A system strains, and inmates die
This story was reported by Globe Spotlight Team members Beth Healy, Michael Rezendes, Francie Latour, Jonathan Saltzman, and editor Thomas Farragher.
It was written by Healy.
First of three parts
His mother couldn't understand how he got the shoelaces.
After all, everyone knew Jarred Aranda was in danger. He had just tried to kill himself in jail.
Now, the handsome 27-year-old, with a to-do list in his pocket and a smile that hid his troubles, was being evaluated for mental illness at the state prison hospital in Bridgewater. He should have been safe there.
Locked up for stealing sneakers and violating probation, Aranda was deeply depressed. His mind was ravaged by crystal meth and other drugs his mother had begged him to quit. He'd been diagnosed with bipolar disorder, and he was hearing voices.
But he told prison doctors he didn't want to die, and they believed him. Then they forgot about him.
No one from the prison clinical staff checked on him for 10 days. When a doctor finally did show up again, Aranda said he felt hopeless, and couldn't sleep. But the next day, he was allowed to walk into a shower, unattended, for 17 minutes. He had a set of shoelaces with him.
When an officer found him hanging from the shower door and sounded the "Code 99" alert last March, Aranda became the next in a series of 15 suicides in Massachusetts state prisons since early 2005. The deaths were coming at an alarming pace, roughly triple the rate in other states.
Last year alone, seven inmates killed themselves, and another's attempt left him brain dead; four have taken their lives so far this year.
Department of Correction officials say the suicides are random and unrelated. But a Globe Spotlight Team investigation of the deaths and detailed reconstruction of how they occurred found that they were far from random.
Most of the suicides came after careless errors and dangerous decisions by correction officials and the staff at UMass Correctional Health. And the trail of violence is far wider than the number of dead would indicate, as hundreds more inmates each year have wounded themselves or attempted suicide.
In fact, such incidents are soaring.
So common has it been to find a man with a makeshift noose around his neck that some correction officers have taken to carrying their own pocket tools to cut them down. The tally of suicide attempts and self-inflicted injuries - 513 last year and more than 3,200 over the past decade - tells a story of deepening mental illness and misery behind the walls of the state's prisons, despite repeated calls for better training of officers and safer cells for mentally troubled inmates.
The Globe found that background screens were botched as inmates arrived at prison. Medical and mental health records went missing or were never reviewed. Security rounds were skipped. Inmates in distress were punished for behavior that amounted to a cry for help, or at least a signal that greater precautions were needed.
"You're taking people who are vulnerable and can't cope in society," said Dr. Carl Fulwiler, a psychiatrist who consults to prisons and is an assistant professor at University of Massachusetts Medical School, "and putting them in the worst situation imaginable."
The Department of Correction guards the details of these events in secrecy, revealing little to the public, or even to the families of the suicide victims.
But internal investigative reports obtained from other prison sources by the Globe show that, in case after case, the suicides occurred at times when inmates were predictably at risk - within days or hours of arriving at prison, being sent to isolation, or withdrawing from drugs. Or, as with Jarred Aranda, in the tenuous period after a prior suicide attempt.
Aranda's grandfather was the first to get the call that he was dead. Then his mother.
"Who let him go in the shower alone?" Leslie Aranda would later ask tearfully. "I thought he was safe."
A system under strain
They are people whom society has, in many cases, written off.
Among the 15 suicides, almost all of them men, half were criminals convicted of murder or rape. Some were small-time thieves or drug dealers. A few hadn't been convicted of anything; they were in prison awaiting trial. The one woman was in only to detox.
Virtually all of them were troubled long before they were locked up, with mental health issues or drug abuse dating back to their youth. They and others like them increasingly are populating prisons in Massachusetts and across the country.
Today, one-quarter of the state's 11,000 prisoners are being treated for some kind of mental illness, up from 15 percent in 1998. It's a legacy, in part, of the elimination of many state mental institutions in the 1980s and half the state's detox beds in 2004. In June, there were 1,097 inmates taking antipsychotic medications, up from 595 in December 1998.
The suicides are just the most visible signs of a system under strain. State taxpayers spend $55 million a year on medical and mental health care for inmates in the state prisons, and nearly half a billion dollars for all prison costs. And while troubled inmates are dying and hundreds more are trying to die, most will serve their sentences and one day be released - often sicker than when they arrived.
