• Y Combinator group partner Jared Friedman last year switched to using robotaxis exclusively.
• Friedman told Business Insider that he estimated spending 4% of his waking hours in a Waymo in 2024.
• Friedman was also an early angel investor in Cruise, which was acquired by GM in 2016.

Angel investor and Y Combinator group partner Jared Friedman spends a lot of time in a Waymo.

To be more exact, Friedman told Business Insider in a recent interview that he estimated spending about 4% of his waking hours this past year in a Waymo robotaxi, getting to and from his home and office in San Francisco.

"For me, the great thing about self-driving cars is you can really work out of them," he said. "So I just get into the Waymo, I tether my laptop to my phone, and it's basically like my office on wheels."

According to his stats from the Waymo app, which Friedman shared in a post on X, the angel investor has spent 12,536 minutes inside a Waymo, traveling 2,105 miles for a total of 517 trips in 2024.

"Hit 2,000 miles in Waymo last year," he wrote in the post. "Hard to imagine life without it at this point."

A spokesperson for Waymo confirmed to Business Insider that Friedman is in the top 1% of Waymo riders.

Friedman's enthusiasm for self-driving cars may not come as a surprise.

He was an early angel investor in Cruise, the robotaxi company founded in 2013 and acquired by General Motors three years later. Friedman said he knew Cruise cofounder Kyle Vogt back when Vogt was working on Justin.tv, which eventually became Twitch.

Vogt, who stepped down as Cruise's chief executive in 2023, recently criticized GM after the automaker announced that it was pulling back its investment in Cruise.

"In case it was unclear before, it is clear now: GM are a bunch of dummies," he wrote on X.

Friedman recalled one of his first rides in a Cruise from more than 10 years ago and reveled in the progress self-driving technology has made since then.

"I remember getting to do a very early ride in a Cruise car when it was still just driving around in parking lots, and it was very jerky and kind of terrifying — very far from where we are now," he said. "But even at that time, there were some bold people who believed that this would be possible and 10 years and $10 billion later, it is."

Last August, Friedman said on X that he would exclusively get around San Francisco via self-driving cars since Cruise and Waymo at the time were more available to the public.

Cruise paused its robotaxi services in October 2023, shortly after California regulators suspended the company's permit to operate in the state due to several safety incidents.

Friedman said he took his first Waymo ride around the summer of last year. While he believes anyone can work in an Uber, Friedman said the Waymo experience is much smoother. He said he hasn't dealt with safety issues in any of his rides with a Waymo.

"You can do that in an Uber, but the Uber drivers are often quite aggressive," he said. "The Waymos are just very smooth drivers. You can really just focus. I think this has the potential to change the way people live and work."

Few technological innovations in his lifetime have instantly given Friedman that impression.

"One of them was the first time I picked up an iPhone," he said. "One of them was when I first used ChatGPT. And one of them was my first ride in a self-driving car."

"It was just absolutely obvious — instantly — that the world would never be the same," he said.

• The Big Four firms reported revenue growth in 2024 but consulting lagged behind other services.
• The firms reported more growth in tax and legal services while demand for consulting has slowed.
• PwC cited market factors and political uncertainty as reasons for slower growth in consulting.

The Big Four professional services firms — PwC, Deloitte, EY, and KPMG — all reported revenue growth this year, but growth in their consulting arms lagged compared to their other services.

After experiencing a boom during the pandemic, the consulting industry has faced economic headwinds and slowing demand over the past couple years. Major firms have conducted layoffs, delayed start dates, and cut partner pay.

Financial reports released by the Big Four professional services firms throughout the year showed their consulting arms grew slightly, but by less than their legal, tax, and assurance businesses.

In its financial report released in October, PwC cited a number of factors contributing to the slower growth in consulting.

"A continuing slow market for mergers and acquisitions, sluggish economic growth in a number of key markets and political uncertainty holding back investment in some key projects meant that the growth of our advisory operations slowed over the last twelve months," the report said.

KPMG, which was the last Big Four firm to report its 2024 financials this month, reported the highest overall revenue growth at 5.1% year-over-year.

Here's a breakdown of how the Big Four firms performed this year.

Deloitte

• Fiscal year end: May 2024
• Global revenue: $67.2 billionaire n
• Revenue growth, year-over-year: 3.1%

• Revenue growth by category:

  • Tax and legal: 8.7%
  • Audit and assurance: 4.1%
  • Consulting: 1.9%
  • Financial advisory: - 3.8%
  • Risk advisory: 3.2%

PwC

• Fiscal year end: June 2024
• Global revenue: $55.4 billion
• Revenue growth, year-over-year: 3.7%

• Revenue growth by category:

  • Tax and legal: 6.3%
  • Assurance: 3.4%
  • Advisory: 2.6%

EY

• Fiscal year end: June 2024
• Global revenue: $51.2 billion
• Revenue growth, year-over-year: 3.9%

• Revenue growth by category:

  • Assurance: 6.3%
  • Tax: 6.3%
  • Strategy and transactions: 2.3%
  • Consulting: 0.1%

KPMG

• Fiscal year end: September 2024
• Global revenue: $38.4 billion
• Revenue growth, year-over-year: 5.1%

• Revenue growth by category:

  • Tax and legal: 9.6%
  • Audit: 6.2%
  • Advisory: 2%

Have a news tip or a story to share? Do you work in consulting? Contact this reporter at [email protected].

• In 2005, my husband and I decided to throw a white elephant party.
• We've kept the tradition and are celebrating our 20th white elephant party this year.
• I think planning ahead is the one big secret to hosting a party.

In December 2005, the second Christmas my husband and I were married, we thought it'd be fun to have a few friends over for a white elephant party. The idea was a classic one, and the ambiance was as simple as you'd expect for a pair of 22-year-old newlywed hosts.

About a dozen of our friends gathered at our condo for an exchange of ridiculous presents, a pan of boxed-mix brownies, and a few two liters of soda (complete with requisite red Solo cups).

We all ended up laughing so hard over gifts that the next year, we decided to do it again, and then again, and then again. This December marks our 20^th white elephant party.

We gather with 50 people

What began as a handful of new college grads "adulting" has evolved into a 50-person dinner event people tell us they look forward to all year long. Though we've classed things up with a fancy menu and a bigger, more tastefully decorated house, our gifting rule remains the same: bring the worst, funniest gift you can find. I've had this year's gift picked out for months, and no I'm not telling what it is.

Putting on such a large holiday gathering for two decades has taught me a few things about gracious hosting. My goal every year is to create a white elephant party that's fun and memorable — but doesn't take over my entire December. Though I still get a bit tense on the day of the event, I always end the evening feeling like my emotional cup is full. Here are some of my top tips for lower-stress holiday entertaining.

I always plan ahead

It's a dead horse to beat, but I'm convinced planning ahead is the key to successful entertaining. If you want to host a party during the holiday season, set a date early and let invitees know. I mail paper invitations sometime in mid-November for a mid-to-late December party.

Planning is also critical for details like food and party activities. Outline a menu a few weeks in advance or pin down a caterer who'll do it for you. Then, use the weeks leading up to a party to make and freeze food or give potluck assignments. I also feel some kind of planned activity always enhances a party. Eating and chit-chatting are all well and good, but group games or giving silly gifts make an event truly distinctive.

I don't try to do it all myself

I'm a nutritionist and, admittedly, a bit of a perfectionist. In other words, it's tough for me to hand over the cooking reins to others. But I find I'm far less stressed when I don't do it all myself. My secret to feeding 50 people is a combination of homemade and purchased items. I'll snag a catered tray of Middle Eastern or Italian fare from a local restaurant, then supplement it with complementary homemade sides and desserts.

I love mixing groups of friends

Worried that folks won't get along because of their politics or personalities? That's OK. Your friends are grown-ups. Trust them to be civil to each other. And this year in particular, don't be afraid to make a statement at the start of a party to the effect of "no politics tonight."

I've personally witnessed that bringing different types together in a social setting often helps people humanize those "on the other side." Friends from different corners of my life have become real friends due to our annual white elephant. Make your home a space for people to come together to have fun despite their differences. Everyone will be better for it.

I enjoy what I've created

My favorite thing about our 20 years of white elephant parties isn't the decadent cheesecake I always make or even the hilarious-to-the-point-of-legend gifts.

It's knowing that my husband and I have created memories of fun and friendship for the ones we love. Our party is the Christmas gift I give to our friends every year.

It delights me every bit as much as I hope it delights them. In your own holiday entertaining, take a moment to appreciate the beauty of bringing people together to celebrate the season. I promise it's worth it.

