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."

It rained heavily the night before the retaking of New York's Attica Correctional Facility. A guard, William Quinn, had been killed. Negotiations had ended. The men on the D yard waited for the inevitable.

Four days earlier, on September 9, 1971, 1,281 prisoners had wrested control of Attica, taking 42 prison staffers hostage and delivering a manifesto demanding humane treatment including adequate healthcare, independent oversight, and an end to racial discrimination.

"We are men," said L.D. Barkley, one of the leaders of the revolt. "We are not beasts, and we do not intend to be beaten or driven as such."

In the early-morning light on September 13, men in D yard heard the thrum of a helicopter as it flew over Attica's 30-foot stone walls and flooded the yard below with tear gas. Steady gunfire from ground forces tore through the gas clouds, chipping the concrete and shredding the bodies of hostages and prisoners alike. Terrified, the men desperately searched for cover. They found none. One prisoner was shot 12 times at close range by two separate guns. Another lay dying of a gunshot wound when a New York state trooper stepped up to finish him off, firing buckshot directly into his neck. A paramedic later testified he saw a trooper execute a prisoner begging for help at point-blank range. State troopers and corrections officers fired nearly 400 shots, killing 39 people — 29 prisoners and 10 prison staff — and wounding 89 more.

The surviving prisoners were corralled and moved to A yard, stripped, and ordered to lie face down in the mud. If they moved, troopers beat them and threatened to shoot them where they lay. Hours later, still naked, they were ordered to stand and run, hands above their heads, through what judges would later refer to as the "gauntlet" — a tunnel leading inside that was lined with troopers and corrections officers. They struck prisoners with clubs and hurled racist epithets. Many prisoners stumbled to the ground and ended up crawling on pavement littered with shattered glass. Once inside, officers threatened some prisoners with castration. Others they forced to play Russian roulette with live ammunition or lined up against the wall in mock executions.

It took nearly three decades for the surviving D yard prisoners to reach a final resolution on their claims that those nightmarish days and nights constituted "cruel and unusual punishments," in violation of the Eighth Amendment. In the intervening period, a series of new laws and legal standards changed the landscape for incarcerated plaintiffs. The Supreme Court introduced one standard in 1976, further codified in 1994, that prison officials violate the Constitution only when they are "deliberately indifferent" to a prisoner's suffering. And in 1986, the court granted broad protections to law enforcement, as long as their actions were not "malicious and sadistic." Guards, the justices found, often had to make decisions "in haste, under pressure, and frequently without the luxury of a second chance."

One set of claims, over the failure of New York's corrections commissioner, Russell Oswald; Attica's warden, Vincent Mancusi; and other senior officials then in charge to provide adequate medical care and prevent retaliatory violence by officers after the uprising was quelled, was decided on the new deliberate-indifference standard. Those claims settled in 2000 without state officials admitting any wrongdoing; damages were capped at $10,000 for anyone not subject to torture, serial beatings, or gunshot wounds.

Another set of claims, covering the planning and execution of the retaking itself, was decided in 1991 on the malicious-and-sadistic standard. The plaintiffs' lawyers argued that the standard had been met, as defendants were responsible for the "wanton infliction of pain and suffering for the purposes of 'maliciously and sadistically' punishing rebellious prisoners."

The judges of the 2nd Circuit disagreed. Aspects of the plan, such as declining to give prisoners an ultimatum before opening fire or allowing correctional officers to participate in the retaking "despite the extreme hostility the officers bore toward the prisoners as a result of the takeover," might constitute negligence or even indifference, Judge Jon O. Newman wrote. But that was not enough, without evidence that those elements were designed to wantonly inflict pain. "Tactical decisions needed to be made," he wrote, and courts cannot substitute their own judgment for that of law enforcement officials on the ground.

One of the most infamous campaigns of state violence against incarcerated people in US history did not, in the eyes of the court, constitute cruel and unusual punishment.

A lone prisoner victory

Senior corrections officials agree that physical force is sometimes necessary to maintain order and safety for both staff members and the prisoners in their care. If prisoners are harming themselves or another person, for example, quick intervention can be critical.

Training documents Business Insider obtained from 37 state departments of correction show that officers in most states are guided to use the minimum amount of force necessary to maintain order. Many departments train officers on de-escalation techniques meant to defuse violence before force is necessary and instruct them to use force "only as a last resort."

But in the 50 years since the Attica uprising, many corrections departments have failed to check staff violence when it tips into excess. Government oversight reports and journalistic investigations over the years have documented systemic abuse in multiple state prison systems: guards brutalizing incarcerated people in New York state, a pattern of sexual assault committed by prison staff in California, and a culture in Alabama prisons in which "unlawful uses of force" were common, including two beating deaths by staff in 2019 alone.

In the face of these institutional failures, federal courts have declined to step into the breach. BI analyzed a sample of nearly 1,500 Eighth Amendment lawsuits, including every appeals court case with an opinion we could locate filed from 2018 to 2022 citing the relevant precedent-setting Supreme Court cases and standards. Of these, 208 cases involved claims of excessive force.

