Kesha Jackson was preparing for her husband, John, to be home in a few weeks. He was incarcerated in Forrest City federal prison in Arkansas, awaiting a court hearing for early release after 18 years. But then Jackson got a concerning call from other inmates.

Her husband, in the special housing unit, was going in and out of consciousness, the inmates told her. He tried banging on the door for help. Three days later, an officer handcuffed him and tried to give him CPR.

He died soon after. And as she waited for some explanation, Jackson was surprised to learn what prison officials pronounced as the manner of death: “Natural.”

By deeming the death natural, prison authorities were not required to conduct an autopsy for Jackson’s death. It’s how they characterize at least three-quarters of all federal prison deaths since 2009, yet NPR has found “natural” deaths with details that raise questions for family members.

“When his medical records came home after he passed away, I saw that it was MRSA,” Jackson said.

MRSA is a staph infection – caused by a type of dangerous, drug-resistant bacteria. But it is not generally fatal if treated immediately. John contracted it after he was moved to the Forrest City federal prison in 2017. According to his medical records, he still had the infection over two years later.

“Saying that it’s a natural death can sometimes be misleading because I believe that having the proper medical treatment could have possibly saved his life,” Jackson said.

The CDC says natural deaths happen either solely or almost entirely because of disease or old age. Yet 70 percent of the inmates who died in federal prison the last 13 years were under the age of 65. After speaking to some of the families of these inmates, NPR found that potential issues such as medical neglect, poor prison conditions and a lack of healthcare resources were left unexplained once a “natural” death designation ended hopes of an investigation. Meanwhile, family members were left with little information about their loved one’s death.

In Jackson’s case, she called the prison for six hours before she got a response. A correctional officer told her that the warden was in a meeting about her husband and she will get a call back. She says she never did.

“The prison doesn’t have to contact family members unless it’s a matter of life and death, I guess,” Jackson said. “Well he’s dead, so where was the contact? I should have been contacted as soon as there was an incident.”

Jackson remembers multiple calls with her husband where he complained about the lack of hygiene and cleanliness in the prison. He complained of an infected wound in his calf and was asked to wait more than a week for medical attention. After the wound burst in the shower, he was hospitalized for a day and a half and got diagnosed with MRSA. But he wasn’t given medication regularly. He bought aspirin from the commissary and drank lots of water, according to Jackson.

Homer Venters, a federal court monitor of jail and prison healthcare, calls deaths like Jackson’s “jail attributable.”

He says this is when “things that happened behind bars significantly contributed to the outcome of death, despite the fact that a medical examiner ultimately says it was a natural-causes death. This is a very common problem and it’s a commonly missed source of the health risks of incarceration.”

Venters says that calling a death natural often does not provide a full picture.

“So we have this very old, antiquated idea that the coroner or medical examiner, when they say a death was from natural causes or from homicide, that that should somehow determine whether or not people got what they needed behind bars,” Venters said.

The Office of Inspector General for the BOP recently launched an investigation into all non-natural federal inmate deaths in custody from 2014 to 2021. Natural deaths are not included in this investigation.

But NPR spoke with multiple families of inmates who died natural deaths who believed their loved one’s death warrants scrutiny. For instance: an inmate in a prison medical center in Springfield, Mo., waited weeks to be treated for bleeding in his digestive tract. He died soon after hospitalization. An inmate in Arkansas complained of stomach pain for a year and a half before his death. His family was not provided with any more details.

Another inmate in Missouri died of respiratory failure, and his death was pronounced natural. But according to medical examiner records obtained by NPR, his death was later treated as a homicide. His family found out about this information for the first time from NPR.

Andrea Armstrong, a professor at the Loyola University New Orleans College of Law who researches prison and jail conditions, says that categorizing natural deaths differently could make a change.

“It helps us figure out which of these deaths were influenced and, in fact, more likely to be preventable if they had more timely action and intervention,” Armstrong said. “Just saying natural causes obscures the role that medical care that was provided within the facility played in the death and to what extent that actually complied with community standards of care.”

On a Sunday morning in March, Celia Wilson got a Facebook message from an unknown account. It was about her brother, Lenny Wilson, and turned out to be from his prison cellmate.

The message said her brother “was running on the track and collapsed” and then taken to a hospital. After Wilson tried for several hours to get ahold of a prison official, she called three hospitals in the surrounding area before she found one that confirmed her brother had been admitted there.

The first call she got from the BOP came two days later, from her brother’s case manager. He told her not to worry.

“He said that my brother is communicating and we think he’s going to be just fine,” Wilson said. “We were so relieved at that point. And we all sit down, write letters, get him letters in the mail that day.”

But Alison Guernsey, Wilson’s attorney and also a clinical professor at the University of Iowa, found different information in his medical records.

“Celia [Wilson] would say they think that there’s signs of life and maybe vitals are getting better. And then we would ask for those medical records and they wouldn’t actually say that,” Guernsey said.

She had to file public records requests every day for updates on Lenny Wilson’s health after the collapse.

“It was quite difficult to get someone from the Bureau of Prisons to actually tell us what was going on,” Guernsey said.

Two weeks after his collapse, Wilson’s brother died. His death was pronounced natural.

“They wouldn’t give us any information while he was in the hospital,” Wilson said. “I just received a call on Easter Sunday morning that he had passed.”

Wilson later was told by her brother’s cellmate that he had not received help for almost ten minutes after his collapse. She is still waiting to receive his autopsy report.

“Everybody says that it’s someone else’s job to make sure things happen,” Wilson said. “But I can tell you that I am so exhausted from doing this and beating my head against a wall and trying to get just something, give us something so that we can attempt to start to put closure.”

Currently, autopsies are not required for federal prison deaths that are pronounced natural, unless deemed necessary by the warden. However, the BOP does submit a multi-level mortality review report to the Office of Quality Management, which is meant to summarize how the death was handled. This report is not provided to the public or the families of the inmates. NPR submitted a public records request for all mortality review reports since 2009 and have yet to receive them.

The BOP declined NPR’s request for an interview but said that all deaths are investigated thoroughly. A spokesperson also said that there are detailed procedures to notify family members after an inmate’s death.

Wilson, who worked in corrections for 20 years, said she believes the BOP could have done more.

“I still work in government and this is not the system I know,” Wilson said. “My brother didn’t deserve to die in prison.”

Robert Little edited this story. Noah Caldwell produced it. Additional data analysis by Nick McMillan and Dan Wood. Photo editing by Emily Bogle.

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