How people die inside: Fact patterns in civil litigation for in-custody deaths

Abstract

Civil litigation provides a novel and underutilized source of information about deaths in U.S. jails, particularly when official data are incomplete. This study systematically analyzes verdicts, settlements and judgments to explore patterns in practices linked to preventable mortality in U.S jails.

Results:

Content analysis of facts alleged in 90 cases filed between 2015 and 2020 revealed thematic patterns related to inadequate or delayed medical care. Alleged facts routinely included observable signs of serious medical need—such as incoherence, convulsions, or pleas for help—followed by failures to provide timely or medically appropriate care. In cases of suicide, allegations commonly describe known mental health conditions, discontinued medication, and lapses in monitoring or suicide prevention protocols. Despite repeated warnings—by the individuals themselves, fellow incarcerated persons, or family members—jail staff frequently failed to act. A small subset of cases resulted in judgments for the defense, often where some care was provided or protocols were followed, even if outcomes were still fatal.

Conclusion:

These findings suggest that in cases resulting in reported settlements, verdicts or judgments in-custody deaths in the U.S. could be prevented through improved intake screening, timely medical monitoring, care coordination, and adherence to established protocols. Litigation records offer important insight into how systemic failures contribute to jail mortality, with implications for policy, public health, and correctional practice.

1. Introduction

Between 2000 and 2019, more than 20,000 people died in U.S. jail custody,¹ with many deaths being attributed to preventable causes such as suicide, overdose, drug withdrawal, or assault.^2–4 Mortality rates in jails rose by 35 % from 2009 to 2019, with suicide accounting for a quarter of these deaths.⁵ Over three-quarters of the persons who die in jail custody have not even been convicted of a crime at the time of their death¹; they died while awaiting trial.

These troubling patterns underscore the urgent need for reliable information about the conditions that contribute to jail deaths. Yet, official reporting of jail deaths remains incomplete; a 2022 Congressional report found more than 900 uncounted deaths in two years and 11 states failing to report any data to the federal government on deaths in custody.⁶ The report noted that journalists, scholars and nonprofit organizations have had to rely on news reports, freedom of information requests, and pleadings in lawsuits, among other sources, to offer some insight into the factual circumstances of deaths occurring in jail custody.^5,6 To grasp why so many people die preventable deaths in jail custody, researchers must look beyond incomplete official data to alternative sources of factual detail. In this context, litigation records become a critical and underutilized source of information, offering factual detail about jail conditions that may not be captured elsewhere.

Jails have a legal duty to take reasonable measures to prevent injury and death,⁷ including a duty to provide adequate medical care.⁸ Failures to meet constitutional standards of adequate care expose jails to litigation, financial penalties, and public scrutiny.^9–11 Because litigation records center on alleged failures to meet the minimum standard of care, they provide a novel and underutilized source of factual detail about jail conditions and practices associated with preventable deaths.

While prior work has linked facility-level characteristics to higher mortality,² few studies have systematically examined the factual allegations in civil litigation, despite their potential to reveal patterns of neglect and systemic failure. This study builds on our prior analysis of litigation patterns in jail deaths, which quantitatively documented case outcomes, causes of death, legal allegations, and settlement trends across multiple databases.¹¹ While that study provided a broad statistical portrait of the carceral death litigation landscape, it did not analyze the underlying fact patterns or narrative descriptions of alleged failures in care. The present study addresses that gap by applying qualitative content analysis to case summaries and in doing so identifies recurring themes in how care failures are described in litigation, offering novel insight into the alleged conditions and practices contributing to preventable in-custody deaths.

2. Methods

2.1. Data source: corpus creation

The corpus of documents analyzed was retrieved from Westlaw’s Jury Verdict & Settlement (“JVS”) database. We contacted Westlaw and were informed that at the time of our search, the JVS database consisted of jury verdicts, settlements, judgments, and arbitration summaries from federal and state court cases published in the following publications: ALM Media Properties, Inc.; The Association of Trial Lawyers of America (ATLA); Trials Digest; Thomson Reuters/West business; Florida Legal Periodicals, Inc.; Jury Verdicts Northwest, Inc.; LRP Publications, Inc.; Verdict Reporter, Inc.; and West. Each summary in JVS is written by an experienced legal editor and contains a presentation of facts, case type, case analysis of facts, and award.¹²

To identify cases involving deaths in jail custody, we used the search string “‘ESTATE OF’ & (jail or correction!)” and limited results to the years 2015–2020 (n = 135). Because estates typically file lawsuits on behalf of deceased individuals, this approach isolated cases involving deaths rather than injuries. Of 135 results, 90 cases met inclusion criteria: (1) the underlying lawsuit was filed for a death and (2) the death occurred in jail custody.

