Sepsis is 'very treatable.' For inmates, it's often a death sentence.

Locked in a segregation cell at a county jail in Oklahoma, Terral Ellis Jr. begged for his inhaler, his voice raspy and desperate.

“I think I’m dying,” the 26-year-old father pleaded through the door.

Surveillance camera footage shows the jail nurse sauntered over to his cell, clearly exasperated. “There ain’t a damn thing f------ wrong with you,” she snapped, before slamming the door shut. A nearby inmate cracked a joke about the “boy who cried wolf.”

By the time paramedics arrived hours later, Ellis was barely conscious. He died that day from septic shock brought on by pneumonia – an infection he could have survived, if treated earlier.

Ellis’ story repeats itself hundreds of times each year in jails and prisons scattered from coast to coast. Arrests for infractions as minor as trespassing or a missed probation meeting turn into death sentences when correctional facilities delay or deny medical care that inmates need. Grieving families then sue for millions, often leaving taxpayers to foot the bill.

Map: Where correctional facilities reported sepsis-related deaths

Click on a jail or prison in the map below to see its details. You may also enter an address in the search box to locate the nearest correctional facilities. Don't see a map? Click here.

In New Mexico, a 34-year-old mother named Carmela DeVargas was left quadriplegic and on life support, dying from sepsis the month after she was booked on a probation violation in 2019. At the county jail in Boulder, Colorado, Avery Borkovec, 22, died of a staph infection and sepsis shortly after his arrest in 2022. And at a western Massachusetts jail, another young mother, Madelyn Linsenmeir, 30, died in 2018 from a heart infection and sepsis after her complaints of chest pain went unanswered.

Unhygienic conditions and medical delays mean Americans are dying in jails and prisons at unexpectedly high rates from sepsis, an extreme immune system reaction to infection. When caught promptly, the condition can often be treated simply with antibiotics and fluids. Left untreated, it quickly leads to organ failure and death.

USA TODAY’s review of unredacted in-custody death reports from the U.S. Department of Justice reveals at least 1,780 people have died with sepsis or septic shock over a recent eight-year period.

Ellis and many others likely would have survived sepsis had they been free to head to their doctor’s office or a nearby hospital. Behind bars, though, inmates are about three times more likely to die from sepsis, according to an academic study of sepsis deaths at a Florida hospital.

These often-preventable deaths have occurred at hundreds of local jails and state and federal prisons across nearly every state in the country. This tally is certainly an undercount of the true death toll from sepsis since USA TODAY found many records to be incomplete or missing altogether.

“This literally could happen to anyone,” said Dianne Bottino.

Her brother Rick Hall had a mental health crisis that left him rambling incoherently and tossing items around a bar parking lot late one night in May 2021 outside Baltimore. He was booked into jail and died two weeks later after an ulcer ruptured, allowing infection to fester untreated in his belly.

“He’d never had any trouble with the law,” Bottino said. “Not a drug addict. No other problems. Something contributed to unexplained behavior, and they put him in jail. And he was left there.”

Common medical crises like strokes, blood sugar spikes or heart conditions could trigger a similar mental break or leave any of us unable to explain unusual behavior to police, Bottino said, putting detainees at the mercy of whatever level of care jail clinicians can provide.

“It could be a byproduct of illegal drug use or excessive alcohol, sure. Does that mean that person doesn’t still deserve treatment?” Bottino asked. “Let’s help them.”

In the end, failure to respond appropriately to medical emergencies in correctional facilities devastates families and local budgets alike since the payouts to settle wrongful death lawsuits often reach into the millions.

Take, for example, the compensation a jury awarded to Ellis Jr.'s family, which county leaders have appealed. Should the decision stand, taxpayers in this small, rural county will be on the hook for almost all of the $33 million judgment – about 15 times the county’s annual tax revenue.

On the other hand, researchers say the average hospital stay for severe sepsis costs about $25,000 – roughly the same as a new Honda Civic. Instead of just one car, the Ellis family’s judgment could buy them a fleet of over 1,300 Civics.

‘A forgotten, underappreciated population’

Today, Dr. Jason Chertoff treats patients in the intensive care unit of a hospital in Zanesville, Ohio, but about a decade ago, he was learning about critical care at the University of Florida.

“We had a lot of prisoners come into our ICU. Anecdotally, by the time the prisoners got to us with sepsis, it was already too late to do anything. Most of them, if not all of them, would die, which is not typical,” Chertoff said. “Septic shock is certainly life-threatening and serious, but if caught early, it’s very, very treatable.”

