Globe Spotlight

UMass finds gap between studies, real life

Email|Print| Text size + By Michael Rezendes
Globe Staff / December 10, 2007

They took control at a time of crisis, hoping to transform the way the state dealt with the mentally ill inmates whose growing numbers and desperate troubles had already overwhelmed the prisons.

It was 1998, and the inmate suicide rate had soared to nearly four times the national rate, with eight prisoners taking their lives during the previous year.

But Dr. Kenneth L. Appelbaum and his colleagues at the University of Massachusetts Medical School had a plan. It was based on their study of how the system failed one of its most notorious inmates, John Salvi, the antiabortion zealot who killed two abortion clinic workers in 1994. Salvi was found dead in an isolation unit after prison officials brushed aside concerns that he was mentally ill, never taking his history of aberrant acts and apparent psychosis seriously.

What was needed, the UMass team said, was a new approach to care: more mental health workers and psychiatrists; new systems for sharing vital information about potentially suicidal inmates; and special treatment programs in secure settings for the most troubled inmates.

But after a decade with UMass in charge, the system still fails far too often. The Globe Spotlight Team found that UMass made basic errors or provided questionable treatment in handling eight of the 14 inmates who committed suicide under its watch over the last three years.

Indeed, the prison suicide rate is about as high as it was during the 1998 crisis. Over the past three years, as inmates died, warning signs went undetected, vital records were not consulted, and inmates clearly at risk to themselves were approved for housing in conditions likely to make their mental disturbances worse.

The difference is that the reformers - Appelbaum and his UMass colleagues - now share responsibility for the system's failings.

They made progress, just not nearly enough. For the UMass team, the experience was an education in the gap between studying the needs of mentally ill inmates and actually dealing with them.

It also highlighted a long-running culture clash between mental health workers whose overarching goal is compassionate care, and a system whose primary responsibility is safety and security. It is a clash that raged until UMass was stripped of the contract for prison mental health earlier this year.

The errors by UMass included failures in assessing the mental health of inmates, and neglect in tracking the disorders of prisoners moved from one institution to another.

The death of Russ Dagenais is a case in point.

Dagenais was 31 last winter when he hanged himself at the maximum-security Souza-Baranowski Correctional Center, 10 years into a life sentence for murdering his former girlfriend. By that time, he had told UMass mental health workers of his mental health problems, and of his long history of bouncing from one psychiatric institution to another.

But when Dagenais was assigned to isolation after a water fight with a fellow inmate, the UMass clinicians who assessed him to see if he could handle being locked up alone 23 hours a day never reviewed his medical record.

Six hours later, Dagenais was dead, hanging by his scrubs.

In the aftermath, the correction department accused UMass of violating its contract, saying the medical school "failed to provide a clinically appropriate and professional mental health screen."

UMass strongly disagreed, saying the major fault lay with prison record keeping.

"Pertinent mental health information may be scattered throughout multiple volumes, which could take hours to retrieve," wrote Patti Onorato, program executive director of UMass Correctional Health.

It was another chapter in the blame game that colored relations between UMass and the department for years. In the meantime, inmates were endangered - or turned up dead.

In one suicide case last year, the handling of an inmate by UMass clinicians bordered on the macabre.

Manuel Tilleria, a wheelchair-bound prisoner, hanged himself last July in the Souza-Baranowski infirmary - just 15 feet from the nurse's station - three days after he was transferred from Lemuel Shattuck Hospital, the state public health hospital in Boston where inmates are treated.

Tilleria, 51, had pleaded guilty to manslaughter and was admitted to Souza-Baranowski suffering from a long list of medical problems. And, though he denied feeling suicidal, his discharge statement from Shattuck said he had a history of anxiety and depression and was being treated with psychotropic medications.

Nevertheless, in its review of the case, the correction department found there was a failure to communicate between hospital psychiatrists and prison mental health staff -- a gap that might have made a difference. Improving such connections was identified as a priority when UMass studied the Salvi suicide.

The review of the Tilleria suicide also noted that the UMass clinician who conducted Tilleria's initial mental health evaluation at Souza-Baranowski failed to file an update of Tilleria's condition and neglected to sign the assessment. Both are important steps in keeping prison staff alert to the state of an at-risk inmate.

And here is where the Tilleria case takes a strange turn. Records show that the next morning, after Tilleria was found dead, a mental health supervisor signed the incomplete evaluation and sketched out plans for treatment that could only have been delivered beyond the grave.

"Although he was aware that Mr. Tilleria had died, he not only signed the note, but added to the initial recommendation section by indicating that . . . a comprehensive treatment plan was to be completed," the review said.

A UMass spokesman said in an e-mail that neither the mental health clinician nor the supervisor was formally disciplined, and that neither of them would answer questions about the case. The Globe sought to interview many of the clinicians involved in the treatment of prison suicide victims, but, through UMass, all declined to comment, citing privacy or legal concerns.

"They understand that they're likely to get written about in the Globe as being somehow deficient or neglectful, which is not how they see themselves, and not how they see the work that they do or the care they provide," said Mark L. Shelton, associate vice chancellor for university relations.

