Finalist: The Boston Globe, with contributions from the Organized Crime and Corruption Reporting Project

By Jessica Bartlett 

Sungida Rashid gave birth at St. Elizabeth’s Medical Center in October, and barely a day later she was bleeding to death.

The 39-year-old’s heart had already stopped once. Medical teams revived her, but the clock was ticking. Doctors soon identified the problem: a bleed deep within her liver. In the operating room, caregivers had a plan to quickly treat it, but the staff there soon discovered something alarming — the embolism coil that doctors could have used to stop the bleeding wasn’t available.

Weeks prior, the hospital’s inventory of the devices had been repossessed, according to hospital staff. A company rep from the manufacturer, Penumbra, explained to staff that Steward Health Care, the parent company for St. Elizabeth’s, hadn’t paid the bill.

Some of the staff members at the Brighton hospital had feared this would happen, raised the alarm with executives, discussed it among themselves. But the warnings hadn’t reached all staff. Now, as the emergency unfolded before them, they did not have the coils.

According to court records, similar invoices had been going unpaid for more than a year throughout the nine-hospital Steward system in Massachusetts — from elevator repair companies to staffing agencies that employ front-line workers. Two hospital executives told the Globe that Steward doctors had begun asking other hospitals for permission to do their work elsewhere.

Steward Health Care’s sprawling operation covers 16,000 health care workers and 200,000 patients each year across the eastern part of the state, in mostly low-income neighborhoods from the New Hampshire border to the South Coast. The Globe reported this month that Steward’s financial challenges have grown so acute that hospital executives and state officials are now working hurriedly to stave off a round of possible closures that could trigger a public health emergency.

As the financial challenges mount, some patients say they have struggled to access care, with doctors blaming the system’s financial problems as the cause.

In a statement, Steward said it does its best to keep the supplies on hand that it needs to serve patients.

“Understanding that the demand for supplies and staff can fluctuate at any given moment due to changing and unpredictable volumes of patients, Steward is confident we have adequate supplies for our physicians, providers, and health care professionals to continue providing high-quality care to our patients,” the health system said in a statement.

Steward’s hospitals, it says, “have for several years now been consistently recognized among the best in the nation and state by the likes of highly credible ratings organizations for providing excellent life-saving surgical and critical care.”

The health system did not respond to questions about how its financial troubles are affecting patients. Steward also declined to comment on Rashid’s case, which the Globe reconstructed from accounts provided by her husband and multiple medical professionals with knowledge of the situation.

On that dire day in October, as Rashid’s condition worsened, her husband sat in the recovery room, waiting for updates.

He couldn’t help but worry.

By the time Rashid and her husband, Nabil Haque, moved from Thailand to Boston on Aug. 30 for his new job in academia, she was only a few weeks away from giving birth. The Bangladeshi couple was thrilled to start their family.

Rashid’s pregnancy was routine and uncomplicated, but still she ran into problems navigating American health care. At one Boston hospital, an OB-GYN said they didn’t accept patients who were already beyond 28 weeks.

However, St. Elizabeth’s was close to where the family was staying in Boston and accessible by train. More importantly, Rashid felt taken care of. Both of her parents had died when she was young, and the couple was far from other family. The midwife seemed to the couple to feel a similar kinship and closeness, joking that she could be Rashid’s grandmother.

People gravitated to Rashid. Hardship had shaped her to be funny and open, her husband said. Haque knew she was whip-smart, but finding humor in the midst of adversity — that took something else.

Haque recalled walking to the hospital on Sunday, Oct. 15, Rashid energetic and determined for a second induced delivery attempt in as many days.

Labor began slowly, eventually stretching through Monday into Tuesday. Haque grew anxious. Still, doctors said Rashid was healthy. They didn’t want to operate if it wasn’t necessary. Early Tuesday morning, finally, Rashid gave birth to a healthy baby girl.

The couple named the baby Otindria, a word in Bangladeshi meaning “extra senses.” Rashid had always joked that Haque’s senses were underdeveloped. He could have selective hearing. The kitchen could be aflame, and Haque wouldn’t smell the smoke. She will complete you, Rashid told her husband.

Haque remembers the staff’s attentiveness after the birth, the way they came in on the hour. Rashid was bleeding more than normal, and was taken to another room for a D&C, a procedure sometimes used after childbirth to help clear the uterus.

After a few hours of sleep, the family woke up and announced their news to the world. Relatives near and far marveled over a video call at the couple’s new miracle. Haque took a photo of Rashid and the baby, and then of the three of them. Rashid’s smile was wide as she held up her tiny bundle, Otindria’s dark hair and plump cheeks peeking out from hospital blankets.

Rashid revealed to her nurse in the early evening that she was in some pain. Staff made a plan — medication and ice packs and heating pads. But that didn’t help. An hour later, Rashid was unable to sit still, then was wildly nauseous.

A staff member who had been present for the birth earlier that morning came in. But the lively, tenacious woman from hours earlier looked different, her eyes moved slowly across the room. It was a warning sign, triggering alarm and action from the staff. Something was very wrong.

As Rashid and Haque were making sense of the region’s health care system in advance of their daughter’s birth, Steward was facing a crisis.

Workers across the care team, from respiratory therapists and dietary staff to patient transport professionals and pharmacy technicians, had “consistently raised concerns over the precarious position management has placed both patients and caregivers,” according to a memo sent this month by 1199SEIU United Healthcare Workers East to its 5,000 members working at Steward’s nine Massachusetts facilities.

The Jan. 12 email, from union vice president Cari Medina, predicted that the coming weeks and months would be difficult.

“It is long overdue for Steward to address its mounting financial issues and the impact it has on workers and patients,” Medina wrote in the email.

A string of legal disputes, first reported by the Globe, tells a similar story. In January 2023, dialysis provider Fresenius Management Services told Steward it would stop providing services to several Massachusetts hospitals owned by Steward after the health system had failed to pay the company, according to court documents.

Penumbra, the company that according to staff at the hospital supplied the embolism coils at St. Elizabeth’s, sued Steward and several of its executives in a Texas court in late October alleging millions in nonpayment.

Steward also declined to respond to questions about how it managed dialysis services or embolization devices after the vendors departed.

Sten Willander, a nurse anesthetist who has worked as a contractor in Steward hospitals in Massachusetts for years, said he would be giving anesthesia to patients, and certain supplies wouldn’t be on hand, as Steward hadn’t paid the vendor.

While he didn’t see shortages that he believed endangered patients, such issues were unique to his experience at Steward — and they made his work more difficult.

“It adds a layer of complexity to my job I wouldn’t experience at another facility,” he said. “I work at Beth Israel, Cambridge Health Alliance. No one does this.”

Willander said he stopped working at Steward in March 2023, after he had worked since January without pay. Ultimately Steward paid him a portion of what he was owed in late March, Willander said.

Steward did not respond to allegations that it had not paid contract employees promptly.

Meanwhile, the chief executive of a large vendor that delivers services critical to multiple Steward hospitals said the vendor is currently owed just shy of a million dollars by Steward.

That executive, who requested anonymity due to the ongoing billing dispute, said the company would be inclined to stop working with Steward if not for its concern over public health.

“The only reason we’ve continued [services], though they owe us, is because if we stop, there’s no one who can pick up the pieces,” the executive for the company said. “It puts the state, the hospital in jeopardy. That’s why we’ve continued to do it.”

What started as an inkling that something was wrong with Rashid soon turned into a crescendo. Haque said doctors took Rashid’s vital signs, then descended onto the room en masse.

According to Haque, the moments unfolded in snapshots as he and the baby were ushered to the nursery. Rashid was taken for a CT scan. The tests showed her abdomen was filled with blood. At some point, doctors told him her heart had stopped. Haque called a friend, who immediately left to come to the hospital.

In surgery, staff had identified her liver as the source of the blood. An embolism coil would be used to stop the bleeding, doctors told Haque.

Dr. Raymond Liu, an associate radiologist within the Division of Interventional Radiology at MGH, who was not involved in Rashid’s care, said embolism coils, metallic devices that help promote clotting, are sometimes used to stop internal bleeding. Whether using a coil or another device, embolization can be a useful technique. It’s precise and minimally invasive, sometimes reaching blood vessels that cannot be reached through surgery.

In a trauma situation, such treatment typically needs to happen quickly. Most situations of rapid internal bleeding are considered urgent, Liu said.

Not every kind of hospital has this kind of equipment. However St. Elizabeth’s defines itself on its website as a Level IV maternal care center, “the highest designation available from the American College of Obstetricians and Gynecologists.” According to that organization, basic interventional radiology, which includes the capacity for embolization, is a requirement for such a designation.

While there are many ways to deal with an internal bleed — and it’s impossible to know whether any of them could have changed the course of Rashid’s treatment — Haque said hospital workers told him the plan was to insert a coil to try to stop the bleeding in her liver.

Staff debated what to do next. They could get supplies from another hospital. There are several nearby. However embolism devices are not all the same, but specific to the equipment used to deploy them. What if their devices weren’t compatible? The patient would be taken to Boston Medical Center instead.

Staff told Haque that Rashid would be transferred and said the baby would be fine in the nursery while he went to the other hospital. They brought Haque to the emergency department hallway. He watched his wife as she was loaded into the ambulance, wrapped in silvery heating blankets as if in a cocoon, surrounded by bags of blood.

It seemed an act of unending effort, that staff would stop at nothing to save his wife. He remembered thinking, they are doing everything they can do.

Rashid wasn’t the only person to face consequences from Steward’s financial stress.

Kelley Kassa, from Watertown, said multiple doctors who treated her at St. Elizabeth’s have left over the past 18 months, including three orthopedic surgeons and an ear, nose, and throat specialist. She said she tried for six months to schedule a mammogram, before being told by her primary care doctor that the hospital didn’t have enough staff to answer calls or return messages.

Ultimately, Kassa said, her primary care doctor told her he’d be leaving Steward, too.

“His concern was patient care,” Kassa said.

Dr. Brian Patel, chief medical officer for Sturdy Memorial Hospital and its health system, said patients have come to the Attleboro hospital, which is not affiliated with Steward, from Brockton because they cannot get care at Steward’s Good Samaritan Medical Center or the wait times are too long. Surgeons from Steward have also reached out to the hospital to get privileges to perform elective procedures at Sturdy.

According to another health executive, who requested anonymity to discuss sensitive details of hospital operations, other hospitals in Massachusetts have also received credentialing requests from Steward physicians.

In its statement, Steward said it had a “steadfast commitment” to serving the most vulnerable populations across the state “who often have nowhere else to turn for help,” and it said its staff and providers were committed to delivering excellent patient care.

As an example, Steward said Good Samaritan had stepped up to accommodate a flood of patients in the aftermath of the closure of Brockton Hospital due to a fire in February 2023. Separately, Steward said it is the largest provider of in-patient behavioral health services in the state, a service line that often loses money.

“These accomplishments simply would not be possible if Steward were not making sustained, active investments in the necessary resources needed to ensure that our facilities can offer high-quality, compassionate care that’s been at the heart of our mission since 2010,” the system said.

State officials have been in talks with Steward for five months, partly related to concerns from employees at the hospital, according to a person with direct knowledge of ongoing conversations, who asked not to be named given the sensitivities of the discussions.

The person did not provide specifics, and state officials did not provide requested records by publication time. But according to the source, state officials have done investigations and required Steward to develop corrective action plans to maintain quality of care in Massachusetts. Some investigations are ongoing.

When Haque arrived at BMC at midnight, he met with two ICU specialists to prepare him for the journey ahead. The surgery was major, they told him, and would take several hours.

But the bleeding was too much. In the operating room, doctors struggled to insert the coil, as Rashid’s blood pressure had dropped too low and her veins had collapsed, doctors later informed Haque and his family.

Rashid’s heart had stopped again. An hour after surgery began, doctors returned to Haque. Rashid was dead.

Staff at St. Elizabeth’s seemed as upset by Rashid’s death as the family was, Haque said. Haque sat with his newborn baby in the hospital the following week, hesitant to take her home in the midst of his grief and shock, and staff kept coming by to offer condolences. Haque’s friend noted to him that as each nurse left the room from their visit, they were crying.

Days later, doctors at St. Elizabeth’s met with Haque, his parents, who are both physicians, and another family friend who is also a doctor. Haque said that friend asked doctors why Rashid was transferred at all. Is it because you didn’t have an embolism coil? The answer was one word — yes.

Haque has made some decisions. With help from his parents, he brought home his baby girl. Shortly after her death, Rashid’s body was taken to Bangladesh, where she was buried by her brother. Haque and his daughter moved back to Bangladesh in January.

But months after his wife’s death, questions still linger. Haque still does not know what caused his wife’s liver to bleed, or whether, with sooner intervention, she might have survived. For his part, he does not blame the doctors, who he feels did all they could.

He’s unsure whether the hospital shoulders any blame. He only found out why the embolism coil wasn’t available after being contacted by the Globe.

There are questions, too, that he says torment him, questions that seem to be echoed by others in the health care industry trying to make sense of what has occurred. He wonders whether he should have chosen a different provider.

“It’s always going back to that, what could I have done differently to have a different outcome?” Haque said. He paused. “That’s part of grieving.”

This story was reported by Liz Kowalczyk, Chris Serres, Jessica Bartlett, Elizabeth Koh, Mark Arsenault, and Yoohyun Jung. It was written by Arsenault and edited by Brendan McCarthy.

Gilberto Melendez-Brancaccio often became confused and seized by religious delusions when he didn’t take his antipsychotic medication, and that was how the police found him, in June 2021, in a Quincy hotel, telling people he was God.

The police summoned an ambulance. “No,” Gilberto said at first. “I am God.” But then, as if his words and actions were operating on different wavelengths, he collected his wallet and phone, and went with the officers.

“Good,” Gilberto told them, according to a police report. “I’ll go to the hospital.”

He was a husky 5-foot-8, with a shaved head and sculpted goatee. His eyes were stunningly dark and expressive, often caught in photos with a look of melancholy. Perhaps that was from the sad things he had witnessed in his turbulent 31 years, such as his mother being consumed by mental illness, before Gilberto himself began exhibiting signs of schizoaffective and bipolar disorders.

He climbed without hesitation into the ambulance.

Even amid a psychotic break, he trusted in the hospital as a place where he could count on compassion and expert care.

His trust was misplaced — betrayed, in fact.

The ambulance drove him to Carney Hospital in Dorchester, part of the national Steward Health Care chain. It was a desperately depleted hospital, so starved for resources by its corporate bosses that some employees had begun referring to it by a dark nickname: Carnage.

Carney was but one piece of the failing empire of neglected Steward hospitals, some now shuttering for good or being parceled off in a bankruptcy fire sale.

The breadth and tragic consequences of Steward’s mismanagement have not yet been told in full. There has been a vast human toll, tallied in lives lost, suffering endured, physical injuries, and moral indignities. This Spotlight Team investigation is the first major effort to document the full dimensions of the harm done.

Gilberto, of course, had no idea. When he became combative, the Carney staff tried to calm him with antipsychotic and anti-anxiety medications. They put his arms and legs in restraints. Three times, he tried to flee; each time, he was again sedated and restrained.

By late morning, his heart rate had soared. His oxygen levels plummeted so low that nurses gave him a breathing mask.

Doctors ordered that Gilberto be continuously monitored; a patient bound by restraints must, under hospital policy, never be left alone.

But on this overnight, Carney’s emergency department was understaffed and didn’t have enough people for one-on-one monitoring. The sitter assigned to Gilberto was also watching two other patients, federal investigators later found. The investigators concluded that inadequate training and other lapses were “reasonable contributing factors” to the tragedy that followed.

This is what happened. Gilberto was left alone, tied down with Velcro straps, struggling to breathe.

Nobody noticed when his heart stopped. No one was there to raise an alarm. He died alone, in bed, in a bright blue-dot patterned hospital gown.

Nineteen hours after Gilberto entered a Steward hospital looking for help, his body was wheeled into the morgue.

A portrait of neglect

As Gilberto’s death painfully shows, those who run Steward Health Care did not have to put their hands on patients to do harm — they did it by starving the system of staff and resources.

At hospitals across the country owned by the nation’s largest private for-profit health system, countless surgeries have been canceled because unpaid vendors refused to deliver vital equipment. Time-sensitive medical tests, such as cancer biopsies, have been routinely delayed. Overworked staff members were regularly forced to scrounge for supplies, sometimes bringing items like toilet paper and pens from home.

All the while, the Boston-born company, led and largely owned by former Massachusetts heart surgeon Dr. Ralph de la Torre, prioritized expanding the chain and taking huge dividends for de la Torre and others.

The Globe first exposed Steward’s deadly failings in January with a report on the case of Sungida Rashid, a woman who died soon after giving birth at Steward’s St. Elizabeth’s Medical Center in Brighton. Doctors there were unable to properly treat her because the hospital was out of a common medical device used to stem internal bleeding. The device was out of stock because Steward had been stiffing its vendor. And much more news about Steward has unfolded in the months since, including a bankruptcy filing, the recent deals to sell six of its hospital campuses in Massachusetts, and the closure of two others — one of them the beleaguered Carney.

But the full scope and tragic consequences of Steward’s mismanagement were still to be chronicled.

Deaths like Sungida Rashid’s have occurred time and again at Steward hospitals.

The Spotlight Team identified at least 15 instances in which Steward patients died after failing to receive professionally accepted standards of care due to equipment issues or staffing shortages. This total omits deaths due to individual lapses in judgment or medical errors in order to focus on the real, systemic Steward scandal, the one driven by radical under-investment by management in hospitals that mainly serve patients on the lower end of the economic spectrum — often those most in need of care.

One died in the registration line at the Good Samaritan Medical Center emergency department in Brockton, on a day eight nurses were working when there were supposed to be 19.

Another died after forcing open a faulty window at St. Elizabeth’s Medical Center, and then leaping to his death, multiple nurses have confirmed to the Globe. He was in the hospital for fall injuries from an earlier suicide attempt.

At least 16 other patients suffered injuries in similar circumstances, the Globe probe found. And at least 2,000 more were found by federal regulators to have been put in immediate peril.

The Spotlight Team undertook a review of hundreds of government reports, staffing complaints filed by nurses, federal data, and wrongful death lawsuits. The investigation also relied on conversations with patients’ families and their lawyers and interviews with more than 100 current and former Steward workers.

What emerged was a portrait of staggering neglect. Not by Steward doctors and nurses, most or all of whom were driven by the medical practitioners’ pledge to “first, do no harm,” but by business-side executives who plainly were not.

On the whole, the more than 30 hospitals Steward operated have been among the worst, the most troubled in the country over the last five years, according to several measures.

Between June 2019 and June 2024, federal inspectors who enforce hospital health and safety standards sounded the loudest-possible alarm against Steward at least 32 times — citing the company with findings of “immediate jeopardy,” a level of deficiency so serious it means patients have died, been injured, or put at grave risk. Such findings can threaten a hospital’s Medicare reimbursements, which effectively would kill a hospital.

Immediate jeopardy findings are rare; just 13 percent of 6,101 Medicare-certified hospitals received one in that same five-year span, according to the Centers for Medicare and Medicaid Services. Yet about a third of Steward’s hospitals received an immediate jeopardy finding, a pace of failure nearly three times the national rate.

Beyond the immediate jeopardy cases, federal investigators have documented more than 300 deficiencies at Steward hospitals in the past five years, including 10 deficiencies calling out serious failures to ensure patient safety by Steward’s “governing body” — its leadership. Only one hospital chain had more such leadership deficiencies in that five-year span: Universal Health Services, which had 12, though it is several times bigger than Steward.

Further, Steward hospitals are also among the bottom-dwellers in CMS hospital quality ratings, which take into account death and readmission rates, patient experience, and measures of timely and effective care.

Steward’s corporate leaders were well aware of the shortages in staff and supplies plaguing its hospitals, according to company emails obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe, federal inspection and financial documents, and the statements of current and former Steward administrators, who addressed increasingly urgent concerns about unpaid bills to their corporate bosses.

Getting business done in a local Steward hospital, such as getting bills paid, was a major challenge because everything ran through corporate, Dr. Peter LaCamera, chief of the division of pulmonary, critical care, and sleep medicine at St. Elizabeth’s Medical Center, told the Globe.

“When it got to the point of putting heads through walls,” he said he would reach out directly to the number two person in the company, Dr. Michael Callum, executive vice president, and “plead” his case. That helped sometimes, LaCamera said, but there was always another problem looming on the horizon.

The COVID-19 pandemic tested all hospitals in innumerable ways, but Steward’s issues were a constant, before — and well after — the rise of the virus.

Internal Steward emails viewed by the Globe reveal high-level discussions about vendors going unpaid at least as far back as 2019. In January that year, Douglas Costa, chief operating officer of Steward Health Care Network, complained in an email chain among top executives:

“We have an incredible amount of vendor invoices and employee expense reports outstanding right now. We have vendors discontinuing important services to our members. I won’t even get into how much I’m floating on my personal credit card at this point in time. How can we fix this?”

That discussion included chief financial officer John Doyle, vice president of finance Jacob Frumkin, and Ruben King-Shaw, a former member of the Steward board of directors, who at that point was chief strategy officer. King-Shaw rejoined the board in 2022.

In one specific 2019 case, the head of plant operations at Steward’s Jordan Valley Medical Center in Utah told federal inspectors he had warned corporate bosses that the vendor who provided salts for the water softening system — necessary to sanitize instruments — had threatened to stop delivery for nonpayment. His warnings went unheeded — and the vendor ultimately cut Steward off. During that time, surgical instruments were found to be contaminated, possibly leading to a patient’s infection. An employee informed hospital administrators: “Our list of credit holds by vendors is getting out of control. We will soon be in a position of not being able to acquire critical services.”

De la Torre and other Steward executives did not address a detailed list of questions sent by the Globe. “The company has no comment,” company spokeswoman Josephine Martin said in an e-mail.

The list of Steward’s failures goes on and on.

In December, a patient came to Steward’s Melbourne Regional Medical Center, in Florida, with stomach pain from a perforated bowel that needed immediate surgery. But after hours of waiting for a transfer, she died en route to another hospital 50 miles away because Melbourne, incredibly, had no general surgeon on call.

Early last year, administrators at Steward’s Holy Family Hospital in Methuen ordered staff to call patients with scheduled biopsies and tell them that their procedures — vital to early interception of cancers — had been canceled. The staff was told not to mention the reason: The company that provided the mobile testing equipment had not been paid.

Over the course of several years, St. Elizabeth’s, in an affront to basic human dignity, was out of “bereavement boxes,” the small cases used to carry the remains of deceased newborns, according to six employees, including three who said they lobbied for Steward to buy more.

Infant remains went to the morgue in bankers boxes, and when those ran out, in shipping boxes that nurses adorned with home-knit blankets and prayer cards.

“I remember seeing a very early demise, like about 17 weeks, and a nurse having to put the baby in this, just — supply box,” a Steward staff member told the Globe. “The nurses are amazing, they make everything look perfect. But it was the indignity of it.”

Paul C. Smith, president of St. Elizabeth’s, said in a statement to the Globe that he was unaware of “any situation where we did not have appropriate bereavement supplies,” and that he made these supplies a priority, “even if I had to help procure them myself.” Several of the staff members who confirmed the shortages also said that Smith, then chief operating officer, offered his personal credit card around 2019 to buy bereavement boxes.

‘Would you pray for us?’

One sunny Friday last May, in the city of West Monroe, La., a massive human chain stretched around the brick mid-rise that houses Glenwood Regional Medical Center, the most troubled Steward hospital, data suggest. Some 400 people gathered at the facility, called by a local church to support a hospital in crisis. Medical workers in teal and navy scrubs stood hand-in-hand with area residents.

The prayer circle had been inspired by Glenwood’s staff, which was trying to keep their hospital afloat and their patients safe, while corporate bosses at Steward choked off operating cash and drove away employees who could only take so much.

“I heard staff members say, ‘Would you pray for us?’” said Tim Spencer, executive pastor of First West Church, which organized the prayer circle. “I heard it over and over again.”

This sort of public show of faith is wired into the DNA of northeastern Louisiana, sitting as it does midway along the southern Bible Belt. First West Church typically draws some 1,800 people for Sunday worship in an auditorium tiered like a Broadway theater.