In analyzing these cases, BI found that courts have often sanctioned extreme acts of violence by guards against prisoners. Dozens of plaintiffs in BI's sample said they were beaten while immobilized in restraints. Another dozen said they were subjected to racist abuse or threatened with retaliatory violence. Others said they were placed in life-threatening chokeholds or hit with plastic or rubber bullets shot at such high velocity they cracked femurs and skulls. Multiple people said they were sexually abused by prison staff, including two while in restraints. All of these plaintiffs lost their cases.

Judges dismissed many excessive-force claims under strict administrative requirements imposed by the Prison Litigation Reform Act, a 1996 federal law designed to curb "frivolous" prisoner lawsuits. Judges dismissed others for failing to meet the malicious-and-sadistic standard, or due to doctrines that protect law enforcement officials like prison guards. Judges rarely questioned the authority of prison staff to determine when a use of force was justified.

Sixty-one of the excessive-force cases, almost a third, settled. Only one of the excessive-force plaintiffs, Jordan Branstetter, won his case in court.

In that case, Branstetter said a corrections officer at a state prison in Hawaii had viciously assaulted him for nearly 20 minutes, punching him in the back of the head as he curled into a fetal position on the floor, then kneeing him in the back, breaking two ribs, and choking him.

The Hawaii Department of Corrections and Rehabilitation did not respond to requests for comment.

Less than a third of the cases reached settlements — far less than is typical for civil suits filed in the outside world. Of the excessive-force settlements made public, two were for more than $1 million, but the typical award was about $9,000. None of those cases involved an admission of wrongdoing. Whether for technical reasons or because they viewed the use of force as necessary, federal courts across the country offered impunity to officers accused of excessive force the vast majority of the time.

In September 2022, Judge James Jones of the District Court for the Western District of Virginia ruled that officers at Virginia's Red Onion State Prison were justified in deploying a dog to attack Cornelius Lightfoot. Two officers, thinking Lightfoot had a weapon, tried to frisk him and, when he resisted, tackled him to the ground; a handler then allowed his dog to tear open the flesh of Lightfoot's thigh. An incident report showed that Lightfoot was unarmed by the time the dog attacked; he said in his complaint that the officers had acted in retaliation, taunting him just before the attack that the dog would get his "grievance-filing ass."

The officers said they thought Lightfoot had posed "a serious threat to staff safety." Jones reviewed surveillance footage and determined that Lightfoot was resisting the officers as they tried to subdue him and dismissed the case, ruling that "no reasonable jury could find that any of the defendants used physical force or the canine 'maliciously and sadistically to cause harm.'"

The UCLA law professor Sharon Dolovich discussed the malicious-and-sadistic standard in a 2022 Harvard Law Review article. "That this standard is intrinsically defendant friendly," she wrote, "is undeniable."

Jones, and every other judge mentioned in this story, declined to comment on the record for this story or did not respond to queries. Kyle Gibson, a spokesperson for the Virginia Department of Corrections, declined to comment on the Lightfoot case but said that the agency had "zero tolerance for excessive force or abuse" and that violators "are disciplined according to agency operating procedures."

At about the same time as Jones' ruling, judges with the 5th Circuit appeals court ruled that five officers at a Texas prison known as Coffield Unit were justified when they pepper-sprayed a prisoner who had refused to leave his cell, then put him in a chokehold and wrestled him to the ground. The prisoner, Robert Byrd, was serving a life sentence for capital murder; as he was splayed under the weight of four officers, a fifth officer smashed his outstretched arm with a riot baton, breaking a bone.

While officers later photographed a wooden shank they said was recovered from Byrd's cell, an internal prison investigation determined that Byrd was restrained and unarmed when he was struck and that at least one officer, the one wielding the baton, had deployed excessive force. Still, the appeals court decided that even if Byrd was unarmed, he was violently resisting, so force was "obviously necessary." All the officers had deployed force, Judge Stuart Kyle Duncan wrote in the majority opinion, "in a good-faith effort to maintain or restore discipline."

Amanda Hernandez, a spokesperson for the Texas Department of Criminal Justice, said the video footage of the incident was key to the state's case because it showed a "'hostile, combative, utterly noncompliant' prisoner who was committed to violent resistance."

"We are to accord prison officials 'wide-ranging deference,'" Duncan, one of the 5th Circuit judges who heard Byrd's case, wrote, quoting case precedent. "The Supreme Court has told judges not to micro-manage the force necessary to quell such volatile situations."

Judges dismissed other cases on technicalities.

In August 2022, D'Andre White, a prisoner at Ionia Correctional Facility in Michigan, filed suit claiming that, earlier that year, he'd been shackled by his hands and feet in a bathroom stall during a court appearance when he asked a guard to uncuff one hand so he could more easily use the toilet. The guard refused, White said, then grew irate at how much time White was taking. White said the guard then grabbed him by the throat, slammed him to the ground, kicked him repeatedly, and dragged him to the court's holding cell.