• US Navy submarines are key to countering China's naval expansion in the Indo-Pacific.
• China's military expansion includes a large navy, posing a threat to US naval dominance.
• US submarines, despite challenges, maintain an edge with advanced capabilities and strategic roles.

The threat of a conflict with China has risen tremendously over the years. Beijing is undergoing some of the largest military expansion and modernization efforts since World War II, building a formidable arsenal of missiles able to threaten surface ships and massive naval force, but the US Navy still has the means to sink Beijing's dreams of supremacy in the Indo-Pacific.

The US is looking to solutions like anti-ship missiles, but a key answer to China's expanding surface and logistics fleet that could number over 700 ships in a conflict is submarines.

Hunt and Sink

The US Navy would play a leading role in a potential conflict with China in the Indo-Pacific. This region's vast maritime domain is ideal for naval and air operations.

China understands that, and Beijing has been investing heavily in its navy, the largest in the world according to the Pentagon. China has built three aircraft carriers with plans for more, possibly nuclear-capable flattops, new amphibious assault ships, and increasingly capable destroyers.

Where there are surface warships, there is an opportunity for submarines, and undersea capabilities are an area where the US maintains a clear edge over China, even as it strengthens its force and invests in anti-submarine warfare solutions.

An important role for the US submarine force in a conflict would be to hunt and sink Chinese warships and logistical vessels. Sailing routes around Taiwan and in the South China Sea would potentially be ideal hunting grounds for stealthy submarines like those operated by the US Navy.

In a war game conducted last year by the Center for Strategic and International Studies simulating an intense fight over Taiwan, the think tank found that "submarines were able to enter the Chinese defensive zone and wreak havoc with the Chinese fleet," but it also found the number of subs available was insufficient, indicating a need to prioritize these capabilities.

Attack submarines can be deadly for enemy shipping and change the course of a war. The Falklands War between Argentina and the United Kingdom in 1982 is a perfect recent example of the potential of submarines in a state-on-state conflict.

During the war, the Argentine Navy transported men and weapon systems to the islands, creating a lifeline with mainland Argentina about 400 miles away. The Royal Navy went to war 8,000 miles away with six submarines leading the way, and they enforced an exclusion zone around the islands.

When the need arose, HMS Conqueror, a nuclear-powered attack submarine, sunk the ARA General Belgrano battlecruiser, one of the largest warships in the Argentine fleet. The shock of the sinking and the potential for further attacks forced the Argentine Navy to withdraw from the area, thus allowing the British ground forces to land unopposed.

Similarly, US submarines could help disrupt or destroy a Chinese amphibious force heading to Taiwan and limit the movements of the Chinese navy across the theater of operations.

Submarines aren't unstoppable, though. Advances in anti-submarine warfare have made submarines increasingly vulnerable. For China's navy, ASW has been a growing priority to counter the American sub threat. Additionally, uncrewed undersea vehicles can also pose a threat and help detect prowling subs, as can underwater sensor systems like the US operates and China has looked to as added security.

They can't stay under indefinitely without support. Munitions resupply — US subs are powered by nuclear force, meaning they don't have to refuel — is another challenge, especially in a high-intensity battlefield.

And the US faces challenges maintaining its undersea advantage. A key priority in the Navy's fiscal year 2025 budget proposal was investment in the submarine industrial base.

Submarine Fleet

The US Navy has the largest and most advanced submarine force in the world, with 71 vessels and a lot of variety. And given the challenges from China, much of that capability is in the Pacific.

The Navy's submarine fleet is comprised of attack, guided-missile, and ballistic-missile subs.

Attack subs are the staple of any submarine fleet. Their job is to find and sink enemy ships. The three classes of attack subs in the US fleet (Virginia, Los Angeles, and Seawolf) can do this by sailing stealthily underwater and firing torpedoes and cruise missiles. The Navy has 53 attack subs.

Guided-missile submarines support ground and naval forces by firing long-range munitions, but they can also sink enemy shipping via torpedoes. Each of the four Ohio-class guided-missile subs on the active fleet can pack over 150 Tomahawk cruise missiles.

Finally, ballistic-missile submarines make up America's maritime arm of the nuclear triad. The 14 Ohio-class ballistic missile submarines carry 20 Trident II ballistic missiles with nuclear warheads each. Although the subs also pack torpedoes like their attack and guided-missile siblings, the main mission of ballistic-missile subs is to rain down destruction in the event of a nuclear conflict.

• American Airlines has grounded all of its US flights over a technical issue.
• "Your safety is our utmost priority," the airline said in a post on X.
• Bloomberg reported that the issue is impacting American's ability to calculate flight weight requirements.

American Airlines says it is experiencing technical issues impacting all of its US flights, as airlines gear up for the Christmas travel rush.

All the airline's flights across the US are currently grounded, the Federal Aviation Administration said in an advisory statement.

"Your safety is our utmost priority. Once rectified we'll get you safely in the air and where you need to be," the airline said in response to one user who posted on X about the disruption.

The issue is preventing the airline from calculating weight and balance requirements for its flights, Bloomberg reported Tuesday morning.

This is a developing story.

All American Airlines flights nationwide were halted Tuesday morning after what the airline called a "technical issue."

Why it matters: The nationwide outage threatens to snarl traffic on Christmas Eve for the world's largest carrier.

Catch up quick: Bloomberg reported the airline may be experiencing a software issue calculating weight and balance for flights.

• The FAA issued a nationwide ground stop for all American flights at the airline's request as of 6:49 a.m. ET.
• It's scheduled to last until at least 8:30 a.m. ET, but could be extended.

What they're saying: "A technical issue is affecting American flights this morning," the airline said in a statement.

• "Our teams are working to resolve the issue as quickly as possible, and we apologize to our customers for the inconvenience."
• Multiple passengers posted on X that their planes had been forced to return to gates, and in some cases all passengers had to get off.

Flashback: Southwest Airlines was fined $140 million and spent months rebuilding customers' trust after a Christmas week meltdown in 2022.

Editor's Note: This story has been updated with further details on the outage.

• Cruise lines are spending millions on private islands and ports exclusive to their guests.
• These private Caribbean properties are money trees for companies like Carnival and Royal Caribbean.
• In-house destinations are becoming increasingly necessary amid rising fuel costs and port restrictions.

About 140 miles east of Miami, Royal Caribbean's private Bahamas island, Perfect Day at CocoCay, receives thousands of eager families virtually every day of the year.

The cruise line and its competitors don't just own ships — they also have land-based portfolios. Across the Caribbean and in countries like Honduras and Belize, almost every major cruise company has snatched up and developed beachfront properties exclusively for their guests.

To travelers, these secluded ports of call are convenient, safe, and cherished: "The vast majority of people love the islands," Patrick Scholes, a lodging and leisure research analyst at Truist Securities, told Business Insider in March.

To cruise lines, they're cash cows. And now, maybe more than ever before, a necessity as operators seek out profits amid rising operating costs and ever-restrictive ports.

The industry is cruising into a private island renaissance

Cruise lines like Princess, Holland America, and MSC collectively own 17 ports and private destinations in the Caribbean (including properties still under development).

Michael Bayley, president and CEO of Royal Caribbean International, told analysts in 2023 that the CocoCay had seen robust demand, including from repeat travelers. As such, the financial returns on the $350 million investment have been "exceptionally high and significantly above its target," Naftali Holtz, CFO of Royal Caribbean Group, said a few months prior.

Given travelers' appetite, the cruise giant has continued to grow its splashy Bahamas getaway.

The most recent extension opened in January, adding the adult-only Hideaway Beach to CocoCay's 14-slide waterpark, upscale beach club, massive pool, and umbrella-lined beaches. Perfect Day Mexico is set to open in 2027.

Carnival is also growing its real estate portfolio — next with Celebration Key, a $600 million resort on Grand Bahama Island scheduled to open in 2025, and expansions to its private Half Moon Cay a year later.

Private ports have become a cruise line goldmine for three major reasons.

1. Fuel is expensive

Fuel is a major expense for the cruise industry. Fortunately, most Caribbean private destinations are only a night's sailing from Florida's major ports.

Amid rising fuel costs, it's easy to see why cruise lines are increasingly focusing their itineraries on these nearby stops.

In September 2023, Josh Weinstein — president, CEO, and chief climate officer of Carnival Corp — called the forthcoming Celebration Key a "win-win-win for the environment, our guests, and the people of the Bahamas," citing the property's proximity to its Florida homeports and the subsequent reduced fuel expenditure.

It could certainly be a "win" for travelers: In the same call, he told analysts that a guest-fronted fuel surcharge is "certainly not off the table."

2. Private destinations keep profits in-house

These private ports offer plenty of opportunities for guests to spend big. And with no need for third-party excursion operators, cruise lines can keep more profits in-house.