2.2. Descriptive variable extraction

Case summaries were downloaded as PDFs and imported into QDAMiner 5, a qualitative coding software.¹³ Using QDAMiner 5’s data extraction feature, we extracted the following descriptive variables from the PDFs: the outcome of the case, monetary damages, the state in which the death occurred, and whether the case was filed in federal or state court. The extraction tool identifies recurring words, headers, or formatting patterns across documents, which enabled us to systematically pull structured information from case summaries that followed a similar format. Each extracted variable was manually reviewed and corrected where needed to ensure accuracy.

A “cause of death” variable was created manually for each case. Guided by findings from a related prior study on jail death litigation,¹¹ causes of death were categorized as: suicide, overdose, substance withdrawal complications, failure to provide medical care for a physical illness, assault by another incarcerated person, or assault by a correctional officer.

2.3. Content analysis

We then conducted a qualitative content analysis of the case summaries. Content analysis is a systematic method for interpreting textual data through coding and categorization to identify recurring themes.¹⁴ Two coders independently coded each summary, which included the alleged facts contributing to the in-custody death. A codebook was developed inductively, with new codes added as themes emerged until thematic saturation was reached. Once saturation was achieved, the finalized codebook was applied systematically across all cases. Intercoder reliability was addressed through regular comparison of coded text; disagreements were discussed and resolved by consensus. Given the high rates of suicide deaths in jails, we conducted a sub-analysis of themes presented in cases involving suicide deaths and presented the results herein.

3. Results

3.1. Descriptive statistics

Seventy percent of cases in the sample (n = 63) were cases that were filed in federal court, with the remaining 30 % filed in state courts (n = 27). In approximately one-quarter of cases (n = 22), the court ruled for the defendants (3 defense judgments –decisions made by a judge—and 19 defense verdicts—decisions made by juries), and three-quarters of cases (n = 68) resulted in monetary awards to the plaintiff (14 plaintiff verdicts and 54 settlements). Plaintiff verdicts ranged from $327,759 to $11,857,344, with a median of $1,575,000. Settlements ranged from $15,000-$10,000,000, with a median of $362,500.

Cases analyzed included filings in 26 of the 50 states. Twenty of these cases occurred in Illinois, 19 in California, 8 in Oregon, 5 in Washington, and 4 in South Carolina. Arizona, Florida, Missouri, and Pennsylvania had 3 cases each. Colorado, Mississippi, New Jersey, and Ohio had 2 cases each. Alaska, Indiana, Iowa, Michigan, New Mexico, New York, Nevada, Oklahoma, Texas, Virginia, and Wisconsin had 1 case each.

3.2. Thematic results

3.2.1. Types of observable facts demonstrating medical need or serious risk of harm

According to constitutional legal standards, jails violate incarcerated persons’ individual rights when they demonstrate deliberate indifference to a serious medical need. In the cases analyzed, facts alleged to demonstrate a serious medical need included (1) indications of a medical issue on the intake form, (2) medical history obtained by the jail during the individual’s prior arrests, (3) obvious indicia of health distress (incoherence, non-responsiveness, vomiting, shaking, convulsions, etc.), and (4) one or more requests by the deceased for medical care (through either official formal channels—such as the filling out of a form—or by verbally requesting medical care).

In most cases, facts were alleged in multiple of the aforementioned categories—particularly in cases of substance use withdrawal. In some of these cases, jail personnel were alerted during intake that the person may have consumed substances, because the charges were related to intoxication or because the individual admitted to substance consumption prior to arrest. This was then followed by obvious facts demonstrating indicia of physical health distress or was accompanied by direct requests for medical care. For example, in Pitkin v. Corizon Health, Inc. (No. 3:16-cv-02235-AA [D. Or. December 18, 2017]), a case that settled for $10 million, Ms. Pitkin was arrested for unlawful possession of heroin. She experienced debilitating symptoms of opioid withdrawal and submitted four healthcare request forms to jail staff, all of which went unanswered. Ms. Pitkin died from complications due to opioid withdrawal.

Ms. Pitkin’s case is just one of many cases where one or more requests for medical attention were made by the deceased, and these requests were (1) not passed along to medical staff (or where there was no medical staff in the jail, the incarcerated person was not transferred to a medical facility for care), or (2) medical attention was significantly delayed, resulting in death. A few of these cases noted that correctional officers failed to follow jail protocols regarding referrals to medical staff, while other cases did not indicate the existence of any protocols. In some cases, not only did the person in need of medical care request it, but these requests were also followed by pleas for medical aid by other incarcerated persons—further demonstrating that the need for medical care was apparent to any lay observer and therefore should have been obvious to any jail staff. For example, in Beagle v. Yamhill County (17 Or. Lit. Arb. Rpts. 238 [D. Or. 2017]), which resulted in a settlement of $5,000,000, Mr. Beagle was assaulted by two other incarcerated persons. Mr. Beagle was transported to the medical unit after the assault; however, he was left in the medical cell without further evaluation. Video surveillance showed Mr. Beagle pacing, clutching his side in pain, and with visible injuries. The surveillance video also revealed that he urinated blood and pressed the medical call button 19 times but was ignored by jail staff. Other incarcerated persons in the medical unit also pressed their call buttons on Mr. Beagle’s behalf but were similarly ignored. Mr. Beagle did not receive medical care for his injuries despite these requests and subsequently died from his injuries.