Robert Jonker, a judge in the District Court for the Western District of Michigan, ruled against White, finding that he had not fulfilled his prison's internal grievance process before filing suit, as required by the PLRA.

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

Two years later, in 2024, Judge Christine O'Hearn of the District Court for the District of New Jersey dismissed the case of Tyrone Jacobs, a federal prisoner who said that four officers had retaliated against him for filing complaints against the prison. He said the officers handcuffed him, pulled him from his cell, and, out of view of surveillance cameras, slammed his head against the wall and dragged his face along the concrete. Jacobs said one officer screamed, "I will fucking kill you."

Because Jacobs had missed a deadline to appeal his internal prison grievance, O'Hearn decided in favor of the defendants.

A 'good-faith effort' to restore discipline

In BI's sample of excessive-force lawsuits, one facility stood out: California State Prison, Sacramento, popularly known as New Folsom. The vast complex surrounded by steel fences and guard towers was built in the 1980s, just across from the Gothic granite tower of Old Folsom, the site of Johnny Cash's legendary 1968 live album. The new facility has a reputation for violence. California Department of Corrections and Rehabilitation data shows corrections officers there deployed force at a far higher rate than any other California prison over the past decade. In 2023, the most recent year for which data is available, New Folsom officers used force — fists, baton strikes, pepper spray, or high-velocity less-lethal ammunition — in nearly 700 documented incidents. That's nearly twice a day. By comparison, officers at the California City Correctional Facility, a high-security facility in Southern California that was recently decommissioned, used force 192 times — less than four times a week.

Violence by guards at New Folsom sparked three complaints of excessive force in BI's sample; all of the plaintiffs lost.

The allegations contained in the legal complaints, together with evidence from state oversight reports and criminal cases against former officers there, hint at a corrections culture in which casual violence prevails and retaliatory cruelty often goes unchecked.

Terri Hardy, a spokesperson for the California Department of Corrections and Rehabilitation, emphasized that in each California case mentioned in this story, the department prevailed, and said the department "takes every allegation of employee misconduct seriously."

One complaint describes an incident that took place in February 2015, in New Folsom's C yard, where a man named Tshombe Kelley, who was serving 52 years for murder, approached a group of officers to ask a question. When he and another prisoner didn't immediately comply with an order to back away and drop to the ground, incident reports show, officers swiftly reacted. One officer, who said he saw Kelley clench a fist, blasted him in the face with pepper spray. Kelley said he reeled back and stumbled to the ground; officers said he again failed to comply with an order to lie flat. Two other officers then deployed physical force, an incident report shows; Kelley said they punched him, kicked him, and dragged him in the dirt. Transcribed surveillance video describes the officers wrestling Kelley into handcuffs and pinning him down with their knees on his shoulder and back, as he pushed against their combined weight.

An officer heard him plead, "I can't breathe."

Instead of easing up, officers deployed a spit mask, a cotton bag that covers the face and head. Blinded and panicked, his throat burning from the pepper spray, Kelley later said, he lost consciousness.

Kelley sued and lost. Officers said in court filings that they feared Kelley and another prisoner might attack them; they said Kelley had refused a direct order to hit the ground and resisted their attempts to restrain him, and only one recalled hearing Kelley say he couldn't breathe. Surveillance video showed that as Kelley was pinned down — and struggling to breathe — he arched his back and thrashed his legs. Carolyn Delaney, a magistrate judge with the District Court for the Eastern District of California, found that the officers' use of force was necessary to combat Kelley's "ongoing resistance."

Judges also sided with guards who injured prisoners they didn't perceive to be resisting.

In October 2020, less than a year after Kelley's case was dismissed, a prisoner named Nathanael Carter Jr. noticed a fight erupt in the New Folsom B yard, according to his civil suit. Guards ordered all prisoners to the ground. Carter immediately complied, dropping to his stomach, arms spread-eagled. From the guard tower, an officer fired two less-lethal rounds from his state-issued 40 mm launcher into the crowded yard, according to multiple incident reports. Both shots missed the men fighting. But one round smashed into Carter's skull, leaving a hematoma the size of an egg and triggering migraines, blackouts, and memory loss.

Like Kelley, Carter lost his case. He'd argued in court filings that he was an innocent bystander who was shot despite "getting on the ground following instructions." The guard said he'd hit Carter by accident, and Dennis Cota, an Eastern District magistrate judge, ruled that the use of force related to "the prison's legitimate penological interest in maintaining security and order."

In more than a dozen cases in BI's sample, judges found that the question of whether a use of force was malicious and sadistic was immaterial, as long as officers were doing their job.

Federal courts grant broad protections to law-enforcement officers for actions taken "under the color of law" — in the line of duty.