"That's the danger of the larger prison culture we're creating," said Dr. Scott A. Allen, a former prison physician in Rhode Island and now co-director of the Center for Prisoner Health and Human Rights at Brown University. "As a society now, we've taken mental health problems into this prison setting, and we're dealing with them in a punitive way."
The casualties are people like Andrew Armstrong, 22 and mentally ill, who hanged himself eight hours after being locked in an isolation cell for getting into a fight.
Or Nicole Davis, 24, who was found hanging after asking for medical help all night; she was depressed and detoxing, alone in her cell.
Or Nelson Rodriguez, 26 and mentally retarded, who killed himself in MCI-Cedar Junction's dungeon-like "10-Block" wing, despite warnings by the mental health staff that solitary confinement would likely harm him. New rules put in place after his death have proved far from foolproof: In July, a mentally ill man killed himself in 10-Block, prompting the US Marshals Service to investigate and to remove some federal detainees from the Walpole prison.
Case study in disaster
Anthony Garafolo is a case study in how a difficult situation can turn to disaster at the Department of Correction.
The 46-year-old Ludlow native, admitted to MCI-Shirley in June of 2006, had spent a third of his life behind bars, convicted time and again of stealing to support a drug habit. In one 1990 robbery, he took a bullet in the back that left him paralyzed from the waist down.
He was an angry man in prison, and often hard to handle.
Garafolo had been emotionally broken since being abused by a notorious priest at age 15. And he was depressed at the disability that left him using a wheelchair and made basic bodily functions a difficult chore. Over the years, he racked up a stack of disciplinary reports for breaking rules and verbally abusing prison staff. He had twice before tried to kill himself in prison, once while in isolation.
On June 19 last year, he was caught in a downward spiral that was steep and violent. It was 90 degrees outside the walls of the prison that day, and behind the thick, locked door of Garafolo's prison infirmary room, it felt even hotter.
A wound had reopened after a recent surgery - an ulcerated sore from sitting long hours in a wheelchair. He had a fever and kept asking for pain medication, records show. He couldn't reach the sink for water. He was filthy and needed to bathe, but the shower in the corner of his room wasn't wheelchair-accessible.
And he wasn't making his care any easier, angrily banging on his door, shouting and cursing at the staff.
No doubt, the recent change in his prison circumstances had also inflamed him. Garafolo had gone from an unshackled interlude at UMass Memorial Medical Center for surgery - a comparatively happy time with family visits and a birthday celebration - to a stopover in the locked-down wing of the Lemuel Shattuck Hospital in Boston, to the infirmary at Shirley.
And for reasons top department officials cannot explain, at Shirley he was being held in segregation - the prison regime for troublemakers - meaning he was in isolation for 23 hours a day with no basic privileges, no phone calls, no TV. And, it seemed to Garafolo, no air. Despite his pleas, the officers on duty would not unlock the food trap in his door, about the size of a large mail slot, according to his cell-block neighbor, Miguel Perez, who said he was allowed the small bit of ventilation.
When Garafolo's mother visited, she had to talk to him through a glass window - a punishment reserved for segregated prisoners.
"I couldn't touch him," said Lorraine J. Jaillet, who last saw her son three days before his death. "He was crying. I've never seen so many tears."
Virtually every safety measure that might have helped Garafolo in the last six days of his life failed, prison records show.
First, the booking officer at Shirley looked up Garafolo's suicide-attempt history but did not tell the mental health staff what he found. Second, his prison records didn't arrive with him that night, so the intake nurse never examined them. She relied on Garafolo to say if he had any mental health issues, and he said no.
Third, the medical staff failed to alert mental health clinicians that Garafolo had been prescribed psychiatric medication at the hospital. MCI-Shirley's mental health director, Merleen Mills, told department investigators she was away when Garafolo arrived and didn't know he was there until his fifth day. Records show that no one from her staff went to see him.
That was particularly troubling, given the dangerous confusion over Garafolo's segregation status. Reports filed by correction officers say he was being protected from inmate enemies. But that was not reflected in the official prison record. As a result, Garafolo was never seen by a mental health clinician, as required when an inmate is segregated, to ensure he can handle the psychic strains of isolation.
It seemed everyone knew Garafolo was in crisis except the jailers and medical staff charged with his care. His half-brother, Dennis, also incarcerated at Shirley at the time, heard Anthony was in trouble and managed to visit him briefly. A sympathetic officer unlocked the slot in the door, Dennis Garafolo recalled, so he could reach his arm through it. Anthony just held his hand and cried.