The circle that morning was so large, organizers signaled prayer should begin with the bugle-like blast of a shofar, an ancient instrument made from a ram’s horn.

Heads bowed, the people of West Monroe prayed for Glenwood’s staff, for patients and their families, and they prayed that somebody with good intentions would buy their city’s hospital from the company that had led it to ruin.

Glenwood should have fit neatly within Steward’s early visions for what the chain could be: a cheaper alternative to big-city teaching hospitals, a community provider that could serve people where they lived.

West Monroe, which depends on Glenwood, is in Ouachita Parish, a unit of Louisiana government similar to a county. The parish’s median household income is about $46,000, low even for Louisiana, one of the poorest states in the country. The US national median is about $75,000. Many in the parish earn their living in agriculture. Here, corn is a big crop, along with beans, cotton, rice, and timber, which feeds the local paper mill.

The hospital stands amid a cluttered row of fast-food franchises, one after another. It opened as a public hospital in 1962. Steward acquired it in 2017.

Quickly, Glenwood became a focal point for Steward’s management failings: a one-star rated hospital that led the Steward chain in immediate jeopardy findings the past five years, with nine such violations. It is among the 10 worst hospitals nationally for immediate jeopardy citations, the Globe analysis shows.

As at many Steward hospitals, unpaid vendors placed Glenwood on credit hold, meaning the hospital struggled to get routine supplies, such as catheters and angioplasty balloons, pacemakers and surgical mesh, according to federal inspection documents. At one point this January, the director of radiology told federal inspectors that the hospital “cannot go much longer like this and that it will eventually fall like a house of cards.”

Staffing and supplies have been so short, state officials capped the 270-bed facility at 91 patients.

Inspectors documented 151 beds with broken nurse call buttons. Radiation safety badges worn by the radiology staff sat in the outgoing mail for months, not sent to a lab for testing. The vendor that sorted the mail had not been paid.

Not even Glenwood’s cafeteria was spared: The coffee vendor repossessed the coffee pots.

In the late summer of 2021, deadly, almost invisible mold spores took root in the lungs of some of the most vulnerable patients at Glenwood.

That September, the family of Theresa Williams visited her at Glenwood’s COVID ICU, seeing her only through glass. The 79-year-old great-grandmother, from a village outside West Monroe, was on a respirator, fighting for her life. She was known as a fancy dresser in high-heeled shoes, a good cook and seamstress who raised a family and then worked 25 years at a chicken processing plant.

Eleven days after Williams had been admitted, a fluid sample from her lungs tested positive for a mold known as aspergillus.

Aspergillus is generally not harmful to healthy people, but it is wildly dangerous to certain patients, including people who are immunocompromised. Under a microscope, the mold looks like a tree branch, specialists said, and that is how it grows, invading and essentially destroying lung tissue in its wake. Preventing aspergillus is one of the reasons hospitals sterilize and clean; a full-blown aspergillus infection is hard to treat and fatal in most cases.

Theresa was the fourth patient to contract an aspergillus infection in Glenwood’s COVID ICU in August and September 2021. The first three had already died, according to federal inspection reports. A fifth infection would be detected in early October. Federal records reflect no action by the hospital after the first infection, and still no action after the second.

“Two cases in the same unit would be very concerning,” Dr. Eric Dickson, CEO of UMass Memorial Health, who trained as a respiratory therapist, told the Globe. “It’s a rare disease, clusters are concerning and a second case would warrant rapid investigation.”

But the understaffed Glenwood infection prevention department did not begin an internal investigation until the third case of aspergillus, losing two critical weeks, according to federal reports.

Steward later acknowledged the understaffing, conceding in government documents that “it had already been recognized” that Glenwood’s two-person infection prevention department needed more help. The company promised to hire an additional person. A high-ranking hospital employee told the Globe that Steward did add another person for a spell, but that the staff is now back to its 2021 level.

Glenwood also reported that the company it hired to clean the hospital lacked the right equipment to “properly clean in a healthcare environment.” The contract cleaners did not even know they needed to dust thoroughly, cleaning away the particles that can carry mold spores.

A former critical care doctor at Glenwood told the Globe that Steward’s lack of investment in the basics was to blame. “It harmed patients,” said Dr. Adebanke Vogt-Davis. “Aspergillus — I really think patients died because they had mold and fungus.”

Theresa Williams’s family knew none of this and never would have thought to ask. They had faith in the hospital. And then they got a call from Glenwood early on Sept. 27. Better get down here fast, the family was told. Theresa died that day at 9:42 a.m.

The Williams family only learned of the mold outbreak when a Globe reporter reached out last month.

The details about the mold infections, outlined in dire, damning terms in federal inspection reports, are publicly available, if tricky to find. They were shared with Steward administrators and executives. But no one told the affected families the extent of the outbreak. The federal reports do not name the patients. The Spotlight Team identified them by matching dates and other details to death records acquired by the team.

“The hospital didn’t mention anything about any mold,” said Chad Cappo, grandson of Patsy Strickland, 78, who died in the COVID ICU and whose death record matches the case cited in the federal report. “She was a hard-working, independent woman. … We miss her a lot.”

A Glenwood doctor initially told the family of David Varnado, 61, that David was recovering from COVID, said his wife, Joni. Later, that same doctor reported that David had a “yeast infection” in his bloodstream. He was the first case of an aspergillus infection at Glenwood that summer. Joni knew nothing about the subsequent mold investigation, she told the Globe.

The abundant problems at Glenwood have put a question on the lips of many in West Monroe: How could it be that a company can just come into your community and ruin your hospital?

“They’re not selling swimming pool chemicals, they’re selling health care,” said the city’s mayor, Staci Mitchell, speaking of Steward. “If you want to run your pool chemical company like that, that’s your business. But this is people’s lives.”

In 2023, 10 medical leaders at Glenwood, including doctors who head major departments, wrote to the hospital governing board, saying that the company’s practice of not paying vendors was dangerous. They expressed “deep concern regarding current issues that we strongly feel are hindering our ability to render safe and effective care to patients.”

Mayor Mitchell said she personally interceded on behalf of a local landscaping business when Steward refused to pay it. Mitchell took the matter to Steward south regional president Josh Putter, and Steward ultimately paid the bill, she said.

Pent up rage at Steward bled through a hearing in April at the Louisiana State House. Debra Russell, an acute care nurse practitioner who worked 33 years at Glenwood before quitting last November, told lawmakers of the shortages plaguing the hospital, from a lack of cardiologists to life-saving drugs.

“It’s the saddest thing I’ve ever been around,” Russell said, softly.

Angry legislators learned that the regional president, Putter, was at the hearing and called on him to take some questions. He declined.

“Let the record show,” said the chair of the videotaped hearing, with frustration, “that the south regional president of Steward has refused to testify.”

With Putter watching and taking notes, a lawmaker asked Russell directly: “Based on what you’ve seen and your experience with Steward and their team, have people died because of [Steward’s] negligence?”

Russell flinched. She took a long pause, squeezed out a heavy breath, and responded in a cracked voice: “I don’t want to say yes. I don’t want to.” She paused again. “I’ve just seen too much.”

Dividends and debts

Steward was supposed to be a model of a new way of providing care, not the agent of this sort of neglect. Its driven and charismatic leader, Ralph de la Torre, had painted — promised — a vision of a new brand of community hospital: efficient, convenient, and more cost-effective. De la Torre was persuasive and he certainly had elite medical credentials: He had been one of Boston’s most esteemed heart surgeons, renowned for his devotion to the search for life-saving innovations.

De la Torre helped start Steward in 2010, when the Boston Archdiocese sold its chain of six Massachusetts community hospitals to Cerberus Capital Management, a New York private equity firm named for the three-headed dog in Greek mythology that guards the gates of hell. De la Torre, then CEO of the chain, stayed on as head of the new, for-profit company.

The new chain quickly expanded by gobbling up more community hospitals.

In 2016, Steward struck a company-defining $1.25 billion deal with Medical Properties Trust, a Birmingham, Ala., real estate investment trust. Steward would go on to sell its hospital land and buildings to MPT, and then lease the hospitals back, under a new “asset light” philosophy that purported to free up cash for hospitals to re-invest. This model, instead, adroitly converted physical assets into huge payouts for Steward’s owners and their investors, while saddling community hospitals with massive rent payments.

In 2017, Steward acquired the IASIS hospital chain, out of Tennessee, in a $1.9 billion deal that made Steward the country’s largest private for-profit hospital group.

Steward maintained its ambition to grow. De la Torre looked internationally for new opportunities, striking hospital operating deals in Malta and Colombia. Company emails obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe show Steward’s interest in expanding into Saudi Arabia, Turkey, the United Arab Emirates, Montenegro, Georgia, Albania, and Croatia.

Meanwhile, other internal Steward emails show executives juggling invoices from vendors, deciding which companies to pay and which bills to sit on.

“Why are we holding steris, globus, J&J, medtronic and boston sci?” a Steward executive wrote to the company’s vice president of finance, Frumkin, in April 2020, listing unpaid medical equipment vendors. “I think we need to be getting them something because they probably won’t supply us with materials for surgeries if we aren’t paying anything.”

The emails depict an invoicing dance as Steward officials lobbied one another over whom to pay and whom to put off.

Within a year, Steward executives bought out Cerberus for $335 million. After a decade of ownership, Cerberus departed with $800 million in profit, the company reported to Congress.

In January 2021, de la Torre and Steward’s remaining owners paid themselves $111 million from company funds, despite facing millions in vendor bills.

And, as the Globe has reported, while Steward sank into insolvency in recent years, it prioritized payments for private air travel and to a British private intelligence firm used to surveil and dig up dirt on company critics.

The enterprise collapsed in May. Steward filed for bankruptcy, seeking protection from about $9 billion in debt.

Steward’s financial problems have resounded from state houses and courthouses to the halls of Congress. De la Torre was subpoenaed to testify before a Sept. 12 hearing of the Senate Committee on Health, Education, Labor, and Pensions. On Wednesday, de la Torre signaled he wouldn’t testify, saying through a representative that testimony from him at this time would be “wholly inappropriate.”

There has been comparatively little public discussion of what has taken place beyond the corporate office, in the wards and hallways of the foundering chain.

Patients double-parked in hallways

The morning that EMTs rushed Michael Shea, 66, to the hospital, the emergency department at Good Samaritan Medical Center in Brockton was already drowning. It had been for months. Sick patients on stretchers were double-parked in a hallway, on the day after Thanksgiving, 2021. The harried staff was half-a-dozen nurses short. An inexperienced manager had to step in to care for Shea, who moaned in pain.

Mike Shea worked as a phlebotomist, but his real love was rock guitar, which he taught himself to play at age 12. By his 60s, he had collected 17 guitars, mostly electric, and was a regular musician on the Facebook site Riff of the Day, covering Aerosmith, Stevie Ray Vaughan, and Jimi Hendrix.

He had received a terrible shock the month before in October, when he was diagnosed with pancreatic cancer. His oncologist at Dana-Farber Cancer Institute wasted no time planning Mike’s treatment.

Mike didn’t look ill, so he and his wife, Joan, decided not to immediately share Mike’s diagnosis with their four adult children. The Sheas’ eldest son was about to get married. Let’s tell the kids later, they decided. “The intent was not to have people sad at a wedding,” Joan said in a Globe interview.

Photographs from the reception show Mike on the dance floor, in a black tuxedo and scarlet bowtie, smiling wide enough to show off his dimples.

By Thanksgiving, though, Mike was painfully sick, too nauseous to attend dinner with his in-laws. After vomiting most of the night, he asked Joan to call an ambulance. He knew he needed hospital care.

EMTs took him to the closest one, Good Samaritan. It was a Steward hospital, struggling with the chain-wide pattern of corporate neglect that left it short of nurses, patient sitters, monitoring equipment, catheters, and even beds in the emergency department.

Mike was put on a stretcher in the hallway, connected to a heart monitor and intravenous fluids. A doctor told Joan that Good Samaritan planned to transfer Mike to Brigham and Women’s Hospital in Boston, where, in partnership with Dana-Farber, he was receiving his cancer care. With a transfer imminent and no out-of-the-way place in the hallway for Joan to stand, she went home. It was about noon.

The doctor called Joan several hours later. Mike had “coded” and Joan “could come back to the hospital if she wanted,” Joan recalled.

She rushed back.

Nurses and doctors were pumping Mike’s chest and squeezing air into his lungs.

Joan clutched Mike’s hand. It was already cold.

A few minutes later, the doctor pronounced Mike’s death. It was about 4:15 p.m.

Joan sat stunned. All she could think to do was apologize — to her husband.

“I’m sorry I wasn’t there for you,’’ she spoke to Mike. She couldn’t understand what had happened. She had just been talking with him a few hours before.

The next month, the state’s largest nurses union took action, filing a complaint with the Massachusetts Department of Public Health. The nurses reported that Mike had been discovered dead in the hallway.

Dana Simon, director of strategic campaigns at the Massachusetts Nurses Association, said nurses have for years fought with Steward over staffing levels. “What we heard incessantly for a decade,” he said, “from chief nursing officers and department directors and sometimes from hospital presidents is: ‘I can’t get approval from corporate for our staffing needs.’ "

In Mike’s case, nurses said the emergency department required 16 nurses that day; there were 11. The outcome “certainly may have been different if there was adequate nursing staff on to handle the number and acuity of patients that shift,” said Ann Marie Ryan, a nurse and union representative.

State public health officials investigated the union’s complaint the following January. They did not address Mike’s death in their findings, nor the death of another patient who arrived in the overcrowded emergency department that November, but they found the hospital at fault for lapses that included leaving critically ill patients with no nurse to care for them.

Joan was unaware of the nurse shortage or the union’s complaint until the Globe described them to her. The information helped nudge into place for her some puzzling aspects of Mike’s death. His death certificate listed his cause of death as cardiac arrest, and the time at 2:15 p.m., not 4:15, when the doctor pronounced the death in Joan’s presence.

Joan knew that cancer likely would cut short her husband’s life. But not so suddenly. Not without his children having a chance to say goodbye. And she would have never let him die as he did — in a crowd, and yet entirely alone.

‘It was so preventable’

Gilberto Melendez-Brancaccio, who died unmonitored in the Carney ED, is buried in a hilltop grave in Quincy. The cemetery plot had been intended for Gilberto’s grandmother, but the family didn’t have the money to buy another when Gilberto died.

Every so often, on quiet evenings after work, Gilberto’s aunt Catherina Brancaccio, who helped raise him, plays back voice messages saved on her phone. In Gilberto’s final message, months before his death, his trembling voice asks his “auntie” for medical advice in case “the worst happens.”

“I’m just doing all I can to maintain my sanity,” he says on the recording.

Months before Gilberto died, a San Diego staffing company had yanked its nurses from Carney and other Steward hospitals because Steward allegedly owed it $40 million. Carney scrambled to fill the vacancies, but the emergency department was dangerously short of staff the day Gilberto arrived, according to two people who worked at the hospital at the time.

“It was chaos,” recalled Stephen Wood, a longtime nurse practitioner at Carney.

“The death was absolutely devastating to everyone, because it was so preventable,” said Wood, speaking of Gilberto.

The hospital created new protocols after Gilberto’s death to tighten up the monitoring of psychiatric patients. Those included more frequent checks on patients under restraint. Yet the hospital never hired enough staff to implement these changes, Wood said. Mostly, the emergency department just pulled nurses from other units in the hospital, he said.

The staffing shortages persisted. In an internal email from September 2023, a Carney ED nurse described showing up for her shift to discover just four nurses for 25 patients. Furious, she threatened next time to sit in her car in the parking lot until more staff arrived. “This is seriously dangerous and no one should be expected to work like this,” she wrote.

Gilberto’s mother, who declined to be interviewed, is looking to force change in her own way. She filed a wrongful death lawsuit in Suffolk Superior Court against Steward and five medical professionals at the hospital, seeking justice for her loss. Her case, like much litigation against Steward, is frozen now in legal purgatory, stayed by the courts because Steward is in bankruptcy.

While Steward fights over debt and money, accountability is on hold.

Gordon Russell and Hanna Krueger of the Globe staff, and Khadija Sharife of the Organized Crime and Corruption Reporting Project contributed to this report.

This story was reported by Chris Serres, Liz Kowalczyk, Elizabeth Koh, and Brendan McCarthy. It was written by Serres, Kowalczyk, and Koh.

The phone call to Steward Health Care chief executive Ralph de la Torre from the state’s top health official came days after a veteran nurse at Steward’s Good Samaritan Medical Center was fired for a devastating lapse — one that a federal investigation later deemed a violation of basic care.

On Sept. 13, 2023, a triage nurse in the Brockton hospital’s overwhelmed emergency department received a plea for help from a patient in the registration line. Suffering from acute chest pain and shortness of breath, 37-year-old Jennifer Knight believed she was having a heart attack.

But 10 hours into her nonstop shift, with too few nurses to handle a surge of patients, the nurse sent Knight back to the line, without evaluating her or checking her vital signs, according to investigators. Knight collapsed just 20 minutes later and died.

That decision, and the tragedy that followed, led to the nurse’s termination weeks later, according to hospital records, and prompted an immediate protest from the nurses union.

The response from the Healey administration was also swift. Secretary of Health and Human Services Kate Walsh reached out directly to Steward’s CEO. In that call, she didn’t focus on the fatal lapse in care. Rather, she had a request.

Walsh wanted de la Torre to rehire the nurse, Holly Zachos, whose husband, George, is also a top state health official under Governor Maura Healey. Walsh made it clear the request came from Healey’s office, that Zachos had ties to the administration, and that Steward should retrain Zachos after rehiring her, according to two people briefed on the matter.

The call — which circumvented any official appeal process — occurred at a time when Steward was careening toward bankruptcy, and seeking millions in bailout money from the Healey administration. Within days, Zachos was back on the job.

The Globe Spotlight Team learned of the exchange through documents and sources close to the matter, who said they considered it a clear request for a political favor. Healey, Walsh, and George Zachos declined repeated interview requests. Just prior to publication of this story, Healey’s office acknowledged the phone call and that the request took place, saying her office intervened because the administration believed the nurse’s firing was unjust.

In a statement, Walsh said she had good reason to make the call. “When a patient dies in a hospital, it is almost never one person’s fault,” the statement read. “This tragic death at Good Samaritan Medical Center might have been avoided had Steward Health Care invested in quality and safety in their facilities.”

The direct ask of de la Torre, and his rapid response, is one of the most telling examples of the often-accommodating relationship that long persisted between Steward executives and state regulators.

While de la Torre and other Steward executives have faced withering scrutiny for their alleged mismanagement and plundering of one of the nation’s largest private, for-profit hospital chains, the Globe Spotlight Team has found they benefited from insufficient scrutiny from elected officials and regulators until the company foundered and it was too late.

From nearly the moment of Steward’s founding in 2010, Massachusetts officials failed to discipline the Boston-born hospital chain for regulatory violations, check its aggressive expansion plans and relentless cost-cutting, or respond forcefully to dire warnings as it spiraled toward financial collapse, the Spotlight Team has found. Critical reports were softened, alarming financials went unheeded, and broken promises by Steward were unpunished. These failures spanned multiple administrations and contributed to a crisis that has harmed communities and cost lives.

Time and again, Massachusetts health regulators acquiesced to Steward’s demands even as Steward flouted state laws. Handed a loose rein, Steward’s executives rode the hospital chain right into bankruptcy.

Among the Spotlight Team’s findings:

• A top state health official directed a subordinate in 2015 to remove information about serious patient care problems at Steward from a public presentation.
• Then-Attorney General Healey’s office, which had substantial sway over health care companies, reworked a 2015 report about Steward to downplay its perilous financial condition — to the surprise of one of the report’s lead authors.
• State health officials ignored repeated pleas from Steward nurses, including Zachos, to force significant improvements at besieged hospital units, where patients languished, and in some cases died, after receiving inadequate care. At the same time, they did little as Steward eliminated critical-care beds to focus on more profitable services, closed key medical units without legally required notice, and kept its growing financial problems from public view. Steward repeatedly claimed that its finances were proprietary, and thus exempt from the disclosures required of every other hospital system.
• At pivotal moments, Steward executives pushed employees and their families to donate generously to key players on Beacon Hill and beyond, filling the campaign coffers of their would-be regulators. All told, executives and their spouses gave at least $2.4 million to federal and state candidates — largely in states targeted for hospital expansion, according to a Spotlight review of campaign finance databases.
• Some of the elected officials now most vocal about Steward’s implosion collectively took in hundreds of thousands in campaign dollars from its executives and employees.

Maura Healey is among them.

This summer, Healey slammed de la Torre for fleecing hospitals, calling his actions “really reprehensible and unforgivable,” and suggesting he had fooled the state.

“He basically stole millions out of Steward on the backs of workers and patients,” she said. “Our administration is working night and day to protect jobs, protect patients, and pick up the pieces of the situation that Ralph de la Torre has put us in.”

The administration, in response to questions from the Globe, highlighted several steps it took this year to demand financial transparency from Steward and to pressure the company to transfer ownership of the hospitals.

But over her 10 years in statewide office — first as attorney general and now as governor — much more could have been done, regulatory experts said. She has had as much power as anyone else to regulate the chain.

Just months after she became attorney general in 2015, Healey’s office said Steward had fulfilled its obligations under a state oversight agreement in place since the company’s founding. Yet, the chain’s financial projections portended grave problems. As governor, Healey’s administration was briefed in the summer of 2023 about Steward’s likely collapse, records show. There’s no evidence the administration took significant action in response to the warning, the Spotlight Team found.

The crisis began to unfold publicly in 2023, but state officials that year didn’t send in monitors to protect patients, nor did they negotiate with other providers to take over Steward’s hospitals — actions that, regulatory experts and hospital workers said, might have saved lives.

“What we witnessed with Steward was not state regulation — but the charade of regulation,” said Alan Sager, a Boston University professor of health law, policy, and management. “Everyone just went through the motions.”

So, when it comes to a quick and forceful state response, the call to de la Torre stands out.

Word of the state intervention gradually spread. In addition to the three people briefed on the details of Walsh’s phone call, several Steward nurses, as well as company insiders, independently told the Globe they were made aware that Healey’s administration had stepped in.

Julie Pinkham, executive director of the Massachusetts Nurses Association, told the Globe that after Zachos’s firing, she called Walsh directly to demand the nurse be rehired. Two hours later, Pinkham said, Walsh called back and said she had spoken to de la Torre directly and that Zachos would get her job back.

Holly Zachos declined to be interviewed. She and her husband said in written responses that they didn’t reach out to the Healey administration about her firing. The nurses union said Zachos, a union steward, was scapegoated because she was a longtime critic of hospital management.

A Steward spokeswoman declined to comment, and a representative for de la Torre, who left the company on Oct. 1, also didn’t comment.

The company, now based in Dallas, is at the center of a federal criminal investigation into alleged fraud, bribery, and corruption. Last month, federal agents separately served de la Torre and Armin Ernst, a Brookline resident who leads Steward’s international entity, with search warrants and seized their phones, the Globe has reported.

The consequences of Steward’s financial straits were first exposed in a January Globe report about Sungida Rashid, a 39-year-old woman who died after giving birth at Steward’s St. Elizabeth’s Medical Center in Brighton. Doctors there were unable to treat her because the hospital ran out of a common medical device to stem internal bleeding. The device was out of stock because Steward hadn’t paid the vendor.

A follow-up Spotlight investigation uncovered at least 14 other deaths here and across the country of Steward patients who didn’t receive professionally accepted standards of care. Hundreds were injured or put at risk because hospitals lacked enough staff or adequate supplies.

In the wake of these incidents there were calls from front-line hospital employees to hold Steward accountable, but they were weakened by a revolving door of regulators — some of whom came directly from Steward’s management ranks. In one case, a Steward hospital executive left to become the state’s top health official, a role in which he allegedly pressed for new regulations that benefited Steward’s expansion plans, according to an email reviewed by the Globe, a former state official, and allegations filed in a civil suit. And then he returned to Steward.

“The state had zero response to Steward’s greed and charlatan way of operating,” said Dr. Paul Hattis, a senior fellow at the Lown Institute, a Brookline health care think tank. “They were clearly not up to the challenge.”

The Spotlight Team reached out to Healey’s office in late November and sought interviews with the governor, Walsh, and George Zachos, executive director of the Massachusetts Board of Registration in Medicine and the husband of the fired nurse. Each declined the request.

