After months of digging up roadside ditches and crawling through drains to find their sister, Dalee Marez and Kalia Zachary were told that a body had been found in a morgue on the outskirts of Sacramento. There, they found Tonya. Her eyes were missing; so was her skin.

“They said she died of hypothermia,” Zachary said. “Then why did she look like she’d been eaten by wolves?”

The living nightmare of Tonya Walker’s disappearance and death is part of an alleged pattern of wrongdoing by a multibillion-dollar health care company that operates dozens of hospitals across California. Dignity Health has been accused of “callous, reckless, and outrageous failure” in multiple lawsuits that allege it lost patients’ bodies, failed to issue death certificates and neglected to tell family members that their loved ones were dead. Some of these cases led to families and law enforcement carrying out monthslong missing persons searches, all while the bodies were left to decompose at an off-site morgue, the lawsuits allege.

In two civil complaints recently filed in California, Dignity Health has been accused of gross negligence and intentional infliction of emotional distress. In response to the damning audits carried out by the California Department of Public Health in 2022 and 2023, seen by SFGATE, the president of the hospital, who retired this summer, told the Department of Health and Human Services, “We assumed the remains being stored did not have families.”

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Tonya Walker stopped returning calls from her family on Nov. 2, 2023. The 51-year-old mother of four had been struggling off and on with drugs and homelessness in Sacramento, but would often stay with family members and was in regular contact with them until the moment she vanished.

“She was homeless during the time of everything that went down,” Walker’s sister Kalia Zachary told SFGATE. “But she never complained. She just was a happy-go-lucky person. She was a very loving person.”

Walker’s family reported her missing to the Sacramento County Sheriff’s Office on Nov. 10, initiating an official missing persons search. The effort involved distributing hundreds of flyers, posting to social media and searching high and low through Sacramento. The family offered a cash reward of $3,500, which led to numerous fake tips and scams from bad actors attempting to take advantage of the family.

“She’s over here, she’s buried over there. They overdosed her, or they beat her up real bad and put her somewhere,” Marez said of the tips. One message said that Walker was being held for ransom alongside a manipulated image of her in a body bag, demanding a CashApp payment. The sisters searched inside drains and dug up the gravel by train tracks.

Then, on May 31, 2024, seven months after Walker disappeared, a sheriff’s deputy told the family they had found her on a shelf in a morgue on an industrial street in South Sacramento named Quinta Court. “It was a what the f—k moment,” Zachary said.

Although the sheriff’s office closed the missing person case with the discovery, the horror of the family’s search wasn’t over. When they arrived at Mortuary Support Services of Northern California, sometimes called Cremations Only, to identify the body, they were warned not to go in, Marez said.

“They tried to convince us not to see her,” Marez said. “But we weren’t going anywhere. We’d been searching for her for months.”

When they finally gained access to identify Walker’s body, they said they were met with a sight they will never forget: Walker was unrecognizable, and it appeared that her eyes and skin had been removed.

The case against Dignity Health and the contracted crematorium alleges that alongside failing to tell the family Walker was dead and not issuing a death certificate, Walker’s body was “harvested” for organs, despite her never opting to be a donor. Walker’s family eventually managed to obtain notes from Mercy General, the Dignity Health hospital where she died, stating that she was admitted on Oct. 31, 2023, suffering from hypotension, hypothermia and other symptoms. They also learned that she gave an address to the hospital, a home in Sacramento she sometimes shared with her adult son. The sisters never found out how she arrived at Mercy General.

The case also accuses the owner of the mortuary, Michael Lofton, of “gross negligence” for his alleged part in storing dozens of unidentified bodies at a warehouse on Quinta Court.

“This final image of Ms. Walker is now engrained in Kalia and Dalee’s minds as the last image of their beloved sister,” the suit states. “It will haunt them forever.”

