For years, those whose loved ones died while in the care of Dr. Yvon Nazaire have wondered, often in angered tones, how he got his job.
How could anyone make a doctor with a public history of neglecting emergency room patients in New York responsible for the medical needs of women in the largely unsupervised world of the Georgia prison system?
Now, deposition testimony from a recently settled lawsuit has provided an answer — and the answer is stoking more anger.
In testimony for the wrongful death case of a woman who died at Pulaski State Prison, the former medical director for Georgia Correctional HealthCare has admitted that when he hired Nazaire he was aware of his disciplinary record in New York but didn’t think the matter was serious.
The reason, Dr. Edward Bailey acknowledged, was he didn’t read the medical board’s full report.
"The guy admitted he never bothered to read the report?" said Wayne Morris, whose sister, Peggy Walker, died of ovarian cancer at Emanuel Women's Facility in Swainsboro in 2011. "I usually have words for stuff like this, but, I mean, I have nothing here. This is pure negligence."
Bailey's deposition was obtained last year by lawyers for Bonnie Rocheleau, who died of pneumonia in 2015 after long suffering from COPD.
The lawsuit, which alleged that Nazaire failed to respond to Rocheleau’s symptoms as they worsened, was settled this past March with the state agreeing to pay the family of the 58-year-old Valdosta woman $925,000.
Beyond insight into Bailey’s decision-making, his deposition reveals that Georgia Correctional HealthCare, the branch of Augusta University that employs the state’s prison doctors, had long relied on temporary physicians — called locums tenens — without checking their backgrounds before they began their assignments.
Nazaire was working on a temporary basis when he started at Pulaski in 2006, a time when Georgia Correctional HealthCare assumed that placement agencies would properly vet such doctors.
Bailey testified that the healthcare organization felt comfortable relying on the agencies because he said they checked with state boards as well as accessed the National Practitioner Data Bank, the federal clearinghouse of physician discipline available to authorized users.
“They would check for licensure, they would check for, you know, the state where (the license) was previously held and they would do a National Practitioners Data Bank check as well,” he testified.
However, the AJC found that neither of the entities involved in placing Nazaire temporarily at Pulaski had access to the data bank or sought to verify the status of his New York license.
Bailey’s deposition is particularly compelling because it’s the first time he described in any fashion what he knew about Nazaire’s past when he hired him.
Lance Lourie, one of the attorneys representing the Rocheleau family, said he was stunned when he heard Bailey say he had known of the New York board’s action, yet hadn’t read the full report.
“I thought I would hear him say he was unaware of all that,” Lourie said. “Hiring someone you know has problems is frightening.”
Bailey, who retired in 2012, declined to be interviewed for this story, referring all comment to Georgia Correctional HealthCare.
Christen Engel, Augusta University’s associate vice president for news and communications, wrote in an email that the credentialing of new doctors by Georgia Correctional HealthCare currently requires checks with the medical boards in all states where applicants previously worked as well as with the National Practitioner Data Bank. Those requirements were implemented in 2015 along with a policy that no longer allows relying on placement companies for vetting temporary physicians, she wrote.
Quickly transformed
The Rocheleau case shows just how easily Nazaire was able to reinvent himself as a Georgia prison doctor while in the midst of three years’ probation imposed in 2006 by New York’s Office of Professional Medical Conduct.
The probation, which required that his practice be closely monitored, was based on an agreed order in which Nazaire acknowledged gross negligence in his treatment of five ER patients at a Brooklyn hospital. Those patients included a 28-year-old man who died of a heart attack a day after Nazaire sent him home with antihistamines.
In addition, Nazaire was subject to four malpractice death claims in New York, including one in which the doctor's insurance carrier paid $2.55 million of a $3 million settlement to the family of a woman who died from a pulmonary embolism.
Nazaire was fired by Georgia Correctional HealthCare in 2015 after The Atlanta Journal-Constitution exposed how at least nine women had died agonizing deaths under questionable circumstances while in his care at Pulaski and Emanuel Women's Facility. As the women languished, Nazaire earned praise from his supervisors for saving the prison system money by limiting outside consultations, the AJC revealed.
