Markus Johnson slumped naked against the wall of his cell, skin flecked with pepper spray, his face a mask of puzzlement, exhaustion and resignation. Four men in black tactical gear pinned him, his face to the concrete, to cuff his hands behind his back.
He did not resist. He couldn’t. He was so gravely dehydrated he would be dead by their next shift change.
“I didn’t do anything,” Johnson moaned as they pressed a shield between his shoulders.
It was 1:19 p.m. on Sept. 6, 2019, in the Danville Correctional Center, a medium-security prison a few hours south of Chicago. Johnson, 21 and serving a short sentence for gun possession, was in the throes of a mental collapse that had gone largely untreated, but hardly unwatched.
He had entered in good health, with hopes of using the time to gain work skills. But for the previous three weeks, Johnson, who suffered from bipolar disorder and schizophrenia, had refused to eat or take his medication. Most dangerous of all, he had stealthily stopped drinking water, hastening the physical collapse that often accompanies full-scale mental crises.
Johnson’s horrific downward spiral, which has not been previously reported, represents the larger failures of the nation’s prisons to care for the mentally ill. Many seriously ill people receive no treatment. For those who do, the outcome is often determined by the vigilance and commitment of individual supervisors and front-line staff, which vary greatly from system to system, prison to prison, and even shift to shift.
The country’s jails and prisons have become its largest provider of inpatient mental health treatment, with 10 times as many seriously mentally ill people now held behind bars as in hospitals. Estimating the population of incarcerated people with major psychological problems is difficult, but the number is likely 200,000 to 300,000, experts say.
Johnson’s mother has filed a wrongful-death suit against the state and Wexford Health Sources, a for-profit health care contractor in Illinois prisons. The New York Times reviewed more than 1,500 pages of reports, along with depositions taken from those involved. Together, they reveal a cascade of missteps, missed opportunities, potential breaches of protocol and, at times, lapses in common sense.
Prison officials and Wexford staff took few steps to intervene even after it became clear that Johnson, who had been hospitalized repeatedly for similar episodes and recovered, had refused to take medication. Most notably, they did not transfer him to a state prison facility that provides more intensive mental health treatment than is available at regular prisons, records show.
The quality of medical care was also questionable, said Johnson’s lawyers, Sarah Grady and Howard Kaplan, a married legal team in Chicago. Johnson lost 50 to 60 pounds during three weeks in solitary confinement, but officials did not initiate interventions like intravenous feedings or transfer him to a nonprison hospital.
And they did not take the most basic step — dialing 911 — until it was too late.
Markus Mison Johnson was born March 1, 1998, to a mother who believed she was not capable of caring for him.
Days after his birth, he was taken in by Lisa Barker Johnson, a foster mother in her 30s who lived in Zion, Illinois, a working-class city halfway between Chicago and Milwaukee. Markus eventually became one of four children she adopted.
From the start, her bond with Markus was particularly powerful, in part because the two looked so much alike, with distinctive dimpled smiles. Many neighbors assumed he was her biological son. The middle name she chose for him was intended to convey that message.
“Mison is short for ‘my son,’” she said standing over his footstone grave last summer.
He was happy at home. School was different. His grades were good, but he was intensely shy and was diagnosed with attention-deficit/hyperactivity disorder in elementary school.
He was hospitalized for the first time at 16, and given medications that stabilized him for stretches of time. But the crises would strike every six months or so, often triggered by his decision to stop taking his medication.
Family members say Markus wanted desperately to prove he was tough, and emulated his younger, reckless group of friends.
Like many of them, he obtained a pistol. He used it to hold up a convenience store clerk for $425 in January 2017, according to police records. He cut a plea deal for two years of probation.
In late July 2018, he was arrested in a neighbor’s garage with a handgun he later admitted was his. He was still on probation for the robbery, and his public defender negotiated a plea deal that would send him to state prison until January 2020.
Johnson saw prison as an opportunity to learn a trade so he could start a family when he got out.
On Dec. 18, 2018, he arrived at a processing center in Joliet, where he sat for an intake interview. He was coherent and cooperative, well-groomed and maintained eye contact. He was taking his medication, not suicidal and had a hearty appetite. He was listed as 5 feet, 6 inches tall and 256 pounds.
