'Dying in the dark': Investigation finds 'astronomical' death rate in Maricopa County jails

Debra Ruiz said her son Alex Chavez was the backbone of her family. At age 32, he was a son, a brother and a surrogate father figure. He was a protector who wasn't afraid to play Barbies with his niece.

"He had the biggest heart," she said. "But he was a typical human — and we all have flaws."

Chavez struggled with drug addiction. He was arrested on Aug. 5, 2022, for charges related to shoplifting and possession of drugs and weapons. A week later, he was dead.

Struggling with severe withdrawal symptoms, Chavez acquired 250 fentanyl pills while in Maricopa County's Lower Buckeye Jail. He attempted to take his own life by snorting seven of the pills and was taken to a hospital.

Upon his recovery and return to the jail, Chavez was given a suicide prevention pamphlet and put back in the general population rather than being placed on suicide watch.

"How could you just hand him a flyer and send him back to his cell when you know how much pain he's in?" Ruiz wondered. "These people dropped the ball on so many levels."

A day later, while Chavez was left unattended in a cell for more than an hour, he attempted suicide again, this time by hanging. He was taken to the hospital again. This time, seven days after his arrest, he died from his injuries.

Chavez was among a record number of suicides in Maricopa County's jails in 2022, but he wasn't included in the official tally because he was released from custody a day before he died in the hospital.

Forty-three people are known to have died in the Maricopa County jail system that year. More than one-quarter of those deaths were suicides. Forty-three more people died in the jails in 2023.

A review by The Arizona Republic of Maricopa County's in-custody jail deaths from 2019 through 2023, the most recent year available, found that the death rate was among the highest of major jail systems in the country.

Scholars who study in-custody deaths in U.S. jails and prisons said those numbers are incredibly high when compared with similarly sized jail systems and even jails with much larger populations. “Astronomical,” in the words of one researcher.

Drug overdoses, drug withdrawals and suicides were among the leading causes of death.

The Maricopa County Sheriff's Office said it was working to bring the death rate down, and a representative for the county's Board of Supervisors suggested the opioid epidemic was a contributing factor, pointing to an overall increase in drug-related deaths in the county. In the past five years, one-third of the deaths "are natural as the detainee population has become older and sicker," according to a county spokesperson.

Maricopa County's jails remain understaffed, according to the current and former Sheriff's Office administrations, which has hindered operations and challenged efforts to maintain safe conditions.

Researchers say it is difficult to get an accurate picture of in-custody deaths nationwide because data reporting practices for in-custody deaths vary from place to place. Plus, they say, the federal government is failing its mandate to identify trends in the data to prevent more deaths, keeping the public in the dark.

Federal law directs state and local agencies to report in-custody deaths to a commission that collects the data for the federal government. The numbers the Sheriff's Office initially provided to The Republic were much higher than those it had reported to the federal government via the commission. After inquiries from The Republic, the Maricopa County Sheriff's Office revised the number of deaths it had reported for the past five years.

The Republic verified and supplemented the death data from the Sheriff’s Office with information from the Maricopa County Examiner’s Office, reviewing more than 50 medical examiner reports of people who died while in Maricopa County jail custody in 2022 and 2023 and talking to several of the families of the deceased. In that review process, The Republic found five people who died in the county jails that the Sheriff's Office did not disclose.

The family of Remon Yohannes believes a mistake by jail staff cost him his life.

Yohannes had been writhing in his bunk at the Fourth Avenue Jail in downtown Phoenix all night, getting up only to vomit in the toilet. On the morning of Oct. 14, 2023, he told Maricopa County jail staff that he was extremely thirsty.

Yohannes had been in jail before, and officials had access to his medical history. Despite knowing Yohannes was a Type 1 diabetic, and although he was showing signs of diabetic ketoacidosis, medical staff gave him Gatorade instead of insulin.

He was taken to the hospital and died the next day.

Yohannes had been picked up by police and booked into jail on suspicion of drug use — a misdemeanor offense — two days before he died. His family says his brief time in the Maricopa County jail system should not have become a death sentence.

Edmon Yohannes said the loss of his younger brother devastated their family.

“He cared deeply about helping those in need and finding the humanity in everyone," Edmon Yohannes said.

After reviewing his brother's medical information, Edmon Yohannes said he found the jail's treatment to be abhorrent.

The Yohannes family is suing the county, claiming gross negligence resulted in Remon Yohannes' death.

