a Better Bubble™
Every year, the Supreme Court’s nine justices fill out a form that discloses their financial connections to companies and people. Until now, however, those disclosures and connections haven’t been mapped, aggregated and made searchable. Using our new database, you can now search for organizations and people that have paid the justices, reimbursed them for travel, given them gifts and more.
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The quality of care that residents receive in a nursing home can be profoundly affected by who owns it, studies have shown. It’s not always clear who should be held accountable, though: Many nursing homes are owned by companies that are owned by other companies, obscuring who has the ultimate decision-making power. As more nursing homes are sold, information about an incoming owner’s performance in other homes becomes more relevant, as it may provide insight into how their latest acquisitions will fare.
To help navigate the confusing world of nursing home ownership, ProPublica’s Nursing Home Inspect now publishes detailed ownership information for facilities and an upgraded search to help you sift through the information.
The data comes from the Centers for Medicare & Medicaid Services, which publishes “affiliated entities” for nursing homes — lists of people or companies that have an ownership stake in or operational control over multiple nursing homes. CMS’ goal is to provide a better understanding of an owner or operator’s performance across all the nursing homes they are associated with. Some entities are affiliated with only a handful of homes, while others, like Genesis HealthCare or The Ensign Group, are affiliated with hundreds of homes across multiple states. Because CMS does not provide this data in a way that’s easy for most people to use, we’ve added it to our Nursing Home Inspect tool.
Our new affiliated entity pages allow users to easily explore data on each company or person who is responsible for nursing homes, listing all homes associated with that entity and showing recent serious deficiencies — failure to meet care requirements — found at those homes. You can even view a list of all affiliated entities nationwide.
We also added detailed ownership information to individual nursing home pages, allowing users to see who has an ownership stake in the home, as well as who has managerial control over the facility and how long they have held that position.
To go along with these additions, we’ve also expanded the database’s advanced search capabilities so journalists and others can quickly identify affiliated entities that have a history of serious deficiencies or other problems. For instance, users can search for all serious deficiencies associated with Life Care Centers of America.
Separately, users can also now filter searches by F-tags, which are a system for specifying the types of compliance issues that may be found during a CMS inspection. These tags allow users to narrow their search beyond broad categories such as “infection control deficiencies” to more targeted queries such as deficiencies associated with reporting COVID-19 data to residents and families or ensuring staff are vaccinated against COVID-19.
ProPublica plans to continue enhancing Nursing Home Inspect with new data and features in the coming months. If you write a story using this new information, come across bugs or issues, or have ideas for improvements, please let us know!
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published. This story was co-published with the Tow Center for Digital Journalism at Columbia University.
“My sisters have died,” the young boy sobbed, chest heaving, as he wailed into the sky. “Oh, my sisters.” As Israel began airstrikes on Gaza following the Oct. 7 Hamas terrorist attack, posts by verified accounts on X, the social media platform formerly called Twitter, were being transmitted around the world. The heart-wrenching video of the grieving boy, viewed more than 600,000 times, was posted by an account named “#FreePalestine 🇵🇸.” The account had received X’s “verified” badge just hours before posting the tweet that went viral.
Days later, a video posted by an account calling itself “ISRAEL MOSSAD,” another “verified” account, this time bearing the logo of Israel’s national intelligence agency, claimed to show Israel’s advanced air defense technology. The post, viewed nearly 6 million times, showed a volley of rockets exploding in the night sky with the caption: “The New Iron beam in full display.”
And following an explosion on Oct. 14 outside the Al-Ahli Hospital in Gaza where civilians were killed, the verified account of the Hamas-affiliated news organization Quds News Network posted a screenshot from Facebook claiming to show the Israel Defense Forces declaring their intent to strike the hospital before the explosion. It was seen more than half a million times.
None of these posts depicted real events from the conflict. The video of the grieving boy was from at least nine years ago and was taken in Syria, not Gaza. The clip of rockets exploding was from a military simulation video game. And the Facebook screenshot was from a now-deleted Facebook page not affiliated with Israel or the IDF.
Just days before its viral tweet, the #FreePalestine 🇵🇸 account had a blue verification check under a different name: “Taliban Public Relations Department, Commentary.” It changed its name back after the tweet and was reverified within a week. Despite their blue check badges, neither Taliban Public Relations Department, Commentary nor ISRAEL MOSSAD (now “Mossad Commentary”) have any real-life connection to either organization. Their posts were eventually annotated by Community Notes, X’s crowdsourced fact-checking system, but these clarifications garnered about 900,000 views — less than 15% of what the two viral posts totaled. ISRAEL MOSSAD deleted its post in late November. The Facebook screenshot, posted by the account of the Quds News Network, still doesn’t have a clarifying note. Mossad Commentary and the Quds News Network did not respond to direct messages seeking comment; Taliban Public Relations Department, Commentary did not respond to public mentions asking for comment.
An investigation by ProPublica and Columbia University’s Tow Center for Digital Journalism shows how false claims based on out-of-context, outdated or manipulated media have proliferated on X during the first month of the Israel-Hamas conflict. The organizations looked at over 200 distinct claims that independent fact-checks determined to be misleading, and searched for posts by verified accounts that perpetuated them, identifying 2,000 total tweets. The tweets, collectively viewed half a billion times, were analyzed alongside account and Community Notes data.
ProPublica and Columbia University’s Tow Center for Digital Journalism identified more than 2,000 tweets by verified accounts that contained debunked claims based on out-of-context media. Quds News Network made five of those posts and continues to post about the conflict. Some of its English-language accounts on Facebook and Instagram have been suspended. (Screenshots of X taken and annotated by ProPublica and the Tow Center for Digital Journalism.)The ongoing conflict in Gaza is the biggest test for changes implemented by X owner Elon Musk since his acquisition of Twitter last year. After raising concerns about the power of platforms to determine what speech is appropriate, Musk instituted policies to promote “healthy” debate under the maxim “freedom of speech, not reach,” where certain types of posts that previously would have been removed for violating platform policy now have their visibility restricted.
Within 10 days of taking ownership, Musk cut 15% of Twitter’s trust and safety team. He made further cuts in the following months, including firing the election integrity team, terminating many contracted content moderators and revoking existing misinformation policies on specific topics like COVID-19. In place of these safeguards, Musk expanded Community Notes. The feature, first launched in 2021 as Birdwatch, adds crowdsourced annotations to a tweet when users with diverse perspectives rate them “helpful.”
“The Israel-Hamas war is a classic case of an information crisis on X, in terms of the speed and volume of the misinformation and the harmful consequences of that rhetoric,” said Michael Zimmer, the director of the Center for Data, Ethics, and Society at Marquette University in Wisconsin, who has studied how social media platforms combat misinformation.
While no social media platform is free of misinformation, critics contend that Musk’s policies, along with his personal statements, have led to a proliferation of misinformation and hate speech on X. Advertisers have fled the platform — U.S. ad revenue is down roughly 60% compared to last year. Last week, Musk reinstated the account of Alex Jones, who was ordered to pay $1.1 billion in defamation damages for repeatedly lying about the 2012 Sandy Hook school shooting. Jones appealed the verdict. This week, the European Union opened a formal investigation against X for breaching multiple provisions of the Digital Services Act, including risk management and content moderation, as well as deceptive design in relation to its “so-called Blue checks.”
ProPublica and the Tow Center found that verified blue check accounts that posted misleading media saw their audience grow on X in the first month of the conflict. This included dozens of accounts that posted debunked tweets three or more times and that now have over 100,000 followers each. The false posts appear to violate X’s synthetic and manipulated media policy, which bars all users from sharing media that may deceive or confuse people. Many accounts also appear to breach the eligibility criteria for verification, which state that verified accounts must not be “misleading or deceptive” or engage in “platform manipulation and spam.” Several of the fastest-growing accounts that have posted multiple false claims about the conflict now have more followers than some regional news organizations covering it.
We also found that the Community Notes system, which has been touted by Musk as a way to improve information accuracy on the platform, hasn’t scaled sufficiently. About 80% of the 2,000 debunked posts we reviewed had no Community Note. Of the 200 debunked claims, more than 80 were never clarified with a note.
When clarifying Community Notes did appear, they typically reached a fraction of the views that the original tweet did, though views on Community Notes are significantly undercounted. We also found that in some cases, debunked images or videos were flagged by a Community Note in one tweet but not in others, despite X announcing, partway through the period covered by our dataset, it has improved its media-matching algorithms to address this. For tweets that did receive a Community Note, it typically didn’t become visible until hours after the post.
This last finding expands on a recent report by Bloomberg, which analyzed 400 false posts tagged by Community Notes in the first two weeks after the Oct. 7 attack and found it typically took seven hours for a Community Note to appear.
For the tweets analyzed by ProPublica and the Tow Center, the median time that elapsed before a Community Note became visible decreased to just over five hours in the first week of November after X improved its system. Outliers did exist: Sometimes it still took more than two days for a note to appear, while in other cases, a note appeared almost instantaneously because the tweet used media that the system had already encountered.
Multiple emails sent to X’s press inbox seeking comment on our findings triggered automated replies to “check back later” with no further response. Keith Coleman, who leads the Community Notes team at X, was separately provided with summary findings relevant to Community Notes as well as the dataset containing the compiled claims and tweets.
Via email, Coleman said that the tweets identified in this investigation were a small fraction of those covered by the 1,500 visible Community Notes on X about the conflict from this time period. He also said that many posts with high-visibility notes were deleted after receiving a Community Note, including ones that we did not identify. When asked about the number of claims that did not receive a single note, Coleman said that users might not have thought one was necessary, pointing to examples where images generated by artificial intelligence tools could be interpreted as artistic depictions. AI-generated images accounted for around 7% of the tweets that did not receive a note; none acknowledged that the media was AI-generated. Coleman said that the current system is an upgrade over X’s historic approaches to dealing with misinformation and that it continues to improve; “most importantly,” he said, the Community Notes program “is found helpful by people globally, across the political spectrum.”
Community Notes were initially meant to complement X’s various trust and safety initiatives, not replace them. “It still makes sense for platforms to keep their trust and safety teams in a breaking-news, viral environment. It’s not going to work to simply fling open the gates,” said Mike Ananny, an associate professor of communication and journalism at the University of Southern California, who is skeptical about leaving moderation to the community, particularly after the changes Musk has made.
“I’m not sure any community norm is going to work given all of the signals that have been given about who’s welcome here, what types of opinions are respected and what types of content is allowed,” he said.
ProPublica and the Tow Center compiled a large sample of data from multiple sources to study the effectiveness of Community Notes in labeling debunked claims. We found over 1,300 verified accounts that posted misleading or out-of-context media at least once in the first month of the conflict; 130 accounts did so three or more times. (For more details on how the posts were gathered, see the methodology section at the end of this story.)
Musk overhauled Twitter’s account verification program soon after acquiring the company. Previously, Twitter gave verified badges to politicians, celebrities, news organizations, government agencies and other vetted notable individuals or organizations. Though the legacy process was criticized as opaque and arbitrary, it provided a signal of authenticity for users. Today, accounts receive the once-coveted blue check in exchange for $8 a month and a cursory identity check. Despite well-documented impersonation and credibility issues, these “verified” accounts are prioritized in search, in replies and across X’s algorithmic feeds.
If an account continuously shares harmful or misleading narratives, X’s synthetic and manipulated media policy states that its visibility may be reduced or the account may be locked or suspended. But the investigation found that prominent verified accounts appeared to face few consequences for broadcasting misleading media to their large follower networks. Of the 40 accounts with more than 100,000 followers that posted debunked tweets three times or more in the first month of the conflict, only seven appeared to have had any action taken against them, according to account history data shared with ProPublica and the Tow Center by Travis Brown. Brown is a software developer who researches extremism and misinformation on X.
Those 40 accounts, a number of which have been identified as the most influential accounts engaging in Hamas-Israel discourse, grew their collective audience by nearly 5 million followers, to around 17 million, in the first month of the conflict alone.
A few of the smaller verified accounts in the dataset received punitive action: About 50 accounts that posted at least one false tweet were suspended. On average, these accounts had 7,000 followers. It is unclear whether the accounts were suspended for manipulated media policy violations or for other reasons, such as bot-like behavior. Around 80 accounts no longer have a blue check badge. It is unclear whether the accounts lost their blue checks because they stopped paying, because they had recently changed their display name (which triggers a temporary removal of the verified status), or because Twitter revoked the status. X has said it removed 3,000 accounts by “violent entities,” including Hamas, in the region.
On Oct. 29, X announced a new policy where verified accounts would no longer be eligible to share in revenue earned from ads that appeared alongside any of their posts that had been corrected by Community Notes. In a tweet, Musk said, “the idea is to maximize the incentive for accuracy over sensationalism.” Coleman said that this policy has been implemented, but did not provide further details.
False claims that go viral are frequently repeated by multiple accounts and often take the form of decontextualized old footage. One of the most widespread false claims, that Qatar was threatening to stop supplying natural gas to the world unless Israel halted its airstrikes, was repeated by nearly 70 verified accounts. This claim, which was based on a false description of an unrelated 2017 speech by the Qatari emir to bolster its credibility, received over 15 million views collectively, with a single post by Dominick McGee (@dom_lucre) amassing more than 9 million views. McGee is popular in the QAnon community and is an election denier with nearly 800,000 followers who was suspended from X for sharing child exploitation imagery in July 2023. Shortly after, X reversed the suspension. McGee denied that he had shared the image when reached by direct message on X, claiming instead that it was “an article touching it.”
Community Notes like this one appear alongside many false posts claiming Qatar is threatening to cut off its gas supply to the world. This note was seen more than 400,000 times across 159 posts that shared the same video clip, and it appeared on nine out of nearly 70 posts in our dataset that made this claim. (Screenshot of X taken and annotated by ProPublica and the Tow Center for Digital Journalism.)Another account, using the pseudonym Sprinter, shared the same false claim about Qatar in a post that was viewed over 80,000 times. These were not the only false posts made by either account. McGee shared six debunked claims about the conflict in our dataset; Sprinter shared 20.
Sprinter posted an image of casualties from the Hamas attack on Oct. 7, most of whom were civilians, and purported that it showed Israeli military losses during the ground war later in the month. Another post mistranslated the words of an injured Israeli soldier. (Screenshots of X taken and annotated by ProPublica and the Tow Center for Digital Journalism.)Sprinter has tweeted AI-generated images, digitally altered videos and the unsubstantiated claim that Ukraine is providing weapons to Hamas. Each of these posts has received hundreds of thousands of views. The account’s follower count has increased by 60% to about 500,000, rivaling the following of Haaretz and the Times of Israel on X. Sprinter’s profile — which has also used the pseudonyms SprinterTeam, SprinterX and WizardSX, according to historical account data provided by Brown — was “temporarily restricted” by X in mid-November, but it retained its “verified” status. Sprinter’s original profile linked to a backup account. That account — whose name and verification status continues to change — still posts dozens of times a day and has grown to over 25,000 followers. Sprinter did not respond to a request for comment and blocked the reporter after being contacted. The original account appears to no longer exist.
Verification badges were once a critical signal in sifting official accounts from inauthentic ones. But with X’s overhaul of the blue check program, that signal now essentially tells you whether the account pays $8 a month. ISRAEL MOSSAD, the account that posted video game footage falsely claiming it was an Israeli air defense system, had gone from fewer than 1,000 followers, when it first acquired a blue check in September 2023, to more than 230,000 today. In another debunked post, published the same day as the video game footage, the account claimed to show more of the Iron Beam system. That tweet still doesn’t have a Community Note, despite having nearly 400,000 views. The account briefly lost its blue check within a day of the two tweets being posted, but regained it days after changing its display name to Mossad Commentary. Even though it isn’t affiliated with Israel’s national intelligence agency, it continues to use Mossad’s logo in its profile picture.
“The blue check is flipped now. Instead of a sign of authenticity, it’s a sign of suspicion, at least for those of us who study this enough,” said Zimmer, the Marquette University professor.
Verified Accounts That Shared Misinformation Grew Quickly During the Israel-Hamas ConflictSeveral of the fastest-growing accounts that have posted multiple false claims about the conflict now have more followers than some regional news organizations actively covering it.
(Lucas Waldron/ProPublica)Of the verified accounts we reviewed, the one that grew the fastest during the first month of the Israel-Hamas conflict was also one of the most prolific posters of misleading claims. Jackson Hinkle, a 24-year-old political commentator and self-described “MAGA communist” has built a large following posting highly partisan tweets. He has been suspended from various platforms in the past, pushed pro-Russian narratives and claimed that YouTube permanently suspended his account for “Ukraine misinformation.” Three days later, he tweeted that YouTube had banned him because it didn’t want him telling the truth about the Israel-Hamas conflict. Currently, he has more than two million followers on X; over 1.5 million of those arrived after Oct. 7. ProPublica and the Tow Center found over 20 tweets by Hinkle using misleading or manipulated media in the first month of the conflict; more than half had been tagged with a Community Note. The tweets amassed 40 million views, while the Community Notes were collectively viewed just under 10 million times. Hinkle did not respond to a request for comment.
All told, debunked tweets with a Community Note in the ProPublica-Tow Center dataset amassed 300 million views in aggregate, about five times the total number of views on the notes, even though Community Notes can appear on multiple tweets and collect views from all of them, including from tweets that were not reviewed by the news organizations.
Hinkle misleadingly claimed that China was sending warships in the direction of Israel, even though the ships had been in routine operation in the region since May. Hinkle also posted footage claiming to show Hezbollah’s anti-ship missiles, but the video is from 2019 and not related to the current conflict. (Screenshots of X taken and annotated by ProPublica and the Tow Center for Digital Journalism.)X continues to improve the Community Notes system. It announced updates to the feature on Oct. 24, saying notes are appearing more often on viral and high-visibility content, and are appearing faster in general. But ProPublica and Tow Center’s review found that less than a third of debunked tweets created since the update received a Community Note, though the median time for a note to become visible dropped noticeably, from seven hours to just over five hours in the first week of November. The Community Notes team said over email that their data showed that a note typically took around five hours to become visible in the first few days of the conflict.
Aviv Ovadya, an affiliate at Harvard's Berkman Klein Center For Internet & Society who has worked on social media governance and algorithms similar to the one Community Notes uses, says that any fact-checking process, whether it relies on crowdsourced notes or a third-party fact-checker, is likely to always be playing catch-up to viral claims. “You need to know if the claim is worth even fact-checking,” Ovadya said. “Is it worth my time?” Once a false post is identified, a third-party fact-check may take longer than a Community Note.
Coleman, who leads the Community Notes team, said over email that his team found Community Notes often appeared faster than posts by traditional fact-checkers, and that they are committed to making the notes visible faster.
Our review found that many viral tweets with claims that had been debunked by third-party fact- checkers did not receive a Community Note in the long run. Of the hundreds of tweets in the dataset that gained over 100,000 impressions, only about half had a note. Coleman noted that of those widely viewed tweets, the ones with visible Community Notes attached had nearly twice as many views.
To counter the instances where false claims spread quickly because many accounts post the same misleading media in a short time frame, the company announced in October that it would attach the same Community Note to all posts that share a debunked piece of media. ProPublica and the Tow Center found the system wasn’t always successful.
For example, on and after Oct. 25, multiple accounts tweeted an AI-generated image of a man with five children amid piles of rubble. Community Notes for this image appeared thousands of times on X. However, of the 22 instances we identified in which a verified account tweeted the image, only seven of those were tagged with a Community Note. (One of those tweets was later deleted after garnering more than 200,000 views.)
We found X’s media-matching system to be inconsistent for numerous other claims as well. Coleman pointed to the many automatic matches as a sign that it is working and said that its algorithm prioritizes “high precision” to avoid mistakenly finding matches between pieces of media that are meaningfully different. He also said the Community Notes team plans to further improve its media-matching system.
According to annotations on Community Notes on X that we found, a note for this image was displayed on at least 7,200 posts. We found 22 tweets with this image, but only seven had a Community Note. The second image has been deleted, but not before it garnered more than 200,000 views. (Screenshots of X taken and annotated by ProPublica and the Tow Center for Digital Journalism.)The false claims ProPublica and the Tow Center identified in this analysis were also posted on other platforms, including Instagram and TikTok. On X, having a Community Note added to a post does not affect how it is displayed. Other platforms deprioritize fact-checked posts in their algorithmic feeds to limit their reach. While Ovadya believes that continued investment in Community Notes is important, he says changing X’s core algorithm could be even more impactful.
“If X’s recommendation algorithms were built on the same principles as Community Notes and was actively rewarding content that bridges divides,” he said, “you would have less misinformation and sensationalist content going viral in the first place.”
MethodologyProPublica and Columbia University’s Tow Center for Digital Journalism identified and analyzed more than 2,000 tweets by verified accounts that posted clearly debunked images or videos in the first month of the Israel-Hamas war. The posts, which encompassed more than 200 false claims, were published by more than 1,300 verified accounts and collectively received half a billion impressions. We then looked at Community Notes and account data associated with those tweets.
Since the metrics on tweets, accounts and Community Notes were viewed at various points in time, they may not be current; for example, the status of accounts or Community Notes may have changed and the number of impressions on tweets and notes might be different after the time frame of our analysis.
In this review, we focused on claims that could be unambiguously debunked, including those based on generative AI images that aren’t labeled as such, old pictures and videos presented as current, falsified social media posts and documents, footage from video games described as real events, doctored images and mistranslated videos. To compile our list of debunked claims, we reviewed fact checks from multiple news organizations, including BBC Verify, Logically Facts, two stories from The New York Times, The Associated Press, Agence France-Presse and Reuters. We also identified debunked claims by filtering Community Notes data by relevant keywords (Gaza, Palestine/Palestinian, Israel, IDF, Hamas/Hammas, Mossad, Iron Beam, Iron Dome), and verified the note using independent news organizations or reverse image searches to ensure that each was accurate. We did not include claims that could not be independently verified or that were contested under the fog of war.
We compiled tweets using X’s text search functionality and Google’s reverse image search. Reverse image search was able to identify both images and videos (using a frame from the video). The claims and tweets we compiled are a convenience sample, not an exhaustive survey of all media-based misinformation on X during the first month of the Israel-Hamas war: The dataset relies heavily on images that Google has indexed as well as tweets that use identical or very similar language, which allows X’s search functionality to surface them. Additionally, the accounts mentioned in the story might have tweeted more false claims than those we identified. Tweets deleted prior to our searches are not captured in our dataset. (In its response, X provided us with 18 examples of Community Notes and tweets that were not in our dataset and could not be located because the tweets were not yet indexed by Google or could not be easily found by X’s search function.)
We also analyzed the accounts that were posting these tweets, using account data collected by researcher Travis Brown from July through November 2023. We used this data to determine account status, follower count, handles and usernames.
For Community Notes, we downloaded X’s open-source datasets and filtered by notes with the above-mentioned keywords. A single tweet can have multiple Community Notes and the same note can appear alongside multiple tweets. Our analysis ensured we took both relationships into account.
X’s Community Notes data contains the current status of a note as well as the time at which that status was set. It also includes when the Community Note was created and the note’s text. For some tweets that use repurposed media (i.e. media from a tweet that’s already been debunked by Community Notes) the note appears immediately due to improvements in X’s media-matching algorithm. This means that occasionally the time of creation or visibility of a note will be before the time the tweet was posted.
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Elizabeth Yaboni of the Tow Center for Digital Journalism contributed research.
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. This story was co-published with the USA TODAY NETWORK-Wisconsin.
One dairy farm worker said he was fired and thrown out of the house where he lived after he told his boss his hands were frostbitten from working outside in below-zero weather. Another said it took his supervisors nearly an hour to call an ambulance after he was crushed by a metal gate and left lying on a manure-covered barn floor. A third worker said her boss blamed her and refused to pay her medical bills after she was trampled and thrown over a fence by a bull. And yet another said his supervisor told him not to go to the emergency room after he tore open his finger when he fell trying to catch a runaway calf. He was told to call the veterinarian instead.
These are some of the stories immigrant workers will tell you about getting hurt on Wisconsin dairy farms — and what happened afterward.
Others will say everything is fine — “Just the usual” — until you ask the question five or six ways: Have you been kicked? Has a cow stepped on you? Have you fallen? Did you see blood? Do you have chronic pain in your back, arms or hands? Then, almost inevitably, the answer is yes.
Wisconsin’s celebrated dairy industry would almost certainly collapse without the immigrants who do the dirty, dangerous work that farmers across the state say U.S. citizens won’t. But when these workers get hurt — and they get hurt with such frequency that it’s considered a routine part of the job — the laws are stacked against them.
Many, if not most, of the state’s 5,700 or so dairy farms aren’t required to have workers’ compensation insurance because they have too few employees, while at larger farms the supervisors often brush off workers’ injuries. Employers can fire and evict injured workers almost without consequence. And the threat of being deported factors into any decision workers make to assert the limited rights they do have.
As a result, many workers get no medical care for their injuries, compensation or even time off to recuperate. Instead, they are at the farmer’s mercy and have to brace themselves for the possibility of losing their jobs and the roof over their heads.
“Once you’re no good to them, they get rid of you,” said a worker who was fired and, along with his wife and two children, evicted in November after he developed tendonitis in his hand from repetitive motions at work. “I wouldn’t want anybody else to go through this.”
What we know about the frequency of injuries on dairy farms is widely understood to be an undercount. The U.S. Bureau of Labor Statistics relies on farms to self-report injuries, but it only surveys the largest farms. Wisconsin’s workers’ compensation system offers some insight, showing that just over 170 claims were filed in 2021, the most recent year available, according to the state officials. But that figure excludes injuries that occurred on small farms that don’t have workers’ compensation coverage, and those that were never reported. Often, workers say they are so afraid of losing their jobs that they tell hospital staff their injuries happened at home.
Over the course of the past year, ProPublica has interviewed more than 60 current and former workers who said they suffered injuries on Wisconsin dairy farms. All but a handful of them were undocumented immigrants; the others have work permits. Nearly every one asked not to be fully identified because they fear losing their job or being deported. Most asked that the farms where they got hurt not be named either; they or their relatives continue to work and live on those farms, and they are afraid of retaliation.
Few injuries leave a paper trail. Workers don’t always take photos of their broken legs or smashed teeth or torn-off fingers. Sometimes they don’t even know the name of the farm where they were kicked by a 1,500-pound cow. No medical records exist for injuries that go untreated. Farm owners, meanwhile, don’t consistently report injuries to authorities. Law enforcement records offer a glimpse of the worst farm accidents, but only when somebody calls for an ambulance. That rarely happens.
“It’s almost like people are disposable. And it’s horrific,” said Martha Burke, an employment discrimination and workers’ compensation attorney in Milwaukee. “Employers aren’t supposed to fire you for being injured, but that doesn’t mean it doesn’t happen.”
Excluded from many basic protections that other workers are entitled to, Wisconsin’s immigrant dairy workers are left to fend for themselves. They ask the owners of the nearest Latino-owned grocery store for advice about finding a doctor or a lawyer or even a place to sleep. They buy painkillers one capsule at a time and rub a tingly blue lotion for cow udders on their bruised arms. Most said they work through the pain because they need the paycheck.
Some workers quietly leave their jobs — and Wisconsin altogether — to nurse their wounds with relatives. Some go home to Mexico or Central America.
“It was months of pain,” said a man who dislocated his shoulder when he slipped on a cow’s placenta. “The pain only went away after I left the farm.”
Farmer Andy Lodahl and his wife told their workers to get ready because a storm was coming and they would need to work “a lot of hours” in the cold, wind and snow. “Make sure you all have a lot of warm clothes,” they said they typed into a phone, then translated into Spanish and showed the workers.
It was late December 2022, and Lodahl said he and his wife let the workers end a shift early and gave them an advance on their pay so they could buy winter gear.
Seferino José García, 62, was familiar with Wisconsin’s brutal winters. An immigrant from the Mexican state of Oaxaca, García had worked on dairy farms on and off for about a decade before he was hired about two weeks earlier on this small farm about 45 minutes northwest of Milwaukee. He was one of three workers and, in an arrangement that’s typical on dairy farms, lived in a house on the property.
One morning, García and his co-workers wore thin cotton gloves over latex gloves to do a number of tasks outside, including shoveling snow and feeding calves. García said it was hard to wear gloves at all and maintain his grip. It was below zero with wind gusts of more than 30 miles an hour. García said he felt like the wind was going to carry him away.
Blisters began forming on his hands. At one point, he submerged them in hot water, but that made the blistering worse. Still, he kept working. He finished his first eight-hour shift around 11 a.m. and went back to the house. He said he called the farmers and told them he couldn’t return for his 3 p.m. shift.
“I couldn’t feel my fingers anymore,” García said in an interview. “I couldn’t feel my own body when I touched it.”
The farmers told García he couldn’t take the afternoon off; the cows needed to be milked. But García told his bosses he wasn’t able to work. One of his co-workers couldn’t either; his fingers were frostbitten, too.
Lodahl and his wife told them both to vacate the property immediately. (The third worker also had frostbite but continued working, according to Lodahl.) García grabbed what he could from the house and left.
Most workers we spoke to know somebody who lost their job after an injury or have experienced this themselves. Several also were evicted, including the man who couldn’t use his right hand after he developed tendonitis from the repetitive motions of driving a skid steer. Adding insult to injury: He said his final paychecks bounced, so he’s still owed two weeks of wages.
“I’ve never been treated so badly in all my years working on farms,” said the man, who in mid December was still sleeping in a nephew’s living room along with his wife and two daughters. “Maybe there are laws that protect you, but for people like us, we don’t know where we can turn.”
Most Wisconsin dairy workers are considered at-will employees, which means they can be fired without cause, though employers can’t fire them in retaliation for asserting certain rights such as filing a workers’ compensation claim. Meanwhile, several attorneys said workers’ rights in the face of eviction are gray. Those who can show that there’s a landlord-tenant relationship — if housing costs are deducted from their wages, for example — may get more time to move out. But few workers challenge firings or evictions.
“These folks don’t want problems,” said Gabriel Manzano Nieves, a lawyer who provided García with legal counseling but didn’t file a case. “They don’t want the police called on them. He’s obviously not going to push back too much under those circumstances.”
After he was fired and evicted, García drove to Lupita’s Market & Restaurant in the nearby city of Beaver Dam, where he usually bought his groceries. Meinardo Enriquez, the store owner, said he chided García for not wearing proper gloves. He squeezed the fluid out of some of his blisters to relieve the pain and encouraged García to get medical care.
That night, García slept in the laundromat next door. Before dawn, he headed to South Carolina, where he has a niece. He put a shirt on his lap to catch the blood that dripped from his hands. As he drove, he said he tried to push bad thoughts out of his head and focus on the positive. “I was thinking about my mother. My sisters. My children. My wife,” he said. “Oh, dear Lord, why did this happen to me?”
(Zeke Peña, special to ProPublica)After he arrived in South Carolina, his niece took him to the hospital despite his protests. He was worried about the cost. García returned a few more times to be examined but stopped going in February when he ran out of money.
By April, he said the feeling had started to return to his fingers. He’d lost six of his nails and had been told the rest would fall off, too. He was giving himself physical therapy he’d been taught at the hospital. He wanted to find a job but didn’t know what he could do since his hands didn't work like they used to.
Lodahl, meanwhile, said that losing two workers unexpectedly put him and his wife under immense pressure right before Christmas. It took several days to replace them — days in which the farm owners had to work around the clock with their one remaining worker to keep everything running.
“The cows do not stop making milk because people made the choice to be insubordinate and not have the ability for self-preservation and not show up to work,” he wrote in an email.
Lodahl said he and his wife were justified in firing and evicting García and the other worker for refusing to do their jobs. The workers, they said, were to blame for not wearing better winter gear and getting frostbite.
(Workers who get frostbite and other injuries related to extreme temperatures can pursue workers’ compensation claims, state officials and attorneys said. But Lodahl’s farm didn’t employ enough workers to be required to have coverage.)
Before winter arrived this year, the Lodahls bought heavy gloves for their employees.
On another dairy farm near Milwaukee, a Nicaraguan woman worked for months without seeking medical care for an injury because she didn’t know how she would pay for it.
Carmen, who is 40, said she felt so much pain in her head, back and arms that she could barely think clearly. She said she didn’t know how she got injured but suspected it was related to the repetitive motions of attaching and detaching milking tubes to cow udders hundreds of times a day.
“I couldn’t even walk straight,” she said. But she felt she had “to keep my head down and swallow” the pain because she needed the money.
Carmen, a single mother, makes $12 an hour and works 10 hours a night, six nights a week. In addition to supporting her young daughter and her ailing mother back home, as of November she still owed $13,000 to the person who loaned her money to immigrate to the U.S. last year.
She said she hasn’t told her employer about the injury because she is afraid he will get upset and fire her. Carmen and her daughter live in a house the farm owners provide their workers.