Johnson described his mood as “go with the flow.”
A few days later, after arriving in Danville, he offered a less settled assessment during a telehealth visit with a Wexford psychiatrist, Dr. Nitin Thapar. Johnson admitted to being plagued by feelings of worthlessness, hopelessness and “constant uncontrollable worrying” that affected his sleep.
At the time he was incarcerated, the basic options for mentally ill people in Illinois prisons included placement in the general population or transfer to a special residential treatment program at the Dixon Correctional Center, west of Chicago. Johnson seemed out of immediate danger, so he was assigned to a standard two-man cell in the prison’s general population, with regular mental health counseling and medication.
Then, in the spring of 2019, his grandmother died, sending him into a deep hole.
Johnson spent more time in bed, and became more surly.
By early August, he was telling guards he had stopped eating.
At some point, no one knows when, he had intermittently stopped drinking fluids.
Then came the crash.
On Aug. 12, Johnson got into a fight with his older cellmate.
He was taken to a one-man disciplinary cell. A few hours later, Wexford’s on-site mental health counselor, Melanie Easton, was shocked by his disoriented condition.
He was so unresponsive to her questions she could not finish the evaluation.
Easton ordered that he be moved to a 9-foot by 8-foot crisis cell — solitary confinement with enhanced monitoring. At this moment, a supervisor could have ticked the box for “residential treatment” on a form to transfer him to Dixon. That did not happen, according to records and depositions.
By mid-August, he said he was visualizing “people that were not there,” according to case notes. At first, he was acting more aggressively. But his energy ebbed, and he gradually migrated downward — from standing to bunk to floor.
Lt. Matthew Morrison, one of the few people at Danville to take a personal interest in Johnson, reported seeing a white rind around his mouth in early September.
On Sept. 5, they moved Johnson to one of six cells adjacent to the prison’s small, bare-bones infirmary. Prison officials placed him on the official hunger strike protocol.
Morrison, in his deposition, said he was troubled by the inaction of the Wexford staff, and the lack of urgency exhibited by the medical director, Dr. Justin Young.
On Sept. 5, Morrison approached Young to express his concerns, and the doctor agreed to order blood and urine tests. But Young lived in Chicago, and was on site at the prison about four times a week, according to Kaplan. Friday, Sept. 6, 2019, was not one of those days.
Morrison arrived at work that morning, expecting to find Johnson’s testing underway. A Wexford nurse told him Young believed the tests could wait.
Morrison, stunned, asked her to call Young.
“He’s good till Monday,” Young responded, according to Morrison.
“Come on, come on, look at this guy! You tell me this is OK!” the officer responded.
Eventually, Justin Duprey, a licensed nurse practitioner and the most senior Wexford employee on duty that day, authorized the test himself.
Morrison, thinking he had averted a disaster, entered the cell and implored Johnson into taking the tests. He refused.
So prison officials obtained approval to remove him forcibly from his cell.
What happened next is documented in video taken from cameras held by officers on the extraction team and obtained by the Times through a court order.
Johnson is scarcely recognizable as the neatly groomed 21-year-old captured in a cellphone picture a few months earlier. His skin is ashen, eyes fixed on the middle distance. He might be 40. Or 60.
Then they move him, half-conscious and limp, onto a wheelchair for the blood draw.
For the next 20 minutes, the Wexford nurse performing the procedure, Angelica Wachtor, jabs hands and arms to find a vessel that will hold shape.
She did not request assistance or discuss calling 911, records indicate.
Soon after, a member of the tactical team reminds Wachtor to take Johnson’s vitals before taking him back to his cell. She would later tell Young she had been unable to able to obtain his blood pressure.
Duprey, the nurse practitioner, had been sitting inside his office after corrections staff ordered him to shelter for his own protection, he said. When he emerged, he was let into Johnson’s cell. Finding no pulse, Duprey asked a prison employee to call 911.
The Wexford staff initiated CPR. It did not work.
At 3:38 p.m., the paramedics declared Markus Mison Johnson dead.
This article originally appeared in The New York Times.