Second of three parts
This story was reported by Globe Spotlight Team members Francie Latour, Michael Rezendes, Beth Healy, Jonathan Saltzman, and editor Thomas Farragher. It was written by Latour.
To the teen mother who struggled to raise him, he was slow, abnormal, and often out of control.
To the counselors who tried to steer him from trouble in Springfield, he was a child trapped in the body of a pudgy young man, the charmer who couldn't count the change in his own pocket.
And to prison clinicians who knew him behind bars, he was, above all, a "frequent flier," their code for inmates who require the constant attention of the mental health staff.
By the time Nelson Rodriguez walked through the heavy metal doors of state prison in 2004, convicted in a stabbing case, he had long since been diagnosed as mentally retarded and mentally ill - a man unable to grasp even the most basic concepts.
But as an inmate, the 26-year-old Rodriguez was routinely punished for acting out in ways he could not control. Time and again, his jailers used the same blunt tools - isolation and loss of basic privileges - to deal with him.
The discipline never improved his behavior; in fact, he got worse. It ran directly against warnings by prison clinicians. But it kept coming - for him as for many of the mentally ill who have overwhelmed the prison system.
During 18 months in state custody, the young man with the lazy eye and troubled mind spent a quarter of his time - about 145 days - in solitary confinement.
On Dec. 20, 2005, five days after his last transfer into the forbidding Walpole prison unit known as 10-Block, Rodriguez's isolation was pressed to the extreme. Officers shut an outer solid door over the bars of his cell and walked away.
Sometime in the next four hours, Rodriguez tied a strip of bed sheet to the metal cover around his cell's smoke detector. He wrapped the other end around his neck, and hanged himself.
When it comes to suicide behind bars, it is impossible to expect total prevention, state Department of Correction officials say. With some determined inmates, Associate Commissioner Veronica Madden said, "It seems that they really wanted to die."
But the death of Nelson Rodriguez in cell 49 is not that kind of story. Rather, his is the story of the kind of inmate now flooding the corrections system: the mentally ill for whom prison is increasingly the asylum of last resort. The Globe Spotlight team dwelled in depth on his short life and sorry end as a way to understand why men like Rodriguez wind up behind bars and why too many die there.
Rodriguez was a man-child with a hard-wired inability to learn at the mercy of a system where punishment and more punishment is often the only real response to inmates with little or no ability to control their behavior.
It is a practice that amounts, in some cases, to an invitation to give up on life.
"He is someone who definitely should not have been put in isolation because of his condition. There's no question about that," said Terry Kupers, a national specialist on mental illness in prisons, who reviewed Rodriguez's records. "Putting [mentally ill inmates] in segregation and then closing the solid door to their cell is like asking them to commit suicide."
Madden told the Globe that Rodriguez's suicide was a tragedy, for him, his family, and for her department.
"This was a deeply troubled young man presenting with a very complex set of circumstances in a very noncomplex system that we run," she said.
Madden also said that she had not known that Rodriguez was mentally retarded.
"We hear now that he was mentally retarded," she said. "I don't have any documentation on that. Did that come up in court? Where was that prior?"
In fact, court records and internal reports are peppered with references to Rodriguez's mental retardation. Those records include a 2006 suicide review in which Madden herself was an observer. They stretch back to Rodriguez's first contact with the Department of Correction in 2003, and among those who treated him it was anything but a secret.
"You could talk to him about skills and ways to cope and strategies, but he wouldn't retain it," said one of Rodriguez's former clinicians, who treated him for about a year and who asked not to be named because of department policies that forbid discussing inmates. "He didn't have the skills to say, 'If I'm good for three more days, I'll be out of [solitary confinement].' He just couldn't do that."
Instead, Rodriguez lashed out - and fell apart.
Yet he wasn't on the radar screen of the mental health staff as a high-risk inmate, according to one internal Correction Department review obtained by the Globe.
At Walpole, no one in charge seemed to know anything about a doctor's warning that placing Rodriguez in solitary confinement posed a serious danger to his mental state, and to his safety.
Instead, after he cut his arms and throat, he was sent to one of the most restricted and bleak holding units Walpole had to offer: 10-Block.