Chertoff and two colleagues combed through thousands of sepsis cases treated at their hospital and discovered incarcerated patients had roughly three times the risk of dying from sepsis when compared to non-incarcerated patients. Almost half of the inmates died, compared to 15% of the non-inmates.

Together, they published their findings in 2018 in one of the very few studies on sepsis mortality among prisoners.

“It's just kind of a forgotten, underappreciated population that, frankly it sounds awful, but not many people care about,” Chertoff said. “A lot of people probably think, ‘Oh, they deserve that treatment.’”

And it’s not just sepsis. Chertoff rattled off a list of other treatable conditions that commonly kill inmates: heart disease, lung cancer, hepatitis C, diabetes and liver cirrhosis.

To be clear, people outside jail and prison also die from these diseases, but Chertoff said those behind bars face increased barriers and delays in getting emergency care. On-site medical staff is often limited, and inmates may need to submit formal requests for any sort of care.

“You or I could just go to the ER if we're not feeling well and feel like we're dying, but they have to go through hoops just to get EMS to be called to address their issues,” Chertoff said.

Even when they do get prompt medical treatment, prisoners’ lifestyles have often left their bodies less equipped to stave off infection than the general population's.

“Prisoners, in general, are not healthy,” Chertoff said, noting they’re more likely to have chronic conditions like liver disease or HIV/AIDS. “When you’re in prison, you can't really adjust your nutrition or exercise habits quite as easily as someone who's not.”

All those challenges aside, Chertoff said, the best treatment for sepsis behind bars remains the same as for cases outside: early detection, followed by broad-spectrum antibiotics and intravenous fluids.

“There's no reason why you can't recognize and treat sepsis in the prisons just like you would in the community. There's nothing magical about being in the community that they can't do [in prison].”

‘The boy who cried wolf’: What happens when inmates aren’t believed

Small shops and chain restaurants line historic Route 66 as it passes straight as an arrow through the dusty little town of Miami, Oklahoma. One block away sits the Ottawa County Jail, a squat beige brick building framed by curlicues of razor wire.

On Oct. 10, 2015, surveillance footage shows 26-year-old Ellis shaking hands with his grandfather in the lobby as two guards look on. Ellis had missed court for a DUI charge, so a judge had issued a warrant for his arrest. Instead, Ellis chose to turn himself in.

“He was motivated and eager to get down there and get this thing taken care of, so he could do better for his family and be a better father,” said his father, Terral Ellis Sr. “He didn’t get to do that. They took that opportunity away from him.”

Ellis Jr. was in good health, other than occasionally using an inhaler for asthma, his father said. A week later, though, Ellis Jr. started experiencing uncontrollable sweating, dehydration and severe back pain that left him unable to even walk to the toilet.

The jail’s licensed practical nurse gave him some ibuprofen and promised a nurse practitioner would see him when she made rounds, an internal report shows. A couple days later, paramedics arrived to check on Ellis Jr. when he reported suffering a seizure for the first time in his life. According to the lawsuit that the Ellis family later filed, jail staff told the paramedics he was faking his illness and that the county wouldn’t foot his medical bills – so they didn’t take him to the hospital.

Instead, jailers moved Ellis Jr. into a segregation cell away from other inmates who’d been caring for him. The next morning, Oct. 22, 2015, Ellis Jr. thought he was struggling through an asthma attack as the undiagnosed pneumonia filled his infected lungs with fluid.

“I can’t breathe! Help!” Ellis Jr. pleaded with a guard. “Look at my legs! My legs are black and purple.”

Surveillance footage shows nurse Theresa Horn, arms on her hips, walked to his door and peered in.

“Look at my legs!” Ellis Jr. told her. “My legs are black and purple.”

“Listen to me and shut up!” she screamed. “We’ve had EMS come over and check you out. There ain’t a damn thing f------ wrong with you. Your legs are fine. They are not black.”

As Ellis Jr. protested, Horn slammed the cell door on him. Then she re-opened it, screaming louder and threatening discipline if he continued to complain.

Three hours later, only faint moans can be heard on the video footage when a jail guard opened the cell door again and summoned Ellis Jr. out to see the nurse. He was in respiratory distress. He didn't react at all 25 minutes later when paramedics tapped his face as they lifted him onto a gurney and wheeled him away.

Later that day, Ellis Sr.’s phone rang. He hadn’t heard from his son in the nearly two weeks since he went to jail.

