The state's official account of Kelly Jo Griffen's death, four years ago in a prison infirmary, describes a swift eight-minute decline, from the first warning sign to lifelessness.
But medical records obtained by the Globe indicate that the medical staff at MCI-Framingham was aware of Griffen's deteriorating condition much earlier that morning of July 23, 2003, and took no action to help her, as she battled the side effects of heroin and alcohol withdrawal. Two hours before a doctor started CPR, a nurse reported that she attempted three times to measure Griffen's blood pressure but could get no reading. She also was unable to detect a pulse.
According to the records, nurse Magdalena Grodzki told Griffen -- whom she described as alert, but shaking -- that a doctor would check her shortly, but there is no indication that he ever arrived.
Since Griffen's death, as she awaited arraignment on a minor drug charge, the system's healthcare provider has ordered staff training in detoxification. But the Department of Correction has never publicly disclosed what happened to the 24-year-old mother from Lynn or launch an investigation into who -- if anyone -- was responsible for her death.
In its only public statement, issued in October 2003, the state program that provides healthcare services in the prisons asserted that the medical staff "immediately provided all necessary care and treatment." In its mortality review, the department commended the staff for its quick response when Griffen stopped breathing.
"She never should have died," said her aunt, Karen Scovil of Malden, who is caring for Griffen's two daughters, ages 7 and 5. "If they had taken her to a hospital or given her fluids and just paid a little more attention to her, her two little kids would have their mom right now. Something is wrong here."
Griffen's death occurred a month before the prison murder of defrocked priest John Geoghan, and gained headlines only after his death raised questions about the safety of inmates in the state's prison system.
Despite a series of commissions and investigations, the Department of Correction remains in turmoil four years later, as it grapples with a high suicide rate and disclosures that inmates have been confined longer than their sentence allows.
The family has filed a wrongful death suit against Grodzki, Nicholas Rencricca, and Khalid Mohamed, the two doctors who were in charge of her care the morning she died. In the suit, lawyer Howard Friedman alleges that Griffen died of dehydration -- after being unable to keep down the medication she was given to calm her withdrawal symptoms. Over several hours, Friedman believes, the dehydration changed Griffen's blood chemistry and triggered a heart attack. A medical examiner's report the day after her death cited cardiac arrest and flu-like symptoms.
Nearly three months after her death, UMass Correctional Health -- a program run by the University of Massachusetts Medical School to provide medical services in the prisons -- said that "the immediate cause of her death remains unknown both to us and to the medical examiner."
Lawyers for the defendants declined to comment on the events that led to Griffen's death, as did officials from the Department of Correction and UMass Correctional Health, citing the pending lawsuit. Messages left at the home of the nurse and the offices of the two doctors also were not returned. They all still work in the prison system.
"Our sympathies go out to the family," said James Bello, who represents UMass Correctional Health and two of the defendants, Grodzki and Rencricca. "We continue to believe both nurse Grodzki and Dr. Rencricca acted appropriately in the care and treatment they provided. At the end of the day, if this case were to proceed to trial, we believe the jury would agree."
Mohamed's lawyer, Kurt Schmidt, also declined to comment.
But medical records turned over to her family by lawyers for the state, raise a series of new questions about her care. At 6:20 a.m., the records show, Rencricca's name appears on an order clearing Griffen for a court appearance that day. That was less than an hour after Grodzki was unable to read her blood pressure on three attempts or to find a pulse, and just an hour before she was found not breathing. But the records do not indicate that Rencricca actually saw her until he was summoned to resuscitate her at 7:30 a.m.
And while UMass Correctional Health's own rules, included among the litigation records, require that inmates be transferred to a community hospital if their condition deteriorates during detoxification, Griffen was left in the medical unit at MCI Framingham as her health declined.
In addition, a Globe review of records of the state's Board of Registration in Nursing show that Grodzki, the nurse who cared for Griffen during her final hours, had previously been disciplined for providing substandard care.
Grodzki was placed on probation by the nursing board for six months in 2001 after she gave the wrong medication to an 88-year-old patient at the Providence Extended Care Center in Worcester.
Grodzki was terminated, the nursing board records say, after she gave insulin instead of the blood thinner heparin to the patient, who became unresponsive. The patient was rushed to the emergency room, where he was stabilized.
Correctional Medical Services, which ran the prison health system until 2003, hired Grodzki after that episode. As part of the probation agreement, CMS was required to monitor Grodzki's performance and report back to the board. In December 2001 and March 2002, CMS reported that Grodzki was doing a good job.
Griffen's circuitous trip to Framingham began on Sunday, July 20, 2003, when she was spotted by Lynn police as she walked to the beach with her two girls and mother, according to details provided by the Essex Country district attorney's office, Griffen's aunt, and her lawyer. The police arrested her on an outstanding warrant charging her with leaving the scene of an accident and driving without a license. While at Lynn District Court on Monday, authorities discovered a second warrant -- alleging possession of a syringe -- issued in Salem. Griffen was taken to MCI Framingham for the night so she could be transported to Salem District Court for her arraignment the next morning.
But by the time she arrived at Framingham, Griffen, who also suffered from diabetes and a seizure disorder, was in the throes of withdrawal. According to medical records, she complained of nausea and shakes. The next day a doctor found her too sick to go to court, noting that she was "in severe withdrawal."
Throughout the day, according to the records, she reported feeling "so sick." At 1 a.m., less than seven hours before she died, she told Grodzki she was having a seizure. The nurse reported seeing her vomit. There is no sign in the medical records that a doctor saw Griffen at any time that night.
An inmate in the room with her said Griffen was "sick from the second she got there" and got worse fast.
"She was very, very pale and had to keep getting up to vomit," said Diane Solari, who was also detoxing from heroin. "They were giving her medication for vomiting and diarrhea but whatever she took she threw up immediately five minutes later. Soon she couldn't get up to go to the bathroom and was throwing up in a bucket. I'd empty it and she'd throw up again."
"She was so sick," said Solari, who shared a room with Griffen and two other inmates. "She was begging for an I.V. She must have said it 30 times."
Before sunrise, Solari said, Griffen became too weak to walk and fell on her face trying to get to the toilet. "She was drawn pale, gray. She couldn't stand up," Solari said." She could talk but her mouth was dry. I never saw anybody that sick."
Solari, by now in severe withdrawal herself, was laying on a bed waiting to take a shower. "Someone said, 'She's turning blue.' I looked and Kelly was bluish. I screamed Code 99," she said, the designation for a medical emergency.
At that point, she said, the medical staff "came running." They were not able to revive her.
Since Griffen's death, the Department of Correction and UMass have taken steps to improve the prison medical system, particularly for those detoxing from drug or alcohol addiction, according to inmates and lawyers familiar with the system.
"Until now the department's oversight of the medical providers has been little more than bean counting -- did they file their reports on time?" said Leslie Walker, executive director of Massachusetts Correctional Legal Services, which represents prisoners. "But things are getting better. They've hired better doctors. We heard from prisoners at Framingham that there is a great doctor who spends a ton of time with each woman."
That provides some solace to Griffen's aunt, who has been clamoring for change since Griffen's death.
"People who have drug habits or mental issues, they don't belong in prisons," said Scovil. "They belong in rehab centers and hospitals. Major changes need to be made. I'm hoping Kelly Jo's death at least brings attention to that fact. Maybe they'll make the changes and save some lives. Too many people are dying."