The Globe also found that the mental health care available to violent prisoners held in isolation can amount to little more than token gestures and "drive-by" visits.

That practice was especially notable in the Departmental Disciplinary Unit at Cedar Junction. The DDU, as it is commonly known, houses some of the most violently troubled inmates in the system, and it is a particularly challenging setting for anything approximating confidential therapy.

Thomas Walker, a disruptive inmate whose DDU sentence still has more than four years to run, said contact with mental health workers was limited to cell-front sessions that last all of 30 seconds. He said the routine went like this: "How you doing? Has anything changed in your life? How are the meds working? We'll see you next week."

Top UMass officials said the drive-bys are a problem that should be corrected, although there may be limits to what the system can accomplish.

"It's not only a staffing matter, it's often an infrastructure matter," Appelbaum said, noting that moving an inmate from isolation can be a time-consuming process. "If the place where you're moving them to is no more private than the cell front, what have you accomplished?"

As for the department, Deputy Commissioner James R. Bender said, "We acknowledge that it has been an issue and that we are trying to resolve it."

The struggle to manage violent mentally ill inmates predates the arrival of UMass in the prisons by more than 20 years. In 1989, for instance, a panel of experts recommended creating three mental health centers on prison grounds, with up to 210 beds for men, and an additional mental health center for women. But over the next two decades, only about 100 of the beds for men were provided, while 40 were created for women. None were designed for violent mentally ill inmates who have maximum-security status.

Meanwhile, the number of mentally ill prisoners has soared - from an estimated 600 at the time the recommendation was made to nearly 2,700 today.

Much of the foot-dragging can be attributed to the state Legislature, which has been loathe to pay for special units for the mentally ill, and to a succession of governors unwilling to spend significant money on programs designed to provide assistance to inmates.

In February, the department released a study by Lindsay M. Hayes, a Mansfield-based prison expert, that again called for alternative housing for mentally troubled inmates. And since then, it secured funding for treatment units for about 80 maximum security inmates.

But inmate advocates, frustrated by the history of inaction, say it is a fraction of what's needed and have filed suit, accusing the department of subjecting mentally ill prisoners to cruel and unusual punishment. Said Richard M. Glassman, litigation director for the Disability Law Center: "We filed the lawsuit because their feet need to be held to the fire."

The shortage of secure facilities for seriously mentally ill inmates can make one key job for prison mental health staff seem all but futile. Even when clinicians determine that violently disruptive inmates can't handle isolation, there is often no other place to put them.

That hard reality was underscored by the case of Andrew Armstrong, a 22-year-old inmate who was confined to isolation at Souza-Baranowski when he killed himself two years ago.

Just 20 when he began serving a 15-year sentence for assault with intent to murder, Armstrong drew the attention of the mental health staff after he told them he had been treated for bipolar disorder and suffered from a variety of other mental health disorders.

But his condition deteriorated until, in the early morning hours of June 20, 2005, he slashed his left forearm with such fury that doctors needed 20 surgical staples to close his wounds. Assigned to isolation after a fight with a fellow inmate, it was not long before correction officers were finding him awake at night, and complaining of nonexistent cameras and listening devices in his cell.

UMass mental health workers twice sent Armstrong to Bridgewater State Hospital for a psychiatric evaluation and possible commitment - only to have UMass clinicians there bounce him back after determining that his problems did not warrant hospitalization.

After Armstrong was discharged from Bridgewater for the second time, he was ordered back to an isolation cell. And, on the evening of Oct. 22, a nurse making a late delivery of Armstrong's medications discovered he had completed what he had started four months earlier, hanging himself with a bed sheet.

In their review of Armstrong's suicide, department officials criticized the two Bridgewater evaluations, saying they did not adequately emphasize Armstrong's erratic behavior, and noted "the lack of an appropriate alternative housing unit for this type of inmate."

When UMass's four-year contract to provide medical and mental health services expired in June, the correction department decided to shift gears. The medical school would still deliver prison medical care but would be stripped of responsibility for mental health services. That work is now being provided by MHM Correctional Services, a Virginia firm.

"If they don't want us there, we really don't want to be the provider," UMass Vice Chancellor Joyce A. Murphy would later say of the department's decision. "This work is tough enough."

It wasn't about to get any easier. After MHM had been in charge for less than a month, Miguel Velasquez, a 33-year-old federal detainee who had a history of mental illness, hanged himself in the 10-Block isolation unit at MCI-Cedar Junction.

It was an all-too-familiar tale: a nurse who neglected to review Velasquez's mental health record, and a correction officer who broke the rules by closing the solid door covering the bars of his cell, without ensuring that mental health staff was notified, according to the department's preliminary review.

So on July 29 at 1:03 a.m., when Sergeant Richard McArthur opened the solid door to Velasquez's cell, he immediately reached for his radio. "Code 99," he said, "inmate hanging."

Globe Spotlight Team members Beth Healy, Francie Latour, Jonathan Saltzman, and editor Thomas Farragher contributed to this report.

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