Three inmates at the Fluvanna Correctional Center for Women had to contend with this reality in the past year. Only one is still alive to tell her story.

* * *

Sitting in the living room of her Lynchburg home in early September, Sherry Richburg is sipping an Orange Crush and taking sparse drags from a cigarette. She’s quit for the most part, opting instead for a vaporizer, but likes to make the occasional return to the real thing. It had been more than six months since the 63-year-old left the Fluvanna prison, and she’s happy to be free of the place.

It had only been about a month since the Virginia Department of Corrections announced that two inmates of the prison, 70-year-old Carolyn Liberto and 38-year-old Deanna Niece, had died in custody.

Their deaths were not only “frighteningly similar,” but preventable, according to a filing from the Legal Aid Justice Center in Charlottesville. In February 2016, and following years of legal maneuvering and negotiation, the Department of Corrections settled a federal lawsuit filed on behalf of several inmates, agreeing to improve medical conditions at the prison.

But little has been done to make those necessary improvements, Legal Aid alleged in early September. The organization is now asking a federal judge to hold the department in civil contempt, citing — among other things — the “preventable fatalities” of Liberto and Niece.

The Department of Corrections declined to comment for this story, citing the pending litigation against it.

According to Legal Aid’s filings, Liberto died of cardiopulmonary failure on July 21, following months of prison staff repeatedly allowing her blood pressure medication to run out and failing to recognize the seriousness of her repeated episodes of high blood pressure. Two days before her death, two prisoners in her unit saw Liberto complaining of high blood pressure but receiving little assistance. The day she died, another prisoner saw her complaining of chest pains but being told that her vitals were fine.

The night Liberto died, she pleaded for help, saying that she couldn’t breathe. There were no oxygen tanks in her housing unit, nor was there a stretcher to transport her for emergency help, according to her death report and Legal Aid’s filing.

* * *

Four days later, Niece complained of shortness of breath and fell to the ground at least once, unable to walk due to her breathing problems. She was never referred to the medical bay for further evaluation. That night, she began to convulse, vomit and cough up blood. There was no suctioning equipment available to clear her breathing passages, no oxygen tanks and no stretcher available in her building, according to her death report and Legal Aid’s filing.

She died less than three weeks before she was due to be released.

The factors that are said to have led to Liberto and Niece’s deaths and other critiques of the correctional center’s treatment are in line with reports from Dr. Nicholas Scharff, the doctor entrusted with monitoring the prison’s compliance with conditions of the lawsuit settlement. In his June 2017 report, Scharff found that, despite some areas of improvement in medical care, on six of the settlement’s stipulated “performance indicators,” including patient access to medical information, the prison was non-compliant.

Scharff further criticized the sick call process in his report, stating that during his firsthand observation of sick call for five patients, none of the patients had their medical issues adequately addressed. After reviewing additional charts, he found that only 44 percent of medical issues had been addressed adequately.

“A functioning grievance system is critically important in correctional health care systems, with their inevitable complexities and barriers to care related to restrictions on patient movement and communication with caregivers and custodial imperatives,” Scharff wrote in his June report. “Returning 75-97 percent of grievances unread for seemingly arbitrary reasons communicates simply and clearly that the system just doesn’t care about the grievances. Clinically, this is shortsighted, dangerous and likely negligent.”

Richburg is glad she got to make it home.

“People expect their family member to come home at some point,” Richburg said, thinking of the two women. “Well, they did come home, but they came in a pine box.”

Scantly looking down at the empty space where her right leg once was, Richburg wagers that if she had stayed any longer, she would have been among the fatalities.

* * *

Unfortunately, Richburg is no stranger to a wheelchair. Her problems with her leg started more than a decade ago, after she received a femur transplant. When a leakage in her home caused her to slip and fall, she broke the new femur in three places and shattered her hip in the process. From 2007 to 2014, she was either in a wheelchair or on crutches.

In September 2014, doctors put a prosthesis into Richburg’s leg, allowing her to walk again. But the physical therapy process became complicated by a bowel obstruction and a bacterial fungus that attached itself to the metal in the prosthesis. A nurse would visit her home four times a week, changing tubes that pumped medicine to her heart. Medication was delivered daily from the pharmacy.

It was around that time that Richburg found herself in trouble with the law. In April 2015, the then-61-year-old pleaded guilty to a heroin distribution charge and was given a 20-month active sentence.

