Misdiagnosed and ignored: How preventable deaths sparked a takeover of Arizona's prison healthcare

PHOENIX - Help is available. If you or someone you know is struggling or in crisis, call or text 988. The 988 Suicide and Crisis Lifeline provides free and confidential emotional support 24 hours a day, 7 days a week to civilians and veterans. Support in Spanish is also available. You can also chat with crisis counselors via online chat.

CLICK HERE for the warning signs and risk factors of suicide.

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Sarah Harbeke served four years at the Perryville women’s prison for various crimes including drug violations, shoplifting and forgery. Since her release in 2021, she has completely changed her life for the better.

While she takes accountability for her past, she says the state needs to be held accountable for how healthcare was handled on the inside.

What they're saying:

"Take some TYLENOL or ibuprofen, drink some water, and go walk the track," she said. "That was the most typical responses for medical."

Executive Director of Middle Ground Prison Reform Donna Hamm agrees that when inmates report symptoms, often times they are not evaluated correctly.

"And they don't get those tests, they get TYLENOL, and then you end up down the road with someone with stage three or stage four cancer," she said.

In February, federal judge Roslyn Silver handed down a scathing 83-page order. She wrote that while appointing a receiver is an extraordinary measure, after 14 years of eighth amendment violations within Arizona’s prison healthcare system, she had no choice but to strip control away from ADCRR.

"That is a rare order, and it's rare because it's a last-ditch effort, and that's where we are with the department of corrections under the current director," Hamm said.

On May 16th, Harbeke was a witness to a suicide response. She was visiting a friend at Perryville Prison in Goodyear and says she watched medical staff run through the yard—only to be slowed down by a locked gate and plastic chairs blocking the walkway that ultimately leads to the Santa Cruz housing unit.

"Those chairs were set up, the nursing staff tripped over them, and by the time he realized that the gate was locked when he got there, he screamed, ‘Why the f--- are these gates locked?’ And medical was hindered because DOC staff was taking their time fixing chairs and getting to the gates to unlock it." she said.

That day, a 34-year-old Crystal Walker died after hanging herself in her cell. A spokesperson for ADCRR says staff "immediately responded and conducted life-saving measures" until paramedics arrived. Walker had been in custody since November 2025, on drug convictions.

FOX 10 asked the agency if she had a known history of self-harm or mental illness, and we are still waiting for a response.

Harbeke says that, according to other inmates, Walker went to the chaplain’s office that same day to talk to someone, but no one was available.

"It’s a frightening zoo to go into because of the way that the department is just unskilled," she explained. "They don't really have the training or the expertise to deal with people who are mentally ill. And of course, that ends up being to the detriment of someone who, in particular cases like this, has suicidal ideation and is going to follow through."

Judge Silver’s order highlighted eight deaths that court-appointed monitors called "preventable."

Dig deeper:

They say the incidents were likely avoidable if ADCRR had complied with a permanent injunction to increase salaries and fix critical medical staffing shortages.

Court records outline the alleged egregious failures. Among them – a 48-year-old man whose metastatic lung and brain cancer was misdiagnosed as depression.

"Just getting diagnosed with a problem is an uphill battle for people because they're reporting symptoms, and they're being ignored or downplayed," Hamm said. "And finally, when they ultimately get a diagnosis, it's often an advanced stage of cancer or something that could have been prevented or easily dealt with a lot sooner."

A 35-year-old man who complained of a cough was seen by a nurse and had a low oxygen level. Instead of getting tested, he was given over-the-counter medication. Days later, he was found "almost gray" – and died of severe pneumonia due to a nine-day delay in care.

And a 78-year-old man died after a prolonged seizure. Court documents show the facility’s medical director abruptly cut off his anti-seizure medication without ever reviewing his medical history of having seizures.

"Unfortunately, these are not anecdotal examples. These are representative of the profound failures in the care system," said Corene Kendrick.

Kendrick is one of the attorneys fighting the department of corrections in court. She serves as deputy director of the ACLU’s national prison project.

"It's a pretty rarely done step in litigation, and courts only do it when they're dealing with a defendant who just refuses to abide by the court's past orders," she said.

We asked ADCRR Director Ryan Thornell if he wanted to speak about the incoming receivership. We did not get a response.

Judge Silver criticized the state’s leadership for playing a game of "accountability hot potato" by deflecting responsibility to NaphCare, the private healthcare vendor contracted to treat inmates. 

By the end of 2024, 100 contracted positions had not been filled, but Silver says ADCRR appeared to want praise for only having a hundred vacancies. Just months before that, a court monitor’s investigation into a cluster of suicides revealed major deficiencies in mental healthcare delivery.

"I feel like if you’re a ward of state, and you are in a facility where security is prioritized, you should never have the opportunity to commit suicide," Harbeke said.

Harbeke points to a friend she met during her time at Perryville Prison – Tracie Otero died by apparent suicide in September 2020. Harbeke says she explicitly remembers otero begging for treatment before her death.

"She also was having issues with medical staff. She had complained about her pain. She was in severe pain," said Harbeke. "The medical provider at the time had told her she was just a drug addict."

Judge Silver has nominated Annette Chambers-Smith to take over the prison health care system as the receiver. Both the ACLU and the state support the pick. Once official, she will have the authority to renegotiate contracts and implement permanent policy changes.

Chambers-Smith recently stepped down as director of Ohio’s department of rehabilitation and correction.

Arizona’s department of corrections noted Chambers-Smith’s work to resolve a 2003 federal class-action lawsuit regarding correctional healthcare in Ohio, reaching a five-year settlement – implementing major reforms in medical staffing, training and chronic care.

"What they said was that she is very savvy, very smart, and turned around a broken healthcare system in the Ohio prison system," said Kendrick.

Harbeke is hopeful for real change and improvement... so that those serving time can get their constitutional right to adequate healthcare.

"Just because you are locked in a prison with an ADC number, doesn’t mean you’re not a human being," she said.

The ACLU is now asking the court to fast-track Chambers—Smith’s appointment. The goal is to get her to the jump into the process of negotiating the prison system’s 2027 fiscal year budget, which will be approved by June 30th.

Help is available. If you or someone you know is struggling or in crisis, call or text 988. The 988 Suicide and Crisis Lifeline provides free and confidential emotional support 24 hours a day, 7 days a week to civilians and veterans. Support in Spanish is also available. You can also chat with crisis counselors via online chat.

CLICK HERE for the warning signs and risk factors of suicide.

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