Before its debut, pre-cruise bookings for CocoCay's new Hideaway Beach surpassed the company's expectations, Jason Liberty, president and CEO of Royal Caribbean Group, told analysts in October 2023.

Admission can cost up to $89 per person during peak season. Nearby, entry to the more exclusive beach club could be shy of triple that cost.

Even the otherwise complimentary parts of the island have splurge-enticing options like rentable cabanas and snorkeling gear.

Travelers content with a basic beach chair and the lunch buffet don't have to ball out on these up-charged luxuries. But they sure are hard to resist, especially as cruisers have become eager to spend more on their vacations.

For families, skipping CocoCay's waterpark could be as sacrilegious as skipping Disney World during an Orlando vacation, Scholes said. A day pass to Thrill Waterpark can exceed $100 per person — that's more than $400 down the drain for a family of four in one afternoon.

3. Some popular ports are saying 'no' to giant cruise ships

The world's largest cruise ship, Royal Caribbean's Icon of the Seas, can carry 7,600 guests and 2,350 crew.

This sudden influx of travelers could overwhelm smaller destinations and their locals, like the more than 25,000 residents of Santorini, Greece, and 25,600 of Key West, Florida.

With concerns like pollution and over-tourism, it's no surprise the popular Greek island limits daily cruise visitors, while its Florida counterpart has faced a fraught battle to restrict cruise tourism.

They're not alone. Cities across the US and Europe have increasingly limited travelers coming by sea — either through size restrictions, daily visitor limits, or complete bans. This includes desirable ports like Juneau, Alaska, French Polynesia, and Venice, Italy.

Ironically, at the same time, mass-market cruise lines have continued to grow the size of their vessels — so much so that several of these new mega-ships are now simply too big to fit into some ports.

So, if you can't beat the ports, why not join them? Especially if you can outfit your private properties with dozens of profit-growing amenities.

On the morning of March 16, 2015, the night-shift nurses of Martin Correctional Institution clustered in the medical exam room to brief Robert Silvis, the prison's nursing director. Silvis had just started his shift at the facility in Indiantown, Florida, and the nurses looked stunned. They explained, as well as they could, what had occurred the night before.

A man was dead.

Silvis called a prison captain and pulled the surveillance tape.

The video showed someone Silvis recognized as Carolyn Conrad, a licensed practical nurse, entering the D block dormitory at 7:24 p.m. to begin the nightly ritual of distributing medication to the men. When a corrections officer arrived outside cell D2210, he discovered Christopher Cox sprawled on his stomach on the concrete floor. Cox was unresponsive, his arms slack against his sides, his face bloodied and pressed against a pillow, a white T-shirt twisted into a noose around his neck.

Corrections officers handcuffed Cox's cellmate, Hurley Brown, then cuffed Cox's arms and legs before turning his limp body to the side and removing the noose. At 7:28 p.m., Conrad entered the cell. She left seven minutes later. Records show that Conrad, who had been working at the prison for only a month, did not call 911 or start CPR.

Silvis was taken aback. He knew someone with a practical-nurse license, which requires a high-school diploma and a year of vocational school, is not credentialed to diagnose or decide a course of treatment. Anyone with that license certainly lacks the training or authority to declare a person dead. When she saw that Cox was unresponsive, Conrad was required to alert emergency services and start CPR until a more senior medical professional could relieve her. Instead, witnesses later told a state investigator, she left Cox while his skin was still warm.

Silvis called Conrad to demand an explanation. He recalls her telling him she hadn't started CPR on Cox because she believed he was already dead.

As with many men and women incarcerated in the United States, Cox's life was left in the hands of overstretched and minimally qualified medical providers operating in institutions that rarely face accountability for shoddy care. At Martin that night, there was no doctor on duty, only one registered nurse and a group of four LPNs, including Conrad, to care for up to 1,500 men.

Outside the prison walls, someone witnessing a murder can call for an ambulance. But incarcerated people cannot visit a medical clinic on their own, or choose their own doctor. They cannot seek a second opinion, make an appointment with a specialist, pursue additional testing, or control the type or quality of care they receive. They cannot dial 911.

Injury and illness are commonplace in prisons. In a 2009 study of nearly 7,000 men incarcerated in 12 state prisons, 19% reported being physically assaulted by a fellow prisoner over a six-month period; 21% reported being assaulted by prison staff. Meanwhile, waves of men and women, locked up during the height of the war on drugs and mandatory minimum sentences, are now growing old behind bars, often with chronic health conditions such as HIV. Over a third of those incarcerated in US prisons have been given diagnoses of mental illness — a higher rate than on the outside.

Prison healthcare budgets have struggled to keep pace with these growing needs, and much prisoner healthcare has been outsourced to for-profit providers. With fixed per-patient revenue, these privately owned companies have an incentive to avoid expensive procedures and otherwise cut costs. Prisons and private contractors alike have depended on less-trained health providers, such as licensed practical nurses, to keep staffing costs low. A legal settlement in California established that one leading private prison health provider, Corizon, had saved 35% for every low-level nurse who did the work of an RN. Prisons may have a single doctor on staff, and recruitment and retention have become such an acute problem that medical contractors have often retained doctors who have racked up a long history of complaints.

As these problems mounted in the 1980s and 1990s, Congress and the Supreme Court limited prisoners' ability to get relief. To win a lawsuit over constitutionally inadequate medical care, a prisoner must now survive the many restrictions imposed by the Prison Litigation Reform Act, which in 1996 mandated preliminary screenings and other measures meant to weed out frivolous prisoner lawsuits. A prisoner also has to overcome a Supreme Court standard known as "deliberate indifference." As defined in the 1994 case Farmer v. Brennan, the standard says that "cruel and unusual punishments" hinges on the defendant's mindset. Under this standard, the potentially lethal effects of Conrad's decision not to treat Cox would not be enough. A successful Eighth Amendment suit would have to show that Conrad was aware of the risk of harm her inaction presented.

While prisoners can file malpractice claims in state court, there they typically face caps on damages and are unable to recoup attorney fees. And any prisoners seeking injunctive relief — such as a transfer to a hospital — must file a federal constitutional claim. So the barriers to relief in the federal courts introduced by Congress and the Supreme Court have proved nearly insurmountable, preventing claims of even the most egregious forms of medical neglect from prevailing in court.

Business Insider analyzed a sample of nearly 1,500 federal cases alleging cruel and unusual punishment in violation of the Eighth Amendment, including every appeals court case with an opinion we could locate filed from 2018 to 2022 and citing the relevant precedent-setting Supreme Court cases and standards. Nearly two-thirds of those cases involved allegations of constitutionally inadequate medical care. Among them were claims of grievous harm: untreated infections so severe they resulted in amputations; deaths from treatable conditions like gallstones or appendicitis; and agonizing months and years spent waiting for diagnosis and treatment as cancerous tumors swelled, metastasized, and grew lethal.

Hundreds of prisoners complained of inadequate treatment for potentially fatal illnesses such as hepatitis C and HIV or said their mental-health crises were met with violence or solitary confinement rather than care. Dozens said they experienced excruciating pain — stemming from conditions such as collapsed vertebrae or severe infections — that went untreated for months or years. Still more said they were denied basic medical accommodations such as dentures and walkers.

Together, the claims describe a US prison medical culture defined by a gross disregard for human life.

For generations, federal courts have understood the constitutional protection against cruel and unusual punishment to guarantee prisoners the right to adequate healthcare. Occasionally, over the past 30 years, the ACLU or other powerful litigators have managed to win Eighth Amendment cases in which courts have mandated oversight measures and reforms in a prison's, or a prison system's, medical care. But such sweeping accountability measures are rare.

In BI's sample, nearly nine out of 10 cases alleging substandard care were unsuccessful. Most of the remainder settled; many for a few hundred dollars, and all without an admission of wrongdoing, whether by the prison, the department of corrections, or the private medical contractor.

Plaintiffs in only five of these cases won their Eighth Amendment claims.

"Medical treatment only violates the Eighth Amendment when it is 'so grossly incompetent, inadequate, or excessive as to shock the conscience or to be intolerable to fundamental fairness,'" the judges of the 11th Circuit Court wrote in 2022, citing case precedent in denying a claim of inadequate care by a prisoner named Maximo Gomez, who was at risk of suicide.

Such readings of the Constitution have largely insulated prison healthcare providers from legal accountability.

In 2017, Gomez told officers at Hamilton Correctional Institution in Florida that he was experiencing intense distress, extreme depression, and suicidal ideation, according to his civil complaint. A licensed practical nurse employed with Centurion Health, then contracted to provide care in some Florida prisons, spent six minutes conducting what appeared to be a cursory mental-health assessment and determined that he did not need to be placed in an observation cell. Corrections officers, Gomez said, joked that they'd treat him with "hot sauce," slang for pepper spray.