She was first sent to Lynchburg City Jail, where the bacterial fungus continued to thrive, prompting doctors to prescribe her Diflucan, an antifungal medication. She would have to take the medication for the rest of her life, she said, to keep the fungus from spreading.

The medication was expensive — $766 for 60 tablets, she recalled. But the city jail provided it to her, as well as any other medication she’d been prescribed, including potassium and blood pressure medication.

Roughly a year into her sentence, Richburg was moved to the Fluvanna Correctional Center for Women, where she was to finish her sentence by February 2017. When she arrived, she had all of her medications. Before long, the Diflucan started to run out, so Richburg requested more.

“I continuously told them, ‘I have to have this medication. I’m going to get real ill if I don’t have it,’” she said.

All she received, Richburg said, were excuses. “It hasn’t come in; we don’t have it just yet; it’s coming.”

By July, the Diflucan ran out. Richburg “started hurting,” and her requests continued.

“I dealt with it, but I just kept telling them, ‘I have to have my medicine. If I was at home, I’d be taking it,’” Richburg said. “They’d say, ‘well, you should have thought about that before coming in here.’”

After several more “sharp” requests, Richburg said she was finally approved in September to see a doctor, who told her: “You should have had this medication; [it] should have been here.”

* * *

The pain continued, and soon after her doctor visit, one of Richburg’s cellmates noticed she was “looking funny.” Two other inmates told her she was “turning gray.” With no mirrors in the prison, Richburg took their word for it and went to take a shower. When she returned, “the diarrhea just came out of nowhere.”

Three inmates, including a cellmate, brought her back to the shower and repeatedly called for a nurse. Before long, Richburg began to lose consciousness while her fellow inmates continued to scream for medical assistance.

Richburg was brought to the infirmary, where she saw a doctor begin checking for a pulse while the rest of her surroundings went hazy. The doctor told staff to call 911.

“They wanted to put me in an orange uniform to let them know that I was a prisoner,” Richburg remembered. “They wanted to put the chains and all that on, and [the doctor] said, ‘no, you can’t do all that, she does not have time.’”

When she arrived at the University of Virginia Medical Center, Richburg was treated by the same doctor who had performed previous surgeries on her leg. The doctor asked Richburg why she hadn’t been taking her prescribed medications.

Richburg underwent surgery, where doctors cut into the length of her thigh and cleaned out the bacterial fungus, replacing the metal prosthesis with cement.

The night after her surgery, Richburg recalled waking up to see the prison’s new warden, Eric Aldridge, standing in her room, asking her how she was feeling and saying he wanted to check on her.

“In the back of my mind, something told me something must’ve really, really been wrong for a warden to be in my room,” Richburg said. “There were other inmates in that hospital. He didn’t go to anybody else’s room. Why was he in mine?”

Aldridge did not respond to a request for comment for this story.

The cement prosthesis would prove to be short-lived. Toward the end of last October, the pain was again getting progressively worse. Lying in the prison infirmary, Richburg was assisted by another inmate into a wheelchair and rolled to the bathroom.

“I made it to the restroom, and in the process of pulling myself up on the rails and trying to get to the commode, I slipped,” she said. “I grabbed a hold of the sink with the other hand on the commode, but when I went down, I hit real hard.”

Richburg immediately knew something was wrong. The cement in her leg had broken. This was three weeks after her return from the hospital.

When a nurse finally reached Richburg, he told her it was time to go back to the hospital, noting that she looked as ill as she had prior to her last hospital trip.

“[That nurse] was one of the good guys,” Richburg said.

Back on the operating table, the doctors again opened up Richburg’s leg. She was put back on Diflucan, but the fungus had gotten so bad that the medication “wasn’t going to do much good,” she said.

* * *

When Richburg entered the Fluvanna Correctional Center for Women in May 2016, she weighed 176 pounds. By the time her family collected her in February, she had lost more than 50 pounds.

The prison infirmary had informed the Richburg family that their matriarch would require a hospital bed at home, prompting her children to turn Richburg’s cozy living room into a “makeshift hospital.”

In mid-March, Richburg’s family held a birthday party for her, with children and grandchildren in attendance. Her daughter fixed all of Richburg’s favorites, which her oldest son cut into small pieces and fed to her.

Standing out on her porch, the cadre of Richburg kin knew something had to change. Three days later, her youngest son wrapped her in a blanket and carried her to the back of a car headed toward the hospital.