"The way I saw that room, it was like being in the hole," Dennis Garafolo said, using prison slang for isolation.
For the last 20 hours of his life, Anthony Garafolo lashed out at staff members and beat on his door. He threatened to harm the wife and children of a sergeant, and demanded to be sent to another prison. When Garafolo smashed his cell window, his neighbor, Perez, feared for him.
The commotion stretched into the early-morning hours, but no one called the mental health staff, records show. Not the captain who threatened Garafolo with four-point restraints. Not the nurses, who had to have him shackled to give him care. Not the officers who had him locked down in segregation.
At 5:56 a.m. on June 20, Garafolo was found hanging from a sheet tied to the shower knob - a long reach from his wheelchair.
A handwritten letter by his bed said: "I can't fight any longer. . . . I going crazy just being in here this long. Don't let this happen to nobody again."
To this day, Lorraine Jaillet insists her son did not kill himself and plans to sue the Department of Correction. Family and friends say Garafolo would not have ended his life without writing to his mother. A pastor who visited Garafolo several times, Paul Suckling of the United Church of God in Worcester, was stunned. "There was frustration, sometimes depression, but nothing close to suicide," Suckling said.
His brother Dennis said, "Either my brother was pushed to that, or he felt doomed."
Desperation in isolation
Emotional desperation is common among those in isolation. It makes even healthy people sick and has a disastrous effect on people with mental illness, according to psychiatrists familiar with the effects of solitary confinement.
"It leaves you alone with your own delusions," said Dr. Matthew P. Dumont, a Cambridge psychiatrist. "It is actually the stupidest and most dysfunctional thing to do to a mentally ill prisoner."
And yet it remains a common form of discipline. In October, there were 345 inmates segregated in Massachusetts prisons, not including those held in other isolated settings, like Garafolo's infirmary room. Nationally, there were 80,870 segregation beds in 2000, following a political push, begun in the mid-1990s, for harder time for convicts and more maximum security cells, according to the Vera Institute of Justice, a research group.
But the Spotlight investigation found that, even as the suicide rate climbed, the prison system continued to rely on this dangerous tool, saying it had no alternative for violent inmates. Nine of the Massachusetts's suicides since 2005 have involved inmates held in isolation.
Dr. Robert B. Diener, a psychiatrist and medical director at Bridgewater State Hospital, regularly sees men who have been in isolation at Walpole, kept in a 9-by-6-foot cell 23 hours a day. He said it is psychologically unhealthy for inmates to be confined that way for long periods.
"They're deprived of normal life experiences," he said. "They can become outrageous."
Even a short period of isolation can be too much for some. It was for Miguel Velasquez.
He was not a convict but rather a federal detainee awaiting trial on gun possession charges when he arrived at MCI-Cedar Junction, the maximum security facility in Walpole, just over a year ago. He had a history of mental illness for which he was being treated, and his behavior behind bars had been generally good.
But then in July he punched another inmate. The price for that would be steep: a trip to the infamous 10-Block isolation unit, home to some of the system's most difficult prisoners. Facing that prospect, Velasquez snapped, records show. He resisted a mandatory strip search, then angrily refused to put his clothes back on. And so he was shackled and marched naked down the hallway to a tiny, windowless cell, according to written reports of the incident.
An officer locked the door with bars, and then, as punishment, shut the outer, solid door as well. Velasquez, 33, was dead three hours later, having hanged himself with a piece of the shirt he wouldn't wear. He was the third inmate in two years to take his life behind a solid door in 10-Block.
The last hours of Velasquez's life were marked by two critical failures by prison and medical staff, the department's preliminary suicide report says.
The nurse who cleared Velasquez for isolation did not examine his mental health records, according to the report. Then, the officer who closed the solid door of his cell door did so without telling his commander or ensuring that mental health clinicians were notified, as department rules require.
His death alarmed Miriam Conrad, the lawyer in the federal defender's office who had represented Velasquez. "Pretrial detainees have a basic right, as well as a constitutional right, to be treated humanely," she said.
The US Marshals Service was paying the Department of Correction $90 a day for Velasquez's "housing, safekeeping, and subsistence." Yvonne Bonner, the acting US Marshal in Boston, said Velasquez's assignment to the state's bleakest prison was purely by chance.
"It's an old facility. It's a depressing site," Bonner said. But, she observed, "I would think being in segregation would be the safest place they could be."
