Leonard Engel spent much of his 16-year tenure as assistant ombudsman at Cheshire Correctional Institution, a building more than a century old that’s known informally as “The Rock.” As he’d interview prisoners who’d filed complaints about their living conditions, he’d see people getting shuttled in and out of “the hole,” cells used for punitive segregation located right next to the interview room.

Once, he saw a man get dragged in after beating up a correction officer. Covered in blood, the man was babbling to himself. To Engel, it appeared the man was having a mental health crisis. Prison staff put the man in solitary confinement and placed him in restraints to make sure he didn’t hurt himself or anyone else.

“Who is going to bring this to their attention? ‘This is a problem that you’re not solving by shackling them to the bed?'” Engel asked, who reported what he saw to the warden. “Those things would bubble up through the ombuds.”  

For 37 years, Connecticut had a corrections ombudsman who addressed incarcerated people’s complaints and investigated allegations they had been treated unjustly by the Department of Correction, but the office was eliminated in 2010 to save money.

Nine years after the ombudsman office closed, Robby Talbot was admitted to the New Haven Correctional Center. A 30-year-old man who had been diagnosed with severe bipolar disorder with schizoaffective features, Talbot had been in and out of jail for a slew of low-level crimes.

On March 19, 2019, he was admitted to the jail on Whalley Avenue for the last time. He died two days later, alone, in a jail cell in an ill-fitting orange jumpsuit, his ankles and wrists shackled and tethered by a chain.

Colleen Lord watches the water in the evening. Her son Robby Talbot, who used to walk along the beach with her, died in New Haven Correctional Center on March 21, 2019 after being pepper-sprayed and placed in in-cell restraints. Yehyun Kim / ctmirror.org

There was no ombudsman to investigate the systemic problems at the New Haven jail that might have contributed to Talbot’s death. 

Although lawmakers approved a bill in 2019 requiring ombudsman services for minors in adult prisons — just 39 of the 9,020 people behind bars as of July 1 were under age 18 — an effort this year to expand the office to the rest of the prison system failed when Gov. Ned Lamont vetoed legislation containing the funding.  

That legislation, dubbed the “PROTECT Act,” which received final passage in the House on June 5, would have expanded the office’s purview, allowing the ombudsman to receive and assess complaints from the entire incarcerated population.

But Lamont vetoed the bill, instead issuing an executive order limiting the use of solitary confinement, including in-cell restraints, the type of confinement in which Talbot was placed. Lamont’s order did not, however, mention the ombudsman office.

“I think an ombudsman would have prevented what happened to Robby because it would have given staff and incarcerated people a place to report some of the injustices and abusive practices that are policies that the Department of Correction has in place to treat people with mental health issues,” said Kevnesha Boyd, who was a social worker at the New Haven Correctional Center for four years and resigned after Talbot’s death.

She pointed to gaps in the social safety net, cracks made into crevices by the unkept promises to fund community-based mental health services following the closure decades ago of large psychiatric institutions.

“Essentially, the Department of Correction is the new psychiatric hospital,” Boyd said. “And there’s no external accountability. So you’ve got a system that’s designed to enslave people, that’s designed to punish people, also in charge of the health care and the treatment and the rehabilitation of people.”

“Essentially, the Department of Corrections is the new psychiatric hospital,” said Kevnesha Boyd, a former social worker at New Haven Correctional Center. “And there’s no external accountability. So you’ve got a system that’s designed to enslave people, that’s designed to punish people, also in charge of the health care and the treatment and the rehabilitation of people.” Yehyun Kim / ctmirror.org

The governor’s veto means the current grievance system remains in place. To many, that system — an internal procedure where prisoners can log complaints about the conditions of their confinement — is insufficient.

“Whether it’s the corrections or any other agency, if you’re looking to provide oversight, that oversight is best coming externally, not internally,” said Sen. Gary Winfield, co-chair of the Judiciary Committee. “Your perspective is skewed by the fact that you’re looking at yourself.”