In sum, the facts presented in many cases showed observable indications that could have been identified by jail personnel as evidence of immediate need for medical care, and these observable and tangible pieces of evidence were overlooked or ignored.

3.2.2. Absence of medical care or inadequate medical care

A common theme that emerged in many of the cases reviewed was that persons in need of medical care received no medical care at all or inadequate medical care. In some cases, such as Mr. Beagle’s and Ms. Pitkin’s cases, the deceased did not receive any medical care, despite formally requesting medical care. In other cases, some medical care may have been received, but was not constitutionally adequate.^8,15 Inadequacy of medical care was often demonstrated when healthcare or jail personnel did not follow the protocols for care adopted by the jail or healthcare provider for the underlying condition. Consider, for example, in Lopez as Administrator of Estate of Pajas v. County of Monterey; California Forensic Medical Group, 2019 WL 1466996 (N.D.Cal.), where the plaintiff alleged inadequate care for substance withdrawal that resulted in death and settled for $1.6 million. Mr. Pajas was arrested for riding his bicycle down the wrong side of the road and for possession of drugs. The plaintiffs alleged that upon intake, Mr. Pajas informed the officers that he had consumed heroin that day and would need medical care for withdrawal. After several hours, Mr. Pajas was screened by a nurse who noted his elevated blood pressure and initiated the jail’s detoxification protocols, which called for Mr. Pajas to be placed in a “sobering cell,” where he would be checked on every 15 min by jail staff and every 4 h by medical staff.

Allegedly, Mr. Pajas went into the sobering cell only after his booking, and the jail staff did not notify the medical staff that he was placed there. Jail staff decided they would check on Mr. Pajas every couple of hours. Mr. Pajas was left alone in the sobering cell for 7 h when a nurse finally administered some medication, which he threw up. Mr. Pajas’ condition worsened, and jail staff documented “‘staggering, swaying, unsteady and pale’ and had ‘poor coordination,’ ‘slow speech’ and ‘watery’ eyes.” Four hours later, he was again visited by a nurse who offered him Gatorade and anti-nausea medication, but he notified her that he could not move and he would just throw it up. No vital signs were taken at this time. When jail staff placed another individual in the sobering cell approximately an hour later, they discovered Mr. Pajas unconscious in a pool of vomit. The jury ruled that the jail was liable because they did not adhere to their own protocols and thereby provided inadequate medical care.

3.2.3. Factual themes prevalent in cases involving suicide deaths

Facts that were alleged in cases involving suicide deaths were grouped into those that demonstrated a (1) failure to properly supervise or monitor an incarcerated person with a (a) history of mental illness, (b) suicidal ideation, or (c) other risk factors for suicide (such as substance use withdrawal), (2) failure to screen incarcerated persons for behavioral health issues at intake, and (3) failure to prescribe medication for underlying mental illness (including cases where jail personnel refused to allow individuals to continue their psychotropic medication after arrest).

To demonstrate that jail personnel should have known about the suicide risks, plaintiffs alleged facts showing (1) a history of past suicide events while incarcerated in the same jail facility for prior arrests, (2) a medical history of past or present mental illness that was provided to the jail during intake or by a family member notifying the jail, or (3) disclosures made by the incarcerated persons that they were taking psychotropic medication.

For example, in Ponzini v. Monroe Cty., 789 Fed. Appx. 313 (3rd Cir. 2019), for which the plaintiff received a jury award for $11,857,344, Mr. Barbaros reported being prescribed Trazodone and Prozac at the time of his arrest and having “psychological challenges.” His medication was withheld from him for 4 days, and an expert witness testified that the medical staff should have known that doing so would increase the risk of suicide. Mr. Barbaros suffered from SSRI discontinuation syndrome as a result of the delay and died by suicide.

3.2.4. Facts demonstrating adequate care

A subset of cases were those in which the judge or jury found that the jail or healthcare personnel were not liable for the death. This finding does not mean that the death was not preventable. It simply means that the jail or healthcare providers met the minimal standard of care. For cases in which the jury found for the defendants (e.g., that adequate medical care was provided), the facts of the case often detailed the type of care and follow-up provided to the incarcerated person. This care included prescribing appropriate medication and proactive monitoring of the health condition. Evidence of patient non-compliance, patient failure to report symptoms, or patient failure to disclose pre-existing conditions or medications during intake also appeared in cases in which the jury or judge found for the defendants. It is important to note that in a few cases, a defense was raised that limited jail budgets prevented adequate care, but these cases did not result in a verdict for the defendant, suggesting that courts are reticent to accept budget shortfalls as a defense to inadequate medical care.