A surveillance camera recorded Gomez flinging himself to the ground, screaming that he needed help and might kill himself. It showed corrections officers wrestling him into arm and leg restraints; his complaint said they then locked him in a shower cell, punched and kicked him in the face, and blasted him with pepper spray as he begged for psychiatric care.

In court filings, the officers said they used force on Gomez "to force compliance" after he refused to submit to restraints but denied punching or kicking him, and the Centurion nurse said she gave Gomez a mental-health assessment according to correctional staff instructions.

Gomez's lawsuit was dismissed. "The Eighth Amendment," the judges wrote, quoting precedent, "does not require medical care to be perfect, the best obtainable, or even very good."

The Florida Department of Corrections declined to comment on individual cases but said each prisoner is "continuously monitored and evaluated for medical, dental, and mental health needs throughout incarceration" in accordance with Florida law.

A 'difference of medical opinion'

The night Cox died, he was three years into a 25-year sentence for murder. At about 7 p.m., a prisoner named Derek Cedri heard the sounds of a struggle in the cell next to his and then a cry for help, he later told a Florida Department of Corrections investigator. On the other side of the cell block, a second prisoner peered through his narrow cell window and caught a glimpse of Brown with his arm wrapped tightly around Cox's throat.

Cedri did the only thing he could: He shouted to a nearby corrections officer that a man was being killed. The officer did not respond; he later told investigators he didn't hear Cedri cry out. Meanwhile, Brown continued to attack Cox; medical records would later show he bludgeoned Cox's face and stomped on his head and neck.

"Man down!" other prisoners yelled. Soon men across the unit were battering their steel cell doors into a steady thunder. Nearly 30 minutes passed before prison medical staff and corrections officers appeared. Four minutes after that, Conrad, the licensed practical nurse, arrived and left without performing CPR.

Conrad did not respond to inquiries by phone, email, or mail.

Her decision not to provide care may not have been an anomaly. In dozens of cases in BI's sample, incarcerated people said they were denied emergency medical treatment by corrections officers or medical staff despite obvious medical distress.

While incarcerated at Camille Griffin Graham Correctional Institution in South Carolina in April 2019, Julie Mason later told a court, she woke nauseated and in severe abdominal pain.

Because she was incarcerated, Mason had only one way to seek medical care: placing a sick call. These written requests don't always prompt immediate attention; in some cases, court records show, they go unanswered for weeks. Even when a diagnostic test for cancer is delayed or an appointment to address excruciating pain is repeatedly rescheduled, prisoners have no internal recourse except to submit another sick call — or submit a complaint to prison administrators. Prisoners' requests for care, court records show, are sometimes met with suspicion if not outright contempt: the prisoner with acute appendicitis denied emergency care by a nurse who thought he was just seeking pain meds; the suicidal prisoner who said he begged for psychiatric care and was told by a guard to "go for it."

In her civil complaint, Mason said she had sent repeated sick calls requesting emergency medical treatment over two days, all unanswered. When Mason continued to complain of severe pain, she said, a corrections officer offered her Tylenol but failed to report her condition to medical staff. The next day, another officer discovered Mason in her cell, collapsed in her own vomit. Mason was sent to medical twice, where nurses checked her vitals; one sent her back to her cell with anti-nausea medication. Hours later, she suffered a grand mal seizure. Only then did a nurse seek sign-off from a prison doctor to send her to a local emergency room, where she was given a diagnosis of necrotizing pancreatitis, a condition that puts a patient at risk for a fatal septic infection. Mason spent nine days in the hospital.

The US District Court for the District of South Carolina agreed with defense arguments that the nurse had sent her for emergency care, and that the corrections officer had "checked on her" and provided "something for her pain at least one time." Under the deliberate-indifference standard, the judges decided, those actions were enough to show that Mason had received adequate care. She lost the case.

The South Carolina Department of Corrections did not respond to requests for comment.

"Where a prisoner has received some medical attention and the dispute is over the adequacy of the treatment, federal courts are generally reluctant to second guess medical judgments," Judge Anthony Celebrezze of the 6th Circuit wrote in a 1976 court opinion. Over successive decades, such judicial caution has become pervasive. In hundreds of cases BI analyzed, if healthcare professionals offered any medical attention at all, judges deferred to their judgment.

Many chalked up the gap between the medical care a prisoner said they required and what was provided to a "difference of medical opinion."

The judges of the South Carolina District Court, and all but one of the other judges mentioned in this story, declined to comment or did not respond to queries.

For months in the summer of 2016, James Kirk complained to the healthcare staff at Jackson Correctional Institution in Wisconsin of classic symptoms of heart failure — acute chest pain and labored breathing. Kirk had a history of heart attacks and had been told he had coronary artery disease and congestive heart failure. But according to his complaint and internal grievance files, the prison medical staff denied Kirk's request to be seen at a hospital. Instead, they issued him an inhaler, attributing his chest pain to his age, history of smoking, or inclement weather. A month later, Kirk collapsed and was transferred to a local hospital. There, doctors discovered a total obstruction of one of his coronary arteries.

Kirk received treatment and survived. When he sued the medical staff involved in his care, the defense argued that Kirk "appeared stable and they were trying different treatments and medications to address his symptoms." The judges of the 7th Circuit found that under the deliberate-indifference standard, the "disagreement" between the hospital doctors and the prison's health providers over Kirk's medical needs was insufficient for an Eighth Amendment claim. He lost the case.

Beth Hardtke, a spokesperson for the Wisconsin Department of Corrections, declined to comment on the Kirk case but said the department "strives to provide the same quality of healthcare as is available in our communities."

In at least a dozen cases BI examined, outside medical authorities, such as hospital doctors, testified that the medical treatment prisoners received was substandard. Yet such testimony rarely persuaded judges that claims had met the deliberate-indifference bar.

One particular case stood out. In late 2010, Dr. Jerry Walden, a physician who'd once served as chief medical officer at a federal prison, was asked by the family of a Michigan prisoner, who had advanced hepatitis C and end-stage liver failure, to advocate on his behalf. After reviewing the medical records, Walden wrote to the Michigan Department of Corrections that the prisoner, Kenneth Rhinehart, who had been serving time for murder since 1973, needed specialized acute care and that if prison administrators were unable to provide it, they "should seriously consider pursuing a medical commutation for this very ill man."

Rhinehart was never offered medical release, and medical staffers at the G. Robert Cotton Correctional Facility continued to delay his treatment. His medical appointments were rescheduled and canceled. His repeated petitions for care were dismissed or ignored. In March 2011, Rhinehart sued, asking the court to compel doctors with Prison Health Services — the private company that then provided medical care to Michigan prisons and later merged with Corizon — to offer care that would prolong his life.

Months later, in June, Rhinehart was rushed to the emergency room after he complained of severe abdominal pain. Arteries in his esophagus had burst — a complication of advanced liver failure, hospital doctors later said. Rhinehart underwent emergency surgery to repair the tears in his throat.

An MRI scan during his hospitalization showed that a mass on his liver had grown to 11 centimeters. Walden wrote again to prison administrators. The mass might be cancerous, Walden wrote, and prison doctors had left it untreated for over a year. Rhinehart needed to be seen by an oncologist immediately.

The prison's medical contractors never scheduled the appointment.

Not long after, the arteries burst again. He woke in his cell doubled over in pain. Blood poured from his mouth and nose, nearly filling a small trash can in his cell. He had a second emergency surgery. To decrease his chances of another bleed, Dr. Lynn Schachinger, who performed this surgery, recommended Rhinehart be transferred to an acute-care facility for the installation of a stent. Rhinehart's condition was serious, Schachinger wrote to Rhinehart's prison doctors, and without further treatment he might "bleed to death."

Corizon doctors refused to authorize the stent procedure, and Rhinehart was sent back to prison instead. When a colleague of Schachinger's insisted on documenting the prison's decision to withhold care, Jeffrey Stieve, then the prison's chief medical officer, balked. "I believe he was threatening me and the department with his refusal to accept our primary management of the patient," Stieve wrote in Rhinehart's medical file.

Stieve and the Michigan Department of Corrections did not respond to requests for comment. A spokesperson for YesCare (formerly Corizon) declined to comment on individual cases but said the correctional healthcare industry "is filled with mission driven professionals who are committed to serving incarcerated individuals, many of whom have never received healthcare in their life, within a challenging prison environment."

By February 2013, Rhinehart's disease was consuming him. He died after a Corizon provider gave him a high dose of morphine. An autopsy commissioned by Rhinehart's family listed the cause of death as an overdose.

