Clerk of the Superior Court

*** Electronically Filed ***

T. Formosa, Deputy
3/31/2023 3:55:05 PM
Filing ID 15763434
Jesse M. Showalter, Esq. (026628)
1
Anne E. Findling (010871)
2 Lauren E. Channell (033484)
ROBBINS CURTIN MILLEA & SHOWALTER, LLC
3 301 East Bethany Home Road, Suite B-100
4 Phoenix, Arizona 85012
Tel: (602) 400-4400
5 Fax: (602) 265-0267
jesse@rcmslaw.com
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anne@rcmslaw.com
7 lauren@rcmslaw.com
Attorneys for Plaintiff
8
IN THE SUPERIOR COURT OF THE STATE OF ARIZONA
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IN AND FOR THE COUNTY OF MARICOPA
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

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Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 Carlos Catalano, individually and as Case No. ______________________

CV2023-005022
301 East Bethany Home Road, Suite B-100

statutory beneficiary of Mackenzie

12 Catalano, deceased,
COMPLAINT
Phoenix, Arizona 85012

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Plaintiff,
14 (Wrongful Death)
vs.
15
Jury Trial Demanded
16 State of Arizona, a governmental entity;
Centurion of Arizona, LLC, an Arizona Tier 3
17 limited liability corporation,
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Defendants.
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Plaintiff Carlos Catalano, for his Complaint, alleges:
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THE PARTIES
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1. Mackenzie Catalano, age 24, was an unmarried woman, who died on
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April 7, 2022, while in the custody of the State of Arizona, Department of
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Corrections Rehabilitation & Reentry (hereafter, "ADC").
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2. Carlos Catalano is the surviving father of Mackenzie Catalano and
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brings this claim individually and as Mackenzie Catalano’s statutory beneficiary.
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3. Defendant State of Arizona is a governmental entity organized under
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the Constitution of the United States. Its subdivisions and/or agencies include the
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ADC.
Page 1 of 9
 1 4. Defendant State of Arizona maintains a prison system through the operations
2 of the ADC for the custody and control of individuals, such as Mackenzie Catalano,
3 including the Arizona State Prison Complex – Perryville (“ASPC-PV” or “Perryville”).
4 5. Defendant State of Arizona has a non-delegable duty of care, custody, and
5 control over the inmates within its custody, including, but not limited to, the duty to provide
6 medical and mental health care for the serious medical and mental health needs of the
7 inmates.
8 6. Defendant State of Arizona is liable for the acts and omissions of its employees
9 within the scope of their employment and agency, including the Director, officers, and other
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

10 employees of the ADC under the doctrine of respondeat superior.

Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 7. Pursuant to A.R.S. § 31-201.01(F), any and all causes of action which may
301 East Bethany Home Road, Suite B-100

12 arise out of tort caused by the Director, prison officers, or employees of ADC, run only
Phoenix, Arizona 85012

13 against the State.

14 8. Defendant State of Arizona is also liable for the acts and omissions of its
15 healthcare contractor pursuant to its non-delegable duties.
16 9. ADC created a Monitoring Bureau to follow the medical care and treatment of
17 inmates after privatization of health services effective July 1, 2012, through which it retains
18 control and oversight of the medical care provided to inmates.
19 10. Defendant Centurion of Arizona, LLC (hereafter "Centurion"), is a for-profit
20 Arizona limited liability company that is authorized to and does business in Arizona,
21 including in Maricopa County.
22 11. Effective July 1, 2019, the ADC contracted with Centurion to provide medical
23 and mental health care to the inmates housed at certain prison complexes, including
24 Perryville.
25 12. Under the terms of the contract, Centurion is required to follow ADC’s
26 policies and procedures, including Department Orders, director’s instructions, and
27 healthcare and mental health technical manuals.
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 1 13. By virtue of their relationship, the State of Arizona remains liable for any
2 injuries caused by Centurion or its employees.
3 JURISDICTION AND VENUE
4 14. The events that form the basis of this action occurred in Maricopa County.
5 Venue is, therefore, properly with this Court.
6 15. The amount in controversy exceeds the minimum jurisdictional limits of this
7 Court.
8 FACTUAL ALLEGATIONS APPLICABLE TO ALL COUNTS
9 Centurion’s Responsibility to Provide Medical and Mental Health Care
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

10 16. At all times relevant to this Complaint, mental health services were
Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 provided by Centurion, including the provision of all mental health services for
301 East Bethany Home Road, Suite B-100

12 patients housed in any of the Arizona State Prison Complexes.

