LANSING – Deaths in Michigan prisons spiked in 2018 to the highest rate in at least 25 years.

And a Free Press investigation, using Michigan's Freedom of Information Act, found the Michigan Department of Corrections has not accurately or consistently tracked the number of prison deaths, as required by the U.S. Justice Department, and no longer counts all prison deaths in an annual report sent to the Legislature, which alarms groups advocating for prisoners and their families.

The 135 state prison deaths reported to the federal government for 2018 was the highest number reported since 2009, when 148 Michigan prisoners died. But the state prison population has shrunk by nearly 7,000 inmates since then. The rate of Michigan prison deaths in 2018 surpassed 2009 and was the highest since at least 1994, based on state records and reports sent to the U.S. Department of Justice.

Nowhere was the increase in deaths more pronounced than at Michigan's only women's prison, the crowded Women's Huron Valley Correctional Facility near Ypsilanti, where there were 10 prisoner deaths in 2018 — more than double the number reported there in any year since 2010.

A Free Press investigation found:

The 2018 Michigan prison death rate of 348 deaths per 100,000 prisoners surpassed the 2009 rate of 325 deaths per 100,000 prisoners — the previous high since at least 1994, based on available records. Nationwide, the state prison death rate was 256 per 100,000 prisoners between 2001 and 2014, according to the Bureau of Justice Statistics.

The 2018 death rate at Women's Huron Valley, which was experiencing a yearlong and undiagnosed scabies outbreak documented by the Free Press, was 483 per 100,000 prisoners, or 89% higher than the national prison death rate.

was 483 per 100,000 prisoners, or 89% higher than the national prison death rate. State lawmakers would have no way of knowing about the surge in Michigan prison deaths. The department's 2018 annual statistical report, which prison officials said will report 135 deaths, had not been published on the department's website as of Wednesday. And in February 2016, the department unilaterally, and without notifying lawmakers, changed the long-standing definition of a "critical incident" to exclude deaths that prison officials deem to be the result of terminal illnesses.

And in February 2016, the department unilaterally, and without notifying lawmakers, changed the long-standing definition of a "critical incident" to exclude deaths that prison officials deem to be the result of terminal illnesses. Critical incidents, which until 2016 included all deaths, along with assaults, injuries, escape attempts, and major events such as a fire or a furnace failure, generate detailed reporting and under state law must be counted, categorized, and communicated to the Legislature. The most recent annual report on critical incidents, submitted to the Legislature March 1, referenced only 44 prison deaths statewide in 2018, of which five were at the women's prison. The report did not explain that the definition of a critical incident had changed, though the change was added to a long list of policy directives on the department's website.

The department has not accurately tracked prison deaths. Spokesman Chris Gautz told the Free Press in a late October email there had been five 2018 deaths at Women's Huron Valley, but records the Free Press obtained under FOIA show there had already been nine deaths at that time. The department created one of those records three days after it received the March 2019 FOIA request, despite the fact the woman died in May 2018. On Wednesday, Gautz confirmed a 10th death at the women's prison in 2018.

The department acknowledged Wednesday that errors resulted in incorrect death counts in its annual statistical reports for the years 2013 through 2017, which were posted on the department's website. From 2009 through 2012, the annual death count in the statistical report matched the number of deaths sent to the U.S. Justice Department, as required by federal law. But since then, the two numbers have varied each year by as many as eight deaths, with the state sometimes reporting a lower number to the federal government than it recorded in state records, while other times giving the federal government a higher death number than the state kept. The department investigated after the discrepancies were pointed out by the Free Press. "The numbers reported to the DOJ are correct," and the state numbers are in error, Gautz said Wednesday.

The department, which has been under scrutiny for the quality of both its food and its medical care, had no explanation for the spike in deaths, other than the fact the prison population is getting older.

"Maybe it's an anomaly," said Gautz, who blamed the inaccurate death counts in recent statistical reports on a combination of errors that resulted in some deaths being counted twice and other deaths not being counted at all.

Lois Pullano, the founder of the Corrections Department's family advisory board, said she is "increasingly concerned about the medical and mental health care inside the prison system," and said families need to know about all prison deaths to assess whether investigations are needed.

"These are people's lives, not just the one who passed on, but families impacted out here in our communities, some with children involved," said Pullano, who is also president of the Michigan group Citizens for Prison Reform.

"These families deserve answers."