Across the state, dairy workers face a variety of barriers to getting medical care: limited transportation, the challenges of finding someone to fill their shifts and the high cost of medical care without health insurance.
Many workers said their supervisors dismissed their injuries and told them to get back to work, even when they were unable to walk. Among them: a 52-year-old woman who said she was knocked unconscious by a cow two years ago on a large farm in western Wisconsin. When supervisors refused to take her to the hospital, a co-worker drove her, according to the woman and the co-worker.
Later, a doctor said she could return to work, as long as she took frequent breaks. But the farm owner told her he couldn’t accommodate her needs and fired her, she said. Today, the woman can’t work at all, sleeps in a friend’s trailer and relies on a food pantry. She walks with a cane and can’t afford any additional medical care. She also owes nearly $70,000 for the treatment she has already received.
“They haven’t paid the bills,” she said of her former employers. “They offered me $2,000 to go back to Mexico.”
Other workers said they had been humiliated, insulted or called racial slurs by their supervisors after saying they had been hurt. As a result, they didn’t press the issue and never got medical attention.
“You get scared to say anything because they get mad and start yelling and saying bad words,” said one 54-year-old worker who said a cow kicked him in the chest last year while he was milking it. “I healed on my own. I thought I would die.”
Even when supervisors allow workers to get medical care, they face other barriers. Workers typically make between $11 an hour and $15 an hour. Few get health insurance through their jobs. The state’s public insurance program, BadgerCare Plus, doesn’t cover undocumented adults unless they are pregnant or in labor. If they have a serious medical emergency, undocumented immigrants may qualify for some BadgerCare Plus coverage, but this option is not widely known by workers.
In addition, the state bans undocumented immigrants from getting driver’s licenses, as ProPublica has previously reported, forcing many workers to rely on friends, co-workers and supervisors for rides to the clinic or hospital.
Then workers have to weigh whether they can afford to take unpaid time off to see a doctor. Workers routinely log 70 to 80 hours a week, split among multiple shifts each day, sometimes with no days off. That’s especially true for recent immigrants who want to work more hours to help pay down the debts they owe to people who help them get into the U.S.
And while Wisconsin guarantees workers at least one day of rest each week, the law excludes the dairy industry.
Workers also have to find somebody to cover their shifts, and “the boss has to say that that’s okay,” said Lisa Schiller, an associate professor at the University of Wisconsin-Eau Claire and nurse practitioner who runs a mobile health clinic with county health departments that visits dairy farms. She said she knows of some farmers who help workers get to their appointments or even fill their shifts themselves. But others don’t.
Several workers said they were pressured to return to work before they recovered, including a man who lost part of his finger and worried about getting cow feces in his healing wound. He said he overheard a supervisor tell the doctor not to perform surgery to close the wound because the worker was needed on the farm the next day. The worker said he was so shocked he asked a hospital interpreter if he heard right; she confirmed it, adding that he had the right to be treated without his supervisor present. The worker asked his supervisor to leave and got the surgery.
Others said their jobs got filled by another worker while they recovered.
Federal law allows many workers to take time off for their health needs without losing their jobs. But it applies only to employers with at least 50 workers, and few Wisconsin dairy farms are large enough to qualify. Meanwhile, the Americans with Disabilities Act requires employers to provide reasonable accommodations for workers whose injuries leave them with a disability or a perceived disability. But the federal agency that enforces the law covers only employers with at least 15 workers.
Workers at smaller farms who believe they were fired because of their disability can lodge a discrimination complaint with a state agency. The state does not track discrimination complaints by industry, though several attorneys said dairy workers rarely file them.
One worker said he needed six weeks to recover after a bull slammed into him, breaking his nose, jaw and several teeth. In that time, the farm hired another man to replace him as the lead worker in the milking parlor. When he returned to the farm, he had to work under his replacement.
He said he got frequent headaches and experienced blurred vision and felt pressured to quit. Eventually, he did. It took him more than four months to find another job.
Some farmers do make sure their workers get the treatment and recovery time they need after they’re injured. Several workers said a farm owner drove them to an emergency room or clinic and paid out of their own pocket for medication. Some said their supervisors didn’t hesitate to file a workers’ compensation claim so their medical care was covered.
One man, an immigrant from Nicaragua, described with awe his boss’ reaction after a cow kicked his hand against a metal post. The owner of the small farm in central Wisconsin, where he is the only employee, took him to a clinic, paid for the visit and gave him a week off to heal at full pay. When the worker tells friends on other farms what happened, he said “they can’t believe it. It’s something that rarely happens.”
For Alicia Fetzer, who is the business office manager for her family’s large farm in western Wisconsin, it’s a matter of basic humanity. She said the farm typically covers the costs related to minor injuries, leaving workers’ compensation claims for serious accidents.
But she knows not all farms can easily afford to do that. “I’m not dumb to the fact that we are very successful; therefore we have the funds to say, ‘Hey, I’ve got to take this guy to the ER and we might be paying this bill,’” she said. “That doesn’t put me in a pinch.”
At many farms, the expectation is that workers will pay for their own care after work injuries. One man whose two front teeth were snapped in half after a cow kicked him last month said his employer gave him a piece of paper with the name and number of a dental clinic that treats uninsured residents. He called, scheduled an appointment, and is now waiting to be treated.
In the meantime, the man said he tries to keep his mouth closed when he’s outside so the winter air doesn’t hit his open teeth. “It’s uncomfortable,” said the man, who is 32. “When you’re here illegally, sometimes you just say, ‘Oh well.’ What are you supposed to do?”
Several workers said they have received treatment through free or sliding-scale clinics or hospital charity care programs. Rebecca Steffes, the nurse manager of a free clinic in Dodgeville, in southwest Wisconsin, said she routinely sees dairy workers come in with a range of injuries — from kicks or chemical exposure to lower back pain or carpal tunnel symptoms. The clinic helps workers with more serious injuries get charity care from a local hospital.
“I would really like the farmers to effectively take responsibility for their workers,” said Steffes, who grew up on a dairy farm in the state. “They are bringing them here. They are working here. We’ve got to create a system that also takes care of their workers and their families.”
Sometimes injured workers eventually get connected to medical care by the generosity of somebody outside the farm who happened to notice them. That’s what happened to Carmen, the Nicaraguan woman who is afraid to tell her boss she is hurt.
A few months ago, Carmen was walking with a limp and held her head with such obvious discomfort that the owners of the Mexican store where she cashes her checks convinced her she needed medical care. The owner called his mother and asked her to drive Carmen to a hospital.
Carmen told the doctor only about the pain in her arms and back that made it difficult to do her job. She didn’t mention her constant, throbbing headache or the irritation in her eye from having an iodine solution used to sanitize cow udders splash in her face. She was afraid of asking about too much and being billed for treatment she could not afford.
The doctor told Carmen that her shoulder and back pain were due to the repetitive motions of her job, as she had suspected. He prescribed medication for her pain and told her that the overnight shifts were putting additional stress on her body.
But she is still in severe pain. She said she can’t afford to return for follow-up care.
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Chris Cole lay on his back in the gravel beside the railroad tracks, staring up at the overcast sky above Godfrey, Illinois. He could not see below his waist — a co-worker had thrown himself over Cole’s body to spare him the sight, although the man couldn’t keep himself from repeating: “Oh my god, Chris. Oh my god.” So, instead of looking down where his legs and feet should have been, Cole looked up. What’s going to happen to my family? he remembered thinking.
Moments earlier, Cole — a 45-year-old brakeman, engineer and conductor with over two decades of experience working on the railroads — had attempted a maneuver he’d done many times: hoisting himself onto a locomotive as it moved past him. Although dangerous, Cole’s employer, Kansas City Southern Railway Company, did not prohibit workers from climbing on and off equipment that was moving at a “walking speed.” In fact, the company went from banning the practice in the mid-’90s to steadily increasing the permissible speed at which workers could attempt to climb onboard, a change other freight companies would also adopt in keeping with the spirit of a modern strategy to move cargo as quickly as possible.
As he pulled himself up onto the rolling train, Cole said he felt something strike his right shoulder — a rectangular metal sign close to the tracks that read “DERAIL.” He lost his balance and slipped beneath the wheels of a graffiti-covered boxcar. The train crushed and nearly severed his right foot and his left leg at the knee.
Somehow Cole maintained consciousness, calling his co-workers for help before undoing his belt to tie a tourniquet around one of his legs. As the engineer dialed 911, the conductor ran to Cole’s side and used his own belt to tie a second tourniquet around the other leg. A crew of firefighters arrived within minutes. They loaded him onto a medical helicopter that airlifted Cole to an emergency room in St. Louis, just across the nearby Missouri border.
Cole awoke in the middle of the night alone in a hospital room; it was April 2020, just a month after the surging coronavirus was declared a pandemic. Neither his wife nor his daughter were allowed to visit, and so he was alone when a trauma nurse informed him that he lost both of his legs. Cole, a burly man who once stood 6 feet tall, knew his railroading career was over, as were his hopes of providing enough so that his wife — who’d recently been diagnosed with multiple sclerosis — could stay at home with their 12-year-old daughter.
The next morning, Cole called his manager to tell him that he was alive. Afterward, the manager wrote an email to other members of the company summarizing Cole’s description of the accident: “Upon mounting equipment he stated there was a derail sign that struck him off of the engine and he fell.”
But within days, according to company and court records, Cole’s managers and higher-ups at the rail company began to shape a new narrative — one that erased the role of the sign, leaving Cole solely at fault, entitled to nothing under the railroad industry’s version of workers’ compensation for his devastating injuries.
“The culture of management is that we are going to cover ourselves and cover the railroad and make sure that it doesn’t look bad in the public eye,” Cole said. “And if we got to bury one of our employees, or somebody else, we’re going to do that.”
In many ways, the fight centered on the metal derail sign. Within 48 hours of the accident, before state regulators had a chance to examine it, the sign was gone.
Railroad companies have a long history of hiding injuries, as ProPublica recently reported. But in some catastrophes like Cole’s, in which the injuries are so grievous they can’t be denied, ProPublica found that companies moved almost immediately to cover up their culpability.
Some attempts to deny the causes of accidents obscured safety hazards, such as faulty latches, which could have put more workers at risk, ProPublica found. Others took actions that made worker injuries far worse.
In 2014, after two BNSF workers in Minneapolis breathed in a cloud of highly toxic chemicals that may have vented from passing rail cars, managers claimed that the men were exposed to a far less dangerous substance. One of the workers, Scott Kowalewski, suffered severe, permanent neurological damage. The other later died by suicide, a tragedy that was impossible to incontrovertibly link to the accident.
When Kowalewski sued, BNSF claimed that he didn’t say he was exposed to the more toxic material until three-and-a-half years after the incident and maintained throughout the case that his deteriorating health had nothing to do with the exposure. But a jury sided with Kowalewski in 2018 and awarded him $15.3 million. And a judge concluded that the railroad’s “misrepresentation prevented Kowalewski from receiving appropriate medical treatment that might have remediated his injury.” The judge ordered BNSF to pay an additional $5.8 million penalty for its misconduct, writing that the extent of it was “vast, and spans from the outset of its initial sham investigation.”
Cole’s case wasn’t even the first involving a railroad sign. Bradley Anderson was riding on the side ladder of a rail car in 2019 when he struck his head on a milepost sign that was too close to the tracks. He was diagnosed with a traumatic brain injury. Officials from his company, BNSF, pulled the sign out of the ground before its position was adequately documented.
This July, the federal judge on Anderson’s case excoriated the company. “Despite receiving multiple court admonitions for destroying and concealing evidence, BNSF engaged in the same type of misconduct here,” U.S. District Judge Rebecca Goodgame Ebinger wrote in an order, declaring that the company was responsible for Anderson’s injury, and approved sanctions for the damage caused by the “bad faith” removal of the sign. The case eventually settled.
She also said she was forwarding the case to the Iowa Supreme Court Attorney Disciplinary Board and the Illinois Attorney Registration and Disciplinary Commission, “in the event either body should see fit to initiate an investigation into an apparent abuse of legal procedure.”
Neither of those bodies would disclose to ProPublica whether they had received the judge’s referral or whether they planned to act on the information.
In civil litigation, it falls on workers’ attorneys to prove companies tampered with evidence. If a judge agrees, they can sanction the companies for millions of dollars or, in an extreme case, even enter a default judgment for the worker. (The judges in Kowalewski’s and Anderson’s cases entered such default judgments against BNSF.) But outside of those repercussions, there is little else in terms of punishment for companies that repeat the behavior. “It comes out in an individual case,” said Daniel Gourash, editor of the American Bar Association book “Spoliation of Evidence.” “The sanction that would be given would not be because of a habitual spoliation activity or conduct or behavior.”
BNSF did not comment on either case but said in a statement that “the safety of our employees always has been and always will be a priority. We believe that’s reflected in our safety culture and record over the last decade, which produced the lowest number of injuries in our railroad’s history.”
In a statement to ProPublica on the Cole case, a Canadian Pacific Kansas City spokesperson denied that any of its actions were an attempt to avoid culpability. (This year, Kansas City Southern Railway Company merged with Canadian Pacific Railway.)
“Through a thorough investigation that lasted several months, Kansas City Southern sought to determine how the incident occurred so appropriate action could be taken to prevent such an incident from happening again,” the company said.
Within hours of Cole’s accident, a bevy of Kansas City Southern supervisors from across the region converged at the scene. They took pictures. They stayed until dark fell.
Early the next morning, Cole called two of his managers from his hospital bed: assistant trainmaster Michael Cline and Chris Knox, general manager of the KCS North Division. Cline sent two emails to several managers at the company: “He stated there was a derail sign that struck him off of the engine and he fell between the engine and cars where the incident took place with the dismemberment of his legs.” Cline told ProPublica he would check with his employer before commenting but then did not respond further. Knox didn’t respond to calls or text messages.
A short time later, four inspectors from the Federal Railroad Administration gathered at the scene along with KCS managers. An FRA operating practices inspector named Larry Piper wrote up his initial findings about what happened to Cole.
“His body struck a derail sign on a metal post adjacent to the pass track, knocking him off the locomotive and to the ground,” the report stated, adding that railroad and FRA officials watched video footage captured on a nearby security camera. “Even though the quality was not perfect, it did substantiate what the employee was saying,” the report said.
Piper communicated those findings to a member of the Illinois Commerce Commission, the agency that performs inspections and enforces state regulations on the railroad, including sign placement.
“It appeared to him that the derail post sign was too close to the rail,” recalled Dennis Mogan, the ICC railroad safety specialist, in a deposition. “The FRA didn’t have any regulations on that, and he thought that the state did and that we should take a look.”
But before that could happen, KCS roadmaster Jeffrey Brickey removed the sign and pulled its pole from the ground entirely. He also covered the hole left behind.
“We’re not supposed to leave any divots or anything like that for trainmen to walk on, so yeah, I cleaned it up,” he testified. Brickey did not respond to ProPublica’s requests for comment.
Photos taken by a KCS representative show the derail sign after Cole’s accident. (Court records)By the time a railroad safety specialist from the ICC named Troy Fredericks arrived about a week later, the sign was long gone. When Fredericks asked Brickey about it, he said Brickey “couldn’t discuss” the sign and “would not talk about” the injury incident. The company did not comment on whether it had been forthright with Illinois regulators; the ICC told ProPublica that Brickey was “responsive to ICC Staff’s concern in the days after the incident.” Before Fredericks left the accident scene, he made note of a completely different sign not far away that he said was positioned too close to the railroad tracks and then left.
Around the same time that the sign disappeared from the site, it also began to fade from the railroad company’s narrative of the incident, despite the existence of the FRA’s initial report confirming Cole’s account. Wendell Campbell, an assistant division superintendent who was one of the first to arrive in Godfrey after the accident, wrote on an employee injury form that the sign struck Cole. But in subsequent paperwork, Campbell omitted any mention of the sign: “Employee was trying to board moving equipment.” Campbell declined to comment when reached by ProPublica.
In a deposition, Mary Lyn Villanueva, the KCS employee in charge of submitting information to the FRA, said that before she filed her report, she had several conversations with the company’s claim agents, who investigate accidents and injuries on behalf of the railroad. Villanueva, who had access to both versions of the story Campbell submitted, also omitted any mention of the sign. Through a company spokesperson, she declined to comment to ProPublica.
In its statement, Canadian Pacific Kansas City said it “filled out the FRA-required forms properly, noting the cause of the incident was still under investigation at the time.” The company denied that it misled the FRA, saying the sign was measured and photographed in the presence of agency officials and then removed.
But according to Nelson Wolff, Cole’s attorney, leaving the sign out of subsequent paperwork was not a harmless omission. “It was part of an obvious attempt to change the narrative and to conceal evidence that the sign was the actual cause,” he said.
Less than a week after the accident, managers made another decision: They wanted Cole, who in his 11-year career with the company had never been injured, investigated for rule violations. The company issued him a notice, which Cole initially did not receive — he was still in the hospital, going in and out of surgeries to save what remained of his legs.
Cole had 10 surgeries in the six weeks after his accident. (Courtesy of Chris Cole)Six weeks after the incident, the hospital finally cleared Cole to go home. But there was no home to go to.
The Coles’ previous apartment was on the second floor of a building with no elevator and no way to navigate it in a wheelchair. Instead, Cole checked into an Extended Stay America hotel, where he was finally reunited with his wife, Iris, and his daughter, Lily.
Although grateful to see him in person for the first time in over a month, the meeting was a shock for Iris and Lily — it was the first time they’d seen him without his legs, and his wounds were still fresh. “I gave him the biggest hug, but I looked down at his legs,” recalled Iris, who confessed in court to being squeamish around blood. “He had a wound vac on the right leg, and how I did not pass out, I don’t know.”
Cole’s daughter, Lily (Bryan Birks for ProPublica)The meeting was emotional but brief. Cole’s wife and daughter left to finish putting their belongings into storage. The family continued living separately for months before finding a wheelchair-accessible apartment. In the process, the Coles racked up over $10,000 in hotel room costs.
A little over a week after Cole got out of the hospital, his union representative wheeled him into a small hotel conference room in East St. Louis, Illinois, to hear the railroad’s case against him. They were joined by Brandi Foulk, the engineer, and Brian Loy, the conductor; it was the first time all three had seen one another since Cole was airlifted away.
In front of a presiding officer from Kansas City Southern, Cole’s manager Campbell made the argument: He said Cole attempted to mount a locomotive going faster than 4 miles per hour, or walking speed, without first notifying Foulk by radio, a violation of a KCS rule. A second KCS manager presented data from the train’s black box recorder, which he said showed that the locomotive reached 8 miles per hour at some point before it stopped, though he acknowledged it was possible Cole tried to board at 4 miles per hour.
Though Campbell knew Cole reported being struck by the sign, he made no mention of it. Both Foulk and Loy tried to speak up for Cole, saying they believed it was possible the train was going closer to 4 miles per hour when he made the attempted boarding.
“Chris is one of the safest people I’ve ever worked with,” Foulk said. “Him not saying something to me on the radio just let me know that he felt safe enough to get on equipment going the speed that it was going.”
The hearing took less than an hour and a half. A week later, the railroad determined Cole broke the rule and gave him a 30-day suspension, despite the obvious fact that he would never be able to return to work on the railroad again. Cole, who was still in acute pain at the time of the investigation, did not raise the issue of the sign at the hearing, which he later regretted. At the same time, he said he knew he’d be found at fault regardless. The company did not respond to ProPublica’s questions about the disciplinary proceedings against Cole.
It is a common refrain among rail workers that the companies’ internal investigative hearing process is a “kangaroo court.” Hearings typically run like this: They are presided over by railroad managers, workers are not allowed to have their lawyer represent them and they cannot force the railroad to turn over evidence for their defense. In a case against Norfolk Southern, a railroad manager who served as the presiding officer in about 50 investigative hearings estimated that she found in favor of the employee only once. The hearings are often a precursor to firings, and when Occupational Safety and Health Administration officials have weighed in on subsequent wrongful termination claims, they wrote that hearings were “at best perfunctory” and not “fair and impartial,” and “showed bias.” After employees sue, the rail companies frequently settle with workers they claim to have proven were fully at fault. In other cases, the workers have gone on to huge jury verdict wins.
“If you go to an investigation, you have already been found guilty,” Cole told ProPublica. “My ends were hurting, and I just wanted to get out of there and get it over with.”
Still, he admitted he was surprised that the company was in such a hurry to discipline him.
“That’s when I kind of lost all faith in them,” he said.
Cole stayed at this hotel after being released from the hospital because he couldn’t access his second-floor apartment with a wheelchair. (Bryan Birks for ProPublica)In the fall of 2022, when Cole’s civil trial against Kansas City Southern Railway Company began in St. Louis County Circuit Court, a central figure in the case reemerged: the derail sign. Almost as mysteriously as it had disappeared, the sign was back.
According to the lawyers for the railroad, there was a third version of events: They now admitted the sign was placed too close to the tracks on the day of the accident, by about 1 1/2 to 2 feet, in violation of Illinois law. But Cole, they argued, never hit the sign. Therefore, the sign and who had placed it too close to the tracks and where it went after the roadmaster removed it and why it went was all moot. They even used the sign to demonstrate to the jury that it was too “flimsy” to knock a 245-pound man off balance. (Although fighting nerves, Cole was amused at one point when one of the lawyers banged loudly into it. Doesn’t sound flimsy to me, he thought.)
Throughout the two-week trial, the railroad’s legal team presented a more robust version of the same case it had made in Cole’s internal hearing in June 2020: that he boarded a moving train when it was going too fast, in violation of company rules and general safety best practices. They added a roster of three expert witnesses who reconstructed the scene using imperfect videos — one from locomotive cameras that missed the fall and one from a nearby warehouse that was grainy and far away; the company’s experts enhanced them with 3D computer modeling to show Cole slipped on his own. The true culprit, they argued, was rule violations. “If you follow the rules, you don’t get hurt,” the lawyer told the jury.
Cole’s attorney, Wolff, countered with his own expert, who argued the same videos plausibly showed Cole hitting something before falling. Wolff also argued that there was no safe speed for getting onto and off of moving trains and that companies like KCS that had once prohibited the activity were now walking the policies back to keep freight moving faster. Brandon Ogden, an expert witness and former BNSF manager, blamed this on the industry’s increasing reliance on precision scheduled railroading, a business philosophy that prioritizes maximum efficiency. “It’s all about moving faster, increasing production and boosting profits,” Ogden testified. “It negatively affects safety of railroad employees.”
Cole’s daughter, Lily, and wife, Iris, testified about the difference the accident made in their lives. His daughter, by then 15, called her dad a “knight in shining armor” who could no longer go swimming or ice skating with her. His wife described how the family was adapting to Cole’s new physical limitations in some ways, while others remained a struggle. “He is quick to get upset over things. I mean, really, really quick,” she said. “We have to tell Chris, don’t do that. Please don’t do that.”
When Cole was called to the stand, he told the jury the story: how he’d felt the sign strike his shoulder before his fall, about his long, ongoing recovery, sometimes feeling “worthless” now that he could not take care of his family. At one point, he removed his prosthetics for the jury, demonstrating the system of liners, pushpins, buckles and Velcro straps.
On cross-examination, the railroad’s lawyer grilled Cole on his understanding of the safety rules about boarding moving trains. He played the videos of the incident again, urging Cole to admit that his memory of hitting the sign was faulty or that his own poor decisions caused the fall. Cole stuck to his version of events.
“While we all do recognize you have suffered a very, very significant injury, you would agree with me that it has allowed you to develop stronger relationships with your wife and daughter?” the lawyer asked Cole at one point. “While you loved your job at the railroad, that took you away from your family, yes?”
On redirect, Wolff turned the line of questioning around.
“It looks like the railroad is asking for you to say thank you,” he said to Cole. “Would you rather be out there working on the railroad, providing for your family like you had been doing for decades … being able to walk on your own two feet?”
“That is correct,” Cole responded. “Yes.”
Wolff left the jury with a succinct explanation for the sign’s appearance, disappearance and reappearance in the railroad company’s narrative: “cover-up.” The railroad vehemently denied it.
After the long, contentious trial, and just under five hours of deliberation, the jury returned with its verdict, agreeing that Kansas City Southern had violated Illinois sign clearance law. It determined that Cole was 21% at fault for his accident, while the railroad company was responsible for 79%. The jury awarded Cole $12 million.
“A big weight lifted off my shoulders,” Cole said of the moment he heard the verdict. “Someday, we’re going to be fine.”
Cole, his daughter, Lily, and his wife, Iris (Byran Birks for ProPublica)After the verdict, Kansas City Railway filed an appeal, which is ongoing. Company officials reiterated to ProPublica that they still do not believe Cole hit the sign before he fell. Read the full Canadian Pacific Kansas City statement here.
While he awaits the outcome, Cole works part-time during baseball season with Iris, greeting customers at the St. Louis Cardinals team store near the downtown stadium. Cole enjoys it, so long as he can steer clear of the rowdy baseball crowds that jostle his wheelchair. He cringes when fans thank him for his service, replying simply that he got hurt at work.
In the short term, he focuses on becoming more mobile on his prosthetics. Lily is 16 years old now, and Cole figures he still has time to learn to walk before he escorts her down the aisle at her wedding.
Though he said he doesn’t dwell much on the former railroad colleagues who tried to discredit him, he wonders why regulatory agencies don’t do more to discipline managers and companies.
“Instead of maybe a fine, why don’t you put somebody in jail?” he asked. “Maybe they’ll learn better that way and stuff will stop happening like this.”
Both the ICC and the FRA decided Cole’s accident warranted no further investigation. Neither agency issued any kind of penalty or fine.
A spokesperson for the ICC said it has authority to issue fines only after putting the railroad on notice of a violation and then holding a hearing, and that because the company “corrected the violation” — by removing the sign — the commission did not pursue the matter.
Following its practice at the time, the FRA never finalized its initial report concluding that Cole hit the sign and didn’t share it with anyone until ProPublica asked questions about the accident this month. It’s unclear how the report would have changed any element of the legal fight, but Cole finds it disappointing that the regulator didn’t take a more aggressive role in holding the railroad accountable.
“That is what the FRA is supposed to do, it is supposed to monitor and to sanction railroads when they do wrong,” he said. “You go out and you say, ‘Hey, you know, this sign was definitely way too close to the track and you had an employee got hurt, but we’re just going to tuck it in a drawer somewhere, we’re just going to forget about it.’ ... That’s what’s disappointing.”
The regulators, he went on, had nothing to lose, while Cole, in his words, “lost everything, pretty much.”
Dan Schwartz contributed reporting. Gabriel Sandoval contributed research.
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“With Every Breath,” a new documentary from ProPublica and the Pittsburgh Post-Gazette, is an intimate glimpse into what happens when patients and a doctor learn that a lifesaving device may be causing harm.
In 2021, Philips Respironics issued a massive recall of as many as 15 million sleep apnea devices and ventilators. This film follows people who use and prescribe the DreamStation, a continuous positive airway pressure, or CPAP, machine that has a serious defect. The foam the company had chosen for it could crumble in heat and humidity and send potentially carcinogenic material into the noses, mouths, throats and lungs of users.
In statements, the industry giant said it acted as soon as it learned of the “potential significance” of the problem and that the machines are unlikely to cause harm. But an investigation by ProPublica and the Post-Gazette revealed a different story. Over the course of more than a decade, Philips held back from the government thousands of complaints about the machines as stock prices soared. Again and again, previously undisclosed records and interviews with company insiders show Philips suppressed mounting evidence that its profitable breathing machines threatened the health of the people relying on them, in some cases to stay alive.
Weaving personal stories with lush cinematography, “With Every Breath” visualizes the stories of three people, who face the unanswerable question of how their health has been impacted, and a sleep medicine doctor who leads her patients through the chaotic recall. The film humanizes a public health crisis that has affected millions.
Directed by Liz Moughon and produced by Almudena Toral, this 20-minute film accompanies the investigative series about the Philips CPAP recall also called “With Every Breath,” published in partnership with the Post-Gazette.
Debbie Cenziper of ProPublica, Michael D. Sallah and Michael Korsh of the Pittsburgh Post-Gazette and Margaret Fleming, Nicole Tan and Bridgette Adu-Wadier of the Medill Investigative Lab contributed reporting. Benjamin B. Braun of the Pittsburgh Post-Gazette contributed cinematography.
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The New York Police Department has agreed to end its practice of withholding body-camera footage of police shootings from civilian investigators, a practice that sometimes derailed independent inquiries into deaths at the hands of police.
The change came weeks after ProPublica and The New York Times Magazine asked the NYPD about the practice as part of their investigation into the use of body cameras.
For years, the Civilian Complaint Review Board, which is charged with investigating police misconduct in New York City, has often been hamstrung in its ability to move ahead on the most serious cases because the NYPD refused to share footage of shootings and other serious incidents while the department did its own, often lengthy, internal investigation.
“We are pleased to have come to this agreement with NYPD and hope it will ensure officers who commit misconduct cannot avoid discipline due to a technicality,” said CCRB Chair Arva Rice in a statement.
Our investigation published last week detailed how the NYPD’s refusal to share footage had short-circuited the civilian agency’s efforts to punish an officer who had killed a young man named Kawaski Trawick.
NYPD did not give the civilian agency any footage of the April 2019 incident until more than a year and a half later. When the department finally handed it over, the footage showed one officer shot and killed Trawick, despite the officer’s more experienced partner repeatedly telling him not to use force. “No, no, don’t, don’t, don’t, don’t, don’t,” the more senior officer said.
The CCRB filed disciplinary charges against the officer, triggering an NYPD trial earlier this year. But the police judge in the case decided there should be no discipline — because the CCRB had failed to file charges within an 18-month statute of limitations. The reason the CCRB hadn’t done so? The agency didn’t have the footage it needed to move ahead.
NYPD countered in a statement to ProPublica that “The CCRB could have brought charges prior to the expiration of the statute of limitations, but did not do so.”
The new agreement between the NYPD and CCRB, which was signed Dec. 5, stipulates that the Police Department will hand over footage and other records within 90 days of a request. The deal is essentially a good faith agreement between the two agencies. It does not have the force of law or lay out penalties.
A few other cities have taken a different approach. The civilian police oversight bodies in Chicago; Washington, D.C.; and New Orleans all have direct access to footage, mandated by law. Rather than relying on the police to send them the video, they have their own logins to the systems where videos are stored.
The deal also does not apply to the public disclosure of footage, an area in which the NYPD has lagged. Three years ago, the NYPD announced it would disclose footage from police shootings and other serious incidents within 30 days. Our investigation found that of 380 such serious incidents since then, the police have released video within a month just twice. (In response to our questions about that, the NYPD pointed to several exceptions in the department’s policy.)
The CCRB will have no shortage of footage to review. Through the first week of December, there were 28 shootings of civilians this year by New York City officers. The CCRB will now be able to get footage from all of them 90 days after the agreement was signed.
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In early January 2000, Supreme Court Justice Clarence Thomas was at a five-star beach resort in Sea Island, Georgia, hundreds of thousands of dollars in debt.
After almost a decade on the court, Thomas had grown frustrated with his financial situation, according to friends. He had recently started raising his young grandnephew, and Thomas’ wife was soliciting advice on how to handle the new expenses. The month before, the justice had borrowed $267,000 from a friend to buy a high-end RV.
At the resort, Thomas gave a speech at an off-the-record conservative conference. He found himself seated next to a Republican member of Congress on the flight home. The two men talked, and the lawmaker left the conversation worried that Thomas might resign.
Congress should give Supreme Court justices a pay raise, Thomas told him. If lawmakers didn’t act, “one or more justices will leave soon” — maybe in the next year.
At the time, Thomas’ salary was $173,600, equivalent to over $300,000 today. But he was one of the least wealthy members of the court, and on multiple occasions in that period, he pushed for ways to make more money. In other private conversations, Thomas repeatedly talked about removing a ban on justices giving paid speeches.
Thomas’ efforts were described in records from the time obtained by ProPublica, including a confidential memo to Chief Justice William Rehnquist from a top judiciary official seeking guidance on what he termed a “delicate matter.”
The documents, as well as interviews, offer insight into how Thomas was talking about his finances in a crucial period in his tenure, just as he was developing his relationships with a set of wealthy benefactors.
Congress never lifted the ban on speaking fees or gave the justices a major raise. But in the years that followed, as ProPublica has reported, Thomas accepted a stream of gifts from friends and acquaintances that appears to be unparalleled in the modern history of the Supreme Court. Some defrayed living expenses large and small — private school tuition, vehicle batteries, tires. Other gifts from a coterie of ultrarich men supplemented his lifestyle, such as free international vacations on the private jet and superyacht of Dallas real estate billionaire Harlan Crow.
Precisely what led so many people to offer Thomas money and other gifts remains an open question. There’s no evidence the justice ever raised the specter of resigning with Crow or his other wealthy benefactors.