“Mr. Ellis, this is Terry Durborow, sheriff of Ottawa County. I’m sorry to inform you that your son has passed away, and he didn’t die here in jail. He passed away at the hospital.”

“Then he hung up. That was it,” Ellis Sr. told USA TODAY.

The medical examiner ruled Ellis Jr.’s cause of death to be septic shock due to pneumonia. Ten years later, the family is still waiting for justice. In 2023, a federal jury sided with the family in their wrongful death lawsuit, awarding them a $33 million judgment. They haven’t seen a penny of that, though, since an appeal from the county is still pending.

“Please realize that the jail nurse at the time of the incident, a decade ago, was derelict,” wrote Doug Pewitt, district attorney for Ottawa County, in an email to USA TODAY. “Jailers on staff called for an ambulance but were overridden by the jail nurse who believed the detainee was malingering.”

Pewitt called Ellis Jr.’s death “tragic and deeply regretted” and listed changes the jail has made to prevent more deaths: The current sheriff has contracted a medical service provider. Anyone with medical complaints must be screened at the emergency room before being detained, and all detainees have their vitals checked at booking.

Legal filings show the county argues in its appeal that the large judgment resulted from flawed jury instructions and misconduct from an Ellis family attorney, an allegation the family's attorneys have denied.

“The jury panel had no way of knowing that Ottawa County has a small tax base and a very small sheriff's office,” Pewitt wrote to USA TODAY, adding that these details were not allowed as evidence in court. “The plaintiffs' attorney in the closing argument repeatedly used words and phrases that encouraged the jury to award damages based upon outrage, which is impermissible.”

A decade after losing him, Ellis Jr.’s family keeps waiting.

“It completely turned my life around for the worse. I just didn’t care about anything anymore,” Ellis Sr. said about coping with his son’s death. “We all, as a family, deserve the right to move on. To move forward. And right now, we’re all still in limbo waiting for this thing to close up.”

Promises of inmate health care are ‘a toothless right’

The way America’s correctional system is set up, each state’s prison system and the thousands of city and county jails may craft their own policies around medical care and any complaints about that care.

One constant, though, is inmates’ constitutional right to health care behind bars. Fifty years ago, the Supreme Court ruled that deliberate indifference to serious medical needs can amount to “cruel and unusual punishment,” which the Bill of Rights outlawed centuries ago.

“And yet it's not what we see happening in the real world,” said legal scholar Andrea Armstrong. “In some ways, it’s a toothless right.”

Armstrong calls American jails “individual fiefdoms” that have been allowed to hide the conditions within from the public.

“And it is impossible to fix what is invisible and hidden,” she testified during a 2022 Senate committee hearing about in-custody death records missing from the federal data USA TODAY analyzed for this report. “The federal government has unique authority to be able to collect this information from the jails.”

Armstrong teaches law at Loyola University New Orleans, and her students have spent years hounding jail wardens across Louisiana for records of inmate deaths, which they feed into a website they say tracks all the known deaths behind bars in the state over the last decade. Her students have uncovered both more deaths and more specifics on individual deaths than the federal records provide, Armstrong testified.

In theory, Armstrong says we might expect better health outcomes for prisoners considering their highly controlled environment – they’re supposed to be kept away from illegal drugs and motor vehicles, which kill lots of people on the outside. And, even in facilities that lack on-call doctors or nurses, staff are likely trained in some emergency first-aid.

However, that’s not what happens in many correctional facilities, as prisoners often report higher rates of illness than the general public. The reasons are many and vary by facility, but USA TODAY found some common threads:

• Tight budgets can cause understaffing, limiting the time and attention for each inmate’s issues. The jail where Ellis Jr. died only had one nurse on staff, five days a week, to care for nearly 100 inmates, according to his family’s lawsuit.
• Medical staff may suspect inmates’ ailments are attempts to obtain drugs or escape work details. This so-called “malingering” can result in fines or discipline such as reduced visitation time, reduced access to buy snacks or hygiene products, or even time in solitary confinement, Armstrong said.
• Inmates may choose not to request treatment they truly need when they’ve been doubted in the past or if the facility charges health care fees, several inmates told USA TODAY.
• Common federal rules governing Medicare and Medicaid don’t apply behind bars, meaning prison doctors and nurses aren’t always fully licensed due to disciplinary issues elsewhere. This was a major element in a 2015 class-action lawsuit against the Louisiana State Penitentiary, yet Armstrong said the practice continues in several states.