When first contacted by the Globe, Bonner said her office had no plan to probe Velasquez's death beyond a cursory review of the Department of Correction's report. But after learning from the Globe of the errors reflected in prison documents, Bonner reopened the investigation. She said that no federal detainees would be placed at Cedar Junction until the investigation was completed. Several detainees with known mental health issues have since been moved to other prisons.
James R. Bender, the Department of Correction's deputy commissioner, said staff members who failed to follow protocol in the Velasquez case could be disciplined.
A man unraveling
Glen Bourgeois lasted four months in 10-Block.
He landed at Walpole in August 2006 after getting caught in a relationship with a female employee at Old Colony Correctional Center and for having a hacksaw and other contraband in his cell. At 44, he had served 21 years for his role in a murder during a robbery, and he had allegedly been planning to escape. Bourgeois had recently lost hope about his appeal attempts, according to a friend of his and correction officers, and was grappling with the life sentence ahead of him.
In letters to his brother, Bourgeois complained about the oppressive boredom of "the hole." He read books and newspapers, and wrote letters to a pen pal.
For the most part, Bourgeois didn't give correction officers trouble in his final months. But the preliminary prison report on his suicide describes a man falling apart.
Bourgeois complained of panic attacks soon after arriving at 10-Block, saying the noise made him want to bash his head against a wall. But when a clinician came to see him, he said he was "all set."
Twice Bourgeois refused orders to allow the solid door of his cell to be closed, once sticking his arm through the bars to block it. For that he was to receive further punishment: No radio until mid-December and no telephone calls until Jan. 21, 2007, a date he wouldn't live to see.
By October, Bourgeois had been suffering from migraine headaches for two months. He was prescribed Prozac for stress.
In November, Bourgeois went on a hunger strike, but records show he wasn't seen by mental health, as required. They did finally visit him on Nov. 16, for the 90-day mental status checkup required for all inmates in segregation.
On Dec. 27, Bourgeois was found hanging at 4:34 a.m. No one could see him do it because his solid door was closed. Prison officials say he asked for it to be shut, for quiet.
Bourgeois's brother, Michael Hook-DiMarino, was disturbed when he saw the text of his brother's suicide note, a note he said prison officials had told him did not exist. "Consider my sentence paid in full," it said. "I did the only thing I felt I could do to stop my headaches. I have plan this for almost a month, there was no one I could ask for help without being put in worse living conditions than I am in already."
With Bourgeois's death, Hook-DiMarino lost the last member of his immediate family. He said of his brother: "You have to pay for your crime. But you're still human."
A sentence without a crime
The warning signs are often obvious. But prison staff, hardened by what they consider inmates' manipulative behavior, can be blind to them.
Last December, Nicole Davis was sent for detox to MCI-Framingham, the state women's prison, for 30 days. She was not serving a sentence for a crime.
Her family had filed court papers to have Davis civilly committed, to help her shake the drugs she had been addicted to for years - and to head off the arrest warrants she was facing for several open theft cases, and for using a credit card her boyfriend had stolen.
Her parents had hoped to commit her to a private facility. And Davis's lawyer argued to send her to a New Bedford treatment center used by the state as an alternative to prison for women in detox. But Judge Robert G. Harbour at Taunton District Court felt she should be sent to a "secure facility."
"The judge told us she'd be safe at Framingham," said Nicole's mother, Rosamond.
But that was not to be. Judge Harbour told the Globe, "It's something that I'll never forget."
The detox regime was primitive. Coming down off heroin, the antianxiety drug Klonopin, and possibly other substances, Davis was locked in a room at night, with correction officers periodically watching her door. She told a mental health clinician that she had been depressed since the death of her baby boy, Nathan, in foster care seven months earlier.
She denied feeling suicidal, according to prison records. But her parents said they saw real distress on their visit Dec. 19, the day after Davis's 24th birthday. Davis begged them not to leave.
"She said, 'I want you to stay because if you don't stay, I have to go back up in the hole,' " her mother recalled. Davis hated to be alone, her father said.
That night, Davis was left alone in a spartan cement cell in the infirmary. She was kept there after alleging that a male officer had groped her. It was a claim the officials doubted, according to the investigative report of her death.
Around midnight, Robert and Rosamond Davis were awakened by police at their Norton home. They called MCI-Framingham, as directed, and soon heard prison Superintendent Lynn M. Bissonnette tell them their daughter had died in a "bizarre incident," Robert Davis recalls.