"He'd never make it there," Rodriguez's former clinician said of Rodriguez's transfer. "I mean, he didn't make it there, obviously."
A troubled child
When he was a little boy, Nelson Rodriguez was haunted by a monster. It tormented his dreams and lurked around corners.
At age 10, he told a psychologist that the monster would kill his friends, eat his mother, and throw him into water burning with fire. Naturally, he gave the monster a name: Freddy, as in Freddy Krueger, the horror movie serial killer.
If Rodriguez's fantasy world was horrific, his boyhood reality was filled with frustration and pain.
His IQ was well below normal. He had a seizure disorder, and tests strongly suggested some form of brain damage. As he approached his 11th birthday, he still wet his bed. And he had no friends. Instead, his peers taunted him mercilessly.
All the while, the mother he dreamed that Freddy would devour was at once the focus of all the boy's devotion, and his rage.
Mildred DeJesus, 18 years old when she gave birth to Rodriguez, couldn't handle her son's violent outbursts, or any of the burdens of raising a child who, in her words, "was not normal." After Rodriguez began exhibiting strange, hypersexual behavior - exposing himself and preying on his toddler stepbrothers - DeJesus grew desperate. Ultimately, she signed over custody of her son to the state.
To his relatives in Springfield, it was clear what had happened. In an interview, Rodriguez's aunt, his grandmother, and his youngest half-brother described young Nelson as a torment, even as they acknowledged that his disability and mental illness were to blame.
"You wanted to trust him," said Dezi Rodriguez, who at 20 has just begun to forgive the brother who once menaced him. "You wanted to give him a chance, but you couldn't."
When told that Rodriguez would speak of his mother with longing to almost anyone he would meet, all three looked up, stared, and fell silent. "Believe me," Mary DeJesus, Rodriguez's aunt, said finally of her sister, who died of AIDS in 1999. "She would try so hard to love that kid."
As Nelson grew into adolescence, little changed. Clinicians still saw traits bordering on psychosis. At 17, he was admitted to a psychiatric hospital for six weeks. He bounced erratically between foster families and group homes.
And in a system already awash with unwanted children who soon grow into unwanted teenagers, Rodriguez became his own worst enemy: He was just smart enough to know he did not want to be labeled "retarded," and just verbal enough to try to convince people that he wasn't.
Jim Nash, a Springfield-area advocate for the disabled, was one of several counselors who took Rodriguez in for short periods of time as a young adult. Rodriguez was 18 at the time, but, with his goofy grin and impossible naiveté, he struck Nash as more like his own two toddlers than as a young man.
"He was able to posture and hold himself and look like some regular dude walking down the street," Nash said. "But in reality, there was nothing below the surface. There was no good framework for how to face the world."
At a critical period, between the ages of 18 and 22, Rodriguez's posturing fooled many of those charged with determining his future. In 1999, clinicians and the courts deemed him competent to care for himself without a guardian.
To the frustration of advocates, Rodriguez was in a social services limbo. He was too old for DSS services and would not ordinarily be eligible for services from the Department of Mental Retardation until age 22, although local DMR caseworkers tried to intervene.
At the same time, no one could force him to accept help. That was key, because Rodriguez was fed up with services, rules, and restrictions.
Jason Nelson, a part-time counselor and
But after a year of hostile, unexplained outbursts from Rodriguez, Jason Nelson found himself hitting the same brick wall Rodriguez's mother had reached years earlier.
"I was at my wit's end," he said. "I was emotionally, mentally, and physically exhausted from it."
Rodriguez was spiraling. Between 1997 and 2002, he was in and out of coun ty jail on various misdemeanors - petty larceny, breaking and entering, property damage.
Inexorably, he was slipping into the growing ranks of the wandering mentally ill, whose outbursts and episodes eventually lead to arrest, prosecution, and prison.
A changing diagnosis
For years, Rodriguez had been fascinated by Teenage Mutant Ninja Turtles.
Something about a cartoon team of mutant reptiles, isolated from society and trained as warriors, clearly spoke to him. And he obsessed over martial arts. One day in the early summer of 2003, while living at a Springfield homeless shelter, he began taking kung fu classes. Then he bought a sword at a local pawn shop.
