Deaths of two women inmates put focus on Georgia prison doctor

Physician was hired after lawsuits over four New York hospital deaths, state probation

For weeks, they grew sicker, two women in a Georgia prison on the verge of dying. One with an abdomen so distended she looked pregnant. Another so jaundiced her skin was yellow.

At Emanuel Women’s Facility in the summer of 2011, it was clear that Peggy Leigh Walker and Sharon Diane Blalock needed a doctor’s attention, and quickly. When it never came, worry spread. Who would be next?

“It was very unsettling, the way we saw both of them suffer,” said Lisa Turner, an Emanuel inmate at the time who knew Blalock well. “We were in fear that we would never be treated and die in prison ourselves.”

The deaths of Walker and Blalock raise new questions about the state’s decision to place the health of prison inmates in the hands of Dr. Yvon Nazaire, hired even though he had been sued at least four times over patient deaths in New York.

The two Georgia women’s deaths also call into question whether the state’s drive to reduce prison medical costs is jeopardizing patient care. Nazaire won praise and pay raises after clamping down on outside consultations and other expenses.

An Atlanta Journal-Constitution investigation based on medical records, email, letters and other documents shows that even as the health of the two women deteriorated noticeably, they apparently were never seen by Nazaire, then serving as Emanuel’s medical director while based 80 miles away at another prison.

Moreover, evidence suggests that when an advanced practice nurse on site specifically requested that Walker and Blalock be permitted to consult with physicians outside the prison, Nazaire flatly refused to allow it.

Nazaire declined the AJC’s interview request. Told that the subject was the two deaths at Emanuel, he replied: “No one died while I was covering Emanuel. Otherwise, my name would be on the death certificates.” He then ended the conversation.

In Walker’s case, records her family provided to the AJC show that the 45-year-old died of ovarian cancer that wasn’t diagnosed until she was hospitalized due to heavy vaginal bleeding two weeks before her death.

The cancer was discovered when 4.8 liters of fluid — more than a gallon — was removed from her abdomen at the hospital.

“In our minds, it was clear from the beginning she did not receive the medical attention she should have received,” said Walker’s brother, Wayne Morris.

Blalock, who had hepatitis C when she entered prison, died of liver failure just five days after she blacked out in front of prison officials, prompting a 911 call for an ambulance to transport her to a local hospital.

In letters to Blalock’s family after her death, nine Emanuel inmates described watching the 55-year-old deteriorate to the point where she had become disoriented and unable to control her bladder or bowels.

“I hung with your daughter for approximately three months,” one inmate wrote Blalock’s mother. “During that time I watched her go from a vibrant, happy, caring woman to a woman so sick she was afraid to go to sleep for fear she wouldn’t wake up.”


Deaths in New York

Nazaire, 59, is among the 50 physicians employed by Georgia Correctional Health Care, a division of Georgia Regents University that contracts with the Department of Corrections to provide health care services for public prisons.

He has served as the medical director at Pulaski State Prison, a facility that houses 1,200 female inmates in Hawkinsville, since being hired nine years ago. In 2011, he also took on responsibility for Emanuel after that facility in Swainsboro was reconfigured from a transitional center to a prison for 550 women.

According to the Department of Corrections, Nazaire’s oversight for Emanuel ended in December 2013 “due to travel inconvenience.”

The AJC reported in December that Nazaire was licensed in Georgia in February 2006 and hired by Georgia Correctional Health Care six months later even though he was in the midst of a three-year probation imposed by the medical board in New York.

That probation required that Nazaire’s practice be closely supervised, but no such restriction was placed on his Georgia license. The New York board’s decision was based on a finding that Nazaire was negligent in his treatment of five hospital emergency room patients, one of whom, a 28-year-old man, died from a heart attack.

However, the AJC’s investigation indicates that the New York board’s order tells only part of the story.

Court records in New York show Nazaire was a defendant in four malpractice suits over deaths at hospitals where he worked. In one, the family of a 34-year-old woman who died from a pulmonary embolism received a $3 million settlement, $2.55 million of which was paid by the insurance carrier for Nazaire and the company he then worked for.

“I just don’t get it,” said Angelo Carieri, a New York advertising executive who alleged in another lawsuit that his 95-year-old mother died as a result of inattention from Nazaire. “This man should not be a doctor.”