Throughout her last evening alive, Nicole Davis repeatedly asked for medical care, Dr. Philip DeChavez said in the department's suicide review. The staff checked on her but thought she was just seeking drugs or attention. At 10:29 p.m., an officer found her, sitting on the cell floor with a sheet around her neck.
Clinicians and staff members involved in Davis's suicide review mulled some fundamental questions. Might inmates undergoing drug or alcohol withdrawal be at risk to themselves once they're sober? Should they have a new mental health check-up after detoxing?
The panel members decided such assessments would not help. However, Bissonnette, the superintendent, did propose that women no longer be left alone. According to the report, she was concerned that heightened feelings of isolation could "result in an increase risk of self-harm."
"The women," Bissonnette told the Globe, "can't tolerate it."
At great risk
Sean Turner was another left to fight through detox on his own.
Turner was alone in a cell at MCI-Concord, withdrawing from daily intravenous heroin use without proper medical oversight on the day he took his life.
According to the Department of Correction's own procedures, Turner should not have been admitted to Concord at all on July 11, 2005. At that time, the old prison on Route 2 had no beds for inmates going through withdrawal. The department's review of Turner's suicide says, "MCI Concord does not have detox protocols in place and all detox patients are transferred to infirmary sites or the local hospital for care." But, it goes on to say, "Mr. Turner was released to population," meaning to an ordinary cell.
When Turner, 47, arrived at Concord that night - awaiting trial on motor vehicle and drug charges - he was experiencing nausea from withdrawal. A physician reviewed his intake report, and the nurse ordered detox medication, according to the department's reports. But she did not write a progress note or notify the on-call physician of the detox plan.
Over the next two days, Turner was quiet, according to inmates interviewed by the department. He sat alone in the chow hall, played dominoes, and went to the library, they said, but he was depressed and fearing a long prison term.
On the morning of July 13, Turner went to the medication line at 8 a.m., an inmate said, but was turned away. He took a shower about 10:30 a.m., went to lunch, and was seen lying on his bunk at 1:45 p.m. An inmate says he asked Turner for stamps at 2:10 p.m.
At 2:30 p.m., when most inmates were out in the yard and his cellmate was away at court, Turner was found hanging from a sheet attached to a wall vent. He'd had plenty of time to do it: Two correction officers on duty failed to make their scheduled hourly rounds that afternoon, according to department investigators' review of a prison videotape. The officers lied in the investigative interview, claiming they had made the rounds. They received 30-day suspensions.
"I just can't imagine that they would put anyone in his circumstance into a room and just leave them," Turner's mother, Dianne Hawkes, said of her eldest child, a smart student with a knack for mechanics, woodworking, and photography. "I think they were completely negligent."
Aside from the physical dangers, psychiatrists and prison officials say detoxing can bring on severe depression. For some inmates, it's the first time they've been sober in months or years, and they find themselves suddenly facing the reality of incarceration, said Karin T. Bergeron, superintendent at Bridgewater State Hospital.
"Many of these men are at great risk for suicidality," she said.
Falling through the cracks
That was certainly the case for Jarred Aranda. By the time he arrived at Bridgewater last spring, he'd been at the Bristol County jail in North Dartmouth for three months.
Aranda was in the midst of the longest stretch of sobriety he'd experienced in recent memory, he told a Bridgewater psychiatrist, and he was feeling poorly. He had all but forgotten the comforts of his youth: the house with the big lawn, the swimming pool, the dinners in his grandmother's kitchen. He hadn't wanted his mother or sister to see him at Bristol County, where he stole a correction officer's lunchbox and fought with him. He tried to hang himself with shoelaces, then cut his wrist with a plastic knife.
Days later he spent his first night at Bridgewater, alone in a treatment unit, but under frequent watch. The next day, he was removed from seclusion but kept under close observation. Two days later, he was sent to a less restrictive area.
That's when Aranda fell through the cracks. No one took responsibility for him for nearly two weeks, according to the department's records.
On his last full day alive, Aranda told a psychiatrist his depression was getting worse. On a scale of 1 to 10 (10 being worst), he felt like a seven or eight. The doctor prescribed Lithium and Seroquel for Aranda's bipolar symptoms and Wellbutrin for depression. It's unclear if Aranda took the medication; he had refused it since arriving at the hospital.
Just a few days before, Aranda's father and stepmother had visited him. They said he talked about the future, about changing his life. He didn't complain; he never wanted his family to worry.
But on the night of March 30, prison records show, Aranda took the laces out of his roommate's sneakers. And headed for the shower. 