The lesion started out small, maybe the size of a Q-tip, but then rapidly progressed to the size of a half dollar and then a silver dollar. Michael Boswell tried to bring it to the attention of the medical staff at the Washington State Penitentiary in Walla Walla, where he was incarcerated, but he was told the lesion was benign, according to a report in The Seattle Times.
The prisoner filed grievances and pleaded for treatment in May 2019, and the lesion was finally excised the following September. The diagnosis was malignant melanoma, and the surgeon recommended “urgent” full body imaging, lymphatic mapping, and re-excision of the melanoma site, as well as sentinel lymph node biopsy to check for metastasis. At a separate visit, a medical oncologist agreed that these interventions were urgently needed. However, treatment was delayed for months, and Boswell did not begin to undergo chemotherapy until June 2020. By then the cancer had metastasized. He died a month later at the age of 37 years.
This is just one case. Delays in diagnosis and treatment in prisons are likely “a widespread issue, and one that isn’t limited to patients with cancer,” said Patricia David, MD, MSPH, CCHP, director of patient safety and performance review, Office of the Governor, Office of the Corrections Ombuds (OCO), in Washington State.
She was commenting to Medscape Medical News about an investigative report conducted by the OCO that found at least 11 cases in which cancer diagnoses and treatments had been delayed during the past few years.
The OCO is an independent, impartial public office that serves the state of Washington by promoting positive change in corrections.
The report found “long delays in diagnostics and evaluations, misdiagnosis, and delays in treatment,” commented David. “Given the findings in this investigation, it’s likely that delays in diagnosis are occurring for patients with other diseases as well.”
Another inmate, Kenny Williams, who had been incarcerated at the Monroe Correctional Complex, in Monroe, Washington, died after treatment for his cancer was delayed for more than a year. During an appointment in March 2018, a nurse discovered a lump in Williams’ breast. Results of a follow-up biopsy confirmed that it was malignant. However, he wasn’t seen by an oncologist until almost 6 months later, at which point he was diagnosed with advanced breast cancer. Chemotherapy was recommended. Williams never received treatment, and although he filed grievances in accordance with prison protocol, nothing happened.
“The oncologist told me on Aug. 22nd, 2018 that I needed to start aggressive chemotherapy ASAP and that he would schedule me for the following week. This was now seven weeks ago….” Williams wrote in one appeal, The Seattle Times reported. “I am dying, what is holding up the treatment that will save my life?”
His cancer metastasized into his bones. Williams died in June 2019, 15 months after the lump had been discovered. He never received any treatment. His release from prison had been scheduled for December 2020.
Willaims’ family has now filed a lawsuit against the Department of Corrections (DOC) in King County Superior Court, alleging that “systemic negligence” led to his suffering and death and seeking $10 million in damages.
“On paper, this is one of the worst cases of medical neglect that we have ever seen,” said Ed Budge, whose Seattle law firm, Budge & Heipt, is representing the family members who filed suit.
Complaints About Care
“The delivery of health services in the correctional environment does have challenges which make it different from the community setting,” the OCO’s David told Medscape Medical News. “These folks often arrive without having ever received previous medical care.”
David, who formerly worked for the Washington State DOC as director of medical quality, pointed out that prison healthcare practitioners have to conform to the institutional priorities of safety and security and that patients cannot seek another medical opinion if they are dissatisfied with the care they receive.
“However, the recognition of a serious or potentially serious medical condition should not be affected by a prison setting,” she said. “In other words, a melanoma in the community has the same appearance as a melanoma in the prison ― so the time to diagnosis shouldn’t be affected by incarceration.”
Prisons are obligated to provide medically necessary healthcare to inmates, but problems have been brewing for some time within the Washington State DOC.
The OCO was created in 2018 to provide independent oversight of the DOC. Its first annual report, issued in November 2019, found that 1 in 5 complaints it received involved healthcare.
During the first 10 months of its establishment, the OCO received 2002 complaints about the DOC. It reviewed about half of them. Overall, healthcare was the “largest area of concern” with the DOC. There were also concerns about mental health problems.
