This company promised to improve health care in jails. Dozens of its patients have died.

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NORMAN, Oklahoma — Two days after Thanksgiving in 2022, Shannon Hanchett walked into an AT&T store for a new phone, and ended up in handcuffs.

Hanchett ran the Cookie Cottage, a popular bakery in this college town, where she made treats named for places across the state, from Stilwell Strawberry to Lawton Lemon. But lately, her mental health seemed to be fraying. She was falling behind on orders. Her marriage was crumbling. And the 38-year-old mother of two had picked fights with family and friends.

It all detonated that day in the AT&T store. Employees phoned police after Hanchett began pacing, ranting and calling 911. Body camera footage shows an officer from the Norman Police Department talking to her for several minutes, then tackling, handcuffing and arresting her for misusing the emergency line.

Like so many people experiencing mental health crises in the U.S., Hanchett landed not in a psychiatric hospital, but in a county jail. In her case, it was Norman’s Cleveland County Detention Center, which contracts with a for-profit company to provide medical care: Turn Key Health Clinics.

And for Hanchett, that’s where things got even worse.

As local jails have morphed into some of the largest mental health treatment facilities in the U.S., many counties have outsourced medical care to private companies that promise to contain rising costs. Turn Key is one of the fastest growing in the middle of the country.

At least 50 people who were under Turn Key’s care died during the past decade, an investigation by The Marshall Project and The Frontier found. Our reporting unearthed company policies and practices that have endangered people in jail — especially those with mental illness.

In dozens of cases, Turn Key employees didn’t send people to the hospital when they were in crisis, catatonic or refusing to eat or drink. The company staffed mental health and other medical positions with low-level nursing assistants trained to perform basic tasks like taking vital signs, but not to diagnose or assess medical conditions.

Medical doctors and more advanced-level nurses working for Turn Key frequently consulted over the phone for a limited number of hours per week instead of making in-person visits, according to government records and documents obtained through lawsuits.

Until last year, the company often restricted the kinds of medicines it would provide people in jail, not giving them long-acting psychiatric drugs and prescriptions they had received before their arrests.

We obtained records from sheriffs who raised concerns about the company not providing the proper medications for people in jail with mental illness. “I have been told that Turn Key does not prescribe those types of medications,” one Texas sheriff wrote in a 2022 email. “This is causing a cascade of problems not only for their safety and well-being, but for the staff and facility as well.”

Turn Key officials declined interview requests for this story. In response to written questions, the company issued a statement from its medical director, Dr. William Cooper: “Turn Key’s goal is to provide the highest level of care pursuant to the client’s budget. … The company continues to expand because of the quality of the care provided.” He added that Turn Key is “constantly working to build on the quality of care it provides.”

To examine the company’s practices, we obtained records, including internal documents and emails between company leaders and public officials, in nearly 70 counties across Oklahoma, Texas, Arkansas, Louisiana, Colorado, Kansas and Montana. We also reviewed more than 100 lawsuits involving jail deaths and injuries. Many were dismissed for not meeting legal hurdles required for civil rights lawsuits: Plaintiffs must prove that the company wasn’t just negligent, but showed “deliberate indifference” to patients’ medical needs, among other requirements. Some suits resulted in settlements, many of which were confidential, and nearly two dozen suits remain pending.

A woman in Colorado died after a bag of drugs she’d hidden in her body burst, while a Turn Key nurse allegedly dismissed her symptoms and refused to call an ambulance. A man in Arkansas died after medical staff didn’t give him medication to prevent deadly symptoms of alcohol withdrawal and didn’t call an ambulance until he became unresponsive. Another man in Arkansas died after medical records show he wasn’t given the seizure medication he needed, and he was strapped to a restraint chair and covered with a spit hood.

Turn Key declined to respond to questions concerning these incidents.

Medical care in jails can be complicated and costly, said Dr. Anne Spaulding, founder of the Center for the Health of Incarcerated Persons at Emory University in Atlanta. Most people in jails are there awaiting trial, and many arrive with complex needs — some are in drug withdrawal or experiencing mental health crises; others need expensive treatments such as HIV drugs, insulin or dialysis.

Jail operators have a constitutional obligation to supply necessary medical care, whatever the illness, she said. “When you lock the door of a jail or prison cell, you are preventing the person from going out and seeking health care elsewhere,” she said. “So you have to provide it.”