Healey’s office emailed the Spotlight Team a statement Wednesday night.

“The Attorney General’s Office under AG Healey exercised all power and authority it had to monitor Steward Health Care System and report publicly on their financial situation,” the statement read. Healey’s office noted she defended the state as attorney general when Steward sued to withhold its financial statements.

Walsh, secretary of Health and Human Services, said the administration has always focused on protecting access to care, preserving jobs, and stabilizing the health care system. She said her call seeking Zachos’s reinstatement was motivated by her determination to do ”what I know to be the right thing — not only for this individual nurse, but for the hospital as a whole.”

Dr. Robert Goldstein, the commissioner of the Department of Public Health, said that the administration had few options in responding to Steward’s violations. The department could “deny them future expansions or take away their license completely,” which could leave patients without medical care, he said. “Regulations are black and white and we are operating in a very gray space.”

Two months ago, the Globe sent half a dozen records requests for documents, emails, calendars, and any communications from around the time Walsh called de la Torre. The state provided limited records but has not yet completed any of the requests.

Promises broken, warnings ignored

Signs of trouble emerged early in Steward’s history — and were all but ignored.

When Steward bought the Caritas Christi chain of six Massachusetts hospitals in 2010, buoyed by a huge infusion of private equity capital, top executives made a series of promises to then-Attorney General Martha Coakley. They pledged not to close or sell any of the hospitals for at least three years.

After it acquired more hospitals, Steward promised to maintain the same scope of services at two — Quincy Medical Center and Morton Hospital in Taunton — for the next 10 years.

Steward soon broke those promises.

In the summer of 2013, Steward closed Morton’s pediatrics unit. Then on the day after Christmas in 2014, Steward closed the 196-bed Quincy hospital altogether — making Quincy the largest Massachusetts city without an acute-care hospital. The abrupt closure violated a state law requiring 90 days’ notice.

The state, resisting public pressure, took no legal action to hold Steward accountable.

By then, Steward’s financial condition was rapidly deteriorating. The company’s annual net loss more than tripled from 2012 to 2014, while its cash reserves were severely depleted, state records show.

Yet Steward’s escalating troubles did not prompt heightened scrutiny. In early 2015, staff under then-Attorney General Healey began analyzing Steward’s compliance with the terms of its takeover of Caritas. They concluded in a now-controversial report that Steward had fulfilled the obligations it agreed to in 2010.

One of the report’s lead authors was surprised by its favorable findings — and now says Healey’s office softened the report’s portrait of Steward’s dismal finances.

Nancy Kane, a management consultant and then-health policy professor at the Harvard T.H. Chan School of Public Health, was hired by Healey’s office to analyze Steward’s financial health. What she found was unsettling: After years of staggering losses, Steward was teetering toward insolvency. The company’s cash balances had eroded while its unfunded pension and debt obligations had mushroomed. By 2014, the company had a net worth of negative $185 million. Its total liabilities exceeded $1.4 billion, she found.

“It was clear then that they were in deep financial trouble,” Kane told the Globe.

Kane said she was also alarmed by another finding: That despite losing tens of millions of dollars a year, Steward in 2013 had disbursed $30.9 million to top executives in the form of loans secured by the company’s stock. To Kane, the distribution was alarming, in part because Steward leaders had committed not to extract payouts for at least three years after the Caritas deal.

“That really disturbed me at the time because it showed that Steward executives were already taking out large amounts of money to pay themselves,” she said in an interview. “My first thought was, “Whoa, I don’t trust these guys.’”

Yet when Healey’s office sent her revisions to the report, Kane said, she found her language had been softened to downplay Steward’s precarity. Kane worked under a confidentiality agreement and is unable to provide copies of the report.

The report went through “endless rewrites,” she said, in which Healey’s staff would insist on more upbeat language. The $30.9 million payout was relegated to a footnote. Kane believes it deserved more prominence.

“They kept editing [the report] to make it look happier,” Kane said. “I kept saying, “No, no, it’s not happy. They have loads of debt.’”

In a statement to the Globe, Healey’s office said the 2015 report “was clear about Steward’s financial problems.”

Rewriting the law, to Steward’s benefit

The muting of Kane’s findings fit a pattern. When state employees and health finance experts pointed to violations of the law and cracks in Steward’s facade, state regulators deflected the warnings or accepted the hospital chain’s excuses.

And as the more stubbornly skeptical regulators learned, Steward typically got what it wanted.

In 2014, Steward wanted to open a cardiac catheterization lab for diagnosing heart problems at its Fall River hospital, Saint Anne’s. But the state, aiming to avoid a medical arms race, had forbidden hospitals from opening such labs within a 30-minute drive of an existing one. Competitor Southcoast Health had a cath lab less than two miles — or about an eight-minute drive — from Saint Anne’s.

But Steward had a key ally: John Polanowicz, the then-state Health and Human Services secretary who had recently left his position as president of Steward’s flagship hospital, St. Elizabeth’s. Polanowicz allegedly encouraged officials in the Department of Public Health, which he oversaw, to rewrite the rules, which later allowed Steward to build the heart center.

Deborah Allwes, a former health department official, said the exception was specifically tailored to benefit Polanowicz’s former — and future — employer.

In response to questions from the Globe, Polanowicz said that Allwes was “mistaken” and that the new rules were based on research about the safety of cardiac catheterization and “not to benefit any one hospital or system.”

Polanowicz said he always acted ethically while health secretary. “I did not advocate for Steward while EOHHS Secretary. I did not help the company get permission to build a cath lab,’ he said.

The favorable treatment of Steward continued, the Globe found.

In a 2016 deposition, Allwes said she was ordered by then-Public Health Commissioner Dr. Monica Bharel to remove data from a public presentation on a different matter that portrayed Steward in “a negative light.” Allwes said she had to alter slides in her presentation to omit descriptions of patient harm in Steward hospitals — incidents known as “serious reportable events,” according to the deposition taken in a Southcoast lawsuit against the health department over the cardiac catheterization issue.

Soon after, Allwes said she was scolded by Bharel, an appointee of Governor Charlie Baker, for not giving Steward adequate time to review her presentation and provide feedback on it, according to the deposition, portions of which were obtained by the Globe. Then, at the last moment, state health officials falsely claimed that Allwes was sick and unavailable to make her presentation, a move that prevented her work from immediately reaching the Public Health Council, a regulatory body chaired by the commissioner, according to a deposition by Eileen Sullivan, the Department of Public Health’s chief operating officer.

Months later, the state allowed Steward to open the heart center.

In a recent interview, Allwes, now head of a national health care company, affirmed the picture she painted in her deposition. “There was a general reluctance to hold Steward accountable and always an eagerness to make sure things were beneficial to them,” she said.

Bharel did not respond to requests for comment.

Laws flouted without consequence

On paper, Massachusetts boasts some of the nation’s strongest regulations for protecting public health when hospital systems seek to close or discontinue essential services. The regulations require operators to notify the Department of Public Health at least 90 days before the closure to prevent patients from being cut off from critical services.

Over the past decade, state health officials have allowed Steward to flout these regulations without any apparent disciplinary action.

A Spotlight review found at least eight instances in which Steward closed hospitals and critical-care units without proper notice — sometimes without even informing state regulators at all. In at least four other instances, Steward broke contracts with the state by closing hospitals or units they had specifically promised to keep open.

In April 2020, at the height of the pandemic, nurses at Nashoba Valley Medical Center in Ayer and Holy Family Hospital in Haverhill discovered the doors to their intensive care units had been shut — without any notice to state or local authorities. Days later, ventilators and other equipment were carted out of the hospitals, according to the Massachusetts Nurses Association.

Yet when the union called on the state health department to inspect the shuttered ICUs, the agency responded in an email that Steward had assured them the units were open, according to documents shared with the Globe by the nurses union.

Frustrated nurses ventured inside the ICU unit at Ayer to take videos of the vacant rooms, unused medical equipment covered with sheets, and empty patient logs — and sent them to the Executive Office of Health and Human Services as evidence.

The state health department then sent in inspectors to confirm what was long evident: that the ICU was empty and sick patients were being boarded in the hospital emergency department. Even so, then-Secretary of Health and Human Services Marylou Sudders, a Baker appointee, took no immediate action, and the critical ICU beds reopened 45 days later only after legislators raised alarms. Sudders declined to comment.

Soon, another crisis hit.

On May 11, 2020, poor maintenance and a wandering mouse triggered a power outage at St. Elizabeth’s and heart monitoring equipment and other devices stopped working, the nurses union said. Nurses had to use smartphone flashlights to rush patients out of darkened rooms and into an ICU packed with COVID-19 patients.

Again, the state was alerted and failed to act.

Leaders of the nurses union told state health officials of “horrifying conditions” and possible fatalities, emails and letters show. More than 24 hours later, a state official called the union and said no action was needed because “Steward says all the lights are on,” according to Dana Simon, director of strategic campaigns at the nurses union. Eventually, the nurses turned to the city of Boston, which dispatched a team of inspectors who helped restore the power.

“I am shocked that no one died,” Ellen MacInnis, a nurse there during the 38-hour outage, told the Globe. “The state just blew us off like we were crazy.”

Over the next few years, Steward would close units in at least four other hospitals without giving proper notice and holding public hearings as required.

“If it’s an essential service, then you can’t just look the other way — but that’s what the state does, time and again,” said Hattis of the Lown Institute. “Why even have these laws if they aren’t enforced?”

Through a spokesman, Baker, who was governor for much of Steward’s downward spiral, released a statement disputing that the state went easy on the hospital chain. Rather, his administration had, during the time of COVID-19 recovery, “restricted access to distressed hospital payments” because of Steward’s non-compliance with state reporting requirements.

Throughout the pandemic, the spokesman added, Massachusetts and many other states loosened regulations on an emergency basis to help providers maintain operations.

“Many of the events the Boston Globe raises here fell within this period of unprecedented strain on the entire Massachusetts health care system,” the statement read. “Governor Baker is outraged by the behavior of de la Torre and the senior leadership team at Steward as they apparently put their own personal gains ahead of their patients’ and workers’ wellbeing.”

‘Credit to the boss’

Steward’s executives were not shy about trying to stay in the good graces of elected officials.

As the company expanded, its leaders gave generously to federal and state candidates in regions where Steward did business, according to a Globe review of campaign finance databases. Those executives’ donations spanned states from Massachusetts to Texas and totaled millions of dollars.

Steward aggressively pushed its employees to donate.

At headquarters, handwritten notes were placed on desks requesting donations — often for specific dollar amounts — for Healey, Coakley, Baker, and others, former employees told the Globe. The company’s lobbyists would also routinely email people about which of the various House and Senate races around the country to give to, sometimes with barely a day’s notice, according to emails obtained by global journalism outlet the Organized Crime and Corruption Reporting Project and shared with the Globe.

In those emails, Steward lobbyists and lawyers urged recipients to donate the maximum possible — and even use their spouses’ names to double personal contribution limits — so the company could raise funds “that we will credit to the boss.”

“It is vital that you go on line and make your donations by tomorrow,” one email read.

Though emails said the requests were voluntary — mandating donations is illegal — former employees said they felt pressured to give.

A former top administrator in Steward’s corporate suite recalled being asked by company executives to write $200 and $500 checks to Healey, Coakley, and a half-dozen other state politicians. He was told to hand the checks over to a Steward lobbyist, who would “bundle” them with checks from other employees.

“I gave more than I ever would have given on my own — out of fear,” said the administrator, who asked not to be named due to fear of retribution. The Globe confirmed through state campaign finance records that these donations were made.

In Massachusetts, the company focused on the state’s gubernatorial and attorney general races. De la Torre had, early in his career, hosted lavish fund-raisers for candidates including former attorney general Coakley. He once held a fund-raiser featuring then-President Barack Obama. (The Obama fund-raiser in 2010 — which snarled traffic for blocks in de la Torre’s West Newton neighborhood — netted Democratic campaigns nearly a million dollars, according to reports at the time.)

Healey was among those who reaped the benefits of Steward’s giving: She raised more than $63,200 just from a handful of Steward executives, board members, and their spouses over the last decade. Baker raised at least $28,400 from the same group.

In Healey’s statewide runs for attorney general and governor, Steward ranked in the top 20 employer groups donating to her campaigns.

De la Torre made sure the politicians knew who was putting up the money. In August 2022, Steward lobbyist Jason Zanetti wrote in an email to company executive Armin Ernst that “Ralph has agreed to help Maura’s campaign with some fundraising.” Zanetti requested Ernst donate $1,000 — the maximum amount under state law — and use a dedicated link so de la Torre would get credit. Less than 24 hours later, Ernst responded: “Done.”

A ‘massive missed opportunity’

With support from state regulators, Steward executives fulfilled their ambitious expansion plans by around 2019. Here again, health officials failed to ensure Steward followed the law.

Six current or former Department of Public Health officials, in interviews, described the state process for approving hospital expansion plans as toothless.

In some cases, they told the Globe, staffers charged with reviewing Steward’s proposals simply cut and pasted language from the proposals because they lacked the staff and accounting skills to scrutinize the assertions.

“The sad part is that the [permitting] process had the potential to hold bad actors accountable,” said a former state official who oversaw hospital expansion plans and who asked to remain anonymous because she continues to work with state agencies. “With Steward, it was a massive missed opportunity.”

For the past decade, Steward has been the only hospital system in the Commonwealth to refuse to comply with a law requiring that audited financial statements be filed annually with the state. The company stopped filing its full financial statements in 2014. The reports are designed to help regulators track spending trends and detect signs of financial stress.

Steward’s failure to file the statements was no secret — and was seen by many as a red flag.

Had regulators kept tabs on Steward’s finances, they would have seen that Steward’s expansion was funded by massive amounts of debt, and that it was on the hook for billions of dollars in future rent payments to its landlord. Regulators could have intervened to prevent, or at least limit, the devastating toll caused by Steward’s collapse, health regulatory experts told the Globe.

In 2016, state health officials developed a new, stronger law — dubbed by some the “Steward provision” — that strengthened the health department’s authority to deny hospitals’ applications for new services if they were not complying with state law.

“We crafted the ‘Steward provision’ so that they can’t get all the things they want to make money until they give you this data,” according to a former state official involved in the process who asked his name not be used for fear of retribution.

The new rule was promptly ignored. The audited financial statements still have not been filed.

Nevertheless, in reports approving Steward projects, health department officials continued to assert that Steward was in “good standing” with federal and state laws and regulations. Had the rule been enforced, regulators might have slowed Steward’s expansion, according to several former Department of Public Health officials.

Distress signals overlooked

By the summer of 2021, anyone with internet access could have uncovered evidence of Steward’s crumbling balance sheet. That’s because its publicly traded landlord, Medical Properties Trust, was required to disclose Steward’s audited financial results to securities regulators. The results were alarming: Steward reported an operating loss of $439 million and a negative net worth of $1.5 billion as of 2020.

In interviews, top state health officials acknowledged they were aware that Steward was in deep financial distress nearly a full year before the company filed for bankruptcy.

By April 2023, the Health Policy Commission, a state agency that oversees health costs, had seen enough signs of trouble to begin playing out adverse scenarios, said David Seltz, the commission’s executive director.

“There was a growing sense of concern and alarm with each month that passed,” Seltz said.

Steward sent multiple distress signals to state health regulators as well.

In the fall and winter of 2023, several Steward executives made regular trips to Beacon Hill to seek emergency financial help. In September, the executives sought and received a $12.65 million infusion of cash — an advance on anticipated Medicaid payments — from Healey’s administration.

By January, de la Torre and Steward executive vice president Dr. Michael Callum delivered to Walsh a grim prognosis: Steward’s losses were unsustainable and the company would have to transition its hospitals to new owners.

Fired nurse had political connections

The Healey administration intervention on behalf of Holly Zachos, the nurse at Good Samaritan, in September 2023, came as the meetings with Steward executives were underway.

Zachos had connections to Healey that stretched back a decade: Her husband, attorney George Zachos, was chief of the state’s Medicaid fraud division under Healey. Healey publicly lauded his “strong leadership and expertise” in “protecting the integrity of our health care system.”

He left the attorney general’s office in 2016 to become the executive director of the state’s powerful doctor licensing board, but continued to support Healey’s political career, donating to her run for governor in 2022.

Word of Healey’s intervention quickly spread through Good Samaritan’s emergency department. Several nurses said they were surprised to see Zachos back on staff, especially after state and federal health investigators cited Zachos’s actions in an investigation into Knight’s death. (The union lost its challenge to the company’s forced retraining of Zachos.)

“This basically sends a message that you can throw the nursing standard of care in Massachusetts out the window,” said Jodi Moen, a veteran emergency department nurse at Good Samaritan, who described the intervention as “appalling.”

Healey herself spoke with Holly Zachos in March 2023 when the governor, along with Walsh, took a tour of Good Samaritan, according to Pinkham, of the nurses union. During that visit, Zachos spoke with both officials in the hospital’s chapel about the dangerous conditions within the hospital, a move that, union officials allege, put her at risk with Steward executives.

“She was very worried, and expressed this to me frequently, that she’s got a huge target on her back,” said Simon, the director of strategic campaigns at the nurses union.

It’s unclear whether Steward executives were made aware of the conversation with the governor. Zachos’s termination letter made no mention of anything beyond her failure to “follow nursing standards of care” in relation to Jennifer Knight’s September 2023 death.

In the four years before Knight’s death, the Massachusetts Nurses Association repeatedly warned state officials about deteriorating conditions and understaffing at Good Samaritan. In letters and phone calls, nurses described patients dying unmonitored on hallway stretchers because they had nowhere else to put them. Often staff lacked enough portable heart monitors and electrical outlets for people queued up in the corridors. On some nights more than 80 people packed the emergency department, with the registration line stretching to the sidewalk, several emergency department nurses told the Globe.

The perilous conditions reached a critical point in the summer of 2023.

Severely ill patients who required care within minutes were left unwatched in the waiting room for hours, according to a federal investigative report. In one instance, a nurse left a vomiting patient in the waiting room for 11 hours. A friend discovered the patient barely conscious. Inspectors were critical of the hospital’s response, which consisted of sending an email to nurses, “reeducating” them on procedures. The inspectors noted that the hospital didn’t track who opened or read the email.

Two days after Knight’s death, Zachos filed an “unsafe staffing form” with the hospital that noted the emergency department that night was at more than double its capacity. There were 90 patients, with waits so long that many patients left without being diagnosed. Twenty-three nurses should have been on duty, her report said. There were only eight.

Margaret White, an emergency department nurse at Good Samaritan, said she still has recurring nightmares of patients screaming out for help from hallway stretchers — and being unable to reach them in time. Almost every shift for a year, until early 2023, White said she called a 24-hour Department of Public Health complaint line to report unsafe conditions — but eventually gave up due to a lack of response.

“We all felt hopeless,” said White, who is on a leave of absence after she was assaulted by a patient. “There were times I would run into that [hospital] chapel and pray, ‘God, please sustain us for the next four hours.’”

Conditions at the Good Samaritan emergency department did not improve until after the state sent in monitors to Steward hospitals on Jan. 31 of this year, after the Globe reported on the death of a pregnant woman at another Steward hospital and the financial crisis engulfing Steward finally became public.

‘They should be held accountable’

A year after their daughter’s death, Donna and Joseph Knight struggle with unanswered questions. How could someone complaining of chest pain collapse and die just feet from nurses trained to provide life-saving care? Why was she not admitted earlier? Would it have made a difference?

An autopsy later showed she had a severe blockage in one of her arteries.

When the couple arrived at the emergency department that September night, they were left alone for what felt like hours in a conference room.

Not then or after, did the hospital inform them of the events surrounding her death. Until reached by a Globe reporter, the Knights didn’t know about Zachos’s firing — or her rehiring. Nor were they told that state and federal regulators had faulted the nurse in the care of their daughter.

In his eulogy at Jennifer’s funeral, Joe Knight, a retired State Police sergeant, recounted his daughter’s lifelong love for the Boston Bruins and her devotion to her mother. Among the more than 200 attendees was a large contingent from Alloy Wheel Repair Specialists in Randolph, where Jennifer Knight was a popular office manager.

The failure of the state to act forcefully baffles her mother.

“I just don’t understand,” Donna Knight told the Globe. “They should be held accountable.”

Jessica Bartlett and Hanna Krueger of the Globe Staff contributed to this report. Khadija Sharife of the Organized Crime and Corruption Reporting Project also contributed.

This story was reported and written by Rebecca Ostriker and Catherine Carlock. It was edited by Gordon Russell.

VESTAVIA HILLS, Ala. — It felt like the beginning of a beautiful friendship.

When Dr. Ralph de la Torre, a brash and brilliant son of Cuban immigrants, jetted into the Birmingham airport in 2015, he was a man with a vision for the struggling Steward Health Care chain, a new approach that could vault it from its roots as a network of Catholic hospitals in Massachusetts to a for-profit giant of national and even global importance.

He couldn’t do it without money. That’s where a business executive raised in small-town Alabama came in.

Edward K. Aldag Jr. had been inspired to achieve financial success since childhood, when his grandfather, a German immigrant who worked as a locksmith at the New York Stock Exchange, showed him around the place.

“Ed, this is where dreams come true,” his grandfather said, in Aldag’s telling.

Young Ed was listening. After college, and a stint managing real estate firms, he had a eureka moment.

In 2003, he founded Medical Properties Trust, aiming to fill a market niche no other real estate investment trust in the world had thought to claim — hospitals. His brainchild: Make hospitals “asset-light” by buying up their buildings and land and then leasing them back. This would allow health care firms to “unlock the value of their real estate,” according to MPT, by taking cash from the sale and spending it on facility improvements, technology upgrades, staffing, and growth. With hospital operators left to focus on health care, MPT could sit back and collect rent — yielding hefty profits for years.

Aldag and his inner circle would get extraordinarily rich along the way.

It was a persuasive pitch, and MPT, which by 2005 was traded on the stock exchange where Aldag’s grandfather had worked, grew quickly. By the time Aldag and de la Torre met in 2015, MPT had about $4 billion in assets. Today, it is the largest hospital landlord in the United States, and the second biggest private owner of hospitals in the world. MPT owns 435 properties worth more than $16 billion, including 42,000 hospital beds in nine countries — making it a huge force in medicine.

“Every time we’ve been able to sit down with a CFO of a hospital and walk through this model, we’ve been able to win the financing of it,” Aldag said in a 2011 speech.

In 2015, Aldag and de la Torre were both around 50 and at a similarly critical juncture in their lives — ready, at mid-career, to go big with their dreams. De la Torre’s goal for Steward was nothing short of “world domination,” according to an internal MPT email reviewed by the Globe. Aldag was looking to turbocharge the already rapid growth of his firm.

The two “hit it off immediately,” according to an MPT annual report. Aldag and de la Torre “felt destined to work together.”

For the next nine years, the high-flying CEOs and their firms would take an extraordinary entrepreneurial journey, their fortunes intertwined, their ascent breathtaking.

MPT financed Steward’s expansion across the country, buying hospitals at premium prices. Steward soon became the country’s largest private for-profit health system, and by far MPT’s biggest single investment and source of revenue.

But behind the scenes, little was as it appeared. Steward began to founder under the weight of the new rent payments and eventually started cutting corners on the basic expenses of medicine — nurses, equipment, maintenance — putting patients at risk. MPT couldn’t afford to let its biggest tenant fail, so it intervened in substantial, sometimes secretive ways to funnel money to Steward and bolster its balance sheet.

Finally came the steep financial fall of recent months, with hospitals closing, communities desperate for health care, and both companies facing public condemnation. De la Torre recently resigned as Steward’s chairman and CEO; Aldag remains on top at MPT. But their wild ride together is over.

The Boston Globe Spotlight Team has spent months investigating this unusual partnership to lay bare another critical piece of the Steward saga.

Among the team’s findings: MPT and Steward, which were supposed to operate at arm’s length, instead often operated in concert. MPT — which in addition to being Steward’s landlord was a creditor and minority owner — quietly routed money to Steward, helping its biggest tenant make rent payments. MPT hid Steward’s ailing financial health from investors, which may have bolstered its bottom line, but may have also violated federal securities laws, according to experts and analysts who spoke to the Globe.

Citing the circular transactions, some observers have likened the entire arrangement to a Ponzi scheme. The question, as with all Ponzi-like ventures, was how soon and how badly it would end.

