One third of the prisoner deaths in Illinois reviewed by an independent expert were preventable. That’s according to a new report that rips health care in Illinois prisons as extremely poor, with medical professionals committing egregious errors and little accountability or oversight. The findings by the independent expert echo the horror stories inmates have been telling for years.

One of the people who died was a 24-year-old man incarcerated at Dixon prison. He had a mental illness and experienced hallucinations. In 2017, a guard observed the man swallowing two plastic sporks. A nurse documented that the patient “will have no complication from swallowing a foreign object” and did not refer him to a doctor.

The next day, a different nurse talked to a doctor, and X-rays were ordered. They appeared normal (which the report says, might be expected with plastic objects). Over the next few months, the man complained of stomach pain and an inability to eat. He lost 24 pounds in a single month and told medical staff he had swallowed the sporks and needed them removed, but no action was taken to remove them. Three months after swallowing the sporks, he died. The autopsy found internal lacerations and bleeding and attributed the death to the two sporks. The Illinois Department of Corrections reviewed the case and found no problems with the medical care he received. But the report from the court expert said the death could have been prevented.

In 2016 and 2017, 174 people died while in an Illinois prison. The report looked at 33 deaths. It found 12 of them were preventable, another seven were possibly preventable, and nine were not preventable. The other five deaths were not properly documented, which the expert report said made it impossible to assess the deaths.

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The court expert noted a range of issues lead to these kinds of deaths, including a reluctance to send patients to specialized care or an outside hospital, even when it is warranted. The report said the “single most important variable” in preventable deaths was the quality of physicians working in Illinois prisons. The report concluded that doctors didn’t have the proper training or oversight.

The report said that there were “numerous grossly and flagrantly unacceptable episodes of care” that should have resulted in peer review. It also said peer review inside IDOC was ineffective and “physicians who commit repeated egregious medical errors continue to practice and continue to harm patients.”

The report was written by a court-appointed expert as part of a lawsuit alleging the department fails to deliver proper medical care to prisoners.

The Department of Corrections would not comment on the report, saying it’s part of pending litigation. But the department has consistently lacked transparency around prisoner deaths. This lack of transparency extends to families. WBEZ has reported on a family, who believes their loved one was murdered in prison, but even four months after his death, still had received no information from the prison or the department.

WBEZ has sought records from the department on inmate deaths. In many instances, the department did not know, or does not track, the cause of death. In some cases, the department said it didn’t even have basic records — like death certificates or death reports. WBEZ requested a sit down with the department to talk generally about how it tracks and investigates deaths. The department refused.