“Big picture, the health care that's delivered behind bars is designed as a sick-call system,” Armstrong said. “The treatment that you get is designed to address the symptom that you are complaining of. But if you don't know, for example, that you have this disease progression until it is showing a symptom, then oftentimes you have missed the early opportunities to address it in a targeted and efficient way.”

‘Catch-22s, twisted logic’ block inmate care

In May 2021, Bottino, whose brother had been arrested for acting strangely outside a bar, sat staring at three words emblazoned across the waiting room wall of a Baltimore-area police station: “Protect and serve.”

“I’m going to throw up,” she thought to herself, slowly re-reading the words. “Because you did anything but. You held and harmed. You did not protect and serve.”

That day, Bottino’s brother Rick Hall was supposed to be sitting before a judge for a competency hearing. Jail staff told her that being deemed incompetent would allow for Hall's transfer from the Howard County Detention Center to a state psychiatric hospital, which could provide better care.

Instead, Bottino was collecting Hall’s belongings. He died at the jail the day before, after an infection from a ruptured ulcer festered in his belly for two weeks without treatment.

“It was just a series of Catch-22s and twisted logic and circumstances,” Bottino said. “So many times over, it could have been prevented, which is even more maddening.”

Three weeks earlier, everything seemed normal. Hall was feeling good about his career with a logistics company and planning for his 50th birthday party, Bottino said.

After leaving work on May 6, 2021, Hall sat down by himself at a bar, scrolling through his phone over a plate of food and a beer.

But then, something snapped.

At closing time, Hall started “banging on the door” and “being crazy, screaming in people’s faces,” according a 911 call referenced in Bottino's lawsuit. When two officers arrived at the bar at about 4 a.m., Hall appeared to be talking to imaginary people.

“Do you believe me now?” he screamed, tossing his belongings around the parking lot. “You have no idea!”

He then yelled that he would not leave nor go to jail, pulling off his pants in the process. But the jail is where he ended up, charged with indecent exposure and trespassing.

Jail staff noted Hall had a fever and a “severe mental health problem” the day after he arrived on site, according to the lawsuit, but they didn’t complete the full medical assessment required at booking due to his uncooperative, irrational behavior.

Over Hall’s first week in jail, a doctor prescribed painkillers and anti-psychotics, but it’s unclear whether he took any medication. Guards noted he’d become visibly thinner and shaky, considering he hadn’t eaten more than a spoonful of oatmeal since his booking.

Meanwhile, Hall’s colleagues reached out to Bottino, concerned when he didn’t show up to work. Filing a missing person report quickly pointed her to the jail. Despite calling around the clock for days on end, Bottino was never allowed to visit or speak with her brother. Detainees may make phone calls, but they need to be able to dial the phone on their own.

“He’s not talking sensibly right now,” jail staff told Bottino. “He’s kind of out of touch with reality, so he can’t program the phone, so he can’t call you.”

“Do you hear yourself?” Bottino responded, despairing at the Catch-22. “I’m telling you he needs help. You’re confirming that he needs help, but you won’t let me help him.”

Bottino worked the phones for 10 days, pleading with anybody who’d listen to help her brother: jail nurses, the jail administrator, security guards, the police officers who’d arrested Hall, even a public defender.

They kept pointing back to Hall’s competency hearing, scheduled for May 21. She knew being deemed incompetent wasn’t going to bring a miracle, but it would get Hall out of jail and into a hospital that could help him.

Her frustration had given way to exhaustion by May 20, when local police appeared at her doorstep with news of Hall’s death. In that instant, it became rage. But eventually, it subsided to grief and resolve as she tidied up her brother’s affairs.

Bottino said she was looking for accountability and change when she sued the county for denial of adequate medical care and gross negligence in March 2024.

“It was the most extreme case of indifference to a human I've ever seen,” said Bottino’s lawyer, Kristen Mack. “I can't say this about many places, but Howard County acknowledged that this was a bad situation, and they had already made changes at the time, before we even brought the lawsuit.”

“Do they want a medal? Like, they’re not getting it from me,” Bottino recalled telling her attorney when she learned about the jail’s staffing changes and training efforts. “That’s a good start, but there’s still a lot that needs to be changed.”

The county did not respond to USA TODAY’s requests for comment.