Steward and MPT were able to keep the house of cards they built standing for nearly a decade. Over that time, Aldag and de la Torre steered tens of millions of dollars into their own pockets, even as Steward sank into bankruptcy and MPT’s stock price collapsed.

This story draws on dozens of interviews, including seven with former MPT and Steward executives and employees, as well as in-depth property data analyses and a trove of tens of thousands of confidential financial documents and internal emails obtained by the Globe Spotlight Team and the Organized Crime and Corruption Reporting Project, a global journalism outlet.

Steward and de la Torre, whom the Senate voted unanimously last month to hold in criminal contempt of Congress, have come in for most of the public opprobrium as Steward’s hospitals withered or closed. But the Spotlight Team’s investigation shows that this unprecedented crisis and alleged profiteering would not have been possible without the extraordinary financial backing of MPT and Aldag.

This “appears to me to be serious white-collar crime,” said Steve Weisman, an attorney and expert on financial scams who teaches at Bentley University and has followed the Steward saga. Weisman likened MPT’s activities with Steward “to the type of accounting fraud perpetrated by executives at Enron.”

“They make the hospitals look profitable when they’re not,” said Weisman. “It very much is all smoke and mirrors.”

MPT spokesperson Drew Babin called the Globe’s findings “false and misleading” and said MPT had no direct influence over Steward’s day-to-day operations, with its role primarily limited to that of landlord.

“Over the years, MPT has occasionally stepped in to provide bridge loans, rent deferrals, and other forms of financing when no other party was willing to because we have always believed Steward’s hospitals are critical to the healthcare of their communities,” Babin said. “MPT stands firmly behind our rigorous underwriting process as well as the completeness and accuracy of our disclosures. We have unfailingly disclosed each of our transactions — including those with Steward — as and when required under applicable securities law.”

Aldag declined to speak with a reporter who sought him at his office and home in Alabama.

Steward declined to comment. De la Torre said through a spokesperson that the Globe’s findings contained “factual inaccuracies,” and that he believed eight years ago — and still believes — that partnering with MPT was the most viable option for Steward.

It “was a prudent decision to choose the asset-light REIT model in 2016 over private equity alternatives because the former represented a long-term capital partner whose returns on investment were conditioned upon Steward’s continued success,” said his spokesperson, Rebecca Kral. After exploring “a multitude of options,” Kral said, de la Torre decided “the best way, and likely the only way, to generate necessary capital for the Steward hospital network at the time was through the 2016 sale-leaseback.”

A pattern of overpayment

In 2016, just over a year after de la Torre and Aldag first met in Alabama, MPT made a spectacular deal for Steward’s real estate. The prices were astonishingly high. For Steward’s nine Massachusetts hospital campuses, MPT would pay nearly $1.3 billion, nine times what Steward had paid less than a decade earlier.

For example, MPT paid Steward $263 million for Carney Hospital in Dorchester — 21 times what Steward had paid in 2010.

If the transactions appeared illogical, there was a method to the madness: The sellers got rich, and the value of MPT’s portfolio soared.

A huge chunk of the money for MPT’s 2016 purchase of the Massachusetts hospitals, for instance, was converted into a payout for Steward’s then-owner — the private-equity firm Cerberus Capital Management.

Cerberus got the lion’s share of the $790 million, allowing it to recoup its initial investment in Steward plus a profit of $473 million, according to Cerberus. De la Torre reaped his own considerable payday for his share of the firm.

For MPT, the massive deal and its jaw-dropping price markups also had upsides. The company’s growth had long been fueled by vast sums of money from Wall Street and lenders. The Steward acquisition allowed the firm to announce it had booked another long-term tenant — one that would be paying hundreds of millions of dollars in rent over the decade-plus ahead.

After the Massachusetts purchases, more deals quickly followed. MPT financed Steward’s expansion into states including Florida, Ohio, Texas, and Utah. The pattern of overpayments continued. While national sales data are spotty, a Spotlight Team analysis of more than two dozen Steward hospitals shows that MPT paid over three times the total value that had been assigned to the hospitals by local tax assessors.

The dynamic was perhaps captured most neatly in a pair of transactions in West Texas. On one day in April 2019, Steward bought a hospital in Big Spring for $11.7 million. That same day, MPT bought the building and the land it sits on from Steward for more than twice as much: $26 million.

Such overpayments almost certainly did damage to MPT’s long-term health. But they paid off handsomely in the short run for Aldag and other top executives, whose compensation was linked for years to the size of the deals they closed, according to filings with the Securities and Exchange Commission.

Last year, Aldag’s compensation reached a high-water mark of $17.85 million, an SEC filing shows. Over the last two decades, Aldag and two other MPT cofounders — chief financial officer R. Steven Hamner and retired chief operating officer Emmett E. McClean — were collectively granted compensation of more than $300 million.

Babin, the MPT spokesperson, said the company’s executive compensation plan is closely aligned “with shareholder interests,” adding: “Over the last two years, executive pay has been significantly impacted by stock price performance.” He cited an SEC filing that said with more than 80 percent of CEO compensation tied to stock price, the amount “actually paid” to Aldag in that span was far less.

While top executives netted huge payouts, it was obvious to some MPT employees that the fundamentals of the company’s deals often made no sense.

Four former MPT employees told the Globe that many company acquisitions were based not on due diligence or careful underwriting, but on executives’ desire for high-dollar deals and more properties.

The goal was “pure growth, growth at all costs,” explained Alex Hubartt, a former MPT financial analyst. “Whatever direction came from the leadership, regardless of what the numbers say, you’ll find a way to get it done.”

Another former employee, who spoke on the condition of anonymity for fear of repercussions, put it plainly.

“Everybody wins with the highest price,” the employee said. “That was the goal: How do we maximize the rent stream?”

The employee added that company analysts were sometimes pressured to sign off on deals even when the values were “insane.”

To what end?

“The bottom line of all this is greed,” said a former MPT executive, who also spoke on condition of anonymity. “Greed motivates individuals.”

Signs of trouble

It didn’t take long for cracks to appear in the shiny facade Steward and MPT had constructed.

Steward posted heavy losses in 2017 and 2018.

The red ink should have been predictable. Steward’s hospitals tended to serve working-class people, many of them on Medicaid, whose payments often lag far behind costs, and some uninsured. The company billed itself as focused on underserved and rural communities and “leading the way for a remarkable new world of access to affordable, high-quality care for every human being.” It was not a formula for generating the kinds of returns Steward would need to pay millions in rent, a huge expense after Steward sold its real estate.

Whether or not the financial strategists at Steward and MPT knew, at the outset, the risks of what they were doing is impossible to determine. But it’s clear both parties understood early on that Steward was in trouble. Their solution was to hide it behind MPT’s cash infusions and bullish claims. MPT investors had no way to know how badly things were going.

There was no turning back. The fortunes of MPT and Steward were now inextricably bound together.

MPT first took a 5 percent stake in Steward when it made the 2016 Massachusetts real estate deal. With the multistate Steward expansion that followed, MPT’s stake grew to 9.9 percent — just below the maximum allowed under federal laws aimed at ensuring real estate trusts aren’t too reliant on a particular tenant.

By then, MPT had become heavily dependent on its biggest renter. According to a quarterly MPT report, Steward hospitals by early 2019 made up 38 percent of MPT’s assets and a whopping 44 percent of its revenue.

At MPT, things had long appeared to be going swimmingly, at least on paper. The company’s assets more than doubled between 2016 and 2019, and its stock price rose by almost 70 percent. But its success was at great risk if the troubled state of Steward’s finances became public.

Their futures interlinked, the companies were about to launch their boldest gambit.

An unholy resurrection

In 2020, Steward was facing its worst year yet, with an expected loss of about $400 million, according to internal documents.

But MPT’s leaders couldn’t let Steward crumble. So they concocted a secret rescue plan, dubbed “Project Easter,” documents show. Through a complex web of transactions that hid the scheme’s intent, MPT would “infuse $400 million of ‘new’ capital into Steward” to “assure Steward has adequate liquidity,” according to a confidential MPT board presentation, masking Steward’s financial problems and by extension MPT’s.

The “recapitalization” plan, as MPT privately called it, would also free Steward from its corporate parent, Cerberus, and its restrictions. MPT loaned $335 million to de la Torre and fellow Steward executives to help them buy out Cerberus. In 2021, Cerberus walked away with a total profit of $800 million, the company has said.

MPT also signed off on a payout of $111 million to Steward’s shareholders, with de la Torre — now the majority owner — getting about three-quarters of it, according to internal Steward documents reviewed by the Globe. MPT itself got $11 million.

Critics in Congress and elsewhere have questioned the ethics of such individual enrichment in the face of so much financial wreckage. But the rest of the scheme was just as troubling. Simply put, Project Easter was a circular transaction — a landlord giving a tenant money that helped it pay rent, and then recouping it. It was a lie.

That may be one reason MPT took pains to disguise what it was up to. Rather than making a straightforward transaction, the firm routed the money into joint ventures. It provided half of its $400 million capital infusion in exchange for an international Steward subsidiary that had “negative cash flow,” according to a confidential Steward board presentation reviewed by the Globe.

MPT conjured the other $200 million by converting the mortgages on two Utah hospitals to leases, and paying Steward an “additional cash consideration” based on what MPT later described as the hospitals’ “relative fair value.” MPT said they were worth a stratospheric $950 million, then hired appraisers “with clear and appropriate instructions” to reach “a high level estimate,” according to internal emails.

But MPT’s support could hardly be called “temporary” or “limited.”

Over half a dozen years, MPT pumped more than $1.5 billion into Steward through a series of loans, equity deals, and other transactions, according to a Globe analysis of Steward bankruptcy documents, SEC filings, and internal records. That works out to more than six years of rent and interest payments from Steward, and it’s about three-quarters of the total rent and interest collected from Steward over the life of the two firms’ relationship, according to MPT.

Steward’s need for money could be urgent. One stark example came in 2022, when Steward’s chief financial officer said he had “reached his limit with vendors” and demanded MPT wire Steward $75 million by “tomorrow,” according to an MPT email reviewed by the Globe.

Acquisitions could also be a way to channel funds to Steward. The 2019 hospital purchase in West Texas was one example. That same year, Aldag emailed de la Torre about a potential project in Turkey. Though it never panned out, he said he was considering another infusion of money.

“I am trying different scenarios to get the maximum amount of cash to you guys,” Aldag wrote. “I am trying to come up with a structure that we can pay you (Steward) for the real estate over and above what we pay Turkey.”

MPT said Steward repaid some of its loans, in whole or in part. But as a publicly traded company, MPT may have violated federal securities laws, legal and financial experts say, by quietly propping Steward up and misrepresenting its financial health to investors.

Internal emails reviewed by the Globe make clear MPT wanted to keep its investors in the dark. For instance, as they prepared for a call with investors and analysts after their launch of Project Easter in 2020, Aldag and other company leaders circulated talking points, including a list of “THINGS WE WILL NOT COMMUNICATE.” Among them: “Steward valuation math” and the word “recapitalization.”

Aldag was breezy and optimistic in an earnings call later that year, telling listeners: “Our operators are performing beautifully across the world.”

Two years later, in 2022, Aldag again brushed off questions about Steward’s faltering finances. “Steward has always performed well at the hospital level,” he told an interviewer. “All of the bad is behind Steward.”

Steward’s bankruptcy filing was less than two years away.

As late as February 2024 — just over two months before Steward went bust — Aldag was assuring nervous investors in an earnings call that Steward would be able to start paying full rent starting in June. “We’ve been getting weekly cash flow reports from Steward’s advisers,” he said, “to which they’ve exceeded every one of them thus far.”

By then, Rob Simone of the investment research firm Hedgeye Risk Management, one of MPT’s earliest and most outspoken critics, was sounding the alarm; he had, in fact, been issuing emphatic warnings for two years, and had advised investors to short the stock.

“It’s the biggest fraud that hardly anyone knows about,” Simone said in an interview. “The entire company story — the narrative, and now the numbers themselves — is basically a giant bluff.

“While they are telling people — investors, the media, analysts — that things are always getting better … it just keeps getting worse. The lies get bigger, and the misrepresentations get more preposterous. And eventually the lies fall in on themselves.”

The reckoning

In January 2022, MPT’s stock hit a peak. A long slide soon began, as some tenants’ struggles started to come into view, and short sellers and other analysts began raising increasingly urgent questions about the stability of the whole enterprise.

By the time Steward declared bankruptcy in May 2024, shares of MPT had fallen by more than 80 percent. They’ve since inched up slightly, but MPT’s long-term future appears uncertain. The firm’s credit has been downgraded to “junk bond” status.

Steward’s bankruptcy filing showed it was on the hook for $6.6 billion in future rent payments to MPT, a debt that will never be paid. It’s a huge number, even for a firm, like MPT, with assets estimated at about $16 billion.

The once-cozy relations between MPT and its biggest tenant have soured. Steward complained in filings that onerous leases had “crippled” its hospital operations, and it attacked MPT’s “self-interested involvement and interference” in hospital sales.

MPT suggested Steward had only itself to blame. “Rent is virtually never the primary cause of financial stress for hospitals,” it said in a public statement. Left unsaid: Many hospitals don’t pay rent in the first place.

Now billions of dollars in debt, MPT is trying to persuade Wall Street that it can surmount the crushing losses set in motion by Steward’s slide into bankruptcy. One show of confidence: Construction is well underway on a sleek new $150 million headquarters in Vestavia Hills, just outside Birmingham. Last month, the firm trumpeted the news that it had agreed to long-term leases with new tenants for a passel of former Steward hospitals.

But the same press release acknowledged that MPT’s new tenants won’t pay a dime of rent for the rest of 2024. By the end of next year, they’ll pay just half of their eventual projected rent. The announcement was greeted with some skepticism by analysts, including Hedgeye’s Simone, who opined: “The math does not work.”

As MPT scrambles to right itself, shareholders have filed nearly a dozen lawsuits alleging securities fraud and other malfeasance.

John Cuomo, 62, of Las Vegas, a retired forklift mechanic, is the lead plaintiff in one class-action lawsuit. He stated that he lost about $182,000 on MPT stock because of the company’s subterfuge.

Joseph Crognale, 27, of Dedham, an engineer with a couple thousand dollars worth of MPT shares, also filed suit.

“I thought it was a great investment, and then everything started tanking,” Crognale said. His suit accuses MPT executives and board members of breaching their fiduciary duty and says some unjustly enriched themselves using “nonpublic information to sell their personal holdings” while MPT stock was “artificially inflated.”

For MPT, “there is certainly a real chance of liability” for securities fraud, according to John C. Coffee Jr., a Columbia University law professor and authority on securities law and white-collar crime. He cautioned via email, however, that MPT “can escape liability if it can convince a jury that Steward Health Care’s decline was not fully (or adequately) understood by it.

“Do not assume that this is a slam-dunk case,” Coffee added. “Truth and what can be proven in court are two spheres that overlap only marginally, like Venn diagrams.”

MPT, meanwhile, has filed its own defamation lawsuit against Viceroy Research, a short-selling financial research group that has criticized MPT for possible fraud. The MPT lawsuit is “illogical and farcical,” said Fraser Perring, a British financial analyst and founder of Viceroy. “It’s 100 percent malicious.” A judge denied Viceroy’s motions to dismiss the case.

In addition to litigation, both Steward and MPT face heavy scrutiny from Congress and federal agencies.

Steward’s implosion has triggered congressional hearings, and a Senate committee chaired by Vermont Senator Bernie Sanders is exploring the causes of Steward’s bankruptcy. Also, a federal grand jury in Boston is asking questions and seeking records about Steward’s relationship with MPT, according to people familiar with the inquiry. And the SEC has repeatedly sought information from MPT, including Steward’s audited financial statements. MPT has said it was willing to supply the files, but doesn’t have them.

In response to a Globe request for documents pertaining to possible investigations of MPT, the SEC said it was withholding records from the newspaper under an exemption that “protects from disclosure records compiled for law enforcement purposes, the release of which could reasonably be expected to interfere with enforcement activities.” It added that the reference to law enforcement did not necessarily indicate any violations of law.

In April, Massachusetts Senators Elizabeth Warren and Edward Markey wrote that MPT’s “investments have all the appearances of a Ponzi scheme that is continuing to harm Steward-owned hospitals.”

They have introduced legislation that would impose new restrictions on real estate investment trusts in the medical sector.

“MPT, along with other corporate vultures, plundered Steward’s Massachusetts hospitals and drove them into bankruptcy,” Warren said in a statement provided to the Globe last month. “After Ralph de la Torre and Cerberus sold the land from under the hospitals to make a fat profit, MPT saddled the hospitals with onerous leases and ran what looked like a Ponzi scheme. Ultimately, this looting caused the hospital system to fail and patients to suffer.”

Their outrage continues unabated despite de la Torre’s recent exit from Steward, and Steward’s from Massachusetts. With federal probes pending, full accountability has not yet been assessed.

Some of the most passionate testimony at a recent Senate committee hearing came from Louisiana state Representative Michael Echols, whose Monroe-area district is near Glenwood Regional Medical Center — perhaps Steward’s most troubled hospital.

At least six patients unnecessarily died at Glenwood because of Steward’s failure to uphold basic standards of medicine, according to earlier reporting by the Spotlight team.

Echols, a Republican who has worked in the health care industry, told the committee that MPT and Steward had “facilitated a Ponzi-like scheme” and urged the federal government to take steps to prevent a repeat.

“These have been fraudulent activities. They’ve killed my constituents,” Echols said in an interview with the Globe, speaking of the two firms. “They are health care terrorists of the highest order, and I want to make sure that they never get to come back to my state.”

Khadija Sharife of the Organized Crime and Corruption Reporting Project contributed to this report. 

By Hanna Krueger

VALLETTA, Malta — The most sweeping corruption trial in the history of this Mediterranean country kicked off with a former prime minister and a host of top government officials parading through a phalanx of police into a courthouse.

Hundreds of onlookers crammed narrow cobblestone streets, some screaming of their distrust in the government and disdain for the men who allegedly used their power to line their pockets. A throng of supporters bellowed about a witch hunt and a sham trial, and shouted at local journalists.

Over the course of eight hours one weekday late last month, a judge methodically rattled off formal charges against the high-powered defendants. Seventy-eight cardboard boxes of prosecution evidence sat below her bench. Though the proceedings were in Maltese, she repeated three English words over and over: Steward Health Care.

The Boston-born, national health care system is at the eye of this storm, a major player in the seismic scandal that has paralyzed this island nation’s government, ensnared federal officials, and jeopardized the country’s public health care system.

Harvard-educated physician Armin Ernst, a Brookline resident and head of Steward’s international venture, as well as Steward’s chief executive, Ralph de la Torre, a longtime Boston health care power broker, are each accused by Maltese federal prosecutors of participating in a bribery scheme, diverting millions to “consultancy fees” instead of using the funds to improve Maltese hospitals.

In the United States, Steward faces an existential crisis, mired in a high-profile bankruptcy case, numerous state and federal investigations, and a corporate meltdown that’s put all eight of its Massachusetts hospitals at risk.

In Malta, a reckoning is already underway. The Steward name became notorious here after the firm failed to live up to a 4 billion-euro government contract to manage three of the nation’s hospitals.

Last month, a Maltese magistrate concluded a four-year criminal investigation into the controversial deal. In her 1,200-page report, the magistrate recommended Ernst and de la Torre be charged with money laundering, criminal association, and corruption of public officials, including the nation’s former prime minister, Joseph Muscat. The Steward executives have so far not been charged.

In an interview with the Globe, Muscat proclaimed his innocence and denounced the government investigation, while acknowledging the shortcomings of the deal with Steward.

“They did not deliver,” he said. “Whether it was their fault, our fault, a third party’s fault — that’s something else, but they did not deliver.”

The magistrate’s criminal inquiry describes a Steward culture where cash is king and health care a secondary concern. It alleges Steward executives — namely de la Torre and Ernst — leaned on a cast of shadowy consultants to secure the hospital deal and shuffled millions of dollars of taxpayer funds through secretive channels and into the pockets of Muscat, as well as other politicians and businessmen. Altogether, Steward is mentioned more than 1,700 times in the lengthy court document, which draws on physical evidence and an examination of data on Steward Malta’s computer servers through September 2021.

“The emails confirm that top ranking officers within Steward were aware that the payments were being made for political purposes rather than consulting services,” Maltese investigators wrote, citing correspondence seized from Steward’s servers.

A tranche of other emails sent by Armin Ernst to his associates — obtained by the global journalism outlet Organized Crime and Corruption Reporting Project and shared with the Times of Malta and The Boston Globe — appear to corroborate several of the inquiry’s findings and debunk claims by Steward that the deal and payments were legitimate. The leaked Ernst emails show questionable accounting practices, little corporate attention to due diligence, and executives cutting corners on an aggressive path to profit.

Altogether, the material suggests Steward’s domestic operations are not as divorced from its international venture as the company has repeatedly claimed. It also provides a critical window into the business practices of the third-largest hospital system in Massachusetts — one of the biggest for-profit systems in the US — as well as the leadership of de la Torre, a charismatic local cardiac surgeon whose grand ambition led to the rise of the Steward chain.

It is unclear if Ernst, who still lives in Brookline, or de la Torre, who relocated to Dallas along with Steward’s headquarters in 2018, will appear in court in Malta. Under Maltese law, defendants cannot be charged in absentia, but the United States does have an extradition treaty with the island nation. To be triggered, Maltese authorities would need to present the Department of Justice with evidence compelling enough to issue a warrant.

De la Torre declined to comment through a Steward Health Care Systems spokesperson.

Ernst declined to comment on the contents of his emails, but a representative from a public relations firm representing Steward International said, “Steward International entered Malta in good faith and has been consistently transparent and focused on providing maximum value to patients and taxpayers. We categorically deny any accusations of wrongdoing and will vigorously defend ourselves. During the course of the four-year inquiry in Malta, we have never been asked to provide any information in any form. A simple request during that period should have been considered and would have allowed for an objective and reliable investigation. We look forward to setting the record straight.”

The State Department, which monitors overseas business activity by US firms, referred the Globe to the US Embassy in Malta, which said, “As a general matter, we do not comment on ongoing law enforcement matters.” Both the US Securities and Exchange Commission and Department of Justice declined to comment.

Before his work for Steward in Malta, Armin Ernst was a widely admired Tufts University School of Medicine professor. The German national first landed in Boston for a post-residency fellowship at Beth Israel Deaconess Medical Center and rose through the ranks as a pulmonologist, authoring more than 200 medical publications and editing seven textbooks, according to his professional biography.

He married a local doctor and purchased a seven-bedroom home in Brookline, records show. And in September 2010, he joined fledgling Steward Health Care, led by fellow Beth Israel alumnus Ralph de la Torre.

De la Torre trumpeted the new network as an accessible low-cost alternative to Boston’s pricey medical goliaths. Already considered one of the most talented cardiac surgeons in the city, he would soon become the face of private equity-financed health care.

Ernst saw Steward rise from a small local chain to a national empire. Then he jumped ship for an overseas opportunity as chief executive of an emerging European health care group, Vitals Global Healthcare, a press release shows.

That career move brought Malta into his sights. Just months earlier, the government of Malta had awarded Vitals a 30-year, $4.35 billion private-public hospital contract. Many considered it a surprising partner. Despite the company’s name, Vitals leaders had no background in hospital management but were tasked with operating and renovating three of the nation’s eight public hospitals.

When Ernst joined Vitals in July 2016, the company was — at least on paper – in the second month of executing the government contract, receiving roughly 188,000 euros a day to manage 712 hospital beds. But the months dragged on, and it became clear to Maltese officials that Vitals could not, or would not, deliver on its end of the deal. Ernst left the company less than a year after joining it.

But he did not leave Malta. Instead, he reconnected with his old boss. De la Torre and Ernst eyed this Mediterranean archipelago as the first stop in Steward’s aggressive campaign to expand internationally.

Emails quoted in the Maltese criminal inquiry describe Ernst working with de la Torre to orchestrate Steward’s takeover of the hospital contract as early as January 2017.

That year, Steward Health Care International Ltd. was incorporated with Ernst listed as CEO, according to the Maltese business registry, and with de la Torre as the owner through an American entity called Steward Health Care International LLC. The company, records show, shared the same Boston office as Steward Health Care Systems.

