In the 23 days Dezaree Archuleta was booked in the El Paso County jail, she made 16 cries for help. Her medical record was riddled with threats of suicide, hallucinations and serious acts of self-harm.
Despite her pleas, medical staff at the jail took her off suicide watch. She told a doctor, again, that she had constant suicidal thoughts. Less than two hours later, the 18-year-old died by hanging herself in her cell.
If medical staff at the El Paso County jail had not ignored Archuleta’s “almost constant” pleas for help in 2022, she would still be alive, her mother alleged in a federal lawsuit filed Monday against the jail’s former medical provider, Wellpath.
Archuleta’s risk and need for help was so obvious to staff and other inmates inside the jail that several El Paso County deputies openly questioned Wellpath officials’ choices to remove her from suicide watch and documented Wellpath employee, Edward Keaveny’s “callous decision-making” in official reports during the jail’s investigation into her death, the lawsuit stated.
“I feel like they failed completely. They failed her,” Shelly Romero told The Colorado Sun in an interview about her daughter’s death. “That was their one job.”
Romero is calling for change in the way jails address the mental health needs for those struggling behind bars. Wellpath, the largest prison health care contractor in the country, serves about 300,000 patients in at least 34 states.
“I believe in second and third chances. I know that jail is a place you go when you do things wrong,” Romero said. “But I believe that Dezaree would have thrived in life, I know she would have. I just want some change.”
The lawsuit, filed in U.S. District Court for the District of Colorado, marks the latest claim of substandard care by for-profit health care contractor Wellpath of Nashville, Tennessee. The company, formerly known as Correct Care Solutions, has repeatedly fallen under scrutiny for claims of negligence and inadequate medical care in El Paso County and has a history of lawsuits in multiple states over complaints about a lack of mental health care, dying of thirst and withholding prescription medicine.
The suit names three mental health workers who worked at Wellpath at the time of Archuleta’s death, including a psychologist who oversaw all mental health services, including training mental health service providers and establishing procedures.
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El Paso County relied on the controversial correctional health care company for more than two decades, for three years as Wellpath and many more under its former name, before cutting ties with the company at the start of the year.
During Wellpath’s tenure there between 2020 and 2023, at least 15 people died at the jail, according to the lawsuit. Nine, including Archuleta, died in 2022.
The county signed a contract Jan. 1 with VitalCore Health Strategies “to better serve those in custody” at the jail, Sheriff Joe Roybal said in a recorded statement posted to his office’s YouTube page.
Roybal said he and his staff intentionally chose Topeka, Kan.-based VitalCore to ensure “the best available medical contractor within the walls of the jail,” which houses about 1,200 people on average each day.
A spokesperson from Wellpath did not return a request for comment on the lawsuit. A spokesperson from the El Paso County Sheriff’s Office declined to comment, but cited the county’s $1 million settlement with Archuleta’s estate .
“I figured she was protected in there”
Archuleta was a “people pleaser” and always caring for others, her mother said, but as her mental health plummeted, her daughter began to struggle.
“She made sure that I knew that she loved me every day,” Romero said. “She was very affectionate — she was very appreciative of everything.”
By the time she was booked into the El Paso County jail in May 2022, the 18-year-old had attempted suicide twice and was diagnosed with several mental health disorders, including major depressive disorder and post-traumatic stress disorder while she was institutionalized in a state-run treatment facility.
At an intake screening, she told jail staff that she wanted to kill herself and had recently tried to hurt herself, records provided by Romero’s attorneys show.
Wellpath officials did not request her medical records from the facility, where she was prescribed antidepressants and was being monitored every four minutes because of her serious mental health issues, the lawsuit stated.
Her pleas to Wellpath’s medical staff were consistent and obvious during her 23 days in jail, the lawsuit stated, citing an instance when a deputy found her naked in her cell with about 30 deep and dark-red two-inch cuts running down her thighs. Archuleta said used a screw from a light fixture.
Another time, after Archuleta asked to see a psychiatrist and be prescribed medicine, therapist Keaveny gave her pamphlets and told her to “use her coping skills.” A deputy later found her naked again, punching herself in the mouth. She didn’t stop until several deputies came into her cell and put her in a restraint chair.
Despite staff identifying serious risk factors for suicide, she wasn’t placed under the intense monitoring that Archuleta’s mother believes could have saved her daughter.
Placing her in a single cell without the monitoring provided by suicide watch was dangerous, the lawsuit said, because it allowed for her to go unobserved for long periods of time. If she had a cellmate, some risk of suicide may have been decreased because her cellmate could report any suicide attempts.
When on suicide watch, incarcerated people must wear “turtle suits,” which are designed to restrict a person’s movement and prevent them from attempting suicide. Instead, she was dressed in normal inmate attire, which posed a risk for its potential to be used in suicide attempts.
Romero said she tried to visit her daughter while she was in jail, but her scheduled visits were often canceled.
In her final phone call with her daughter, a day before she died, Romero remembered her daughter sounding like she was “giving up.”
“She told me that she couldn’t handle it. It was too hard,” Romero said. “You don’t ever expect that to happen, and I figured she was protected in there.”
Less than two hours after telling a Wellpath therapist she wanted to kill herself, a guard found her dead in her cell. She had used a piece of her jumpsuit to kill herself, the lawsuit stated.
An inmate who was housed about two cells down from Archuleta told staff that Wellpath officials knew she was suicidal every day she was in jail and that before she died, staff at the jail “constantly talked” about how suicidal she was, the lawsuit stated.
Romero is asking for an unspecified amount of money to compensate for her daughter’s death and a formal apology from the defendants and more training for Wellpath staff.
“But it’s beyond that,” she said. “It’s about not having another family have to go through what me and my family have to go through.”
A trail of lawsuits
For decades, Wellpath and other for-profit jail health care companies have been subject to intense scrutiny and accused of placing profit over patients.
Criminal justice experts and county sheriff’s often argue the hectic environment of jails, coupled with staffing shortages, often make it difficult for local jails to provide quality care to an underserved population.
Still, the care for those suffering behind bars often falls short, advocates say.
Last December, Wellpath came under fire by a group of Democratic lawmakers who said the cost-cutting measures and chronic understaffing have placed inmate’s lives in danger.
In a 12-page letter to Wellpath executives, U.S. Sen. Elizabeth Warren, D-Massachusetts, and other lawmakers wrote that their “deep concern” stems from federal investigations, press reports and accounts by incarcerated people alleging Wellpath’s negligent care.
Prior to its merger with Wellpath, Correct Care Solutions had been the subject of nearly 1,400 federal lawsuits. From 2014 until 2019, Wellpath and its predecessor companies were sued for causing more than 70 deaths.
In a 2021 Department of Justice report about the San Luis Obispo County jail in California, investigators said Wellpath and its staff “appear not to take seriously” prisoner’s medical concerns and seemed to discourage follow-up mental health care. It noted that the company’s health services administrator used a popular meme from the television show “Downton Abbey” to mock prisoners’ concerns as “whining” during a presentation made to jail leadership.
The DOJ also found that when inmates are released from suicide watch, Wellpath customarily conducted follow-up using licensed marriage and family therapists rather than psychiatrists and that there was customarily no structured suicide assessment performed by these officials.
The senators asked for detailed information about the company’s contracts, deaths in custody, complaints about care, and procedures, including how they respond to suicide attempts.