That's how one California prisoner's case failed before the District Court for the Eastern District of California. In his complaint, the prisoner said that six corrections officers at a federal prison in Atwater in April 2021 threw him to the ground, handcuffed him, and slammed his head against the wall before dragging him to a holding cell where they physically and sexually assaulted him while calling him racist slurs.

Magistrate Judge Stanley Boone recommended dismissal of the case, finding that any remedy the court might impose "risks interference with prison administration." District Judge Jennifer Thurston agreed and dismissed the case.

Ben O'Cone, a spokesperson for the Federal Bureau of Prisons, did not address the Atwater case but said the agency "does not tolerate excessive use of force" and thoroughly investigates all allegations of employee misconduct.

Cases against corrections officers run into another set of challenges under the doctrine of "qualified immunity." Unless a court has previously found that a particular use of force constituted a constitutional violation, a defendant is given the benefit of the doubt under the doctrine. The Supreme Court standard, established in 1967 and refined in 1982, shields public officials from civil liability when they're legitimately acting in the line of duty. The standard has drawn national attention as an obstacle to police accountability. In prisons, BI has found, qualified immunity has also protected corrections officers who have been accused of excessive force.

That's how things played out in court in the wake of a December 2016 incident at the Darrington Unit, now called Memorial Unit, in East Texas. That day, a prisoner named Marquieth Jackson threw water at a corrections officer passing by his solitary-confinement cell. Incensed, the officer brandished his pepper spray and threatened Jackson. He then spun and blasted a prisoner in a nearby cell in the face at point-blank range.

Why he did so is contested: The officer, Tajudeen Alamu, said that after he was doused with water, he ran for cover by the cell of the other prisoner, Prince McCoy Sr. Alamu said that McCoy threw something that hit him in the face — court documents later identified it as a wad of toilet paper — and that his mind then "went blank" and he reacted instinctively. McCoy denied throwing anything and said Alamu attacked him in anger "for no reason at all."

Alamu did not respond to requests for comment by phone and mail.

After losing at the district court level, McCoy appealed and got a rare finding from the judges of the 5th Circuit. They decided that Alamu had been "malicious and sadistic" in his use of force, in violation of the Eighth Amendment. But after finding that no previous case in the 5th Circuit had established that pepper spraying a man confined in his cell constituted excessive force, they granted Alamu qualified immunity.

"How could any guard not know that an unprovoked use of pepper spray is unlawful?" Gregg Costa, one of the appeals court judges, wrote in a furious dissent. "Yet the majority concludes it would have been reasonable for a guard to think the law allowed him to gratuitously blind an inmate."

The other judges' reading of the qualified-immunity standard, Costa wrote, "ensures vindication of the most egregious constitutional violations."

McCoy appealed, and the case made it to a jury, which again found for the defendant. But the jury disagreed with the 5th Circuit on one critical point: The pepper-spray deployment, they found, had not been malicious and sadistic.

A culture of silence

This pattern of rejection by the courts is especially devastating to prisoners, given how hard it is for them to file suit in the first place.

For nearly 30 years, thanks to the PLRA, any prisoner who wants to file an excessive-force claim has to first file an internal grievance — a petition to prison administrators to address violations committed by their staff. But it can be dangerous for prisoners to report an incident involving the very officers who control every aspect of their daily lives. The cases BI reviewed contain multiple claims of retaliation against prisoners who decide to complain.

One complaint, filed by a New Folsom prisoner named Christopher Elliott, offers a window into the ordeal prisoners often face when they seek redress.

In January 2021, Elliott tried to raise an excessive-force complaint, filing a grievance that said a corrections officer had shoved him onto the concrete floor of his cell and jumped on him while his legs were shackled and his arms were cuffed behind his back. Medical records show a laceration on his left hand, which he said got pinned behind him in metal cuffs, spattering blood across the floor.

After Elliott filed the grievance, he said in a court filing, the corrections officer returned to his cell to issue a threat: If Elliott didn't stop pursuing the grievance, the officer would force Elliott to perform oral sex on him — and order Elliott killed.

When asked about allegations of violent retaliation by prison staff, Hardy, the California corrections spokesperson, said the department had "fundamentally reformed" its approach to investigating allegations of staff misconduct and had deployed body cameras and audio surveillance to "create an environment in which incarcerated and supervised persons are comfortable raising concerns without fear of retaliation."

Akiva Israel, a transgender woman who was incarcerated at another California men's prison, Mule Creek, filed an internal grievance in April 2021 accusing an officer named J. Padilla of threatening to sexually assault her. She said other gay and transgender prisoners immediately warned her to be careful: Reporting the officer might invite even worse consequences.

Israel later filed a civil complaint saying that a week after she submitted the internal grievance, officers handcuffed her and brought her to a prison administrator's office where they hurled transphobic and homophobic slurs and again threatened her with sexual violence. "You fuck with Padilla," she quoted one officer saying, "You fuck with me."