But there are no national standards for what constitutes necessary medical treatment in jail, and federal courts are split over what level of care is adequate, especially for people awaiting trial. Close to half of people in jail have received a diagnosis of a major mental illness, according to government data last compiled in 2017, and two-thirds suffer from substance abuse. Women, the fastest-growing group of people in jails, have even higher rates of mental health and addiction problems.

Some, like Hanchett, have undiagnosed psychiatric issues and were arrested after public episodes. It took 10 days after she was put in jail before a doctor consulted on Hanchett’s care. Turn Key’s primary psychiatrist prescribed antipsychotic pills and noted Hanchett didn’t respond to questions. Medical staff recorded her symptoms as “severe — having a marked impact on the inmate’s ability to function satisfactorily in the current outpatient setting.”

By then she had been lying on the floor of an empty cell for days, mostly naked, dehydrated and in deep psychosis, records show. The licensed practical nurse at the jail consulted with an off-site Turn Key nurse practitioner, who said to give Hanchett some Gatorade, according to jail records. Her pulse was weakening, her blood pressure dropping — she couldn’t stand up or dress herself.

A nurse reported hearing Hanchett saying: “They are going to kill me.”

Short-staffed

As the population of people it treated in jails doubled over a span of six years to more than 20,000, records show Turn Key had four doctors, three psychiatrists and 10 nurse practitioners on staff. Some oversaw care at multiple jails in different states.

Turn Key has staffed its jails with mostly licensed practical nurses or certified medical assistants, according to depositions and internal documents. These workers can get licensed with a year or less of schooling and are trained to perform basic tasks like checking pulse rates, not to assess medical conditions. In 2020, a contract monitor for the Tulsa County Sheriff’s Office complained in an email that the company was using low-level personnel to fill the role of mental health technicians, which raised “questions if inmates are truly being serviced accordingly.” The sheriff’s office declined to comment for this story.

In its statement, Turn Key said it “maintains an on-call team that has doctors, nurses, and mental healthcare providers who are available 24 hours a day, every day of the year.”

But in many of the cases we examined, the on-the-ground workers failed to recognize severe health problems, and did not seek counsel from doctors and more senior nurses who consulted remotely.

The outcomes were sometimes fatal, as in the case of Marconia Kessee. He lived in and out of hotel rooms and struggled with severe mental illness, said his uncle, Michael Washington. In 2018, Kessee went to a hospital for help and ended up in jail in Norman. Police body camera video shows Kessee stumbling and falling after officers ordered him to walk across the street to a homeless shelter — so the officers arrested him for trespassing.

At the county jail, a licensed practical nurse working for Turn Key did not recognize that Kessee was overdosing on methamphetamine and prescription drugs, instead accusing him of faking symptoms that included seizures, according to a lawsuit filed by his family. The nurse and jailers left Kessee alone in a cell.

Within two hours, he was dead of an overdose. He was 35.

In response to the lawsuit, the nurse said he hadn’t been trained on overdoses and wasn’t qualified to determine if someone was experiencing one. Turn Key’s medical director agreed — and conceded that without such knowledge, the nurse was unlikely to ask a higher-up for help.

In a confidential agreement, Turn Key settled the case for an undisclosed amount last year. The company did not respond to questions about Kessee’s death.

Building an empire

From the beginning, Turn Key has asserted that it can provide quality care to people in jails at a lower cost.

The week after Cleveland County Sheriff Joe Lester took office in 2009, a bookkeeper brought him a stack of unpaid bills from the local hospital and health clinics. It added up to about $1 million in medical debt for treating jail detainees, Lester said later in a court deposition. The department’s total budget for the year was half-spent, and the sheriff’s office was getting collection calls.

“When somebody goes to the hospital, whether it’s a headache or what, it’s a big expense,” Lester said.

Hospitalizations also strain jail staffing because a deputy often remains with the detainee until they return to jail.

Lester reached out to Jon Echols, who ran a company that provided health care personnel to local nursing homes. The county awarded his company a contract to provide 24-hour nursing personnel at the jail.

The company finished the first three months of the contract under budget and sent just one person to the hospital by ambulance, Echols told county officials in 2009, according to a local newspaper report. He and his business partners formed the company that would become Turn Key Health Clinics.