Rhinehart's brothers continued his federal case, accusing Corizon, the company's health providers, and other defendants of inflicting pain, depriving their brother of potentially life-prolonging treatment, and then giving him a lethal morphine dose. In court filings and depositions, Walden, Schachinger, and three other outside doctors all testified to the profound inadequacy of Rhinehart's care, saying his treatment "constituted cruel and unusual punishment."

Corizon doctors argued in court filings that Rhinehart's prognosis was poor and his suffering would have been acute with or without the treatment delays. They argued that the stent procedure would not have prolonged his life and their treatment plan of beta blockers, pain medication, and 24-hour surveillance was sufficient.

Judges of the District Court for the Eastern District of Michigan and the 6th Circuit appeals court nevertheless found that the Corizon doctors had provided constitutionally adequate care. Their decision not to install a stent boiled down to a "mere difference of doctors' opinions," so they had not been indifferent to his suffering.

Hesitation by the courts

The Supreme Court's deliberate-indifference standard hinges on something that, the data shows, is nearly impossible to prove: mindset. Judges are asked not only to assess the cruelty of what a prisoner experienced but to decide whether that harm was the result of someone's reckless disregard. In doing so, judges have accepted the slightest bit of care as evidence that prison healthcare providers were doing an adequate job.

Mark Mann's experience in the Florida prison system echoed Kenneth Rhinehart's. Mann first complained of stomach cramping and blood in his stool in May 2014. Prison doctors ordered an abdominal X-ray and stool screenings, which returned normal results. As Mann's abdominal pain continued over the next two years, according to medical records, prison medical staff ordered X-rays and lab work but did not conduct a thorough oncological screening. The prison doctor gave diagnoses first of hemorrhoids, then of acid reflux. He prescribed Imodium and Maalox. It wasn't until June 2016, after Mann repeatedly complained of "extreme pain," that the prison's doctor ordered a CT scan.

Mann had Stage 4 colon cancer.

In 2019, Mann sued Corizon and Centurion Health, the private companies then contracted to provide care in Florida prisons, and his prison doctors. He called an expert witness, a colon and rectal surgeon, who described Mann's doctor as "grossly negligent" for failing to order further tests over a period of two years as Mann's cancer progressed.

A spokesperson for Centurion declined to comment on Mann's case but told BI that "Centurion seeks to improve the lives of all those entrusted to our care."

Corizon called an expert witness, too, a family and internal medicine doctor, who said Mann was appropriately treated and a colonoscopy was not warranted given that Mann was young — he was in his 30s at the time — and had no risk factors for colon cancer. Centurion said its medical providers gave Mann continuous care, diagnosed his disease, and "were not indifferent to Mann's cancer" but rather "helped cure it." (Mann has since died.)

Eleventh Circuit judges found that this scope of care, including the X-rays and lab work, was enough. The treatment Mann received may have violated the "applicable standard of care," the judges said, but Mann's symptoms had been addressed with both testing and medication. "When a prison inmate has received medical care," the judges said, citing an earlier decision, "courts hesitate to find an Eighth Amendment violation."

Beverly Martin, a former federal appeals court judge, reviewed Cox's case in 2019, the same year Mann filed suit. "The law was exceedingly tough on prisoners back in 2019," she told BI. "And I think it has gotten tougher since then."

The judicial hesitation to second-guess medical providers was visible in another case the following year, when a group of prisoners at Federal Correctional Institution Elkton, a low-security prison in eastern Ohio, sued the federal prison system at the start of the pandemic. They asked the court to order the release of medically vulnerable prisoners and mandate additional COVID-19 safety precautions. By the time they filed suit in April 2020, three men at the facility were already dead. Hundreds of other prisoners were believed to be infected. The prisoners won a preliminary injunction requiring the prison to evaluate medically vulnerable prisoners for temporary release. But the Bureau of Prisons got the injunction reversed on appeal.

The 6th Circuit Court agreed with defense arguments that since the prison had implemented an "action plan" of sorts — including issuing each prisoner two paper masks and a 4-ounce bottle of soap each week — the bureau had not been indifferent to the spread of the deadly virus among the 2,300 men trapped in Elkton's crowded housing units. The case eventually settled, with the bureau agreeing in May 2021 to track COVID-19 infections at the facility.

Ben O'Cone, a spokesperson for the bureau, declined to comment on specific cases but said the bureau is committed to upholding prisoners' constitutional rights and makes "every effort to provide essential medical, dental, and mental health (psychiatric) services."

BI identified nearly 200 cases in the sample in which courts found that prisoners had suffered serious harm — including heart failure and untreated cancer — but struck down their cases on mindset alone. In more than 250 other cases, federal judges never made a finding on the objective severity of the harm, deciding solely on the basis of mindset that no constitutional violation had occurred.

In 2023, most malpractice suits in the United States settled, and the average medical malpractice payout was about $400,000, according to a federal database. A 2019 study of insurance claims calculated that the average payout for grievous malpractice — such as a cancer misdiagnosis — was above $700,000.

In the handful of settlements in BI's sample in which the damages were disclosed, the settlements were far smaller. Leaving aside two cases in which prisoners died, no settlement over inadequate care was larger than $45,000, and many were for far less.

One of these cases was filed by a woman incarcerated at Coffee Creek Correctional Facility in Oregon. Her 2017 civil filing said that after a fellow prisoner sexually assaulted and beat her in the shower, corrections officers responded to her screams for help by pepper spraying her and putting her in solitary confinement. The pepper spray, she said, left her with excruciating blisters on her underarms, under her breasts, along her cesarean-section scar, and on her genitals. For over a week, while locked in solitary, she begged for medical treatment without response.

In 2023, she reached a settlement for $251 in damages.

The Coffee Creek defendants denied in court filings that they'd withheld medical care, saying the prisoner was "seen numerous times by medical following the incident." In settling, they admitted no wrongdoing; the Oregon Department of Corrections did not respond to requests for comment.

Medical attention without medical treatment

The most frequent repeat defendants in BI's sample were not individual doctors and nurses, but for-profit companies such as Wexford, Centurion, CoreCivic, and the private-equity-backed Wellpath and Corizon (now YesCare) that receive multimillion- or billion-dollar contracts to provide medical care in state prisons.

As defendants in prisoner suits, the companies have an advantage over individuals: To win an Eighth Amendment claim against a contractor, a prisoner must prove their suffering was due to a company policy or custom. In BI's sample, private medical contractors almost never lost.

In a strongly worded 2022 decision in a class action suit in Arizona, a district judge found that the state, in partnership with Wexford, Corizon, and Centurion, had provided "plainly grossly inadequate" healthcare. She mandated the creation of new policies to force both "quantitative and qualitative" improvements in care and appointed a court monitor.

Such court outcomes are extremely rare.

Of the 210 cases in BI's sample that named private medical contractors or their employees, the defendants prevailed 84% of the time. Almost all of the remaining cases settled.

A 2020 New York University Law Review article argued that the PLRA and the Supreme Court's deliberate-indifference standard had effectively shielded private medical contractors from large liability damages, court monitoring, or other significant forms of federal judicial oversight — and that this had shifted companies' cost-benefit analysis. "The absence of any true threat of legal action exacerbates this environment of unaccountability," Micaela Gelman, then an executive editor of the law review, wrote, and "leads to dangerous, ineffective healthcare that is shielded from constitutional challenge."

Gelman further argued that the low chance of facing penalties, combined with pressure from state agencies to cut costs and pressure from investors to maximize profits, had incentivized private companies to cut corners.

A spokesperson for Centurion, a defendant in 16 cases in BI's sample, said it was "spot on" that funding levels for prison healthcare lagged behind marketplace costs but added: "Any assertions that denying care or using staff with insufficient licensure or credentials to increase profit are patently false. Not providing the very services a company is hired to provide is not a sound, long-term business model for any company in any industry, particularly healthcare."

Ryan Gustin, a spokesperson for CoreCivic, a defendant in seven cases in the sample, said, "We take seriously our role and responsibility to provide high-quality comprehensive medical, dental, and mental-health care to every individual," noting that medical personnel were onsite 24/7 and worked closely with outside hospitals and specialists.

In a 2009 review of cases filed on behalf of Massachusetts prisoners alleging inadequate medical care, Joel H. Thompson, the managing attorney at the Harvard Prison Legal Assistance Project, found evidence that in fact private contractors had exploited the deliberate-indifference standard to avoid accountability. He found that private contractors delayed medical testing when it might have led to diagnoses that would obligate them to pay for more advanced care; that they avoided referring patients to expensive specialists or outside facilities; and that they conducted routine examinations documenting patient complaints but rarely prescribed further medical intervention.