Phoenix, Arizona 85012

13 17. ADC policy required Centurion to identify the mental health needs of
14 patients by assigning a mental health service level to each patient.
15 18. ADC policy, and the applicable standard of care, required Centurion to
16 ensure that patients with elevated mental health needs had a written, identifiable,
17 and accessible individual treatment plan based on the individual clinical needs of
18 the patient.
19 19. ADC’s policies require each prison complex to identify patients who
20 engage in self-harm, identifying whether the self-harm was a suicide attempt or self-
21 injurious behavior.
22 20. ADC’s policies require that patients with verified serious suicide
23 attempts be identified with a higher mental health score so that their need for mental
24 health care can be met.
25 21. ADC’s policies and the applicable standard of care requires medical
26 staff to consider known medical and mental health history in treatment decisions
27 with the goal of continuity of care.
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 1 22. In providing health care to inmates, Centurion staff have available an
2 electronic medical record system through which medical and mental health conditions and
3 events can be recorded and maintained to ensure continuity of medical and mental health
4 care.
5 23. In providing health care to inmates, Centurion staff often rely on the
6 observations and reports of security personnel in monitoring inmates with mental health and
7 medical concerns, particularly inmates who present with danger to self or others arising from
8 mental illness.
9 24. To the extent that Centurion staff rely on the observations and reports
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

10 of security personnel in monitoring inmates, such security personnel must be

Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 appropriately trained and supervised.

301 East Bethany Home Road, Suite B-100

12
Mackenzie Catalano Enters the Arizona Prison System with Serious
Phoenix, Arizona 85012

13 Mental Health Needs.

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25. On December 8, 2016, Mackenzie Catalano received a sentence of one
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year in connection with a charge relating to a drug paraphernalia. She entered the
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Arizona state prison system for the first time on or about April 14, 2017.
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26. During her first admission, Mackenzie was diagnosed with mental
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health conditions including: an anxiety disorder, psychoactive substance use,
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adjustment disorder with mixed anxiety and depressed mood, unspecified mood
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disorder, and major depressive disorder.
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27. On June 14, 2017, Mackenzie submitted a health needs request
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notifying Defendants that she was suffering from extreme anxiety and wanted to
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meet with a provider regarding medication.
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28. Medical records indicate that on June 19, 2017, Mackenzie either
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attempted suicide or reported a history of suicide attempt or self-harm.
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29. On June 23, 2017, Mackenzie was evaluated by a psychiatrist, who
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prescribed psychiatric medication and increased her mental health score.
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 1 30. Mackenzie was released to community supervision on or about August
2 1, 2017, to include a treatment program.
3 31. Mackenzie was released with active prescriptions for psychiatric
4 medications related to her mental health needs and with an elevated mental health
5 score.
6 32. On or about August 8, 2017, Mackenzie returned to prison to finish her
7 custodial sentence.
8 33. Mackenzie was ultimately released from custody and supervision on
9 November 30, 2017, and given active prescriptions for psychiatric medications.
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

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Mackenzie Catalano Attempts Suicide
Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 34. On November 6, 2019, Mackenzie received a sentence of two and one-

301 East Bethany Home Road, Suite B-100

12 half months for a dangerous drug violation. She reentered the Arizona state prison
Phoenix, Arizona 85012

13 system on or about February 7, 2020, and was housed at Perryville.

14 35. Although Mackenzie had previously received mental health treatment
15 and had been assigned an elevated mental health score, a chart note on admission
16 incorrectly noted that she had no history of mental health services.
17 36. On March 8, 2021, Mackenzie was released to community supervision
18 and was readmitted on August 25, 2021.
19 37. Shortly after she returned to custody, she was placed on a watch for
20 suicidal thoughts and was assessed at moderate risk for suicide.
21 38. On August 30, 2021, she experienced an unwitnessed fall that she later
22 revealed as a suicide attempt. She was again placed on watch.
23 39. On August 31, 2021, she told a provider that she had attempted
24 strangulation with a sock tied around her neck as well as intentionally falling from
25 her bunk.
26 40. Notwithstanding the circumstances of the attempts, Centurion failed to
27 “flag” Mackenzie’s medical chart.
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 1 41. Following the suicide attempt, Mackenzie participated in mental health
2 treatment, including psychiatric medications.
3 42. Mackenzie was again released to community supervision on December
4 30, 2021, and she was readmitted on March 31, 2022.
5 Mackenzie’s Final Incarceration Ends with Her Suicide.
6 43. Upon Mackenzie’s March 31, 2022 readmission, Mackenzie reported
7 recent IV drug use, putting her at risk for opiate withdrawal. She was placed on
8 opiate withdrawal protocol, and she was noted to have bipolar disorder.
9 44. On April 2, 2022, Mackenzie was placed on suicide watch for active
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

10 mental health symptoms, history of self-harm including attempted suicide, and

Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 substance abuse history. Mackenzie reported that she was thinking of hanging
301 East Bethany Home Road, Suite B-100