She said the officers then marched her to solitary, stripped her naked, threw her to the floor, and kicked her in the head. They then yanked her off the ground, she said, suspending her by the metal cuffs, causing "excruciating agony," and slammed her to the concrete floor.

Kimberly Mueller, a judge with the District Court for the Eastern District of California, dismissed Israel's case without prejudice on a technicality. Handling her case without an attorney, she had missed a deadline to file an amended complaint while being treated for breast cancer.

In Elliott's case, Kendall Newman, a magistrate judge in the same court, also recommended dismissal on technicalities: Elliott might have a case, Newman said, but he had not signed his complaint filing and his claims of retaliation were unsupported by evidence.

It has become so rare for the courts to find constitutional violations that the wins send shock waves through prison communities. On October 17, 2022, William Shubb, a senior judge in the Eastern District, sentenced a former New Folsom guard, Arturo Pacheco, to 12 years in prison for knocking the legs out from under a handcuffed 65-year-old prisoner who landed face-first on a concrete walkway, breaking his jaw. The prisoner, Ronnie Price, suffered a pulmonary embolism and died two days later.

In the lead-up to Pacheco's sentencing, a New Folsom prisoner named Mario Gonzalez fired off an urgent letter to Shubb, saying Pacheco and another indicted officer "know more than what they've shared." He said many more staff there should be prosecuted, including corrections officers who he said "cuff us and beat us" and lieutenants who he said had lied in incident reports to cover up excessive force.

In an earlier civil suit, Gonzalez said he'd reported to his prison psychologist that a group of officers was committing "illegal beatings of fellow inmates" and that he feared for his safety. Soon after, he wrote, four officers cornered him in his cell: One put Gonzalez, who then used a walker, into a headlock, wrenching his spine backward until he feared it would snap. Three others kicked him in the ribs, torso, back, and groin, then scooped urine and feces into his mouth.

"My back was broken. My ribs were broken," Gonzalez wrote to Shubb, injuries that he had documented in his civil suit and in prison grievances. "I have night terrors at least 4-5 times a week. I also cannot get that piss and shit taste out of my mouth." He said he reported the incident but believed no internal investigation had taken place. His case was dismissed repeatedly over six years while he was in prison, most of the time without a lawyer. He wrote to Cota, the Eastern District magistrate judge, alleging that officers were retaliating against him for being outspoken by locking him in solitary confinement and inciting fellow prisoners to attack him.

"I pray you please take action cause my life is endangered," he wrote in one letter.

Still, his complaint languished. Only after Gonzalez got a new lawyer and was released from prison in the fall of 2023 did Cota allow his case to continue. (The case remains ongoing.)

The California state prison system has been under official scrutiny for decades, springing from a 1995 decision by a federal judge finding a pattern of egregious violence perpetrated by guards at Pelican Bay State Prison, some 380 miles northwest of New Folsom, in violation of the Eighth Amendment. California prison officials, the judges found, "permitted and condoned a pattern of using excessive force, all in conscious disregard of the serious harm that these practices inflict."

It remains the only case decided under the malicious-and-sadistic standard to spark significant prison reforms in the state.

The court mandated a suite of new oversight mechanisms, including the appointment of a special master and a new use-of-force action plan.

Nearly a decade later, the special master issued a scathing evaluation: California prison officials had deliberately misled the court by filing false or misleading reports. The report found that administrators had endorsed a "code of silence" — an informal but aggressively policed policy under which corrections officers refuse to report misconduct to avoid being labeled "a rat."

The special master found California's entire system for investigating and disciplining officers accused of excessive force was "broken to the core." The court ordered a new plan, which included direct oversight and annual reports from the state's inspector general.

The special master's mandate has long since expired. Yet the inspector general's annual reports continue to identify severe deficiencies in how California prisons deploy and investigate the use of force.

In 2023, the most recent year examined, the inspector general reviewed 730 use-of-force incidents and identified 225 that appeared to involve staff misconduct, including 82 incidents where staff may have deployed excessive force. Prison officials initially failed to refer nearly half of those 225 incidents to internal affairs for investigation, including incidents involving the potential use of excessive force and those involving the potential withholding of medical treatment or failure to follow protocol.

The inspector general found that officers repeatedly failed to turn on their body cameras, sometimes wrote misleading or blatantly untrue use-of-force incident reports, or failed to report deployments of force at all. In the vast majority of cases, supervisors rubber-stamped the use of force as acceptable, often without interviewing the prisoner in question or reviewing all of the available video evidence. Even after the inspector general's investigators identified cases that appeared to involve excessive force, they found that prison officials sometimes declined to open internal affairs investigations into the officers involved.

These patterns had been long documented. In each of the five years preceding 2023, the inspector general found that California prison staff appeared to have violated use-of-force policies in at least 40% of the hundreds of incidents the office reviewed. Each year, the office also found significant deficiencies in how managers investigated use-of-force incidents — and found that supervisors regularly declined to take action against officers who deployed "unreasonable force."