They provided medical attention without providing medical treatment, he concluded. And the courts signed off.

Prisoner court filings describe all of these patterns at Wexford, one of the nation's largest prison health providers. The privately held company was a defendant in 94 suits across eight states in BI's sample — nearly half of the cases with private-sector defendants.

Several of the suits, according to one federal judge, accuse Wexford of running a business designed "to skimp on medical care in order to enrich themselves" by means of chronic understaffing, routine delays in critical cancer screenings and necessary surgeries, and declining to provide even basic medical treatment. As with the other private companies, Wexford typically prevailed. The company settled one in five cases in BI's sample, mostly for undisclosed amounts and all with no admission of wrongdoing, and lost two cases outright. In one case, Wexford paid $155,000 in damages to the widow of an Illinois prisoner, William Kent Dean, who died of kidney cancer after Wexford doctors delayed lifesaving care.

Wexford did not respond to requests for comment.

A 2018 decision by the 7th Circuit appeals court in a case filed by Kelvin Norwood, then incarcerated at another Illinois prison, Stateville Correctional Center, was typical. Norwood's knee was badly injured, and he had sued Wexford, several Wexford employees, and other defendants for providing him with inadequate medical care for a tear in his meniscus, severely damaged cartilage, and a partially ruptured Baker's cyst. His claim had failed against all of the defendants at the district court.

In his appeal, Norwood argued that two Wexford healthcare providers, Dr. Parthasarathi Ghosh and a physician assistant, had prescribed insufficient pain medication and delayed or withheld critical treatment, including medically necessary surgeries and assistive devices such as a brace and a cane. They had done so for eight years, Norwood said, years marked by intense pain.

"Norwood has been the victim of serious institutional neglect," the judges found. "These delays look like features of the Wexford system of healthcare, rather than anything Dr. Ghosh controlled." Still, they decided in the defendants' favor, finding that Ghosh and the PA had not been indifferent because they had provided ongoing care.

Neither Ghosh nor his attorneys responded to requests for comment.

Ghosh was a defendant in multiple cases in BI's sample, though he always prevailed. And he was not alone. Dozens of prison healthcare workers were repeat defendants. The two doctors with the most complaints were, like Ghosh, employed by Wexford.

One, a doctor named Saleh Obaisi, was sued by Illinois prisoners nine times over five years over claims that he'd provided inadequate medical care, delayed essential surgeries, or failed to treat crippling pain. In each case Obaisi denied he'd been indifferent to his patient's medical needs, and he prevailed in all but three.

Vipin Shah, another Illinois doctor employed by Wexford, appeared as a defendant in eight cases. Shah was accused of providing inadequate care for severe infections and, like Obaisi, delaying necessary surgeries. Shah also denied each time that he'd been indifferent; he prevailed every time.

Despite these red flags, Obaisi remained employed with Wexford until his death in 2017, and Shah, according to court filings, remained on Wexford's payroll until July 2021, a year after the last of the eight complaints against him was filed.

Shah, Obaisi's estate, and their attorneys did not respond to requests for comment.

Wexford was the company in charge of Cox's care at Martin Correctional Institution that spring of 2015.

Wexford misses 'red flag' symptoms

The morning after Cox died, Silvis, the nursing director, began to ready charges against Conrad with the Florida nursing board. He thought her failure to provide CPR constituted a violation of her medical license.

That day, March 16, 2015, he called Wexford, his employer, to report what had happened and inform them of his decision. Silvis' manager told him not to report Conrad, who was at the time employed by a Wexford subcontractor. Instead, Silvis recalled, the manager asked him to quietly bar Conrad from ever returning to work at Martin.

Wexford wanted it buried, Silvis thought. How could you protect a nurse who went against practice and cost someone their life?

Less than three months later, Wexford did fire someone — and it was Silvis.

On June 10, he wrote to a Florida state investigator to report the Cox incident and charge that "upper mgt at Wexford is not concerned with inmate care or safety." The state investigator closed Silvis' complaint against Wexford, saying the allegations had previously been addressed in two related cases. Conrad was barred from working at any Florida state prison, according to the investigative report, and she was later fired from her job at the nursing temp agency. In a deposition, Conrad said she retired.

In addition to Silvis, BI spoke with three other former Wexford healthcare providers. All four described the company's cost cutting as extremely dangerous. They said the company drove revenue by chronically understaffing facilities and retaliating against staff who reported lapses in care.

One of those providers was a 16-year prison nursing veteran named Tracie Egan, who found a job as a health-services administrator with the company at Southern New Mexico Correctional Facility in Las Cruces, New Mexico, in April 2022. She said she knew almost immediately that she'd made a mistake.

On her first day, she expected training. Instead, she told BI, she got a pile of outdated policy manuals and a chilly welcome. Within a few days, multiple nurses quit. By her first weekend, Egan was left with a skeletal medical staff to serve nearly 1,000 men, many of whom were on complex combinations of medication or had significant medical needs.

In a suit Egan later filed claiming retaliation, she said she was soon working 19-hour shifts, scrambling to sort pills and handle prisoner sick calls. Sixteen nurses short of a full staff, she was drowning. Routine care was falling through the cracks, she said in court filings. Without dedicated nurses to administer the prison's pharmacy, medications were haphazardly stored, sorted, and distributed, increasing the risk of mix-ups or accidental overdoses. Men sometimes went weeks without their pills and longer without nurse's visits.

She asked Ronald Martinez, then the prison warden, for more staff, training, and resources. In October 2022, she said in court filings, she reported the facility to the state pharmacy board for what she said was a lack of safety precautions in the handling of medications. Then she appealed to Wexford's regional managers. Her daily requests turned into desperate pleas. She told Martinez and her regional managers that she considered the situation extremely dangerous, both for herself and for the people in her care.

She said that Martinez responded by criticizing her job performance and that her Wexford regional managers refused to take remedial action.

Martinez did not respond to requests for comment. Brittany Roembach, a spokesperson for the New Mexico Corrections Department, noted that Martinez and the department were recently dismissed from Egan's lawsuit and said that the agency "remains committed to the health and safety of our inmates and to maintaining high standards of care within our facilities."

Egan said she returned home after one shift, about six months into her job, feeling demolished, only to find two $50 gift cards and a signed note from a Wexford official, Jim Reinhart, thanking her for sticking with the job. "Wexford appreciates everything you are doing to try and fix Southern," Reinhart, who is now Wexford's director of business affairs and transitions, wrote. "Most people would have walked away by now but somehow you have stuck it out."

Reinhart did not respond to requests for comment.

She felt proud and even hopeful. She decided to email Reinhart directly, according to her complaint, alerting him to her working conditions and asking for assistance.

Egan was fired shortly after. In court filings, Wexford denied that Egan was insufficiently trained, that her workplace was unsafe, and that the company had failed to respond to her requests for support. Wexford said any harm that Egan suffered was caused by Egan's conduct alone. Egan's retaliation suit against Wexford remains ongoing.

A December 2023 monitoring report, the result of a consent decree requiring Illinois to improve care in the state's prisons, where Wexford runs medical operations, documented the company's routine failure to meet its medical care obligations. The report describes a litany of preventable deaths and critical lapses in treatment.

The Illinois Department of Corrections did not respond to requests for comment.

The monitor reviewed records of 107 prisoner deaths in the state from 2021 to 2023 and identified nearly 900 treatment deficiencies. Over and over, Wexford doctors and nurses did not recognize or treat "red flag" symptoms; chronically delayed or denied treatments, tests, and referrals to specialty care; and failed to provide basic emergency medical care such as taking vital signs or calling 911.

In dozens of cases, the report found, men and women under Wexford's care were subjected to prolonged treatment delays. A critical lack of staff, the report said, may explain the "widespread and therefore systemic" deficiencies. As of June 2023, the report said, Wexford had failed to fill even half of its contractually obligated medical positions.

In December 2023, Illinois state officials awarded Wexford another five-year contract worth more than $4 billion.

'There was nothing more I could do'

In the months and years after Cox's death, the state's investigative report and subsequent court filings laid out the events of his final hours in granular detail.

At 7:28 p.m. on March 15, 2015, Carolyn Conrad, the Wexford subcontractor, entered Cox's cell at Martin Correctional Institution. She noted his stilled chest and blood trickling from his nose and mouth. Two corrections officers told a Florida state investigator they saw Conrad search for a pulse at Cox's wrist. In a later deposition, Conrad said she also checked Cox's pupils, looked for breath or other signs of life, rubbed her knuckles against his sternum to check for reflexive movement, and administered a few chest compressions, though the officers who were present recall none of this.

"He's dead," she told them, and exited the cell.