George Priest, a Yale Law School professor who has vacationed with Thomas and Crow, told ProPublica he believes Crow’s generosity was not intended to influence Thomas’ views but rather to make his life more comfortable. “He views Thomas as a Supreme Court justice as having a limited salary,” Priest said. “So he provides benefits for him.”
Thomas and Crow didn’t respond to questions for this story. Crow, a major Republican donor, has not had cases at the Supreme Court since Thomas joined it and has previously said Thomas is a dear friend. David Sokol, a conservative financier who has taken Thomas on vacation on a private jet, said in a statement that he and Thomas had never discussed the justice’s finances or when he might retire.
Thomas’ comments in 2000 were to Florida Rep. Cliff Stearns, a vocal conservative who’d been in Congress for 11 years and occasionally socialized with the justice. They set off a flurry of activity across the judiciary and Capitol Hill. “His importance as a conservative was paramount,” Stearns said in a recent interview. “We wanted to make sure he felt comfortable in his job and he was being paid properly.”
There’s an often-criticized dynamic surrounding most important jobs in the federal government: The posts pay far less than comparable jobs in the private sector, but officials can cash in once they leave. Ex-regulators sell advice to the regulated. Generals retire to join military contractors. Former senators get jobs lobbying Congress.
But there is no revolving-door payday waiting on the other side of a lifetime appointment to the Supreme Court. Justices generally stay on the bench past their 80th birthday, if not until death. In 2000, justices were paid more than cabinet secretaries or members of Congress, and far more than the average American. Still, judges’ salaries were not keeping pace with inflation, a source of ire throughout the federal judiciary. Young associates at top law firms made more than Supreme Court justices, while partners at the firms could earn millions a year.
Note: Median American figure is for full-time, year-round workers. Law partner figure is for the highest-paying of the 100 largest firms. (Sources: U.S. Census Current Population Survey, The American Lawyer)Some of Thomas’ colleagues were extremely wealthy — Justice Ruth Bader Ginsburg was married to a high-paid tax lawyer and Justice Stephen Breyer to the daughter of a wealthy British lord. Thomas did not come from money. When he was appointed to the court in 1991, he was 43 years old and had spent almost all his adult life working for the government. At the time, he still had student loans from law school, Thomas has said.
The full details of Thomas’ finances over the years remain unclear. He made at least two big purchases around the early ’90s: a Corvette and a house in the Virginia suburbs on 5 acres of land. When Thomas and his wife, Ginni, bought the home for $522,000 a year after he joined the court, they borrowed all but $8,000, less than 2% of the purchase price, property records show.
Public records suggest a degree of financial strain. Throughout the first decade of his tenure, the couple regularly borrowed more money, including a $100,000 credit line on their house and a consumer loan of up to $50,000. Around January 1998, Thomas’ life changed when he took in his 6-year-old grandnephew, becoming his legal guardian and raising him as a son. The Thomases sent the child to a series of private schools.
In early January 2000, Thomas took the trip to the Georgia beach resort. Thomas was there to deliver a keynote speech at Awakening, a “conservative thought weekend” featuring golf, shooting lessons and aromatherapy along with panel discussions with businessmen and elected officials. (A founder and organizer of the annual event, Ernest Taylor, told ProPublica that Thomas’ trip was paid for by the organization. Thomas reported 11 free trips that year on his annual financial disclosure, mostly to colleges and universities, but did not disclose attending the conservative conference, an apparent violation of federal disclosure law.)
Thomas spoke at the Awakening conference in 2000. (Screenshot by ProPublica of Awakening <a href="https://www.documentcloud.org/documents/24190165-awakening-2000">brochure</a>)On a commercial flight back from Awakening, Thomas brought up the prospect of justices resigning to Stearns, the Republican lawmaker. Worried, Stearns wrote a letter to Thomas after the flight promising “to look into a bill to raise the salaries of members of The Supreme Court.”
“As we agreed, it is worth a lot to Americans to have the constitution properly interpreted,” Stearns wrote. “We must have the proper incentives here, too.”
Stearns’ office soon sought help from a lobbying firm working on the issue, and he delivered a speech on the House floor about judges’ salaries getting eroded by inflation. Thomas’ warning about resignations was relayed at a meeting of the heads of several judges’ associations. L. Ralph Mecham, then the judiciary’s top administrative official, fired off the memo describing Thomas’ complaints to Rehnquist, his boss.
“I understand that Justice Thomas clearly told him that in his view departures would occur within the next year or so,” Mecham wrote of Thomas’ conversation with Stearns. Mecham worried that “from a tactical point of view,” congressional Democrats might oppose a raise if they sensed “the apparent purpose is to keep Justices [Antonin] Scalia and Thomas on the Court.” (Scalia had nine children and was also one of the less wealthy justices. Scalia, Mecham and Rehnquist have since died.)
It’s not clear if Rehnquist ever responded. Several months later, Rehnquist focused his annual year-end report on what he called “the most pressing issue facing the Judiciary: the need to increase judicial salaries.”
Stearns sent a letter to Thomas after their conversation about pay and possible resignations at the Supreme Court. (George Washington University Special Collections Research Center)Several people close to Thomas told ProPublica they believed that it was implausible the justice would ever retire early, and that he may have exaggerated his concerns to bolster the case for a raise. But around 2000, chatter that Thomas was dissatisfied about money circulated through conservative legal circles and on Capitol Hill, according to interviews with prominent attorneys, former members of Congress and Thomas’ friends. “It was clear he was unhappy with his financial situation and his salary,” one friend said.
Former Sen. Trent Lott, then the Republican Senate majority leader, recalled in a recent interview that there were serious concerns at the time that Thomas or other justices would leave.
The public received hardly a hint that such conversations about Thomas were unfolding in Washington. Thomas did once allude to government salaries, in a 2001 speech praising the value of public service. “The job is not worth doing for what they pay. It’s not worth doing for the grief,” he said. “But it is worth doing for the principle.”
Thomas delivered a speech in 2001 on the value of public service. (Screenshot by ProPublica via C-SPAN)Around that time, Thomas was also pushing to allow justices to make paid speeches — a source of income that had been banned in the 1980s. On several occasions, Thomas discussed lifting the ban with appellate Judge David Hansen, who chaired the judiciary’s committee responsible for lobbying Congress on issues like pay, according to Mecham’s memo.
At Sen. Mitch McConnell’s request, a provision removing the ban for judges was quietly inserted into a spending bill in mid-2000. Why McConnell made the proposal became a subject of scrutiny in the legal press. After the Legal Times reported the measure had been dubbed the “Keep Scalia on the Court” bill, Scalia responded that the “honorarium ban makes no difference to me” and denied that he would ever leave the court for financial reasons. (The ban was never lifted. McConnell did not respond to a request for comment.)
During his second decade on the court, Thomas’ financial situation appears to have markedly improved. In 2003, he received the first payments of a $1.5 million advance for his memoir, a record-breaking sum for justices at the time. Ginni Thomas, who had been a congressional staffer, was by then working at the Heritage Foundation and was paid a salary in the low six figures.
Thomas also received dozens of expensive gifts throughout the 2000s, sometimes coming from people he’d met only shortly before. Thomas met Earl Dixon, the owner of a Florida pest control company, while getting his RV serviced outside Tampa in 2001, according to the Thomas biography “Supreme Discomfort.” The next year, Dixon gave Thomas $5,000 to put toward his grandnephew’s tuition. Thomas reported the payment in his annual disclosure filing.
Larger gifts went undisclosed. Crow paid for two years of private high school, which tuition rates indicate would’ve cost roughly $100,000. In 2008, another wealthy friend forgave “a substantial amount, or even all” of the principal on the loan Thomas had used to buy the quarter-million dollar RV, according to a recent Senate inquiry prompted by The New York Times’ reporting. Much of the Thomases’ leisure time was also paid for by a small set of billionaire businessmen, who brought the justice and his family on free vacations around the world. (Thomas has said he did not need to disclose the gifts of travel and his lawyer has disputed the Senate findings about the RV.)
By 2019, the justices’ pay hadn’t changed beyond keeping up with inflation. But Thomas’ views had apparently transformed from two decades before. That June, during a public appearance, Thomas was asked about salaries at the court. “Oh goodness, I think it’s plenty,” Thomas responded. “My wife and I are doing fine. We don’t live extravagantly, but we are fine.”
A few weeks later, Thomas boarded Crow’s private jet to head to Indonesia. He and his wife were off on vacation, an island cruise on Crow’s 162-foot yacht.
Do you have any tips on the Supreme Court? Justin Elliott can be reached by email at justin@propublica.org or by Signal or WhatsApp at 774-826-6240. Josh Kaplan can be reached by email at joshua.kaplan@propublica.org and by Signal or WhatsApp at 734-834-9383.
Kathleen Quinn and Marissa Muller from Berkeley Journalism’s Investigative Reporting Program contributed research.
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In the last 10 years, taxpayers have spent millions to outfit police officers across the country with body-worn cameras in what was sold as a new era of transparency and accountability. But a survey by ProPublica shows that when civilians die at the hands of police, the public usually never sees the footage.
At least 1,201 people were killed in 2022 by law enforcement officers, about 100 deaths a month, according to Mapping Police Violence, a nonprofit research group that tracks police killings. ProPublica examined the 101 deaths that occurred in June 2022, a time frame chosen because enough time had elapsed that investigations could reasonably be expected to have concluded. The cases involved 131 law enforcement agencies in 34 states.
In 79 of those deaths, ProPublica confirmed that body-worn camera video exists. But more than a year later, authorities or victims’ families had released the footage of only 33 incidents.
In 101 police killings in June 2022, body-camera footage … Jason Kao/ProPublicaWe filed public records requests for the video in the remaining 46 cases and in 26 were told it could not be publicly released or did not receive any response. In 14 cases, law enforcement agencies offered the video for a fee, ranging from $19 in Lowndes County, Georgia, to nearly $16,000 in Hillsborough County, Florida. Six departments eventually gave ProPublica the footage for free.
The lack of disclosure undermines the promise that equipping police with body cameras would increase transparency around fatal police encounters and hold officers to account for bad or criminal behavior.
President Barack Obama made body-worn cameras a centerpiece of his police reform efforts after Michael Brown, an 18-year-old Black man, was shot and killed by police in Ferguson, Missouri, in 2014. Police claimed they were acting in self-defense, while witnesses said that was not true. Weeks of protests ensued. It was one in a series of police killings in which the officers’ stories differed from witness accounts or videos taken by civilians nearby. Brown’s family, advocates and even some law enforcement leaders called for the widespread use of body-worn cameras in hopes they would help restore trust between police and a public that had lost faith.
The Justice Department allocated millions to help departments across the country outfit officers with the technology.
“They were wholly sold as an accountability tool to reassure people that police would be held accountable for their actions or for what they are doing while operating under the powers of the state,” said Hans Menos, who advises police departments with the Center for Policing Equity and formerly headed the Police Advisory Commission in Philadelphia, an early adopter of body cameras. “If we don’t provide that level of transparency, what we’ve really done is made people pay for something that they don’t get any tangible benefit out of.”
Philadelphia signed a $12.5 million contract in 2017 to equip its entire police force with cameras. Since then, at least 27 people have been killed by Philadelphia police, according to Mapping Police Violence, but in only two cases has body-camera video been released to the public.
ProPublica’s review shows that withholding body-worn camera footage from the public has become so entrenched in some cities that even pleas from victims’ families don’t serve to shake the video loose.
In Savannah, Georgia, for instance, neither Saudi Arai Lee’s family nor the public has been allowed to see the footage of the fatal shooting of the 31-year-old Black man.
Savannah police and Georgia state investigators say Lee was walking down a street June 24, 2022, when an officer stopped to question him. Lee told the officer he had a permit to carry a gun and pulled out his wallet. He lifted his shirt to show the gun. Then, for an undisclosed reason, the officer began chasing Lee, and shot and killed him. It was the fifth killing by Savannah police in a year. The agencies won’t release the footage, they said, because the killing is still under investigation.
Lee’s uncle, Timothy Lee, arrived on the scene minutes after the shooting and spoke to witnesses. “He was reaching for his wallet and that’s when the man shot him,” Timothy Lee said people told him. “We want justice. We think he should go to jail for the rest of his life for what he did.”
On the same day, halfway across the country, Christopher D. Kelley was killed by police in Topeka, Kansas. His family also wants the footage of his killing to be made public, according to their attorney, LaRonna Lassiter Saunders. The family and lawyer have seen the video and believe that if it were made public it could serve to prevent similar tragedies in the future.
Kelley, a 38-year-old Black Marine veteran, was in the midst of a mental health crisis, Saunders said, when police found him behind an Amtrak station, standing on a pile of rocks and holding a knife. More than a dozen officers surrounded him with guns drawn and spent almost an hour trying to convince Kelley to drop the knife, even firing nonlethal bean bags at him, according to a report by state investigators. Then, according to the district attorney, who cleared police of wrongdoing, Kelley “raised the knife and charged” toward police, prompting three officers to open fire. If the public saw exactly what happened, Kelley’s family has said, maybe the next time Topeka police are called to help someone in a mental health crisis, they won’t end up killing them.
“If you want to create transparency and accountability and to restore the trust that this community has lost … release the doggone tapes,” Kelley’s sister Christian said at a press conference in February.
The Promise of Body-Worn CamerasAfter Brown’s killing, the Department of Justice stepped up funding for police to buy body-worn cameras, providing more than $184 million over the next decade. By 2016, nearly half of 15,328 law enforcement agencies across the country, and 80% of police departments with more than 500 officers, had begun using the cameras, according to the Department of Justice. For many police officers in America today, body cameras are standard-issue equipment that they are supposed to turn on during most law enforcement activities.
The videos, advocates say, can help civilians fact-check the official account of what happened in a contentious incident, such as when police use force or take someone’s life.
“Law enforcement has the power of credibility on their side,” said Dawn Blagrove, an attorney with Emancipate North Carolina, a group that helps families get access to body-worn camera video. “Even though time and time again they are proved to be uncredible or unreliable, people still are disposed to believing whatever narrative law enforcement puts out.”
Sometimes the release of those videos can spur change. In the last two years, Raleigh, North Carolina, police banned no-knock warrants and adopted a deescalation policy for encounters with people in a mental health crisis. The reforms were made, Blagrove said, because body-camera video helped document what police were doing wrong in such encounters so they could try to fix it.
Varying Disclosure PoliciesPolice departments involved in 14 of the June 2022 deaths that ProPublica reviewed released the body-camera footage because a department policy or a state or local law demanded it. The requirements vary. Seattle, for example, has a department policy calling for video to be released within 72 hours of a “critical incident,” while in California, a state law requires all departments make the footage public within 45 days.
The videos often begin with a brief introduction by an officer, followed by edited and redacted footage. Sometimes, they are accompanied by 911 recordings and video from dash cameras or drones. Other times they include stills of a weapon the victim allegedly carried. When Akron, Ohio, city leaders held a news conference to release video from the June 27 shooting of Jayland Walker, they included footage from eight officers,
When Akron, Ohio, city leaders held a news conference to release video from the June 27 shooting of Jayland Walker, they included footage from eight officers, in accordance with a city law mandating such disclosure within a week of an incident.
“It is clear what our community wants is to be able to review the information for themselves,” said Mayor Dan Horrigan at the news conference. “It is our commitment to be as open and transparent as we can be.”
The videos showed that officers shot 25-year-old Walker 46 times in under 10 seconds, sparking protests. In April, a grand jury decided the officers should not be indicted on criminal charges. Walker’s family has filed a civil suit against the city.
But Akron isn’t the norm.
Some departments that have disclosure policies don’t always follow them. The New York Police Department, the largest in the country, is supposed to release video within 30 days of a critical incident. But a ProPublica review of the department’s data found that of 380 such incidents since the policy was enacted, the department released videos only 64 times, and only twice within its own 30-day time frame. A spokesperson for the NYPD said that privacy concerns, local laws or unspecified department policies kept it from releasing more of the videos. “The NYPD remains wholly committed to its policy of releasing such recordings as quickly and responsibly as circumstances and the law dictate,” the spokesperson wrote.
Many other departments — including 11 from ProPublica’s June 2022 review — said they cannot disclose body-camera footage while incidents are under investigation.
That’s the reason Savannah police cited when they denied requests from ProPublica to see the video of Lee’s killing.
Advocates for more transparency, though, say making video available to the family and the public should happen regardless of how an investigation is proceeding.
“The point of the tape being released is expediency in getting it to the public,” said Juandalynn Givan, a state lawmaker in Alabama who has pushed for more transparency there. “You might not have convened a grand jury for six or eight months."
State Law Blocks the WayIn many states, the roadblocks to disclosure are encoded into the law.
In Pennsylvania, for example, a law passed in 2017 — after the state supreme court ruled body-worn camera footage is a public record — requires requests for video to be made in person or via certified mail within 60 days of an incident. And police and prosecutors are given broad discretion to withhold video if they see it as evidence in an investigation. “It actually serves more as a block to accountability and transparency than it does to foster release of information,” said Terry Mutchler, an attorney who has helped clients obtain video through court orders.
That’s what allows Philadelphia, one of the largest departments in the country, to routinely withhold video.
A spokesperson said the department is “committed to transparency and accountability” and added that “the legal framework governing the release of BWC footage is designed to balance the public’s right to information with the need to protect ongoing investigations and sensitive details.”
In Alabama, Kansas and South Carolina, the law makes footage confidential by default, often classifying it as an investigative record akin to a police interrogation, which can be released at the discretion of police or a judge.
Alabama’s Law Enforcement Agency cited state law when it refused ProPublica’s request for video of the June 9, 2022, fatal shooting of Robert Tyler White by an off-duty Rainbow City police officer. Police say White tried to enter the officer’s vehicle and an elementary school. White’s family has said he suffered from depression and may have been suicidal but does not think he was trying to harm others.
Kansas law allows families of victims to view footage within 20 days of a request, but there is no requirement for police to release it to the public.
ProPublica’s request for footage of Kelley’s killing was denied under that law. Releasing the video, the city of Topeka said, “is not in the public’s interest.”
But Kelley’s family members, who have seen the video, want it to be made public because they say it highlights how police mishandled a mental health emergency. Saunders, the family’s attorney, says the video shows police surrounded Kelley and unnecessarily escalated a situation. “After 50-plus minutes of him asking them to leave him alone, him trying to run away … you can see he just got to a point where he was already broke,” Saunders said.
She said he did not charge at police with a knife, as the department has claimed. “He tried to make a run for this little path that they had made, but as soon as he headed down that path they shot him several times,” she said
State investigators and Topeka police declined to comment on what the video showed and directed questions to the district attorney’s office, which did not respond to interview requests. In September 2022, the district attorney cleared the officers of wrongdoing.
Four months after Kelley’s death, Topeka police killed another man whose family had called 911 because he was having a mental breakdown. Saunders, who has seen body camera video from that incident as well, said it showed police chased Taylor Lowery and surrounded him as he held a wrench and stood next to a knife. Five officers then shot and killed him. The district attorney found the killing was justified, saying Lowery had tried to carjack someone and was a threat to police officers. Lowery’s family disagrees and wants video of that killing to be released to the public.
Having the public see what transpired, Saunders said, could spark reforms like redirecting 911 calls to mental health crisis teams rather than police. But, she said, that first requires the public to see the video that contradicts the official narrative. “They’re making it look like these two men were violent or attacking, and that was not the case,” Saunders said. “If anything, they were under attack, they were retreating, they were running, they were trying to get away. And so they [the families] just want the public to see the real truth.”
North Carolina law requires a court order for footage to be released to the public. ProPublica found three killings in June 2022 for which video exists but has not been released, and in each case police denied our request, citing that law.
Even families must petition a judge to get a copy of video. Without a court order, they have to ask police to let them view the footage at police stations. Police chiefs, district attorneys and a host of other law enforcement personnel, possibly even the same officers involved in the killing, can legally be in the room and have the power to choose which parts of a video a relative can see based on their interpretation of the statute.
“There is no way for you to watch the video without essentially going into the belly of the beast,” said Dawn Blagrove, who crisscrosses the state to accompany relatives to police stations to view footage. Their goal, she said, is “making sure that when people are having to relive, or see for the first time, a loved one taking their last breath, that they don’t do that without some support, that they don’t do that alone.”
In the wake of the May 2020 murder of George Floyd, advocates in North Carolina attempted to reform its body-camera law as part of a broad criminal justice reform bill that included provisions for releasing video to the public, said Blagrove, who served on the governor’s Task Force on Racial Equity in Criminal Justice, which drafted the bill. “Once they got it into the General Assembly, the real substantive parts of those recommendations that would have created real change were gutted,” said Blagrove.
Instead, changes to the law made accessing video even more difficult, requiring a court order. The fallout from the law, Blagrove said, has been devastating. “It is just a system that is designed around protecting law enforcement and, simultaneously, creating a chilling effect on friends and family who want to get some answers as to how and why their loved one has died.”
In many of these states, lobbying groups representing law enforcement officers and prosecutors have played a decisive role in keeping video out of public reach. The North Carolina Sheriffs’ Association, for instance, successfully blocked the reforms Blagrove and other advocates were hoping to enact into law after 2020. In Alabama, lobbying on behalf of police chiefs, sheriffs and district attorneys helped block two proposed laws that would have allowed the public to request video. Law enforcement lobbying groups have also thwarted efforts at reforms in Kansas since 2015.
Selective ReleaseWithout uniform state policies in place for when video must be released to the public, Blagrove and other advocates say police departments have been able to selectively release footage to support their narrative, while often hiding images that might be embarrassing or worse.
This January, police in Raleigh said they killed Daniel Turcios, a Hispanic man they encountered on the interstate after a traffic accident, because he was high on drugs and threatening them with a knife. Police released an edited video supporting that narrative. But after public pressure, they released the full video along with a toxicology report, which showed something very different, Blagrove said. “They chased him and they shot him and killed him in front of his family,” Blagrove said. “They had him written off as this knife-wielding, drug-induced man, and by the time we were finished with it, it was like a family man was shot in front of his children.”
Alabama lawmakers adopted North Carolina’s law, almost word for word, this June.
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This story details allegations of sexual assault.
This article was produced for ProPublica’s Local Reporting Network in partnership with The Salt Lake Tribune. Sign up for Dispatches to get stories like this one as soon as they are published.
In June 2022, Yanett Bernal walked into the police station in Provo, Utah, to report that her OB-GYN had sexually assaulted her. She said after making a written statement she told a detective over the phone how David Broadbent conducted painful vaginal and rectal exams during her last pregnancy.
A month later, Bernal went back to the station to ask for a copy of her report. A worker at the reception desk told her that a report didn’t exist, she recalled.
“They said they had nothing,” she said, “and didn’t tell me I should do it again or anything.” What they did tell her, she said, is that she should call a number to speak with someone in Spanish and to wait for a detective to call her back.
Another month went by, and still Bernal hadn’t heard from the detective.
So Bernal turned to an independent victim advocate named Gloria Arredondo. She had been fielding similar questions from women who, like Bernal, were having difficulties making reports about Broadbent to Provo’s Police Department or accessing their records. All were native Spanish speakers from Mexico. Some told her it was hard to get someone at the department to take their cases seriously or even to call them back.
Arredondo suggested that Bernal and others visit the Mexican Consulate, an hour away in Salt Lake City, for help.
Arredondo, who has worked with Latino victims of crimes since 2012, said this was the first time she’s involved a consulate in order to get a callback from the police.
“It’s been very frustrating to see them not be able to make a report,” she added. “For me, it was common sense that you went to the police, they took your report and started to work on it.”
The consulate confirmed that at least two women did go to its offices “looking for support” and that it called the detective in charge in August to ask for an update on the case. The goal, said Maria Fernanda Gomez Contreras, head of the consulate’s office of protection, was “to ensure that the women are being heard and that they deserve the same treatment as anyone else.”
Bernal, who did go to the consulate, is one of 49 women who went to Provo police over the last nearly two years to report that Broadbent sexually abused them. Utah County prosecutors are considering charges in some of the cases but have not decided whether to criminally charge the doctor. He has agreed to stop practicing medicine while this police investigation is ongoing. As part of a separate civil case, Broadbent’s attorneys have said sexual assault allegations against him were “without merit”; the doctor did not respond to a request for comment, sent through his lawyer, about this case.
In March, 20 Mexican immigrants filed a civil lawsuit against two hospitals where Broadbent worked, saying that they knew of his alleged misconduct and failed to act. (Attorneys for the two hospital systems have asked a judge to dismiss the suit, arguing that Broadbent’s alleged actions against these women didn’t take place on their premises. One of the hospitals, MountainStar, also said in a statement it was not aware of complaints being made to the hospital itself, that Broadbent is not and was not a hospital employee, and that he doesn’t have privileges there now.)
The Salt Lake Tribune and ProPublica interviewed 14 of those women who, between March 2022 and April 2023, went to the police station to allege that he inappropriately touched their breasts, vaginas and rectums during exams — often without warning or explanation, and in ways that hurt them and made them feel violated.
Valencia, first image, and Alvarez, second image, went with a group of women to the Provo police station in March 2022 to report Broadbent for sexual assault. Valencia told them the doctor touched her in ways that felt inappropriate as she was seeking care in 2006 for a high-risk pregnancy. Alvarez said Broadbent conducted painful exams and made comments about her appearance that felt inappropriate during her visits in 2011. (Francisco Kjolseth/The Salt Lake Tribune)The interviews by the two news organizations also reveal that many of these women faced delays, language issues and insensitive interviews when they went to the police. Of the 14, five said police turned them away at least once.
Getting the Mexican Consulate involved appeared to have worked for Bernal: She said soon after, she heard back from a detective regarding her case.
“That was when they changed here,” Bernal said. “They changed and they listened to us.”
Provo police Capt. Brian Taylor did not address the women's complaints, saying he couldn’t publicly discuss case specifics. He said the department “systematically collected interviews and presented reports to the Utah County Attorney’s Office.”
“Reporting sexual abuse is a deeply personal decision,” he added. “We honor victims who come forward and encourage people to do so.”
Over the last year, The Tribune and ProPublica have investigated obstacles that Utahns face when seeking justice against medical providers who they say sexually assaulted them. A February article detailed how a different group of women similarly accused Broadbent of sexual misconduct and sought justice in civil court — just to have a judge dismiss their case, ruling that it fell under medical malpractice law instead of a civil sexual assault claim. The women have appealed the ruling to the Utah Supreme Court, which is considering the case.
An August investigation by the news organizations showed how patients of a Utah County therapist had reported alleged inappropriate touching to both state licensers and local leaders within The Church of Jesus Christ of Latter-day Saints; neither group reported the therapist to law enforcement. Both said they take allegations of sexual assault seriously and indicated that they had addressed the complaints through their own processes.
But Bernal and these other women did go to the police. And they’re still waiting to see if anything comes of their efforts.
“He Said the Doctor Was Doing His Job”From the beginning, some of the 14 women we interviewed said their efforts to give statements about Broadbent to the police were stymied. Body-camera footage shows that in at least two cases, police officers took initial information in a hallway — sitting on a bench under the station’s public “Wall of Honor” in the police lobby, where photos of fallen officers are displayed — rather than a private interview room.
In this screenshot of police bodycam video, one woman who went to report Broadbent — who was obscured by police behind the rectangle to protect her privacy — was interviewed under the station’s “Wall of Honor.” On her left, Wilma Castro, a Spanish-speaking victim advocate with Provo police, sits with the alleged victim as an officer conducts a preliminary interview. In at least two cases, police officers interviewed alleged victims of sexual assault in the lobby instead of a private room. (Obtained by The Salt Lake Tribune and ProPublica)A staff victim advocate accompanied the officer as each case was discussed out in the open. Taylor said officers taking initial reports will move an alleged victim to a more private area, he said, if there are people in the police lobby. It is not clear from body-camera footage whether there were others in the hall during the interviews, but in one instance, audio on the video picks up others passing by and talking within earshot of the woman sharing her complaint with the officer. Arredondo, who accompanied one of the women, said the hallway felt like an unusual place to ask the women to share.
“I worried about their privacy,” she said.
The first detective on the case was Kevin Fernandez, who joined the Provo Police Department in 2018 after becoming a sworn officer. Fernandez’s family comes from Mexico City, according to a 2020 Daily Herald article, and he grew up in Southern California. The detective speaks Spanish, and the Police Department said he has conducted more than 300 investigations as a Special Victims Unit detective in his six years with the force. The Tribune and ProPublica did not speak to Fernandez directly, but Taylor said the detective was consulted in response to questions sent to the department.
In the first six months of the investigation, Fernandez was the assigned officer in 30 reports involving Broadbent.
Maria Eduviges Bernal, who is Yanett’s aunt and also reported Broadbent to the police, remembers that she struggled to detail to Fernandez how Broadbent touched her vagina in ways that felt inappropriate during 2018 appointments. After providing her statement, Eduviges Bernal said Fernandez concluded that her doctor hadn’t done anything criminal.
“He didn’t see it as a crime,” she said he told her. “He said the doctor was doing his job.”
In his summary notes, Fernandez expanded on this assessment:
“I advised that there is no way to prove there was any sexual intent or gratification on behalf of the doctor. The doctor had a legitimate reason for having his hands on and in the patients [redacted]. The doctor did not do any inappropriate movements that would show any sexual intent. I advised [redacted] of how the interaction does not meet the elements of a crime and that this case would be closed. [redacted] advised she understood and is glad this is being documented.”
This immediate conclusion stunned and broke her morale, Eduviges Bernal said. Not usually an outspoken person, she said she was intent on filing the report — if only for her records and so that other women in her family, including her daughter, might avoid future harm.
“You go [to the police] because you think they’re going to help you or they’re going to give you attention,” Eduviges Bernal said. “I wasn’t expecting for him to have an opinion.”
Provo police station, located within the community’s City Hall (Francisco Kjolseth/The Salt Lake Tribune)Deciding before an investigation whether a crime took place is discouraged by The International Association of Chiefs of Police sex assault investigation guidelines. So is including an opinion in a written police report.
“Every effort should be made to exclude officer opinion in the written report and to avoid asking leading questions,” the IACP guidelines recommend.
Taylor did not respond to a question asking if Fernandez should have offered his conclusion that there was no way to prove sexual intent in Eduviges Bernal’s case.
In January, civil attorneys representing some of the women became concerned about the detective’s investigative methods. A year had gone by since some of their clients reported Broadbent to police, and Fernandez had still not gotten their clients’ medical records.
Attorneys Eric Nielson and Marianne Card sent a request to prosecutors asking that the police assign a new detective. That did happen, though Taylor said the new detective was assigned in order to balance the workload as she transitioned into the Special Victims Unit.
Card said that once the new detective was assigned, most of her clients were interviewed again.
According to RAINN, a national anti-sexual-violence organization, trained law enforcement teams should work together to “reduce repetition of questions and interviews.” These re-interviews also seem to go against Provo’s own best practices; Taylor said detectives “work to minimize the number of times a victim has to make a disclosure." Any re-interviews in this case, Taylor said, were done at the request of the civil attorneys. Nielson, however, said he believed the re-interviews were a “tacit admission” from police that the investigation wasn’t done properly the first time.
Santacruz (Francisco Kjolseth/The Salt Lake Tribune)Martha Santacruz, one of the 14 who spoke to The Tribune and ProPublica, said she had a positive experience making a report with Fernandez but found being re-interviewed and reviewing her evidence this past April difficult.
“I felt very bad because it is a very hard thing to relive. ... I kept thinking what happened with the other report that we already had?” Santacruz said. “I don’t know what he did. I don’t know what happened.”
“Highly Deficient” Language ServicesAs low-wage immigrant workers and mothers, going to law enforcement to accuse an American doctor of sexual assault was an unprecedented experience for all. And one of the major issues they encountered was finding an officer who could understand Spanish.
Some of the women told The Tribune and ProPublica they were turned away because no one was available at the department who could speak Spanish. Others were met with delays: In one police report, it was noted that a woman called the department because she had been told a Spanish-speaking detective would contact her, but she had been waiting for four days and hadn’t heard back.
The American Civil Liberties Union of Utah this summer labeled the Provo Police Department’s policies for language access as among the worst in the state, calling its language services policies to non-English speakers “highly deficient.”
The nonprofit examined police policy manuals throughout Utah and noted that Provo does not have a formal written policy addressing access to language services. The city was one of four Utah municipalities to receive a “highly deficient” rating.
Utah led the nation in population growth over the previous decade, according to the 2020 census, becoming less white and homogenous. A quarter of Provo’s population of nearly 115,000 people speak a language other than English in their homes, according to the Census Bureau’s most recent American Community Survey. Latinos now make up almost 18% of the population, and Spanish is the most common language after English.