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In April 2023, 31-year-old Jessie Peterson suffered a serious diabetic episode and was admitted to the ICU unit at Mercy San Juan Medical Center, another Dignity hospital, around 12 miles from where Tonya Walker died. Jessie had been diagnosed with Type 1 diabetes at the age of 10 and visited the hospital numerous times throughout her life. Two days after she was admitted, Jessie called her mother, Ginger Congi, asking to be picked up from the hospital, but Congi told her she needed to stay at the hospital to heal. This would be the last time Congi spoke to her daughter.

Around two hours after that call, Peterson went into cardiac arrest while suffering from diabetic ketoacidosis and died; she was then placed into cold storage, the suit states. Peterson’s mother said she received zero calls from the hospital after her daughter’s death, despite her being listed as an emergency contact on her daughter’s chart. Three days later, Congi called the hospital, worried about Jessie.

“Ginger was then informed that her daughter left the hospital against medical advice,” the suit alleges. “This was not true.”

In the following months, Peterson’s mother and sisters searched everywhere for her. They spoke to friends, posted flyers, asked around homeless communities and filed missing person reports with the county and the state Justice Department. A year later, on April 12, 2024, a detective with the Sacramento County Sheriff’s Office called Congi, informing her that her daughter was found in a warehouse morgue — the same facility where Walker would be found a month later. “Jessie was placed on Shelf Number Red 22 A and not a second thought was given to her or her family,” a lawsuit filed by Peterson’s family alleges.

“Jessie had been in and out of Mercy San Juan Hospital probably 10 times in her life since she first was diagnosed with diabetes when she was 10 years old,” the family’s attorney, Marc Greenberg, told SFGATE. “They knew her. They knew the family.”

Peterson’s body was recovered by her family, but her remains were “so decomposed that an open casket funeral was not feasible,” the lawsuit states. The state of the body also meant that no autopsy could be carried out to prove or disprove medical malpractice, the family said.

“While a patient that doesn’t survive may be just another lifeless body to the Defendants, Jessie was a family member, a daughter, and a sister and her family deserved the dignity and respect the Defendants so grossly failed to provide,” the case alleges.

The suit against Dignity Health filed by Peterson’s family was recently amended to broaden its scope after lawyers said they discovered that dozens of other patients’ remains were allegedly held at the Cremations Only offsite morgue for months, or even years, without death certificates. California law requires a death certificate to be filed within eight days of a death.

Sacramento resident Michael Gray died of an accidental overdose in 2021 at San Juan Medical Center, a 2022 lawsuit alleges. Gray lived with his mother, Valerie Gray, but the hospital allegedly neglected to contact her upon his death, despite his wallet, cell phone, identification and home address being on his person at the time. For a month, Valerie Gray “was beside herself with worry and fear for the fate of her son,” the complaint states. The Sacramento County Sheriff’s Office was enlisted to help find Michael, whose decomposed body was allegedly eventually located at the same offsite morgue.

“To add insult to injury, the hospital claimed that ‘a chaplain’ had called Plaintiff Gray to notify her about the death of her son, but had mistakenly called the wrong number and failed to leave a message or follow up,” the complaint alleges. “This unknown chaplain was never identified by the hospital.”

A 2022 California Department of Public Health audit, seen by SFGATE, found significant failures at Mercy San Juan Medical Center in processing the dead, including the mishandling of another unnamed patient. A contact number listed on that patient’s notes was found to be a wrong number, another was out of service. “This failure resulted in Patient 1’s family not being notified of Patient 1’s death for 6 weeks,” the report found.

Another 2023 CDPH report found that an unnamed patient’s body at Mercy Sun Juan apparently went missing after being picked up by an unknown person.

"Patient 1 expired and documentation of the location of the body was unknown. This failure resulted in Patient 1's son being unaware of his mother's body whereabouts and caused family emotional distress," the report said. "The morgue signature page did not have a signature or the location where Patient 1's body was taken, it was left blank, and the person picking up the body did not sign."

A plan of corrective action demanded by the Department of Public Health in 2022 was ignored by the hospital, the Peterson family’s lawsuit alleges. “It was not until Dignity Health’s dirty little secret became a matter of public news reporting that it began to correct its statutory, ethical, and moral failures,” the suit states.