In short order, the government of Malta transferred the hospital deal to Steward, along with a stipulation that if the contract was ever annulled by the courts, the company would receive a 100 million-euro payout. The ownership exchange was so swift that Steward could not complete any of the due diligence typically done when closing such a mammoth deal.

“Just to clarify Steward/my position we gave up the due diligence for a variety of reasons, one it being the pressing timeline,” Ernst wrote in an email at the time. “But that means we are not pursuing ANY pre-purchase [due diligence].”

It was an unorthodox admission for a deal that leveraged such a swath of the island’s capital. Two employees of the US Embassy told the Globe that Steward did not reach out about the deal.

“American companies would typically come to us and ask for advice or opinions when they’re getting ready to do a big investment in Malta,” said then-Ambassador G. Kathleen Hill.

Hill said she met de la Torre only once, at a soiree in his honor in Malta during the summer of 2018.

That fall, it was Steward’s turn to host. Ernst escorted Muscat around Boston, first to St. Elizabeth’s Medical Center in Brighton and then Steward Health Care’s headquarters downtown. The trip ended with a handshake between then-Governor Charlie Baker and a smiling Muscat, an image that was posted by the governor’s office.

“It is customary for governors to meet with foreign dignitaries when they are traveling through Massachusetts and this was a typical, ceremonial meeting with a foreign dignitary,” said a spokesperson for the former governor.

After the fanfare and photo opportunities, Malta expected Steward to get to work. But Steward missed all of its deadlines to improve the three hospitals, a Maltese judge later ruled. At the same time, Steward received anywhere from 40 million to 79 million euros from the government each year, records from Malta’s National Audit Office show. The money was meant to fund both operating costs and renovations.

Steward was instead focused on the payment of so-called consultancy fees, according to the federal inquiry. Maltese investigators allege that, after inking the hospitals deal, Steward funneled millions of dollars to companies connected to government officials and shady businessmen under the guise of legitimate consultancy payments.

The emails obtained by OCCRP show that one alleged recipient of these fees was Shaukat Ali, a Pakistani businessman who helped secure the original hospital deal with Vitals back in 2015.

“Ralph and I shook hands with the 2 major principles: Father and son Ali. We assured each other that we are in this together and that we will take care of each other,” Ernst wrote in an email three months before Steward took over the Vitals deal. “Please remember that without them we would not even be close to having a shot at Malta and quite a few of our prospects are tied to their relationships and effort.”

In another email, from November 2017, Ernst described the father-son duo as “political consultants” who were “exceedingly well connected and equity shareholders of [Vitals Global Healthcare].” He arranged for them to receive a monthly fee of 80,000 euros and equity opportunities in Steward Health Care International.

Shaukat Ali made for an interesting business partner. According to the Maltese inquiry, he and his family “were involved at the highest levels of Colonel [Muammar] Gaddafi’s notoriously corrupt regime in Libya, working with the healthcare systems there.”

“His mode of operating is also therefore well established, and he would not and did not pass any due diligence properly carried out on his suitability to be involved in a Public Private Partnership,” wrote investigators.

Ali, in an email to the Globe, declined to comment, saying the pending Maltese charges mean he can’t discuss the matter.

Records of transactions and emails obtained by OCCRP show that Steward paid Ali and his family at least 7.6 million euros. Most of these transactions occurred via a Swiss payroll company called Accutor AG, the records show. The criminal inquiry depicts the company as a centralized money-laundering hub for millions of dollars of payments to former prime minister Muscat, his chief of staff and health minister, and Ali.

“We have entered into a consulting agreement with Accutor supporting political and government activities and interactions,” wrote Ernst in an August 2019 email to Steward International’s chief financial officer. “Payment is 100k euro per month and the first bill will arrive this month to be paid at months end. I will need to sign off on all bills — Ralph is aware.”

The criminal inquiry argued that Steward used Accutor to set up a “political support fund” and “used monies diverted from the concession to fund payments to, or on behalf of” Muscat and two of his top staffers. The payments, according to the inquiry, often flowed through Steward’s American bank accounts.

One particular February 2018 transaction to an Ali-affiliated company in Tunisia for the sum of $514,993 was sent from Steward’s office in Dedham.

In an email thread a month later, Steward accountants in the United States appear perplexed by a $3,146,000 wire.

“I ... thought the $3M transaction in my initial email below related to consulting, but it looks like we just purchased the VGH [Vitals Global Healthcare] Malta hospital in Europe,” wrote one analyst from a Steward office in Westwood.

Then the US vice president of finance chimed in.

“It’s the wire for the purchase of the Malta hospitals concession from Vitals. Eventually we will do some purchase accounting work around that,” he wrote in the email thread.

A spokesperson for Steward Health Care said last week that Steward Health Care International, which was incorporated in Malta and later moved to Madrid, is a separate entity from the American flagship brand. The company has steadfastly maintained this in the past as well.

The day before he was formally charged in the case, former prime minister Joseph Muscat sat for an interview with the Globe at his villa in Malta. He has repeatedly deemed the investigation a “politically motivated witch hunt.”

He allowed that the deal with Vitals did not go as planned, though he wouldn’t say whether that was “their fault, our fault, or a third party’s fault.” But he maintains Steward was an obvious choice to take over the contract.

After all, the company had the stamp of approval from Boston, the bastion of American health care, Muscat said.

“There is the impression from the outside that in the United States there is scrutiny in most sectors, so having one of the largest private hospital operators in the United States with one of the main private equity funds as their backers, I couldn’t see the problem,” said Muscat.

The deal officially fizzled after Muscat stepped down from office in January 2020 amid public outrage over the assassination of Daphne Caruana Galizia, a journalist who was first to report on alleged corruption within the hospital deal. Prosecutors allege she was killed in a contract killing, paid for by a top Maltese businessman with government ties.

Two years later, in 2022, Maltese authorities raided Muscat’s hillside villa and seized all his electronics as part of the probe into the fraudulent partnership. An incensed Muscat refused to provide them with the devices’ passcodes, according to the inquiry.

A Maltese magistrate judge advised investigators to consult global experts in cracking electronics and extracting their data: the US Department of Homeland Security Cyber Crimes Center.

The Maltese investigators met with a US Department of Homeland Security special agent in the five-star Westin Dragonara hotel in the St. Julian’s neighborhood and handed over the bundle of devices. The exchange occurred a short walk from Steward’s Malta outpost.

By the following spring, that office would be empty.

Some 490,000 residents live on the big island of Malta, packed into apartment buildings that tower over cramped city streets that make the country the ninth-most densely populated in the world.

The remaining 40,000 live on the sister island of Gozo, where a bustling ferry terminal welcomes hundreds of tourists each day to explore rural beaches and snorkeling coves.

Just one hospital serves this population: Gozo General. It sits on the outskirts of the city of Victoria, looming over an undulating rocky landscape dotted with dense shrubs called salt trees, the occasional giant cross and cathedral, and an expanse of cerulean waters.

As part of the hospital deal, Steward was tasked with transforming this dilapidated hospital into a world-class medical facility, a credit to Malta and worthy of the Steward brand. The royal blue Steward logo was the first thing to be added. Next, according to local media reports, a billboard with a doctor making a heart-shaped symbol, accompanied by the message: “Modern health care designed around you.” One helicopter was purchased and some temporary trailers installed, court documents show. And then, the renovations trickled to a halt.

By 2023, Steward had received an estimated 400 million euros from the government of Malta with little to show for it, according to national audits. That February, a watershed court ruling struck down the deal once and for all, finding that it was “fraudulent.” The judge also rescinded Steward’s 100 million-euro escape clause.

“The court had no doubt that [Steward] was well aware of the shortcomings of Vitals,” the judge said during the January 2023 hearing. In defense, it was expected that Steward would offer up witnesses to prove the contract had actually been fulfilled.

But all that Steward produced — more than six years after taking over the multibillion-dollar deal — was a one-page affidavit and photos that boasted about the new helicopter and toilet renovations.

This court “is really perplexed by the poverty of the evidence Steward brought before this court,” the judge wrote, adding that it “probably reflects the poverty of investment.”

A visit to Gozo General Hospital last month found the aging stone edifice surrounded by a wire fence and yellow warning signs that read, “Caution: Falling debris!” The hallway off the hospital’s main wing featured a shattered glass door and an unfinished ceiling with exposed wiring, dangling fire alarms, and daylight poking through.

A big white tent in the doctor parking lot shaded a mobile MRI unit. The government purchased the machine as a stopgap measure after taking back the hospital from Steward in 2023. A parliamentary question earlier this year revealed that almost 16,000 people in Malta were waiting for an MRI, double the number reported six months earlier.

The unprecedented criminal trial in Malta will likely last years. No prime minister has ever faced corruption charges in the nation’s history. Many doubt the court will actually deliver justice, given the dysfunction and corruption rife in Malta’s judicial system.

“Within the public here, there is a hope at least that if our courts fail us, which they very well might, potentially the long arm of the law of the United States might reach as far as here. After all, bribery is a two-way crime,” a Maltese bank chairman told the Globe. Fearful of speaking out against Muscat, he asked to go unnamed.

Two men with direct connections to Steward — company legal counsel David Melli of Malta and Asad Ali, the son of Steward consultant Shaukat Ali — have appeared in court and have been formally charged with a slew of corruption and money laundering charges.

Steward representatives declined to say if Ernst or de la Torre will travel to Malta to be formally charged in court.

As health care services suffered, Steward prioritized intelligence-gathering on those who were viewed as opponents, records show.

This story was reported by Hanna Krueger, Jessica Bartlett, Mark Arsenault, and Elizabeth Koh. It was written by Krueger and edited by Brendan McCarthy.

One night last year, a surveillance team camped outside a financial analyst’s English country home and videotaped him as he watched television with his partner. The team — contracted through a British private intelligence agency — put a tracker on the analyst’s car, watched his daughter go to school, and followed him into pubs and on errands, even during a bike ride.

Another time, staffers of an intelligence firm pored over details from a health care executive’s phone and seized on sensitive tidbits: a text message with a sex worker, consultations with a doctor about cosmetic surgery, and lewd photos.

On another occasion, an intelligence firm targeted a top Maltese politician and circulated an allegedly fraudulent bank wire transfer that suggested he had illegally granted a passport in exchange for a multimillion-dollar bribe.

The lone link among these targets? They dared to criticize or question the business practices of Steward Health Care, drawing the attention of executives at one of the largest for-profit health care systems in the United States.

As Steward struggled to provide services and pay vendors in many of its three dozen or so hospitals in Massachusetts and across the country, its executives spent millions on intelligence firms, according to corporate records, videos, and other files obtained by the global journalism outlet the Organized Crime and Corruption Reporting Project and shared with the Boston Globe Spotlight Team.

In all, senior Steward executives authorized and spent over $7 million from 2018 to 2023 on firms that provide research, intelligence-gathering, and surveillance services, according to emails, encrypted messages, and financial records reviewed by the Spotlight Team.

The surveillance was part of what Steward’s general counsel called a “spare no expenses mission” to gather dirt on people who were viewed as problematic by the hospital chain’s executives. And files show that the private intelligence firms discussed ways to potentially weaponize the compromising material, if necessary.

These surveillance operations coincided with Steward’s ignominious downfall. The Boston-born company careened from a hospital chain with a visionary model and a commitment to the underserved to a flailing venture in which executives reeled in hefty bonuses while services suffered.

Business intelligence and research work are commonplace in the high-stakes corporate world, but such behavior is atypical of health care providers, experts say, and the operations carried out here go far beyond the norm.

It is unclear if the actions violated the law, given the multinational jurisdictions where the operations took place. Nonetheless, the tactics raise questions about an organization that lists among its core values “accountability” and “accepting responsibility for continuous performance & improvement.”

Founded in 2010, the for-profit health care chain has become one of the largest, most powerful US health care companies of its kind. It’s also become one of the most troubled.

The company first enlisted the help of intelligence firms in Malta, where a controversial hospital deal with the nation’s government erupted in flames, with officials saying Steward failed to deliver on its promises. Two top Steward executives are ensnared there in a criminal conspiracy case related to the deal, with authorities recommending they face charges for corrupting Maltese public officials.

In the United States, Steward is mired in bankruptcy, the fate of its network hazy, while its Massachusetts properties head for the auction block. In recent years, crippling staff shortages at Steward hospitals have put patients at risk, records show. Dozens of lawsuits from unpaid vendors — from elevator companies to orthopedic suppliers — have piled up in court.

Records show that Steward executives prioritized intelligence-gathering over most everything else. Monthly bills ran as high as $440,000. They were to be paid on time and in full.

“We are relying on [them] for truly existential work,” Herbert Holtz, counsel for Steward, said in a January 2022 voicemail to the company’s chief financial officer. “We really do need to keep them high on our list of must pays.”

It was Holtz who called the work of one firm part of “a spare no expenses mission,” the recording shows. And he said in the voicemail that a newly extended contract with one firm came at the direction of Steward Health Care CEO Ralph de la Torre.

“While general counsel and as a private lawyer since then, Holtz has neither recommended nor sanctioned any illegal or unethical activity,” said a Steward spokesperson in a statement to the Globe. The spokesperson did not respond to questions directly about the intelligence work.

In a statement, Holtz said that he “acted appropriately and ethically” at all times and that he was “bound by attorney client privilege from responding” to questions about these matters.

Experts told the Globe that large companies often hire firms to compile corporate intelligence on competitors.

“In these cases, you have a lot of people who say, ‘I want to hire somebody who is going to get [the critic] and make their life miserable,’ ” said security expert Ira Winkler, the chief information security officer for CYE Security and author of several books on corporate espionage.

What’s irregular is that Steward — a health care system with a focus on community hospitals that serve low-income patients — would put so much of its focus and resources on these activities.

“Following people, surveilling someone, that’s beyond the lines,” Winkler said. “It could be considered harassment. But even if legal, it’s weird for a hospital system to be spending resources on this.”

The intelligence missions and research work were assigned code names, nods to predators of the animal kingdom. Kestrel, like the small, fierce falcon, and Albacore and Bluefin, like the tuna species. Former combat veterans and seasoned crisis communicators were tapped to handle difficult “opponents.” The most sensitive details of their communications took place in encrypted chats, but snippets of the missions are detailed in various email correspondence, documents, and audio recordings.

The recurring bills from the firms were sometimes so large that they surprised corporate finance managers who had to approve the costs.

The Steward executives linked to or referenced in the correspondence include de la Torre; Armin Ernst, the CEO of Steward International; Mark Rich, president of Steward; and Holtz.

Holtz’s digital fingerprints are evident in nearly all of the surveillance missions. One of Boston’s most renowned litigators, Holtz left his seven-attorney firm in 2018 to join Steward as general counsel in Dallas, where the company relocated from Boston.

At the time, Holtz told Massachusetts Lawyers Weekly that he had “no regrets” about the decision to join Steward. The hospital system was ballooning in size as it sought to expand its unique model of community-based care through nationwide acquisitions and a bid overseas in Malta.

But within a few years, the shine had worn off. Top executives were suspicious of just about everyone, even their Steward co-workers.

A surveillance operation in 2023 took aim at a former Steward executive who other executives feared might spill company secrets to an independent auditor. The man had been a thorn in the side of executives, with a habit of asking questions about expenses, according to one internal email.

A search of the man’s company-issued phone revealed two juicy bits of information. One, the man had seemingly solicited the services of a sex worker. And two, he’d discussed cosmetic surgery with a physician.

“Efforts to recover and analyze additional information from the extracted device image are ongoing and further results will be briefed separately as soon as they come in,” wrote a director with the British firm Audere International in a subsequent report.

Audere, founded by a former British Army officer named Charles Blackmore, had been working for Steward since 2018 on assignments connected to the company’s partnership with the Maltese government.

“To know is to empower” is the motto of the UK firm. “It’s what you don’t know that affects the outcome. Our timely intelligence fills the gap.”

In the Audere report, the Steward executive under scrutiny was identified only by his first name and otherwise assigned an alias.

Blackmore received a compromising photo of this same executive — whom the Globe has chosen not to name due to the personal nature of the material.

Blackmore, correspondence shows, considered using the supposed sex worker to gather more information. He also mulled arranging for a female agent to get close to the former executive by expressing an interest in receiving leadership coaching from him.

The correspondence shows that each of these plans, according to Blackmore, was to be run by “Herb” for approval — an apparent reference to Holtz. The records do not make it clear whether the tactics were approved or deployed.

When contacted by the Globe, the former executive had a representative issue a statement on his behalf, saying he was “unaware that he was the subject of any surveillance until contacted by a reporter.”

A spokesperson for Steward said: “The portrayal of the experience with a former Steward employee is inaccurate. A mutual non disparagement clause between the employee and the company prevent specific comment.”

That same spring, Steward deployed Audere on yet another mission. This time, Audere gathered intelligence that could be used to potentially smear one of Steward’s most outspoken critics: British financial analyst Fraser Perring.

Perring founded the financial research group Viceroy Research LLC. There, he investigates publicly traded companies and then speculates — and bets — on the decline of their stock. These types of short sellers typically focus on firms with opaque disclosure and complex ownership structures. Both apply to Steward, which stopped filing its mandated complete financial statements in Massachusetts nearly a decade ago, as well as its landlord, the publicly traded Medical Properties Trust.

In February 2023, Perring authored a report that touched a nerve at Steward, calling into question Steward’s latest international foray in Colombia and the involvement of Steward stakeholder Medical Properties Trust.

A month later, an intelligence team from the security firm Greyprism, which had been contracted by Audere, pulled up outside Perring’s home in northeast England, according to a report prepared for Audere and reviewed by the Globe. For six days, the team followed Perring’s movements. From the living room to the bedroom. On a trip to a steel fabricator and the local pub. For the dropoff and pickup of his 11-year-old daughter from school. And on a bike ride with his family.

In one video reviewed by the Globe, Perring sits on his couch next to his partner, watching a television program. It’s dark outside and the camera shakily peers through a glass door.

The surveillance report does not identify Perring by name, but includes a satellite image of his home and the name of his daughter’s school. In an interview with the Globe, Perring confirmed that he and his partner were the people in the video. He said he first learned of the surveillance after his daughter “became terrified by seeing the same people follow us.” He said he filed a police report shortly thereafter.

Perring said he was appalled and outraged by the invasion of privacy. “And what is particularly shocking is that they did this while Steward was insolvent and unable to meet its basic obligations to its patients, employees, and vendors.”

In a released statement, an attorney for Greyprism said the company was “unable to discuss its work on any specific cases due to client confidentiality and data protection reasons.

“Its work also often involves matters giving rise to legal professional privilege and/or high-risk security issues. GP would not, and has not, acted in the manner alleged and in breach of its legal obligations.”

Audere International was tasked with launching a campaign that would, in Blackmore’s words, “put pressure” on Perring, according to correspondence from an Audere corporate meeting reviewed by the Globe.

Around the same time, an account called viceroyleaks cropped up on the social media platform X.

“This account’s sole purpose is to expose #fraud, #scam and #insidertrading of Fraser Perring and Viceroy,” reads the user’s first post, dated March 8. “We do not forgive. We do not forget.”

Correspondence shows Blackmore reviewed posts to the account before they were published. Again, Blackmore noted he would send posts to “HH” for approval.

That same week, Audere came at Perring from yet another angle. The firm shared a dossier with Perring’s name in the title and included his bank account number and balance as of March 2023, as well as transactions going back over the previous five years. Another report includes records of the numbers, times, lengths, and costs of his recent phone calls. It’s unclear how Perring’s confidential information was procured and if — or how — it was used.

Internal emails show that Ernst, Holtz, and de la Torre were scheduled to meet with Blackmore and other business intelligence contractors in London the same week the Perring operation took place.

It is not clear how much Steward spent in 2023, but the company paid $778,913 to Audere in the first three months of 2022, according to a quarterly report presented in Dallas.

“Our client’s work is confidential and as such they are unable to respond to enquiries about such matters including speculation as to the identity of clients,” a law firm representing Audere said in a statement to the Globe. “Our client takes its legal and regulatory compliance obligations seriously and acts in accordance with the same. Any suggestion to the contrary would be defamatory of our client.”

Just after Steward moved its headquarters from Boston to Dallas, company leaders looked to expand the health care empire overseas. Malta seemed like an easy pick. Ernst, who had spent years working with de la Torre, orchestrated Steward’s takeover of a flailing $4.23 billion hospital deal with the Maltese government.

But almost immediately the deal turned sour and Steward leaders were displeased. The money from the Maltese government was not being transferred quickly enough. And executives directed their ire at the island nation’s health minister, Chris Fearne.

Steward blamed Fearne when payments were held up by disputes over whether Steward was providing all the medical services it had been contracted to deliver under the government contract.

“I’m truly getting exasperated,” Ernst wrote to Fearne in an October 2018 email.

By 2021, Steward was contemplating legal action and “prepared to drop a case in US Federal Court naming Fearne and others as bad players,” according to an email written by Steward executive Mark Rich.

But no court case ever materialized. That December, Steward executives hired a consulting firm called the CT Group. The London-based company was founded by one of the most influential lobbyists in Australia; the firm, self-admittedly, was “long known for its political dark arts.”

Fearne, who had repeatedly and publicly demanded that Steward make good on its contract, soon became the focus of an intensive intelligence campaign. In a proposal for “Project Bluefin,” the CT Group laid out its game plan. They would “identify instances or areas in which the opponent has behaved improperly” and then “deploy the information to secure coverage of the issue in the Maltese media.” The latter step was to be done discreetly and “anonymously.”

Fearne is not explicitly named in this proposal, which quoted the project cost at more than $300,000.

Soon thereafter, the private intelligence agency shared a highly confidential bank wire transfer record purportedly showing 3.2 million euros, about $3.5 million, moving to an account held by the daughter of Fearne’s former chief of staff. The payment, dated November 2019, was sent by a business partner of Igor Levitin, a Russian government official with ties to President Vladimir Putin. Levitin’s brother, the oligarch Leonid Levitin, had just obtained a Maltese passport, despite sanctions that should have prohibited him from obtaining one.

In a document titled “Malta: Abuse of Passport Scheme,” Fearne is described as using his ministerial position to lobby for the issuance of Leonid Levitin’s passport as part of a quid pro quo for payment. Metadata from the document shows that a CT Group director authored the report.

The CT Group shared this information with Steward, emails show.

And in October 2022, Ernst, who runs Steward International, forwarded the wire transfer and the report on the purported Maltese passport scheme to a partner at a British law firm.

But the veracity of the bank wire transfer has been disputed. The Austrian bank allegedly involved in the transfer described the record as “forgery” to the Maltese investigative journalist Matthew Caruana Galizia. The Maltese police also investigated the allegations of bribery by Fearne but “no evidence was found . . . that could lead to a criminal prosecution,” according to a statement police provided to the Times of Malta.

It is unclear whether Ernst questioned the document’s legitimacy. But by the following summer, the wire transfer document and the allegations that Fearne accepted a bribe ricocheted through Ukrainian and Maltese press.

“CT has provided corporate intelligence services to the highest standards for over a decade,” the firm said in a statement to the Globe. “CT is committed to and complies with all laws and regulations in all jurisdictions in which it works and is confident the intelligence sourced in this project is genuine and accurate.”

The CT Group is currently involved in two unrelated defamation lawsuits in British court. The claimants, former clients of CT Group, allege that the firm engaged in “industrial-scale forgery,” as well as “apparent criminality” in relation to genuine documents. In the first case, the High Court said the evidence that the banking records were forged was “very strong” but that did not demonstrate “wrongdoing or improper behaviour by CT Group.”

The CT Group denied any wrongdoing in either case, calling the allegations “an ambush and abuse of the UK courts system.”

While much of this investigative intelligence work was taking place across the globe, Steward’s hospitals in the United States were struggling under the weight of the coronavirus. From 2020 to 2021, Steward hired hundreds of temporary staff to meet the need. But by March 2021, Steward was disputing 3,400 invoices and withholding over $42 million from one staffing agency, which eventually pulled its staff from Steward hospitals, court documents show.

Meanwhile, nearly every Audere invoice that flowed into Steward’s inbox was considered a top priority for payment. In 2020, Audere billed Steward more than $950,000, correspondence shows. Members of Holtz’s staff hounded the company’s finance department to pay the bills in full and on time — sometimes before their due dates — and quickly dismissed any concerns employees raised about their nature.