The next day, Rodriguez used the sword to stab another homeless man in the stomach inside the shelter's bathroom. It's unclear how the conflict began, but, according to police and witnesses, the scene was bloody. The victim, 29-year-old Marcus Roberts, arrived at the hospital holding in his intestines with a towel.
Roberts recovered fully. But despite an unusually passionate appeal by a court-appointed lawyer, this would not be another misdemeanor for Rodriguez. "He wasn't crazy, but he was retarded," said David Burgess of Concord, who asked the judge to send his client to a county jail instead of prison. "He's not as culpable as I would be, or you would be, if we pulled a knife on somebody."
Still, even Burgess could not argue with the judge's bottom line: A person should be able to enter a shelter and not have to worry about being stabbed. The court sentenced Rodriguez to four to seven years.
He was now in the hands of a prison system that struggles to adequately treat or even track mentally ill prisoners and has little capacity to deal with the mentally retarded.
"We don't have enough expertise," said Dr. Kenneth L. Appelbaum, the former mental health director for the UMass Correctional Health, which served the prison population until this summer. "And we don't have the services that those people need in the system. It is, in my opinion, a significant unmet need."
In Rodriguez's case, it was worse than that.
An internal staff review of his death, obtained by the Globe, said clinicians focused far too much on whether Rodriguez was really mentally ill, instead of realizing the danger he posed to himself.
"Despite the fact that his entire mental health history was well documented within the medical record," the report said, "the mental health clinicians at MCI-Cedar Junction seemed to either underemphasize, or simply be unaware of, some of the more critical information contained within his record."
That record, one of distress and breakdown, began even before Rodriguez had been officially sentenced to serve state time.
In November 2003, while still awaiting trial in a county jail in Ludlow, he tried to hang himself, an incident that landed him at Bridgewater State Hospital, the prison system's facility for the mentally ill.
The doctor who evaluated him concluded that while Rodriguez was not profoundly mentally ill, he was a danger to himself. Using italics in her report to stress her point, she noted that clinical staff and correction officers should be aware of the "very real, very substantial" risk of self-harm.
By June 2004, and convicted of the crime, he was an inmate at the Souza-Baranowski Correctional Center, the state's modern maximum-security facility in Shirley. There, his outbursts triggered escalating punishment. He broke his food tray, exposed himself, and repeatedly attacked officers. As a result, he was kept in isolation.
By October 2004, Rodriguez was back for further observation at Bridgewater, where, his relatives say, prison officials should have recognized the severity of his illness and kept him for treatment indefinitely. And for a moment, it looked like that might happen.
In a report correction officials themselves say was crucial, the doctor who evaluated Rodriguez, David W. Holtzen, found that Rodriguez was hallucinating, had thoughts of suicide, was suffering from major depression, and was losing his grip on reality. Holtzen not only wanted Rodriguez admitted, he also wanted a court order to force Rodriguez to take antipsychotic medications.
Then something changed.
About two weeks later, Holtzen evaluated Rodriguez again and deemed him no longer seriously mentally ill but rather "antisocial" and "bored." According to an internal review of Rodriguez's suicide, Holtzen changed his mind after members of Rodriguez's treatment team said they believed Rodriguez was improving.
But Bridgewater's own records show that Rodriguez was still deeply unwell. Shortly after the reevaluation, officers at Bridgewater reported he was punching the cell walls and acting out of control. Despite those warning signs, Rodriguez was back in prison 72 hours after the new diagnosis. And his disciplinary record worsened again.
Through representatives of UMass Correctional Health, Holtzen declined to comment about the change in diagnosis, citing privacy laws of patients. A UMass spokesman called Holtzen's assessment "reasoned."
Even though Holtzen's interpretation of Rodriguez's behavior had changed radically, the doctor did warn that if Rodriguez was placed in conditions akin to solitary confinement, his mental health would be in jeopardy.
"[Holtzen] clearly puts in the chart: Watch this guy, he's a serious suicide risk," said Terry Kupers, the national specialist on mental illness in prisons. "From that moment on, this is a person who should have been tracked."
Instead, the Department of Correction kept losing track of Nelson Rodriguez.
Off the radar screen
By the spring of 2005, Rodriguez began bracing himself for life inside the state's toughest prison: MCI-Cedar Junction in Walpole.
