Doctors diagnosed Carmela DeVargas with sepsis, pneumonia, respiratory failure, meningitis and a MRSA infection when she arrived at a Santa Fe hospital after a few weeks at the local jail. Within four days, she lost the ability to speak or move her arms and legs.
Avery Borkovec, 22, lived in Boulder with his great grandmother, Shirley Borkovec, before he died from an untreated infection during his time incarcerated at the jails in nearby Broomfield and Boulder.
Avery Borkovec, 22, submitted request after request for medical care at the Boulder County Jail in 2022, complaining of ever-more serious symptoms including indigestion, back pain, extreme toothache and generalized body aches.
On Nov. 3, 2022, Avery Borkovec stumbles out of his cell at the Boulder County Jail and collapses in front of a passing inmate.
Bodyworn camera footage shows a deputy assisting Avery Borkovec after he collapsed at the Boulder County Jail in November 2022. He died shortly afterward.
Carmela DeVargas, 34, was a feisty 34-year-old mother of two who loved to cook, her sister Elisa DeVargas told USA TODAY. She loved the outdoors, watching movies and listening to music, including artists like Lauryn Hill.
Carmela DeVargas struggled with opioid use disorder and had been in and out of the Santa Fe Adult Detention Facility several times for minor probation violations before she got sick there and died in 2019.
Carmela DeVargas, a 34-year-old mother of two young children, died with sepsis while detained at the Santa Fe Adult Detention Facility in 2019.

A life-threatening condition called sepsis kills hundreds of people in American jails and prisons each year, a USA TODAY investigation has found, but inmates with a history of drug use are at particular risk.

“Chronic intravenous drug use,” “extensive drug history,” and “suspected illicit drug withdrawals” are just some of the notes USA TODAY found among in-custody death records of inmates who died with sepsis between 2015 and 2023.

Dirty needles can introduce bacteria and viruses straight into the bloodstream, putting drug users at higher risk for infection, doctors say. Sometimes, these infections lead to sepsis, an extreme immune system reaction to infection that quickly causes organ failure and death when left untreated.

That can easily happen behind bars, where inmates told USA TODAY their medical concerns are often doubted and care is delayed.

Map: Where correctional facilities reported sepsis-related deaths

Click on a jail or prison in the map below to see its details. You may also enter an address in the search box to locate the nearest correctional facilities. Don't see a map? Click here.

“Basically, security is standing between you and your health care,” said Andrea Armstrong, a law professor at Loyola University New Orleans who studies prison and jail conditions. “For some health care professionals, there's skepticism about whether the person is telling the truth about their symptoms or whether it is drug-seeking behavior.”

And that skepticism can be compounded for inmates with a history of drug use, like Carmela DeVargas, a feisty 34-year-old mother of two who loved to cook, and Avery Borkovec, a 22-year-old art store cashier with dreams of starting his own family.

Both were jailed on minor charges. Both pleaded for medical care as their symptoms grew worse. And both died of sepsis caused by infections that likely could have been cured if treated sooner.

Jailed for minor offenses

Carmela DeVargas was supposed to be safer in jail. Her younger sister Elisa DeVargas had seen her struggle with homelessness and addiction in the years after they lost their mother to cancer.

She landed on probation in 2017 when she was accused of tampering with evidence in a grand larceny case against her then-boyfriend. After that, Carmela DeVargas developed a pattern: She’d fail a drug test or miss a probation meeting and get locked away at the county jail south of Santa Fe, New Mexico.

Jail, at least, meant shelter, food, medical care and more regular phone calls to her sister.

“OK, she's safe. I don't have to worry as much,” Elisa DeVargas recalled thinking. “She wouldn't completely clean up in jail, but she would get healthier.”

But her final arrest for a probation violation in September 2019 broke the pattern. That summer, Carmela DeVargas had been on Suboxone, a drug that reduces opioid cravings, but the Santa Fe Adult Detention Facility was not providing it, according to the lawsuit her family later filed. Instead, she illicitly obtained it from fellow prisoners. The lawsuit said she openly admitted to the jail doctor she had been injecting Suboxone daily.

Avery Borkovec was trying to clean up his life in Boulder, Colorado. In his final Instagram post, published a month before his arrest, he apologized to the friends he was pushing away.

“I can’t be improving myself if I’m running around the streets,” he wrote in August 2021.

Borkovec was eccentric, his younger brother Dylan Bolt told USA TODAY. He enjoyed horror movies, sold little sculptures at an art store and often toted around his short-haired tabby, Rosie, in a special cat-carrier backpack.

“He really wanted to be a dad,” Bolt said. “Our family dynamic was wild coming down to us, and he really wanted to give a kid some stability.”

That would never come to pass, though. A Walgreens employee called the police for trespassing when they suspected Borkovec of shoplifting from their store, Bolt’s attorney Rachel Kennedy said. There was also an open warrant for his arrest from failing to appear in court on a charge involving identity theft, she added.