Attorney Sean Woods, who is representing the families of Chavez and Yohannes, said both cases are tragic and represent a pattern of wrongful deaths in the Maricopa County jails.

“The systemic issues surrounding inhumane living conditions, lack of access to reasonable medical care and flagrant issues with apathetic staff members permeate the jails,” Woods said. “We believe that the Maricopa County Sheriff’s Office failed Alex and Remon, and their failures ultimately led to their deaths.”

Debra Ruiz said her family's case is not just about Alex's death.

"I want justice, and I want change," Ruiz said. "Because we're not the only family — we're not the only ones that are hurting from our loss. And it's such a big loss."

Sheriff Russ Skinner said his office is taking proactive steps to address deaths in the jail.

“MCSO, in partnership with Correctional Health Services, work closely to monitor our jail facilities as well as review each incident involving attempted overdoses and attempted suicides, including those that result in the death of an inmate,” Skinner said in a statement.

“In addition to the recent projects implemented involving training, scanners, prevention services through our tablet program, and narcotic K-9s in our jail facilities, we are working to enhance additional services through the use of medical monitoring technology,” the sheriff said. “We will remain vigilant and proactive in the effort to connect inmates to needed services and prevention programs."

Former Sheriff Paul Penzone, who presided over the jails as deaths rose, did not respond to requests for comment through his employer. Penzone stepped down as sheriff in January, a year before the end of his term, to become chief community relations officer for Blue Cross Blue Shield of Arizona, and Skinner was appointed to replace him.

In Maricopa County, jail deaths soar as jail population declines

Deaths have skyrocketed in Maricopa County jails in recent years, even while the average daily population has decreased.

The number of deaths in the Maricopa County jails nearly quadrupled in three years.

In 2019, there were 11 deaths in the jails. In 2022 and 2023, there were 43 deaths each year.

The average daily population was 6,829 in 2019. Like most jail systems, Maricopa County's jails saw their population decrease during the pandemic to an average daily population of 5,433 in 2020. The numbers have steadily risen since then but have still not reached pre-pandemic levels. The average daily population in 2023 was 6,569.

The federal Bureau of Justice Statistics determines jail death rates by dividing the number of deaths in a jail system by the average daily population of that jail system.

In 2019, the most recent year the bureau calculated jail mortality, there was an average of 167 deaths per 100,000 inmates in county jails in America.

The death rate in Maricopa County jails in 2019 was 161 per 100,000, slightly lower than the national average. But that rate quadrupled in just three years to 678 in 2022.

With 43 deaths in 2023 and a population of around 6,569, the most recent death rate for the Maricopa County jails was 654 deaths per 100,000 inmates.

In 2024, the Sheriff’s Office has only posted jail deaths for January and February. According to the department, there was one death in January and two deaths in February.

The Maricopa County Sheriff's Office operates five jails, as well as an intake, transfer and release facility.

More deaths in Maricopa County than jail systems twice as large

The death rate for Maricopa County jails in 2023 was twice as high as jails with similar populations, as well as jail systems with much larger populations.

Los Angeles County jails, which house more than twice the population of the Maricopa County jails, recorded 45 deaths in 2023, according to reporting by the Los Angeles Times. That means Maricopa County’s jail death rate for the same year was nearly twice as high.

Sixteen people died last year in the jail for Cook County, Illinois, which includes metro Chicago. The average daily population of the Cook County Jail was roughly 6,000, giving the facility a death rate of less than half that of Maricopa County's jails.

New York City’s largest jail, Rikers Island, houses almost as many inmates as the entire Maricopa County jail system at around 6,000. When that jail saw 19 deaths in 2022, the most in a decade, the city faced nationwide calls to shut down the facility. Maricopa County jails recorded twice as many deaths that year.

The Harris County jail in Texas, with an average daily population of more than 9,000, saw 27 deaths in 2022. That jail serves metro Houston.

Researchers said the death numbers in those systems pale in comparison to the high number of deaths in the Maricopa County jail system. Pima County, which has a smaller jail population than Maricopa County, also had a high death rate in 2022, according to a recent investigation by the Tucson Sentinel. Twelve people died in Pima County jails that year, making that system's death rate about 657 per 100,000 people.

“The number of deaths is shockingly high,” said Aaron Littman, assistant professor at the UCLA School of Law, about Maricopa County's jail death rate. “I think it's striking that it's gone up substantially from the first year of the pandemic when mortality directly caused by COVID infection was at its highest in 2020 and 2021.”