“Language access isn’t a privilege, it’s a right,” said Andrea Daniela Jimenez Flores, immigrants’ rights policy analyst for the ACLU of Utah. “Utah’s laws and policies have to reflect that reality and ensure that no one’s denied justice, dignity or well-being because of the languages they do or don’t speak.”
Some of the women who reported Broadbent told The Tribune and ProPublica that they relied on a volunteer interpreter or a family member when they spoke to police. One woman said on at least one occasion she relied on a cousin to translate for her — an issue of general concern to the ACLU of Utah.
The nonprofit noted in its report that the Provo Police Department doesn’t use authorized interpreters and instead relies on Spanish-speaking officers or on other community resources, such as The Church of Jesus Christ of Latter-day Saints’ Missionary Training Center.
When asked how often this happens in Provo police investigations, Taylor said that using family members to interpret for alleged victims is “a problem.”
“If a family member is used or, even worse, a child, they are also victimized,” he said. “Also, validity of statements is called into question when impartiality of translators cannot be assured.”
Taylor said the police have a “patchwork” of language services and are not staffed 24 hours a day with Spanish-speaking personnel. While there are 21 officers who speak Spanish to some degree, Taylor said, the department doesn’t know how many of its officers would test as proficient in the language.
Taylor said the department agrees with the findings in the ACLU report, adding that limited English proficiency shouldn’t be a barrier.
“We are reviewing our practices,” he said, “comparing them to the recommendations of the ACLU report and reviewing possible policy improvements.”
Left Waiting First image: Bernal told Provo police in July 2022 that Broadbent had grabbed her breast and conducted genital exams that felt inappropriate to her. She said at the time she deferred to his authority: “We come from a ranch,” she said. “We are not educated, so we thought he was doing the right thing because he was schooled and knew what he was doing.” Second image: Jacobo went to Provo police in April 2023 to report that Broadbent had touched her inappropriately during exams when she was pregnant in 2014; she said she didn’t feel supported or believed by police officers when she reported, calling it “one of the worst days of my life.” (Francisco Kjolseth/The Salt Lake Tribune)Even after interventions by lawyers, an advocate and the consulate, the language barriers and delays have continued. In April, when Bereniz Robles walked into the Police Department, it took her three attempts before anyone would take her report about Broadbent.
Each time Robles went to the police station, she said, she was told there was no one working who spoke Spanish. Robles said she was told she could come back later or call at a different time.
She was eventually able to make an early morning appointment in April. Accompanied by Arredondo, the victim advocate, she arrived at the scheduled time — but the doors were locked and they had to wait a half hour before someone let them in.
Robles, who saw Broadbent as a patient more than a decade and a half ago, said she was motivated to make a report in order to keep the doctor from practicing again. But she said there were many moments, including that morning, when she considered giving up.
“There is no point in talking if they are not going to pay attention to you,” she said. “It was one of the moments that I was very discouraged.” She said that while the report she gave accurately captured her experience with Broadbent, the process to get it done left her feeling “worthless.”
Utah County Attorney Jeff Gray said in a November interview that his office is reviewing the cases as a whole and hoped to make a decision on charges by the end of the year. However, on Friday, he said that after consulting with a medical expert, prosecutors determined more follow-up interviews were needed.
But Nielson, one of the civil attorneys, is frustrated and has twice sent letters urging Gray to prosecute the case — drawing parallels to other cases like former Columbia University OB-GYN Robert Hadden and former USA Gymnastics Coach Larry Nassar, both serving prison time for sexually assaulting their patients during exams.
Gray pushed back. “We will file charges, or make a determination on filing charges, when our investigation is complete — no sooner and no later,” the county attorney said.
Gaspar (Francisco Kjolseth/The Salt Lake Tribune)Almost two years after she reported to the police, Maria Gaspar, one of the 14 interviewed, said she still fears not being believed as an immigrant woman who is publicly calling out an alleged sex assault.
And she said her four daughters are her motivation to get through the denials and delays.
“I’m still afraid,” she said, “but at the same time it gives me strength because I say I have to teach them something good, not to keep quiet here or in Mexico.”
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When questioned by federal officials or faced with an accident, the nation’s powerful freight railroad companies say they are among the safest employers in America and tout their injury records to prove it.
But those statistics belie a troubling dynamic within the companies, ProPublica found: a culture that blames workers when they get hurt and motivates supervisors to go to extreme, and sometimes dangerous, lengths to keep injuries off the books.
The playbook is scattered across the pages of sworn court testimonies and complaints to workplace regulators. One supervisor said in a deposition that he drove a track repairman, who had been vomiting and stumbling from heat stroke, to a job briefing site an hour away instead of a hospital. Another admitted he paid a carman to hide his head injury. A third accompanied a hurt worker into an emergency room, according to a recent complaint to regulators, and demanded, successfully, that a doctor change his discharge record so that the railroad would not have to report the injury to the government.
Other railroad workers told ProPublica they had gotten hurt on the job but chose to keep it quiet, saying they were aware of what happened to those who talked.
The allegations of harassment and retaliation came alive in hundreds of interviews conducted by reporters and thousands of records they reviewed, including federal lawsuits stretching back 15 years, complaints to the Occupational Safety and Health Administration as recent as this summer and hours of audio recordings captured by workers.
The reporting showed how railroad officials pushed arguments that workers faked their accidents or were at fault for them, at times hiding evidence to the contrary. The officials then punished and fired workers, including those who lost fingers and limbs, for reasons that fell apart when tested in court.
Judges, juries and regulators found several of these firings unjust and illegal; documents of their official findings burned with outrage:
“Reprehensible.”
“A culture of retaliation.”
“Pattern and practice of willful misconduct.”
“There is no justice for employees injured on the job.”
Though the companies won at least 10 of the cases, every one of America’s six largest freight rail operators, the so-called Class 1s, settled lawsuits with workers who alleged they were retaliated against, harassed or fired after injuries; of 185 suits, at least 111 were resolved this way. Several more are ongoing, and at least a couple resulted in jury verdicts for the injured workers.
In addition, in the past five years, OSHA regulators found merit to at least six complaints alleging retaliation, and administrative law judges working for the Department of Labor sided with workers in at least six more cases within that time period. Regulators acknowledge these cases are likely an undercount, because not all workers will go through the arduous process of filing a complaint or lawsuit.
Several officials who investigate worker injuries told ProPublica that the rails are unique in how aggressively they deal with hurt workers. The antagonism is baked into railroad culture, ProPublica found.
In other industries, employees can draw workers’ compensation, no matter who is at fault for their injuries; in return, they are prevented from suing their companies. The railroads, however, are governed by the Federal Employers’ Liability Act, which allows hurt workers to sue and get bigger payouts but requires them to prove their company was at fault.
Layer on top of that company performance metrics and bonus systems that punish managers for reporting injuries. “We’re constantly going up against that, and it’s very frustrating,” said Michael Wissman, who audits railroad companies for the Federal Railroad Administration, which oversees rail safety. He said he recently set out to investigate an injury an employee’s colleague reported, but then, when he asked the worker about it, the man denied he was hurt enough to need government attention and seemed hesitant to say more.
“I feel for the employee if he was fearful for his job,” Wissman said. “My hands are kind of tied. I have nothing to go on.”
Congress has known for decades of the railroad industry’s propensity for hiding and lying about worker injuries. It held a landmark hearing in 2007 to examine the practice. Congressional staffers found government reports that identified “a long history” of railroads underreporting injuries, deaths and near misses. They had identified more than 200 cases in which workers said they were harassed following injuries and lined up a number of them to speak. “We are going to hear some very startling and dismaying testimony,” House Transportation and Infrastructure Committee Chairman James Oberstar said at the beginning of the hearing, “but it has to be laid out in the public.”
In the wake of those hearings, Congress passed an update of the Federal Railroad Safety Act in 2008, which toughened safety rules, oversight and whistleblower protections and specified that railroad companies had to ensure their injured workers got prompt medical care.
But 15 years later, ProPublica found, many of the problems persist, in large part because many of their drivers persist. “I believe it’s linked to their bonus structure,” Wissman said of the rail companies. “There’s no ands, ifs or buts about it.”
The Association of American Railroads, the industry’s lobbying arm, did not comment on those incentives but said employee safety has improved because of the companies’ concerted efforts.
“Railroads patently reject the unsubstantiated allegation that there is a systemic safety culture lapse or widespread underreporting of injuries,” association officials said in a statement. “Isolated incidents or behaviors do not reflect an industry-wide problem or account for the thousands of professional railroaders who work safely and responsibly every day. Let us be clear: there is no distinction between railroad culture and safety culture. Railroad culture is safety culture.”
The railroad companies mentioned in this story echoed those points, saying their rules require them to promptly report injuries and forbid retaliation against hurt workers. “Allegations that managers are incentivized to hide or ignore injured employees are false,” a Union Pacific spokesperson said in a statement. Read the companies’ and AAR statements.
Karl Alexy, chief safety officer for the FRA, said there is a “yawning gap” between what he hears from top leaders and the management culture on the ground level. “These guys up at the headquarters certainly have the perspective that it’s unacceptable and they don’t want it to happen,” he said. In fact, according to the FRA, Union Pacific disciplined one or more managers this summer for misclassifying injuries so that they didn’t have to report them to regulators.
“But then they’ll turn around and put these unrealistic expectations on these managers out in the field,” Alexy said, “and [the managers] are like, ‘I got to do whatever I can do, because otherwise, I’m going to lose my job.’”
ProPublica previously reported about how, in a quest to maximize profits, railroad companies are pushing managers to keep trains moving at all costs by using performance metrics that penalize them for delays, even those caused by fixing safety hazards. Those scorecards, which can dictate five-figure bonuses, also tally worker injuries. But it’s not just about money.
ProPublica spoke with seven railroad workers who were managers at CSX, Norfolk Southern, Union Pacific and Canadian National between 2011 and 2021. Most are still employed by those companies. All described an industry philosophy that deems every injury preventable — and the fault of the employee and their manager.
Having a spate of injuries can kill a career, they all said. “It decides who is on the fast track for promotion … and it decides who fizzles out,” one manager said. Another said that when he was first promoted, he slammed his finger in a train door and broke it. “There was no way in hell I was going to report that to anybody,” he said. Today, his finger is still bent.
None of the former managers believed that employees should escape discipline for injuries due to sloppiness, poor oversight or failure to follow procedures. But they said the railroad’s prosecutorial approach to handling injuries includes those no one could have avoided.
As supervisors, they all said, the injuries they dreaded most were those serious enough to report to the FRA, because they invite time-consuming government intervention and ire from higher-ups who brag about their safety record to customers, shareholders and the public. Federal regulations require companies to report any injuries that result in a worker being prescribed certain medications, missing time from work or being assigned to light-duty work.
That context helps explain some of the behavior ProPublica discovered.
This August in Minnesota, Canadian Pacific Kansas City bridge specialist Robert Johnston smashed his knee after his leg fell between railroad ties. He said his manager called him repeatedly while he was getting an X-ray at the hospital. “He’s like, I will get you whatever you need, over the counter,” Johnston said. “Anything that you need if you don’t take prescription drugs.”
Johnston had no fractures but was still in pain, his knee swelled to double its normal size, so an emergency room doctor told him to take medicine and a day off from work. But when his bosses later read his discharge papers, they deemed them unacceptable, Johnston told ProPublica and said in a complaint he filed with OSHA.
Robert Johnston said he injured his knee while on the job for Canadian Pacific Kansas City. (Jenn Ackerman for ProPublica)In the complaint and interview, he said Nate Lund, one of his supervisors, told him they needed to go back to the emergency room and get the papers changed. Johnston said he refused, but Lund insisted. “We sat there and sat there and he hounded me and hounded me,” Johnston said. Desperate to go home, Johnston said, he relented. (When reached for comment, Lund hung up on a ProPublica reporter and later did not respond to questions sent by text.)
At the hospital in Wabasha, Johnston said Lund took over, telling medical staff he needed the paperwork to change. The doctor, Johnston recalled, was beside himself, shaking his head in disgust. “Fucking railroad,” he recalled the doctor saying, and then mouthing to him, “Get a lawyer.” Johnston recalled Lund asking the doctor if he could retype the discharge papers. The doctor refused; the most he would do is cross out the instructions in pen, leaving the original instructions plainly visible.
The original papers given to Johnston by a doctor (Redacted by ProPublica. Courtesy of Robert Johnston.)Despite the discomfort in his knee, Johnston said, he went to work the next day and his managers were happy to see him and very accommodating. “I mean, they literally would have given me a La-Z-Boy and fed me grapes,” he said. “They did not want me to do anything, but they didn’t want me to have a day off. It was really weird.”
Johnston resigned from the railroad about three weeks after his accident. In a statement, Canadian Pacific Kansas City said Johnston’s story “does not align with the information [the company] has regarding this situation” and declined to comment further. An OSHA investigation is pending.
A stretch of railroad along the Mississippi River near Minnesota City, Minnesota, about 10 miles from where Johnston was injured (Jenn Ackerman for ProPublica)An earlier case peels back the pressures managers face when their workers get injured.
In 2015, Pierre Hunter, a general supervisor at Illinois Central Railroad, a subsidiary of Canadian National, got a call from a higher-up after one of his employees, carman Cameron Davis, hit a pothole while driving an ATV in a Memphis rail yard and damaged it. Word had gotten around that Davis had gotten hurt in the accident.
Hunter’s supervisor Darrell Hoyt wanted Hunter to make sure the injury didn’t have to be reported, Hunter said in a recorded statement with Davis’ lawyers. “You need to get that fixed. Handle it. Do what you got to do,” Hunter said Hoyt advised him. “Don’t put your job on the line for another employee.”
Hunter said he was certain his job hung in the balance as he repeatedly called Davis and pressured him not to tell anyone he’d had doctors look at his head, which was throbbing and swollen. Davis recorded some of the calls, which later became part of a lawsuit against the company. “Just stick to your story if anybody asks. You never went to a damn hospital. You ain’t injure yourself at all,” Hunter said. “Don’t say shit else to … no goddamn body, not a fucking soul on CN property.”
“You Ain’t Injure Yourself at All”Pierre Hunter, a general supervisor at Illinois Central Railroad, asks carman Cameron Davis not to tell anyone about an injury.
(Obtained by ProPublica)“What’d the doctor say?” Hunter continued. “They give you something or they say you’ll be all right? … No medication, none of that shit, right?”
In the recorded call, he advised Davis to cover the big bump on his head with a knit hat so that he wouldn’t arouse talk among his co-workers.
Hunter later told Davis the best way out of trouble for the accident was to sign a statement admitting it was his fault, not tell anyone about his injury and take a 15-day suspension without pay. “Take my word, they want to get rid of you,” Hunter recalled telling Davis. Davis said he couldn’t afford to be off for two weeks, but Hunter had a way around that, too: “Bribe him to not report it,” he said in his statement to Davis’ lawyers. While Davis served out his suspension, Hunter gave him $1,500.
Davis ultimately reported the injury anyway. About six months later, he was fired, accused of violating safety rules like not maintaining the proper distance away from moving equipment and working without protective eyewear. "I was targeted because of what happened,” Davis told ProPublica. “It was retaliation for the injury.”
Once the railroad heard the taped phone call, it also fired Hunter.
Emails, calls and social media messages to Hunter went unanswered. Hoyt told ProPublica in a message that he didn’t remember the affair and that it wasn’t “consistent with company policy or my application of safety commitments.” Canadian National settled the case with Davis for an undisclosed amount. A spokesperson told ProPublica the railroad doesn’t comment on “individual personnel cases.”
During the 2007 hearings on Capitol Hill, workers testified about being left to die by the tracks while railroad managers ignored pleas for care. The 2008 update to the Federal Railroad Safety Act required the companies to provide “prompt medical attention” and mandated that railroads bring injured workers to the hospital as soon as they ask.
About five years after the harrowing congressional testimony, outside Chicago, a supervisor was driving a Union Pacific machine operator, Jared Whitt, to the hospital. Whitt’s lips felt as if they were about to burst and his arms and legs tingled, he testified as part of a lawsuit he later filed. He closed his eyes and thought about his five kids. Was he dying? “Please,” he recalled telling his manager: “Get me there. Please hurry.”
Whitt had suffered a heat stroke as June temperatures climbed to about 100 degrees, and his manager, work equipment supervisor Dave Birt, believed Whitt was going into cardiac arrest, Birt said in his deposition. They had just started toward the hospital when Birt’s cellphone rang. “Well,” Whitt heard Birt say, “what do you want me to do?” A pause. “I’m no doctor, but when a man’s arms are numb and tingling, I’d say he needs to go see one.” Pause. “I’m pulling over.”
Birt held the phone to Whitt’s ear. Whitt couldn’t hold it himself because his numb arms had retracted, his fists clenched at the top of his chest, Whitt said in his pretrial deposition. The man on the other end was Birt’s boss, manager of track programs Talmage Dalebout. “Why don’t we just bring you back here to the job site and get you cooled down,” Whitt recalled Dalebout saying. “If you get cooled down, you’ll probably be OK.” Birt declined to comment when reached by ProPublica. Dalebout didn’t respond to calls, texts and social media messages.
Union Pacific claims in the lawsuit that Whitt never requested to be taken to the hospital and, when Birt says he asked, Whitt chose the job site. But experts say workers suffering from heat stroke —a potentially life-threatening condition marked by confusion in which body temperatures can rise to 106 degrees — lack the faculties to make any decision for themselves; someone should always take them to the hospital regardless of what a worker requests. In hindsight, Birt said later in deposition, he wished they had continued to the hospital.
Back at the job site, Whitt testified that he remained in Birt’s truck for some time. A co-worker brought him Gatorade and bottles of water. Then he recalled ending up in a trailer, where people were pouring cold water over him and his co-workers were rubbing his arms to restore circulation, according to Whitt. He didn’t get to the hospital until some four and a half hours after his body started tingling and his consciousness began slipping, according to court records. His roommate drove him.
The heat stroke partially disabled Whitt, he said in his court deposition. He no longer had the strength to work at the railroad and for years struggled with his left arm and hand, which went numb whenever he raised it above his shoulders. Two years later, Whitt had surgery to restore movement to his left arm. The surgeon cut away part of his left pectoral muscle and removed his left upper rib. Whitt sued Union Pacific, and the railroad settled with him for an undisclosed sum.
Whitt, who now works as a home inspector, said he still can’t believe that a manager intervened to redirect him away from the hospital. “It’s unfathomable,” Whitt told ProPublica. “I can’t imagine treating a human that way.” Today, he says, his arm remains tight, with a limited range of motion and numb at the armpit.
The cautionary incident didn’t appear to influence what happened three years later, when another Union Pacific worker fell ill on a blistering hot day in Kansas, according to records from a lawsuit he later filed.
Guillermo Herrera worked in the same road crew as Whitt, which roves throughout the company’s western region repairing tracks. On July 26, 2015, Herrera’s worried co-workers called higher-ups. The track repairman had vomited and was out of it, according to the court records. When the bosses came to get Herrera, he needed assistance getting into a pickup truck. He whispered a plea for help into his foreman’s ear; “Ayudame,” he said, according to a court deposition.
Considering the shape he was in, Herrera’s co-workers assumed he was being taken to a hospital, they testified. And indeed, there was one 21 minutes away. But instead, track supervisor Charley Diaz drove him to a job site to cool down, according to his deposition. The job site was about an hour away.
Once again, Union Pacific defended its actions, saying that Herrera would have been taken to a hospital if he had asked, and that Herrera at one point said he wanted to go back to his motel room. (Herrera contends that he was in and out of consciousness but kept saying the word “hospital.”) Either way, Diaz himself suggested he was concerned about Herrera’s mental state. “I told him to stay awake,” Diaz testified. “I didn’t want him going to sleep or anything like that, so I just watched him and asked him how he was feeling mostly.” (Diaz did not respond to calls and text messages.)
Diaz drove Herrera to the job briefing site, a boxcar office on wheels. Safety captain Bobby Steely testified that he checked on Herrera in the truck several times, each time asking him if he wanted to go to a hospital. (Steely declined to comment when reached by ProPublica.) After about 20 minutes, he said, Herrera finally said yes.
Herrera was ultimately diagnosed with heat stroke, which profoundly altered his life.
In the year that followed, he later testified, he could no longer drive safely or get a decent night of sleep. His morning walk around the block was so difficult, he had to sit down for a half hour or so until the tingling in his legs dissipated. His days were all about rest and heat avoidance, and he did physical therapy six hours a week. His family barred him from the kitchen because his memory issues had caused him to start two small fires.
He sued Union Pacific in 2015, a case that settled for an undisclosed amount. Union Pacific did not comment on either of the cases, but a company spokesperson said in a statement that nothing is more important than safety. “Employees complete annual training on how to respond to and handle injuries,” the spokesperson said.
An injury can paint a target on a worker’s back, ProPublica found.
It happened to Montana conductor Zachary Wooten, who damaged his right wrist so severely in 2015 after falling from a BNSF train that he needed surgery. The culprit, he said, was a defective latch on the train; he struggled to open it and felt a stab of pain as his wrist popped. When he tried to climb back up onto the engine after inspecting the train, his wrist gave way and he fell to the ground.
From that moment forward, court and company records show, his supervisors and BNSF lawyers searched for ways he could have come to work already hurt. “They always tried to blame it on something else that happened at home and say you dragged it into work,” said Wooten’s union representative, retired switch foreman Mark Voelker.
Mark Voelker, a retired switch foreman, was the union representative for an injured Montana conductor. “They always tried to blame it on something else that happened at home and say you dragged it into work,” he said. (Tailyr Irvine, special to ProPublica)According to records from an internal company hearing, a superintendent of operations had visited 27-year-old Wooten when he was in the emergency room and asked him how he got a scrape on his other arm. Wooten, who was on pain medication, told the manager he got the rug burn during sex a day before the injury — an episode that also involved his bed breaking. The company took that morsel of information and used it to insinuate that’s also how he damaged his hand, records show. “I am not comfortable answering questions about my sex life,” Wooten told railroad officials during the internal hearing.
ProPublica learned of other unusual arguments used to blame workers, and not safety hazards, for their injuries. Machinist Bobby Moran was wearing his company-issued safety gloves in 2019 when one got caught in a lathe, snapping bones from his forearm down and severing a finger; another damaged finger later had to be surgically amputated. Union Pacific fired him after accusing him of using the equipment in the Arkansas yard for personal reasons, perhaps to manufacture a firearm silencer. “I was fearful,” Moran said. “Me and my wife were thinking, ‘When is the FBI going to show up?’”
Moran said he had been creating a piece of equipment that would improve the functionality of a hydraulic pump he and his fellow machinists worked with in the repair shop; his legal team showed the railroad’s attorneys the device’s schematics and a video of it working just as he said it would. According to Moran’s lawyer, Union Pacific never provided evidence to support its weapon theory before it settled the case. Union Pacific did not comment on it.
Moran at home in Rose Bud, Arkansas. He lost fingers in a lathe accident. (Rachel Boillot for ProPublica)As for Wooten, BNSF pulled several angles of videos to show how, in the hours before the accident, he appeared to be favoring his right wrist by using his left hand. What the company didn’t know is that, according to Wooten, he is ambidextrous, as adept with one hand as with the other. Two months after his accident, the company fired him, accusing him of lying about his injury. Then, when Voelker gave information to Wooten’s attorney about the unrepaired loose handle on the locomotive, he, too, was fired. His dismissal letter cited his “misconduct and failure to comply with instructions when you disclosed confidential BNSF business information.”
A jury believed Wooten’s story, finding he was wrongfully terminated in retaliation for his on-the-job injury; he was awarded $3.1 million. U.S. District Judge Dana L. Christensen denied the company’s appeal, calling BNSF officials’ testimony biased, unreliable, inconsistent and lacking in credibility. “They latched on to an early formed presumption that Wooten was being dishonest that jaded their treatment of Wooten throughout,” the judge said. The company settled with Voelker over his wrongful firing claim.
BNSF has lost at least three cases in recent years in which it tried to allege a worker faked or exaggerated their injuries. In one, the company fired a worker in 2020 who suffered neck and back injuries in a crash because a private investigator surveilled him exercising at the gym — part of a physical therapy and a workout regimen ordered by his doctor. OSHA described the behavior as a “knowing and callous” disregard for his rights and found merit to his argument that he was retaliated against for getting hurt. The company settled his case in court in May.
BNSF did not comment on any cases but said it prohibits retaliation against employees for reporting injuries or safety concerns. “We take any alleged violation of those policies very seriously,” the company said in a statement.
Former managers interviewed by ProPublica said their companies foster a culture in which every injury claim is treated with skepticism. The presumption, one said, is: “How is the person trying to [screw] me? How can we prove he’s lying?”
ProPublica obtained about 10 hours of recorded railroad manager phone meetings that give a window into how supervisors discuss injuries and their efforts to catch employees violating rules. They took place among Norfolk Southern managers in its Tennessee region between January and April of 2016 and were led by Division Superintendent Carl Wilson and Assistant Division Superintendent Shannon Mason. Wilson, whose LinkedIn page describes him as retired, did not respond to calls, text messages, social media messages and a letter sent to his home. Mason, who is still with the company, declined to comment. Norfolk Southern wouldn’t answer ProPublica’s questions about the calls, only saying that they were “routine and focus on safety.”
While the meetings were indeed largely devoted to business like company performance, productivity and safety, the tenor changed nearly every time an injury was brought up, as Wilson and the other supervisors expressed incredulity that it was legitimate and discussed ways the injury could be proven to have been the employee’s fault.
In one call, they discussed an employee who also owned a motorcycle repossession business and questioned whether the injury could have happened there. Wilson told the managers he asked for surveillance of the engineer. “Hopefully he messes up,” Wilson can be heard saying in the call.
On another call, Wilson described one 67-year-old employee with a shoulder injury as a “piece of work” and insisted he was trying to get out of a training session. The managers cast doubt on another employee who said he was attacked by bees: “If there was anything, it looked more like a shaving bump.” Wilson, in another call, lamented losing the chance to fire an employee before he injured himself by slipping and hitting his head: “Quite honestly, he got us before we could get him.” And when they brought up a female conductor who felt her knee pop when she stepped onto a train, the conversation turned to her weight.
“She’s a big gal,” said Wilson, who also referred to her as “cheerful.” “Her joints, her knees are gonna wear out eventually sooner than most of us simply because we don’t carry the amount of weight that she carries.” He joked that if another manager had run her out of the company earlier, they “wouldn’t have this problem.”
The comments disgusted the worker, Amy Simmons, who called the discussion “embarrassing” and “unprofessional” when ProPublica shared the recording with her. She said that railroaders’ knees wear out because they are asked to walk mile after mile along rocky ballast and the company has cut staffing to the bone, demanding moreand more from each employee. “They’re wearing us out because they won’t give help,” she said. “It’s not my weight. If anything, it’s the fact that they overwork us.”
Former conductor Amy Simmons once felt her knee pop when she stepped onto a train. During a phone meeting among Norfolk Southern managers in its Tennessee region, the conversation turned to her weight. She said that railroaders’ knees wear out because they are asked to walk mile after mile along rocky ballast. (Jessica Tezak for ProPublica)She has since left the industry and said she regretted the amount of time she wasted and all that she sacrificed trying to be a good employee. To her, the calls illuminate the way railroad companies truly see their workers.
“They hire you to fire you,” she said. “They don’t care.”
Jeff Kao, Carolyn Edds, Mollie Simon, Mariam Elba, Miriam Pensack and Ruth Baron contributed research.
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When Shawn Murphy’s wife died in 2009 after a botched gallbladder surgery, he presumed the doctor who performed the operation would be forced out of medicine for good.
Dr. Pachavit Kasemsap, a former Air Force surgeon, had cut Loretta Murphy’s aorta during that common procedure, according to a database of malpractice payments kept by Florida insurance regulators. She never left the hospital and died just shy of her 40th birthday. Shawn Murphy was left to raise their two daughters, then 13 and 17, on his own.
During the weeks that Murphy prayed for his wife to recover and the months that he fought Kasemsap in circuit court in Brevard County, Florida, he didn’t know that other families had complained that their loved ones had suffered under the same doctor’s care.
Kasemsap has settled five malpractice cases for a total of $3 million, according to the Florida malpractice payment database. That includes $1 million paid to the Murphy family. In one of the cases Kasemsap settled, a patient said the doctor negligently stapled and stitched her rectum to her vagina. Kasemsap denied doing that, and in legal filings in all five cases, the doctor denied that he was negligent.
The doctor’s LinkedIn profile says his last job as a surgeon ended in December 2012, months before he settled the last of those five cases. But there was one industry ready to welcome him regardless: health insurance.
Kasemsap got a job as an insurance company medical director, where suddenly he had the power to impact the lives of far more patients than he would ever have seen in the operating room.
For most policyholders, the inner workings of their health insurer are a black box: Requests to cover treatment or pay claims go in, and approvals or rejections are spit out.
The pivotal gatekeepers inside the box are medical directors like Kasemsap. They can, without ever seeing a patient, overrule the judgment of the doctor who did and deny payment for a recommended procedure, test or medicine.
Insurers say medical directors steer patients away from unnecessary or risky care and expensive treatments for which there are less costly, equally effective alternatives. Patients and their physicians complain that insurance company doctors routinely, and wrongly, deny payment for critical lifesaving treatments because they are expensive.
The stakes are high: A refusal to pay for treatment can drive families into bankruptcy. Some patients, facing the cost, forgo care altogether. And a single medical director can rule on 10,000 cases a year, according to court testimony in a case involving Aetna. Some Cigna doctors have ruled on more than 10,000 cases in a month without opening the patient file, as ProPublica and The Capitol Forum have reported.
Despite the key role insurers’ medical directors play in the lives of patients, their identities and backgrounds, and their qualifications for making such life-altering assessments, remain largely hidden.
Many states require medical directors to be licensed physicians, but beyond that it is generally up to insurers to determine which medical professionals are fit for the job.
Patients and the doctors who treat them don’t get to pick which medical director reviews their case. An anesthesiologist working for an insurer can overrule a patient’s oncologist. In other cases, the medical director might be a doctor like Kasemsap who has left clinical practice after multiple accusations of negligence.
As part of a yearlong series about how health plans refuse to pay for care, ProPublica and The Capitol Forum set out to examine who insurers picked for such important jobs.
Reporters could not find any comprehensive database of doctors working for insurance companies or any public listings by the insurers who employ them. Many health plans also farm out medical reviews to other companies that employ their own doctors. ProPublica and The Capitol Forum identified medical directors through regulatory filings, LinkedIn profiles, lawsuits and interviews with insurance industry insiders. Reporters then checked those names against malpractice databases, state licensing board actions and court filings in 17 states.
Among the findings: The Capitol Forum and ProPublica identified 12 insurance company doctors with either a history of multiple malpractice payments, a single payment in excess of $1 million or a disciplinary action by a state medical board.
One medical director settled malpractice cases with 11 patients, some of whom alleged he bungled their urology surgeries and left them incontinent. Another was reprimanded by a state medical board for behavior that it found to be deceptive and dishonest. A third settled a malpractice case for $1.8 million after failing to identify cancerous cells on a pathology slide, which delayed a diagnosis for a 27-year-old mother of two, who died less than a year after her cancer was finally discovered.
None of this would have been easily visible to patients seeking approvals for care or payment from insurers who relied on these medical directors.
When patients look for doctors, they can first check the physicians’ education, experience and qualifications. Most states allow consumers to see if doctors have been sanctioned by a medical board for providing substandard care, and many also provide some information about malpractice payments. But that kind of up-front scrutiny isn’t possible with medical directors because patients typically don’t learn their identity until a denial arrives.
Kasemsap’s history of malpractice payments was no secret before Cigna hired him in 2019. Two years earlier, he was the subject of a front-page story in the South Florida Sun Sentinel headlined “Dangerous Doctors.” In addition to handling appeals for the insurer, Kasemsap obtained a certification through a Cigna physician leadership program and oversees the work of 13 other medical directors there, according to his LinkedIn profile. Cigna CEO David Cordani posed with him and others in a photo at a recent company leadership event.
When told Kasemsap was working in this critical role, Murphy was shocked. “This guy should not be deciding medical questions,” he said. “I don’t care if it’s an earache.”
Kasemsap wrote in an email to ProPublica and The Capitol Forum: “Please know that I carry every patient outcome with me, and those experiences reinforced my commitment to being a compassionate, detail-oriented, dedicated colleague who puts our members at the center of everything I do.” Kasemsap said he was responding on his own behalf, not Cigna’s. He did not answer other questions about his malpractice cases or his role at the insurer.
Cigna, in a statement, said all of its medical directors are board-certified, credentialed physicians and the company holds its medical directors to the same standard as doctors who participate in its network. “We use a comprehensive suite of materials and discussions to assess how our medical directors support patients efficiently and effectively,” a company spokesperson wrote.