State Sen. Sylvia Santana, D-Detroit, said she wants all prison deaths reported to the Legislature, regardless of the cause, as a way of ensuring oversight of both Corrections Department managers and the way the department's health care contractor are performing.

The department's errors in counting deaths are "very concerning," Santana said Thursday. "They really need to make sure those numbers are in line. There shouldn't be that much of a discrepancy."

Two federal lawsuits have already been filed in connection with the scabies outbreak at the women's prison, and at least two other attorneys said they are exploring health conditions there.

Aging population

Gautz pointed to an aging prison population, among both male and female inmates, and an apparent increase in cancer, cardiac and respiratory-related deaths.

Some of those deaths, such as deaths from cancer, still have to be counted in reports to the U.S. Justice Department and in the department's annual statistical report, but are no longer being included in the reports on critical incidents sent to the Michigan Legislature.

The department says the proportion of its inmates who are 60 or older grew from 2.8% at the end of 2003 to 8.1% at the end of 2017, while the proportion of inmates between 50 and 59 grew from 9% to 15.1% during that time.

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But those numbers don't explain why the death rate would spike in 2018, rather than edge up gradually. Based on death numbers reported to the Justice Department, the death rate remained relatively constant between 2003 and 2010, at around 260 deaths per 100,000 prisoners.

Gautz said there were 42 cancer deaths in 2018, almost as many as the 48 cancer deaths in 2016 and 2017 combined. He said there were 32 cardiac deaths in 2018, compared with an average of 12 the previous two years, and 20 respiratory deaths, compared with only 10 respiratory deaths in the previous two years combined.

He had no explanation for the one-year spike in cancer, cardiac and respiratory deaths, other than the gradually aging prison population.

"One year does not a trend make," Gautz said.

"To us, all death is tragic, and while we have fewer prisoners than a decade ago, the prisoners that remain with us are now older and sicker."

Gautz rejected questions about whether the spike in deaths could be related to problems with either the prison's food or its health care.

"Food service would have nothing to do with someone dying in prison," and "the same would be true for the health care contract," he said.

The department returned state employees to the prison kitchens late in 2018. That ended a nearly five-year experiment with privatized food service, which was marked by widespread problems with food quality and sanitation, as well as problems with kitchen employees smuggling contraband and getting overly familiar with prisoners.

Tennessee-based Corizon Health Inc., the company that holds a five-year, $715.7-million prison health contract with the state, was fined $360,000 for various contract infractions in 2018, including $246,000 for problems related to timeliness of care, records show.

A Corizon nurse must see routine referrals within five business days and urgent referrals within one business day, Gautz said. Fines are assessed when those deadlines are missed.

Counting errors

Gautz blamed department errors for inconsistencies among death numbers the department has reported to the federal Bureau of Justice Statistics and those it has compiled in its own annual statistical report.

During the three-year period from 2010 through 2012, the two sets of numbers matched. But there has been wide variance since then.

In 2015, for example, the department reported 118 deaths to the federal government, and 110 deaths in its annual statistical report. In 2016, the numbers were 106 in the federal report and 111 in the state report.

Gautz said the reports submitted to the federal government in recent years are accurate and the numbers included in the department's annual statistical reports are not. Certain deaths were counted twice in some years and in other years, deaths of prisoners who had been sent to a hospital were not counted, when they should have been, he said.

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To calculate the prison death rate, the Free Press used the year-end prison population and death numbers Michigan submitted to the federal government beginning in 2001, when the Death in Custody Reporting Act took effect. Prior to 2001, the Free Press used the death number from the department's annual statistical report.

The federal government gives detailed instructions on state prison death reporting, telling departments to include all prisoner deaths, including prisoners who die while being treated in a hospital or while in transit, but to exclude prisoners in county jails, on parole or probation, in federal prison, or being held in state prison in another state.

The number in the state statistical report should mirror the federal report and will do so from now on, Gautz said.

Historically, the Corrections Department also prepared a multi-page critical incident report for all prison deaths, including when prisoners die in a hospital.

But starting in early 2016, the department stopped writing critical incident reports in cases where "the death is expected due to a terminal illness," regardless of whether the death occurred inside a prison or in a hospital, records show. This was to cut down on paperwork and interviews, Gautz said.

From then until July 2018, Gautz said, no public report was required for what was likely dozens of Michigan prison deaths deemed "expected due to a terminal illness," except for a one-page "certificate of discharge" that includes only the prisoner's name, number and the date of discharge by reason of "death while under sentence."