In a letter outlining his issues with the PROTECT Act, Lamont said the ombudsman program “creates security and litigation risks.” He said he was concerned about the investigator’s access to DOC records because they could disclose information that leads to security breaches at correctional facilities. He also said he worried the ombudsperson could access, and then disclose, records protected by attorney-client privilege.

An ombudsman would not have investigated Talbot’s death. But an ombudsman might have investigated the conditions of confinement at the time of Talbot’s incarceration and death: namely, the use of chemical agents and in-cell restraints to immobilize people with serious mental health conditions who, because of their disabilities, had trouble complying with orders from corrections staff. The ombudsman could recommend policy changes to the DOC or send their findings to lawmakers, who could then pass legislation.

Talbot’s mother, Colleen Lord, believes an ombudsman’s work could lead to widespread changes in prisons and jails. Maybe, she hopes, they could prevent future abuse.

Purple was her son Robbie Talbot’s favorite color. Colleen Lord surrounds herself with purple objects, including the purple hydrangeas in her garden. “I just grab on to signs of him,” she said. “You’re desperate for comfort.” Yehyun Kim / ctmirror.org

“The problem is there’s absolutely no oversight or transparency,” Lord said of the Department of Correction. “Everything they do is behind locked doors.”

Much of Lord’s life is spent investigating what led to Talbot’s death. Conscripted by tragedy, she has undertaken two entwined onerous duties: seeking justice for her son and fighting to make sure other mothers don’t lose their children to the same practices that occur behind locked doors in the state’s prisons and jails.

Pepper sprayed and restrained

On March 21, 2019, New Haven jail staff sent Talbot to shower after they found him smearing feces on himself and on his cell walls. He’d been two days into withdrawal from methadone — a condition Lord said could trigger a manic or psychotic episode — and was awaiting a psychiatric evaluation from jail.

Body camera footage from that morning obtained by the CT Mirror shows a crowd of corrections staff standing outside the shower. Lt. Carlos Padro stands over Talbot and sprays him with pepper spray before kicking him in the chest. Talbot screams, “I can’t breathe” several times, begging for help.

The video then shows staff walking Talbot down the hall to a station where he can get the chemical agent washed out of his eyes. Padro walks up to the camera and explains the situation: “Inmate Talbot refused to get out of the shower. He laid down.”

Custody staff shackle Talbot’s wrists and place him in a wheelchair. Five correction officers wheel him toward an elevator.

“My skin hurts. It’s burning,” Talbot says.

“Where are we going?” Talbot asks as he is wheeled into an elevator. He screams for help and wriggles out of the chair. Padro sprays him in the face again with the chemical agent.

The COs walk him a short distance to a solitary cell with a turquoise door.

“The nurse is going to check you out,” Padro tells Talbot. Two COs fiddle with Talbot’s restraints as he shifts on the bed.

Padro sprays Talbot again. Another corrections officer recoils, closing his eyes and scrunching his face to avoid the effects of the chemicals.

Talbot coughs and stands on the bed and tries to face the barred window.

“Will you calm down?” Padro asks. “Just relax. You’re overreacting.”

Talbot, handcuffed, says he’s “on fire.” Another corrections officer asks for “in-cells,” referring to in-cell restraints, a form of confinement the DOC uses if an incarcerated person presents an immediate harm to themselves or others.

The chains rustle as the COs place the restraints on Talbot’s legs and ankles. His wrists and ankles are tethered as he lies on his back, his head a few feet from the barred window. The gray cuffs are connected by a black chain and locked to a black box, preventing Talbot from having a wide range of motion with his hands.

According to the state’s attorney’s investigation, DOC staff checked on Talbot every 15 minutes after that. At 8:30 a.m., Talbot appeared to be talking to himself. Jail staff went to the cell shortly before 9 a.m. to see if Talbot could have his restraints removed. By that point he wasn’t breathing.