However, legal filings show Howard County denied Bottino’s allegations of inadequate care and misconduct before offering a settlement admitting no fault for Hall’s death. Just six months after she’d filed, Bottino accepted $1.25 million – an amount she said she hoped would force the county to re-evaluate how it treats prisoners.

Attorney cites culture of dehumanization

“Do I feel like justice was served? In a word, no,” Bottino said. “There is no amount of money that brings Rick back. He is gone.”

USA TODAY reviewed dozens of lawsuits from families who lost a loved one to sepsis behind bars over the past decade. Many falter on legal technicalities or take years to wind their way through the justice system, like the lawsuit from the Ellis family. Others, like Bottino’s case, lead to swift settlement payouts.

The families USA TODAY interviewed largely echoed Bottino's sentiments: It’s nice to get some compensation, but it doesn’t fill the void left when a loved one dies. If inmates were just treated humanely, they say, the cost – both in human lives and in dollars – could be avoided.

Taxpayers have ended up holding part of the bill for preventable sepsis deaths in case after case across the country. Insurance doesn’t always cover the full cost of settlements. Plus, these lawsuits put them at risk of higher premiums or canceled policies.

For example, Michael Barton, 54, died in 2018 after a case of the flu turned into pneumonia and then septic shock at the Oregon State Penitentiary. The state is self-insured and paid $2.75 million to settle his family’s lawsuit.

In western Massachusetts, the city of Springfield paid $900,000 from its free cash reserves in 2024 to settle a lawsuit from the family of Madelyn Linsenmeir, who died at a nearby jail. The jail’s operator, the Hampden County Sheriff’s Office, agreed to pay out a separate $600,000 settlement in May.

That's just a sampling of the dozens of lawsuits that USA TODAY reviewed. Mack, Bottino’s attorney in Maryland, said her law firm gets three to four calls per week from families looking for representation dealing with health care issues at correctional facilities.

Dan Smolen, a civil rights attorney from Tulsa, Oklahoma, who represents Ellis Jr.’s family, also gets multiple calls per month from families looking for help with a loved one who died in custody. From his experience litigating these cases, he believes a culture of dehumanization has taken root within America’s jails and prisons.

“You hit that jail – you are not a human, and you are treated less-than. And that’s the mentality from the very beginning, and so that carries into the medical care,” Smolen said. “It’s very rare that I don’t have a case where they believe the person’s faking, and that’s usually what gets you to sepsis.”

Since Ellis Jr.’s death, a private contractor has taken over medical care at the Ottawa County Jail, but that company and others like it have seen plenty of wrongful death lawsuits as well. Smolen said these for-profit companies have little reason to send sick inmates to the hospital because it cuts into their profit margins.

“All of that combined is how you end up with the [sepsis death] numbers like you’re seeing,” Smolen said. “You’ve got to change culturally the way we're approaching health care in a correctional setting. You have to take out the profit side of things.”

Another problem with for-profit prison medical contractors, Mack said, is that those who have racked up debt through lawsuits can declare bankruptcy and essentially start over.

“The name changes, but we still see the same doctors at the facilities,” Mack said. “There's not enough being done to address people that aren't doing their job well.”

The principle of "innocent until proven guilty" remains the bedrock of America’s legal system, and Mack pointed out jail inmates generally have not yet been tried or convicted of a crime.

“Even if they did do something wrong, they're still human beings. They're being imprisoned as their sentence. That doesn't mean that they shouldn't be entitled to medical care,” Mack said. “It shouldn’t be a death sentence to go to jail.”

Yet, it was for Terral Ellis Jr., Rick Hall, Carmela DeVargas and hundreds of others killed by sepsis behind bars over the past decade.

“It's not supposed to be the way of things that I just turned 23, and now I've outlived my brother,” said Dylan Bolt, whose family’s lawsuit against Broomfield County, Colorado, remains ongoing. Nov. 3 marked three years since his brother Avery Borkovec died pleading for medical care at a nearby jail. The county has denied all allegations of wrongdoing in legal filings.

Without fail, everyone that USA TODAY spoke with who lost a brother, sister, son or daughter to sepsis in correctional facilities echoed some form of Bolt's disbelief. They say their loved ones were treated like animals, or worse. Some were left to die alone, cold and naked on concrete cell floors. Others were shackled to beds in prison hospitals, as officers stood guard at their bedside, keeping family away from one final goodbye.

As long as medical care in correctional facilities remains underfunded, privatized and plagued by what Smolen calls a culture of dehumanization, families will continue burying loved ones. The lawsuits will keep coming. And so will the deaths.