Echols won a seat in the Oklahoma House of Representatives in 2012. A Republican, he now serves as House majority floor leader. In March, we asked Turn Key corporate leaders for an interview, including Echols, who was still listed as the company’s president and founder. He did not respond, but his title and photo have since been removed from the company’s website. His most recent financial disclosure, filed in May with the Oklahoma Ethics Commission, shows he retained a “non-controlling minority ownership interest” in the company, and received a salary through 2023.

Turn Key has since expanded into a multimillion-dollar company with contracts to provide medical care for more than 75 jails — and 23,000 people — in 10 states.

At first, most of the jails where Turn Key operated were lockups in small counties. But in 2016, the company won its largest contract, in Tulsa, after the local sheriff changed the bidding requirements, allowing the company to qualify. At the time, Echols told The Frontier: “I wanted a fair opportunity. … There’s no doubt that I asked that we be able to bid.” Turn Key promised to cover up to $500,000 a year in outside medical costs, including hospitalizations; the county would pay for anything over that amount.

Turn Key later boasted to prospective clients that it reduced emergency transfers in Tulsa by 77% and the number of days prisoners spent in the hospital by 35% within a few months.

The company went on to get the contract for the troubled county jail in Oklahoma City, the state’s largest, on similar terms.

In its statement, Turn Key’s medical director said the company tries to reduce medical costs by providing treatment before emergency care is required. The company added that it “rarely, if ever,” reduces staffing when it wins a new contract.

Deadly decisions

Christa Sullivan was jailed in Oklahoma City in 2020 after she suffered delusions, heard voices and attacked her husband with a knife. It was the first time the 64-year-old grandmother and military wife had ever been incarcerated.

She told the jail staff she had been diagnosed with anxiety, schizophrenia, insomnia, a heart condition, high cholesterol, hypertension and fatty liver disease, records show. She reported a history of suicide attempts and hallucinations. She had been prescribed medicines, including the anti-anxiety drug Ativan.

Sullivan was put on the lengthy state waitlist for people who need treatment because they aren’t competent to stand trial. Turn Key was in charge of her care while she waited.

Within a few days of her arrest, Sullivan tried to kill herself by cutting her wrists, records show. She went on to attempt suicide numerous times, trying to drown herself in a toilet and to strangle herself with an adult diaper.

Sullivan repeatedly asked for Ativan, the drug she’d been taking before jail. She was told it wasn’t on Turn Key’s approved list, known as a formulary, according to her medical records.

In its statement, the company said it monitors Ativan and other “controlled substances that are addictive and prone to abuse and use as illicit currency in a correctional setting,” and added that access to those medications is “closely moderated.”

Sullivan had been in jail for more than six months when she confronted a doctor about her access to Ativan in January 2021. He wrote in his notes: “As I approach her cell, I see she is walking around naked. Not currently screaming. I greet her and she tells me ‘You lied to me. You have Ativan here. A nurse told me.’ I advise her again that Ativan is not on the psychiatric formulary.”

Instead, records show, doctors at the jail injected her multiple times with the antipsychotic Haldol, which was on the company’s list of approved drugs.

Sullivan was often in deep psychosis, records show. She developed pressure sores from lying naked on the floor. Medical exams noted she was “at extremely high risk for complications including sudden death.”

But she wasn’t taken to a hospital for nearly a year. Then, twice in one week, she was sent to the emergency room to be treated for dehydration, kidney issues and injuries to her head and back — and then promptly returned to jail. After Sullivan’s return, a doctor noted that she was showing severe signs of “failure to thrive, at high risk for poor outcome.” Medical records note she’d lost almost 30 pounds since her initial booking, and that she was allergic to Haldol — the drug Turn Key had been injecting her with. A psychiatrist finally prescribed her Ativan on March 25, 2021, records show.

On April 13, 2021, she was found dead in her cell. The medical examiner labeled her cause of death “undetermined.” An investigation by the Oklahoma State Department of Health found the jail did not provide Sullivan adequate care, in violation of state standards. A spokeswoman for the Health Department said it referred the case to the local district attorney’s office for criminal investigation. No one was charged.

A spokesperson for the Oklahoma County district attorney’s office said that Sullivan’s death happened under a previous administration, and the office didn’t have records about the decision to not file charges.

A lawsuit filed by Sullivan’s family alleges Turn Key repeatedly showed “deliberate indifference” to her condition and refused to transfer her to a hospital because the company didn’t want to bear the cost for treatment. Turn Key has denied the allegations and contended in its response to the lawsuit that Sullivan’s treatment was “reasonable and within the applicable standards of care.” The case is scheduled for trial next year.