Dr. Edward Bailey, who was the medical director for Georgia Correctional Health Care at the time Nazaire was hired and was also in that position when the two inmates died at Emanuel, declined to be interviewed. Bailey, who retired in 2012, also declined to respond to questions emailed from the AJC regarding his knowledge of Nazaire’s background and the deaths.

The agency’s current medical director, Dr. Billy Nichols, did not respond to interview requests. In November, he told the AJC he was unaware that Nazaire had been sanctioned in New York.


`Cancel, cancel, cancel'

 Marilyn Ringstaff, who worked as an advanced practice nurse at Emanual in the summer of 2011, said Nazaire repeatedly rejected her requests to allow inmates with serious health concerns to consult with physicians outside the prison. Nazaire cancelled the requested consultations, she said, even though he never saw the inmates himself. Walker and Blalock were among those inmates, she said.

“There had to be at least 20 — cancel, cancel, cancel,” Ringstaff said.

Walker’s medical records show that, eight days before she was hospitalized, Ringstaff requested that the inmate receive a radiology consultation. The request noted that Walker was suffering from rapid abdominal distention, the cause of which was unknown.

Nazaire canceled the consultation request with no explanation other than a note, “Cancelled per Dr. Nazaire.”

Nazaire typically did not provide a written explanation when he denied a consultation, although he sometimes would discuss his thinking on the phone, Ringstaff said.

“He would always justify it, `They’ll be out soon. Not that big a deal,’” she said.

Ringstaff, who operates a nonprofit clinic that provides health services for low-income and uninsured women in Rome, said she was due to work three months at Emanuel that summer but was asked to leave with a month remaining. That was about the time she began openly complaining about Nazaire, she said. She said it was alleged that surveillance video showed her removing a medical chart from the facility when in fact what she was carrying was an authorized iPad.

Ringstaff provided the AJC with emails she said she wrote in the days after her dismissal to Bailey and to Emanuel’s warden at the time, Alexis Chase. The emails detailed her concerns about Nazaire and specifically mentioned the two deaths.

“Both of these women I tried to get assistance for and Dr. Nazaire refused it both times,” she wrote to Bailey.

Neither official responded, Ringstaff said.

Chase, who retired in 2012, said in an interview that she had no concerns about Nazaire’s treatment of either woman.

“I never had any problem with him,” she said. “In fact, he was one of the best doctors I worked with in my prison career.”

Ringstaff caused problems, Chase said, by “overstepping her boundaries, (acting) like she was a physician.”

Neither death resulted in the filing of an incident report by the prison, even though Department of Corrections procedure says such reports are to be completed for “activities that are outside the normal routine and might cause public concern or notoriety.” The deaths were addressed only in "ad hoc" reports that lacked the detail of full incident reports.

Sarah Geraghty, an attorney with the Atlanta-based Southern Center for Human Rights, said she has obtained numerous incident reports for Georgia prison inmates who died in custody, including some whose deaths occurred at hospitals.

“When someone dies, even if you have discretion (in following the policy), I would think you are abusing that discretion if there’s no incident report,” Geraghty said.

The AJC asked for data from the Department of Corrections showing medical consultations requested, approved and denied for all state prisons in the last five years. The data for 2011 — the year the women died — didn’t include Emanuel even though it was open for nine months of that year. Responding to questions by email, a spokeswoman for the Department of Corrections said Emanuel wasn’t included in the data because it wasn’t a prison the entire year.

The spokeswoman, Gwendolyn Hogan, said “medical conditions were not ignored” for the two women. Both deaths were subject to clinical mortality reviews by physicians, she said. The department considers those reviews confidential.

Walker’s medical records include a preliminary mortality review by Dr. David M. Walker, her attending physician when she died in hospice care at Lee Arrendale State Prison. The review said the inmate’s treatment “met community standards.” It noted the consultation Nazaire had denied but said the decision had no bearing on the outcome.


Cost-cutting and praise

 Throughout his time with Georgia Correctional Health Care, Nazaire has consistently earned praise from his superiors, much of it for efforts to limit consultations and other expenses. At the same time, his annual salary has increased more than 20 percent, from $150,000 to $174,300.

In a performance review prepared in May 2007, it was noted that Nazaire had “dropped the consult rate to low numbers thus keeping Pulaski below budget.” Another evaluation, in 2010, stated that the physician had used “new data from the medical world” to “better manage the medical problems of the inmates thus saving GCHC and GDC … money.”