“Herb is asking to initiate payment immediately — is there something you need from me in order to expedite?” wrote one of Holtz’s executive assistants in a September email.

A set of bills from the fall of 2021 appeared to have surprised two Steward finance employees. Holtz’s executive assistant sent them the Audere invoice with the instructions to pay the sum “ASAP,” noting that the amounts were in British pounds, as opposed to dollars.

“500k???” wrote one accountant in a private thread to his colleague, who responded, “That’s like $700k usd . . .”

That set of bills was paid directly by Steward Health Care System LLC in Dallas.

Holtz, through a company spokesperson, said he “advocated for prompt payment to consultants to the legal department” and “did not opine on prioritizing those over other hospital or medical vendors.”

Holtz also oversaw the dispute with the unpaid staffing agency, which he accused of “pandemic profiteering” in an internal memo.

As the invoices continued to pile up, Steward and the staffing agency battled in a Massachusetts court, a case that remains ongoing.

Conditions at the time grew grim in Steward’s Massachusetts hospitals. At Good Samaritan in Brockton, a union representative with the Massachusetts Nurses Association spelled out her concerns in a memo that was also sent to the federal government.

“For the past eighteen months deteriorating conditions in the Good Samaritan ED resulting from extremely poor RN and tech staffing . . . has continued to worsen to beyond crisis conditions,” the representative wrote. “More often than not, the ED is understaffed in the realm of 50% of required RNs.”

On one night in the fall of 2021, there were 101 patients in the emergency department with only six nurses to care for them, creating a 14-hour wait for some patients in the waiting room, the memo noted. On another, seven full ambulances idled outside the hospital as 11 nurses juggled 71 patients in the emergency room.

A day after Thanksgiving, 11 nurses were assigned to 95 patients and a patient with acute renal failure was left unattended.

That patient was later found dead in the hallway.

This story has been updated to reflect that Igor’s Levitin’s brother, Russian oligarch Leonid Levitin, was the beneficiary of an alleged Maltese passport bribery scheme.

Khadija Sharife (OCCRP), Tom Stocks (OCCRP), and Jacob Borg (Times of Malta) contributed to this report.

This story was reported by Hanna Krueger, Yoohyun Jung, and Brendan McCarthy. It was written by Krueger and edited by McCarthy.

Steward Health Care CEO Ralph de la Torre and his top deputy jetted last summer to Jamaica for an escape from the scorching heat in Dallas. Among the worries they left behind: the unpaid bills that were piling up at headquarters.

They stepped off the company’s private plane and onto de la Torre’s personal yacht, bound for a weeklong cruise through the Caribbean. They followed that trip with a few days back in the office. And then de la Torre headed to the Virgin Islands on another break.

And then another — and another. Jamaica, Antigua, St. Kitts, Bermuda, Turks and Caicos. In all, the CEO spent 34 days in the tropics — plus a long weekend in the French Riviera — last summer as his health care company teetered on the brink of bankruptcy, according to a new Globe Spotlight Team analysis of public flight records, yacht records, internal company documents, and interviews with people close to the matter.

Nearly half of the 582 flights flown in 2022 and 2023 were to or from destinations more than 100 miles away from any official Steward location, such as hospitals or corporate offices. Passengers included de la Torre’s fishing friends, a luxury yacht salesman, and high-profile horse trainers.

De la Torre flew to Massachusetts — the birthplace of his company and then home of eight of its hospitals — just seven times in two years, records show. Each trip lasted a day or less.

In many, if not all, instances, the private jet excursions were paid for by Steward, records show, the funds pulled directly from the coffers of one of the nation’s largest — and most troubled — for-profit, private hospital chains.

De la Torre’s personal spokesperson, in a statement to the Globe, confirmed that the executive was paid for such travel and noted that de la Torre views the benefit as supplemental to his pay.

“For safety reasons, Dr. de la Torre elected to use the plane as part of his compensation rather than receive a substantially higher salary,” Rebecca Kral said.

By the time de la Torre returned to the office last September, unpaid vendors had repossessed medical supplies across the hospital chain, putting lives at risk. A recent Spotlight investigation found at least 15 cases in recent years in which Steward patients died after failing to receive professionally accepted standards of care due to equipment issues or staffing shortages.

The use of the company’s jets raises a host of legal questions about corporate disclosures and possible tax avoidance.

“When you’re at the point where the company jet is at the disposal of third parties who are not employees or there’s no business purpose for the flight, it is going to get very tricky for the accountants to classify that as a legitimate expense,” said David Yermack, a finance professor at New York University and author of two papers on executive jet use.

In February, the IRS announced a crackdown on large corporations and high-income taxpayers who use business jets for personal reasons. Federal tax code allows a corporation to deduct money spent maintaining a corporate jet — but only if that plane is used for business use.

A Steward spokesperson responded to a list of questions from the Globe by saying the company has no comment.

Last week, de la Torre failed to appear before a Senate committee investigating the implosion of his health care chain. The committee voted Thursday to hold the executive in contempt of Congress, referring him for civil and criminal charges over his refusal to testify.

The Spotlight Team previously reported that de la Torre often used Steward’s bank accounts as his own; to purchase and renovate an 8 million euro apartment in Madrid; to donate millions of dollars to his children’s prep school; and more. Some of these transactions are now under scrutiny by a federal grand jury in Boston, people close to the matter have told the Globe.

This new Globe analysis rounds out a globetrotting portrait of how de la Torre and other executives spent their time — and the company’s money — in the months and years before it went under.

De la Torre almost exclusively used the company’s Bombardier Global 6000, the more lavish of the two models.

Another jet — the slim Dassault Falcon 2000 – was used mostly to fly other Steward executives throughout the United States and Acosta to Costa Rica, records show. The one exception: the summer of 2022, when both jets were used to ferry guests to de la Torre and Acosta’s wedding on the Amalfi Coast.

In the released statement, de la Torre’s spokesperson said the executive’s contract “incorporates the personal use of corporate jets.” She did not address questions about specific flights or travel by de la Torre’s and Acosta’s friends and associates. Nor did she respond to questions about de la Torre’s awareness of Steward’s financial woes amid his non-business travel.

The spokesperson noted that the locations in which Steward hospitals operate or seek to operate carry significant security risks and threats of “terrorism, high levels of violence, and kidnapping of high-net worth individuals.”

“A third-party private security consulting firm strongly recommended that he and his family use private transportation, including private air travel, for safety reasons given ‘the threat profile the head of a major health care system inherently faces.’”

The statement continued: “To be clear, his use of the corporate plane not only counted as compensation but was also taxed appropriately. Further, as we have said before, it is highly inaccurate to say or imply that the costs of the plane were born solely by Steward Health Care. Two other entities, including Steward International contributed significantly to these costs.”

Steward’s global entity, Steward International, was registered first as a company in Delaware in 2017, with de la Torre and Callum listed as managers. The Globe has previously reported that Steward executives regularly mixed funds among the entities, and that the companies are not as separate as executives claim.

A super midsize jet such as the Falcon costs roughly $1,900 an hour to operate, according to experts contacted by the Globe. The Bombardier runs closer to $2,700 an hour. At those hourly rates, roughly half a million dollars were spent flying Steward jets to and from Costa Rica from 2022 to 2023.

“One has to wonder,” said Bernard Black, a professor at Northwestern University with expertise in corporate governance. “Did the board know about all this and really think it was a good use of company funds? And how much time did this guy spend doing work?”

Khadija Sharife of the Organized Crime and Corruption Reporting Project contributed to this report.

This story was reported by Chris Serres, Elizabeth Koh, and Brendan McCarthy. It was written by Koh and Serres and edited by McCarthy.

When Ralph de la Torre resigned Tuesday from Steward Health Care, many of the nurses and doctors across the national hospital chain rejoiced and called it the start of a new era.

“It was about time,” said RaeAnne Hallahan, a longtime nurse at Holy Family Hospital in Methuen.

But the new Steward may not look all that different from the old one. Steward’s board of directors, in a step experts in corporate governance call highly unusual, eschewed appointing a successor to de la Torre, leaving the teetering health system without even an interim CEO or chairman. Now, Steward is led by that same board — and many of the same people — that seems to have offered little or no resistance as Steward’s hospitals were starved of resources and de la Torre got rich on massive dividends.

The board includes several top Steward executives and close de la Torre associates, as well as high-profile powerbrokers such as former US House speaker John Boehner and local real estate developer James Karam. Former Trump administration national security adviser H.R. McMaster served four years on the board before resigning in 2023.

All told, the group largely rubber-stamped de la Torre’s strategic vision for years and took home six-figure salaries for attending quarterly meetings. Several also benefited from de la Torre’s extravagant use of company funds on far-flung excursions, entertainment, and meals, a Globe Spotlight investigation has found.

Board members signed off on key deals supporting de la Torre’s aggressive for-profit model even as Steward slid toward financial ruin and patients’ lives were imperiled by staff and medical equipment shortages. Several joined de la Torre on his personal yacht to exotic retreats or dined with him at lavish restaurants, according to records obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe Spotlight Team. Some board members attended a European opera ball and went scuba diving together in the Adriatic Sea.

“This is a massive governance failure, because this board is clearly not leading,” said Douglas Chia, president of Soundboard Governance LLC and a senior fellow at the Center for Corporate Law and Governance at Rutgers Law School. “They are abdicating their duties.”

A federal grand jury in Boston has taken notice. Several board members have been summoned to answer questions from federal prosecutors or subpoenaed to appear before the jury, according to a person familiar with board operations.

The board’s inaction has alarmed many inside and outside the nation’s largest private for-profit hospital system, who point to it as a textbook case of corporate cronyism and the perils of insular boards.

“The board was overpopulated by sycophants who refused to speak up, ask questions, or take action,” said the person familiar with the board’s work.

Four corporate governance experts told the Globe that Steward’s board failed in dramatic fashion when it came to fulfilling its most fundamental duty: holding its chief executive accountable.

De la Torre’s mismanagement and blurring of corporate and personal funds should have prompted Steward’s board to fire him, they said, rather than allowing him to step down amicably. By itself, his refusal last month to appear before a Senate committee — in defiance of a government subpoena — marked a serious enough breach of his duties to remove him, they said.

“That’s a grave offense,” said Lawrence Cunningham, director of the John L. Weinberg Center for Corporate Governance at the University of Delaware. “If the CEO is unwilling to testify before Congress, I think the board should start looking for a new CEO.”

The Globe reached out multiple times, starting in July, to every person who served on Steward’s board in the last four years to ask about their oversight of the company. All of them either declined to comment or did not respond to interview requests.

Company spokesperson Josephine Martin declined to respond to several questions about the board. De la Torre declined to comment through his personal spokesperson, Rebecca Kral.

Public companies are required to have a board of directors. Though Steward is a private limited liability company, registered in Delaware, companies like this also typically have a board that oversees the managers of a business, provides a layer of oversight, and interacts with investors, experts said.

Steward’s board was closely aware of the company’s inner workings in part because many members were company executives themselves. Corporate governance experts told the Globe that the executives were in a position to have outsize influence on a relatively small board and this is considered detrimental to independent oversight.

Among the company executives who served as board directors: Michael Callum, the company’s executive vice president for physician services; chief strategy officer Ruben King-Shaw Jr., a former high-ranking official with the federal Centers for Medicare and Medicaid Services; and Mark Rich, the current president of the company. Sister Vimala Vadakumpadan, another board member, has been a longtime chairperson of the board of St. Anne’s Hospital in Fall River.

At one point last year, Steward executives, including de la Torre, held nearly half of the board’s nine positions. (The board recently added two directors, William Transier and Alan Carr, who are part of a “transformation committee” overseeing company matters related to the bankruptcy.)

The whole board was regularly updated on the company’s financial dealings, hospital budgets, and aggressive expansion plans, internal emails and board records show. Directors received multiple updates on international endeavors like Steward’s disastrous foray into Malta. In one 2021 board meeting, the Maltese operations were described in a PowerPoint as a “rapid success.” Today, Steward’s dealings in the island nation are part of a sweeping criminal corruption case being prosecuted there.

The board was also briefed on a massive $111 million payout to Steward shareholders in January 2021, according to de la Torre’s spokeswoman. That deal, in which de la Torre was the main beneficiary, too has come under scrutiny.

In other instances, directors received detailed briefings on and approved key Steward transactions, including its critical dealings with Medical Properties Trust, the Birmingham, Ala.-based landlord to which Steward paid hundreds of millions of dollars in rent.

During meetings, which typically occurred quarterly, the board was expected to review the company’s financials and advise management on risks to the company. For their part, board members received at least $125,000 to $250,000 a year from Steward, payouts, plus expenses and stock grants, documents show. By comparison, the median pay last year for non-employee directors in large companies listed on the Standard & Poor’s 500 index was $110,000, according to a recent survey.

Several directors reaped even more benefits from Steward’s largesse.

Callum and his spouse ventured off on a weeklong voyage on de la Torre’s yacht Amaral to Greece, Croatia, and Montenegro in 2022, according to internal emails. He and de la Torre were also aboard the Amaral the previous year to tour the Mediterranean islands of Sardinia, Corsica, and Monaco, capped by a night at the opulent Casino de Monte Carlo in Monaco.

McMaster, the former Army lieutenant general and adviser to Donald Trump, was listed on an itinerary with his wife as guests on a five-day trip to Austria with de la Torre, an excursion linked to a Steward Health Care International board meeting. That trip included a visit to the Vienna State Opera ball and a performance at a Spanish horse-riding school. A 2023 excursion to the same ball — including a dozen tickets, private box, and hotel stay — cost approximately 120,000 euros, or roughly $130,000, according to emails shared with the Globe by OCCRP, a global journalism outlet.

McMaster, who stepped down from the board in 2023, declined through a spokeswoman in July to answer questions about his time at Steward. He was recently on a book tour and did not respond to additional requests for comment.

High-profile directors like McMaster and Boehner are often recruited by companies to build credibility and to attract new investors. Yet Steward appeared to use them to serve an additional purpose: making political connections to try to help secure lucrative overseas contracts.

McMaster, a decorated military commander who served in the First Gulf War, Iraq, and Afghanistan, used his rolodex of foreign connections regularly on Steward’s behalf. He brokered introductions for Steward executives to influential people, including the former US deputy national security adviser to Saudi Arabia, whom he called the “best connected person in the Kingdom,” emails show. Executives also prepped McMaster with talking points ahead of conversations with Malta’s prime minister and Saudi Arabia’s ambassador to the United States, according to emails reviewed by the Globe.

Steward executives gushed over Boehner’s and McMaster’s star power. Steward president Mark Rich referred to McMaster in one May 2021 email as “the friggin hero of the 1st Iraq War” and Boehner as a “republican non-Trump icon.”

“These are not men to be trifled with,” Rich wrote.

Corporate governance specialists invoked a parallel between Steward’s board and that of Theranos, the disgraced blood-testing company that packed its board with eminent statesmen and high-powered politicians.

“Too often, people like Boehner and McMaster are invited into boards and become little more than symbols, or trophies to adorn the boardroom — instead of benefiting these companies with their insight,” said Wei Jiang, a professor of finance at Emory University’s Goizueta Business School in Atlanta. “Clearly that didn’t work in this instance. It’s a lot like Theranos.”

With Theranos, board members managed to avoid culpability by showing they were misled by a conniving CEO. That may be more difficult in Steward’s case if board members were privy to more detailed knowledge of the company’s dealings, said corporate governance experts.

The small size and tight relationships of Steward’s directors may have also hampered the board’s ability to check de la Torre’s management actions and personal excesses, experts said.

The boards of major hospital systems in New England far eclipse Steward’s in size. Mass General Brigham has a 22-person board, and Beth Israel Lahey Health’s board has 20 members.

The Steward board’s decision to forgo naming a successor to de la Torre, at least for now, reflects its ineffectiveness and detachment, experts said.

“Clearly no one is in charge,” Chia said. “This board was completely subservient to Ralph [de la Torre]. They were so checked out that when he was gone they didn’t even have a clue what to do.”

Larger boards have greater potential oversight capacity: They can bring in more independent directors with different perspectives and create specialized committees to monitor executive performance, pay, and internal controls, experts said. As recently as May 2020, Steward had just five directors on its board — a number so small that it’s shared by fewer than 2 percent of boards of large companies in the Standard & Poor’s 500 index, according to the Conference Board, a research firm.

“For a CEO who doesn’t want to be monitored, this kind of board structure would be a dream,” said Cunningham, the corporate governance expert.

Boards of private companies, like their public counterparts, can be subject to legal liability for failed oversight of company affairs, particularly if they have ignored red flags, the legal and corporate governance specialists told the Globe. Investors and creditors are among the parties that could sue boards for serious breaches of their responsibilities, they added.

Fifteen current and former company officers and directors have already incurred legal fees and expenses because of the ongoing investigations into Steward, the company disclosed last month in a bankruptcy filing. Steward sought a court order to allow insurance policies to cover those expenses, saying those investigations “have required, and will continue to require” those officers to pay legal fees.

“These board members need to be thinking seriously about what their personal liability might be,” said Todd Haugh, a professor of business law and ethics at Indiana University’s Kelley School of Business.

Lawsuits against company boards used to be rare, in part because the bar for bringing them was especially high. That changed in 2019, when a Delaware court allowed shareholders to sue ice-cream maker Blue Bell Creameries’ board after a listeria outbreak killed three people and caused the company to recall its products. Since then, more claims against directors have survived court challenges, putting boards on notice that they can’t turn a blind eye to clear evidence of malfeasance.

In the last few months Steward’s board has continued to meet, sometimes even weekly.

The meetings have traditionally started with Vadakumpadan, the Dominican Sisters of the Presentation nun and longtime board director, leading the group in reflective prayer. Often this year, the prayers have been for “strength and hope,” according to records reviewed by the Globe.

But in late April, Vadakumpadan opened the meeting with an invocation for something different: “humility and surrender.”

A week later, Steward filed for bankruptcy.

Mark Arsenault, Jessica Bartlett, and Hanna Krueger of the Globe staff, as well as Khadija Sharife of the Organized Crime and Corruption Reporting Project, contributed to this report.

By Mark Arsenault, Chris Serres and Elizabeth Koh

In a sign that a criminal probe into Steward Health Care has picked up steam, a prominent member of the company’s board of directors, former US House speaker John Boehner, appeared at the federal courthouse in Boston Thursday where a grand jury is investigating allegations of fraud, bribery, and corruption within the national health care chain.

Boehner ignored several questions from a Globe Spotlight Team reporter Thursday morning at the John Joseph Moakley Federal Courthouse. Boehner, who recently received a federal subpoena, was inside the courthouse for two hours.

As a member of Steward’s board, Boehner was privy to key financial details about the company as its financial situation cratered and patients’ lives were imperiled by staff and medical equipment shortages. The Globe reported last month that several board members had been summoned to answer questions from federal prosecutors as part of the grand jury probe.

Federal law enforcement also has been in talks with several top Steward executives, the Spotlight Team has learned.

Grand jury proceedings are secret and law enforcement is prohibited from discussing them. Christina Sterling, a spokeswoman for Acting US Attorney Joshua S. Levy, said the office doesn’t “confirm or deny” investigations.

The grand jury is scrutinizing various allegations regarding Steward’s domestic and international operations, including potential violations of the Foreign Corrupt Practices Act, a law that prohibits bribery or corruption abroad, according to people familiar with the matter. The jury is also examining the company’s financial dealings, including money allegedly used by former chairman and chief executive Ralph de la Torre, as well as other executives, for personal interests.

The investigation is also looking at broader instances of potential fraud and embezzlement, the Globe has learned.

The prosecution team includes four veteran assistant US attorneys, three of whom are prosecutors specializing in health care fraud and white-collar crime. The fourth works for the civil division of the US Attorney’s Office for Massachusetts.

David Schumacher, a criminal defense attorney who previously served as deputy chief of the health care fraud unit, said it’s common for federal criminal and civil attorneys to work hand in hand, since the cases they put together can include civil fines and possible criminal penalties.

Once the largest private for-profit health system in the country, Steward declared bankruptcy in May. A company spokeswoman declined to comment Thursday.

Boehner, a longtime Republican US representative from Ohio, served as speaker of the House from 2011 to 2015 before resigning from Congress that year. Now a strategic adviser for prominent Washington, D.C., lobbying firm Squire Patton Boggs, Boehner also has served on the boards of tobacco giant Reynolds American and Acreage Holdings, a cannabis company.

Steward’s board members received between $125,000 and $250,000 a year for their service, as well as expenses and stock grants, documents show. In the year before Steward’s bankruptcy, Boehner was paid more than $313,000 in all, according to court filings.

Public flight records and internal company documents also show Boehner traveled on Steward planes at least four times after he joined the company’s board in 2019. He flew to and from Dallas in June 2022 from Hamilton, Ohio, the seat of his longtime congressional district. He flew again to Dallas in April 2023, traveling from Marco Island, Fla., where he owns a condo. A few days later, he flew to Washington, D.C.

Boehner is one of a handful of prominent power brokers who have served on Steward’s board in the last five years. Local commercial real estate developer James Karam is a current member. Former Trump administration national security adviser and Army lieutenant general H.R. McMaster served several years before leaving the board in 2023.

The board also includes Steward executives Michael Callum, executive vice president for physician services; chief strategy officer Ruben King-Shaw Jr., a former high-ranking official with the federal Centers for Medicare and Medicaid Services; and Mark Rich, the current president of the company. Sister Vimala Vadakumpadan, another board member, has been a longtime chairperson of the board of St. Anne’s Hospital in Fall River.

The investigation into potential violations of the Foreign Corrupt Practices Act will include an interview with British corporate investigator Greg Gillespie. Gillespie recently told the Globe that he is scheduled to meet with US law enforcement in the UK in January. In 2021, Gillespie compiled a dossier on the financial irregularities of the Swiss accounting firm Accutor, which he and Maltese officials alleged was used by Steward as a vehicle to bribe Maltese government officials.

Steward’s public-private partnership to run hospitals in Malta is already the subject of a sprawling criminal inquiry in that country. That criminal case has ensnared top political officials and targeted de la Torre and Steward Health Care International president Armin Ernst.

In the US, the Globe has reported, the transactions under federal scrutiny include instances where de la Torre used Steward’s funds as his own. These may include a multimillion dollar donation to his children’s prep school; the use of the company jet to transport friends to tropical destinations; and over $11 million to purchase and renovate an apartment in Madrid, according to people familiar with the matter.

One PowerPoint presentation from 2021, prepared for a Steward Health Care International company meeting, lists that Madrid house transaction as one of several banking movements that require “clean up.”

“All types of economic transactions (wirings) that involve Steward HC International ... need to have proper documentary support,” concludes one slide in the presentation, which was obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe. “Otherwise we will face: corporate governance, reputation issues, risk of money laundering perception with legal responsibilities, tax risk of non-tax deductible expenses, fines, penalties.”

In court, proving fraud would require more than just evidence of extravagant spending, former federal prosecutor Philip Urofsky told the Globe. To prove fraud would require either proof there was no business purpose for the expense, or that the company falsified its records to try to conceal payments, he said.

“One man’s looting could be another man’s retention payment,” Urofsky said. “They could call it a benefits package.”

The Spotlight Team previously identified at least 15 instances in which Steward patients died after failing to receive professionally accepted standards of care due to equipment issues or staffing shortages. At least 16 other patients suffered injuries in similar circumstances, the Globe probe found. And at least 2,000 more were found by federal regulators to have been put in immediate peril.

On Thursday, Boehner arrived at the courthouse’s main entrance around 9:30 a.m., alongside attorney Lee S. Richards III, of the firm Perkins Coie, and two other people. He checked his cellphone with a court officer in the lobby, in keeping with courthouse policy, and then showed his ID to another officer before passing through the metal detector.

At 10:45 a.m., Boehner stepped outside the back entrance of the courthouse briefly to smoke a cigarette. He again ignored questions from a reporter. A Boehner associate attempted to shield Boehner’s face with a piece of paper. “Have a nice day,” Boehner said before reentering the courthouse.

Richards, a New York-based attorney, did not return messages seeking comment.

Board members Callum, Vadakumpadan, and McMaster and William Transier did not respond Thursday to requests for comment. Karam, through a spokesman, declined to comment. When reached by phone on Thursday, Carlos Hernandez hung up on a reporter. Alan Carr declined to comment.