After a suicide inside the Oklahoma County Detention Center in December 2021, the same psychiatrist who’d treated Sullivan, Dr. Gabriel Cuka, emailed an entreaty to local public defenders, giving them a list of 18 “inmates who need inpatient psychiatric stabilization that exceeds the capacity” of the jail, records show.

“Basically, these individuals need forced long acting injectable antipsychotic agents,” he wrote in an email. “I am not saying that these inmates are incompetent in the Oklahoma legal sense of the term. These inmates are very ill and in some cases dying.”

Cuka no longer works for Turn Key and is a defendant in the Sullivan family’s lawsuit. He declined to comment. In court filings, Cuka has denied allegations that he under-prescribed any medication or that Sullivan’s mental health worsened under his care.

Similar problems cropped up at other jails served by Turn Key. An evaluation completed by mental health experts for the jails in Smith County, Texas, noted that detainees couldn’t get long-acting injectable antipsychotic drugs and the formulary limited access to drugs they had been prescribed before being jailed.

A sheriff’s department email we obtained shows Smith County waited weeks in early 2023 to get orders for forced medication for people with severe mental illness because the company’s primary psychiatrist was out of the office. At least one person died by suicide in the jail during that time period, records show.

Jason Weger, the sheriff of Eastland County, Texas, who wrote a 2022 email raising concerns about access to medications, told a local mental health authority: “I am growing more and more concerned about the inmates not receiving the proper medical attention they need. Especially when it comes to the mental health people we are housing.”

Weger declined to comment.

Turn Key didn’t respond to questions about the emails from Smith and Eastland counties, but the company said it always has staff available.

In mid-2023, The Marshall Project and The Frontier obtained a copy of Turn Key’s formulary list after being denied copies numerous times via open records requests. Around that same time, the company stopped using it, records show. Dr. Jason Beaman, a forensic psychiatrist at Oklahoma State University who reviewed the formulary, told us it was missing a key drug for people with schizophrenia as well as many newer, more expensive long-acting injectable antipsychotic drugs.

When Eusebio Castillo Rodriguez was locked up in the Union County, Arkansas, jail on a DWI charge in June 2022, his documented symptoms of alcohol withdrawal — a common problem in jails — went untreated for more than five days, according to a lawsuit filed by his family. Most treatment protocols include a prescription for a medication to prevent deadly seizures or alcohol withdrawal delirium. Instead, a Turn Key doctor consulting over the phone prescribed a blood pressure drug, records show.

The family’s lawyer hired Dr. Thomas Fowlkes, a correctional medicine specialist who frequently testifies on behalf of jail health care contractors, to review Rodriguez’s treatment. In his report, he wrote that Turn Key’s protocols and treatment were “far below the standard of care.”

When Rodriguez’s condition became dire, jail medical staff first attempted to transport him to a local hospital in a deputy’s car, records show — an ambulance was called after he became unresponsive. The hospital life-flighted him to a larger hospital in Little Rock, where he died days later, records show.

Fowlkes wrote: The jail staff “intended for Mr. Rodriguez to be merely dumped off at the hospital with no apparent concern for his wellbeing and without taking any responsibility for the serious medical condition which developed directly as a result of their lack of medical care.”

Cost and consequences

In some of the larger counties where Turn Key had contracts, our analysis of financial data showed jails paid for additional charges for things such as COVID-19 tests and sensors designed to improve health monitoring.

Counties also paid for lab tests and prescription drugs when those costs were excluded from the contracts or exceeded a threshold. In Smith County, Texas, over the three-year period we examined, the jail paid an additional $1 million to Turn Key beyond the amount for base medical services — largely due to payments for certain medications. The company said in its statement that counties never paid more than the contract required.

The company cultivated close relationships with law enforcement. At conferences in Arkansas, Texas, Kansas and Colorado, Turn Key raffled off hunting gear including crossbows and knives to sheriffs and deputies, according to social media posts. It treated clients to steak dinners and delivered packages of smoked bacon for Christmas, according to emails we obtained.

Private equity firms have taken an interest in Turn Key’s growth: Gladstone Capital Corporation invested $11 million in the company in 2021 through secured loans, records show. The Dallas-based private equity group Trive Capital acquired a majority stake in Turn Key by 2019, according to court filings and interviews. Neither firm responded to requests for comment.

