A federal prison doctor first found the mass on Terri McGuire Mollica's uterus in 2016. According to a lawsuit, the fibroid was small, and could be removed with a simple, noninvasive surgery.
But officials at FCI Aliceville, a low-security prison for women in west Alabama, never scheduled the procedure, court and medical records show.
Mollica, then 50, started fainting during heavy periods that lasted nearly two weeks. She used five menstrual pads at a time, she said, with blood often soaking through her prison khakis. The pain was an "8 out of 10," she wrote on multiple sick call forms. In 2018, the same doctor determined the fibroid had grown to the size of a grapefruit. Her uterus swelled as though she were nearly five months pregnant.
Prison officials still did nothing.
Mollica had just one path for recourse: the prison's antiquated administrative remedy system. She would have to fill out a stack of carbon copy forms, following a list of specific rules, and submit them to the warden, then the Bureau of Prisons' regional office and, eventually, Washington, D.C. While she had just weeks to file her complaints and appeals asking for treatment, officials would likely take months to respond.
She would do all that knowing the answer was almost always no.
It has always been difficult to get help inside federal prison. But in recent years, it has become nearly impossible, according to an analysis of federal data by The Marshall Project and NPR. The rate at which the bureau granted grievances has fallen from just under 7% in 2000 to less than 2% in 2023, the last full year of data available.
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For any problem in an incarcerated person's life — from not getting enough toilet paper to being subject to extreme physical abuse — the grievance system is the primary way to speak out. But in the vast majority of cases, those efforts go nowhere. Many are rejected without consideration for the content of their complaint, for arcane reasons such as including too many pages or not filing enough copies.
What should be a gateway to help for people in federal prison, experts say, is instead a brick wall. A 1996 federal law requires prisoners to complete the internal grievance process before filing a lawsuit. If they fail to follow every requirement of that process, their case will likely be thrown out. As a result, the system blocks most people from ever taking their case to court, where a judge could order prison officials to provide relief.
The agency is aware of this drop in grant rates, a spokesperson said, and is working on "updates and additional guidance" related to filing grievances. "The program is intended to solve problems and be responsive to issues raised by inmates," Randilee Giamusso, a Bureau of Prisons spokesperson, wrote in an email, "and does not prevent inmates from pursuing litigation."
She noted that if prison officials don't reply within the established time frame, the filer can appeal to the next level without receiving a formal response, as Mollica did. Giamusso declined to comment on Mollica's experience or any individual cases.
When Mollica first tried to sue officials for neglect, a federal judge dismissed her case, ruling that she hadn't completed the grievance process. But according to court records, she tried to mail her final appeal to the bureau's office in D.C.; officials had never recorded it in the system. A decade after doctors found the fibroid, she is still waiting for surgery. Given the delays, doctors recommend a full hysterectomy, according to her medical records.
"They don't even try to fix the problem, they just look for a reason to deny it," said Mollica, who was sentenced to 17 years for defrauding two nonprofit health clinics and sending narcotics through the mail. She was released to a halfway house in Alabama in January. "I've never seen [the grievance system] help anybody."
Across 24 years of prison filings, healthcare-related requests like Mollica's were the third most common reason for someone to lodge a complaint, behind housing problems and staff-related issues. Of all medical grievances decided in 2023, fewer than 1% were granted.
The bureau's approval rate appears to be far below that of many state corrections departments, the news organizations found, though departments track such data in different ways. In California, officials granted roughly 15% of grievances and appeals in 2023, according to an analysis by The Marshall Project and NPR. In Georgia, nearly 13% of cases were "granted, partially granted or resolved," that year, according to the department. In Texas state prisons, over 4% of complaints and appeals processed that year were "resolved in inmate favor" — a very small portion, but about twice the bureau's rate.
Federal grievances may be thrown out for being trivial, illegible or not pertaining to an issue that can be addressed through the bureau's system. And in some cases, an incarcerated person might get the help they need without having their grievance officially granted. But the data shows the current system obstructs even valid complaints.
According to bureau policy, prison staff "should be flexible" when deciding whether to reject a complaint, "keeping in mind that major purposes of this Program are to solve problems and be responsive to issues inmates raise." But in 2023, almost half of the complaints decided were rejected due to procedural issues.
Attorneys and people in prison recounted the most frustrating reasons for rejections they've seen, like writing with a pencil instead of a pen, or a woman reporting sexual abuse who was rejected for misspelling her abuser's last name. One advocate recalled a case where a Spanish-speaking prisoner filed a grievance asking for translation services, but was rejected for writing it in Spanish.
Giamusso, the bureau spokesperson, denied that these are reasons a person in prison would have their remedies rejected. "The BOP does not reject remedies solely because a submission contains too many pages, is written in pencil rather than pen, or includes a misspelled staff member's name," she wrote. "However…the Administrative Remedy form instructs inmates to write with a ballpoint pen to ensure the carbon‑copy pages remain legible throughout the review process."
Jack Donson, a former bureau official and executive director of the Federal Prison Education and Reform Alliance, said the system is getting even harder to navigate. "I've seen people rejected for too many copies, not enough copies, the rejections are all over the map," he said. "I've never seen it so dysfunctional." As understaffing across federal prisons continues, there are even fewer employees available to review complaints.
The data analyzed by The Marshall Project and NPR was published in July 2024 by the Data Liberation Project, an initiative committed to making large government databases public. The dataset contained information on nearly a million prison grievance cases filed between January 2000 and late May 2024.