After a week in Broomfield, Colorado’s jail, overcrowding meant Borkovec ended up at the jail in nearby Boulder. There, Borkovec admitted to a nurse that he’d been using heroin four times daily, most recently in the week before his arrest.

Though the jail provided withdrawal medications, the lawsuit his family filed stated medical staff “recklessly” concluded his elevated pulse and blood pressure were simply due to withdrawal.

Borkovec suffered from a stomach condition that caused frequent vomiting, and he’d been treated for it in a Broomfield emergency room immediately before his arrest. The hospital’s blood tests would soon reveal it wasn’t just withdrawal.

He was fighting staph bacteremia – an infection of his bloodstream.

Pleading for medical care

When Carmela DeVargas started complaining of stomach pains and fever, Santa Fe’s jail doctor prescribed an oral antibiotic, but the lawsuit alleged she wasn’t physically examined for 10 days after that. The medicine kept her fever down, the lawsuit claimed, but then she took a turn for the worse.

She submitted several medical requests, complaining of fever, back pain and shortness of breath, the lawsuit stated, but she was simply given painkillers and sent back to her cell. Nobody ordered blood tests to check for an infection from the needles Carmela DeVargas had been using to inject Suboxone, even though she’d specifically told the jail staff about it.

“The guards weren’t listening to her, and she was in extreme pain,” her sister Elisa DeVargas said of the last phone call she received from her sister on Oct. 19, 2019. “She was really scared that something was wrong.”

When the Broomfield Detention Center transferred Avery Borkovec to Boulder, his medical records didn’t come with him. Attorneys for his family allege that Broomfield “recklessly chose” not to send him to the hospital or start antibiotics and that they “withheld” his lab results when they sent him to Boulder.

Borkovec still didn’t know the hospital had found staph bacteria coursing through his body. Over his first week in Boulder’s jail, Borkovec submitted request after request for medical care, complaining of ever-more serious symptoms including indigestion, back pain, extreme toothache and generalized body aches.

“Need Tramadol or more NSAID (nonsteroidal anti-inflammatory drugs, such as ibuprofen or aspirin) for pain in body. 1 NSAID isn’t enough. If possible mix w/ muscle relaxers or melatonin for sleep at night,” Borkovec wrote on Oct. 15, 2022.

A nurse noted in Borkovec’s medical chart that he was seen walking down steps without difficulty, concluding his complaints were fake or not serious, the lawsuit alleged.

Nurse after nurse decided Borkovec was faking, the family's lawsuit alleged, adding that nobody performed a hands-on assessment or took his vital signs for nearly three weeks. They simply provided him with over-the-counter medications to assuage his symptoms.

Chance after chance, the lawsuit alleged, they missed the fact he needed antibiotics to flush out the staph bacteria multiplying throughout his body.

Languishing until it’s too late

By Oct. 27, 2022, Borkovec had so grown so weak he could stand just a few minutes at a time to phone his grandmother, who’d raised him. Fluid was filling his lungs, Borkovec told his Nana over the phone, and he was moved to a medical unit when jail staff deemed him too sick to work.

"It doesn't seem like they care about my kid,” Bolt recalled their grandmother telling him at the time.

He’d grown so thin and pale that other inmates took to calling him “Casper.” His lungs made audible gurgling sounds when he breathed, and he’d placed empty milk cartons near his bed where he could spit the chunks of blood he was coughing up, the lawsuit alleged. Yet, his requests to go to the hospital were still ignored.

Shortly after 9 a.m. on Nov. 3, 2022, a sergeant peered briefly into Borkovec’s solitary cell while doing rounds to check on inmates, the lawsuit stated. A minute later, Borkovec stumbled into the hallway and collapsed in front of a passing inmate. The officer quickly returned, and body camera footage showed Borkovec moaning in pain.

“Let’s not make a mess,” deputies told him, according to the lawsuit.

A nurse administered four doses of Narcan, a nasal spray that can reverse opioid overdoses. Then, Borkovec began vomiting blood and bleeding from his nose, mouth and eyes before falling unconscious. Paramedics never managed to get his pulse back.

The jail doctor in Santa Fe sent Carmela DeVargas to the local hospital hours after she made that final panicked phone call to her sister.

Doctors there diagnosed her with sepsis, pneumonia, respiratory failure, meningitis and a MRSA infection. Within four days of being hospitalized, she lost the ability to speak or move her arms and legs.

“Severely quadriplegic…anticipated dismal prognosis,” her ICU doctor wrote in his assessment.

When her sister and father, Elisa and Antonio DeVargas, were allowed to visit Carmela DeVargas’ bedside, they were shocked to see her shackled to the bed.

“That drew up a flood of anger and emotions because she was paralyzed,” Elisa DeVargas said, adding that her father, a longtime activist in the Santa Fe region, immediately confronted the guards. It took a week before the shackles were removed from her motionless arms and legs.

Even though Carmela DeVargas couldn’t speak, Elisa DeVargas said her sister was fully aware of what was happening and able to convey “yes” or “no” through her eye motions.