In an era of growing and aging prison populations, limiting the number of visits to outside providers has become an important element of cost containment, experts in correctional health care say. However, they say, it’s important to make sure that only truly unnecessary consultations are eliminated.

“If care is denied solely for the purpose of saving money, as opposed to being unnecessary, then that is unethical, inhumane and violates constitutional law,” said Dr. Robert Greifinger, a New York-based correctional health care consultant who has served as a court-appointed monitor for the jails in Fulton and DeKalb counties.

Even if there’s a legitimate reason for denying a request, it should be spelled out, Greifinger said.

“The denial of the request should explain why, and if there’s an alternative treatment, that should be explained as well,” he said.


`Yellow as a banana’

 For many who saw Blalock and Walker in the summer of 2011, there were clear signs that both were sick, and getting sicker.

Blalock was among a large group of inmates living in the prison gymnasium. Bunks were lined up in rows and portable toilets and showers were attached to the building. In that setting, her illness was particularly noticeable.

“You’d have to be blind not to see it,” said Billie Duke, a former Emanuel inmate. “Her skin, her eyes. At the end, she couldn’t get out of bed.”

Blalock, who entered the state prison system in June 2011 after pleading guilty to receiving stolen property in Cobb County, had suffered with hepatitis C for years but was able to control it through medication, according to her brother, Joe Blalock.

Joe Blalock said his sister looked fine when he visited her in the Cobb County jail just before she went to prison. When he saw her in the hospital on the day she died, she was “yellow as a banana,” he said.

“From the time she got (to Emanuel), it was like a snowball rolling downhill,” he said.

In a letter to Blalock’s sister, Lisa Turner wrote that she walked the sick inmate to the medical area after medical personnel failed to respond to written requests for help.

“Well, 20 minutes later, she came back to the dorm with a Band-Aid on the back of her hand, saying they took her blood and called the doctor in Pulaski,” Turner wrote. “… They told her they’d get right back to her. When she told me this, I was furious.”

According to Turner, Blalock was never seen by anyone from the medical staff again until she collapsed the following week, leading to the 911 call.

“I watched your sister suffer for no reason,” Turner wrote. “They could have taken her out before it got to this point.”


`Feel the knot’

 The health of Walker, who was in a different area of the prison, declined similarly, according to family members who visited her.

The Clermont woman, sentenced to eight years in prison in 2009 after pleading guilty to embezzling more than $1 million from her employer, Makita USA, began losing weight in June and soon after started showing more troubling symptoms, family members said.

By July, there was a noticeable swelling in Walker’s face, and in mid-August her abdomen was severely swollen as well, said the inmate’s sister, Linda Hill.

During the August visit, Hill said, Walker asked her to put her hand on Walker’s stomach and “feel the knot.” When Hill returned home, she said, she did an Internet search with her sister’s symptoms. Foremost among the results, she said, was ovarian cancer.

“Anyone with any sense could see (her condition) and know something was wrong,” Hill said.

However, it wasn’t until the onset of vaginal bleeding two weeks later that Walker was transported to Fairview Park Hospital in Dublin, where the cancer was diagnosed.

“Initially, this patient came to us from jail because of abdominal pain, nausea and vomiting that lasted three weeks,” wrote one of the physicians who saw her at Fairview Park. “After three weeks, the patient started having some vaginal bleeds, and that is when the jail started paying attention to her complaints and take them seriously.”

Subsequent tests revealed a mass in Walker’s right breast. Although no biopsy was performed, the mass was suspected to be malignant and likely the origin of the cancer.

Walker’s last mammogram was in October 2009, three months after she entered prison. It found nothing “to suggest the presence of a malignancy.” However, it did note dense tissue in both breasts, a characteristic that can make it harder to identify cancer cells with a mammogram.

Wayne Morris said he understands that, even if his sister had been hospitalized weeks earlier, her death was probably inevitable. Still, he believes those extra weeks could have improved the quality of her life at the end.

“If she could have lived a few more weeks, that would have been so important, just for us to be with her,” he said. “Peggy was always so sorry for the pain she caused. She wanted to make up for it.

“What this did was deny her the chance to be with us long enough to make things right.”

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