Andrea Armstrong, a professor at the Loyola University New Orleans College of Law, was equally alarmed by the numbers.

“I feel confident in saying the mortality rate in Maricopa County jails is astronomical," Armstrong said.

She said the sustained increase in Maricopa County jail deaths from 2019-23 was concerning.

“In some cases, in some jails, we do sometimes see a spike in deaths, but then it comes back down,” she said. “In Maricopa County, the deaths have been exponentially increasing each year.”

Armstrong said deaths are a signifier of larger issues in a jail system.

“They’re the tip of the iceberg,” she said. “But you have to know about them, and you have to analyze them to learn what’s needed to prevent people from dying while they’re waiting on a trial.”

Jay Aronson, a professor at Carnegie Mellon University who recently co-authored a book on deaths in custody, said the steep increase in deaths in the Maricopa County jails seemed almost impossible to believe.

“I can’t tell you exactly what’s going on, but there are a hell of a lot of people dying,” Aronson said.

Based on the causes of death provided by the jails and medical examiner, Aronson said he would advise the county to review its policies for drug withdrawal treatment and suicide prevention.

“The raw number of deaths and the suicides are really, really high,” Aronson said. “And the mortality rate is significantly higher than the national average.”

Main causes of death in Maricopa County jails include overdose, suicide

Death in the Maricopa County jails comes in many forms.

The autopsy reports of incarcerated people who died in 2023 describe malnourished bodies that suffered from a litany of health problems while living.

Stark narratives tell of young men in their 20s found hanging from their bunks with white bedsheets.

They often die alone, but some lie down and die in the middle of a cell full of people.

The reports detail seemingly preventable tragedies, like a man who died after falling over in his wheelchair, fracturing his leg, having his leg amputated and succumbing to “complications.”

Many have heart attacks and aneurysms, which are sometimes brought on by drug use.

Several died while withdrawing from opioids. There were three homicides from 2019 through 2023.

The leading cause of death in recent years has been accidental drug overdoses, followed by what the jail calls “natural causes” and suicide.

Drug-related deaths on the rise in Maricopa County jails

Maricopa County Sheriff’s Office officials have acknowledged it's a struggle to keep drugs out of the jails.

In 2023, there was a significant spike in the number of people incarcerated within Maricopa County jails who had to be rushed to the hospital for suspected overdoses or other drug-related issues.

In January of that year, Penzone announced that the Sheriff's Office would purchase and install body scanners in its jails and screen anyone — including correctional staff — who entered the jail.

That announcement came after the Sheriff's Office arrested a correctional officer who was accused of attempting to smuggle fentanyl and methamphetamine into the Lower Buckeye Jail in exchange for cash.

Those scanners have detected no drugs on employees since they were installed, according to the Sheriff’s Office.

“The scanners for employees and all other people entering the jails went live in August 2023,” said Sheriff’s Office communications director Norma Gutierrez. “These scanners are operational on a random basis at each of our jails. Since implementing these scanners, no drugs have been found on employees or others trying to enter the jail.”

A review of medical examiner reports about 2023 jail deaths found many instances where incarcerated people had indicated they were experiencing opioid withdrawal, and the jail initiated an opioid withdrawal protocol.

The Sheriff's Office said one new standard practice is for the Sheriff’s Office to give anyone suspected of opioid withdrawal an electrolyte drink like Gatorade. But Woods claims this blanket policy had a deadly result for Remon Yohannes, who was given four cups of Gatorade despite experiencing diabetic ketoacidosis, not opioid withdrawal.

“A medical service provider's blanket policy to provide Gatorade without reviewing the medical history of an individual puts all Type 1 diabetics in peril and can cause serious injury or even death,” Woods said.

According to the Maricopa County and Correctional Health Services, the health care provider for the jails, 39% of the deaths in county jails over the past five years were drug-related.

Maricopa County spokesperson Fields Moseley said Arizona’s climate has also been a factor.

“Drug use — particularly methamphetamines — makes it difficult for the body to regulate temperature,” Moseley said. “Detainees often arrive at our jails dehydrated and suffering from the effects of withdrawal. (Maricopa County and Correctional Health Services) reports 67% arrive and require a priority health assessment, meaning they are in distress.”

The county cited other efforts that have been taken to reduce withdrawal and overdose deaths. The jail system is now using medication to help with withdrawal. It also is increasing medical staff education and training to monitor withdrawal symptoms better.