If the courts were expected to provide a backstop, they failed.

Over the same five years in BI's sample, no federal judge found for the plaintiff in a single excessive-force claim filed by a California prisoner.

In the 1980s and 1990s, a series of Supreme Court decisions and a new law sought to curb "frivolous" prisoner lawsuits and give more deference to prison officials. Together, they changed the legal landscape of the Eighth Amendment — the foundational constitutional protection against "cruel and unusual punishments."

Heavy criticism soon followed — from the American Bar Association, members of Congress, and Supreme Court justices themselves. Ted Kennedy, then the senior senator from Massachusetts, described one critical measure, the 1996 Prison Litigation Reform Act, as "a far-reaching effort to strip federal courts of the authority to remedy unconstitutional prison conditions."

In successive decades, judges and legal scholars have continued to argue that these developments erode protections for the 1.2 million people incarcerated nationwide. Top law-enforcement officials, on the other hand, have argued that prisoners were clogging up the courts with costly, meaningless actions. And federal judges have hesitated to substitute their own judgment for that of correctional personnel on the ground.

Little has been known about how the Supreme Court standards and the 1996 law shaped outcomes for cases alleging Eighth Amendment violations — and how many of the underlying claims dealt with frivolous matters.

Business Insider set out to investigate. Guided by advice from legal scholars including Margo Schlanger, a law professor at the University of Michigan, and attorneys who have argued Eighth Amendment cases, BI built and analyzed an original database of 1,488 federal Eighth Amendment lawsuits.

BI found that constitutional protections had been dramatically weakened. Cases settled a third as often as civil-rights suits filed by nonprisoners. And plaintiffs won their cases less than 1% of the time.

Here's how we arrived at our findings.

We started with cases in appellate courts

BI sampled lawsuits using Westlaw, a legal-research platform, searching for opinions that cite one of the two Supreme Court standards that now guide how federal courts evaluate Eighth Amendment claims. While Westlaw is one of the most complete databases of legal filings, it is, like the others, not completely comprehensive.

Claims that allege excessive force are governed by a standard called "malicious and sadistic," so to sample those claims BI searched Westlaw for opinions that mentioned the standard and cited one of the Supreme Court's precedent-setting decisions, Whitley v. Albers or Hudson v. McMillian.

Cases alleging constitutionally inadequate healthcare, a failure to protect, or inadequate conditions of confinement are governed by the "deliberate indifference" standard; to sample those claims, BI searched Westlaw for opinions that mentioned the standard and cited Farmer v. Brennan, Wilson v. Seiter, or the earlier Estelle v. Gamble, the relevant Supreme Court precedent-setting cases.

Because so few Eighth Amendment cases make it to the appeals stage, we were able to pull all opinions that fit these parameters over the course of five years — from 2018 to 2022 — spanning two presidential administrations and the COVID-19 pandemic, which affected prisons and courts nationwide.

Then we sampled cases at the district courts

A great many cases filed in district court never reach the appeals courts. In consultation with constitutional scholars, we pulled a sample of district-level cases to understand how Eighth Amendment cases founder earlier in the process. For these, we pulled all cases with judicial decisions filed in the third quarter of 2022 that fit the same search parameters.

Our district sample captured many more cases that failed under mechanisms imposed by the PLRA.

Together, our samples spanned cases from every circuit in the United States filed by prisoners held in hundreds of US prisons in 47 states, Washington, DC, and Puerto Rico. They are likely not comprehensive. If a case file did not mention the Supreme Court standards or the precedent-setting cases — as when a prisoner without counsel lacked knowledge of the law and the case was dismissed on technical grounds at prescreening — our search would not have captured that case. The impact of the PLRA may be greater than our dataset indicates.

About one in 10 cases contained additional claims unrelated to the Eighth Amendment, including claims filed under the First Amendment or the Americans with Disabilities Act. We tracked only the outcomes of their Eighth Amendment claims.

The sample is dominated by suits filed by people while they were incarcerated but also includes cases filed by formerly incarcerated people or their surviving families. BI excluded cases unrelated to incarceration and those pertaining to pretrial detainees. We excluded any case from our district sample that also appeared in the circuit sample. We also excluded cases that had not reached a final disposition, including subsequent appeals, by September 1, 2024.

Our data analysis

A team of researchers read federal court filings associated with each case and logged details in 59 variables including plaintiff names and incarceration status; the claim category and standard applied; defendant names, roles, and employers; alleged harm suffered, such as broken bone, amputation, or death; whether defendants asserted an affirmative defense, such as qualified immunity; whether the plaintiff had counsel; and judge and court names. If a plaintiff had a lawyer at any point during their case, we logged them as having legal representation.

Researchers assigned each case a final disposition category based on the standard or procedural mechanism under which the case was ultimately decided. BI counted all cases that failed under any mechanism of the PRLA — whether they were dismissed at screening, or were struck because prisoners failed to exhaust the prison's grievance process before filing suit, or fell short of any other of the law's requirements — as having failed under the PLRA. This tally included cases in which a judge granted a plaintiff leave to amend. If the plaintiff filed an amended complaint, we logged the case according to its final resolution.