In another statement, the spokesperson wrote, “As I’m sure you’re aware, malpractice claims against physicians are common, particularly in high-risk specialties such as surgery, and the settlement of malpractice claims does not necessarily mean that malpractice occurred.”
Between 2005 and 2014, during the time when Kasemsap settled his malpractice cases, only 6% of doctors nationwide had any paid malpractice claims and only 1% had two or more paid claims, according to a study in the New England Journal of Medicine. A study in the same journal found that while surgeons were more likely to face a claim than physicians overall, less than 5% of general surgeons paid a malpractice claim each year between 1991 and 2005.
“I can say in my 35-plus years doing this that this is the most unskilled surgeon I have ever seen in a case,” said Mac McLeod, a malpractice attorney who represented two plaintiffs who sued Kasemsap, including the woman who said Kasemsap connected her rectum to her vagina.
When asked about McLeod’s assertion, Kasemsap wrote, “This is a mischaracterization of a highly complex medical case that occurred more than 15 years ago.” Kasemsap did not say what was mischaracterized.
A Doctor Goes SleuthingA few days before Christmas in 2021, Terrold Dance was loaded down with electrical tools when he slipped on some ice at a worksite and went to a Colorado hospital for help. An MRI later showed that Dance had torn his rotator cuff, the muscles and tendons that surround the shoulder joint and keep the upper arm bone in the socket.
Workers’ compensation paid for the scan and some physical therapy, but that didn’t fix the problem. By the next Christmas, Dance was still in pain and couldn’t fully raise his arm over his head. A Colorado orthopedic surgeon, Dr. Braden Jones, examined Dance and concluded that he needed surgery.
“The guy had not gotten better for a year,” Jones recalled. “It was a pretty clear-cut case for surgery.”
Pinnacol Assurance, the workers’ compensation company that handled Dance’s policy, required that the surgery be authorized in advance, and the company hired a medical reviewer named Dr. Jon Erickson to scrutinize Dance’s request and medical records. Like a medical director, a contract medical reviewer for Pinnacol evaluates whether a surgery is medically necessary. In a letter to a case manager, Erickson concluded that steroid injections and some physical therapy would likely be enough to fix Dance’s problem. Pinnacol denied the request for surgery.
“I believe the mechanism of injury is somewhat questionable,” Erickson wrote, “and we would be best served by considering a program of nonoperative care which involves injections.”
The letter baffled Jones. It downplayed Dance’s shoulder injury and brushed aside the MRI report, Jones said. Erickson didn’t cite any published research or medical society guidelines to explain why an operation was not needed. Jones said that the letter was such a break from accepted orthopedic practice that he wondered if Erickson had ever been a surgeon.
So Jones decided to check. The Colorado medical board had a copy of Erickson’s medical license and an explanation for why he hadn’t set foot in an operating room in many years.
A disciplinary report from the medical board said Erickson had performed a “substandard” hip replacement surgery in 2013 that led to irreparable harm to a patient. Erickson tried in three additional operations to fix it, the disciplinary report said, but the patient had to undergo a fifth surgery elsewhere and will always walk with a limp.
That wasn’t all. The report criticized Erickson for another faulty hip replacement six months after the first. The surgery had taken place on a Friday, and by Monday the same patient was back on the operating table with a broken hip. Erickson performed a second surgery but something was wrong. An X-ray showed the problem.
Erickson had put the hip in backwards.
In a 2017 settlement with the Colorado medical board, Erickson was allowed to keep his license as long as he never performed any kind of orthopedic surgery again. As a doctor reviewing cases for an insurer, though, Erickson has the power to decide that orthopedic operations are not medically necessary, when he himself is not allowed to perform them.
In an interview, Erickson defended his decision to deny Dance’s surgery and his work overall. “This was a relatively clear-cut case,” Erickson said. He added, “What we do at Pinnacol when we review these cases is prevent a lot of inappropriate care, and we save a lot of money for our clients.”
In a statement, Pinnacol said Erickson was contracted as an independent reviewer and that he did not work directly for Pinnacol. “He is not and has never been an employee,” a spokesperson wrote, adding that Pinnacol no longer uses Erickson to review cases. “Our mission as a not-for-profit, state-chartered carrier is to serve the workers and employers of Colorado, and we would never, nor do we support denying necessary medical care ‘to save our clients money.’”
The company said its claim denial rates are “roughly half the state average.” While Pinnacol is a nonprofit insurer, it does typically return money to its customers in the form of an annual dividend.
For Jones, the experience confirmed all of his worst suspicions about medical directors.
“If you have ever seen a Lego, you know which way the hip goes,” Jones said. “I always considered these medical directors to be sellouts, but I thought an insurance company would have more dignity than to hire someone like this.”
After Jones complained to Pinnacol about Erickson’s history and the wrongheaded nature of the denial, the insurer approved Dance’s rotator cuff surgery, which he underwent earlier this year. Dance has since regained full strength and motion.
Jones was so disturbed by what he discovered that he complained to the medical board. Chief among Jones’ beefs: If Erickson is not allowed to perform orthopedic surgery due to the board action, why is he allowed to rule on insurance cases that affect what orthopedic surgeons in good standing can do? The medical board acknowledged to Jones in a September letter that his complaint remained open but declined to comment to ProPublica and The Capitol Forum. Erickson said he thought Jones’ decision to file a complaint with the medical board “was a little bit overkill.”
Trouble With Medical BoardsDoctors turn to health insurance company work for many reasons. Some do it after burning out on clinical care or a change in circumstance, such as starting a family or retiring from a practice. Many find the work rewarding, saying they can help patients by flagging care that is unnecessary or even dangerous.
The job offers good pay with potential bonuses and a set schedule without weekend work or night shifts. The median pay for medical directors at insurers like UnitedHealthcare, Cigna and Elevance is around $300,000 a year, with the high end of the salary range over $400,000, according to the job site Glassdoor.
Despite this, ProPublica and The Capitol Forum found, insurance companies still wind up employing doctors who state medical regulators have rebuked for providing shoddy care or being dishonest.
A unit of Cigna called eviCore has employed Dr. Lorraine Driscoll as an associate medical director from 2006 through at least March 2022, according to records filed with the Maryland Insurance Administration. The New Jersey medical board in 2013 found grounds for disciplining Driscoll for “dishonesty, deception, and misrepresentation and/or … for engaging in professional misconduct.”
The board reprimanded Driscoll, an obstetrician-gynecologist, for altering patient records in ways that could help her fight a 2004 malpractice case involving a child born with Down syndrome. That case, which wound up settling for $700,000, was one of six that Driscoll settled, according to her application to be certified as a medical director by the Maryland Insurance Administration. (Maryland officials approved her application.) She did not respond to calls, emails or a letter with detailed questions sent via FedEx.
Other insurers, including Aetna and UnitedHealthcare, hire eviCore to determine whether certain treatments are medically necessary.
When asked if Driscoll still works for eviCore, a company spokesperson declined to answer. In a written statement, eviCore said its medical directors are all board-certified physicians “who are dedicated to ensuring that patients receive safe, effective care guided by the latest clinical evidence.” The company added that its doctors “are held to the same legal, licensing and education requirements that physicians treating patients are held to.”
Aetna has on its in-house team Dr. Beth Ann Binkowski, an internal medicine physician who was censured and reprimanded by the New York state medical board in 2015 for failing to appropriately prescribe medications for five patients at Syracuse University with mental health conditions. Binkowski referred a reporter to Aetna for comment. A company spokesperson said all Aetna medical directors are licensed and board certified and that the company follows accreditation requirements and state and federal regulations.
UnitedHealthcare hired Dr. Dolores Rhymer-Anderson as a medical director in 2015 despite the fact that the Georgia medical board had previously reprimanded her for care related to the delivery of a baby born with severe neurological damage in 2000. She settled a related malpractice lawsuit for $2 million. In a legal filing in that malpractice case, Rhymer-Anderson denied that she was negligent and said she exercised the appropriate degree of care and skill ordinarily employed by doctors in the same circumstance.
A peer reviewer appointed by the medical board faulted Rhymer-Anderson for failing to conform to the minimum standard of acceptable and prevailing medical practice. As part of an agreement with the board in 2006, she was required to complete 20 hours of continuing medical education and pay a fine of $1,500. The board order stated Rhymer-Anderson did not acknowledge any impropriety and agreed not to contest the allegations to avoid protracted litigation.
Rhymer-Anderson excluded obstetrics from her practice before the board order, blaming the move on her experience with the lawsuit, according to a regulatory filing. She said she hoped to avoid another legal action.
But in 2008 she was sued again and settled the case for $1 million. That lawsuit faulted her work during a diagnostic procedure to evaluate a patient’s uterus. The patient went into respiratory distress and suffered a brain injury from lack of oxygen. The patient spent a month in the hospital before being transferred to a long-term care facility. The lawsuit accused Rhymer-Anderson of incorrectly administering anesthesia, failing to properly supervise a nurse assisting and failing to secure an airway by endotracheal tube.
In her application to be certified as a medical director in Maryland, Rhymer-Anderson said she settled because the plaintiff was estimating the cost of future care at $16 million, which exceeded her malpractice insurance, and she was concerned a jury award could put her personal assets at risk. She said in the Maryland filing that three expert witnesses concluded that she met the standard of care in the case. In a court filing in that case, Rhymer-Anderson said she acted within the standard of care in treating the patient and did not commit any act of negligence that resulted in injuries. (Maryland officials approved her application.)
Settlements of $1 million or more, referred to as catastrophic claims, are rare. Only 7.6% of claims saw settlements that large in a study of malpractice cases filed nationwide from 1992 through 2014. The same study found the average malpractice payment by doctors in Rhymer-Anderson’s specialty was $432,959.
Rhymer-Anderson did not respond to phone calls, emails and a letter with detailed questions sent via FedEx.
A UnitedHealth Group spokesperson said Rhymer-Anderson left the company last year. The spokesperson also wrote, “Medical directors go through a rigorous hiring process, to ensure they are qualified for the roles for which they are being considered.” He added, “We review individual performances regularly and provide ongoing training to help them with their various responsibilities.”
“Cranking Out Denials”When an insurer shoots down a request to pay for care, the patient’s doctor can call the insurance company’s doctor to make the case for why it should be approved. This is known as a peer-to-peer review.
But doctors often complain they’re not actually speaking with peers when they call an insurer. They get exasperated when an orthopedic surgeon weighs in on a procedure to treat an irregular heartbeat or a pediatrician questions an oncologist’s plan for an adult with lung cancer.
In a survey conducted by the American Medical Association, only 2% of the doctors who responded said that health insurance medical directors were “always” appropriately qualified to assess the requested treatment. More than a third said health plan doctors were “rarely” or “never” qualified.
When Orrana Cunningham’s doctor at the MD Anderson Cancer Center in Houston asked her insurer to approve the use of expensive proton beam therapy to attack her cancer, the decision on whether to pay for the care fell to an Aetna doctor who had not treated patients in more than 20 years, according to records from a lawsuit the Cunningham family brought against Aetna.
Dr. David Massman, a medical director at Aetna, denied coverage of the treatment, ruling that it was “experimental or investigational.”
Cunningham’s radiation oncologist, Dr. Clifton Fuller, then requested a peer-to-peer call so that he could explain why proton beam therapy was the best method for treating Cunningham’s stage IV nasopharyngeal squamous carcinoma, a rare cancer located at the base of her skull. Proton beam therapy was needed, he said, because it could precisely deliver radiation to the cancer site while avoiding devastating side effects, such as loss of sight and memory, that could occur with other radiation treatments.
It was a complex procedure. Fuller wanted someone with a background in treating cancer to be on the call. Instead, he was paired with Massman, a family medicine physician who had never worked in radiation oncology and had never seen a proton beam machine.
Massman went to work for health insurers two decades ago after his Illinois medical license was placed on a four-year probation for issues related to a drug addiction, according to state licensing records. His license is in good standing now.
In their peer-to-peer call, Fuller testified in a sworn deposition, Massman acknowledged Fuller may be right that proton beam therapy was a safe treatment for Cunningham but said he “can’t do anything about it” because the therapy did not comply with an Aetna clinical policy guideline.
Appeals of the decision failed. In all, three Aetna medical directors reviewed the treatment request and subsequent appeals. None of them were radiation oncologists.
As the appeals dragged on, Cunningham grew sicker. Out of options, her husband decided to mortgage the family home and sell other assets to pay for the $92,000 treatment.
Cunningham underwent the procedure in April 2015, four months after her doctors first asked Aetna to approve it. When she returned home in May, she started to behave strangely. She didn’t recognize her husband or son. She was diagnosed with herpetic encephalitis, a disease that her family’s attorney contended was unrelated to the cancer treatment and triggered by stress. She died later that month.
Cunningham’s husband sued Aetna in Oklahoma state court, alleging that the insurer breached its contract with his wife, acted in bad faith and inflicted emotional distress.
At the trial, Massman testified that he could not recall details of his peer-to-peer call with Cunningham’s radiation oncologist, but he said that he would never tell a treating physician that they were right about a treatment Aetna was denying.
In his closing arguments at the trial, Cunningham’s lawyer, Doug Terry, condemned Aetna’s medical directors: “These doctors were not properly qualified to know the first thing about the medical issues involved here. None of them had any experience with radiation oncology or proton therapy. They were cranking out denials as fast as they could.”
Aetna’s lawyer countered that the company was proud of the medical directors who denied Cunningham’s care for “standing up for what is right.” Massman and other Aetna medical directors involved in denying Cunningham’s care sat in the front row as the company’s lawyer made his closing argument, said Terry.
The jury in 2018 awarded Cunningham’s estate and her husband $25.6 million. After Aetna appealed the jury verdict, the parties settled the case under confidential terms in 2021.
Massman did not respond to calls, emails and a letter with detailed questions sent via FedEx.
In a statement, Aetna said its “sympathies continue to be with the Cunningham family.” It said that today any clinical reviews or peer-to-peer conversations related to proton beam therapy are conducted by board-certified radiation oncologists. The company did not answer a question about efforts more generally to match specialists to the treatment requested.
“Frequent Flyers”A small group of doctors — about 2%, termed “frequent flyers” by one study author — are responsible for 40% of medical malpractice claims in the country.
It’s unusual for doctors to make payments in multiple malpractice cases, and that can signal that a physician is providing low-quality care. In Florida, the state health department is mandated to investigate any doctor who has had three or more claims in excess of $50,000 within a five-year period.
In 2013 Dr. John Stripling stopped working as a urologist, according to a deposition he gave in a product liability case. Around that time he faced medical malpractice lawsuits from patients in two states who alleged he botched enlarged prostate procedures.
In total, Stripling settled cases with 11 former patients between 2014 and 2017 with a combined payout of $3.6 million, according to Florida Department of Health records. After receiving “malpractice information,” the Arkansas State Medical Board told Stripling in 2015 that he would have to appear before the board if he wanted to renew his license, which was expiring. He never did.
Stripling was able to maintain his license in Florida, state records show, and he began working for health insurers in 2016, according to his LinkedIn profile. His most recent job, his profile said, was as a medical director for naviHealth, a unit of UnitedHealth Group’s Optum business, where he weighed in on placements of patients released from the hospital. A UnitedHealth Group spokesperson said Stripling left naviHealth in March.
A 2014 lawsuit filed in Arkansas state court by Larry Stanley, a patient of Stripling’s, alleges that dozens of the doctor’s patients in that state and Mississippi experienced severe and unacceptable complications when the doctor performed a procedure known as transurethral laser ablation of the prostate, or TULAP. The procedure uses a laser to treat an enlarged prostate, which can otherwise cause problems with urinating.
The lawsuit alleged that a nurse who worked with Stripling reported to another urologist that 40 of Stripling’s patients who underwent the TULAP procedure experienced “unprecedented complications.” The office manager and head nurse in Stripling’s practice were so alarmed by the high rate of complications that they went directly to the chief executive officer of the company Stripling worked for, according to Stanley’s lawsuit.
After Stanley’s TULAP procedure with Stripling in 2010, he was left incontinent, had to use catheters to drain his bladder and underwent additional surgeries, according to Stanley’s suit. In a court filing in that case, Stripling denied that he was negligent or at fault. The lawsuit was dismissed after both sides said they had resolved the matter, but the court records don’t provide any additional detail. Stanley died in 2019. His son Greg recalled his father received about $300,000 in a settlement.
A steelworker in his younger years, Larry Stanley had later owned and operated a sawmill for 40 years. Greg Stanley said his father was a changed man after the surgery. He rarely left home, worried he would have wet spots on his clothes.
“This doctor butchered him,” Greg Stanley said.
In a 2012 deposition in a malpractice case in Mississippi, Stripling said he stopped doing the laser prostate operation on Dec. 7, 2010, when he had a “coming-to-Jesus meeting” with himself and concluded “this is it.” At least eight of the settlement payments made in his malpractice cases involved incidents that occurred in 2010, according to the licensing records.
Stripling said in the deposition that too many of his patients “were doing poorly” after their operations. “There was something flawed in what was being done; and I didn’t have a clear answer, but it was time to make a decision,” he said. He testified that he went back to performing an older procedure that didn’t involve a laser.
That Mississippi case later settled for $305,000, according to Florida state medical licensing records. In a court filing, Stripling said he complied with the standard of care and was not negligent in his treatment of the patient.
Stripling did not respond to phone messages, emails and letters with detailed questions sent via FedEx. The UnitedHealth Group spokesperson reiterated that the company’s medical directors go through a rigorous hiring process, that their performance is regularly reviewed and that the company provides ongoing training.
Another “frequent flyer” was Cigna’s Kasemsap, who settled five malpractice suits after denying in court filings that he was negligent.
It was in November 2006, during a colostomy reversal surgery, that Kasemsap allegedly connected a 42-year-old woman’s vagina to her rectum, according to a malpractice complaint filed in state court in St. Augustine, Florida. The mistake caused air and feces to pass through the vagina, and the patient had to undergo three more surgeries, according to the complaint.
A month later, according to allegations in another lawsuit, Kasemsap mistakenly cut a patient’s common bile duct and an artery during a gallbladder surgery. A jury found him negligent in that case and awarded the patient $600,000. Kasemsap and the patient subsequently agreed to settle the case.
Kasemsap’s malpractice insurer made another payment to a patient who said in a lawsuit that he had suffered from a mild case of hemorrhoids that Kasemsap wrongly diagnosed as a far more serious case. The doctor then negligently performed a 2007 surgical procedure that left the patient with “constant, severe physical pain and suffering, incontinence and irritation,” the complaint said.
Kasemsap settled two more malpractice cases for incidents in 2009, including one filed by Loretta Murphy’s family after her death, court records show.
Kasemsap started working for insurers in 2013, according to his LinkedIn profile, which boasts about his contributions to companies’ financial health.
As a senior medical director at Highmark, a Blue Cross Blue Shield plan, he claimed credit for saving $3 million a year by removing high-cost specialty drugs from automatic authorization, his profile said. He also said he saved the company $15 million by initiating step therapy in the treatment of macular degeneration. Step therapy generally requires patients to try less expensive treatments before more expensive ones. (When asked about Kasemsap’s profile, a spokesperson for Highmark wrote, “We can’t speak to how Dr. Kasemsap categorizes his work. Medical directors use evidenced-based guidelines and the unique clinical picture of each member’s case to render medical necessity decisions only, which is agnostic of cost.”)
Since late 2019, Kasemsap has worked at Cigna, where he not only has reviewed treatment requests but has also managed other medical directors who handle Medicare Advantage requests for care, according to his LinkedIn profile. Kasemsap has thrived in his role at Cigna, and the company made him part of its Physician Leadership Development Program, which provides business and leadership skills.
Kasemsap’s success at Cigna came as a bitter surprise to the Murphy family.
When Loretta Murphy’s daughter Amanda Cain was young, her mother would play beauty parlor with her. Murphy would do Amanda’s hair like she learned in cosmetology school, and Amanda would paint her mother’s nails — purple with pink and white flowers.
“Her favorite flower was hibiscus, so I would always try that on the toes,” said Cain, who ended up pursuing her own career in cosmetology.
A photo in a family album shows Loretta Murphy kissing her daughter Amanda Cain when Cain was a little girl. Murphy died when Cain was 17. (Greg Kahn, special to ProPublica)Cain was a junior in high school when her mother went to Kasemsap to get her gallbladder removed. The procedure was only supposed to take about an hour. When more than an hour passed, Cain started to get nervous. Her grandparents were in the waiting room and eventually took her home to look after her younger sister.
The next time Cain saw her mother, she was lying in a hospital bed with a machine helping her breathe.
Murphy died a year before Cain graduated from high school. It was just one of many life events her mother never got to witness, including the birth of Cain’s two children.
That Kasemsap has any say in the well-being and health of vulnerable people is maddening, Cain said.
“What do you say about anyone that would hire this guy knowing what they know?” she asked. “How, how would they still hire him?”
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This article was produced for ProPublica’s Local Reporting Network in partnership with the Idaho Statesman. Sign up for Dispatches to get stories like this one as soon as they are published.
It’s no secret that Idaho’s school buildings have problems. The state’s superintendents, maintenance directors, teachers and students see the leaks, pack into crowded hallways and feel the extreme cold and heat throughout the year. But state officials don’t know the extent of the issues because the last full review of school buildings was completed in 1993.
The Idaho Statesman and ProPublica joined forces to explore the deteriorating conditions and the consequences for students and teachers. To identify patterns, we worked with communities to bring together data, documentation and visual evidence from across the state. We spoke to as many people as we could, and visited dozens of schools, to see what conditions were like on the ground.
Here’s what we did.
We surveyed all 115 superintendents in the state and heard from 91% of them. Our data team helped design a survey inviting them to identify significant challenges in their districts. We first showed it to a small group of district leaders, who helped us anticipate and address potential concerns. In May, the state’s association of school administrators shared the link with its members, and regional leaders encouraged them to fill out the survey. We followed up with our own introductions and sent reminders throughout the year.
Our goal was to hear from every public school district so we could analyze how widespread facilities issues were and identify which respondents faced the most serious problems. All but nine responded: Arbon Elementary, Bliss, Council, Culdesac, Mullan, Pleasant Valley, Teton County, Troy and Whitepine. (Prairie Elementary did not complete the survey but provided information in an email.)
The responses came in from May 26 through Dec. 8. Most were filled out by current superintendents or facilities directors, but 14 have since left their positions or changed districts. At least a dozen superintendents shared assessments performed for them by firms or contractors.
Every district said it had at least one problem that posed a significant challenge or required major repairs, and 78% said they had five or more. Twenty percent said they had 10 or more problems. These are the problems, along with the percentage of superintendents who said they had them:
Only 4% of superintendents thought they would be able to address the issues in the next year, while 20% said they may be able to.
When asked what was preventing them from addressing facilities problems, 88% mentioned funding.
We also asked superintendents about how they would rate the physical conditions of their schools. Not all respondents rated every school in their district, but together they rated 677 schools and said 21% were in poor condition, 41% were in fair condition and 38% were in good condition. Thirty-five percent said at least one-fourth of their schools were in poor condition.
We heard from 233 students, parents, teachers and others. In April, we published a callout. We wanted to talk to those most likely to be affected by facilities issues, such as people with disabilities or those in the most rural and remote corners of the state — where communities may not come across our online publications.
Dozens of Facebook and Reddit moderators supported our efforts to reach groups of educators, parents or residents in certain parts of Idaho. We spoke about our efforts at a meeting of the state’s special education advisory panel and handed out flyers at a conference for school administrators. The Idaho Education Association shared our callout with 10,000 members and asked for 200 flyers to put up in schools. Students and recent graduates told their friends about the callout while the Idaho Business for Education and the American Institute of Architects Idaho sent it to their members. Some local media outlets also helped spread the word, including Ben Reed with 99.1 La Perrona, who shared the Spanish translation of our callout.
Teachers helped us hear from students. Moscow High School English teacher Rachel Lyon shared essays from her students. Ninth grade student Natasha Gartstein wrote, “The Moscow High School has been in use for nearly 90 years. That’s before the Kardashians, Michael Jackson, and even the Beatles.”
We also worked with artist Pia Guerra to draw illustrations of five students, two educators and a parent to help bring their stories to life.
Diego Hernandez, a 10th grade student at Canyon Springs High School, told us, “The look of the school is kind of deteriorating. … Just walking in and seeing something that looks like this is almost depressing.” (Pia Guerra for ProPublica)We were given tours of 39 schools from maintenance directors, superintendents or principals. Maintenance staff were able to show us the problems going on behind the walls, which students and educators sometimes couldn’t see, along with the patches they’d used because they couldn’t afford a permanent fix.
During our school visits, we met with students and educators. At six of these schools, we spoke to classes and met with the student government or student media groups. We explained our project and passed out notecards for students to write what they liked about their buildings, what they would change and the impact issues had on them. They often said they appreciated their teachers, who made do with the state of their buildings, and were proud to go to the same schools as their parents and grandparents. But we overwhelmingly heard about facilities problems. It was clear that students were aware of how school funding worked, with some explaining recent bond elections in their community.
ProPublica and Idaho Statesman reporters asked students to write what they liked about their buildings, what they would change and the impact issues had on them. These responses came from Leila Guffey, a senior at Kamiah High School, and Diego Hernandez, a 10th grader at Canyon Springs High School. (Asia Fields/ProPublica)In some districts, we brought a camera that produces instant prints so students could show us the issues in their school buildings from their own perspectives. We received dozens of photographs back.
Idaho Statesman and ProPublica reporters brought a camera that makes instant prints to school visits so students could show the problems in their schools. Students documented a deteriorating locker at Kamiah High School, leaky ceilings at Moscow High School, and bathroom drains bulging up from the floor at Canyon Springs High School. (Courtesy of Kamiah, Moscow, and Canyon Springs students)We verified the information. Before publishing, we reached out to the people who shared information with us to collect more details. We checked those accounts with the district to hear their responses and any updates on the conditions.
Nearly every example that made it into our story was something that the districts agreed was an issue. In a few cases where the district disagreed with parts of a student or community member’s account, we noted that in the story.
If you’d like to get in touch with our team, you can email idahoschools@propublica.org. If you’re an educator who might be interested in using our project in your classroom, we’re happy to assist however we can. If you’re interested in classroom materials or updates about this project, send us an email.
If you want to talk to us about schools in another location, you can use our general tip line at propublica.org/tips. We can’t guarantee that we’ll be able to follow up on everything, but we review everything we receive.
This article was produced for ProPublica’s Local Reporting Network in partnership with the Idaho Statesman. Sign up for Dispatches to get stories like this one as soon as they are published.
No other state spends less on school infrastructure per student than Idaho. As a result, many students, especially those in rural districts, deal with leaking ceilings, freezing classrooms and discolored drinking water. Some students have to miss school when the power or heat goes out.
School districts often can’t build or repair buildings because Idaho is one of only two states that require two-thirds of voters to approve a bond. Some districts have held bond elections several times only to see them fail despite having support from a majority of voters. But the Legislature has been reluctant to make significant investments in facilities. Administrators say they don’t know how they’ll keep their schools running and worry that public officials don’t understand how bad the problems are.
Idaho hasn’t done an official assessment of school building conditions in 30 years. The Idaho Statesman and ProPublica tried to fill this gap with the help of people who know the system best. We surveyed all 115 public school district superintendents, and 91% responded. Every superintendent who responded said they have at least one facilities problem that poses a significant challenge, and 78% told us they have five or more. Then, we went to communities across the state. Thirty-nine schools took us on tours, often led by district maintenance directors. We also collected stories and photographs from 233 students, parents, educators and others, who described how the conditions affect their lives.
Read more about our survey and outreach efforts.
“Communities show what is valuable by what we build,” said David Reinhart, West Ada School District’s chief operations officer. “When our students are in old and run-down buildings, it signals to them that what they do in school is of little value.”
“It makes school less enjoyable, harder to focus,” said Luke Sharon, a senior at Lake City High School in Coeur d’Alene.
“The kids see it,” said Amy Eslinger, who graduated from Emmett High School in 2009. “I grew up knowing how bonds and levies worked but never saw them pass and watched myself and my peers suffer from it.”
Here’s what students and educators across the state told us about the floods and leaks, overcrowding and inaccessibility, safety and security flaws, structural deficiencies and heating and cooling problems that impact every part of their day.
Discolored Water, Falling Ceiling Tiles, Ruined Projects50% of Idaho superintendents we heard from said leaks pose a significant challenge or require major repairs, while 61% said they had problems with their roofs and 58% said the same about bathrooms.
“The leak made us feel like there was yet another way our school is falling apart. We were also sad because something like this could damage our precious instruments that we most certainly could not replace for a long time due to cost.”—Laura Woras, music teacher, Idaho City Middle/High School, Basin School District
Laura Woras’ music classroom has flooded two years in a row.
Woras went to drop off supplies in her Idaho City classroom during spring break in 2022 and found the area around her desk flooded and hot water shooting out of a wall. It destroyed the floor pillows she had bought for students to sit on while playing their instruments. The next year, it happened again. The superintendent told us the old pipes spring leaks once a month and need replacement.
Separately, the school struggles with leaks from its fire sprinkler system. A levy that would have fixed this failed to pass in November.
Video of Woras’ classroom flooding (Courtesy of Laura Woras) Evidence of water damage on the wall months after the second leak (Asia Fields/ProPublica)“Something is always falling apart in our school district.” —Natalie Kulick, science teacher, Idaho City Middle/High School, Basin School District
In Kulick’s class, multiple leaks have sent water pouring down the walls, destroying cards from former students, workbooks, papers and posters.
“The previously leaking roof hadn’t been addressed due to budgetary constraints. Due to the heavy snow and already bad roof, it caused the ceiling to collapse. We’re hoping the repairs will hold until we can figure something else out about replacing the whole roof.” —Jason Moss, superintendent, Grace Joint School District
“In one area, after a particularly hard snow was melting, the custodians rigged up a tarp across the ceiling to catch all the leaks and funnel them into garbage cans and plastic totes that they could dump,” Moscow School District middle school teacher Cyndi Faircloth said.
(Courtesy of Rachel Aiello)“At Post Falls Middle School, class would be moved to a different room temporarily because a tile from the ceiling had collapsed due to water damage. Sometimes we would carry on anyway and ignore it.” —Grey Goodwin, 2023 Post Falls High School graduate, Post Falls School District
The district said it has since repaired sections of the roof.
Water damage to the ceiling in the Caldwell School District, first and second image, and the Basin School District, third image. Ceiling tiles are falling in the Plummer-Worley School District’s high school gym, fourth image, which we also saw in two other districts. (First image: Courtesy of Bernie Carreira. Second image: Asia Fields/ProPublica. Third image: Asia Fields/ProPublica. Fourth image: Asia Fields/ProPublica.)The land that the Basin School District’s schools sit on used to be a pond that had been dredged by miners. During spring runoff, the elementary school floods.
Superintendent Brian Hunicke shows how high the water goes when it floods. (Asia Fields/ProPublica)Spring runoff goes under the building, creating a musty smell. “My first year here I thought it was a dead mouse.” —Jill Diamond, principal, Potlatch Elementary School, Potlatch School District
“There’s a room that you can’t even go in on a rainy day, because it just smells terrible.” —Michelle Tripp, principal, Ross Elementary School, Kuna School District
“The water is loaded with iron and tastes terrible.” —Scott Davis, Kootenai superintendent. (The district scraped together grants and donations to add a filtered bottle fill station to each building.)
“Old buildings with lead in pipes.” —Mark Kress, Snake River superintendent. (The district said it has mitigated lead levels in drinking water and tests the water monthly.)
“Concerns with drinking water have caused us to get water delivered. … Some of the water is colored in some of the classroom sinks.” —Allen Mayo, Shoshone-Bannock administrator
“We have had to bring in port-a-potty restrooms when plumbing systems have failed.” —Matt Diel, facilities director, Lake Pend Oreille School District
Bathroom drains at Canyon Springs High School, an alternative school in the Caldwell School District, are “popping up out of the ground” because of old rusty piping that has shifted, said Bernie Carreira, the district’s maintenance director.
Bathrooms at Canyon Springs High School. Idaho Statesman and ProPublica reporters brought a camera that makes instant prints to school visits so students could show the problems in their schools. (Courtesy of Canyon Springs students) Classes in Stairwells and Closets28% of superintendents we heard from said overcrowding or use of portable buildings is a significant challenge. 58% said accessibility for people with disabilities poses a significant challenge or requires major repairs.
“The first two or three minutes of passing, it’s sardines.”—Tracy Donaldson, vice principal, Kuna High School, Kuna School District.
Donaldson described the crowded hallways. The high school was designed for about 1,400 students, but it serves about 1,900, according to the district.
“Our biggest concern is lack of space. We are using 18 modular classrooms at Rigby High School.” —Chad Martin, superintendent, Jefferson County School District
The district has been relying on portable buildings because there is a shortage of space.