Cox's mother, Monica Stone, commissioned an independent review of the autopsy report by a forensic pathologist. He noted that Cox's brain had swollen against his skull, an indication, he said, that Cox's heart was still beating for an indeterminate period of time after he was attacked. Whatever chance Cox had of survival was lost when no one gave him CPR. That failure, the pathologist wrote, was "grossly negligent and should be considered as contributory to his death."

Five minutes after Conrad left, two other licensed practical nurses arrived sprinting into his cell. They started chest compressions and ordered officers to call 911. Paramedics arrived at 8:16 p.m. and, nearly an hour after Conrad and the corrections officers first saw that Cox was unresponsive, they declared him deceased.

Cox's mother, Monica Stone, sued Conrad, the prison warden, the corrections officers who first arrived at his cell, and the secretary of the Florida Department of Corrections in 2017. She argued that they'd violated her son's constitutional rights by withholding critical medical care.

Conrad had told Florida investigators that she had not received any training from the prison or from her employer, the nursing temp agency contracted by Wexford. In her subsequent court deposition, Conrad said she did not knowingly withhold care because she genuinely thought Cox was dead.

"I believed there was nothing more I could do," she said.

Shaniek Mills Maynard, a magistrate judge, did not find a constitutional violation. Conrad may have been negligent, she reasoned, but if the licensed practical nurse genuinely believed him dead, she had not been deliberately indifferent to his suffering.

A district judge, Robin L. Rosenberg, concurred. In the eyes of the courts, Conrad's failure to give CPR was not constitutionally inadequate care. The District Court for the Southern District of Florida granted summary judgment to every defendant.

On appeal, the judges of the 11th Circuit found Conrad's decision to withhold care "regrettable and potentially tragic."

"But there is nothing in the record," they said, "indicating that it was made in bad faith."

• I recently stayed at the Four Seasons Jackson Hole, a luxury ski-in, ski-out resort.
• My 550-square-foot room had a private balcony overlooking the slopes.
• I thought the room's luxury cabin vibe seemed like an ideal accommodation for a skier.

If I ever take a ski trip, I want to retire to a cozy room with cabin vibes and luxury touches. Ideally, it would be in a slopeside, five-star hotel.

Perhaps the Four Seasons Jackson Hole would fit the bill. In September, I spent one night at the ski-in, ski-out resort.

Although the mountains were not yet covered in snow, my room — which has a starting rate of nearly $1,000 a night during the winter ski season — seemed like a peaceful place to rest after an active day of gliding through powder.

When I arrived at the Four Seasons Jackson Hole on a muggy day in early September, I imagined it covered in snow.

The 63-year-old hotel chain has a luxurious reputation and 133 locations worldwide, each designed to reflect its destination.

"There's a sense of place at every Four Seasons," Kim Cole, the director of public relations for the Four Seasons, told Business Insider.

Cole added that the company describes the Jackson Hole location's aesthetic as "modern mountain chic," catering to hikers, bicyclists, and skiers in the winter.

After checking in, I explored the room with the typical peak-season guest in mind.

The hotel has 106 guest rooms and 18 suites. The starting rate is $525 in the offseason and $995 in the peak winter season. BI received a media rate for a one-night stay.

There are also 31 Resort Residences on-site, built to serve large groups. These residences have kitchens and as many as five bedrooms. Starting prices range from $4,200 to $11,000, depending on the season.

Cole told BI that in the winter, guest rooms are typically booked with active guests who participate in winter sports, so I imagined how the room would feel as a skier.

I thought my 550-square-foot room blended traditional cabin nostalgia with midcentury modern luxury.

My room had a king-sized bed, a full bathroom, and a private balcony.

Renovated by Wimberly Interiors in 2022, the guest rooms were designed to bring the outside in, with metal accents, stone finishings, and a soft, earth-toned color palette. This nature-inspired trend, known as biophilic design, gained traction in 2024.

The bed was plush with warm, fluffy bedding and dense pillows.

The king-sized bed sat between mixed material nightstands with edgy lamps contrasting classic wooden shutters.

With one king-sized bed, the room sleeps up to three adults (or two adults and one kid). The room can also be arranged with two double beds, increasing the maximum occupancy to four adults (or two adults and two kids).

The nature-inspired headboard was a mesmerizing statement piece.

The headboard was the standout piece in the room. A cherry wood frame juxtaposed a bright, white image, giving it a midcentury modern look.

The image was a textured carving of trees that I could feel when I brushed my fingers over the branches. A light bar glowed beneath the board, making it easier to see the details of the monochrome image.

The bed was so comfy that I didn't want to get up — and with smart controls on the in-room tablet, I didn't have to.

The tablet on the nightstand served as the room's control center, commanding everything from the TV to room service. This amenity was added in the 2022 remodel.

The tablet would be especially handy after an exhausting day on the slopes.

The other nightstand held an eclectic shelf of books with a warm white color palette.

Few things are more relaxing on a snow day than cozying up with a good book.

Luckily, my room had a small selection of biographies, historical literature, and novels ranging from realistic fiction to young-adult fantasy.

Publishing dates for these books ranged from 2003 to 2020, but I thought they looked much older. They were all sleeveless with a white or off-white binding.

Across from the bed, a large TV was mounted above a stone fireplace.

Rustic drawers were to the left of the fireplace, while a modern sitting area was on the right.

I noticed all the seating in my room was soft and cushy, which seemed ideal for sore bodies after an active day.

The room also had a private bar with gold trimmings.

The bar had an espresso machine, neutral-toned ceramic mugs, and Four Seasons branded water.

Beneath the bar, a cabinet hid the mini-fridge. It was stocked with alcohol and snacks like peanut M&Ms and gummy bears, which were available for an extra cost.

In the marble bathroom, the oversize tub had a bendy shower head that made me feel like I was in a spa.

The bathroom had complimentary Le Labo toiletries.

The bathroom felt large, with a double sink vanity, a sizable shower, and a separate toilet room.

The mirrors and vanities were replaced by Wimberly Interiors in 2022.

Across from the bathroom, a spacious walk-in closet held bathrobes, a safe, and some classic, upscale amenities I've only seen in ultra-luxury hotels.

I spotted old-school amenities like a shoe horn and shine brush, which I've seen more often in high-end European accommodations than in the US.

The ample size of the bathroom and closet made the room suitable for up to four guests.

The private balcony seated one on a comfortable lounge chair.

I spent some time on the deck, but since I imagined it would be less enjoyable in the cold, I appreciated that there were sliding glass doors to enjoy the view without the low temperatures.

Out there, I had a view of the ski lifts traveling up and down Rendezvous Mountain.

From the balcony, I spotted the slopes towering over the resort's courtyard.

Looking down, I pictured the green courtyard in a blanket of snow as bundled-up skiers got their bearings before hitting the slopes.

• Getting together with family over the holidays can be stressful.
• Afterward, you may feel similar to how you feel when hungover — even if you didn't drink.
• Here's how to deal with the effects of an "emotional hangover."

Whether you're disagreeing over politics or dodging questions about why you've gained or lost weight, getting through a family gathering can feel like you're dealing with a powder keg of emotions. Then you wake up the next day with nausea or a pounding headache.

All signs point to a hangover — except you didn't drink alcohol. Instead, your unpleasant symptoms might be due to an "emotional hangover," which refers to the "feeling of physical and emotional exhaustion that follows an intense emotional situation," Charlynn Ruan, Ph.D., a clinical psychologist and founder of Thrive Psychology Group, told Business Insider.

When you have a conflict or negative interaction with someone, "your nervous system is flooded with adrenaline and cortisol, and you may enter a state of fight, flight, or freeze, which helps you navigate threats and challenges," she added. Following an intense emotional experience, you may develop symptoms like exhaustion, headaches, and brain fog.

Although an emotional hangover isn't a clinical diagnosis, the nausea and fatigue can resemble the effects of consuming alcohol. Below, two psychologists explain what makes you vulnerable to an emotional hangover and how to recover after a tense family gathering.

What situations can trigger an emotional hangover?

Strong emotions like fear and anger can elicit the body's natural stress response. "Once the stress subsides, the body may experience a 'crash,' leading to fatigue, nausea, headaches, irritability, and muscle soreness," Harris Stratyner, Ph.D., a New York City-based psychologist, told Business Insider.

Ruan explained that any situation that triggers the fight, flight, or freeze response can lead to an emotional hangover. For instance, you might feel drained or disoriented after having a heated argument with your partner, mediating conflict between relatives, or returning to a home or town that reminds you of traumatic childhood events.

Accordingly, emotional hangover triggers may be connected to unresolved childhood traumas or present-day conflicts, Ruan said. "If you did something you regret, guilt can linger and create a sense of emotional depletion," Stratyner said.