The company said in bid documents that its revenue grew an average of 87% a year between 2014 and 2019. But as Turn Key has grown, so has the number of lawsuits alleging its care led to deaths and injuries.

In July 2023, a federal judge in Colorado denied the company’s request to dismiss a lawsuit that accused a Turn Key nurse at a jail north of Denver of refusing to call an ambulance for a woman she believed was “acting a fool.” In fact, Amy Lynn Cross was foaming at the mouth before she died of drug toxicity.

Turn Key canceled its contract with Weld County last December.

In bids submitted to officials in Larimer County in northern Colorado in 2022, Turn Key officials said the company had settled only 13 lawsuits, most of them “for nuisance value and for strategic benefit to our clients … a record we are willing to put up against any of our competitors.”

The company did not answer questions about ongoing lawsuits or settlements. In its statement, the medical director said the company “trusts in its front-line healthcare providers, it values input from its correctional partners, and Turn Key investigates sentinel events and incorporates lessons learned to improve outcomes.”

But several jails have ended their contracts with Turn Key over its level of care. Garfield County, Colorado, did so in June 2023 after Sheriff Lou Vallario said he determined the company wasn’t providing enough nurses and mental health staffing.

Ouachita County, in southern Arkansas, ended its contract with Turn Key after just six months, in part because the company wasn’t providing many in-person visits from medical providers, said Robert McAdoo, the county executive.

In September 2023, officials in Smith County, Texas, also opted not to renew Turn Key’s contract. Instead, the jail will use a local hospital system for medical and psychiatric care.

It will cost more money, but having in-person visits from a psychiatrist to treat people with severe mental illness is worth it, said Neal Franklin, the county’s chief executive.

“I know they’ve actually treated this individual and seen them with their own eyes and talked directly to them,” he said.

The cookie queen

Shannon Hanchett’s friends called her The Cookie Queen. Her small shop in Norman sold out of cookies nearly every day.

Bethney Grove became close with Hanchett through Facebook posts about baking. The first time they met in person, Hanchett surprised Grove with a vintage beehive cookie jar decorated with bumblebees — Grove’s favorite symbol.

“She did everything 1,000% — whether it was laugh, tell a joke, get mad, advocate for something,” Grove said.

She said she had assumed that after the post-Thanksgiving encounter with police, Hanchett had been taken to a hospital or psychiatric facility — not locked in jail.

Hanchett’s family said they didn’t want to post her $1,000 bond because they feared that if she were released without treatment, she might hurt herself or someone else.

Four days after her arrest, her uncle, a lawyer, wrote a letter asking a county judge to issue an emergency order to transfer her to a local hospital.

“As a family we are extremely concerned about Shannon staying in jail with her current mental health issues that will continue to worsen without treatment,” Michael Schade wrote. A hearing on her case was still two weeks away.

Shortly after midnight on Dec. 8, Hanchett was found dead in her cell. The mental health evaluation Hanchett’s family had pleaded for was scheduled to take place eight hours after her lifeless body was discovered.

According to an autopsy, Hanchett’s death was caused by complications from a heart defect, with contributing factors including psychosis “with auditory and visual hallucinations” and dehydration.

In January, her widower, Daniel Hanchett, sued Turn Key and Cleveland County on behalf of his sons.

“She was a very loving mother and the boys were her biggest priority in life,” he said.

Turn Key has asked a judge to dismiss the case. In its filings, lawyers for Turn Key and its employees wrote that the case did not meet an evidentiary hurdle showing “an unnecessary and wanton infliction of pain” or that it was “repugnant to the conscience of mankind.”

As in the case of Marconia Kessee, Shannon Hanchett’s jail cell was video monitored. The footage remains under a protective order in federal court, so it is not public. But her family’s lawyer, Daniel Smolen, said she was locked in a cell with no sink, bed or toilet for more than a week.

“When they finally removed her from her cell, they found her naked and so dehydrated that she couldn’t even stand. Instead of calling an ambulance, they dragged her limp, naked body by the arms down a long, concrete floor,” he said. Hours before Hanchett died, Smolen said, nurses didn’t provide her adequate care. “Instead, they mocked and laughed at her.”

Records show three months after Hanchett’s death, Cleveland County renewed Turn Key’s contract.

This article was published in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system, and The Frontier. Sign up for The Marshall Project’s newsletters, and follow them on Instagram, TikTok, Reddit and Facebook.

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