In July 2018, the department altered its policy to create an "incident report" — not one that must be counted and reported to the Legislature — for each expected death due to terminal illness.

"It's a good change," Gautz said. "If there is no report at all, people can speculate."

Women's prison

Michigan's only women's prison had 10 deaths last year, the highest number since 2010, when it reported seven deaths.

Gautz said six of the 10 women's prison deaths in 2018 were due to cancer.

In 2017, 4.8% of female prisoners were 60 or older, and 15.1% were age 50 to 59, records show. By comparison, those percentages in 2010 were 1.3% and 11.5% respectively.

At Women's Huron Valley, the Free Press has reported that storage rooms and day rooms have been converted into cells because of a lack of available space, and that hundreds of women suffered from scabies for extended periods in 2017 and 2018 after the department and its contracted health care provider, Corizon, failed to accurately diagnose the mite infection.

The prison also has a history of leaking roofs, and prisoners have given repeated and consistent accounts of water dripping from ceilings and mold in the shower areas and other areas, which some prisoners have said inmates were instructed to cover with paint. The department says leaky roofs were repaired and has repeatedly denied there is mold in the prison.

Detroit attorney David Steingold said he, along with the law firms Pitt McGehee and Ernst & Marko, has been researching and gathering evidence on the scabies and mold issues.

"There is mold throughout this facility," Steingold said after a Tuesday visit to the women's prison. "It's been there since it opened" and "they know it," he said of prison officials. Steingold believes some of the deaths are related to mold allergies and "neglect and inadequate health care."

University of Michigan professor Carol Jacobsen, who works with female inmates and parolees as director of the Michigan Women's Justice & Clemency Project, said she wasn't aware of the change in the department's classification of "critical incidents," and she's concerned about it.

"Of course, any death in prison should be considered a critical incident, because many of the deaths, from my experience, in the women's prison, are suspicious," said Jacobsen.

Jacobsen wrote to Gov. Gretchen Whitmer and other officials in January, complaining about reports of mold and unsanitary conditions at the prison, as well as "breathing problems, coughing, terrible rashes, bleeding" and "an epidemic of deaths and injuries."

Jacobsen's letter was sent to the internal affairs unit of the Corrections Department for an investigation.

Gautz said the department looked into "every single claim" in Jacobsen's letter, and while he can't disclose the results of internal affairs investigations, he said the letter contained numerous factual errors and Jacobsen did not respond to requests for follow-up information.

To say "without any proof or documentation ... these women died because of 'oozing black mold' is disgusting and hurtful to the families of these women," Gautz said.

On Oct. 24, the Free Press emailed Gautz and asked: "Can you please tell me how many prisoner deaths (both natural and unnatural) there have been at WHV so far in the 2018 calendar year?"

Gautz responded that there had been five deaths. Records later obtained by the Free Press show that there had been at least nine 2018 women's prison deaths by then. On Wednesday, Gautz confirmed a 10th women's prison death occurred on Sept. 21, 2018. Only five of the 10 deaths generated critical incident reports.

"That might have been something I got from the warden," Gautz said when asked about the inaccurate death tally he provided. "Maybe he just pulled the critical (incident report) number."

Only after submitting a March 9 FOIA request asking for records documenting under what circumstances four specific women — whose names were supplied by Jacobsen — left the prison, was the Free Press able to confirm four additional deaths.

One of the records the department sent was a one-page report showing Toni Cato Riggs died, and was therefore recorded as being "discharged" from prison, at age 49, on May 25, 2018. The report was dated March 12 of this year — three days after the department received the Free Press FOIA request by email.

The one-page discharge report gives no information on cause of death. Gautz said Wednesday that Riggs died from cancer.

Gautz said the documentation of Riggs' death was not created sooner through an apparent oversight. He said he couldn't be sure, but it appeared the FOIA request prompted the creation of the record.

The family of another woman who died at the prison in 2018, Donna DeBruin, has retained Southfield civil rights attorney Heather Glazer, who has obtained medical records and is investigating the circumstances of the 60-year-old's death.

Glazer told the Free Press she wants to know whether DeBruin's constitutional rights to adequate medical treatment were violated.

Contact Paul Egan: 517-372-8660 or pegan@freepress.com. Follow him on Twitter @paulegan4. Read more on Michigan politics and sign up for our elections newsletter.