“Underclassmen without cars are forced to eat on the floor in the halls due to the lack of space in the cafeteria.” —Claire Yoo, 2023 alum, Idaho Falls High School, Idaho Falls School District
The school was built for 900 students but serves about 1,250, according to the district. The cafeteria accommodates about 200 students.
Moscow High School has 814 students but room for only about 100 in the cafeteria.
The cafeteria at Moscow High School doesn’t even fit all students who get free and reduced lunch through the school. (Asia Fields/ProPublica)At Heyburn Elementary in the St. Maries School District, a stairwell at the front entrance was turned into the music classroom.
(Asia Fields/ProPublica)Photo class is held in a former storage room in the Plummer-Worley School District.
(Asia Fields/ProPublica)“Most high school PE classes are not able to use the gym most of the time since it’s too small. … Not enough fields were built on campus for the number of students we have now.” —Natasha Gartstein, ninth grade student, Moscow High School, Moscow School District
As a result, the district has to transport students to nearby parks and the University of Idaho for physical education, cutting into class time. On one busy week in the fall, the district had 28 bus trips from the school.
At Heyburn, a teacher’s lounge is in an old locker room, where showerheads are still attached to the wall.
(Asia Fields/ProPublica)About half of superintendents said they have buildings that aren’t compliant with the Americans with Disabilities Act.
Schools built before the act have some flexibility in meeting the requirements.
“He can’t ever really just be free to explore because he could tip over the edge. … I think there’s a lot of learning that kids get when they can freely explore their world. My little guy doesn’t get that.”—Marisa Smith, mother of a second grade student, Discovery Elementary School, West Ada School District
Marisa Smith’s son, Tug, uses a wheelchair and is legally blind. He can’t access the playground unless teachers carry him because it has wood chips and a steep drop from the curb. After reporters reached out, the district said it would make some improvements. But the playground would still have wood chips, which are difficult to navigate in a wheelchair.
“We typically have to move students with physical disabilities out of their neighborhood school to a newer school that can better accommodate their physical needs.” —Wendy Johnson, superintendent, Kuna School District
“It’s kind of just really embarrassing. … I oftentimes would fall out of my wheelchair and hurt my knees again.” —Ammon Tingey, 2023 alum, Highland High School, Pocatello-Chubbuck School District
Ammon Tingey described climbing up and down stairs every day to get to honors classes while he was supposed to be using a wheelchair after an injury. He said he was discouraged from taking the classes because they were on the bottom floor and the school didn’t have an elevator. The district did not list accessibility as an issue in its survey. It said it offers more than one section of honors courses, and there would have been another option for students to access on the main floor. The school also has a wheelchair lift in one section of the building.
Fire Risks, Power Outages, Security Flaws58% of Idaho superintendents we heard from said security poses a significant challenge. 31% said asbestos does and 26% said fire and emergency preparedness do.
“My heart was racing because I’ve heard in the news of things like this happening. … It’s just hard to think what if this would have been real and there actually was someone there and they made a mistake like this. We were like sitting ducks.”—Bryn Bowersox, 10th grade student, Moscow High School, Moscow School District
Bryn Bowersox was in PE class earlier this year when the school went into lockdown because of a shooting threat. The announcement couldn’t be heard in the gym, and the door didn’t lock securely, according to the district. Bowersox said the class learned of the threat late when a teacher received a message on his phone. The district has since installed new announcement systems and purchased new locks.
Superintendents across the state were able to make some security upgrades with a state grant created this year that provided each school with up to $20,000, but many said it wasn’t enough to fully secure their older schools.
“Not all students can hear the public announcements, and not all classroom teachers can easily communicate with the office.” —Superintendent *
“We have no secure entries and high concerns for many ‘what if’ security scenarios.” —Superintendent, referring to the main entrances*
*We are not naming the superintendents or their districts to avoid exposing security concerns.
A fire broke out at Highland High School in the Pocatello-Chubbuck School District earlier this year and destroyed the cafeteria, gym and band rooms.
The building had previously failed a fire inspection, but the district said that the alarm system was still operational. During the fire, the school’s sprinklers went off, but the alarm didn’t activate. The district said it has since serviced alarms at all of its schools. The damage will be covered by insurance, but the district ran a bond election in November hoping to expand and upgrade the school while rebuilding. The bond measure failed, despite garnering 56% of votes.
The Highland High School gym was ravaged by a fire. (Pocatello Fire Department, obtained by ProPublica and Idaho Statesman)“The elementary has no fire suppression system.” —Brian Hunicke, Basin superintendent
“Don’t have a sprinkler system for fires.” —Scott Davis, Kootenai superintendent, about two of the district’s three schools
“Does not have a functioning fire control system.” —David Sotutu, superintendent of New Plymouth School District until June, about the sprinklers in the district’s career technical education building
The boiler at Canyon Springs High School is covered in a material that contains asbestos fibers. (Sarah A. Miller/Idaho Statesman)“The middle school is loaded with asbestos.” —Scott Davis, superintendent, Kootenai School District
The asbestos is not exposed but makes what would otherwise be simple repairs and upgrades challenging and expensive, Davis said.
“A student plugged their laptop into one of these outlets. There was a pop, a spark.” —Jennie Withers, teacher, Meridian Middle School, West Ada School District
An electrical outlet at Meridian Middle School (Courtesy of Jennie Withers)“The kids know it will flicker once, and then they’re waiting. They’re like, ‘OK,’ and it’ll flicker twice, and then they’re like, ‘OK, three times.’ … If it hits the third time, then it’s going to be out for a while — and they know that.” —Brian Hunicke, superintendent, Basin School District
Hunicke said the district had eight power outages last year, and its generator only covers refrigeration, the computer server and emergency lights.
Some districts have also had challenges making Wi-Fi work in their older buildings.
“Some days the Wi-Fi will just stop working. This means that some teachers who rely on PowerPoints or internet access can’t continue with what they had planned for that day.”—Reesa Loewen, senior, Kamiah High School, Kamiah School District
Jill Patton, principal of Pioneer Elementary School in the Salmon School District, said students have been kicked off the internet in the middle of state exams because of the building’s poor Wi-Fi.
At Caldwell’s Syringa Middle School, the breaker trips if a heater and the microwave are turned on at the same time.
(Sarah A. Miller/Idaho Statesman) Deteriorating Foundations and Falling Bricks41% of Idaho superintendents we heard from said structural issues like cracks in the walls or foundation pose a significant challenge or require major repairs.
“The look of the school is kind of deteriorating. … Just walking in and seeing something that looks like this is almost depressing.”—Diego Hernandez, 10th grade student, Canyon Springs High School, Caldwell School District
Caldwell Superintendent N. Shalene French said all 10 of her district’s schools are in poor condition. At Canyon Springs, an alternative school that students describe as deteriorating, about 80% of students are people of color, and more than 96% come from low-income households.
“The foundation is crumbling. … You keep up with what you can; you can’t fix a crumbling foundation.” —Troy Easterday, superintendent at Salmon School District
“Foundation and wall cracks are worrisome.” —Joe Steele, superintendent at Butte County School District
“We know there is probably a crack in the foundation; however, with no money to fix it, we are left to just simply prepare for heavy rains as much as possible and to devote extra time to clean up efforts.” —Megan Sindt, superintendent at Avery School District
First image: Peeling paint and water-damaged ceiling tiles at Canyon Springs High School in the Caldwell School District. Second image: A classroom in the nearly 90-year-old section of Lakeside High School in the Plummer-Worley School District. (First image: Sarah A. Miller/Idaho Statesman. Second image: Asia Fields/ProPublica.)“The state of our buildings, particularly the outer buildings, is embarrassing. … School should be a place of security and a place to be proud of.” —Jennie Withers, teacher, Meridian Middle School, West Ada School District
“Holes in the walls, leaks, exposed wires — they are distracting.” —Leila Guffey, senior, Kamiah High School, Kamiah School District
At Kamiah High School in the Kamiah School District and other schools we visited, students told us that their schools’ appearance affected how they viewed their schools and themselves.
Wires hanging from the ceiling and a deteriorating locker at Kamiah High School in the Kamiah School District. Kamiah Superintendent Paul Anselmo said exposed wires and pipes make the school look “like a warehouse.” (Courtesy of Kamiah High School students)Bricks have cracked and pieces have fallen out at Jefferson Middle School in the Caldwell School District.
They haven’t hit anyone, but it’s a potential hazard, said Bernie Carreira, the Caldwell maintenance director. (Sarah A. Miller/Idaho Statesman) A cracked and settled sidewalk caused by poor water drainage and corrosion at the base of a steel entry column at Stephensen Elementary in the Mountain Home School District. (Obtained by ProPublica and Idaho Statesman from a 2020 assessment by a structural engineering firm)Schools also have structural issues with windows, which were listed as a problem by 55% of superintendents we heard from.
In three districts, teachers or superintendents reported that windows have fallen out. In another, the deteriorated windows allow bats to make their way into the high school two to three times each fall.
“Bats come in through the window casings. … We keep the ‘bat net’ handy at all times.” —Janet Williamson, superintendent, Camas County School District
Blankets, Coal Boilers and Poor Ventilation68% of Idaho superintendents we heard from said heating poses a significant challenge or requires major repairs. 67% said the same for cooling.
“It’s extremely hard to focus on schoolwork while shivering.”—Kendall Edwards, ninth grade student, Moscow High School, Moscow School District
Edwards said some rooms are freezing in the winter. Frank Petrie, Moscow’s maintenance director, said heating is a challenge because of antiquated systems.
“Even as a kid in elementary school, I knew that it probably wasn’t normal to have to wear coats inside occasionally.” —Ali Johnson, 2021 alum, Capital High School, Boise School District
“I know one teacher who keeps a stack of blankets in his room so kids can cover up while he teaches.” —Cyndi Faircloth, teacher, Moscow Middle School, Moscow School District
Brian Hunicke, superintendent at Basin School District, told us that at Idaho City Middle/High School, the heat didn’t work about 10 times last year, not including during power outages. When it happens, students “suffer for about a day” before the district can get someone in to fix it.
“The district is still using coal to heat buildings. The coal creates dirty air outside the buildings, and depending on wind direction it can unintentionally compromise indoor air quality. As we have looked for ways to improve air quality, we recognize that dirty air can impact those with compromised immunity and asthma.” —Shane Williams, superintendent, West Jefferson School District
Coal boilers have become increasingly rare in schools and homes across the country over the past few decades.
Coal used to heat the Swan Valley School District elementary school (Courtesy of Michael Jacobson)Russell Elementary School in the Moscow School District has a boiler from when the school opened in 1926. If it were to break down, it would be hard to find replacement parts, the district said.
(Asia Fields/ProPublica)Heat is also a problem when school starts in the late summer, educators say.
It’s “sweltering.” —Janet Avery, Potlatch superintendent
“Over 100 degrees in the fall and late spring” inside. —Robyn Bonner, head teacher at Peck Elementary in the Orofino School District
“Melting in the hot conditions.” —Erin Heileman, teacher at Morningside Elementary School in the Twin Falls School District
“It gets so hot in the afternoon that students start to put their head down. … It makes it difficult to teach kids.” —Gerald Dalebout, social studies teacher at Moscow High School in the Moscow School District
“There is no ventilation in that school, and it does not meet any EPA standards for fresh air intake or carbon dioxide levels, which were tested by the district.” —Ken Eldore, facilities director until June, Priest River Junior High School, West Bonner School District
Another administrator also told us about the levels, but interim superintendent Joseph Kren, who was hired in October, said he couldn’t find a record of a test.
“Emmett Middle School lacks adequate ventilation, which I believe is a contributing factor to high levels of flu and illness.” —Craig Woods, superintendent, Emmett School District
Emmett High School’s air quality is better than the middle school’s after upgrades, but is still “not up to today’s required air circulation standards,” according to its superintendent.
Emmett High School (Sarah A. Miller/Idaho Statesman) 88% of superintendents we heard from mentioned that funding is preventing them from addressing facilities problems.Districts have cobbled together funds to make some improvements over the years. Administrators said federal COVID-19 relief dollars allowed them to replace expensive HVAC systems and roofs. But that money is nearly gone.
Many superintendents said they felt hopeless about ever passing a bond to renovate or replace schools, especially since funding other educational needs is already a challenge. Districts also regularly ask voters to approve supplemental levies to cover some salaries and operating costs that go beyond state funding.
“Rural school districts can’t pass bonds to build new facilities,” said Todd Shumway, superintendent of the North Gem School District. “It only takes a few to defeat a bond.”
Not passing a bond means districts not only worry about maintaining their buildings, but also about what would happen if a gas line shuts down, the boiler stops working or the sewage system fails. And it means that as Idaho faces a teacher shortage, qualified educators can look across state borders at modern schools in better-funded districts — and decide to leave the state behind.
Kuna School District is building a second high school to relieve overcrowding, but it needs more funding to complete it. A bond measure to do this failed in March despite 56% of voters supporting it. District officials say they may have to consider going to school year-round or in split shifts if the student body continues to grow. (Asia Fields/ProPublica)Design and development by Anna Donlan.
Opener image sources: Asia Fields/ProPublica; Sarah Miller/Idaho Statesman; courtesy of Kamiah High School students; courtesy of Moscow High School students; courtesy of Bernie Carreira; Pocatello Fire Department, obtained by ProPublica and Idaho Statesman
This article was produced for ProPublica’s Local Reporting Network in partnership with the Idaho Statesman. Sign up for Dispatches to get stories like this one as soon as they are published.
Idaho lawmakers are discussing a proposal that would make it easier for school districts across the state to repair and replace their aging buildings.
Idaho is one of two states that require two-thirds of voters to approve a bond, which is one of the few ways a district can secure funding to build new school facilities. The Idaho Statesman and ProPublica have reported this year how this threshold has stymied districts from fixing or replacing antiquated boilers, leaking roofs, failing plumbing, overcrowding and inadequate building security.
As lawmakers head into the legislative session in January, prominent Republicans say they’re now considering ways to change the Idaho Constitution and the two-thirds supermajority requirement.
Drafts of a potential resolution are still in the early stages, and the effort is being headed by Rep. Rod Furniss, a Rigby Republican who represents the legislative district encompassing Salmon, where the school district tried and failed to pass a bond six times in seven years.
Lowering the threshold would require support from two-thirds of legislators, and a majority of voters would need to approve the constitutional amendment on the ballot.
Hundreds of students, educators and school administrators have told the Statesman and ProPublica about the ways school building conditions impact their daily lives. Some have argued it’s nearly impossible for school districts to reach two-thirds support in communities that are low-income or have older households with no kids in school, and it’s creating inequity among districts.
James Gilbert, superintendent of the Mountain Home School District, told the Statesman and ProPublica that school repairs “just continue to add up, and there is no real funding solution to address the issues unless bonds or levies are passed.”
Since 2006, fewer than half of all school bonds have passed. Had a simple majority been required, as is the case in most other states, around 80% of them would have been approved, an analysis by the Statesman and ProPublica found.
Legislators have done little to address the problem despite an Idaho Supreme Court ruling in 2005 that declared the state’s funding system for school infrastructure unconstitutional and tasked lawmakers with making sure facilities were properly funded.
“People are generally getting more and more dissatisfied with the fact that we’re not able to address our aging facilities in public education,” Sen. Dave Lent told the Statesman.
Lent and Rep. Wendy Horman, both Republicans, discussed the proposal during a town hall meeting in Idaho Falls last week. Lent, who chairs the Senate Education Committee and determines the bills introduced by the panel, told the Statesman he plans to co-sponsor the resolution. Horman co-chairs the influential Joint Finance-Appropriations Committee, which sets the budgets for all state agencies every year.
In the past, proposals to lower the supermajority have failed to gain traction.
In 2017, a resolution that would have started the process to lower the threshold to 60% never made it out of a legislative committee. Lawmakers who oppose changing the supermajority have said there should be a high threshold to impose taxes on a community.
“Unless an existing school actually falls to the ground and becomes unusable, I don’t perceive them ever passing a bond,” Josh Tolman, a former Salmon school board member, previously told the news organizations in an interview.
Furniss said in an interview that lawmakers are discussing ways to reduce the vote threshold in elections when turnout is high. That way, bond measures wouldn’t fail with 65% support in high-turnout years — what would be a blowout election in any other race.
On the whole, Furniss expects that “quite a few more bonds might pass,” but only in situations where the election adequately gauges the “will of the people.”
Furniss said lawmakers have looked at systems used in other states, including Montana and Alaska. Montana requires a smaller majority in high-turnout elections and a larger majority in low-turnout elections. But if turnout is low enough, a bond automatically fails, which is one reason Furniss said some lawmakers in favor of reform are leaning against the idea.
Furniss said a different option he favors is to lower the threshold districts would need to meet in years that have historically high turnout. For example, bond measures on the ballot during presidential election years might require a simple majority while those in midterm years could require 60%.
Lent and Furniss acknowledged that lowering the threshold for bonds would be a heavy lift, given that it would need support from two-thirds of lawmakers in Idaho’s conservative Legislature. But Lent said lawmakers are committed to finding ways to help school districts upgrade aging facilities and address maintenance problems.
Lawmakers plan to “take the temperature” once the session starts to determine the proposals that will get the most traction, Lent said. Legislators are also looking at other options to help school districts with their aging facilities, including offering more state funding.
“Our first priority is to figure out a way to have greater state participation and relieve the pressure on local property taxes for facilities,” he said. “We definitely want to have lots of options to see what we can get done.”
Update, Dec. 14, 2023: This story was updated to include comment from James Gilbert, superintendent of the Mountain Home School District.
This article was produced for ProPublica’s Local Reporting Network in partnership with WVUE-TV. Sign up for Dispatches to get stories like this one as soon as they are published.
Update, Dec. 15, 2023: This story has been updated to reflect the fact that after this story was published, another town — Tullos, Louisiana — said that it had appointed a magistrate following WVUE and ProPublica’s inquiries.
Amid questions about how he ran his court, the mayor of the tiny village of Fenton, Louisiana, recently decided he would no longer serve as the town judge.
He had been recorded saying police officers must write more tickets and now found himself defending his impartiality. Some court records included notations by officers and village employees saying not to “fix” certain tickets; other notations said tickets were dropped after someone, often a law enforcement officer, had intervened.
The U.S. Supreme Court has ruled that having a mayor serve as judge is unfair to defendants if a town brings in a substantial part of its revenue through the court and if the mayor is responsible for the town’s finances. The court in Fenton brought in 92.5% of the town’s revenue in one recent year, but the mayor still sat on the bench.
After WVUE-TV and ProPublica reported on what was going on, the mayor last month appointed an attorney to preside over the court instead.
Mayor’s courts, where the authority to enforce local ordinances by default rests with the mayor, exist in small towns throughout Louisiana, which commission annual audits that show how much money each town takes in. The state auditor’s office holds those reports, but it doesn’t track which towns take in enough money from their court to create a potential conflict of interest.
WVUE and ProPublica decided that we would. Looking at recent audits for all municipalities in Louisiana that file them, we could see which towns took in the greatest share of their revenue through fines and related costs. Starting with the towns other than Fenton that collected the highest percentage, we began calling around to confirm that all that money came through their mayor’s court.
Of the 15 towns we reached in the last several weeks, 13 had mayors on the bench even though their courts brought in anywhere from 14% to 82% of their total governmental revenue in the fiscal year ending in 2022. The Louisiana Judicial College, the educational arm of the state Supreme Court, recommends that mayors appoint someone else to serve as judge if their town takes in at least 10% of its overall revenue from court.
Told of our findings so far, a state lawmaker is calling for reform of a court system that exists only in Louisiana and Ohio.
“If 48 states can live without mayor’s court, why can’t we?” said state Rep. Edmond Jordan, a Democrat from Baton Rouge. “You got the town attorney acting as the prosecutor. So everybody is in on the game, except the person being charged with the offense.”
You got the town attorney acting as the prosecutor. So everybody is in on the game, except the person being charged with the offense.”
—State Rep. Edmond JordanJordan said he wants to create a task force to study mayor’s courts. Unlike other courts in Louisiana, they don’t have to follow rules of procedure designed to ensure that they’re run fairly and properly. And unlike municipal judges, who handle the same types of offenses, mayors do not need a law degree to adjudicate cases. Until this year, they weren’t required to undergo any training.
Last year, Jordan filed a bill to abolish mayor’s courts, but it was opposed by the Louisiana Municipal Association, which advocates for the interests of villages, cities and towns. Jordan then tried to require towns with mayor’s courts to appoint attorneys to preside over their courts, but lawmakers resoundingly voted the bill down.
Seven of the mayors in those 13 towns said they’re not convinced they’re doing anything wrong, including four who said they believe they treat defendants fairly despite their reliance on the court for a large portion of the town’s budget. Two of those who defended their practices also said they can’t afford to pay someone else to preside. One said if he finds out that he needs to appoint someone, he will.
However, two towns — Albany, east of Baton Rouge, and Tullos, in north Louisiana — responded by appointing magistrates.
Mayors Step Down From the Bench After WVUE, ProPublica Ask About Court RevenueMost of the 13 towns identified by the news organizations are home to just a few hundred people. They include Turkey Creek, in south-central Louisiana, where the police department is funded entirely by citations.
The village of Dodson, located in north-central Louisiana, collected half a million dollars — 73% of its total revenue — from its mayor’s court in the year ending in June 2022.
Henderson, a town of about 1,600 just east of Lafayette on Interstate 10, had revenues of about $3.5 million in the year ending in June 2022, according to an audit. About $2 million of that came through its court.
Of the 301 municipalities and two combined city-parish governments required to file audits, we found 91 with mayor’s courts that collected 10% or more of the municipality’s revenue through fines and forfeitures in a single year. (Although the state provides no official definition of “fines and forfeitures,” it generally refers to penalties for breaking the law and associated fees.) We called those courts to see who presided — in some courts, the mayor has appointed a magistrate instead — and to confirm how much of that money came through court.
Small Towns Where Mayors Run Courts That Bring in Substantial RevenueThe Louisiana Judicial College advises towns with a mayor’s court to appoint someone other than the mayor to act as judge if court collections account for at least 10% of their overall revenue.
Courts in these towns took in at least 10% of the budget in one year, but town employees confirmed that the mayor still presided there. Two of the 13 changed course after we contacted the towns.
*Appointed a magistrate after WVUE and ProPublica inquired.
Sources: Municipal audits on file with the Louisiana legislative auditor for fiscal year 2022; 2020 U.S. Census; town employees.
Competing Advice for Small Town MayorsStarting this year, anyone who presides over a mayor’s court in Louisiana must complete three hours of video training provided by the state Judicial College, in which the trainer says he “would highly recommend” appointing a magistrate if a town’s court generates at least 10% of its revenue.
Mayors in all 13 towns we identified have taken that training. Two of them pointed out that the guidance about appointing someone else was phrased as a recommendation. Two others said they had followed different advice, including one who said he talked to the Louisiana Municipal Association. About 250 of the association’s 300 or so members have mayor’s courts, and the association publishes a lengthy guide on how to run them.
The Judicial College’s advice is based on a federal court ruling in Ohio, which held that 10% would be considered a “substantial” share of town revenue under the 1972 Supreme Court opinion that addressed the fairness of mayor’s courts. The Ohio town in the Supreme Court case generated between 37% and 51% of its annual revenue through its court.
Bobby King, the prosecutor for a mayor’s court outside Baton Rouge, led much of the Judicial College training. Mayors whose courts take in a substantial amount of money “can be in a bind” if they sit on the bench, he said in the training. If a mayor presides, he said, “you can be held that you’re violating people’s constitutional rights to due process.”
After watching the videos, the mayor of Brusly, whose court accounts for 17% of its revenue, said he asked the Municipal Association if he needed to appoint a magistrate. Mayor Scot Rhodes said he was told by someone in the association’s legal department that the threshold doesn’t apply to the many cases in which defendants simply pay their fines. Instead, he said he was told, it applies only to revenue from the few cases in which defendants appear in court before him to fight their tickets or ask for a break. “I’ve been advised that we’re doing everything on the up-and-up,” he said.
Henderson Mayor Sherbin Collette said he came to the same conclusion after a training session at the Municipal Association’s convention in 2022. “If we find out that it is better that we have a magistrate,” Collette said, “we are going to see that it happens.”
Karen White, executive counsel for the association, told WVUE and ProPublica in an email that the association “does not provide legal guidance, opinions, or advice to municipal members”; that’s up to each municipality’s attorney. When the association participates in events with other entities such as the Judicial College, the state Supreme Court or the legislative auditor, “there are times in which a remark is attributed, innocently but erroneously, to a particular entity.”
White wrote that it is problematic to “adopt a singular guideline for all municipal governments in the state” because there are wide variations in how towns are chartered and operated. “There has been no rule from the U.S. Supreme Court to support any definite threshold as triggering the mandatory appointment of a magistrate.”
The association’s 210-page guide to mayor’s courts says that “it seems prudent that, when possible,” a magistrate be appointed to oversee the court. If a town can’t afford it, the guide says, the mayor should try as much as possible to “separate their duties” as presiding officer of the court from their duties as the town’s chief executive.
The Municipal Association’s guide also offers an alternative: a “hybrid” arrangement in which the mayor handles guilty pleas but an appointed magistrate oversees proceedings in which someone pleads not guilty, as well as any trials or hearings that may be required.
In northeast Louisiana, the mayor for the village of Baskin, which took in 70% of its revenue from mayor’s court in one year, told WVUE and ProPublica that he is considering a hybrid approach when we asked why he presides over court. “I get everyone’s frustration,” Mayor Layton Curtis said. “We really need to be respectful of everybody.”
Mayor’s courts play an integral role in ensuring public health and safety, as their jurisdiction encompasses the enforcement of all municipal ordinances.”
—Karen White, executive counsel for the Louisiana Municipal AssociationWoodworth, near the central Louisiana city of Alexandria, is one of two towns among the 13 that now use that approach. Mayor David Butler said he does this because he doesn’t “want to show any partiality,” although he believes he treats defendants fairly. He said he’s been on the bench long enough that he can read people — “whether they are honest or not honest.”
However, King said he doesn’t believe the hybrid approach addresses a potential conflict of interest for any town where the court takes in at least 10% of revenue. In his training, he tells people that what matters is total collections.
White wrote that questions about conflicts of interest are not unique to mayor’s courts because all types of courts in Louisiana receive some funding from the fines and fees they impose.
“Mayor’s courts play an integral role in ensuring public health and safety, as their jurisdiction encompasses the enforcement of all municipal ordinances,” she wrote. “Neither mayors nor council members have any control over how many persons violate traffic and other ordinances, nor how often.”
“As Long as They Don’t Have a Bad Attitude, I Try to Help Them”Proponents of mayor’s courts say they’re an efficient, informal way to administer justice in small towns. Several mayors said they run their courts simply and fairly, usually without holding trials.
Dodson Mayor Richie Broomfield, who also does maintenance for the town, wears jeans and work boots to court. “I don’t want to intimidate anybody. I don’t want anybody to think bad of me,” he said. “They don’t even stand up, we just sit there and talk.”
But as court records in Fenton suggest, not all drivers are treated the same. There, some records included notations from officers and village employees not to “fix” tickets or “help” drivers who had a “bad attitude.” Fenton village attorney Mike Holmes said cases are adjudicated based on provable violations of law, not those notations.
In Fenton, Louisiana, WVUE and ProPublica found a dozen court records with notations saying not to “help” people or “fix” someone’s ticket because of their behavior. Fenton village attorney Mike Holmes said such notes do not affect how cases are decided. (Obtained by WVUE and ProPublica. Redacted and highlighted by ProPublica.)Broomfield also takes into account drivers’ behavior. When people come to court, he said, they’re usually polite. But that doesn’t mean they were nice when they were stopped, so he reads officers’ notations about drivers’ behavior. “I think I’m very fair,” Broomfield said, noting that speeding cases are often clear-cut. “As long as they don’t have a bad attitude, I try to help them.”
Albany had court revenue of $200,000 in the year ending in June 2022 — about 14% of its overall revenue.
John Boudreaux, a former reserve police officer who lives near Albany, was ticketed there in August for speeding and having an expired license plate. What he found when he went to court to fight the ticket was “very odd,” he said: The mayor was presiding.
“I didn’t even know that existed until that night,” he said. “Either you need to be a mayor or you need to be a magistrate; you can’t be both.”
He said the prosecutor told defendants that if they pleaded not guilty, they would end up being found guilty in a trial and they would end up paying more money.
Keith Rowe, the prosecutor at the time, told WVUE and ProPublica he didn’t say that to defendants and told them instead that they’re presumed innocent. But he said he did tell defendants that they “more than likely” would be found guilty if an officer testified against them. “I just try to tell them the real facts,” Rowe said.
Boudreaux is appealing his case to the local district court.
In an email, Mayor Eileen Bates-McCarroll told WVUE and ProPublica that she knows about “the suggestion” that towns appoint a magistrate and she was considering it. Monday night, the town’s board of aldermen took that step. Rowe will no longer prosecute cases; now he will preside over court.
Joel Jacobs of ProPublica reviewed the data analysis.
This article was produced for ProPublica’s Local Reporting Network in partnership with WPLN/Nashville Public Radio. Sign up for Dispatches to get stories like this one as soon as they are published.
To hear the state of Tennessee tell it, Knoxville’s Richard L. Bean Juvenile Service Center has shown “significant and consistent improvement.” It no longer illegally locks kids up alone in cells, as an investigation by ProPublica and WPLN exposed last month.
But a closer look at the facility’s most recent inspection by the state Department of Children’s Services tells a different story. Instead of secluding children against their will, the facility claims that kids are voluntarily agreeing to be locked up alone. In the first three months of 2023, the facility used this “voluntary” seclusion more than 1,000 times — even though there were usually only about 30 kids staying there. That’s three times as many incidents as a similar period the year before.
Tennessee law closely regulates the conditions under which kids can be locked up alone, against their will in juvenile detention centers. But a 2021 state law permits facilities to isolate children if the child requests a cooling-down period. To be considered truly voluntary under the law, kids have to be able to leave whenever they want.
Zoe Jamail, policy coordinator of Disability Rights Tennessee, says it looks like the facility is classifying the lockups as voluntary to get around the law. Her organization acts as a monitoring agency for juvenile detention facilities in the state.
“One of the effects of calling this voluntary is that you then no longer have to comply with any of the parameters that the state has put around seclusion,” she says.
Both inspections by DCS and reports from detained youth also suggest the seclusions are not truly voluntary.
In 2021, after the new law took effect, a DCS inspector visited the center. She documented that the facility’s reliance on these voluntary seclusions was on the rise, and that it was “unclear” if the youth knew they could leave their cell by choice.
“You can’t come in and out — like, the door’s locked,” says one teenager that we’re referring to by his middle name, Tyler, to protect his privacy as a minor.
A cell at the Bean Center where kids are sometimes kept in isolation (William DeShazer for ProPublica)Tyler spent months at the Bean Center this year. He says a “voluntary lockup” meant at minimum two hours in his own cell before a guard would let him out. And if he asked to get out sooner?
“They’d get mad. They’d be like, ‘You can’t do that.’”
Tyler says he and other kids would request a voluntary lockup to sleep more or get out of class.
But this summer, he says Bean started cracking down on that by sending them to another cellblock called brown pod for even longer than they wanted.
“Bean made it where they move you to brown and you’re in there for like the whole day,” Tyler says. “People who would ask to go on lock up would still be locked up for like two or three days before they’d come back.”
Another teen who we’re calling by his middle name, Francisco, says he was locked up for a day after asking for a brief voluntary lockup.
The way he remembers it: “Mr. Bean decided that he was mad that everybody was taking voluntaries because school wasn’t happening. He just was like: ‘All right, then everybody’s going to brown for a day. And if you don’t go to school no more, you go to brown for the whole day, to the next day.’”
Bean admitted to that policy during our interview in September.
“So what I started doing is put them in seclusion until the next morning, and then they want to go to school,” Bean said then. “And so that’s working pretty good.”
Superintendent Richard L. Bean has been running a juvenile detention center in Knoxville, Tennessee, since 1972. (William DeShazer for ProPublica)Bean and the county board that oversees the center didn’t respond to requests for comment. They haven’t responded since we ran our story last month, which found that the center was locking kids up in seclusion more than other facilities in the state — often as punishment and for longer than the law allowed.
In a statement, DCS said it wants to “ensure that this facility, and any juvenile detention center, has an appropriate policy in place that requires the facility to notify a youth choosing to enter voluntary seclusion that the youth may terminate the voluntary seclusion at will.”
The department says if a kid can’t end the lockup at will, then it no longer qualifies as voluntary. And if it doesn’t, then Bean’s reliance on illegally locking kids up alone has only increased.