“You could see the terror in her eyes at not having access to her body and not being able to communicate,” Elisa DeVargas said.

Notes from Carmela DeVargas’ doctor included in the lawsuit say she “was not looking favorably at remaining on life support for the remainder of her life with no chance of any significant improvement.” In those final days, a priest came to pray with her, and she shared final wishes for her funeral arrangements with her family, Elisa DeVargas said.

Then, Carmela DeVargas had life support removed and died Nov. 9, 2019.

Just four days later, another inmate at the Santa Fe jail, 34-year-old Rex Corcoran, also died while exhibiting signs of withdrawal and a MRSA infection that went septic, Elisa DeVargas said.

Families seek justice

The final step for many families who’ve lost loved ones to sepsis in jail or prison is seeking accountability, reform and compensation – sometimes at the expense of local taxpayers who end up saddled with debt when public institutions settle or lose lawsuits.

In Santa Fe, the DeVargas and Corcoran families teamed up to petition for a grand jury investigation into the county jail, and both eventually sued. Elisa DeVargas said her father’s goal was reforming the jail to provide “adequate and deserved medical care.”

On the advice of his attorney, Antonio DeVargas accepted a settlement of about $790,000 – an unsatisfying decision his daughter Elisa DeVargas said he wrestled with until his death in 2024. Corcoran’s family also settled in 2022, for $1.2 million.

Santa Fe County admitted no wrongdoing in either settlement. Spokesperson Stephanie Stancil called DeVargas’ death a “sad and tragic event,” but disputed the family’s claim that delayed medical care killed her.

“That said, there have been changes since Ms. DeVargas’s passing,” Stancil wrote in an email to USA TODAY. “Over the past five years, state and federal law have expanded the availability of medication-assisted treatment in jail settings.”

She said the jail now offers medications to treat inmates struggling with addiction, along with counseling support and re-entry services.

“We recognize the profound responsibility we carry in caring for individuals in our custody, many of whom face significant medical, behavioral health and/or social challenges,” Stancil wrote.

Some municipalities in the lawsuits USA TODAY reviewed paid settlements directly from taxpayer funds, but Stancil said that wasn't the case in Santa Fe County. Instead, insurance policies – paid for with tax revenue – covered the settlements.

Three years after Borkovec’s death, the lawsuit his family filed against Broomfield, Colorado, remains pending. Broomfield spokesperson Rachel Haslett declined to comment due to the ongoing litigation, but the county denied all allegations of wrongdoing in a legal filing submitted in October.

Additional court filings show a judge dismissed the family’s claim against the Boulder County Sheriff in September because attorneys didn’t prove a pattern of similar violations.

“The dismissals of Boulder County and the Boulder County Sheriff from the lawsuit show they are not at fault for Mr. Borkovec’s death,” wrote Carrie Haverfield, a county spokesperson. “While he had some medical complaints when he was in the jail, jail medical staff promptly responded to and addressed them.”

The federal agency that collects the in-custody death records USA TODAY analyzed for this investigation, the Bureau of Justice Assistance (BJA), has specifically encouraged correctional facilities to create policies to provide medications to help inmates manage withdrawal and to avoid legal liability in case of inmate deaths. However, this medication-assisted treatment for opioid use disorder is still not available everywhere.

“What's happening in a lot of the jails is that they're not implementing those (policies), or they're picking and choosing who has access to it,” said Elisa DeVargas.

She also wants better training for correctional officers to differentiate between withdrawal symptoms and a medical crisis.

“Each person who goes through that system has their history and their reasons for being there, and a lot of the time it's systemic,” Elisa DeVargas said. “Regardless, people deserve to be treated as humans.”

“It’s a weird analogy, but it's essentially a giant daycare with a bunch of people that need some sort of help,” added Borkovec’s brother, Dylan Bolt.

He’s backed up by reports from the U.S. Department of Justice, which have shown disproportionate numbers of prisoners struggle with drug dependence or abuse – as many as two-thirds of sentenced jail inmates.

“Let's fix this,” Bolt said, noting that social workers at his local jail seem few and far between and overworked. “It could be a system that is meant to help rehabilitate people … not a place you just throw people and cross your fingers and hope.”

As he pursues justice for Borkovec’s death, Bolt occasionally visits the patch of private property where they spread his older brother’s ashes. There, he tells Avery he misses him. That he wishes he could see him in person once again.

In New Mexico, the young son Carmela DeVargas left behind is now a teenager. Elisa DeVargas took him in last year when her father died. She said her nephew talks about his mother often, but he was just 7 years old when this tragedy happened. There are so many things he doesn’t remember.

Whenever he laughs like his mother, or does something the way she would, Elisa DeVargas makes sure to point it out to her nephew.

“So that he can feel connected to her.”

This article originally appeared on USA TODAY: Sepsis was killing them. Their jailers thought they just wanted drugs.

Reporting by Austin Fast, USA TODAY / USA TODAY

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