Earlier in the year, Julia Barnett, MD, the medical director at the Monroe Correctional Complex, was fired for misconduct after the DOC concluded that she’d “failed to advocate for these patients and delayed emergency medical care, which was essential to life and caused significant deteriorations in patients’ medical conditions.”
The medical ward staff at the facility had also submitted a vote of “no confidence” to DOC administrators. In their letter, they noted that Barnett had created “a toxic environment” and appeared to make decisions “to reduce health care costs rather than for the benefit of the patient or for the benefit of her staff.”
In the firing of Barnett, the DOC cited the treatment of six prisoners, including three who had died. Several more cases were being investigated at that time, including seven deaths at the facility.
Current Report Cites Delays
In the recent investigative report issued by the OCO, 11 inmates were highlighted. They ranged in age from 35 to 68 years. Their complaints included blood in urine and stool, abdominal pain, nausea, abrupt weight loss, and shortness of breath. They all experienced delays in having those symptoms addressed. The average time to diagnosis for these eleven patients was approximately 6.5 months. The time from initial presentation to diagnosis ranged from 2 to 17 months.
The report noted the following:
For six cases, the delay was associated with the clinician reaching an incorrect diagnostic conclusion.
In five cases, scheduling of consultations with external specialists was delayed, contributing to the delay in diagnosis and/or the initiation of treatment.
In 4 of the 11 cases, delays in scheduling of diagnostic studies contributed to delays in diagnosis and/or initiation of treatment.
In three cases, evaluation by a DOC clinician was delayed; in one case, the delay was caused by refusal of custody staff to bring a patient to the clinic.
In two cases, abnormal lab results were overlooked or were not recognized.
In one case, a delay occurred because an outside radiologist interpreted an MRI as negative after results of a previous CT scan had been positive.
Jacque Coe, a spokesperson for the DOC, told Medscape Medical News that the DOC has taken numerous actions to improve the efficiency, accuracy, and timeliness of diagnosis and treatment of cancer patients in their care.
“Deploying additional transportation teams, creating a software tracking tool to follow cancer care time lines, conducting on-site workflow process assessments, and a focus on quality improvement at a pilot site are just some of the actions taken,” she said.
“In addition to improving processes, the Department submitted legislative requests to fund $5.4 million in new healthcare investments,” Coe explained. “This will provide much needed improvements in patient healthcare, a healthcare delivery model focused on quality assurance, expanded case management and care navigation.
“A significant advancement is funding the initial steps to replace DOC’s current paper health record system with a modern-day electronic health record [EHR] system that will increase our ability to provide timely, well-coordinated healthcare to those who are incarcerated,” she added. “The Department takes very seriously its responsibility to deliver quality healthcare to individuals in its custody and will continue to seek ways to improve the reliability and quality of patient healthcare.”
Action Plan Needed
In an interview, David acknowledged that an EHR system would be helpful for ensuring that appointments (both on site and off site) are scheduled in a timely manner. “The EHR would also be helpful for flagging abnormal labs and other diagnostic studies so that they are not missed,” she said.
“However, the EHR would not fix diagnostic error, such as the failure to recognize a malignant melanoma vs a benign mole, or the failure to recognize that a multi-month history of hematuria and persistent abdominal pain requires further investigation, or the failure to recognize that a hemoglobin of 6.8 is significantly abnormal, or the failure to recognize that antiviral medication for a cold sore should not be renewed for months at a time and without an examination to ensure the lesion is not something else,” she said.
In its report, the OCO recommended that system deficiencies and gaps in resources that are preventing the diagnosis of cancer in the earliest stage possible need to be identified.
It also recommended that oversight by the chief medical officer and other responsible physicians needs to be strengthened. The report recommended shifting to a medical home model of practice so that care can be better coordinated and health needs not forgotten when inmates are transferred between state and county facilities.
Importantly, the OCO report recommended that the DOC “develop an action plan to address these needs, as well as others they may identify through its own internal investigations.”