An investigation later conducted for Augusta University by Dr. William Kanto, one of the school's top medical officials, determined that at least three of the women identified in the newspaper's stories received treatment that failed to meet "community standards" and that Nazaire's performance directly contributed in two of the deaths.
Kanto’s investigation led to a series of reforms, including the more rigorous credentialing.
In his deposition for the Rocheleau suit, Nazaire said he decided to get a Georgia license on the recommendation of an unnamed colleague from medical school who had settled in the state.
Although Nazaire was still on probation in New York when he applied for his Georgia medical license, the Georgia Composite Medical Board placed no restrictions on his practice.
“You know, I apply for that license and it didn’t take me a long time,” he testified.
Not long after getting his Georgia license, Nazaire testified, he was contacted by a physician recruiter in Georgia who was trying to find a temporary medical director for Pulaski. Nazaire said the recruiter, Thomas Harbin, was the only person he dealt with before arriving at the Hawkinsville facility.
Working through a company, Physician Providers Inc., then supplying temporary doctors for the Georgia prison system, Harbin arranged for Nazaire to go to Pulaski.
“The process took one week,” Nazaire testified. “I was (in) shock. One week from when (the recruiter) called me to work for him.”
Nazaire’s Georgia Correctional HealthCare personnel file shows that Harbin, based in Flowery Branch, faxed 12 pages of credentialing documents to the organization when the physician began his temporary assignment. The documents included Nazaire’s Georgia license but nothing relating to his licensing in New York.
Harbin, interviewed recently, said he couldn’t access the data bank and would have provided Georgia Correctional HealthCare what it asked for.
“We identify and present candidates,” he said, describing the role he and others like him play in the process. “That’s it.”
A permanent position
Bailey testified that he offered Nazaire the permanent position at Pulaski after the doctor had worked there “successfully” for several months. It was while Nazaire was considering the offer, Bailey said, that he looked him up on the New York board’s website.
Nazaire’s New York disciplinary order is a 16-page document that includes details of all five cases as well as Nazaire’s agreement that he would not contest the allegations of gross negligence.
However, when Lourie showed Bailey the document during the deposition, the doctor testified that what he saw online was something far less extensive.
“I clicked the link and I came to (a) reference to two cases, but it did not have complete information about all (the issues),” he said. “…It did not have the consent agreement, at least I didn’t see it. And it didn’t have the reference to several other cases that I find here in this document.”
When Lourie asked Bailey if he had tried to obtain the complete document, the doctor replied: “Well, the — no. The order, as I understand it, was complete on the website.”
Asked why he never questioned Nazaire about the matter, Bailey said he considered the two cases he saw online to be “judgments that went awry” and not significant enough to merit further discussion.
All publicly available documents for disciplinary actions against physicians in New York have been online since 2001, according to Jeffrey Hammond, a spokesman for the Office of Professional Medical Conduct.
Learning of Bailey’s testimony, Morris said he couldn’t help but think back to what happened to his sister, her stomach grotesquely distended with fluid before she was finally moved to a hospital, and feel angry all over again.
"We have all suffered greatly from what happened to Peggy, my mother especially," he said. "And it just keeps going. The sorrow from the way this all was handled, it just doesn't end."
» Read the AJC's award-winning investigation, Doctors & Sex Abuse: A 50-state investigation
Our reporting
In a series of stories, Atlanta Journal-Constitution investigative reporter Danny Robbins revealed that, for nearly a decade, women in Georgia state prisons suffered agonizing deaths when they didn't receive treatment that could have saved or prolonged their lives. The physician responsible for their care was Dr. Yvon Nazaire, who had previously been sanctioned in New York for gross negligence. After the AJC's reports, Nazaire was fired, and the state initiated a series of reforms, many aimed at improving the medical care for women in the prison system.
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