AVONDALE, AZ — An Arizona inmate was getting ready for a routine MRI scan at a SimonMed Imaging Center in Avondale when prison records show a SimonMed technician made a troubling mistake causing the inmate and a prison guard to be stuck to the machine.
“She’s in a lot of pain. She has flashbacks of it,” the inmate’s sister Tawny Sonn said.
The incident happened in May of 2022 and the ABC15 Investigators have learned state regulators were unable to investigate or take enforcement action because this SimonMed location and others are not currently licensed or regulated by the state health department due to an exemption.
“I think that it's terrible. I don't even understand that,” Sonn said.
According to a Department of Correction incident report, a SimonMed technician told the prison guard not to remove the metal shackles around inmate Lacey Windust’s waist which caused her to be stuck to the machine.
It’s no secret MRI’s and metal don’t mix. The machine is essentially a giant magnet.
“As I walked closer to the machine about three to four feet away … the magnetic flew me off my feet up into the air and threw me into the machine, up in the circular hole,” Windust wrote in a letter she sent to her sister from prison describing the incident.
Windust said she was immediately in excruciating pain from the belly shackles, which were pulling her harder and harder, and described feeling like she was being ripped in half.
The prison guard wrote in his report that the SimonMed tech then asked him to go in and help Lacey and he was also “stuck to the MRI machine because of my gun.”
“We have two people trapped and injured because of failure to effectively screen or control access to this area,” said MRI safety expert Tobias Gilk, who is familiar with the records in this case.
The prison incident reports described several minutes going by before anyone hit the emergency shutoff button, despite pleas from Windust and the guard.
SimonMed’s own incident report obtained by ABC15 noted the employees were waiting for the lead engineer who had advised them to wait until he got on scene.
Windust was taken to the emergency room and the prison took photos of her injuries. The images showed a deep cut on her hand that required stitches, bruises, and imprints from where the metal shackles pulled on her body.
“I feel like SimonMed and also the prison needs to be held accountable for what happened,” said Sonn.
The Arizona Department of Corrections confirmed the incident happened but pointed the blame at SimonMed. “This secondary medical situation, and resulting injuries, were caused by errors made by the staff at the imaging lab,” the agency said in a statement.
“I would describe it as a pretty catastrophic failure,” said Gilk. “All these things suggest that best practices were not followed.”
Gilk explained MRI best practices include screening patients for metal before they ever step foot into an MRI room.
In this case, prison records showed after the guard removed Windust’s leg shackles. The guard said he asked the SimonMed tech if she also needed her metal belly shackles removed and the tech responded, “No they should be fine.”
“The problem is that there are so few regulations or standards with respect to what constitutes minimum appropriate training in an MRI provider,” said Gilk.
The Arizona Department of Health Services regulates and licenses imaging centers, but records show SimonMed, one of the largest imaging centers in the country, is getting to play by different regulatory rules in Arizona.
“From a regulatory standpoint, MRI safety is really the wild, wild west,” said Gilk.
SimonMed operates more than 60 imaging centers across the state, but a search for its license on the health department’s website found “no records.”
“So, I would ask who are they regulated by?” said Gilk.
The Arizona Department of Health said the SimonMed in Avondale where Windust was stuck to the MRI machine was not regulated by ADHS because of an exemption the state granted the company.
“Given that the facility in question was not under the regulatory authority of the Department at the time of the alleged incident, DHS does not have authority to investigate or take enforcement action,” ADHS said in a written statement.
ABC15 found other imaging centers are licensed by the state health department as outpatient treatment centers including nearly two dozen Banner Imaging locations.
The state health department’s communication team wouldn’t answer ABC15 questions about what makes SimonMed eligible for the exemption or tell us when it granted the exemption.
When ABC15 Investigators called, an employee at the licensing department told ABC15 SimonMed had a private provider exemption because it was physician-owned. ADHS’s website says private providers are only exempt from licensing if they are owned by a doctor or doctors who are treating patients at the clinic.
“I would encourage the state to contemplate where, when and how they want to allow providers to escape regulatory oversight,” said Gilk.
We asked AZDHS how one licensed physician could provide care at the more than 60 SimonMed locations across the state or how SimonMed, one of the largest imaging centers in the country could still be considered physician-owned. Especially after, American Securities, a private equity firm announced a major investment in the company two years ago.
ADHS responded by saying it is now in the process of reviewing SimonMed’s exemption.
“If a determination is made that any of the SimonMed locations do not meet license exemption criteria, DHS will work with the facilities to obtain appropriate licensure. At this time, we are not aware of how many facilities may be affected,” a spokesman said in a statement.
“I don’t want it to happen to somebody else. My sister is seriously traumatized from it,” said Sonn.
SimonMed didn’t answer many of ABC15’s specific questions citing HIPPA privacy concerns, but stressed it is committed to patient safety and is currently working with state regulators.
“We have always had, and continue to have, a constructive and cooperative relationship with the Arizona Department of Health Services, and we are actively working with that agency to determine the appropriate licensure status of our Arizona facilities,” SimonMed said in a statement.
SimonMed shared a complete statement with ABC15:
We appreciate you reaching out. First and foremost, we want to emphasize that at SimonMed Imaging, our primary focus is and always has been on providing exceptional healthcare services to our valued patients. With over 20 years of service in the communities of Arizona, we strive to uphold the highest standards of medical care through state-of-the-art technology and a dedicated team of experienced professionals.
We prioritize patient well-being and safety above all else. We adhere to strict regulatory requirements and guidelines and strive to continually ensure that our employees are properly trained to handle all possible patient and care-related situations, As a healthcare provider committed to the highest standards of quality and patient safety, we understand the importance of transparency, responsibility, and accountability. Any incidents that occur are fully investigated and all such incidents are reported to the appropriate regulatory agencies and accrediting bodies, consistent with the obligations imposed under HIPAA and other state and federal laws and regulations.