When they arrived at the UVa Medical Center, a gurney awaited Richburg. She pleaded to return home, but her children insisted she remain. A doctor reassured their insistence with harrowing news: The bacteria fungus in her leg was spreading rapidly. To save her life, the only option left was to amputate.

At first, Richburg protested. But watching her three grown children crying, begging her to take the doctor’s advice, she relented.

“I was just too sick to fight,” she said.

* * *

“My mind still says the leg is there,” Richburg said. “I’ll get a sharp pain, I’ll wake up to grab it, but there’s nothing there.”

Richburg already has dismissed the idea of getting a prosthesis. The infection had spread so far that doctors had to amputate just below her hip, meaning a functional prosthetic leg would be extremely costly. Instead, she chooses to play the hand she’s been dealt.

But that doesn’t mean she doesn’t want someone held responsible. In her view, this was all preventable. She wasn’t given the medicine she was prescribed. Every time she asked, she was met with more paperwork, more excuses, more indifference and no answers.

Richburg understands her medication was expensive. When the prison would not provide it, she asked if her family could purchase it and send it along. When they rebuked the offer, Richburg realized that her only option was to suffer.

“You’re at their mercy,” she said. “If you say the wrong thing, you’re going to get shoved back.”

The problems she faced at the Fluvanna prison are endemic, Richburg said — problems she believes contributed to the deaths of Liberto and Niece.

And they’re problems that can’t be tolerated in a fair system of justice.

“People make mistakes, but are you supposed to pay with your life?” Richburg asked. “You pay your debt to society by being incarcerated.”

“I’m still paying. And that’s not going to change,” she said. “My leg is gone, and it’s not coming back.”

* * *

Richburg’s complaints don’t exist in a vacuum. Nor do the deaths of Liberto and Niece.

Belinda Gray has been an inmate at the women’s prison for more than 13 years. A recovering drug addict who facilitates recovery groups for her fellow inmates, Gray considers herself an advocate for offenders and serves as a plaintiff in the lawsuit against the Department of Corrections.

The issues at the prison run deep, Gray said — issues with the sick call process, issues with the grievance process, even issues with the distribution of medical equipment, from wheelchairs to bandages.

“I have seen several women who have lost their lives due to lack of medical treatment,” Gray said. “Things that could have been prevented with their medical care.”

Gray knew Liberto, having lived in the same wing as her until July 19. She saw Niece die four days later. She doesn’t know the cause of death but says Niece complained about her breathing problems, only to be sent back to the wing without having seen a doctor.

“I believe her death could have been prevented if that morning they had sent her to see the doctor instead of sending her back in the wing,” Gray said. “It was very traumatizing for me and all the other ladies in the wing to have to witness that. For us, it’s life-altering to see it.”

Cynthia Scott, another plaintiff in the lawsuit, also knew the two women. Serving a lengthy sentence that started in 2003, Scott began experiencing her own set of medical maladies in 2008. In light of Liberto and Niece’s deaths, which she “knew was from medical neglect,” she fears what could happen to her in the years to come.

“It’s scary to know that I still have some time to do, and it scares me not knowing whether or not, if something like this occurs again — will they take care of me?” Scott said. “I know I still have a lot of time to do, but I don’t want to die in here.”

Speaking separately to Scott, Gray and Richburg, all three pointed to the same problem areas within the prison’s medical care system. They said medications aren’t provided or don’t get refilled in a timely manner; requests to go to the infirmary are frequently ignored; and it often takes several weeks and repetitive requests in writing to see a doctor, and even then, there is little to no follow up.

* * *

All three women said they don’t find fault with the entirety of the medical staff at the prison. The problem is retaining the doctors and nurses who seem to truly care.

“The good nurses we have, they work them to death. Then they burn out, then they leave us,” Scott said. “The ones that don’t give a darn about us, they keep them around.”

Further, all three believe things could get better. Gray wishes for better communication between the medical staff and the offenders in responding to emergency situations. Scott hopes that the lawsuit, now back in the spotlight, will remind people that offenders have rights.

“At the end of the day, we’re still human beings,” she said. “We just made a mistake.”

All Richburg can hope for is that someone will take responsibility for what’s happened, both to her and to the other women who’ve suffered under the prison’s watch.

“There’s no excuse,” Richburg said. “And ‘I’m sorry’ just don’t cut it.”