Armstrong said jail systems across the country are dealing with an increase in deaths related to substance abuse and withdrawals. She said the trend raises larger questions — like whether people should be detoxing in a hospital instead of a jail — as well as why individual jails are failing to properly monitor and treat the people in their custody.

Suicides account for one-quarter of deaths in 2022

The number of suicides in Maricopa County's jails has increased dramatically in the past few years, to 11 in 2022 from three in 2019. The Sheriff’s Office reported seven suicides in 2023, but records from the county medical examiner show there were at least eight.

Littman, at the UCLA School of Law, said the number of suicides in the Maricopa County jails was alarming.

“Obviously, it has some relationship to the level of desperation people feel while they’re incarcerated and the conditions that they're being held in,” Littman said. “But it also has to do with administration and staffing, and whether there are enough eyes on people to prevent suicides.”

Samuel Fagan was just 20 years old when he died by hanging himself — a day after he was booked into jail in Maricopa County — on April 13, 2023. The medical examiner's report said he was in a single cell and was last seen walking out of view of the security camera.

Armstrong said many of the suicides she has documented in Louisana were also by hanging, which she pointed out is a method that takes a significant amount of time.

“You have to be able to tie the bedsheet in a particular way. You need to be able to loop it around a fixture, which can then hold weight. And then even once the person is in progress, it takes a moment for that to be completed,” Armstrong said. “And for all of that to be done without observation is really troubling. Especially in a jail where you assume that there is more robust supervision and monitoring, at least by video cameras, if not by actual people.”

In response, Moseley, the county spokesperson, pointed to a suicide prevention initiative that began during the Penzone administration.

Moseley said security and medical staff members are paying coordinated attention to self-harm attempts, new suicide prevention training has been provided for Sheriff’s Office recruits and health care providers who work in the jails, and the county has added suicide prevention information to inmate tablets.

Feds stopped comparing jail deaths, leaving ad hoc system for analysis

The Death in Custody Reporting Act requires states to report deaths that occurred while in the custody of a jail or prison to the U.S. attorney general. However, the way the federal government collects and analyzes that data has changed in recent years.

Scholars say those changes have made it difficult to monitor trends and analyze data. They are trying their best to fill the gap.

Armstrong and other researchers across the country have formed a vanguard seeking out and analyzing death in custody data amid the federal government's information vacuum.

She created Incarceration Transparency, an online database tracking in-custody deaths in Louisiana.

Littman is the deputy director of the UCLA Law Behind Bars Data Project, which began as an effort to collect and analyze public information about the coronavirus pandemic in prisons and jails in the U.S. They now collect carceral mortality data.

According to a spokesperson for the U.S. Department of Justice’s Office of Justice Programs, the Bureau of Justice Statistics stopped collecting mortality data in state and local correctional facilities after 2019. Since then, the Bureau of Justice Assistance has administered the collection of the data.

State departments of corrections and local jails now report their death in custody information quarterly to centralized state agencies, which compile and submit this data to the Bureau of Justice Assistance in accordance with the Death in Custody Reporting Act, according to the spokesperson.

Arizona law enforcement agencies and state prisons report their in-custody death data to the Arizona Criminal Justice Commission.

Since the change in 2019, the Justice Department has not been able to compare jail mortality rates across the country, as the U.S. attorney general outlined in a report from 2022. An Office of Justice Programs report from 2023 stated in-custody deaths, including deaths in jails, are widely underreported across the country.

A Justice Department spokesperson said the agency is no longer able to make comparisons between jail systems, and the agency declined to comment on the number of jail deaths in Maricopa County.

“The fact that they can't comment on trends in the data, or comparisons in the data, is pretty remarkable,” Littman said of the Justice Department. “It totally eviscerates their ability to do a second key component of what’s required, which is to understand the data and help jurisdictions use it to reduce deaths in custody.”

Littman said the federal government's failure to properly collect and analyze death in custody data means incarcerated people are “dying in the dark.”

“How can we even begin to discuss preventive measures when we don’t have the most fundamental information like how many people are dying, who are they and why did they die?” Littman asked.

Littman said the main limitation of comparing mortality rates between jail systems is that they are not age-adjusted, meaning they do not take into account whether the average age of one system’s population is greater than another.

“But even acknowledging that caveat, there seems to be something else going on in Maricopa County because the numbers for 2022 and 2023 are really, really striking,” Littman said.

