- Danny Robbins The Atlanta Journal-Constitution
At least three female inmates died from substandard medical treatment in Georgia prisons, according to a state report that says the prison system provides women with inferior health care.
The report by Augusta University, prompted by an Atlanta Journal-Constitution investigation, says Dr. Yvon Nazaire provided medical care that “fell below an acceptable standard of care.” It also said the deaths of three inmates treated by Nazaire “clearly demonstrated care that fell below the community standards.”
In addition, the report released Wednesday questioned Nazaire’s treatment of two inmates cited in AJC articles whose cancers went undiagnosed until they left prison.
The report was prepared by Dr. William Kanto, a physician and administrator at Augusta, formerly known as Georgia Regents University. A branch of the university, Georgia Correctional Health Care, staffs prison clinics under a contract with the Georgia Department of Corrections.
Nazaire was fired in September over misrepresentations in his credentials when he was hired nine years ago. However, Kanto’s report is the school’s first public reaction to deaths and other patient-care issues detailed by the AJC.
“My recommendation is that Dr. Nazaire be permanently barred from seeing patients for GCHC and that our actions and findings be referred to the (Georgia) Composite Medical Board for their review,” Kanto wrote. The board can revoke a physician’s medical license or take other disciplinary action.
In a separate document, reporting on a broader review of prison health care, Kanto said improvements are needed in female inmates’ health care. His review left him with a “positive impression” of the medical system for male inmates, he wrote, but “unfortunately, there is not a similar system for female inmates.”
Kanto, formerly on the faculty at Emory University and the University of Michigan, was allowed to determine the course of his review and had access to all medical records and “relevant individuals,” Augusta University spokesman Jack Evans said in an email.
“Many of the recommendations have been implemented and the remaining items are in process with the goal of continually improving our quality of care, particularly for women,” Evans wrote.
Nazaire did not respond to a text message from the AJC Wednesday.
Wayne Morris, whose sister Peggy Walker died from ovarian cancer after being in Nazaire’s care at Emanuel Women’s Facility, said the report should have identified those who hired and supervised the physician, who was responsible for the health care of more than half the 3,500 women in Georgia prisons.
“There should be people taking responsibility for this,” Morris said. “This was not just Nazaire. In fact, he never should have been hired in the first place. And after he was hired, they did nothing but defend him. The system is broken because of its leadership.”
Morris has asked U.S. Department of Justice to investigate, he said, “because I don’t believe the people in the system can do it.”
Kanto’s review began after the AJC raised questions about Nazaire’s background as well as his treatment of inmates at Emanuel and at Pulaski State Prison, 80 miles apart in south Georgia. The AJC found that at least nine women had died under questionable circumstances in the nine years since Nazaire was hired.
Nazaire was placed on administrative leave during the review, but was fired after officials confirmed an AJC report that he misrepresented his work history when he applied for the state job. The Georgia Bureau of Investigation is investigating.
Kanto said the physician’s performance was, “on balance,” substandard. Of the nine deaths detailed by the AJC, he wrote, “there were three which I felt clearly demonstrated care which fell below the community standards.”
Kanto did not identify the inmates or explain his conclusion. However, he wrote that two cases “reflect a situation in which the physician’s performance was clearly below community standards” and a third that shows the prison system taking on a patient “whose needs could not be met in a timely fashion.”
Kanto also addressed an AJC story that detailed three former Pulaski inmates battling cancer whose symptoms weren’t diagnosed in prison despite obvious and at times gruesome symptoms. Again, without providing specifics, Kanto wrote that “for at least two of the patients, I felt the management was below the standard of care.” He said he was unable to make a judgment on the third inmate.
“I also have concerns that there was not adequate oversight by Dr. Nazaire of personnel with whom he was working and supervising,” Kanto added.
In a 10-page executive summary of his general findings, Kanto said that the small number of women’s prisons and the limited number of medical personnel working in them has led to lax oversight.
“We should have a heightened sense of awareness of what transpires within these smaller prisons and provide a heightened level of attention to the appropriateness and quality of the care provided,” he wrote.
Kanto said physicians in those prisons should have experience in women’s health and also should be comfortable working in a more independent environment. He suggested the use of an electronic health-record system and that it be implemented first in women’s prisons.
Kanto also said officials have not independently vetted physicians hired to work temporarily in the prisons. His report said Georgia Correctional Health Care has implemented a new hiring process that includes verifying work histories, checking references and checking with the licensing board in every state in which a prospective physician has worked.
Dr. Edward Bailey, who was the GCHC statewide medical director at the time Nazaire was hired, has declined repeated interview requests from the AJC. However, Bailey’s successor, Dr. Billy Nichols, acknowledged in an interview with the AJC that Georgia Correctional Health Care did not check with any state boards other than Georgia’s when looking into a doctor’s background. In Nazaire’s case, that meant Georgia officials didn’t know the doctor had been cited in New York for gross negligence in his treatment of emergency room patients.
Kanto also recommended a more extensive process for conducting mortality reviews and said Georgia Correctional Health Care and the state Department of Corrections should share a database of inquiries and complaints. Information should also be placed in the practitioner’s personnel file, he said.
“This recommendation was developed during the last two weeks,” he wrote, apparently referring to an AJC story that detailed how complaints about Nazaire to both GCHC and DOC officials went unheeded for years and were never included in his personnel file.