FOR IMMEDIATE RELEASE
April 8, 2025
Inmate with ALS and Opiate Withdrawal Died within 24 Hours of Arrival at Bridgeport Correction Center; Investigative Report Reveals Multiple Systemic Failures, Numerous Violations of Federal, State Law and Dept. of Correction Policy
Disability Rights Connecticut Report Substantiates Failure to Provide Adequate Medical Care and Lifesaving Measures; Urges Legislature, State Agencies to Take Action to Prevent Deaths
Disability Rights Connecticut (DRCT), following a comprehensive, detailed and alarming 31-month investigation, is calling on the state legislature and the Department of Correction (DOC) to act immediately, because “if the systemic issues that DRCT identified are not addressed, more people could die in custody.”
The investigation began in the wake of the death of an individual in the custody of Bridgeport Correctional Center, less than 24 hours after arriving at the facility.
DRCT, in an extensive 25-page report which includes a series of recommendations, concluded that multiple corrective actions are imperative, noting that the investigation “substantiated multiple systemic violations of federal and state law, and DOC policy,” and “significant deficiencies in the DOC’s policies, practices, and staff accountability with respect to medical care, staff training, disciplinary processes, and operational procedures.”
The report outlined a series of failures, including:
· Failure to provide adequate medical care.
· Failure to provide lifesaving measures.
· Failure to follow multiple state laws and DOC policies and procedures, and
· Failure to implement corrective action in a timely manner.
DRCT initiated the investigation based on a neglect complaint alleging that the Department of Correction failed to provide adequate care and treatment to the individual, named as John Doe in the report, who died on June 25, 2022, less than 24 hours after entering into DOC custody.
The DRCT report findings detail the failures of both correctional and medical staff responsible for the care and lack of treatment of John Doe, leading to his untimely death.
The report also includes recommendations that stress the critical need for improved staff training, stronger accountability measures, and better coordination between medical and correctional personnel to ensure the safety and well-being of incarcerated individuals.
The report, which includes a timeline of events, explains that “although the DOC knew that John Doe had ALS” (Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease) “and was experiencing opiate withdrawal, DOC staff failed to provide him with adequate care in a number of ways,” pointing out that “the nursing staff failed to address John Doe’s specific needs related to his ALS diagnosis,” which “put him at risk for choking and aspiration.” The nursing staff also failed to address his opiate withdrawal needs even though nursing staff described him as “an extremely frail individual” who had an “unsteady gait” and “who struggled to complete basic daily activities such as eating and swallowing.”
The investigation further concluded that when he “was found lifeless in his cell, no DOC staff members called for help,” and correctional and nursing staff failed to perform CPR or other life-saving measures, administer Narcan, and “did nothing to resuscitate him.”
The nursing and correctional staff violated “more than 10 DOC policies and procedures,” the report noted, including that two nursing and three correctional staff violated state law when they falsified DOC records and/or failed to try to save John Doe’s life. The specific violations are listed in the report appendix. “Absent urgent systemic reform, similar tragedies may continue,” the report stated.
Amidst the DRCT investigation, “DOC confirmed that it had no plan of correction” and the DRCT report also indicated that “CPR drills have not been completed statewide for DOC staff since 2018.”
Call for Action by State Legislature and Department of Correction
Disability Rights Connecticut is calling on the legislature to:
· Direct the DOC Commissioner to provide annnual reports of inmate deaths in all of its facilities, including the status of the completion of each DOC death investigation, and descriptions of actions taken to correct deficiencies identified in each investigation.
· Direct the state’s Sentencing Commission to conduct a study on the Health Service Unit, correctional staff, and the DOC’s death investigative practices and procedures.
· Establish a DOC death investigation task force to evaluate and make recommendations for improvements to DOC practices and procedures.
· Investigate the appropriateness of DOC’s staff disciplinary actions under federal and state law.
· Investigate Department of Public Health practices and procedures to evaluate delays in the agency’s ability to make final disciplinary decisions impacting professional licenses.
The report by DRCT also urges the Department of Correction to take steps including:
· Conduct a comprehensive review of its policies and procedures that impact the health services it provides to inmates, including policies directing specialized care provided to inmates with disabilities; and regulate Medical Panel Reviews.
· Revise and implement corrected policies in response to comprehensive reviews.
· Implement an accountability system to monitor deficiencies in the completion of rounds by correctional staff.
· Provide and document staff training, and retraining, as needed.
· Establish a protocol to ensure that staff discipline is addressed in a timely manner.
Among the violations detailed, the report states that “three correctional staff members violated state law when they falsified informaton on official DOC records.” DOC staff was mandated to perform 15-minute checks on John Doe for his safety, given his medical needs. The correctional officers falsely documented a total of 15 entries in the BCC Hospital Unit log book. DOC video footage confirmed that these documented tours never occurred.
The Department of Public Health, responsible for responding to nursing care violations, has yet to take disciplinary action against nursing staff that did not adhere to professional standards by initiating or assisting in efforts to save John Doe’s life.
The DRCT report notes that “the Due Process Clause of the Fourteenth Amendment requires prison officials protect pretrial detainees from harm, including medical neglect and unsafe conditions,” pointing out that the failures outlined in the report “amount to deliberate indifference under the law and violate John Doe’s constitutional rights.”
DRCT begain its investigation on July 5, 2022. The investigation included interviews, record reviews, and three site visits to Bridgeport Correction Center. Interviews were conducted with DOC staff and inmate witnesses. Records reviewed included medical and non-medical records, video surveillance footage, policies, staff emails, personnel and disciplinary records, and investigative reports from other state agencies, including the Office of the Chief Medical Examiner, Office of the Inspector General and Department of Public Health.
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About Disability Rights Connecticut
Disability Rights Connecticut’s mission is to advocate, educate, investigate, and pursue legal, administrative, and other appropriate remedies to advance and protect the civil rights of individuals with disabilities to participate equally and fully in all facets of community life in Connecticut. Disability Rights Connecticut provides legal advocacy and rights protection to people of all ages with disabilities.
DRCT focuses its legal and other advocacy on a wide range of disability justice issues for Connecticut residents with disabilities. DRCT’s services include advocating the rights of individuals with disabilities on issues including abuse, neglect, discrimination, community integration, forensic mental health, voting, and other rights protection issues. DRCT replaced the Office of Protection & Advocacy for Persons with Disabilities, by Connecticut Law as of June 30, 2017, and is now Connecticut’s federally mandated “Protection and Advocacy System.”
Media Contact:
Bernard Kavaler, for Disability Rights Connecticut
860-729-3021, bernard@express-strategies.com