An earlier version of this story implied Boehner testified before the grand jury early Thursday. Subsequent reporting showed the nature of his activities at the courthouse was unclear.

Hanna Krueger, Rebecca Ostriker, Brendan McCarthy, and Gordon Russell of the Globe staff contributed to this report.

This story was reported and written by Jessica Bartlett, Elizabeth Koh, and Liz Kowalczyk. It was edited by Gordon Russell.

When Melissa Williams looks down at her ruined right hand, all she sees is loss.

Two fingers and part of her palm have been amputated.

Gone, too, is her financial security. Williams has been unable to work regularly since 2017, when she entered a Steward Health Care hospital in Melbourne, Fla., for a common operation, and a botched IV insertion led to searing pain and a host of complications that continue today. Williams sued Steward in 2019 for what seemed an egregious case of malpractice.

Five years later, and facing $500,000 in medical bills, she hasn’t seen a dollar from the hospital chain.

It is unclear why no settlement has been reached, and Steward continues to fight the case in court. But a Globe Spotlight Team review points to a possible explanation for the frustrations Williams and scores of other Steward patients have experienced. Executives at the overextended hospital chain have treated their in-house malpractice insurer, TRACO, like a piggy bank, pulling cash from it at will, and severely depleting the assets meant to cover claims of medical harm.

Indeed, Steward was so eager to spend TRACO’s money that it moved the insurer from the Cayman Islands — a traditionally permissive locale for foreign investors — to Panama, where certain key regulations were even more lax. Auditors had been pushing Steward to shore up TRACO’s balance sheet. But executives had other plans for the insurer’s assets and believed Panama would allow them more freedom to spend, according to three Steward insiders and internal company emails.

The aggressive draining of TRACO’s balance sheet has Melissa Williams wondering if she will ever be compensated for her losses. She and her 14-year-old son recently had to put their belongings in storage and move in with a friend.

“What if your lawsuit never settles?” asked Williams. “What if you never get a dime?”

At the time of TRACO’s relocation to Panama, executives at Steward — then growing from its base of nine Massachusetts hospitals into the largest private for-profit health care chain in the US — had already taken millions of dollars from its insurer, whose leadership overlaps substantially with Steward’s. The borrowing accelerated as Steward hemorrhaged money, with enormous IOUs from the hospital chain replacing TRACO’s funds. By the end of 2023, TRACO’s books showed $99 million in outstanding loans and interest, almost all of it owed by Steward. Separately, TRACO listed $176 million in “accounts receivable.” Bankruptcy documents make clear that most of that sum is owed by Steward.

The real value of those IOUs today is uncertain at best, given Steward’s declaration of bankruptcy in May. As of August, TRACO listed just $3.5 million in cash — an absurdly small sum when stacked against the 517 malpractice claims against Steward that are either pending, like Williams’s case, or settled but unpaid. Steward’s lawyers have said the remaining claims could cost as much as $200 million to settle.

The grim financial picture means that patients who suffered from shoddy care at Steward facilities could be harmed a second time, when they are unable to collect what they’re owed.

At risk, too, are some of the thousands of doctors who worked for the chain and now wonder if the malpractice insurance that was supposed to be protecting them is worthless. At least one lawyer involved in suits against Steward has begun suing doctors personally, betting they have deeper pockets than the chain.

The strip-mining of TRACO and its impacts have gotten limited attention amid a larger pattern of questionable financial dealings at Steward, whose owners took hundreds of millions of dollars in payouts even as their hospitals crumbled. The firm’s stunning collapse is now being investigated by a federal grand jury meeting in Boston.

Timothy Walsh, an attorney for TRACO, told the Globe that “TRACO is not insolvent as long as the debtors adhere to their obligations, which we expect them to do.” TRACO’s biggest debtor, of course, is Steward, which is broke.

TRACO officials declined to answer other questions. Steward representatives also declined to comment for this story.

Born in the islands

TRACO is what is called a captive insurer, a wholly owned self-insurance vehicle of the sort that many hospital systems prefer. Health systems like Steward typically pay premiums on behalf of their doctors, though some 200 Steward-affiliated doctors actually paid Steward malpractice premiums out of of pocket. The premiums are supposed to go into a pool that is used to litigate claims and pay them when necessary.

Money in the pool can be invested, ordinarily with a preference for low-risk vehicles that are easy to cash out. If the company manages its risk well and the pool grows large, some assets can be returned to the firm.

Decades ago, there was no mechanism to set up such captive insurers in the United States. So, in 1988, Steward’s predecessor — Caritas Christi, which was run by the Archdiocese of Boston — incorporated TRACO in the Caymans. The name is an acronym for Tailored Risk Assurance Co.

The Caymans’ reputation for permissiveness helped it become a business hub, but also landed the country on international watch lists for, among other things, failing to adequately combat money laundering. Over the last 15 years, the nation’s leaders tightened things up, and today, “the regulatory structure and requirements” of the Caymans match those of European countries, said Mark E. Reynolds, president of CRICO, the group captive insurer for many Boston teaching hospitals, which was long based in the Caymans.

Panama, by comparison, has not been a beacon of respectability. As Steward finalized its bid to move TRACO there in June 2019, one international body flagged Panama as vulnerable to money laundering. Another found it susceptible to tax evasion.

On top of that, Panama had little or no expertise in setting up and regulating companies like TRACO. The firm is one of only six captive insurers headquartered there.

Nancy Gray, who oversees captives in the region for Aon, a leading insurance consultancy, said she doesn’t know why an insurer would move to Panama. Not one of her firm’s 1,000-plus captive clients is located there.

The Cayman Islands “have been doing this for many years,” Gray said. “There is no reason to recommend a domicile without a developed practice … [and] regulators who understand the business and have been involved for a while.”

The wonders of Panama

But Steward’s leaders were eager to escape restrictions on how they could spend TRACO’s money. They saw Panama as a sanctuary, according to Globe interviews as well as internal emails obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe.

For instance, when auditors from Ernst & Young questioned whether Steward had given Panamanian officials ample notice of a change in finances, a Steward executive assured his colleagues that, unlike in the Caymans, it wouldn’t matter much.

“Seems like EY [Ernst & Young] is missing the ‘so what’ component here,” wrote Jacob Frumkin, Steward’s vice president for finance. “Whether or not we did something we shouldn’t have, the beauty of Panama is the ‘so what’ is not going to be that we’re not an insurance company anymore … it’s probably a discretionary fine of a $1,000 or something like that.”

Perhaps the most important distinction between Panama and the Caymans was the flexibility Panama allowed TRACO in using its money. In Panama, “there is no limitation on TRACO’s ability to loan or invest its assets,” Frumkin explained in an email to auditors and a group of fellow executives. TRACO had to keep a balance of just $150,000 in a Panamanian bank.

In another 2019 email, Steward’s chief financial officer John Doyle pushed for Steward’s lawyers to produce a letter explaining TRACO’s upcoming relocation. “This is needed to get EY [Ernst & Young] off of our backs re the need to fund the Cayman captive,” he said.

By May of that year, TRACO just needed a physical office to complete the relocation. TRACO’s president, Rubén José King-Shaw Jr., had an idea: How about his penthouse, in a swanky part of Panama City?

The firm’s local attorneys balked, saying TRACO would need a “formal office, where the authorities can go and make inspections.”

King-Shaw pushed back. Less than a month later, he emailed fellow Steward executives with good news: Panama would allow TRACO to be domiciled in his penthouse.

Dr. Ralph de la Torre, Steward’s CEO, was jubilant. The move was finally on.

“Yay!” he replied in an email. “Great job!!”

‘Where the cash is’

Even as they plotted to move TRACO to Panama, Steward executives began stepping up the drawdown of TRACO’s treasury.

In 2019, they invested $132 million of TRACO’s money into Davis Hospital and Medical Center in Utah, which Steward had bought two years earlier.

Captive insurers typically invest in vehicles that are easy to cash out.

“If you needed to pay losses, to get funds for the captive, how are you going to be able to do that if you have to sell real estate?” asked Tim Slowick, who helps manage UMass Memorial Health’s captive. “Hospitals aren’t the easiest piece of real estate to sell.”

Steward did eventually sell Davis, in 2023. But there’s no evidence any of the proceeds went to TRACO. Instead, the amount TRACO listed in “investments” on its financial statements dropped by $132 million at the close of that year. And the amount TRACO said it was owed in accounts receivable jumped from $289,000 to $176 million.

Steward’s bankruptcy filings say that TRACO still owns a 30 percent share in Davis, but the hospital’s new owners, CommonSpirit Health, told the Globe they own it free and clear.

The IOUs continued to pile up after the move to Panama, according to emails reviewed by the Globe.

In December 2020, the insurer sent $5 million to another Steward business. Another loan was drafted in 2021, this time taking $6.7 million from a TRACO affiliate. The money was to be used to help acquire and develop a hospital in Colombia, the emails show.

“TRACO is where the cash is I am told and that is where Ralph wanted it funded from if possible,” wrote Mark Rich, then a Steward consultant and now the company’s president.

By that time, Steward had stopped sending the premiums it was paying on behalf of doctors to TRACO, giving the captive an IOU instead, according to one former Steward executive.

TRACO’s habit of accepting IOUs and making loans to Steward, especially given Steward’s precarity, struck others in the industry as suspect.

“If you wanted to be sneaky, you could borrow money from your captive, move it to your parent company, and the captive would be holding an asset that would be that loan,” said Dr. Eric Dickson, CEO of UMass Memorial Health, which has a captive in the Caymans. “The value of that loan if your company went bankrupt is zero. We would never do that.”

While Panama’s rules were looser than those in the Caymans, TRACO nonetheless managed to break them eventually.

Last November, a month after Panama was removed from the international “gray list” for improving its anti-money laundering and financial regulation measures, the country fined Steward $25,000. TRACO was cited for “various irregularities with the administration, mitigation and control of risks,” according to a government website. The company was also cited for “refusing to submit accounting records of its operations.”

Reached by phone, Mary Arjona, chief of the Department of Administrative Law for the insurance department in Panama, said the details are confidential. Pressed further about the country’s rules for captives, she said: “Public officials do not answer these types of questions from journalists.”

The Panamanian government declined to answer written questions posed by the Globe.

Doctors, nurses at risk
Steward has filed for bankruptcy as its finances have cratered. TRACO has denied in bankruptcy filings that it is insolvent, and Steward has sought to assure its doctors and patients that TRACO continues to cover them, paying millions of dollars in defense costs, if need be. But most of TRACO’s assets are IOUs from Steward.

The companies are intertwined in many other ways. TRACO’s board still includes former Steward CEO de la Torre and another top executive, Dr. Michael Callum, though the two recently stepped down from leadership at Steward.

Steward has suggested it will resolve current claims through the bankruptcy — though that may simply mean offering victims pennies on the dollar.

Many former Steward doctors are dubious of the chain’s promises, partly because Steward has a history of not paying its defense counsel. Marc Edward Stewart, a lawyer from Arkansas, said in one of his cases, multiple Steward attorneys have quit over nonpayment.

A physician at St. Elizabeth’s Medical Center in Brighton has been worried about being sued after one of her patients was harmed last year. Months before Steward filed for bankruptcy, she called three law firms for advice. None wanted to represent her, fearing Steward would stiff them.

The physician asked not to be named over concerns of a potential lawsuit.

As TRACO executives, King-Shaw and Callum emailed doctors two months ago to assure them that their insurance was intact. Callum stepped down from TRACO shortly afterward.

The message left some providers incredulous, including Stephen Wood, who worked as a nurse practitioner at Carney Hospital until Steward closed it in August. He and a colleague purchased their own malpractice insurance in May.

“If I were to devise a prank call, this would be a great one,” Wood said. “‘All your medical malpractice is run … in Panama — by the same people who ran your hospital in the ground. But you don’t have anything to worry about! We will take care of it!’ It’s a joke.”

Some lawyers, doubtful they’ll ever collect from Steward or TRACO, have begun to target Steward doctors personally.

Ashton Hyde, a malpractice attorney, filed a suit against a Utah doctor and Steward over a problematic spine surgery in mid-2022. He recently refiled the lawsuit, this time only targeting the physician.

“We are going after the doctor individually and he is effectively uninsured,” Hyde said. “So his personal assets are exposed.”

The question of TRACO’s solvency could be relevant well into the future, because malpractice victims may bring claims years after an incident.

Two health systems — Lifespan and Boston Medical Center — that each acquired two Massachusetts hospitals from Steward have taken the unorthodox step of committing to protect their new employees from past missteps, should TRACO fail to cover them.

Solvency never measured

TRACO’s troubles have drawn little scrutiny from the state agencies that oversee doctors and insurers, though Massachusetts regulations allow either the state Board of Registration in Medicine or the Division of Insurance to require insurers to prove “that funding of the entity is adequate.”

Michele Campbell, a spokesperson at the Insurance Division, asserted that the agency lacks the authority to request the relevant documents from an insurer that, like TRACO, is not licensed in Massachusetts.

The Board of Registration, which licenses doctors, acknowledged in an email from spokesperson Ann Scales that it does not seek financial documents from malpractice insurers. The board pointed to the Division of Insurance as the agency that would theoretically do so.

The board also asserted in an email that TRACO has been paying all its claims – an assertion disputed by multiple attorneys whose clients have unpaid settlements.

‘A bunch of loopholes’

TRACO’s depleted assets and Steward’s bankruptcy have left people like Yasmany Sosa in legal and financial limbo. Sosa’s 35-year-old wife, Yanisey Rodriguez, died a preventable death at Steward North Shore Medical Center in Florida on Sept. 7, 2022, seven days after giving birth to their first child.

Though Steward agreed to a $4 million settlement with Sosa in March, he has yet to be paid.

The money was never going to bring his wife back, or ease his grief. But it was going to help in other ways. Without his wife’s income, Sosa has had to change jobs and work longer hours, he said.

The bankruptcy has made him wonder if he’ll ever get paid.

“They killed my wife, that’s for starters. Second of all, they destroyed my family,” Sosa said through a translator. “This has all become a bunch of loopholes, legal strategies. This really is very difficult for me … I’ve already lost everything.”

Brendan McCarthy and Hanna Krueger contributed to this report.

By Mark Arsenault and Hanna Krueger

Nearly 75 years ago, more than 6,000 people gathered on a Methuen hilltop, under dark skies and in a persistent drizzle. They held umbrellas or newspapers over their heads, and jockeyed for a spot to witness this grand opening.

The dedication of a new Catholic hospital, paid for by donations from the “rank and file,” as their archbishop noted, was a momentous leap for their community.

Nancy Glynn, 13, sensed the magnitude of the moment. The schoolgirl was among the thousands who strolled through the hospital’s open house that September day in 1950. Floors gleamed. New equipment sparkled. Nuns in all-white habits stood sentry at front-line medical posts.

A fund-raising drive, endorsed by the Boston Archdiocese in 1944, had brought in the dizzying sum of $1 million to stand up the sprawling four-story brick-and-mortar building. Businesses gave thousands; working people gave a dollar or two, whatever they could spare. Three years into World War II, people understood sacrifice for the greater good.

A submarine officer from Lawrence sent a $25 check and a letter written in the waters near Okinawa. “I, and the submarine in which I have served, have caused so much destruction in this war that it does my soul good to be able to help construct something.”

Amid this upswell of goodwill and hope, Glynn, the teen from Lawrence, found a calling for service for the sick and needy.

She returned to the hospital in high school to work as a candystriper. She came back after that, for a job as a physical therapist. She so admired the sisters who ran the place and for whom the hospital was originally named that she joined the order.

“What drew me to the Sisters of Bon Secours was they were very human, very down to earth,” Sister Glynn, 87, said recently. “And also the fact that it was a health care community. I knew that I wanted to work in health care.”

The hospital was not merely an asset to the sisters: It was the work of their lives, their reason to be. They not only served at the hospital, they lived in a convent next door. They took winter toboggan rides on the property’s steep grounds. And when they grew old and died, they were buried there, in a cemetery behind the convent.

Holy Family Hospital’s stirring origin story makes its tribulations in recent years all the more devastating. Sold off to a private equity firm and repackaged as a part of the for-profit Steward Health Care chain, this vital public asset — and many others like it — became a victim of Steward’s financial meltdown, which serves today as a warning about what can happen when profit imperative collides with the values and interests of a community.

The rise and fall of Steward tracks a surge in private equity into all sectors of US health care in the wake of the 2010 Affordable Care Act. The annual value of private equity health care deals roughly tripled over the 2010s, reaching $120 billion by 2019, according to experts. Today, private equity firms own around 460 US hospitals, about 8 percent of all private hospitals and 22 percent of all for-profit hospitals, according to the nonprofit Private Equity Stakeholder Project.

At its peak, Steward, with more than 30 hospitals, was a significant slice of that pie. Private equity deals are often pitched as the last chance to save struggling hospitals. Sometimes they do. In other cases, hospital systems have been stripped of assets and neglected while executives and investors reap huge payouts.

Today, Steward is under scrutiny in several ways, including bankruptcy court, where the carcass of the company — $9 billion in debt — is being picked over. And in federal district court, where prosecutors are digging into allegations of financial mismanagement that hastened the company’s collapse.

In Massachusetts, taxpayers are bracing for a $700 million bill to rescue several Steward hospitals, from the same government that permitted this to happen. A Steward spokeswoman said the company declined to comment.

Early this year, the Globe Spotlight Team set out to examine what went wrong in this once-promising, Boston-born hospital chain. The scenes and revelations in this story are drawn from eight months of reporting and more than 100 interviews, including first-hand accounts from key Steward insiders who witnessed, and at times enabled, the company’s downfall. The account also relies on tens of thousands of internal company emails obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe.

What’s emerged is a cautionary tale about letting a wannabe billionaire, a titan of private equity, and a real estate investment trust become stewards of a public necessity like health care. It is about how they took a business dedicated to serving patients, and by their own account, turned it into a business for finance and investing. And it is about how everyone, so far, has gotten away with it.

In the decades following its grand opening, Holy Family suffered a series of indignities, each worse than the one before it. In the 1980s, it was subsumed into the Boston archdiocese’s hospital network, Caritas Christi Health Care, to the dismay of the sisters. They left Methuen in 1988, taking the Bon Secours name and the bones of their departed sisters from the hospital grounds, exhumed to be reburied near their US headquarters in Maryland.

As the archdiocese’s finances grew shaky in the years after the child sex abuse crisis, the six hospitals of its Caritas chain operated on thin budgets.

“The financial challenges were front and center,” recalled Helen Drinan, Caritas’s former human resources chief who worked there in the 2000s.

In 2008, the Caritas board took a big swing at new leadership, hiring a CEO with zeal and intellect, but zero experience running a hospital. Ralph de la Torre was an accomplished heart surgeon, who swaggered into Caritas like a savior in a white lab coat, with a CV chockablock with elite institutions: schooling at Duke University, Harvard Medical School, and MIT; training at Massachusetts General Hospital. He had worked at Boston Medical Center and founded a cardiovascular institute at Beth Israel Deaconess Medical Center.

He also sought personal wealth and power, and exhibited “an unhealthy desire to win at all cost,” as a former colleague put it to the Globe. Several company insiders said De la Torre was often heard to remark: If I’m not a billionaire by the time I’m 50, my life will be a failure.

In response to questions from the Globe, a spokesman for de la Torre released the following statement:

“Dr. de la Torre cannot control what people think they hear. That said, throughout his career, Dr. de la Torre’s mission has been to expand access to high-quality care for underserved communities. You need to look no further than his advocacy for Carney and Saint Joseph’s Medical Center despite their monumental losses.”

When de la Torre took command, the shopworn Caritas hospitals were overshadowed by Boston’s big teaching hospitals, and generally served a less affluent population. But the chain was a vital part of the region’s health care ecosystem. It employed 13,000 and served more than 500,000 patients annually.

De la Torre knew the chain needed fresh capital. But from where? Merger plans with a bigger Catholic health system had failed. Banks hungover from the Great Recession weren’t interested.

That left private equity firms, which attract investment from institutions, such as pension funds and college endowments, and assume stakes in companies seeking cash, expertise, and greater profit margins.

If there’s an episode that best reflects the birth of Steward, company insiders say, it might have been in 2009, at the Ernst & Young Strategic Growth Forum in Palm Desert, Calif. The event brought the celebrities of the business world and more than a thousand executives and entrepreneurs to the JW Marriott Desert Springs Resort & Spa. Along with lectures and panels, the conference offered a chance to network with the stars.

Ralph de la Torre had worked connections to land in a small-group dinner with former Home Depot CEO Bob Nardelli. He had run Chrysler for its private equity owner, Cerberus Capital Management.

De la Torre intended to consult Nardelli on how a deal to reimagine the archdiocese’s hospitals might be structured, and, according to multiple people who heard this story, as the group of self-styled alphas jousted with one another, de la Torre asked Nardelli: Hey Bob, have you ever held a human heart in your hands?

Nardelli came away impressed by de la Torre’s moxie. “This guy had tremendous edge,” Nardelli later recalled. And in the world of private equity, edge is everything. Nardelli later connected de la Torre with the leader of Cerberus’s private equity group.

Cerberus, named for the three-headed dog in mythology that guards the gates of Hades, was cofounded in 1992 by investor Stephen Feinberg, who was recently picked by President-elect Donald Trump to be the next deputy defense secretary. Former Republican vice president Dan Quayle is on Cerberus’s senior leadership team.

Cerberus became one of three private equity firms interested in acquiring the Caritas hospitals in 2010, and the only one willing to invest and stick around for at least five years. That was how long de la Torre said he needed to become profitable, according to a former Steward executive.

At the time, the chain’s rickety finances made it “impracticable, if not impossible” for the church’s hospitals to continue operating as a charity. So said Massachusetts Attorney General Martha Coakley before she signed off on Caritas’s transition into a for-profit business.

The new for-profit hospital chain, Steward, emerged as a subsidiary of Cerberus, allowing the value locked up in hospitals built by sweat and charity to redound instead to Cerberus’s investors.

Like Steward, other private equity-backed hospital chains have cut less profitable services; others have also sold hospital real estate and leased the properties back, choosing quick cash in exchange for ever-escalating rents.

Others paid massive distributions to their owners even as the hospitals they owned struggled. The private equity firm Leonard Green & Partners, for instance, famously took $658 million in dividends and fees from troubled Prospect Medical Holdings, a chain with hospitals in Connecticut and Rhode Island. Prospect is currently being sued by Pennsylvania’s attorney general for “corporate looting.”

With Steward, Cerberus’s initial cash investment was $246 million. That was all the money the firm would put into the company. Steward was required under an agreement with the state to invest at least $400 million to improve its hospitals. That amount would largely come from selling assets and from adding debt — not on Cerberus’s balance sheet, but on Steward’s.

Cerberus, in a recent public statement, said its 2010 investment “saved multiple hospitals that would have otherwise closed more than a decade ago, putting thousands of employees out of work, and leaving the communities served by these hospitals devoid of necessary healthcare services.”

For nearly its first six years, Steward delivered no giant paydays for its private equity owners. That was about to change.

Five years after de la Torre wooed Nardelli in Palm Desert, the relationship between Steward and Cerberus had soured. Though Cerberus provided the catalyst for de la Torre’s company and road to billionairehood, the executive now chafed under its ownership.

De la Torre had taken to preaching about the predatory nature of private equity.

Cerberus is evil. We’re just an asset to them. They don’t care about patients, he’d complain to anyone within earshot, one company insider recalled.

This much was true: Cerberus was out for money. Private equity firms are unlike the 20th-century benefactors of Catholic hospitals. Cerberus’s cash infusion was not charity. They wanted a return. A return with interest.

“You can’t blame a lion for eating you, because that’s what they do,” said one high-ranking Steward executive who heard de la Torre’s pitch.

De la Torre knew it. So he sought a windfall big enough to satisfy Cerberus. To get there, de la Torre and his executive team embarked on a cross-country roadshow aboard a rented plane in search of the big spender that would pay off the private equity giant and supply Steward with the funds to expand.

They started out with the big banks; the Wall Street types with offices in gleaming towers. But no one in New York — or the entire East Coast — would bite.