While acknowledging the lack of recent comparative data from the federal government, Armstrong said the rate of more than 600 deaths per 100,000 people in Maricopa County jails is “a completely different level of crisis” than what is usually found in the data.

Aronson, the Carnegie Mellon professor, also lamented the lack of current federal data on jail mortality.

“It's very difficult to contextualize it because it's just a bunch of individual people who really care with limited resources doing their best to collect the data, either without the support of local officials or in opposition to the efforts of local officials trying to cover up what's going on,” he said. “And so, it's really very challenging.”

Investigation prompts Sheriff's Office to revise jail death reporting

The Republic began this investigation by requesting the total numbers, identities and causes of death for everyone who died in the custody of the Maricopa County Sheriff's Office from 2019 to 2023. The information was cross-referenced with public lists the Sheriff's Office maintained on its website and with reports from the county Medical Examiner's Office. If a cause of death listed by the Sheriff's Office was different from the cause of death provided by the medical examiner, The Republic went with the classification from the medical examiner.

The numbers the Sheriff's Office provided to The Republic were much higher than those it had reported to the Arizona Criminal Justice Commission over the same time period. The commission's numbers were posted on its public website and commission officials updated those numbers in May, after The Republic first contacted them.

After The Republic called the commission's attention to the dramatic rise in deaths, the commission took down its public website and reached out to the Sheriff's Office for clarification on its reporting of jail deaths.

Commission spokesperson Molly Edwards acknowledged the Sheriff's Office's underreported in-custody deaths. After the commission communicated with the Sheriff's Office, Edwards said, the Sheriff's Office revised its reporting and provided new in-custody death figures that were more closely in line with the information the Sheriff's Office provided The Republic.

Sheriff's Office spokesperson Calbert Gillett said his agency had only been reporting "patrol-related in-custody deaths" to the commission.

In 2019, that meant seven deaths went unreported to the commission. In 2020, 17 deaths went unreported. In 2021, it was 24.

Following The Republic's inquiries, the Sheriff's Office began working with the commission to update the data for several past years to reflect both jail and patrol-related deaths, Gillett said. The commission's website has been restored and updated.

Littman said the requirement of reporting all deaths of people in custody to the federal government has been consistent for years.

"The dramatic underreporting of jail deaths in 2019-2021 is very concerning," he said.

In addition to the Sheriff's Office underreporting deaths to the commission, the Sheriff's Office provided The Republic with an incomplete list of people who died in Maricopa County jails in 2023. Through medical examiner records, The Republic identified five additional people who died in the county's jails that year. The Sheriff's Office updated its records after The Republic provided notice of the missing people, Gillett said.

'People need to know what’s going on in there'

Jail records say Jordan Pondexter died of natural causes. But his mother said there was nothing natural about a 19-year-old dying after four days in custody.

Pondexter had been in the Maricopa County jail before, and his records indicated he was an opioid user, at risk from life-threatening drug withdrawal symptoms.

But when he was booked into jail on Sept. 17, 2021, officials failed to properly screen him, according to a legal complaint. Over the next few days, Pondexter complained of vomiting, stomach problems, fatigue and dehydration. On Sept. 21, medical staff gave Pondexter half a liter of water to drink, but it was too late. He slumped forward in a chair at the jail infirmary. Pondexter was taken to a hospital and pronounced dead.

The medical examiner found Pondexter died of sudden cardiac death “in the setting of dehydration.”

While the county did not admit fault, it settled a civil suit with the Pondexter family for $600,000 in March. Maricopa County spokesperson Fields Moseley said Pondexter’s death was a tragedy.

“Maricopa County and its Board of Supervisors hope this settlement allows his mother and other family members to move forward,” Moseley said. “The County will continue to analyze and improve processes related to healthcare in its complex jail system.”

Pondexter's mother, Angie Hursey, was skeptical.

“It’s going to take a whole lot more than words to make this situation better,” she said. “It’s just heartbreaking to me. I hope that things change, but I don’t know. I don’t know.”

“People need to know what’s going on in there,” Hursey said of the jails. “My son didn't deserve to die, but my hope is that by telling his story, someone else’s child can be saved.”

Have a news tip about the Maricopa County Sheriff’s Office? Reach the reporter at [email protected] or 812-243-5582. Follow him on X, formerly known as Twitter, @JimmyJenkins.

This article originally appeared on Arizona Republic: Investigation finds 'astronomical' death rate in Maricopa County jails