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When Barbara and Belvett Richards learned that the police had killed their son, they couldn’t understand it. How, on that September day in 2017, did their youngest child come to be shot in his own apartment by officers from the New York Police Department?
Miguel Richards, who was 31, grew up in Jamaica and had moved to New York about a year earlier after coming to the United States through a work-study program. His father’s friend gave him a job doing office work, and he rented a room in the Bronx. But he started to struggle, becoming reclusive and skipping days of work. His mother, with whom he was particularly close, pleaded with him to return to Jamaica. “It’s as if I sensed something was going to happen,” she says. “I was calling him, calling him, calling him: ‘Miguel, come home. Come home.’”
His parents knew he had never been violent, had never been arrested and had never had any issues with the police. What details they managed to gather came from the Bronx district attorney: Richards’ landlord, who hadn’t seen him for weeks, asked the police to check on him. The officers who responded found Richards standing still in his own bedroom, holding a small folding knife. And 15 minutes later, they shot him.
Richards’ death marked a historic turning point. It was the first time a killing by officers was recorded by a body camera in New York. The new program was announced just months before as heralding a new era of accountability. Now, a week after the shooting, the department posted on its website a compilation of footage from four of the responding officers. The video, the department said in an introduction to the presentation, was produced “for clear viewing of the event as a totality.” And as far as the department was concerned, the narrative was clear. Sometimes “the use of deadly force is unavoidable,” the police commissioner at the time, James O’Neill, wrote in an internal message. The level of restraint shown by all officers, he said, is “nothing short of exceptional.” And, he added, “releasing footage from critical incidents like this will help firmly establish your restraint in the use of force.”
Richards’ parents were not convinced. Belvett watched footage at the district attorney’s office. What he saw, and what was released, did not, in fact, show that the use of deadly force was unavoidable. He later learned that the department had not released all the footage. What else didn’t they know about their son’s death?
Belvett and Barbara Richards’ 31-year-old son, Miguel, was killed by New York City police officers in 2017. (Naila Ruechel for The New York Times)When body-worn cameras were introduced a decade ago, they seemed to hold the promise of a revolution. Once police officers knew they were being filmed, surely they would think twice about engaging in misconduct. And if they crossed the line, they would be held accountable: The public, no longer having to rely on official accounts, would know about wrongdoing. Police and civilian oversight agencies would be able to use footage to punish officers and improve training. In an outlay that would ultimately cost hundreds of millions of dollars, the technology represented the largest new investment in policing in a generation.
Yet without deeper changes, it was a fix bound to fall far short of those hopes. In every city, the police ostensibly report to mayors and other elected officials. But in practice, they have been given wide latitude to run their departments as they wish and to police — and protect — themselves. And so as policymakers rushed to equip the police with cameras, they often failed to grapple with a fundamental question: Who would control the footage? Instead, they defaulted to leaving police departments, including New York’s, with the power to decide what is recorded, who can see it and when. In turn, departments across the country have routinely delayed releasing footage, released only partial or redacted video or refused to release it at all. They have frequently failed to discipline or fire officers when body cameras document abuse and have kept footage from the agencies charged with investigating police misconduct.
Even when departments have stated policies of transparency, they don’t always follow them. Three years ago, after George Floyd’s killing by Minneapolis police officers and amid a wave of protests against police violence, the New York Police Department said it would publish footage of so-called critical incidents “within 30 days.” There have been 380 such incidents since then. The department has released footage within a month just twice.
And the department often does not release video at all. There have been 28 shootings of civilians this year by New York officers (through the first week of December). The department has released footage in just seven of these cases (also through the first week of December) and has not done so in any of the last 16.
Asked about the department’s limited release of footage, a spokesperson pointed to a caveat, contained in an internal order, that footage can be withheld because of laws or department policy. “The NYPD remains wholly committed to its policy of releasing such recordings as quickly and responsibly as circumstances and the law dictate,” the spokesperson wrote. “Though transparency is of the utmost importance, so too is the Police Department’s commitment to preserving privacy rights.” The department did not say which policies require the withholding of footage and did not address other questions about its record on the cameras. (Mayor Eric Adams’ spokesperson did not make him available for comment.)
For a snapshot of disclosure practices across the country, we conducted a review of civilians killed by police officers in June 2022, roughly a decade after the first body cameras were rolled out. We counted 79 killings in which there was body-worn-camera footage. A year and a half later, the police have released footage in just 33 cases — or about 42%.
This article is the product of more than six months spent investigating how the police have undermined the promise of transparency and accountability that accompanied the body-camera movement. We interviewed dozens of department insiders, government lawyers, policing experts and advocates and reviewed hundreds of pages of internal reports, obtained through Freedom of Information requests, and dozens of hours of surveillance-camera and body-camera footage, including some that the New York Police Department fought against disclosing. The reporting reveals that without further intervention from city, state and federal officials and lawmakers, body cameras may do more to serve police interests than those of the public they are sworn to protect.
To Seth Stoughton, a former police officer who is now a professor at the Joseph F. Rice School of Law at the University of South Carolina, body cameras represent the latest chapter in America’s quest for a technological fix to the deeply rooted problem of unchecked state power. “Dash cams were supposed to solve racial profiling,” he says. “Tasers and pepper spray were supposed to solve undue force. We have this real, almost pathological draw to ‘silver bullet’ syndrome. And I say that as a supporter of body-worn cameras.” He later added, “We just said to police departments: ‘Here’s this tool. Figure out how you would like to use it.’ It shouldn’t be a surprise that they’re going to use it in a way that most benefits them.”
Jeff Schlanger, a former New York deputy commissioner who had an oversight role during the implementation of body-worn cameras and left the department in 2021, believes that the police have often failed to use the cameras for accountability and that political leaders need to do more. “Mayors, City Council members, all locally elected officials,” he says, “should be losing sleep over the lack of meaningful independent oversight of the police.”
Jeff Schlanger is a former deputy commissioner who left the New York Police Department in 2021. “Mayors, City Council members, all locally elected officials,” he says, “should be losing sleep over the lack of meaningful independent oversight of the police.” (Naila Ruechel for The New York Times)When full footage has been released, often by prosecutors or after public pressure, it often contradicts initial police accounts. In 2015, a white officer in Cincinnati killed a Black man during a traffic stop. The officer said his life was in danger. But his body-camera video showed that was a lie, and he was prosecuted for murder. (Charges were dropped after two mistrials.) And in Philadelphia this August, an officer shot and killed a man after, the police said, he lunged at officers with “a weapon.” In fact, footage released by the district attorney — who charged the officer with murder — shows that the man was sitting in his own car.
In New York, Miguel Richards’ parents weren’t the only ones who had doubts about the department’s claims that the shooting was unavoidable. The footage the department released stopped right when the officers fired at Richards. It didn’t include the minutes after the shooting, and it didn’t include footage from other police units that responded.
Ruth Lowenkron, a disability rights lawyer who specializes in mental health issues, wanted to see it all. Working for New York Lawyers for the Public Interest, a legal-advocacy nonprofit, she and her colleagues, along with activists, had begun pushing the city to find an alternative to using the police as first responders to people in crisis. On her second day on the job, a sergeant shot and killed a 66-year-old woman who had schizophrenia and was holding a baseball bat in her Bronx apartment. The department’s own investigators concluded that the sergeant escalated the situation and caused the shooting.
Now, watching the video the department released of Richards’ shooting, Lowenkron feared that the same thing happened to him. The department’s edited footage showed the officers making a few attempts to connect with Richards early in the encounter. “What’s your name, man?” one officer asked. But they were also barking increasingly terse commands. “You are seconds away from getting shot,” one officer said. “Do you want to die?” A few minutes later, as one of them warned that Richards might have a gun, the officers fired.
Lowenkron filed a records request, certain that there was more to the story. In releasing the partial footage, the police commissioner had vowed that the “NYPD is committed to being as transparent as possible.” But nearly three weeks after her request, Lowenkron received a different message from one of the department’s records officers: “I must deny access to these records.”
Ruth Lowenkron has fought the New York Police Department for years for access to body-camera footage in various cases. Of one video she received, she says, “It was a horror movie.” (Naila Ruechel for The New York Times)Body-worn cameras were adopted by police departments across the country in the wake of widespread Black Lives Matter protests in 2014, sparked when Michael Brown was killed by the police in Ferguson, Missouri. The officer who shot Brown was not equipped with a camera, and there was a dispute about what happened in the last moments of Brown’s life. Amid deep schisms over race, justice and policing, there was at least agreement that police interactions should be recorded. Brown’s mother pressed for the technology to become standard equipment. “Please,” she begged Missouri legislators, “let police-worn body cameras be a voice of truth and transparency.”
President Barack Obama put the cameras at the center of his plans to restore trust in policing. Cities quickly began spending millions on the devices, expenditures that continue today for storage and software. Los Angeles has spent nearly $60 million since getting cameras in 2016. In Philadelphia, where footage is rarely released, the cameras have cost taxpayers about $20 million. New York City has spent more than $50 million. But whether citizens benefit from the cameras they’re paying for is often up to the police, who have often been able to keep footage hidden from the public in even the most extreme cases. In 2018 in Montgomery, Alabama, an officer unleashed his police dog on a burglary suspect without warning, severing the Black man’s femoral artery and killing him. The police and the city have refused to release footage for five years, arguing that it could cause “civil unrest” and that the officers could face “embarrassment.” But a lawyer for the man’s family, which is suing the city, got a copy of the transcript in the discovery process and entered it into the court record. “Did you get a bite?” an officer asked the one who had the dog, according to the document. “Sure did, heh, heh,” the K-9 officer responded.
The secrecy undercuts the deterrent effect on officer behavior that many had presumed body cameras would produce. Three years before the Minneapolis police officer Derek Chauvin murdered George Floyd by kneeling on his neck, body-camera video caught him kneeling on the necks of others. In 2017, Chauvin dragged a handcuffed Black woman out of her house, slammed her to the ground and then pressed his knee into her neck for nearly five minutes. Three months later, Chauvin hit a 14-year-old Black boy at least twice in the head with a heavy flashlight, choked him and pushed him against a wall. The boy cried out in pain and passed out. Chauvin pushed a knee into his neck for 15 minutes as the boy’s mother, reaching to help him, begged, “Please, please do not kill my son!”
The footage was left in the control of a department where impunity reigned. Supervisors had access to the recordings yet cleared Chauvin’s conduct in both cases. Minneapolis fought against releasing the videos, even after Chauvin pleaded guilty in December 2021 to federal civil rights violations in one of the cases. A judge finally ordered the city and the police to release the tapes this April, six years after Chauvin abused the boy. “Chauvin should have been fired in 2017,” says Robert Bennett, a lawyer who represented both of the victims. If the police had done that, “the city never burns. We’d have a downtown still. It’s a parade of horribles. All to keep something secret.”
A Department of Justice report from this summer found that the secrecy and impunity was all part of a larger pattern in the Minneapolis Police Department. Shootings, beatings and other abuse had routinely been captured on video. But the department didn’t make the footage public or mete out punishment.
There was a similar dynamic in Memphis, Tennessee, where officers in a street-crimes unit regularly abused residents. They wore body cameras but faced no consequences until the case of Tyre Nichols, who was beaten to death this January by officers in the unit, attracted national attention. The footage showed that some of the officers took their cameras off. Others knew they were being recorded and pummeled Nichols anyway. It was only after public outcry that the department took the rare step of releasing footage, which contradicted initial police accounts and led to state and federal charges for five officers.
Some politicians have often quietly enabled obstacles to this kind of accountability. When South Carolina became the first state in the nation to require the use of cameras in 2015, Nikki Haley, the governor at the time, made the announcement with the family of Walter Scott standing behind her. Scott was a Black man who, two months earlier, was stopped by the police for a broken taillight and was shot in the back and killed when he tried to run away. A witness filmed the shooting, and that video contradicted official police accounts.
The way to true reform is through using body cams as an early-warning system, as a way to correct small mistakes before they become big mistakes.
—Jeff Schlanger, former New York deputy commissioner“This is going to make sure Walter Scott did not die without us realizing that we have a problem,” Haley said as she signed the legislation. What the governor didn’t say was that the same law stipulated that footage from cameras is “not a public record subject to disclosure,” thus relieving police departments from any obligation to release it. And indeed, little footage has ever become public in South Carolina.
In 2021, York County sheriff’s deputies responding to a call for a wellness check found a young man sitting in his pickup truck with his mother standing next to him. They fired at him nearly 50 times. The sheriff, who refused to release body-camera footage, said the man pointed a shotgun at deputies. When the man, who survived, obtained the footage after suing, it showed no such thing. So far this year, the police in South Carolina have killed at least 19 people. The police have released footage in only three of those cases. When we asked one department, the Spartanburg County Sheriff’s Office, why it had not, a spokesperson pointed to the law, writing, “We never release that footage.”
The pattern has become so common across the country — public talk of transparency followed by a deliberate undermining of the stated goal — that the policing-oversight expert Hans Menos, who led Philadelphia’s civilian police-oversight board until 2020, coined a term for it: the “body-cam head fake.” And there is no place that illustrates this as well as New York City, the home of the world’s largest municipal police force, some 36,000 officers strong.
New York’s adoption of body-worn cameras started with a moment of unintentional inspiration. In 2013, Judge Shira Scheindlin was hearing testimony in a federal lawsuit in which multiple advocacy groups claimed that the Police Department’s aggressive “stop and frisk” policy was racially biased and unconstitutional. One day during the trial, an expert witness for the city mentioned a new tool for accountability — body-worn cameras — in passing.
“My head snapped when I heard the words,” Scheindlin recalled this year. “I thought, ‘That could be a useful remedy!’”
Two months later, Scheindlin issued a historic ruling that New York’s stop-and-frisk practices were unconstitutional. She ordered the Police Department to begin piloting body-worn cameras, writing that they were “uniquely suited to addressing the constitutional harms at issue in this case.” Scheindlin laid out three ways the cameras would help: “First, they will provide a contemporaneous, objective record of stops and frisks.” She continued, “Second, the knowledge that an exchange is being recorded will encourage lawful and respectful interactions on the part of both parties. Third, the recordings will diminish the sense on the part of those who file complaints that it is their word against the police.”
But in a preview of obstacles that would follow, the department was slow to roll out the devices, even as they were becoming common in other cities. More than two years after Scheindlin’s ruling, the department hired researchers at New York University to conduct a survey about what residents wanted from a body-camera project. The community’s answers were overwhelming and clear: transparency and disclosure.
Officers, however, wanted the opposite. They were concerned that the recordings would “show a different side of the story than what would otherwise be told,” according to a separate NYU survey. To Scheindlin and the plaintiffs in the stop-and-frisk case, that was exactly the point.
When the department released its policy in April 2017, it was clear whose opinions held more sway. No video would automatically become public. Anyone that requested it would have to go through an opaque, often slow-moving Freedom of Information process — in which the department itself would be the arbiter of what would be released (though the courts could review that decision).
The policy blunted the technology’s potential for accountability in other ways. Officers could decide when to start filming, instead of at the beginning of all interactions as the public wanted. And while the public had little access to footage, the police had privileged access: Officers who were the subjects of complaints would be allowed to watch the footage before having to give any statements — something that could allow them to tailor their accounts to the video.
The policy was “so flawed that the pilot program may do little to protect New Yorkers’ civil rights,” Ian Head and Darius Charney of the Center for Constitutional Rights wrote in a guest essay in The New York Times. “Instead, it might shield police officers from accountability when they engage in misconduct.”
Still, on April 27, 2017, Commissioner James O’Neill and Mayor Bill de Blasio held a news conference at a precinct in Washington Heights to celebrate the rollout of body-worn cameras. Stepping up to the lectern, O’Neill said he was initially skeptical of the cameras but had become a believer. “I’m totally convinced now that this is the way forward,” he said. “These cameras have a great potential to de-escalate.”
Then the mayor went to the lectern. Officers had long felt that de Blasio, a self-proclaimed progressive, was too supportive of Black Lives Matter protests and not sufficiently supportive of the police. That sentiment turned into rage when a man espousing hatred of the police murdered two officers in late 2014. Hundreds of police officers turned their backs on the mayor at the funerals. Ever since, de Blasio had been working to repair the relationship.
“This is an historic day for New York City,” de Blasio said, with O’Neill by his side. “This is the first day of the era of body-worn cameras, and that means we are going on a pathway of transparency and accountability that will benefit everyone.”
Five months later, officers killed Miguel Richards, making his case the first in which the potential of body-camera video would be tested. But Ruth Lowenkron, the public-interest attorney who filed a request for the footage, was getting little from the Police Department. After it rejected her initial request, she appealed the decision. The department sent her some redacted footage but again rejected her request for all of it.
Disclosing the full footage would be an “unwarranted invasion of personal privacy,” the department wrote. Whose privacy — the dead man’s or the officers’ — was not explained. Releasing the full footage, the department insisted, could “endanger the life or safety of any person.”
The letter came from the department’s legal unit, led by its deputy commissioner, Larry Byrne, who was known for his fierce advocacy for the department. From the outset of the body-worn-camera program, Byrne made it clear that he was resistant to widespread release of footage. “They are not public records in the sense that, because the officer turns the camera on, they are now in the public domain,” Byrne told NY1 in 2015. In fact, he insisted, “most of this footage” would never be made public.
Lowenkron kept requesting the Richards footage and kept getting rejected or sent redacted video. In July 2018, she and her colleagues decided to file a lawsuit in state court demanding the full footage. They even got a former Police Department lawyer, Stuart Parker, to help litigate the suit pro bono. The department’s various explanations for its denials “pissed me off,” Parker recalls. He retired from the department as an assistant commissioner in 2016, the year before cameras were widely rolled out. But he had been excited by their potential and was frustrated by the department’s kneejerk secrecy. “There’s a good side to the department,” he says, “but there’s always been a self-serving dark side to it too.”
In response to the suit, the department argued in legal filings that it had blurred the footage “in order to protect the privacy of both Richards and his family.” But Lowenkron and her team had obtained affidavits from Richards’ parents saying that the department never asked them whether they wanted the footage released or redacted. And what the Richardses wanted, they said, was for the full footage to be released to the public.
Public disclosure of footage isn’t the only path to hold officers in New York accountable for misconduct. For 70 years, the city’s Civilian Complaint Review Board had been vested with the responsibility to investigate New Yorkers’ allegations against the police. From the start, though, its powers were weak. The agency was actually part of the Police Department, and its board consisted of three deputy police commissioners. The department fought efforts over the years to make the agency independent. In the face of a plan in the mid-1960s to include civilians on the Civilian Complaint Review Board, the head of the largest police union, then called the Patrolmen’s Benevolent Association, said, “I’m sick and tired of giving in to minority groups with their whims and their gripes and shouting.”
The agency eventually became independent in 1993 after stiff opposition months before from off-duty officers. Thousands of them — along with Rudy Giuliani, then a mayoral aspirant after losing the previous election — staged a huge protest outside City Hall, with many of them going on to block the Brooklyn Bridge. After the changes, the review board still relied on an often noncooperative Police Department for records, and its investigations frequently petered out amid competing accounts. And like many civilian oversight boards across the country, in the rare cases when it substantiated misconduct, it could only recommend discipline to the police commissioner, who could and often did ignore it.
Many civilians, whom the board relied on to initiate complaints, had long grown skeptical of the agency’s ability to ensure that officer misconduct had consequences. But the advent of body-camera video promised to fundamentally change how the agency worked. For the first time, staff members would have an objective record of the incidents they investigated. That was Nicole Napolitano’s hope when she joined the review board as its new director of policy and advocacy in September 2017 — the same year body cameras were rolled out in New York and one week after officers killed Richards. “We talked about it in detail” at the agency, she says of the initial footage of the Richards shooting. “We thought, ‘Look at what body-worn cameras can show us.’”
Napolitano, who is married to a retired detective, knew it would be a challenge. As a senior policy manager in the Office of the Inspector General for the New York Police Department, she had seen how the department could simply ignore the recommendations in her reports. Napolitano hoped she would have more direct impact in her new, more senior position at the review board. But what she hadn’t appreciated was how much the police controlled the literal tools of their own oversight.
Nicole Napolitano, as director of policy and advocacy at the Civilian Complaint Review Board, argued for a law that would take away the New York Police Department’s sole control over camera footage. She was let go in November 2020. (Naila Ruechel for The New York Times)As with most civilian boards across the country, the agency did not have its own access to footage. Like the public, it, too, had to rely on the cooperation of the department. To try to obtain footage, the board had to navigate a baroque multistep process. Written requests were submitted to a department “liaison” unit, which in turn forwarded them to the legal unit for review. Then the department had to locate the footage, which was a significant undertaking because it wasn’t cataloging the footage in any systematic way. Unlike in many other cities, the department’s cameras had no GPS location data. If a civilian making a complaint didn’t know an officer’s name or badge number, investigators and even the department could have a hard time finding footage.
Perhaps most problematic for Napolitano, though, was the fact that the review board’s investigators had to agree to a strict set of conditions before watching videos of incidents. If they spotted other, unrelated misconduct, they were not allowed to investigate it. “If you were setting up a system to be shitty,” one agency insider says, “this is the system you’d create.”
At times, the department’s animosity toward the board was palpable. Napolitano remembers one meeting in 2017 between board officials and Kerry Sweet, then a top official at the department’s legal bureau who helped oversee the body-camera rollout. As other police brass shuffled in, Sweet said they had missed a chance to “bomb the room” when only board officials were there, which would have “solved everything.” (Sweet, who has since retired, says he doesn’t recall saying that, but added, “On reflection, it should have been an airstrike.”)
Napolitano and her colleagues noticed an even more troubling trend: The department would often tell the review board that the footage it requested didn’t exist — only for the civilian agency to later discover that wasn’t true. According to an analysis the agency put out in early 2020, this happened in nearly 1 of every 5 cases.
Napolitano thought there was a straightforward solution to the department’s stonewalling: The review board should be able to directly log in to the department’s system where footage is stored. That’s how it worked with civilian oversight boards in a few other major American cities, including Chicago, which revamped civilian oversight after Laquan McDonald was killed in 2014 and the city tried to withhold footage that contradicted officers’ accounts. Chicago’s oversight board now not only has direct access to videos but also regularly releases footage publicly, and its investigators have used it to successfully push for officers to be fired for misconduct. Napolitano didn’t see a reason for it to be otherwise in New York. So in her first semiannual report, at the end of 2017, she noted the challenges of getting footage — and called on the city to give the review board direct access. Both the department and City Hall, Napolitano says, “freaked” out.
“It was a rough time for de Blasio when it came to public safety,” Napolitano added, referring to the mayor’s tenuous relationship with the police. “In a dispute between CCRB and NYPD, City Hall always chose the NYPD. Always.”
“I don’t agree,” de Blasio says. “The tension between the CCRB and the NYPD is natural and built-in. I decided each issue on the merits and according to my values.” He went on, “The blunter truth is when a progressive challenges the police culture and the police unions and the status quo of American policing, the left is not going to have their back. You’re not getting that thank-you card. And the right will viciously attack.”
While the department fought Lowenkron and Napolitano on the release of body-camera footage, there was one group that had access to all of it and could use it to check for misconduct: the department’s own investigators. After every police shooting, detectives with the Force Investigation Division review the incident to see whether officers complied with department policy. The Richards case was the first time body-worn-camera footage could let them see what actually happened in a killing by officers. As investigators dug through the video and interviewed officers in the weeks and months after the shooting, they saw a far more complicated picture than the one the police commissioner painted.
As the tape began, one officer, Mark Fleming, beamed his flashlight into the far side of Richards’ nearly bare, unlit bedroom. Richards was standing perfectly still in the dark, seemingly catatonic, wearing a blue polo shirt and sunglasses and holding a knife in his left hand.
Department guidelines for dealing with people in crisis who do not pose an immediate threat say officers should try to “isolate and contain” the person. “The primary duty of all members of the service is to preserve human life,” department policy states. Officers are also instructed to wait for a supervisor’s permission before trying to subdue someone in crisis.
At first, it appeared that the officers who encountered Richards were following their training. “Look, we could shut the door,” Officer Redmond Murphy suggested to his partner. But Fleming, who had served more years in the department, quickly rejected the idea. He kept telling Richards to drop the knife, and he radioed for an officer with a Taser.
Two officers from the specially trained Emergency Services Unit, which deals with people experiencing mental health crises, arrived. Then Murphy said he thought he saw something, perhaps a gun, in Richards’ right hand, which was obscured behind a backpack on the bed. “Hold up,” one of the ESU officers told Fleming and Murphy before heading back downstairs to grab protective gear. “I don’t know if it’s a toy or a gun,” Murphy quickly added.
As the specialists went downstairs, the officer with the Taser, Jesus Ramos, went upstairs and joined Fleming and Murphy outside Richards’ room. “Do you want to take him down now?” Ramos asked them. “Yeah,” they both answered.
At nearly the same moment, a radio command came from headquarters, emphasizing department guidelines. “Isolate and contain,” the dispatcher told the officers. “Use nonlethal force whenever possible.” As Ramos lifted his Taser and stepped into the room, Fleming — who later said Richards was raising his arm — fired his gun. Murphy fired, too. It’s impossible to see that moment in the grainy, shaky footage. The clearest angle would most likely have been Fleming’s camera, but it was covered by his arm as he held his flashlight.
The shooting of Miguel Richards was the first to be recorded by NYPD body cameras. Police Commissioner James O’Neill wrote in an internal message that releasing footage would show officers’ “restraint in the use of force.” Below are clips from the videos the police initially released. They contain graphic content.
Officers answered a call for a wellness check and found Richards standing still in the far corner of his bedroom, holding a small folding knife. “Look, we could shut the door,” Officer Redmond Murphy said at one point. Instead, police shouted at Richards for the next 15 minutes. Murphy says he thinks he sees something in Richards’ hand: “I don't know if it's a toy or a gun.” Officer Mark Fleming says: “I don’t want to shoot you if you’ve got a fake gun in your hand. You hear me? But I will shoot you if that’s a real gun.” A radio command from headquarters reminded the officers of NYPD guidelines to “isolate and contain” a person in a mental health crisis and to “use nonlethal force whenever possible.” Fifteen minutes after arriving, they opened fire. An internal investigation later found that Richards “was contained and posed no immediate threat of danger.”Fleming and Murphy fired 16 times, hitting Richards seven times, including twice in the chest, rupturing his aorta. As gunshots rang out, the supervisor they were supposed to wait for arrived. (None of the officers responded to requests for comment.)
The internal investigators asked the officers to explain. “We kind of handle everything on our own,” Murphy offered. An internal investigator pressed Fleming about what had “situationally changed” and prompted the decision to “take him at that point.” Fleming said everything changed once his partner said Richards might have a gun. “I perceived that his intentions were lethal,” Fleming said. But his answers suggested that he hadn’t fully grasped Richards’ mental state. “Why would any sane person hide a fake gun?” Fleming asked.
When the investigators asked why the two officers did not broadcast that Richards was an “EDP” — or an emotionally disturbed person — with a knife, as protocol dictates, Murphy told them he and Fleming had handled people in crisis before. Asked why they made the decision to use force, Murphy simply said, “We wanted to, like, end it.”
While the Force Investigation Division ultimately concluded that the officers had been “justified” in shooting — because they were facing an “individual armed with a knife and an imitation firearm” — the investigators also said that Fleming and Murphy should still be punished. Richards, their September 2018 internal report noted, “was contained and posed no immediate threat of danger.” And the officers violated policy by not asking permission from their supervisor before they acted. The department’s full investigative record was first reported by the independent journalist Michael Hayes in his 2023 book, “The Secret Files.” The review recommended that the officers face disciplinary charges that could ultimately result in their firing.
But in New York, as in almost all cities in the United States, the police commissioner has absolute power over punishment. In March 2019, O’Neill, who had extolled the promise of body cameras just two years earlier, overruled his own investigators. He decided that neither Fleming nor Murphy would be punished for killing Richards. Instead, the commissioner docked them three vacation days for something else they did: stopping for pizza before responding to the call for the wellness check. (O’Neill did not respond to questions or requests for comment.)
It would be another three months before anyone outside the department would see the full footage. That June, a New York judge ruled that the “public is vested with an inherent right to know” and ordered the department to turn over the recordings to Lowenkron’s organization.
She received a package with a DVD a month later from the department. Bracing herself, she sat down to view it on her computer. The footage that the department publicly released cut off when the officers fired. Lowenkron now saw the aftermath: Richards collapsed to the floor, crumpled and bleeding in the same spot where he had been standing rigidly seconds before.
“He’s still alive,” Fleming said.
“Holy shit,” Murphy replied. “Just fucking cuff him.”
The officers then flipped over Richards, severely injured, so roughly that his head could be heard bouncing off the floor.
They searched around the room for the firearm they thought Richards had. Eventually, Fleming found a palm-size, silver-colored plastic toy gun. “It’s some fucking little thing,” he said. (The video does not show Richards holding the toy gun.) More than three minutes passed before anyone administered any type of aid to the dying man. It was an Emergency Services Unit specialist who retrieved medical equipment after hearing the shots.
Outside the apartment building, more video recorded other officers milling about. One told a colleague, “They were just hurling fucking shots.”
The NYPD initially withheld the footage of the aftermath of the Richards shooting. Below are clips from the videos that a state judge later ordered released. They contain graphic content.
As the officers move into Richards’ room moments after shooting him, Fleming observes, “He’s still alive.” Murphy is breathing heavily. “Holy shit,” he says. The officers ask one another if they are all right as they mill around Richards’ injured body. He is handcuffed and flipped over so roughly his head can be heard bouncing heavily on the floor. As more officers arrive outside Richards’ apartment building, one tells a colleague, “They were just hurling fucking shots.”Lowenkron was shocked. Officers had shot a young man and roughly handled him as he bled to death. “The utter disrespect,” Lowenkron says. “It was a horror movie.”
New York Lawyers for the Public Interest would go on to share the footage with journalists. It would also use the footage in a webinar for mental health advocates in November 2020. “The point,” Lowenkron told me, “was to get more people engaged on this issue: transforming New York and this country’s response to people in crisis.”
But by then, for another man in distress, it was too late.
In April 2019, one month after O’Neill decided against punishing the officers for the Richards shooting, another officer shot and killed a man named Kawaski Trawick.
The circumstances were remarkably similar to those in the Richards case. Trawick was also a young Black man who lived in the Bronx and was experiencing a mental health crisis in his own apartment. He was also holding a knife when the police arrived. And he was also shot soon afterward. At the Civilian Complaint Review Board, Napolitano was immediately struck by the parallels: “I remember reading the headline on Trawick and thinking, ‘Didn’t I read this already?’”
This time, though, the victim’s family filed a complaint with the review board, providing an opening for civilian investigators to use body-worn-camera footage to make a case that the department and others couldn’t ignore.
But despite repeated requests over many months, the department wouldn’t share the footage — or any other records — with the review board, leaving the oversight agency effectively unable to begin its own investigation of the case. The refusal was in line with the department’s longstanding practice to withhold footage from the board until the department’s internal investigation was over, a process that often takes more than a year. Such delays can effectively torpedo the review board’s investigations: Under New York civil-service law, any disciplinary cases against police officers must be brought within 18 months of the incident.
In the Trawick case, the review board obtained the full body-camera video in January 2021 — more than a year and a half after the killing — and only after a state judge ordered the department to hand it over to Lowenkron’s organization, New York Lawyers for the Public Interest, which had sued for it. The judge determined that the department had been withholding the footage “in bad faith.”
What it showed was even more damning than what was captured in the Richards shooting. As the police entered his apartment, Trawick demanded to know, “Why are you in my home?” One officer, Herbert Davis, who was Black and more experienced, then tried to stop his white junior counterpart, Brendan Thompson, from using force. “We ain’t gonna tase him,” Davis said in the video.
Thompson didn’t listen. Instead, he fired his Taser at Trawick, sending roughly 50,000 volts pulsing through him. As Trawick started rushing toward the officers, Thompson lifted his gun and prepared to fire. “No, no — don’t, don’t, don’t, don’t, don’t,” Davis said, pushing his partner’s arm down. But Thompson fired four shots, hitting Trawick twice and killing him almost instantly, 112 seconds after they arrived at the apartment. (Davis and Thompson did not reply to requests for comment.)
There was also troubling footage of the aftermath of the shooting. Officers swarmed outside Trawick’s apartment. “Who’s injured?” a sergeant asked. Two officers replied in near unison: “Nobody. Just a perp.”
With all that in hand, the review board completed its investigation in June 2021. The agency, through one of the few powers it had gained over the years, can file and prosecute disciplinary cases against officers — which triggers a Police Department trial, after which a departmental judge sends a provisional decision to the police commissioner, who makes the final call.
