Utah prisoners have received delayed and inadequate medical care, audit shows

Legislative auditors say Utah’s prison health care system is rife with ‘systemic deficiencies.’

(Francisco Kjolseth | The Salt Lake Tribune) Prison staff work to safely move inmates from their cells into the common day room to be vaccinated against COVID-19 during a vaccination event with interested incoming inmates at the Utah State Prison in Draper on Tuesday, July 27, 2021. A new legislative audit found an inadequate prison health care system in Utah, one rife with so many “systemic deficiencies” that it has often translated to delayed and inadequate care for inmates.

They rifled through dumpsters, pieced through shredded forms and reviewed patient records from dozens of people who were sick and incarcerated at the Utah State Prison.

What state legislative auditors found, they say, was proof of an inadequate prison health care system in Utah, one rife with so many “systemic deficiencies” that it has often translated to delayed and inadequate care for inmates.

Legislative auditors discovered some prisoners who are diabetic were not getting food quickly enough after receiving insulin. They found private medical logs in a public dumpster outside the prison — twice. And a medical expert hired to review patient charts found at least two prisoners who contracted COVID-19 did not receive medical follow-ups for days as they became increasingly sick.

The primary reason for the problems, according to an audit released Tuesday, was “inadequate oversight from multiple levels of personnel.”

Prison officials agreed with the audit’s findings and are making steps to change, they said, including an internal audit. Details of the audit were discussed Tuesday with legislators at a subcommittee meeting.

What did Utah lawmakers think?

There were several rebukes from Utah lawmakers in response to Tuesday’s audit, with House Majority Leader Mike Schultz expressing concern that medical care at prisons had actually worsened since the review.

During the meeting, Schultz noted that lawmakers had recently received an email from a woman reporting that one inmate — a double amputee — didn’t have access to a wheelchair or shower chair and had to drag himself along the floor.

“Can you understand why something like this would be concerning?” Schultz, R-Hooper, asked Brian Nielson, executive director for the Utah Department of Corrections.

“It would be. I’d be very happy to look into it,” replied Nielson, who said he wasn’t familiar with the case in question.

House Minority Leader Brian King also pointed out that there are few options for inmates who receive inadequate health care. They could sue, but it’s difficult and expensive to press a malpractice case, he said.

“If you don’t have robust systems internally, people have no meaningful recourse when they’re killed or when they’re injured, and their families don’t have meaningful recourse,” the Salt Lake City Democrat said. “You have got to do ... a better job to address systemic deficiencies.”

Treatment of diabetic patients

The audit found that improper monitoring of inmates with diabetes — which is between 8 and 9% of the total prison population — has presented a serious risk to some prisoners. The prison’s current practices don’t meet American Diabetes Association standards, which indicate that blood sugar should be measured at least three times a day. That hasn’t happened with all diabetic prisoners, according to the audit.

Auditors found that Draper inmates with diabetes were often given insulin during “pill line,” then had to wait an hour or even up to 90 minutes before being given food. Diabetics should be fed within 30 minutes of receiving insulin, according to the American Diabetes Association, and auditors noted that prison staff also are trained to make sure diabetic inmates are fed within 30 minutes.

One housing unit failed to provide food within 30 minutes 93% of the time, according to four months of officer logs analyzed by auditors.

“We observed instances of dangerously low and dangerously high blood sugar readings, which likely could have been mitigated through increased monitoring and proper treatment by medical staff,” the audit reads.

Prison officials in a written response to the audit said they will work to remedy this by conducting monthly meetings “reviewing medical standards in comparison to diabetes management protocols” for a random sample of diabetic patients.


Since the start of the pandemic, 21 prisoners have died after testing positive for the coronavirus while incarcerated at the prison’s two facilities or while housed at a local county jail.

Family members and fellow inmates questioned the care those inmates received prior to their deaths, according to a Salt Lake Tribune/FOX 13 investigation.

But while legislative auditors found concerns about patient monitoring when it came to prisoners who contracted COVID-19, incomplete medical charting made it difficult for them to draw conclusions about their care. The audit noted medical charts were lacking, and in several COVID-19 cases, care was reportedly given, but there was no documentation to show it.

Marc Babitz, a doctor contracted to review medical cases, noted in the audit that he couldn’t find documentation of coronavirus-positive inmates who were isolated and quarantined.

Babitz found that care was appropriate for some of the inmates who died of COVID-19. But he added that some charts showed that other patients were not adequately monitored.

“One patient did not have a follow-up check for 4 days,” he wrote. “At which time, he was much sicker. Another patient was found to have a below normal oxygen saturation, but no action was taken until he was much sicker two days later.”

Auditors recommended that the prison develop better policies to respond to medical issues like the COVID-19 pandemic. Prison officials agreed in their response, and said they have updated their internal policies with guidance on handling pandemics and infectious disease protocols.

Medical records in the dumpster

Outside the Draper prison sit two large, brown dumpsters that are accessible to the public. Legislative auditors searched them — twice.

The first time, they found pill packets with personal health information on them. They also found a used syringe, treatment sheets with patient information on them and unused medications that had been thrown away, the audit states.

(Office of the Legislative Auditor General) In these images found in a legislative audit, auditors found private medical information after a search of the dumpsters at the Utah State Prison.

“When we first found personal health information discarded in the dumpsters, we alerted [prison] management,” the audit reads. “Four weeks later, our audit team checked the public dumpsters a second time and found more pill packs containing personal health information and unused medications.”

Auditors advised that the medical records should have been shredded, the syringe should have been placed in a biohazardous waste container and the unused medication should have been returned to the pharmacy.

Prison officials in their response said they will now hold quarterly staff trainings about how to properly protect prisoners’ personal health information.

The auditors also pieced together shredded forms that detailed Draper inmates’ requests for medical help. This information was supposed to be typed in a computer system verbatim, but auditors found that some requests had been thrown away without being entered or tossed after only being partially entered. They recommended more training and supervision of medical personnel.

Mental health copays and the role of EMTs

Auditors noted that prison officials over a four-year period charged inmates $825 in co-pays for mental health services — though the inmate handbook states that they won’t be charged for such services.

Prison officials said that the system has “statutory authority” to collect medical co-pays — including on mental health services. But they acknowledged that the inmate handbook states that prisoners can receive mental health help for free, a measure meant to “remove any real or perceived barrier to accessing mental health services.” Officials have agreed to stop charging inmates for mental health services.

Auditors also documented that the Draper facility was using emergency medical technicians to deliver prisoner medication and assess routine health care requests.

“We question whether the use of EMTs in a nonemergency setting places them in situations beyond their limited clinical training and education,” the audit reads, “which is focused on medical emergencies.”

One EMT told auditors that they did not feel adequately trained for what the prison required them to do, such as delivering medications at pill lines. Auditors noted that prisons in neighboring states use nurses for this type of medical work, and suggested that the prison consider an education loan repayment program as an incentive to hire nurses in those positions instead.

Prison officials in their response said that they have asked a lawyer in the Utah Attorney General’s office to review the prison’s use of EMTs to ensure that no laws or accreditation standards are being violated. If so, the department will “adjust its practices,” officials said.

— Tribune reporter Bethany Rodgers contributed to this report.