The news organizations filed a records request with the Bureau of Prisons for more recent data in February 2025. The bureau has yet to provide those records.
Only a quarter of complaints in 2023 were actually denied, meaning prison officials evaluated the content of the requests and refused them based on their merits. A growing portion, 29%, were "closed" that year for other reasons. That often meant officials responded with a vague answer to prisoners' pleas that is "for informational purposes only," and not registered as a rejection or denial. According to Giamusso, that designation is used for cases that "do not require any corrective action."
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In 2024, Robert Ruff filed a grievance from a federal prison in Pennsylvania, asking for access to the recreation yard. The yard was at the top of a steep set of stairs, which were impossible for him to navigate with a walker. He wanted "to be able to get some sunshine" and watch the softball and football games. In a response to his request, the warden wrote "for informational purposes only" that Ruff still had access to indoor recreation like the chapel or arts and crafts.
Ruff worked with The Remedy Project, a nonprofit that helps people in federal prison file grievances, to appeal his case, but he was never given access to the yard. He has since been transferred to a different facility.
"If you were trying to find a case where they sided with a prisoner, it would be like finding a flea on an elephant's back," said Ruff, who has spent over 40 years in federal prison. "In the last 10 years, it feels like the remedy process transferred over so the prisoner is never right. Now, you don't get no type of justice at all."
It wasn't meant to be that way. The bureau established the grievance system in 1974, in part to stem the number of prison lawsuits ending up in federal court. There was also a growing belief among prison officials, around the time of the Attica prison uprising, that being more responsive to prisoners' concerns would reduce the likelihood of violence or rioting. In its initial version, the system had just two levels of review — the warden in each prison and the agency overall. In a four-month trial at three different federal prisons, more than a third of the complaints were granted.
Since then, the process has stretched to require four different levels of review, each with a list of procedural requirements that pose stumbling blocks for prisoners seeking help.
Corrections departments previously had to prove their grievance systems were fair and accessible if they were to serve as a gateway to the courts. But that basic requirement was scrapped under the 1996 law that required filers to complete the in-prison complaint process before filing suit. Now there is an incentive for prisons to complicate their remedy system, said Professor Margo Schlanger of the University of Michigan Law School.
"You have to cross every 't' and dot every 'i' before it counts as exhausted," she said of federal prison grievances. "It's in the interest of prison officials to come up with as many reasons as possible why the grievances are no good."
Recently passed legislation is supposed to provide another outlet for incarcerated people to pursue accountability. The Federal Prison Oversight Act, signed into law in 2024, would create an independent ombudsman to whom prisoners and their families could file complaints. Congress recently instructed the Justice Department to start planning the new office, but has yet to provide the funding needed.
Mollica filed a grievance in December 2019 over her severe pain and bleeding. "As of this date, I have not received any treatment or additional consults for this problem," she wrote, asking for an appointment with an outside specialist or surgeon within a month.
It took the warden six months to respond, writing in June 2020 that Mollica did have an appointment scheduled with a gynecologist. But "due to security considerations, you will not be told in advance of the date, time, or location of these appointments," she wrote.
Others incarcerated at Aliceville were facing life-threatening health conditions, and made to navigate the same dead-end bureaucracy. The year Mollica was filing complaints asking for surgery, medical requests were the most common grievance filed at FCI Aliceville. None were granted. A 2020 investigation by Reason found three women who had died from alleged medical neglect at the facility, based on interviews and lawsuits.
Hazel McGary died of a blood clot in her heart in 2019, after months of asking to see a cardiologist. "The warden and the region are useless," she wrote in a letter, obtained by Reason, nine days before she died. "They send us through all of these long, drawn-out procedures. By the time [they're done] we will be home or dead."
Officials at FCI Aliceville declined to comment for this story.
Mollica appealed her filing to the regional office; officials took another six months to respond. They replied claiming surgery had not been recommended.
Mollica appealed again, this time writing to the bureau's central office in Washington D.C., via certified mail. She never received a response.
After a judge dismissed Mollica's case, attorneys for the MacArthur Justice Center were able to prove that Mollica had tried to follow every step, and that officials had failed to record her final appeal.
Without attorneys or a certified mail tracking number, Mollica may have been out of luck. In a 2021 court decision, an incarcerated man had tried to sue Bureau of Prisons officials after his cellmate stabbed him and left him blind in one eye. The court threw out his lawsuit because the bureau claimed officials never received his final appeal — which the man said he had delivered in a stamped envelope to the prison mail room. An appeals court upheld the dismissal.
In Mollica's case, the 11th Circuit Court of Appeals ruled in August 2025 that her lawsuit should not have been dismissed, almost nine years after a doctor first found the fibroid on her uterus. But she still faces long odds in court, due to a legal precedent that makes it extremely difficult to sue federal agents for abuse or neglect.
When Mollica returned to Alabama in January, "I told a friend of mine, 'I hope when I get off the plane there's an ambulance waiting to take me to the hospital,'" she said. But she remains under the control of the Bureau of Prisons until 2029. Her surgery has yet to be scheduled.
Data reporting and visuals by Ilica Mahajan and Anna Flagg of the Marshall Project, with additional graphics work by NPR's Connie Hanzhang Jin. Art direction and photo editing by NPR's Emily Bogle and Celina Fang at the Marshall Project.
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