When defendants voluntarily withdrew their cases for reasons clearly unrelated to reaching a settlement; died without a family member or estate to continue their case; or otherwise failed to respond to a court order resulting in dismissal, BI counted these cases as abandoned or withdrawn.

BI's sample included 86 cases with claims governed under both the "malicious and sadistic" and "deliberate indifference" standards. For those, we analyzed the case on both standards, recorded each claim's disposition, and assigned a final disposition category to the case based on the longest surviving claim. For example, if a judge dismissed a plaintiff's excessive-force claim but allowed the plaintiff's claim of inadequate medical care to go to a jury trial, we counted the case outcome under the "deliberate indifference" standard.

In 12 cases, judges granted summary judgment to claims governed by both standards in a single order. Ten of these cases alleged excessive force and alleged inadequate medical care for the injuries they said resulted; two claimed both excessive force and inadequate conditions of confinement. We assigned all these cases as having lost on the "malicious and sadistic" standard since the claims centered on an excessive-force complaint.

The sample includes 28 cases in which a jury found in favor of the defendants. BI counted these as cases in which the plaintiffs lost on the relevant standard.

BI counted cases as having failed on qualified immunity, the Supreme Court doctrine that can shield public officials from civil liability, only when that standard was decisive in the dismissal of a plaintiff's claim. Another Supreme Court precedent, known as Bivens, governs cases filed against federal officials; we tallied a case as a Bivens failure only when a judge dismissed a claim solely because it had not met Bivens standards.

All cases were recorded as having reached a settlement when the settlement was clearly stipulated in the docket or when the defendant and the plaintiff submitted a joint motion for dismissal pursuant to an out-of-court settlement agreement. To identify damages paid, BI reviewed the docket for disclosed settlement amounts and supplemented this research with news reports and public announcements.

BI counted two categories of cases as plaintiff wins: cases in which the plaintiff won at jury trial and cases in which judges made decisions in favor of the plaintiff — whether for damages or for injunctive relief.

To supplement and contextualize our analysis of the 1,488 lawsuits, containing tens of thousands of pages of court records, we reviewed hundreds of pages of training materials obtained through public-records requests from 37 states, as well as medical records, incident reports, and surveillance footage obtained through records requests and court filings. We reviewed scholarly literature on the Eighth Amendment; read Supreme Court decisions, dissents, and archives; and reviewed archived congressional debates. And we interviewed more than 170 people, including prisoners and their families, attorneys and legal scholars, correctional staff and prison healthcare providers, policymakers and law-enforcement officials, and current and former federal judges.

The prisoners write in carefully lettered script or on old electric typewriters. There are sometimes grammatical errors or misspellings. But the language is direct. They describe facing Stage 4 cancer after their symptoms went undiagnosed for years. The denial of orthotic shoes to treat a diabetic condition that led to a severe wound and amputation. Nineteen years locked in solitary confinement.

Some describe beatings and sexual assaults by fellow prisoners that they say corrections officers failed to prevent. Others say they were assaulted by officers themselves.

The Eighth Amendment, which bars "cruel and unusual punishments," was intended by the founders as a bulwark against prisoner abuse. Over the years it came to mean any treatment that "shocked the conscience." But prisoners and civil-rights attorneys have said that it is now nearly impossible to win such claims in court.

To investigate whether that constitutional protection holds, a Business Insider team read tens of thousands of pages of court records for nearly 1,500 Eighth Amendment complaints, including every appeals court case with an opinion we could locate filed from 2018 to 2022 citing the relevant precedent-setting Supreme Court cases and standards. We reviewed hundreds of pages of training materials, medical records, incident reports, and surveillance footage. We read cases from prisoners convicted of violent and nonviolent crimes — some who have spent decades behind bars for murder or sexual assault, others sentenced to short stints for marijuana possession or third-degree assault. We spoke with more than 170 people, including prisoners and their families, attorneys and legal scholars, correctional staff and prison healthcare providers, and current and former federal judges.

We uncovered a near evisceration of protections for this nation's 1.2 million prisoners, largely propelled by legal standards and laws put into place at the height of the war on drugs.

In our analysis, plaintiffs prevailed in only 11 cases, including two class actions — less than 1%.

"If a right is unenforceable, then it's not much of a right," Paul Grimm, a former federal judge for the District of Maryland, said after reviewing BI's findings. "It is essentially unavailable."

One Tennessee prisoner wrote a letter to the court after failing to overcome these steep odds in his own case.

"To everyone I tried to talk to and ask to file grievances and complaints to bring the wrongs to light," he wrote, "I'm sorry that I tried to bring hope and law and order to a place that has no hope or process of order."