This September, the police judge overseeing the Trawick case recommended that there should be no discipline. Her reason had nothing to do with the shooting itself; in fact, the judge wrote that she had “serious doubts” about the decisions of the officer who killed Trawick. But the review board, she said, had failed to file charges within the 18-month statute of limitations, as outlined under state law. In the end, the department’s refusal to give the footage to the review board had effectively run out the clock on any chance the officers would be punished.
“That should not be tolerated,” says Jeff Schlanger, the former deputy commissioner. “Both CCRB and NYPD are city agencies. This is something the mayor needs to resolve.”
In the wake of George Floyd’s murder in 2020, huge demonstrations for racial justice and against police brutality rolled across the country and the world. It was a global reckoning brought on by footage — the video, recorded by a teenager on her smartphone for more than eight minutes, showing Derek Chauvin ending Floyd’s life.
Napolitano and her team at the review board had collected data showing how footage could make a difference in New York too. Access to body-camera footage roughly doubled the likelihood that agency investigators would be able to decide a case on its merits rather than dismiss it as inconclusive. But the backlog was growing. That May, the board filed 212 requests with the Police Department for body-worn-camera footage — and the department sent only 33 responses. (While the pandemic slowed the work of all city agencies, the backlog predated it.)
“The withholding of footage stops investigations and prevents the CCRB from providing adequate and meaningful oversight of the NYPD,” an internal agency memo warned. “The situation for New York City oversight of the police has steadily grown worse during the duration of a BWC program intended primarily to aid oversight.”
We just said to police departments: ‘Here’s this tool. Figure out how you would like to use it’ It shouldn’t be a surprise that they’re going to use it in a way that most benefits them.
—Seth Stoughton, a former police officer who is now a law professor at the University of South CarolinaNapolitano campaigned internally for a law that would take away the department’s absolute control over footage and give the review board its own access. That November, she was let go, along with three other staff members who had sent pointed emails and memos about the department’s withholding of footage. The four filed a lawsuit claiming that their firing violated their First Amendment rights and received an undisclosed settlement. A review-board spokesperson wrote in an email that the agency has “publicly and repeatedly called on legislators to support the fight for direct access. No employee has ever been fired for supporting direct access to BWC footage.”
This spring, the City Council speaker, Adrienne Adams, and the New York City public advocate, Jumaane Williams, sponsored a bill that would give the review board direct access to footage so that it wouldn’t be beholden to the department for cooperation during investigations. “There are difficult split-second decisions that have to happen” in policing, Williams told me. “But if we’re not able to look at the same thing, if we have to take the word of the NYPD, that doesn’t make this conversation any easier.”
The Police Department has opposed the bill. A department official insisted at a City Council hearing in March that the department “does not fear transparency.” But the official argued that it would be an “insurmountable obstacle” to give the review board direct access while following state confidentiality laws. The bill has been stalled for months.
The city, meanwhile, paid out at least $121 million in settlements last year for lawsuits alleging misconduct by police officers — the highest total in five years.
With footage remaining in the control of the Police Department, body-worn cameras have made little difference to the public. This year, a federal court monitor wrote a scathing report about persistent problems with stop-and-frisk, the unconstitutional policing tactic that prompted Scheindlin to order the department to adopt body cameras a decade ago. The monitor found that contrary to Scheindlin’s expectations, police supervisors weren’t using footage to flag misconduct. In a sample of cases the monitor looked at, supervisors reviewing footage of stop-and-frisk encounters concluded that 100% of the cases they looked at were proper stops. The court monitor reviewed the same footage and found that 37% of the stops were unconstitutional.
“It was an experiment,” Scheindlin says, one that didn’t anticipate issues like control over footage. Scheindlin, who stepped down from the bench in 2016, says she now believes that the Police Department should no longer be the sole custodian of its own video. “That troubles me,” she says. “It should always be somebody independent.”
In interviews with a half-dozen former commanders and high-level officials, most of whom were involved in the body-camera program itself, they said that despite its public pronouncements, the department hasn’t committed to using footage for accountability. “Body cams are essential, if done right,” says a high-ranking commander who just retired and who spoke on the condition of anonymity because he still works in law enforcement. “They are a game changer.” He added, “If there’s a problem, you flag — and potentially there’s discipline. But that’s not happening in most cases.” Instead, he says, body cameras have become “an exercise in just work they have to do. It’s a culture thing.”
Rudy Hall has a particularly useful vantage point. He was part of the team that rolled out the body cameras, visiting police departments around the country to see how they were using the technology, and has gone on to work for the federal monitor overseeing the department’s compliance with Scheindlin’s now-decade-old order on stop-and-frisk. “I watch a lot of body-cam videos,” Hall told me. “I have absolutely seen supervisors approve problematic conduct.”
“Body-worn cameras have not been exploited the way they should be,” says Jeff Schlanger, the former deputy commissioner. “The way to true reform is through using body cams as an early-warning system, as a way to correct small mistakes before they become big mistakes. But there weren’t a lot of discussions about it. The NYPD needs to do a lot better.”
One of the most comprehensive studies of the use of body cameras, a 2019 meta-analysis led by researchers at George Mason University, recommended that police departments consider using footage the way sports teams use game tape, to regularly review and improve performance. That’s essentially what the New Orleans Police Department did after the U.S. Department of Justice put it under federal oversight about a decade ago in response to the police killings of several Black men and persistent police violence. Body cameras were a “critical engine for us to continuously evaluate performance,” says Danny Murphy, who ran a unit at the department overseeing compliance with the federal mandate.
Four auditors were hired to join the police force and comb through footage. They looked to make sure that officers were using their cameras and that supervisors were flagging any problematic behavior. “If officers know they’re being viewed, if supervisors know they’re being reviewed, it creates a pressure for accountability,” says Murphy, who left the department four years ago. A 2020 report from the city’s civilian oversight agency — which has direct access to footage — noted a reduction in both the use of force and citizen complaints, which the department attributed to “the use of the body-worn cameras and the increased scrutiny and oversight these cameras provide leadership.” The police in New Orleans also regularly and quickly release video from shootings and other major incidents. But in the end, it’s the police chief who has the final say on discipline.
During his tenure at the New York Police Department, Schlanger had, in fact, started a kind of internal oversight system similar to the one in New Orleans. Schlanger and other senior officials would meet with each of the department’s 77 precincts every six months and look at body-camera footage to identify problematic trends and officers. “It was CompStat for constitutional policing,” Schlanger says, referring to the department’s data-heavy program for tracking crime. “If we saw a precinct doing poorly, we’d work to help them. It made a difference.”
The department quietly ended the review program last year.
A civil suit on behalf of Miguel Richards’ estate was filed against the city in 2018. New York is seeking the dismissal of the case. A judge has been considering the request for two and a half years. “I want answers,” his mother told me, “and haven’t been able to get them.”
The three officers involved in the Richards shooting were honored in 2018 by the largest New York police union, the Police Benevolent Association, which gave them its Finest of the Finest award for “extremely brave and tactically sound action” in the Richards shooting, noting that “the officers had no choice but to open fire.”
The officers were later deposed in the lawsuit. One of them, Mark Fleming, said in his testimony in September 2020 that he had learned a lesson: that the Emergency Services Unit — whose help he told department investigators he didn’t need — is in fact better equipped and trained to deal with situations that involve people having a mental health crisis.
It’s not clear what, if any, lessons the department itself has taken in. Since Richards’ death in 2017, when cameras were widely rolled out, officers have killed at least 11 people in crisis. There is no evidence that officers have been punished in any of the cases.
Photographs of Miguel at the Richards home in Jamaica. “I want answers,” his mother says, “and haven’t been able to get them.” (Naila Ruechel for The New York Times)On a Sunday morning in the Bronx this spring, there was another shooting. Santo de la Cruz called a city emergency line. His son, 42-year-old Raul de la Cruz, was in the middle of a schizophrenic episode and had posted a disturbing video on Facebook that morning. Wearing camouflage clothing and a hat with a patch of an Israeli flag, Raul complained about racist police officers. His father called 311, avoiding 911 because he was afraid of what would happen if the police showed up. “I thought they would send someone capable of dealing with a situation like that,” he says in Spanish. “Because I was calling for a sick person, not to send the police to shoot him up.” But it was the police who arrived, with body cameras rolling. And Raul was holding a knife.
The officers shot him 28 seconds after arriving. He was hospitalized for more than a month before being released, having lost a kidney and part of his liver. A department commander cited the body-camera footage when he gave a brief news conference the day of the shooting to describe what happened. “This situation was fast, volatile and dangerous,” he said. The officers’ “quick response saved at least one civilian and protected themselves.”
But the department has not released the footage or commented in the eight months since.
Lowenkron’s colleagues at New York Lawyers for the Public Interest have once again requested the video, so far to no avail. The department has also withheld the footage from the Civilian Complaint Review Board, per the practice of sharing records with the agency only after its own investigation is done.
On Dec. 5, weeks after we sent questions to the department about that practice, the department signed a memorandum of understanding with the board to send footage to it within 90 days of a request.
But for now, nobody outside the department knows exactly what happened in the de la Cruz shooting, including the family. They have not heard anything from the department. They want to see the footage.
Do you have a tip about policing or another subject? Eric Umansky can be reached by email at eric.umansky@propublica.org and on Signal and WhatsApp at 917-687-8406.
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.
In 2020, the detention of a Michigan teenager for failing to do her homework drew widespread outrage: protests outside the facility where she was held and petitions calling for her release. More broadly, the case of the girl identified as Grace put scrutiny on a troubled system that allowed a 15-year-old to be locked up for months for a noncriminal offense.
The following year, Gov. Gretchen Whitmer appointed a task force to study the state’s juvenile justice system. It recommended changes to state law, policy and funding, many of which advocates had been calling for.
On Tuesday, more than three years after ProPublica highlighted Grace’s case, Michigan’s lieutenant governor signed bipartisan legislation intended to transform how the state handles young offenders.
The package of 19 bills signed by Lt. Gov. Garlin Gilchrist II aims to keep young people out of the court system and detention when they get in trouble and instead provide more funding for community-based help, such as family counseling and mental health treatment. Other reforms include eliminating most fines and fees for juvenile defendants and their families and providing state funding for attorneys to represent young people who want to appeal their cases but can’t afford legal help. (Gilchrist signed the bills because Whitmer was unavailable and criminal justice reform has been a key interest for the lieutenant governor.)
Grace’s mother attended the bill signing.
“It was emotional because I’m like, This is happening, it really is happening, and it is going to benefit so many youth,” she said.
Grace was 15 and the pandemic was just starting when she failed to do her online homework, a requirement of her probation the year before for fighting with her mother and stealing a cellphone, which was returned hours later. A judge sentenced her to a juvenile detention center in a Detroit suburb because of the violation.
A Michigan appeals court ordered her release about a month after ProPublica published its investigation. She has since graduated from high school and is in college.
Grace, who ProPublica has identified by her middle name to protect her identity, called the reforms “a victory for youth and a step toward breaking the pipelines and cycles.”
“I hope we can continue to learn from the youth of yesterday to better support, guide and understand the youth of the future,” she wrote in a text message.
Grace and her mother hug outside their home in suburban Detroit in 2020. (Cydni Elledge, special to ProPublica)Jason Smith, executive director of the Michigan Center for Youth Justice, an advocacy group, said that Grace’s case spurred necessary change. Until then, Michigan leaders had been focused on reforming the adult criminal justice and child welfare systems, but juvenile justice had been less of a priority.
“It definitely was a catalyst for getting folks, especially at the state level, to take juvenile justice reform seriously,” Smith said. “This was an opportunity to really act and address some long-standing issues within the system.”
Many of the changes were recommended last year by the Michigan Task Force on Juvenile Justice Reform, chaired by Gilchrist, with members including judges, lawmakers, court officials and families that had experience in the system. The group spent a year digging into why Michigan incarcerates so many young people for noncriminal offenses and then suggested ways to reduce the number. The task force found that decisions about whether to detain a juvenile as well as access to services, such as mental health treatment, often depend on where you live.
Data obtained by the task force from 32 counties, representing about 55% of the juvenile population, determined that roughly 23% of cases referred to courts by prosecutors were for noncriminal offenses such as truancy, running away and incorrigibility. These “status offenses” are only punishable because the person is a minor. An additional 26% of cases were for low-level misdemeanor offenses. Nearly 12% involved children 12 and under.
The legislative changes will not eliminate the detention of children for technical violations of probation or for status offenses, even though that was recommended by the task force. Some states have outlawed that practice. According to 2017 federal data, Michigan held more young people for status offenses than 46 other states, a ProPublica investigation found. Nearly half of those juveniles were Black, and the majority were female.
Still, through changes in policy and funding, the bills aim to keep low-level offenses out of the courts altogether and, when young people are in court, to steer them toward community services rather than detention.
“Every system that does something other than prepare a young person to be successful is a system that desperately needs to be reformed,” Gilchrist, a Democrat, said at the bill signing in Detroit. “There are a lot of things that you can do to help a person besides lock them up. And so we need to have more options, we need to have more choices, and those choices need to be better supported. And this provides a pipeline and a pathway for more of those services to be available for more people in Michigan.”
One reform signed into law Tuesday requires that courts and law enforcement use screening tools to assess a young person’s risks and needs before deciding whether detention is the right option. The standardized assessments are designed to match youth with the most appropriate level of supervision; only some counties in Michigan currently use these tools.
The legislation also prioritizes state funding for community-based services — such as family counseling, mental health support and substance abuse treatment — over detention and residential placements.
Under the current system, the state’s Child Care Fund Unit reimburses counties 50% for juveniles diverted to community programs. The state will now instead pay 75% of those costs, but still cover only 50% of the cost of detention and longer-term residential placement. The change could encourage county courts to rely more on community service programs because they would get more of the cost reimbursed by the state.
State funding also could be used for what is known as “pre-arrest diversion,” which would allow law enforcement to connect children to services without them being arrested or ordered to court.
Another reform establishes an Office of the Child Advocate, which will be responsible for investigating complaints about juvenile justice facilities, including detention facilities. Until now, a similar office only was responsible for investigating complaints related to children in the welfare system.
Most of the laws take effect Oct. 1 to allow time for the state to provide the increased reimbursements to the counties for community services and for courts to adjust to the changes. The legislation establishing the Office of the Child Advocate is expected to take effect soon.
One bill that did not pass before the end of the legislative session would have mandated legal representation for young people in the criminal justice system who can’t afford it, and it would have required the state to pay for it. The law also would have provided training for attorneys and oversight to help ensure quality representation.
While a separate new law will provide access to attorneys for youth appealing their cases, there is currently no state funding for juvenile defense at the earlier stages, something that Grace’s mother said is crucial for a more just system.
“While there has been progress,” she said, “there is more progress to be done.”
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.
One night in March 1976, a young advocate for people with mental illness arrived at the Idaho statehouse with a warning.
Marilyn Sword urged lawmakers not to ratify a system that would ultimately lock away some of Idaho’s most debilitated psychiatric patients in the tiny, concrete cells of a maximum security prison — a kind of solitary confinement with no trial, no conviction and often no charges.
Idaho didn’t have any psychiatric hospitals secure enough for patients whose break with reality made them lash out in fear, anger or confusion. What it did have was a maximum security prison.
Sword said putting prison officials in charge, as lawmakers were contemplating, could violate the civil rights of patients committed by the court for hospitalization. She said it would burden them with “the double stigma of being mentally ill and then being placed in a maximum security unit at the penitentiary,” minutes of the meeting show.
Idaho leaders plunged forward with the legislation anyway.
In the five decades since, Idaho has continued to ignore warnings over and over that its law fails mental health patients by sending them to a cell block, ProPublica found in a review of legislative records and news clips.
“I think it’s really tragic that it has been this many years, and we’re still at this point,” Sword, now 77, said in an interview this summer.
Marilyn Sword was among the first mental health advocates to warn Idaho lawmakers in the 1970s that Idaho’s plan to house “dangerously mentally ill” patients in prison may violate their civil rights. Sword testified in 1976 as president of the Idaho Mental Health Association. (Sarah A. Miller for ProPublica)Governors, lawmakers and state officials have been put on notice at least 14 times since 1954 that Idaho needs a secure mental health unit that is not in a prison.
They also have been told publicly at least eight times since 1974 that Idaho may be violating people’s civil rights by locking them away without a conviction, and that the state could be sued for it.
The most recent warning came this year, when Idaho’s corrections and health and welfare directors wrote that the practice was a problem “not only because of our lack of appropriate levels of care for this population but because the treatment violates the patients’ civil rights.”
Idaho will soon be the last state to legally sanction the practice of imprisoning patients who are “dangerously mentally ill,” to use Idaho’s parlance, but who are not criminals. New Hampshire is phasing it out.
State leaders repeatedly have defended Idaho’s approach — in 1977, 2007 and 2017 — as a temporary measure while the state worked on a stand-alone clinical unit or a permanent secure wing in a hospital. Those facilities never materialized.
At the start of this year, the Legislature refused to use any of Idaho’s $1.4 billion surplus to build a $24 million mental health facility for patients, opting to continue holding them without charges at the state’s maximum security prison south of Boise.
In placing patients who have not been charged with crimes in prison instead of in a treatment facility, Idaho is at odds with the U.S. Substance Abuse and Mental Health Services Administration. Holding prisoners with mental illness in prolonged seclusion also goes against recommendations of the American Psychiatric Association, the American College of Correctional Physicians, federal courts and the United Nations.
ProPublica and Mississippi Today have reported on a related issue recently: how Mississippi keeps hundreds of people with mental illness in county jails as they await appropriate hospital beds.
Idaho’s practice touches far fewer people and typically addresses more extreme behaviors. But it also stands apart because the Idaho patients are locked up longer — an average of 110 to 160 days in recent years — and in solitary confinement, in a maximum security facility, under a program fully endorsed in Idaho statute.
C Block holds the acute behavioral health unit of the Idaho Maximum Security Institution. The prison block is divided into three sections, one of which has nine cells for men considered “dangerously mentally ill.” They include patients who haven’t been charged or convicted of a crime. (Sarah A. Miller for ProPublica)Joe Stegner, a former Republican leader, helped bring Idaho closer than ever toward building a hospital to replace the cell block in 2007 and 2008. Yet the project he championed was no match for Idaho’s inertia and austerity.
The defeat helped seal his retirement from politics.
“I started thinking, ‘You know, if you can’t have some wins in the Legislature, why are you kicking yourself around?’” Stegner, who served as a senator, said in an interview this summer.
“I set out to make a difference,” he said.
“The Damned and the Forgotten”Two men sat in the Idaho Maximum Security Institution’s C Block near Boise on a recent day, neither of them convicted or charged in a crime.
The cell block was silent. An occasional face peered through a cell-door window the size of a computer keyboard. Inside each cell, another tiny window offered a view of razor wire, floodlights and rocks on the prison grounds.
First image: Patients admitted to the Idaho Security Medical Program spend months, on average, in cells like this one in a state prison near Boise. Second image: A view of the prison yard and desert surroundings from a cell in C Block. (Sarah A. Miller for ProPublica)About a half-dozen civilly committed psychiatric patients a year are housed here and at a women’s prison in eastern Idaho under the Idaho Security Medical Program, state data shows.
The men share a block of nine cells with patients facing criminal charges and needing treatment before they can stand trial. Occasionally, a convicted felon with mental illness joins the mix. The women’s prison has one isolated cell.
Patients who end up here have conditions that can trick them into believing strangers are aliens who must be destroyed, or that the phlebotomist drawing their blood is implanting something in their arm, or that a nurse intends to infect them with a lethal virus. They react with violence.
A part-time psychiatrist, a part-time nurse practitioner and a dozen full-time staff members are expected to bring the patients back from shattered realities.
Certified nursing assistant Emma Wilson makes rounds inside the Idaho Security Medical Program’s section of C Block. (Sarah A. Miller for ProPublica. Patient document blurred by ProPublica.)Civilly committed patients with the most severe symptoms spend as much as 23 to 24 hours a day confined to cells the size of a parking space.
Confinement can become necessary because it takes time to find effective medications that stabilize a patient before cognitive and behavioral therapies can begin, corrections spokesperson Jeff Ray said in an email. Until then, he said, “it is in the patient’s best interest they be kept safely in their cell, so they do not hurt themselves or others.”
Every patient gets checked on at least twice an hour, according to the corrections department. They can leave to shower, handcuffed, shackled and accompanied by guards.
Patients who take their medications, follow the rules and remain calm are allowed to spend time in the common area. There, they can watch television, use a microwave or sit in caged-in phone booths to make calls and send email on a terminal designed for prisoners. There are metal “restraint desks,” designed for shackling a person ’s ankles, bolted to the floor.
“There’s no color. There’s no nice pictures. There’s no couches,” said Kasey Abercrombie, a statewide coordinator for the Idaho Department of Health and Welfare, whose job includes regular in-person visits to these patients at the prison.
“It is prison,” Abercrombie told a roomful of attorneys and judges at a July Idaho State Bar meeting. “And when you think about this population in that setting, it is probably dawning on you how wild this is.”
The men spend hours peeling paint from the walls of their cells, a habit so universal that prison workers debate whether it makes sense to repaint between patients.
First image: Members of the prison staff try to keep patients occupied with worksheets, word searches, sudoku puzzles, radios and, in some cases, activities outside their cells. But the men often spend time in isolation peeling paint off the walls. Second image: A phone for the men in this section of C Block is inside a metal cage. (Sarah A. Miller for ProPublica)“We try to do what we can with what we’re given,” said Mallory Logan, a prison social worker who works with civilly committed patients. But she said her unit can’t match the resources of a true forensic hospital.
Prison employees keep an imaginary barrier between convicted inmates who are in C Block for mental health care and the other patients with no convictions or charges.
There’s a “C” taped to the door of “civil” patients, a reminder that the person inside is not there as punishment. Signs around C Block remind staff members not to let the “civils” commingle with the inmates when they’re out of their cells.
Signs throughout C Block remind staff members not to let the “civils” commingle with criminally convicted inmates when they’re out of their cells. (Sarah A. Miller for ProPublica)Little else separates patients. They are guarded, medicated and fed by the same prison employees. They have the same rules and reward systems that can allow them to have a radio or buy candy from the commissary.
Like many other states, Idaho can hospitalize people against their will under a court-ordered involuntary mental health commitment. At least two professionals must agree that such patients are likely to injure themselves or others or are “gravely disabled” due to mental illness.
If patients lash out — maybe punching or threatening to kill hospital workers — Idaho’s law says the state can ask the court to declare them “dangerously mentally ill” so they can be moved to a maximum security facility.
The typical patient isn’t a character who “really tugs on your heartstrings,” says Walter Campbell, chief psychologist for the Idaho Department of Correction.
“These are the damned and the forgotten,” he says.
Idaho is one of two states known to put people with mental illness in a prison without a criminal charge. The other, New Hampshire, just broke ground on a 24-bed secure mental health facility that will allow the state to end the practice — but not before a patient died last spring.
Psychiatrists and legal scholars commissioned by SAMHSA, the federal government’s main mental health agency, say it shouldn’t happen, period. In a 2019 report prepared for the agency that describes “principles for law and practice” in treating mental illness, the authors wrote, “Unless already incarcerated for a criminal offense, or facing criminal charges … no person who has been committed should be placed in a correctional facility for treatment services.”
One former patient’s mother provided ProPublica with copies of her son’s medical records and documentation of 15 uses of force on him during his stays in the Idaho Security Medical Program while under civil commitment. ProPublica is not naming the 38-year-old man to protect his privacy.
The records show that he was alone in his cell for days on end, aside from showers and short check-ins from staff. He didn’t always take his medications as required under his court-ordered commitment, so officers were called to hold him down for the drugs to be injected. Once, they fired pepper spray through a hatch in the cell door before entering.
His mother said she believes his confinement in a prison cell made it harder for him to recover. It was months before he was released last June to a state psychiatric hospital, where he remains.
The number of times force was used on the patient is unusually high, according to Ray, the prisons spokesperson.
“This is an extreme case which is not representative of the typical patient’s experience,” Ray said, adding that the use of pepper spray “is rare but on some occasions necessary.”
While acknowledging that prison is not the most therapeutic environment for people with severe mental illness, Ray described corrections officers assigned to the unit as “carefully selected, specially trained, and expected to consistently meet high performance standards.”
“They are some of the best correctional professionals in our department,” he said.
The prison psychiatrist who treated this patient wrote, in another medical record, that he told Idaho health and corrections leadership that prison was an inappropriate setting for this patient, who had been placed under involuntary civil commitment and had a history of injuring staff members at hospitals. Idaho’s health and corrections directors later asked legislators to fund a new secure mental health facility. (Obtained by ProPublica)According to psychiatrists and researchers, forced solitude can exacerbate conditions for people with profound mental illness, making them lash out more.
“Solitary confinement is recognized as difficult to withstand; indeed, psychological stressors such as isolation can be as clinically distressing as physical torture,” Jeffrey L. Metzner and Jamie Fellner wrote in 2010 in The Journal of the American Academy of Psychiatry and the Law.
It is “the mental equivalent of putting an asthmatic in a place with little air,” according to a ruling by the 9th U.S. Circuit Court of Appeals, which covers Idaho.
Legal experts said Idaho is on shaky legal footing with its practice.
When told about Idaho’s system by ProPublica, David Fathi, director of the American Civil Liberties Union National Prison Project, called it “shocking beyond belief” and a likely violation of patients’ constitutional rights.
“I think the state has considerable exposure here,” Fathi said, “and I would urge them to discontinue this practice before they get sued over it.”
Megan Schuller, legal director for the Judge David L. Bazelon Center for Mental Health Law, said Idaho may also be violating the Americans with Disabilities Act and should invest in community-based care that keeps people from needing a secure facility.
“The bottom line is, you’re imprisoning people for having a mental health condition — for the manifestations of that condition,” Schuller said. “And that is just absolutely not equal treatment to how we treat any other type of health condition or even mental disability.”
Decades of WarningsThe idea of locking Idahoans with mental illness in a penitentiary was around as far back as 1954, when the Idaho Statesman reported that a county prosecutor had pressed for a place to incarcerate the “criminally insane.” At the same meeting where the prosecutor spoke, an influential Republican suggested putting the ward in the state prison. But Idaho’s health director argued a prison ward wasn’t appropriate; people with illnesses belonged in a hospital.
In the 1970s, a new generation of Idaho health and law enforcement officials offered an alternative. They would jointly operate a secure mental health facility, on the grounds of the new Idaho state corrections complex that was going up south of Boise.
The state health agency would provide psychiatric care, furniture, medical equipment and first aid; the state corrections agency would take care of security and room and board. The unit would house up to 17 patients including “persons considered mentally ill and dangerous” but who committed no crime.
Health and corrections leaders called it “a historical first” and “a new era” for Idaho. The Legislature approved, and the joint unit was open by 1972.
The collaboration quickly unraveled. In 1976, citing “numerous problems with management and operation,” the state prisons director pushed legislation that would give him full control over the unit.
Corrections officials were poised to start running the show, and critics were stunned.
Sword and other mental health advocates quoted in legislative records that year urged the state to keep a separation between civil patients and prisoners.
Marilyn Dorman, a regional behavioral health board chair, argued that mental health care decisions should not be made by corrections officials but by someone “who has the training in mental health and mental hygiene needed to best represent the patients.”
A supervisor at the psychiatric unit, Jeffrey Toothaker, was so outraged that he spoke out publicly against his boss, Idaho health director Milton Klein. In a letter to the editor of the Idaho Statesman, Toothaker said he found it “difficult to work with a good conscience for a department that has at its head a director that supports such a bill.”
Klein acknowledged to lawmakers that the arrangement wasn’t ideal. Without money to build a new secure psychiatric facility, he said, placing patients in the state pen was the best compromise available.
And that approach was designed to be temporary, authorized for only one year. In 1977, legislative minutes show, lawmakers said a secure unit for civilly committed patients would open in 1978 at Idaho’s State Hospital South, replacing the prison ward.
One senator said that while the U.S. Supreme Court might not look kindly upon placing civilly committed patients in prison, it would probably give Idaho a pass if a better solution was in the works.
It’s unclear what happened to construction at the hospital. But in 1979, a year after the ward was supposed to have opened, the Legislature made the civil commitment unit at the state penitentiary permanent.
It’s drawn criticism ever since.
The prison unit where civilly committed patients are housed has the trappings of a place designed for incarceration, such as these metal “restraint desks.” (Sarah A. Miller for ProPublica)A national mental health advocate in 1990 called the unit a “dumping ground” for those with severe mental illness. "Death Row is just down the hall,” said psychiatrist and mental health advocate E. Fuller Torrey, according to an Idaho Statesman article. “Their major crime is schizophrenia.”
The same year, a complaint from a disability rights organization drew a U.S. Department of Health and Human Services civil rights investigation, according to an Idaho Statesman report. The federal agency could find no documentation of the outcome when asked recently by ProPublica.
The state’s behavioral health administrator told lawmakers in 2006 that “Idaho desperately needs a secure psychiatric facility or facilities for these people” instead of prison.
None of the criticism seemed to make an impression. Only once since 1976 have Idaho’s political leaders been united in their desire to give patients the right treatment in the right place.
Stegner, the state senator, was among those leading the charge.
The Hospital Takes ShapeStegner ran his family’s grain-elevator business in north-central Idaho before jumping into politics. He ascended the Republican ranks to become the Senate assistant majority leader by the mid-2000s.
It struck Stegner as wrong when he learned Idaho was locking people with mental illness in prison without a conviction. In 2007, three decades after his predecessors assured people a new hospital wing for civilly committed patients was on its way, Stegner saw an opportunity to make it finally happen.
Sen. Joe Stegner, left, at the Capitol in Boise in 2005. Stegner has since retired from the Legislature. (Dianne Humble/Idaho Press Tribune via AP)State mental health administrators who’d been making a renewed push to build a secure facility had fully scoped it out.
The building would house 300 beds for patients committed to the state as a result of their mental illness, as well as convicted criminals with severe mental illness and violent behaviors. The two groups would be kept in separate areas.
Stegner persuaded fellow lawmakers to set aside $3 million to design the facility. Construction was estimated at $70 million — roughly $101 million in today’s dollars.
Stegner still remembers driving out to the dusty sagebrush-covered land south of Boise to choose the site where the building would go: “a little low draw” behind a hill that would keep the prison out of view from the new psych unit.
State officials toured high-security psychiatric facilities in California, Kansas and Missouri.
Gov. Butch Otter put the project in his budget for the following year and highlighted it in his January 2008 State of the State address.
The House and Senate voted to allow bonds for the project, noting the demonstrated need for a standalone treatment facility.
Several legislators signed a resolution saying people placed in civil commitment and not serving a criminal sentence “should not be housed in correctional facilities.”
Stegner could see a future where Idahoans whose psychiatric diseases made them lash out would have a place to be safely treated. There was political support for it. There was money. There was even an architectural rendering.
And then nothing.
The governor’s office dropped its support, Stegner said.
Otter told ProPublica the plan stalled because of bureaucratic disputes over where to build the facility and, later, because of the 2008 financial crisis. “We all agreed we needed it,” he said of the new mental health facility, but there wasn’t enough money to go around. “And we all agreed we didn’t want to raise taxes,” he said.
Stegner believes one factor made it easier to kill the project. A year before, acting on a proposal from the Otter administration, legislators had tweaked wording in Idaho’s law governing the mental health unit to put corrections officials on firmer ground in the event of a lawsuit. It may have lessened the urgency to build a hospital.
“That was really a crushing defeat for me — one that changed my attitude about remaining in the Legislature, and one that is one of my biggest regrets in my legislative career,” Stegner told ProPublica.
Idaho officials went on to back away from or block the development of a mental health facility two more times.
Most recently, legislators this year failed to take up Gov. Brad Little’s proposal to use a fraction of Idaho’s record-breaking budget surplus to build a 26-bed facility on state land near the state prison.
One additional expense lawmakers did tack on to the budget: $750,000 to enable the execution of death row inmates by firing squad.
The Next OpeningStegner and Sword, the activist who testified against imprisoning civilly committed patients in the 1970s, are looking to Little again in 2024. The governor made mental health care a focus of his administration when he took office in 2019. After getting nowhere on his proposal for a new secure facility this year, Little has signaled he plans to try again.
Based on a request from his administration, the state’s building advisory council gave its blessing Nov. 14 to a $25 million facility. That could bolster Little’s chances of legislative approval. Little’s press secretary told ProPublica the governor sees the building as “a critical part of our state’s behavioral health infrastructure.”
The Department of Health and Welfare would provide the mental health care for patients there. The Department of Correction would provide security. They would operate the facility together, and patients would no longer be held in prison cells.
It would be, by and large, just as state lawmakers envisioned more than 50 years ago.
CorrectionDec. 13, 2023: This story originally misspelled the first name of a coordinator for the Idaho Department of Health and Welfare. She is Kasey Abercrombie, not Kacey.
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