12 herself and disclosed that she had attempted to hang herself another time in prison.
Phoenix, Arizona 85012

13 45. On April 3, 2022, Mackenzie requested that she be placed back on

14 medications that she had previously taken at the prison.
15 46. On April 6, 2022, Mackenzie reported that she was coming off fentanyl.
16 She was assessed as having withdrawal symptoms.
17 47. On April 7, 2022, Mackenzie refused withdrawal assessment and was
18 found several hours later unresponsive, hanging in her cell.
19 48. Despite her request to be restarted on medications, Mackenzie had not
20 been seen by a prescribing psychiatric provider, nor had medication been ordered
21 for her. Contrary to policy, no treatment plan was initiated.
22 49. ADC policies and procedures require immediate initiation of rescue
23 and resuscitation efforts. In the case of a ligature, a cut-down tool is required to be
24 immediately available.
25 50. Plaintiff is informed and believes that employees of ADC may have
26 violated policies and procedures for emergency response causing the loss of a
27 chance for Mackenzie to be successfully resuscitated.
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Page 6 of 9
 1 CAUSES OF ACTION
2 COUNT ONE
3 Negligence / Medical Negligence
4 (All Defendants)
5 51. Defendant State of Arizona had a non-delegable duty to provide
6 healthcare to inmates, such as Mackenzie Catalano. Defendant State of Arizona is
7 liable for the acts and omissions of its contractor Centurion, and/or its employees,
8 and/or its agents.
9 52. Employees of ADC had a duty of care, custody, and control, to include
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

10 observing and reporting changes in behavior that suggest an inmate may be

Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 contemplating suicide.
301 East Bethany Home Road, Suite B-100

12 53. Employees of ADC had a duty of care, custody, and control; and, to
Phoenix, Arizona 85012

13 respond to medical emergencies consistent with their training.

14 54. Defendant Centurion, and its employees, had a duty to provide medical
15 and mental health care consistent with the community standard of care.
16 55. Defendant Centurion and its employees breached that standard of care
17 by failing to properly assess Ms. Catalano’s serious medical condition, by delaying
18 and denying access to the appropriate level of care, and by failing to timely refer her
19 to the appropriate specialty, urgent, and/or emergent medical care.
20 56. Had Defendants met the applicable standard of care, Ms. Catalano
21 would have received appropriate and timely mental health care; thus, preventing her
22 death.
23 57. The breaches set forth herein were a cause and/or contributed to
24 Mackenzie’s death.
25 .. ..
26 .. ..
27 .. ..
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Page 7 of 9
 1 COUNT TWO
2 Wrongful Death
3 (All Defendants)
4 58. Plaintiff re-alleges and incorporates by reference the allegations set forth in
5 the preceding paragraphs of this Complaint as if fully set forth herein.
6 59. At all relevant times, the Defendants had a duty to exercise ordinary care to
7 provide for the safety and well-being of Mackenzie Catalano.
8 60. Defendants breached those duties, as set forth in this Complaint.
9 61. As a direct and proximate result of Defendants’ actions and inactions,
ROBBINS CURTIN MILLEA & SHOWALTER, LLC

10 Mackenzie died.
Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

11 62. Mackenzie’s death has caused, among other damage, Plaintiff’s needless
301 East Bethany Home Road, Suite B-100

12 immobilizing and debilitating grief, anguish, and suffering.

Phoenix, Arizona 85012

13 63. Mackenzie’s death has also deprived Plaintiff of Mackenzie’s love, affection,
14 companionship, comfort, guidance, and sustained other damages that will be demonstrated
15 at trial.
16 JURY TRIAL DEMAND
17 64. Plaintiffs hereby demands a jury trial in this matter as to all her claims and
18 against
19 PRAYER FOR RELIEF
20 WHEREFORE, Plaintiff requests that the Court enter judgment against
21 Defendants and in favor of Plaintiff, as follows:
22 a. For compensatory, general and special damages against Defendants in an
23 amount to be proven at trial;
24 e. For such other relief as this Court may deem proper.
25 ///
26 ///
27 ///
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Page 8 of 9
 1 RESPECTFULLY SUBMITTED: March 31, 2023
2
ROBBINS CURTIN MILLEA & SHOWALTER, LLC
3
By: /s/ Jesse M. Showalter
4 Jesse M. Showalter
5 Anne E. Findling
Lauren E. Channell
6 301 E. Bethany Home Road, Suite B-100
Phoenix, Arizona 85012
7
Attorneys for Plaintiff
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ROBBINS CURTIN MILLEA & SHOWALTER, LLC

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Telephone: (602) 400-4400 ♦ Fax: (602) 265-0267

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301 East Bethany Home Road, Suite B-100

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Phoenix, Arizona 85012

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