Failed oversight

Over decades, federal and state oversight agencies have repeatedly found that US prison systems have failed to protect prisoners in their care. Just this year, an inspector general found that staff in federal prisons had failed to adequately respond to medical emergencies, contributing to 166 prisoner deaths. The Department of Justice recently found that people held in Georgia state prisons had experienced "horrific and inhuman conditions" stemming from what the DOJ called "complete indifference" by the institutions. "Inmates are maimed and tortured," the department wrote, "relegated to an existence of fear, filth and not so benign neglect."

Some years ago, an oversight monitor found that California prisons' system for disciplining officers accused of excessive force was "broken to the core."

For prisoners inside these systems, the courts are often the only backstop left.

But in the 1980s and 1990s, as the nation's prison population exploded, a new law and a series of revised legal standards radically restricted the ability of prisoners to prevail in Eighth Amendment lawsuits.

The 1996 Prison Litigation Reform Act, passed with robust bipartisan support, effectively carved out a separate and unequal system for prisoners who seek to file suit.

It required prisoners to complete a prison's internal grievance process before filing a claim in court — and then survive a screening process. After that, their claims faced exacting Supreme Court standards. Claims that guards had used excessive force were now decided under a 1986 standard that granted broad protections to prison staff as long as their actions were not "malicious and sadistic." Claims that prison staff have failed to keep prisoners safe — whether from violence, negligent healthcare, or inhumane conditions of confinement — were now decided under a Supreme Court standard, refined in 1994, which says such failures violate the Constitution only if officials were "deliberately indifferent."

Together, the standards shifted the focus away from the underlying claims of abuse, however extreme, and onto the question of prison officials' intent.

David Fathi, the director of the National Prison Project at the ACLU, said the emphasis on mindset has become "an enormous barrier to justice for incarcerated people." If abuse or neglect exists in prisons, he said, "that should be enough to violate the Eighth Amendment."

"You shouldn't have to go looking for someone who was thinking bad thoughts."

Altogether, said Kathrina Szymborski Wolfkot, a former appellate attorney at the MacArthur Justice Center, these laws and standards have made federal courts "inhospitable places for incarcerated people." Though some attorneys turn to state courts instead, there they face another set of challenges, such as caps on damages for malpractice claims or, in some cases, weak state constitutional protections.

The Department of Justice, the ACLU, and other powerful litigators have sometimes succeeded in winning Eighth Amendment cases that usher in reforms through consent decrees or injunctive orders. But such outcomes are rare. The DOJ has secured consent decrees in just four prison cases over the past decade.

A separate and unequal system

In restricting access to the courts, lawmakers in the 1990s argued that most prisoners filed suits over "frivolous" matters. Yet only a few dozen of the claims in BI's sample were over minor complaints, such as being denied shoes to wear in a dirty shower.

Among cases that prisoners lost, we logged 161 claims that guards had failed to protect a prisoner from being beaten or stabbed, including four fatalities. We identified 42 failed cases alleging untreated cancer, heart disease, HIV, or hepatitis C. We logged 78 claims of untreated mental illness, including eight that ended in suicide. There were 21 claims of sexual assault by prison staff. There were claims of confinement in extreme filth, including exposure to poisonous spiders, black mold, and feces.

The vast majority of prisoners, BI found, are navigating all of this without attorneys, in part because of the PLRA, which prevents attorneys from recovering their full litigation costs.

In the outside world, most civil suits settle — about 73%, one study found. In BI's sample, only 14% of prisoner lawsuits did, sometimes for paltry amounts or no damages at all. One North Carolina prisoner who said guards beat him while he was in restraints settled for $250.

By the time the cases were settled or decided in favor of the plaintiffs, those in charge — the wardens and medical directors — had almost always been dropped as defendants, limiting the ability of those judgments to drive institutional change.

Billions of taxpayer dollars go to corrections contractors, to run everything from food services to healthcare to staffing to data management, and the legal obstacles introduced in the 1980s and '90s have shielded these for-profit companies as well. For example, hundreds of private prison health providers or their employees were named as defendants in BI's sample. Of these cases, 14% settled and plaintiffs prevailed in less than 1%. One law-review article concluded that the low risk of liability had influenced companies' cost-benefit analysis and "leads to dangerous, ineffective healthcare that is shielded from constitutional challenge."

More than one federal judge described prisoner claims as tragic — before going on to cite precedent or the narrow standards in deciding against the plaintiffs. Several issued fiery dissents. One was issued in an August 2019 case filed by a prisoner who was denied a transfer he said was necessary for his safety. "We do not sentence people to be stabbed and beaten," Judge Robin Rosenbaum of the 11th Circuit wrote.

"The Eighth Amendment does not allow prisons to be modern-day settings for Lord of the Flies," she went on. "The Majority Opinion condones this behavior and ensures it will occur again."

This project was supported by a grant from Columbia University's Ira A. Lipman Center for Journalism and Civil and Human Rights in conjunction with Arnold Ventures. Data analysis and visualization were supported by the Fund for Investigative Journalism.