In 2024, an HHS inspection found that 61 bodies were in storage at an off-site morgue, awaiting processing and burial or cremation. It also found that the hospital had not addressed the failures found in the 2022 report. “Where was the oversight?” Greenberg, the Peterson family attorney, asked of CDPH. “You don’t fine them, you don’t take their certification. How is there no consequence for lying to the Department of Health? How is that hospital still functioning?”

The CDPH, however, recently told SFGATE that the hospital “returned to substantial compliance as demonstrated during onsite revisits,” seemingly contradicting the 2024 report that the plan of action had not been implemented. The department added that license revocation or hospital closure is considered a “last resort.”

“The Department is deeply sympathetic to the pain experienced by the families involved. CDPH investigates all complaints in accordance with the Department’s regulatory authority and applicable laws,” the statement sent to SFGATE by a CDPH spokesperson said. “All appropriate actions were taken in response to the scope and severity of the deficient practices cited and the facility demonstrated a return to substantial compliance with regulations under CDPH’s jurisdiction.”

The department added that the operations of the offsite morgue fall outside of its jurisdiction.

The “callous disregard” and “gross misconduct” at Dignity Health was known by the upper levels of management at Dignity Health, the Peterson family’s lawsuit alleges.

Headquartered a block from Oracle Park in San Francisco’s China Basin, Dignity Health became part of nonprofit health care giant CommonSpirit in 2019. CommonSpirit reported revenue of $37 billion in 2024, an 8.2% increase on the previous year. Dignity Health operates about 30 hospitals in California, and a total of 400 care sites across 22 states, making the company one of the largest health systems in America.

“As a result of Dignity’s actions and inactions, the family members of patients who die in Dignity’s hospitals far-too-often receive no notice of the deaths at all and are left to scour the world for a ‘missing person’ while enduring the excruciating emotional distress,” the case brought by Tonya Walker’s family alleges.

“It’s more than negligence. They knowingly were not issuing these death certificates in complete disregard for the family’s well being,” Walker’s family attorney Rachel Fiset told SFGATE. “I think it was callous.”

The morgue owner, Michael Lofton, is also being sued in the complaint filed by Walker’s family. Lofton is accused of failing to properly store Walker’s remains. “Ms. Walker’s body sat decomposing in improper storage for seven months while Ms. Walker’s family scoured Sacramento’s darkest recesses hoping to find her,” the suit states.

In response to the allegations, Lofton’s attorney sent SFGATE the following: 

“Obviously this is a very unfortunate situation; however, our client, Mortuary Support Services of Northern California, disputes that it has any liability in this matter and we intend to vigorously defend any claims against it. However, as this matter is now in litigation, we cannot comment further.”

Dignity Health spokesperson William Hodges told SFGATE that the company is declining to comment on the allegations. The civil suit brought by Michael Gray’s family was settled out of court, while the two civil cases brought on behalf of Walker’s and Peterson’s families are pending. The Sacramento County District Attorney’s Office declined to comment on whether Dignity Health is facing a criminal investigation.

In October 2024, faced with a litany of accusations of negligence and wrongdoing at his hospital, Mercy San Juan Hospital President Michael Korpiel told HHS that “we assumed the remains being stored did not have families,” before explaining that the patients at the hospital included “high numbers of homeless persons.”

Korpiel retired from his position as president of Mercy San Juan Medical Center this summer. He could not be reached for comment.

In Tonya Walker’s medical notes, there was one detail that stood out to her sisters: It described Walker as homeless. “I don’t understand how that even matters, right?” Zachary said. To this day, Walker’s family doesn’t know how or why she ended up at Mercy General hospital. Jessie Peterson’s family says they have not received an apology for the loss of her body.

“The hospital serves a lower socioeconomic community, so I don’t think they care as much,” Greenberg said. “They just have this attitude that once a patient dies, it’s now just a body. It’s not a person anymore. But to their family, it sure as hell is a person still.”