How a Florida Jail’s Medical Provider Failed Brian Tracey—Experts Say He Should Have Been Hospitalized

Florida Jail’s Private Health Provider Faces Scrutiny After Inmate Death

ST. JOHNS COUNTY, Fla. — Brian Tracey, a 62-year-old inmate with chronic obstructive pulmonary disease (COPD), died on the floor of a Florida jail medical ward in December 2023 after spending 30 minutes struggling to breathe, according to a police report and expert reviews obtained by The Florida Trib and ProPublica. Tracey, who was scheduled for release that day, had exhibited severe symptoms—including passing out and confusion—in the days leading up to his death, yet was never hospitalized. Four medical and corrections experts later concluded he should have been transferred to a hospital based on his condition.

Tracey’s death has intensified scrutiny of Armor Health of St. Johns County LLC, a private contractor responsible for inmate healthcare at the St. Johns County Detention Center. The company, an affiliate of Miami-based Armor Health, is the last known Armor entity still operating in Florida jails, despite a history of lawsuits, a felony conviction in another state, and widespread contract cancellations by sheriffs across the state.

Symptoms Ignored, Experts Say

Tracey was arrested on Dec. 6, 2023, after allegedly pushing an elderly woman he had been dating. Upon arrival at the jail, he was placed in the infirmary to monitor a dog bite wound treated earlier at a hospital. Within hours, medical staff noted his difficulty breathing and provided an oxygen mask, according to the sheriff’s investigative report.

Over the next nine days, Tracey’s condition deteriorated. On Dec. 14, a nurse documented that he was sweaty, complained of shortness of breath, and repeatedly removed his oxygen mask—a sign, experts later said, of severe respiratory distress. His blood oxygen level dropped to 89%, a threshold the Cleveland Clinic warns requires immediate medical attention. The next day, another nurse noted Tracey had passed out in his cell and described his health as declining, with “very low” oxygen levels. Yet no decision was made to hospitalize him.

Surveillance footage reviewed by investigators showed Tracey struggling to breathe for 26 minutes before deputies found him unresponsive. CPR was not administered until after he lost his pulse. An autopsy later determined he died from pneumonia complicated by COVID-19.

Dr. Marc Stern, a correctional healthcare expert and University of Washington professor, reviewed the sheriff’s report and concluded Tracey’s symptoms warranted hospitalization. Rich Forbus, a former jail commander and vice president of the National Commission on Correctional Health Care, agreed, telling the news organizations, You know the person’s a COPD patient and you know he’s sick, I question why he didn’t go out [to a hospital]. If I’m the jail commander, I’m questioning why he’s not at the hospital.

A Pattern of Negligence Allegations

Armor Health and its predecessor, Armor Correctional Health Services Inc., have faced hundreds of lawsuits alleging substandard care, including failures to hospitalize inmates in critical condition. Between 2014 and 2021, the company reported being sued over 450 times, with at least 56 settlements related to medical negligence. Court records show 13 of those cases involved allegations of delayed or denied hospital transfers.

In a 2020 wrongful death lawsuit, a medical expert hired by plaintiffs reviewed internal Armor death reports and identified over 70 instances where the company allegedly failed to hospitalize patients. Armor denied the claims, stating that each case involved “unique medical circumstances” unrelated to hospital transfer decisions.

Nurses who previously worked for Armor have testified in court about corporate pressure to avoid hospital transfers. Carolyn Rubin, a former Armor nurse in Sarasota County, said in a deposition, There was a strong corporate push for the doctor not to send patients out. It was our duty to keep them there as long as possible, to prevent costs of the hospital. Armor has denied such allegations, calling them “counterproductive” and stating that delaying care increases the likelihood of more expensive treatment.

In 2022, a Wisconsin jury convicted Armor Correctional Health Services of felony abuse and falsifying records in the death of an inmate who died from dehydration. Despite the conviction, Armor continued operating in Florida under new LLCs with the same leadership and address. Florida law bars companies convicted of felonies from public contracts, but the state’s Department of Management Services has not taken action against Armor, nor has it confirmed whether an investigation was conducted.

Sheriffs Cut Ties, But One Contract Remains

Before Tracey’s death, at least six Florida sheriffs terminated contracts with Armor entities, citing poor performance, inmate deaths, and accreditation failures. Flagler County Sheriff Rick Staly fired Armor in 2019 after a 23-year-old inmate died from a reaction to prescribed medication. Staly said at the time, In response to this tragedy, Armor has shown little interest in anything other than denying responsibility and trying to bill us for even more money.

Duval County Sheriff T.K. Waters ended Armor’s contract early in 2023, citing the company’s failure to disclose its Wisconsin felony conviction, lapses in accreditation, and noncompliance with public records laws. The decision followed the death of an inmate who was denied antirejection medication for a heart transplant while in custody. Armor later stated the medication was ordered but arrived after the inmate’s release.

Despite these cancellations, St. Johns County Sheriff Robert A. Hardwick has maintained the jail’s contract with Armor Health of St. Johns County LLC. Hardwick declined to comment on the decision. An attorney for the company told The Florida Trib that Armor is in “full compliance” with state requirements and that the convicted entity no longer exists.

Family Seeks Answers, Legal Options Exhausted

Tracey’s sister, Lillian Scharf, said she was told by authorities that her brother died suddenly of a heart issue. She only learned the full details of his death this year, after The Florida Trib and ProPublica shared the autopsy and police report with her. By then, Florida’s two-year statute of limitations for wrongful death lawsuits had expired, and the state does not allow such suits for inmates without spouses or children.

Scharf, who keeps Tracey’s ashes in a box in her Maryland home, said, I just feel like they didn’t give him the opportunity to try to save his life. Armor has declined to release Tracey’s medical records, citing privacy laws.

Former Florida state Rep. Angie Nixon, now a U.S. Senate candidate, has called for federal intervention, writing to the Department of Justice in 2024 to investigate Armor’s operations in the state. The fact that there is a known vendor that has basically allowed people to die while under their care and they can continue to work in our prisons and jails is something that I have a problem with, Nixon said.

Florida’s lack of oversight for private jail healthcare providers has drawn criticism from lawmakers and advocates. Former state Sen. Jeff Brandes, a Republican who served on the Criminal Justice Committee, described the system as a “black box” with “no independent accountability.” The state’s Department of Management Services, responsible for enforcing vendor regulations, has declined to comment on whether it investigated Armor or took any action against the company.

The St. Johns County Sheriff’s Office has not responded to requests for comment on Tracey’s death or the jail’s continued contract with Armor. The company’s attorney, J. Alfredo Armas, cautioned against drawing conclusions about the case, stating that Tracey’s medical records have not been released.