19.”
Tracey was never hospitalized.
Jails can often be dangerous places for individuals who arrive in poor health. In recent years, the Bureau of Justice Statistics reported that jail deaths have been on the rise in the United States, according to ProPublica; but even as the number of deaths increases, healthcare in jails has not followed the same trend.
Former Republican state Sen. Jedd Brandes said, “Healthcare overall in Florida prisons and jails is a difficult and frankly ignored issue that’s put on the back burner.”
Armor Health Management LLC, as well as its predecessor, Armor Correctional Health Services Inc., has previously faced allegations that it “failed to hospitalize patients who needed more intensive care,” according to court records obtained by The Florida Tribune and ProPublica. Armor Correctional Health Services was sued more than 450 times from 2014 to 2021, with two-thirds of those cases involving “lawsuits over subpar jailhouse healthcare” that were filed and dismissed.
According to court documents, in 2020, a medical expert hired to review internal company reports of deaths within Armor facilities claimed “the company failed to hospitalize patients in more than 70 instances,” reports ProPublica. Armor denied those claims.
Florida is not the only state to take action against Armor. In New York, where Armor provided healthcare at two county jails, 14 individuals died. New York sued Armor in 2016 for breach of contract and fraud.
Seven of the deaths were found to be “egregious lapses in medical care,” said the New York State Commission of Correction’s Medical Review Board. Although the agreement between Armor and New York barred the company from operating in the state for three years, it is now allowed to operate there again.
After a verdict was issued against Armor Correctional Health Services, several LLCs were created, including Armor Health Management LLC. Seven Florida jails signed contracts with Armor Health under those new entities.
“Within three years of the company’s conviction, six of the seven Florida jails using an Armor entity stopped contracting with those companies,” according to ProPublica. “St. Johns County, where Tracey died, holds the only known remaining contract with an Armor entity in Florida.”
Pensacola attorney Joe Zarzaur argued in a 2021 wrongful death lawsuit that “those contracts incentivize Armor entities to keep sick inmates in the jails because Armor is paid a flat fee to provide healthcare; that means, he argued, there’s no billable benefit for adding additional services, such as hospitalization,” according to ProPublica.
Zarzaur explained, “This is why Armor’s contractual partners, inmates, and families see this repetitive conduct of delaying or outright denying inmates medical care, which leads to their deaths.”
“They told us he died of a heart issue, that it was sudden, he just fell over and died,” said Tracey Letourneau, the daughter of Tracey’s sister.
Tracey was taken to jail on Dec. 6, 2023, where he was placed in the infirmary to be monitored for a dog bite wound that had recently been treated.
Medical staff soon observed Tracey having difficulty breathing and prescribed him an oxygen mask. One nurse, according to the police report, noted that Tracey was sweaty and complained of shortness of breath. Another nurse noted that his blood oxygen level had dropped to 89%, a level at which the Cleveland Clinic recommends individuals seek immediate medical treatment.
The next day, the sheriff’s incident report said that Tracey had passed out in his cell.
After Tracey’s girlfriend paid his bond, a deputy went to his cell for release. Tracey was found lying in his bed, naked.
Investigators reviewed video footage showing Tracey struggling to dress himself and visibly struggling to breathe.
Sheriff’s deputies, however, reported that they had checked on Tracey and that he was OK in an inmate log report three minutes later.
“At 8:35, Tracey appeared to stop breathing,” according to investigators. ProPublica states that “no one gave Tracey CPR until 9 p.m.”
When Lillian Scharf, Tracey’s sister, asked for his full medical records, she was denied because she was not his legal next of kin.
It was not until this year that Scharf learned the full details of her younger brother’s death, which were provided by The Tribune and ProPublica. “By then, the two-year statute of limitations to sue for a wrongful death or neglect had passed,” states ProPublica.
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