No matter how much cajoling de la Torre did, potential investors kept pointing out an inherent problem with Steward’s pitch: There had been no profit to date and there seemed little chance of a return. Months into the tour, the executives found themselves inside the waiting room of a small Canadian pension fund, according to a person familiar with the trip. They, too, said, “Thank you for coming, but goodbye.”

Eventually, de la Torre found a second life through something an Alabama-based real estate investment trust was calling the “asset-light” model.

Steward would sell its land and hospital buildings to the firm, Medical Properties Trust. The hitch? Steward would need to lease back those properties at premium prices.

The arrangement transformed Steward’s physical assets into immediate cash.

But most importantly and immediately, at least to de la Torre, the deal represented opportunity.

In the 1940s, when the site in Methuen was selected for the Bon Secours hospital, later renamed Holy Family, townspeople swarmed to the spot as if on a pilgrimage. Some even scooped up loose soil in handkerchiefs, pocketing a piece of history. When construction began, hordes gathered each Sunday to watch the hospital come to life from steel, bricks, and mortar.

In 2016, both the hospital and the land on which it sat had become bullet points in the portfolio of a publicly traded firm, headquartered 1,000 miles away in Birmingham, Ala.

Medical Properties Trust would pay Steward a staggering sum — nearly $1.3 billion — for its nine hospital campuses in Massachusetts, roughly nine times what Steward had paid less than a decade earlier. The majority of the proceeds went to dividends and to return Cerberus’s original investment, not patient care or physical improvements. Cerberus took $719 million; de la Torre and his management team got $71 million, according to figures Cerberus later made public.

De la Torre provided slightly different numbers to the Globe, saying about $55 million in cash was divided among the management team and 19 board members. The group also received MPT stock, which taken together with the cash, totaled about $68 million.

“To be clear,” de la Torre said, “Cerberus was the majority owner at the time of this dividend.”

The deal marked a “key turning point” for the company, said one Steward HR executive. De la Torre and his inner circle were suddenly flush with cash. The HR executive was gobsmacked when he found a $1 million check left on a copy machine near the corporate suite. It was made out to a Steward executive vice president. “They had all gotten so filthy rich from that deal,” said the former executive. “The money changed everything.”

Together, MPT and Steward looked to expand the system, from the Rust Belt to the Deep South to the Rockies, and then overseas.

“The ink was hardly dry on Medical Properties Trust’s first sale/leaseback transaction with Steward Health Care … when a second Steward deal began moving through MPT’s pipeline,” MPT announced in an annual report, referencing the purchase of eight hospitals from Community Health Systems in Ohio, Florida, and Pennsylvania.

Several of the facilities were dilapidated. But that wasn’t the point. Growth was the point.

“We are excited to add these properties to our Steward portfolio!” an MPT executive said in an email to de la Torre and his team, which was reviewed by the Globe.

Mark Rich, then Steward’s chief financial officer, responded sarcastically: “Really? Have you seen some of these buildings? Kidding — thanks.”

In September 2017, Steward added facilities in Utah, Arizona, Colorado, Texas, Arkansas, and Louisiana, making the system the largest private for-profit hospital chain in the country.

A hospital deal with the island nation of Malta was the first stop in Steward’s whirlwind international campaign that included plans to partner with Turkey’s strongman president, Recep Tayyip Erdogan.

Just before Christmas in 2017, de la Torre and his second-in-command, Michael Callum, jetted to Rome and enjoyed a tour of the Vatican with two junior employees. The company did not have business at the Vatican, an insider said, though the cost of the trip was billed to Steward.

De la Torre’s spokesman said the Steward executives were in Malta on business, and then stopped in Rome for two days for business meetings.

Upon their arrival at the Vatican, Boston’s own Cardinal Sean O’Malley greeted the group and gave them a tour of St. Peter’s Basilica — along with an endorsement of their work in health care.

“Many people have the misperception that the Catholic hospitals have disappeared from the Archdiocese of Boston,” wrote O’Malley in a blog post that included a photo of the priest with the Steward entourage. “They have simply moved under the ownership of Steward Health … but they continue to fulfill the mission of serving the poor.”

Through 2018, Steward’s stated mission, outlined in annual filings with the Massachusetts secretary of state, seemed aligned with O’Malley’s words. The company existed to “establish and maintain hospitals,” to “carry on scientific research related to the care of the sick and injured” and “promote the general health of the community.”

But the next year marked an official change of heart. All previous mission language was absent, replaced with a simple, declarative sentence: “The company is organized for the purpose of engaging in investment, trading or financing activities of all kinds.”

By their own words, Steward’s leaders were no longer running a health care company, but a financial one.

That self-admitted change in philosophy — with patients no longer at the center of Steward’s universe — was perhaps best encapsulated by the trip company brass took to Vienna in February 2020, ostensibly for a board meeting.

De la Torre took the company’s jet directly from Dallas, where he was met by other top executives. They stayed at the Hotel Sacher Wien, an imperial five-star ode to opulence.

There was little business on their itinerary. The group took a VIP tour of a Gustav Klimt exhibition, and enjoyed a visit to the National Library and a private performance at the Spanish Riding School. The marquee event of the weekend was the Vienna Opera Ball, an annual gala where attendees sip champagne and gaze at young debutantes who waltz about the ballroom.

In just three days, the Steward executives racked up a bill of roughly $200,000. Every penny of it was billed to Steward Health Care, according to emails and internal expense logs obtained by the Organized Crime and Corruption Reporting Project and shared with the Globe.

De la Torre, in a statement, didn’t offer specifics, but said the trip was “for business purposes related to the work of Steward Health Care International.”

Shortly after the executives got back from Vienna, Steward purchased an even fancier corporate jet, with tiger-striped wood finishes and satin gold plating. The cost: $26.5 million.

The company was spending beyond its means. At headquarters, bills for hospital services were stacking up. Vendors were starting to squawk, occasionally staking out the Steward parking lot to demand payment from hospital leaders. And then in March 2020, the pandemic hit.

Already facing massive debt, Steward was pushed to the limit when elective surgeries — the cash cows of health care — were canceled indefinitely. Looking to offload one of its most unprofitable hospitals, Steward gave the Commonwealth of Pennsylvania an unappetizing offer: Give us $40 million within three days or we’ll close our hospital in Easton, a small city in the Lehigh River valley, eliminating 700 jobs and a key health care facility.

This was what it meant to be a financial firm organized for investment and trading. Steward viewed Easton Hospital as a cash sieve. Steward had been in talks since late 2019 to sell it to St. Luke’s University Health Network, based in Bethlehem, Pa., a nonprofit. Steward has said it told the Pennsylvania Department of Health in January 2020 that the hospital would close by late April if it was not sold by then.

But with the onset of COVID, St. Luke’s tapped the brakes.

Nobody in Easton knew life without the hospital. It had been established in 1890, financed by a public charity drive. Many native Eastonians took their first breath there. Community Health Systems bought Easton in 2001, and then flipped it in 2017 to Steward.

Steward’s bailout request to Governor Tom Wolf, dated March 22, 2020, came 16 days after Wolf declared a state of emergency over COVID. When Pennsylvania officials offered $8 million with stiff conditions, Steward tightened the screws, writing on March 27 that Steward was ready to surrender the operation of Easton to the state that very night: “If the Commonwealth has no interest in assuming all operating expenses and liabilities for Easton Hospital, Steward Health Care will proceed immediately on planning to close the facility.”

Some inside Steward were queasy about the hard-nosed strategy. One insider likened the move to an armed stickup of state officials. “It went beyond callousness,” the former executive said, “it was contempt for the state and the need to step up in a global pandemic.”

Even as the virus ravaged his hospitals across the country, de la Torre found himself with a reason to celebrate in May of 2020.

A $95 bottle of Laurent-Perrier Cuvée Rosé was opened in triumph. And not just opened, but sabered. That is, the top of the bottle, cork and all, had been cleaved off with the stroke of a knife, unleashing a foaming geyser, as Napoleon’s soldiers were known to do.

A photo from the moment, which de la Torre shared by email with another Steward executive, shows two champagne flutes, the decapitated bottle, and a gleaming silver saber. The caption: “Ding dong the witch is dead.”

De la Torre’s day had come. Steward, MPT, and Cerberus had confected a complex deal that was aimed at getting the private equity company out. It allowed de la Torre and his team to acquire Cerberus’s shares in Steward for a $350 million loan.

But de la Torre wasn’t quite free of Cerberus’s restrictions. Until the note was paid, Steward was forbidden from distributing money to its shareholders, the most significant one being de la Torre himself.

He wanted a payday. MPT jumped in to help.

“We think we have a plan,” MPT’s chief financial officer R. Steven Hamner, wrote to de la Torre in an email obtained by the Globe, “and then you are free at last and can take a well-deserved distribution.”

In January 2021, MPT loaned $335 million to Steward executives to help them buy out Cerberus, at a discount. The private equity firm exited Steward with about $800 million in profit, an annual return averaging about 14 percent over 11 years, a healthy but not exceptional amount by private equity standards.

Steward then paid a $111 million cash distribution to its owners. The payment was “advisable and in the best interests of the Company,” according to the confidential Steward document authorizing the distribution. It was signed by de la Torre, the majority owner and the prime beneficiary.

De la Torre received about three-quarters of the payment. MPT, which owned about 10 percent of Steward, got $11 million.

De la Torre’s portion of the distribution was intended to “partially offset Dr. de la Torre’s guarantee” of a $200 million loan from MPT that aimed to recapitalize Steward, which he backed with his stake in the company, he has said through a spokesman.

Amid de la Torre’s new wealth, hospitals in the Steward network struggled. At St. Elizabeth’s Medical Center in Brighton, the elevators, particularly in the labor and delivery unit, rarely worked for much of 2023.

Nurses wheeled critically ill newborns to lifts farther away, manually hand-pumping oxygen into their lungs with each step. A ceiling tile once fell and narrowly missed a baby in a bassinet. Crumbling concrete in the parking garages tripped up nurses. One broke her ankle, another fell and hit her face. It was here, at St. Elizabeth’s, that the staff ran out of bereavement boxes for stillborn infants.

Five Irish women founded St. Elizabeth’s in 1869 in a four-story brownstone tucked into a cramped row of Boston’s South End. The fledgling hospital catered to immigrant women who had lived hard, taxing lives of service for others. The 30 beds were always full.

It was clear a bigger space was needed, something “capable of sheltering whatever poor soul, requiring its aid, may knock on its doors — a blessing to the community and an honor to the city,” wrote Horatio R. Storer in a 19th-century book entitled “Nurses and Nursing.”

A century later, the hospital moved to a 12-building complex in Brighton that saw St. Elizabeth’s become an early pioneer in gynecology. But by 2022, the Brighton property was dangerous and derelict due to deferred upgrades and maintenance.

The grim conditions were the norm for a Steward hospital by 2023. Bats took up residence in the attic of Rockledge Regional Medical Center in Florida. Air conditioning units died during a heat wave in Arizona, sending temperatures in the emergency department into the 90s. Broken radiology equipment, scarce blood banks, and shortage of needles drove one Louisiana doctor to liken conditions to “third world medicine” in a federal inspection report.

By May of 2024, Steward owed nearly $1 billion in unpaid bills, $1.2 billion in loans, $290 million in unpaid employee wages and benefits, and $6.6 billion in long-term rent obligations to MPT.

By then, Steward officials had quietly been meeting for months with top Massachusetts health officials to demand help in staving off the seemingly inevitable collapse of the chain. Bankruptcy seemed inevitable. The hospitals would need to be sold or closed.

The executives, who took home hundreds of thousands in bonuses in 2023, came to a humbling realization, as outlined in internal presentations obtained by the Globe.

Perhaps hospitals such as St. Elizabeth’s and Holy Family would be better off under the control of a nonprofit hospital operator?

Steward Health Care officially filed for bankruptcy in May, 14 years after Cerberus made its initial investment. The fallout of Steward’s collapse will be felt for decades to come.

What’s clear today is that de la Torre and his associates ran the system into the rocks and got rich doing it. The ultimate risk of their actions fell on the general public, the health care workers who served in their hospitals, and the patients who sought care in their most vulnerable moments.

Earlier this month, the state of Pennsylvania was faced with yet another Steward ultimatum. Steward demanded the state cough up millions to keep a rural 163-bed hospital afloat. The state declined. The hospital is set to close next week.

Meanwhile, more than 500 outstanding malpractice claims remain unpaid or unsettled after Steward raided the coffers of its in-house insurer. Grievously injured patients await restitution, while doctors foot their own legal bills.

De la Torre, who left Steward in September, has been held in contempt by Congress after not showing up for a September committee hearing on Steward’s demise. But his public shaming seems divorced from the forces that underpinned his rise — a considerable shift in US health care from patients-first to profit-first.

“I wish this were not true, but there are hundreds of Ralph de la Torres who are making a disgusting fortune off of withholding health care from people in need,” said Senator Chris Murphy, a Connecticut Democrat, speaking at a hearing in Washington on the Steward fiasco.

In his own state, Murphy said, a scandal involving Prospect Medical Holdings — another private equity-backed hospital company that also did a huge sale-leaseback deal with MPT — was a near carbon copy of the Steward scandal.

“This is just a choice to decide to commoditize our health care system,” said Murphy. “How have we let American capitalism get so off the rails, so unmoored from the common good?”

It was a rhetorical question.

Steward spent much of this year taking itself apart.

Holy Family, with a campus in Haverhill in addition to the original Methuen location, was bought by Lawrence General Hospital, aided by $165 million in state money.

Sister Glynn, who still has great affection for the hospital, recalled being “very, very sad” when it was sold to Cerberus, because she anticipated hard times under for-profit ownership. “The mission is different than not-for-profit hospitals,” she said. She was pleased to see the hospital emerge from Steward under the control of a nonprofit. “I think it’s the best solution for the provision of health care,” she said recently.

A short drive south, in Dorchester, Steward’s Carney Hospital was deemed unsalvageable. The 161-year-old hospital, established in 1863 with a charitable gift from Irish immigrant Andrew Carney, expired on the morning of Aug. 31.

Anger, sadness, and a deep sense of betrayal swept over the remaining staff that day. Some employees ripped crucifixes from the hospital walls. Others took turns punching and kicking a mannequin in the lobby depicting de la Torre in prison garb.

By dawn, a group of nurses danced to Sister Sledge’s “We Are Family,” blaring from a car stereo outside the ambulance bay on Dorchester Avenue.

Promptly at 7 a.m., closing time, security officer Bob Huxley emerged from behind the automatic doors of the emergency department and yelled, “Last call!” to a crowd of onlookers. He locked the doors and urged anyone who needed emergency medical care to call 911. “To have this happen is an atrocity,” said Huxley, his eyes flooding with tears. “Where are the politicians? Where are people going to go?”

By 8 a.m., the crowd had dispersed. Left in its wake: A handwritten sign that read: “You’ll regret this!”

Chris Serres, Rebecca Ostriker, Elizabeth Koh, Jessica Bartlett, and Liz Kowalczyk of the Globe staff contributed to this report. Khadija Sharife of the Organized Crime and Corruption Reporting Project also contributed.

By Brian McGrory

As yachts go, Ralph de la Torre’s seems particularly stunning — 190 feet in length, many decks tall, an elegantly sculpted creation of glass, teak, and steel. Its six bedrooms hold a dozen passengers, and that doesn’t include the cabins for up to 15 crew members. The Amaral, as it’s called, has a library, living room, dining room, gym, and of course a sun-drenched whirlpool on the top deck.

All of these particulars come courtesy of a pair of websites devoted to the yachting world, YachtCharterFleet and SuperYachtFan, the latter of which describes the Amaral as an example of “exquisite naval craftsmanship.” It put an estimated price tag on it of $40 million and said the annual cost of running it is about $4 million, further proof that nothing in this life comes as cheaply as one might hope.

I wanted to go see it myself until I plugged the details into another site, YachtFinder, and learned that the ship is currently docked in the Galapagos Islands, those islands sitting in the Pacific Ocean off of Ecuador. I tried picturing the editor’s reaction when I proposed a trip to the Galapagos, then thought better of it.

As for the yachtsman in question, Dr. Ralph de la Torre was once a brilliant heart surgeon at Beth Israel Deaconess Medical Center. He went on to become the CEO of Caritas Christi Health Care in 2008 with a mandate to rescue the six troubled community hospitals in Massachusetts owned by the Catholic Church.

By 2010, de la Torre had joined forces with Cerberus Capital Management, a New York-based private equity group, to buy out Caritas Christi and launch a chain of for-profit hospitals. That new company was called Steward Health Care Systems, and de la Torre, its CEO, planned to remake health care across the nation with an innovative edge.

You may have read about Steward recently. Its Massachusetts hospitals, which have expanded to nine, are in financial shambles. The Globe’s Jessica Bartlett has done superb reporting on what has become a full-blown, unfolding crisis, with fears of bankruptcy, talk of hospitals shutting down, the possibility of a state-imposed receivership, and the specter of a taxpayer-funded bailout.

Some 16,000 Steward health care workers might be forced to look for new jobs, communities may lose their anchor hospitals, and an already overburdened state system may be sent over the edge. Think of the absurd and often dangerous wait times in almost any emergency room these days, then think about that with fewer hospitals in the mix. It’s impossible to overstate how bad this could become.

And the guy at the center is the guy with the yacht: Dr. Ralph de la Torre.

De la Torre was never what you might describe as a subtle presence in Boston. He shed testosterone wherever he went, drove fast cars, hosted President Obama at a fund-raiser at his hilltop home in Newton, and badgered his unfortunate lunch companions at the Bristol Lounge. He refined the art of grievance before it actually became a thing. When he moved Steward’s headquarters to Dallas five years ago, he didn’t leave many friends behind — and you can probably lose the “m” from many. I know at least one executive who had simply taken to blocking his calls.

I asked the nice people at Steward if de la Torre had time to talk, and got a polite response that he did not. Maybe he’s feeding the lava lizards near his yacht. His spokespeople, channeling his spirit with amazing accuracy, have lashed out at everyone and everything for Steward’s problems, most especially the unfair limits on how much Steward can charge insurers for its work.

They are not completely wrong. The system needs to change, and vital community hospitals need higher reimbursement rates. But they are far from entirely right. De la Torre and the people at Cerberus took over a fragile chain of underappreciated and under resourced hospitals and proceeded to run it through the wringer.

They accumulated staggering debt and made the kind of complicated deals that only a scavenging private equity partner or greedy CEO would love. I’ll share just one, chronicled in detail by Bloomberg in 2020 and The American Prospect magazine in a pair of jaw-dropping stories last year. Steward sold the land and the buildings out from under its own hospitals, turning them into tenants responsible for hundreds of millions of dollars in annual rent.

That deal allowed Cerberus to cash out in 2021 to the tune of some $800 million, quadrupling its investment, according to Bloomberg, and The American Prospect estimated that the new Steward ownership team, in which de la Torre is by far the majority player, paid itself a dividend of more than $100 million. It was at that time that de la Torre acquired the yacht.

If anyone’s thinking that the Steward hospitals were also the beneficiaries of a much-needed infusion of revenue from all of these transactions, think again. Bloomberg reported that the chain was so slow to pay many vendors that a pizza shop in Brockton had to cut off deliveries to the cafeteria at Good Samaritan Medical Center. Hospital linens, gas bills, boiler repairs – Steward dragged its feet on all of it, according to Bloomberg.

It’s apparently only gotten worse. The Globe’s Jessica Bartlett reported recently that some hospital instruments at Steward’s St. Elizabeth’s Medical Center were repossessed last year for nonpayment, and weeks later, a young mother died from a complication that those tools might have addressed.

The Amaral, as best I can tell, is not in crisis. It has not been stripped down or repossessed and is in no apparent danger of going under. And to be clear, this is not a screed against yachts and mansions and the people who can afford them. But you’d like to think that truly successful people make their millions by creating things that other people want, not by dismantling something that many people need.

The Globe Sunday Magazine did an excellent profile of de la Torre in 2011, as he was launching Steward Health Care. The writer, Neil Swidey, wrote, “De la Torre says it’s ridiculous to think he would leave a rewarding and lucrative career as a heart surgeon to engage in a cynical exercise in accounting tricks. ‘My goal is to fix health care,’ he says.”

These many years later, amid the current crisis, does de la Torre ever reflect on the damage that’s been done? Or does he step out on his deck, breathe the salty air, and revel in his success?

By Brian McGrory

If there is anyone, even a single person, concerned about the toll that Steward Health Care’s bankruptcy is having on CEO Ralph de la Torre, worried about how he must be consumed by the plight of the hundreds upon hundreds of his workers who will soon be out of a job, I have some reassuring words for you.

He’s handling it all better than anyone might imagine.

How much better? Well, when Steward filed court papers in late July to shutter two Massachusetts hospitals, setting off panic and protests in the communities involved, de la Torre wasn’t at his desk in Dallas or visiting his leadership team in Massachusetts. He was in — I can’t believe I’m about to write this — Versailles.

Yes, that Versailles, the one in France, with the palace, the lavish works of art, the Grand Canal, Marie Antoinette, the treaty, all of it.

It’s important to understand that de la Torre, in addition to being a yachtsman, has become something of a horseman as well, because of course he has, with a ranch outside of Dallas and a wife who is deep in the equestrian world, according to those who know him. And Versailles is currently playing host to the Olympic equestrian events, providing what the official website for the games describes as a “truly exceptional and historic setting,” in the heart of Versailles’ stunning gardens. The promotional videos, with muscular horses gamboling across bridges and along grassy fields as the palace windows glint in the sun, say it all.

All of which is to say, nothing — not bankruptcy, not the protests in Massachusetts, not the pain of 1,250 soon-to-be jobless Steward workers — was about to keep Ralph de la Torre away from watching unusually rhythmic dancing horses compete for medals in the Olympic dressage events at one of the world’s most opulent homes of kings and queens.

Multiple people with knowledge of de la Torre’s Olympic trip shared his whereabouts with me as chaos reigned at his company, some of them passing around a since-deleted social media post of de la Torre’s wife holding a glass of wine in Versailles. When I reached out to a Steward spokeswoman with questions about his trip to the Olympics, I received an email back from Rebecca Kral, a partner in an outside public relations firm, who said she’s representing de la Torre “in a personal capacity.” She then declined to comment.

Still, one person with knowledge of de la Torre’s trip, talking on the condition of anonymity, described it as a long-planned family vacation with “unfortunate timing.”

Let’s make sure we capture the entire context of just how unfortunate the timing was. In Dorchester and Ayer last week, outside of the Carney Hospital and the Nashoba Valley Medical Center, frightened workers stood in the heat and the rain protesting the impending closure of their community institutions, sometimes drowning out the politicians who were trying to show their solidarity. At the State House, Governor Maura Healey confessed she was powerless to take meaningful action to keep them open. In Houston, a federal bankruptcy judge continued picking through the wreckage that is Steward Health Care.

All the while, the CEO and founder of the foundering company was watching multimillion dollar horses perform ballet — perhaps his ultimate “let them eat cake” moment.

Is it journalistically appropriate to pause here and ask, are you kidding me? Is there a Hollywood director who would even include such a jarring scene in a movie about the amorality of unwarranted wealth?

The real question, though, is whether this is even surprising, and here I’ll take a stab at an answer. At one level, why anyone would expect anything different from the CEO who sold the buildings and land from under his own hospitals, buried the company in debt, raked in a dividend north of $100 million, cut patient care, failed to pay vendors, and then had the company fund two ultra-luxury corporate jets that he used to soar to every conceivable five-star destination around the world?

But at another level, wouldn’t it be nice to think that maybe, just maybe, a person like de la Torre might learn from his excesses and be capable of some sort of modest change — not redemption, certainly, but a greater awareness that his actions were wreaking havoc on countless others. The Versailles interlude would indicate otherwise.

Perhaps it should make me feel better, though I’m not sure it does, that the two Steward-funded jets, the Bombardier Global 6000 and the Dassault Falcon 2000LX, were recently sold after a column was published about them on these pages, leaving de la Torre to fly commercial to Paris, an indignity for the ages. But this invites a question that Maura Healey might ask as she commits $30 million in Massachusetts taxpayer money to keep Steward’s hospitals afloat: Where exactly did the money go from the sale of the jets?

You can all but imagine even Marie Antoinette taking in this entire sordid situation and proclaiming, “This is ridiculous.”

Maybe. But this, madame, is Versailles.