Other reasons you might experience an emotional hangover include failing in front of others, receiving upsetting news, taking on too much responsibility at work or home, or ending a relationship, Stratyner said. The more you're invested in a relationship, the greater your emotional distress can be.

Besides uncomfortable family dynamics, noise, large crowds, and travel can heighten your distress. The holidays also carry additional pressures like overextending yourself financially or being around family members you might otherwise choose to avoid during the year.

What makes you vulnerable to an emotional hangover?

Certain tendencies and personality traits can make you susceptible to an emotional hangover. "People who are high on the personality trait of agreeableness may have difficulty saying no to activities that are draining or experience cortisol spikes, even if a conflict is between other people and doesn't concern them," Ruan said.

Stratyner said that being high in neuroticism can make you more reactive to emotional stressors, which makes it more difficult to recover from stressful experiences. The same goes for low self-esteem since you're more likely to internalize criticism and struggle with feeling inadequate.

Stratyner said people who describe themselves as introverted or highly sensitive may also experience deeper emotional fatigue after taxing social interactions. They might also be more prone to ruminating about past events and dwelling on negative feelings.

"People-pleasers often suppress their emotions to avoid conflict and keep others happy," Stratyner said. When you can't please everyone or need to be assertive, you might feel conflicted and drained, leading to an emotional hangover.

Like people-pleasers, perfectionists may experience disappointment or shame if they fail to meet their high standards. Additionally, "those with an anxious attachment style are more likely to agonize over social interactions and perceive threats to your relationships even when there aren't any," Ruan said.

How do you recover from an emotional hangover?

One way to prevent an emotional hangover is to engage in soothing activities. For example, you can write down what you're grateful for, spend time outdoors, or take a break from the news or social media, Stratyner said.

Before attending a family gathering that could be triggering or overwhelming, Ruan suggested making time to see friends, booking a session with your therapist, going for a run, or engaging in a relaxing hobby. She also recommended reaching out to supportive family members and discussing how you can help each other or intervene in case you get caught in a stressful conversation.

If you do get an emotional hangover, there are ways to speed up the recovery process. Since your nervous system is depleted, it's important to recharge by resting, catching up on sleep, having a bath, or listening to music.

"Be around friends and family who feel safe and loving, so your nervous system will stop releasing cortisol and adrenaline and start producing oxytocin and serotonin, which help regulate your mood," Ruan said. Additionally, Stratyner recommends small gestures like sending a thoughtful message or volunteering, which can make you feel a sense of purpose or positivity.

"If you feel antsy or agitated, you may need to engage in a high-energy activity to burn off built-up hormones and signal to your body that the threat is over," Ruan said. Activities like boxing, running, and weightlifting can provide a healthy outlet for releasing stress and help you recover from an emotional hangover.

• A strike by Starbucks baristas is expanding, their union said.
• The strike is due to expand to more than 300 locations on Tuesday, it said.
• The union wants better pay and said Starbucks had not settled many unfair labor practice cases.

A strike by Starbucks workers will expand to more than 300 locations on Tuesday, a union that represents the company's baristas said.

Starbucks Workers United said on Monday that walkouts by workers would reach new locations like Atlanta and Buffalo, as well as other locations that had not been announced, The Washington Post reported.

That means some stores in the US's largest coffee chain will be affected on Christmas Eve.

Starbucks workers began striking on Friday over what the union previously told BI were issues over pay and unresolved cases related to labor disputes.

The union said on social media that the company proposed no new wage increases for union baristas and had backtracked on a path it had agreed to with workers regarding collective bargaining and pay organizing.

"The company says they have world-class benefits and pay, but for many workers, that's not the reality," it said. "Starbucks workers often struggle to get hours to qualify for benefits, and annual raises don't match the rate of inflation."

It asked people: "While we're on strike, support workers by NOT buying from Starbucks."

More than 60 locations have temporarily shuttered because of the strikes, the Post reported.

Philly Workers United, a food service workers union, said on X on Monday that five union Starbucks locations across Philadelphia had closed the day before.

Baristas have also gone on strike in locations including Los Angeles, Chicago, Seattle, Columbus, Denver, and Pittsburgh, as BI previously reported.

The union has also shared footage of workers striking in Texas, Massachusetts, New York, and Oregon.

The union said on X that the strike would "escalate each day through Christmas Eve... unless Starbucks honors our commitment to work towards a foundational framework."

The Washington Post reported that baristas are expected to return to their jobs on Christmas or the following day.

It is not clear if strikes will later resume.

A Starbucks spokesperson told BI earlier this week that the company "offers a competitive average pay of over $18 per hour, and best-in-class benefits."

They said the company also offered competitive benefits, including "health care, free college tuition, paid family leave, and company stock grants."

The spokesperson said that "no other retailer offers this kind of comprehensive pay and benefits package."

"Workers United proposals call for an immediate increase in the minimum wage of hourly partners by 64%, and by 77% over the life of a three-year contract. This is not sustainable," they added.

The company also said in a public statement that union delegates "prematurely ended" the bargaining session this week and that it was "disappointing they didn't return to the table given the progress we've made to date."

The company wrote, "We are ready to continue negotiations to reach agreements. We need the union to return to the table."

Shay Mannik, a striking barista in Denver who has worked at Starbucks for two years, told Business Insider, "We've been in contract negotiations with Starbucks for several months now, and things have been going smoothly up until this point — when they have now refused to offer us a viable economic package."

"They just have not been offering us anywhere close to a living wage."

Starbucks has 11,161 self-operated stores and 7,263 licensed stores in North America, BI previously reported, making stores with striking workers a small percentage.

But the union said it was still the largest ever strike against Starbucks.

The union said last week that an "overwhelming" 98% of union partners had voted in favor of the strike authorization.

In a recent post on X, the union wrote: "Starbucks CEO Brian Niccol makes ~$50,000 an HOUR and commutes to work via private jet."

"All while baristas nationwide are struggling to pay their rent and get the hours they need to qualify for benefits," it added.

Brian Niccol became CEO of the company in September and has spoken about wanting to improve conditions for the company's baristas.

He recently announced a new parental leave policy for employees in the US, which is due to increase paid leave for parents from March. It applies to store employees averaging at least 20 hours of work a week.

• An off-duty pilot stepped in to help fly a Boeing 737 after the first office was taken ill.
• The off-duty pilot was a passenger on a Westjet flight from Calgary to Vancouver.
• Pilots are trained for emergencies, and flights always have multiple pilots for safety.

An off-duty pilot stepped in and helped to fly and land a Boeing 737 when the flight's first officer was suddenly incapacitated mid-flight.

The transportation website Paddle Your Own Kanoo first reported that the incident took place on a WestJet flight from Calgary to Vancouver on the morning of December 4.

The off-duty pilot was known to the crew and could be called upon to assist in flying the Boeing 737. The pilot then sat in the cabin for the rest of the flight.

"During cruise, the first officer reported feeling ill and was unable to continue their duties. One of the passengers on board was a Westjet pilot who was able to assume the first officer's duties," a preliminary report from the Canadian Transportation Safety Board said, per the Aviation Herald.

"The incapacitated first officer sat in the cabin for the remainder of the flight. The flight crew did not declare an emergency or request a priority handling. The aircraft landed without further incident," the report added.

WestJet did not immediately respond to a request for comment from Business Insider on the incident.

If a pilot is taken ill, airlines normally declare an emergency and land the plane as soon as possible.

Retired US pilots Kent Davis and Mark Stephens previously told Business Insider that it is "not a big deal" when pilots become unwell during a flight because they are trained to handle these situations.

Stephens said there are at least two pilots on domestic flights, while international flights can have two pilots and two captains.

"Pilots know what they are doing, and they do it repeatedly," he said.

Sometimes, pilots become more seriously ill. In July, an Airbus A320 from London Luton to Lisbon, which was carrying almost 200 passengers, was met by paramedics on landing after the copilot fainted in midair.

"The captain landed the flight routinely in line with procedures and passengers disembarked normally," an airline spokesperson told BI at the time. "At no point was the safety of the flight compromised."

In October, it was reported that a Turkish Airlines captain died in midair on a flight from Seattle to Istanbul, and the plane was diverted for an emergency landing in New York.

"After the initial medical intervention on board proved ineffective, the cockpit crew, consisting of one captain and one co-pilot, decided to make an emergency landing," an airline spokesperson said at the time.

One pilot named Ken Allen told BI he suffered an aneurysm while flying a small plane with a friend and one passenger. He fell unconscious, and the passenger managed to safely land the plane instead.

Stephens, one of the retired US pilots, told BI that there are procedures in place for life-threatening situations. Flight attendants are trained in CPR and have defibrillators, and many planes have a direct line to medical staff.