The clinicians at Souza-Baranowski understood his problems and even found him likeable. But prison officials transferred him after finding themselves overwhelmed by his chronic misconduct.
His state of mind was clear in a letter he wrote to his grandmother, Elsie "Bita" Miranda, and his brother Lorenzo Rodriguez. Using almost no punctuation, he wrote: "I'm trying really hard to survive in jail. . . . My tears been rolling down my cheekbone like crazy. . . . Look I'm gonna be moving to another jail is called Walpole. . . . Pray for me please."
At Walpole, he quickly slipped off the radar screen. His name never appeared on the prison's risk list. And his lengthy mental health history did not catch the attention of the two people at Walpole most responsible for his mental health care: his assigned clinician and her boss, Erika Grandberg, MCI-Cedar Junction's mental health director.
Grandberg would later tell investigators that she knew nothing about the prior warnings that more isolation could hurt Rodriguez or should, at least, trigger more vigilant care. She also defended Rodriguez's absence from the risk list, saying, "At the time, he wasn't somebody who we considered high risk."
But in two months at Walpole, Rodriguez just couldn't follow the rules. He was cited for various outbursts.
Still reasoning like a child, Rodriguez tried to appeal the punishments in the only way he knew how. In November, a month before his suicide, he pleaded to have his television, telephone, and visitation privileges restored. "They don't understand that I'm mildly mentally retarded," records say he told a clinician. "I got a dangerous mind. I can cut myself, hang myself." But nothing came of the appeals.
Rodriguez was 19 months into his prison sentence. He was due for an update on his treatment plan, but the deadline came and went without one, according to the department's review. Rodriguez's clinician told investigators that she had updated it, but that the plan "was not in his chart and she does not know where it went."
In early December, Rodriguez cut his arms and throat, triggering an emergency medical call. He spit on responding officers and bit one of them, records show, and was shackled by his arms and legs. Two days later, he was put on a 15-minute interval watch - a clear sign that he was a high risk for suicide.
And then prison officials decided to send Rodriguez to 10-Block. The prospect led him to further unravel.
On Dec. 14, 2005, a prison psychiatrist discontinued two medications Rodriguez was taking - Remeron, an antidepressant, and Seroquel, an antipsychotic drug - while upping his dosage of a third drug, a mood stabilizer. Department records reviewed by the Globe provide no explanation for the adjustment. The very next day, Rodriguez entered Cell 49 in 10-Block, a foreboding 60-bed, two-story unit where inmates are confined to closet-size cells 23 hours a day.
His brief time in custody had been as volatile as any inmate's. But when Rodriguez underwent a routine assessment as 10-Block's newest guest, the clinician's words had the uneventful tone of a weather report. "Stable, no evidence of psychosis, delusions, or hallucinations. Monitor [patient] per Treatment Plan, [as needed]."
Five days later, officers sounded an alert - Code 99, inmate hanging. They entered Cell 49 and removed the ligature from around Rodriguez's neck. They carried his body down the tier to a landing on the second floor. Chest compressions were begun. An ambulance was called. A Walpole rescue team responded.
He was pronounced dead at 4:44 p.m.
Investigators would later conclude that there were 22 officers assigned to patrol 10-Block that day; 11 of them were responsible for the upper tiers that included Rodriguez's cell. But no one made the required half-hour checks on Rodriguez for four hours, even though the log book for that day contained entries indicating the proper rounds had been made.
And in its review of his suicide, officials seemed to struggle to explain how an inmate like Rodriguez - mentally retarded with a well-chronicled history of dangerous misconduct - could be described as an inmate "not on the radar screen."
The answer, they concluded, may lie in Cedar Junction's operating ethos.
"Due to the overall culture of the institution, mental health staff at MCI-Cedar Junction have a rather high threshold for how they assess and address an inmate's acting-out behaviors and overall mental health status," the confidential internal review concluded.
Conclusions like that ring hollow for people who still remember Rodriguez as the child trapped in a man's body, the inmate who could never learn the rules.
"He never had a chance to have a childhood," Jason Nelson, his former guardian, told state lawmakers three months after his death. "To place a man in a maximum-security prison that is not equipped or staffed to help or even understand the type of mental illness Nelson was plagued with is beyond my understanding."