4. Discussion

This exploratory study presents the findings of a systematic content analysis of reported settlements and verdicts for lawsuits filed against jails for deaths that occurred in custody over a five-year span (2015–2020). The findings presented suggest common characteristics in fact patterns alleged across litigation related to jail deaths. Common themes that emerged in the fact patterns included: (1) failure to collect appropriate information at intake and/or ensure proper follow-up; (2) lack of jail protocols or a failure to adhere to jail protocols; (3) failure to address requests for care or presence of distress by the incarcerated individual, other incarcerated persons and/or jail personnel witnessing medical distress; and (4) inadequate or delayed healthcare.

The findings suggest that, in the cases analyzed, deaths in jail custody could have been prevented. Many cases showed clear, observable indicia of a serious need by the deceased, whether it was for immediate medical care or for increased monitoring and protection from self-harm. The facts alleged (and in many cases adjudicated as true) showed that lack of adequate screening, coordinated care (between correctional officers and healthcare providers and between multiple healthcare providers), follow-up (including monitoring for worsening conditions and visual checks), and failure to develop and adhere to detailed protocols contributed to increased risk of death while in jail custody. Additionally, these facts suggest that additional correctional staff training in identifying and responding appropriately to clear medical needs may be warranted. The results presented here support findings that inadequate screening procedures and a failure to monitor or provide healthcare for persistent medical issues may worsen health outcomes in jail populations.^16–20

These results are subject to some limitations. First, the fact patterns analyzed were summaries written by legal experts and, therefore, did not include all of the factual allegations in the case. Second, because many of the cases were settled, the facts were not necessarily adjudicated to be true. Therefore, some of the fact patterns only contained facts that were alleged to be true. Though some of the summaries included facts alleged by the defense, many cases were limited to the facts alleged by the plaintiff. Despite this, alleged facts maintain their utility in that they point to factors perceived by plaintiffs (and their attorneys) to have caused the death and, therefore, are suggestive of factors that may induce plaintiffs to file lawsuits. Third, the sample population is not necessarily representative of the population of cases filed against jails, because the sample was drawn from cases reported in jury verdicts, judgments and settlements only. While summaries of cases that have been settled or litigated only represent a small subset of fatalities that occur in jail custody and do not include cases that have been settled through administrative grievance processes, they nonetheless provide some factual context surrounding the factors that are perceived to have contributed to preventable in-custody deaths and also shed light on how the actions of jail officials and personnel contributed to the death. Fourth, as this is a qualitative study, we identified the presence of themes but not the prevalence of those themes across all cases. Finally, we acknowledge that the 90 cases analyzed, particularly the four detailed case studies, likely represent some of the most extreme or litigable instances of in-custody deaths, given that they resulted in settlements above the median range; thus, while they are illustrative of systemic issues, they may not be fully generalizable to all in-custody deaths across the United States.

5. Conclusion

Jails have become deadlier, as the number of deaths in jail custody has increased by at least 11 % since 2000.¹ Individuals incarcerated in jail facilities are dying preventable deaths, and our current data collection and monitoring systems do not provide complete data on not only the number of deaths but also the factors contributing to them.⁶ Researchers and nonprofits have had to find creative ways to harness existing documentation of jail deaths in addition to gathering new data. This study provides some insight into facts alleged to have occurred in a subset of these cases by making novel use of settlement and jury verdict reports. Most importantly, this analysis suggests that failures in intake procedures, care coordination, and timely responses to emergent health needs—as described in litigated cases—may contribute both to preventable deaths and to subsequent litigation in U.S. jails. These cases highlight how lapses in constitutionally adequate care can result in significant costs to local governments, not only in terms of financial settlements and judgments,¹¹ but, more importantly, in irreplaceable lives lost to preventable deaths.

The findings from this analysis of litigated cases suggest that local governments and jail healthcare providers may reduce the risk of adverse outcomes—both in terms of in-custody deaths and subsequent litigation—by strengthening policies and training related to intake procedures, recognition of medical needs, and timely responses to medical care requests. While this study is limited to cases that resulted in civil litigation, the recurring themes identified point to potential areas for intervention. These results underscore the importance of striving toward a higher standard of correctional healthcare that meets constitutional requirements.²¹ For policymakers, jail administrators, and others involved in setting operational and funding priorities, this analysis highlights possible targets for reform that could mitigate both human and legal costs.