Talbot died after going into cardiac arrest following his shackling. The Chief Medical Examiner later ruled Talbot’s death a homicide. Padro, who was charged with third-degree assault, was convicted last June and was sentenced to three years of probation.

A section in Lord’s living room is decorated with objects related to her son, including the urn and his pictures. “I always want to keep him as close as I can,” Lord said. Yehyun Kim / ctmirror.org

Talbot had been on Boyd’s case load. She’d grown close to him over the years and understood the severity of his multiple health conditions — obesity, chronic drug use and mental illness.

“We called him Baby Huey. Robby was sweet. He was innocent, he was kind, he was gentle, and he was hilarious,” said Boyd.

The other jail staff also knew Talbot well, Boyd said. For them to see him in the throes of a psychotic episode and respond by pepper spraying him repeatedly, shackling him and putting him in isolated confinement, was unconscionable to Boyd.

“It really was like, ‘I can no longer work for a system that is doing this to people,'” said Boyd.

Boyd didn’t know Lord at the time of her son’s death. But she knew she was an active, worried parent, the kind of mother who called the health care team at the jail to make sure they had the most up-to-date information possible. She was an advocate, someone who hoped Talbot might be rehabilitated when he was locked up because he’d get the treatment he needed.

“If this can happen to somebody whose mother is actively involved, then imagine what’s happening to the poor Black people who don’t have mothers, who don’t have money and who don’t have the voice,” Boyd said. “We’re talking about a high-class white woman here.”

The inside of the door in the cell in which Robby Talbot died. Pictures from State Police file, provided by Colleen Lord.

Engel said he received many complaints from prisoners who were put in different forms of isolated confinement.

“There were always complaints about getting transferred to restrictive housing, because it was such a difficult environment, very little out of cell time,” he said. “People did not want to be there.”

But complaints from people about in-cell restraints were more complicated. The ombudsman would not have been able to resolve a complaint filed by someone shackled in a cell because the nature of that form of confinement is short term, Engel said.

“By the time it’s over, that complaint is moot because the person is no longer undergoing it,” Engel said. “And so our process at that point would be to review the policy itself to determine whether the policy needed to be changed.”

An independent fact-finder

The ombudsman’s office didn’t just handle complaints about isolated confinement. They received an array of grievances, from questions over the legality of prison sentences, to issues with medical care, to dismay over stolen or damaged property.

An informational packet created by the Connecticut Civil Liberties Union in the late 1970s explains that ombudsmen investigate complaints concerning DOC activity if those actions are against the law, are unreasonable or unjust, involve an improper exercise of discretion or are likely to add to “institutional tension because of vague practices and procedures.”

Connecticut had a DOC ombudsman from 1973 to 2010. Support — and funding — waxed and waned over time.

The ombudsman position was created after a riot in a Somers prison in 1972. Federal grants provided the bulk of funds until 1977. After that the state took it over, mostly as a year-to-year contract service.

“At the time there was a high motivation to start looking at prisons and trying to understand what their problems might be, and what inmates’ rights were, and how you might have a better interface between the staff, prisoners and the administration,” said James R. Bookwalter, who served as ombudsman from 1973 to 2010.

“The mission was to basically have a dispassionate person to complain about conduct, activities, quality of life, conditions of incarceration in the Department of Correction,” Engel said. “The primary mission was to be an outside voice and external ear, to hear the complaints, and then a voice to develop a record of what happened.”

Lord had a dream of hugging her son a few days ago. She appreciated the dream so much that she decided to send flowers towards the lighthouse where his ashes were sent. Yehyun Kim / ctmirror.org

When Gov. John Rowland took office in 1995, “immediately he did everything he could to basically transform DOC into a much more security-focused operation,” said Michael Lawlor, who served as Judiciary Committee co-chair from 1995 to 2011. Rowland changed the department’s uniforms to look more paramilitary, Lawlor said, oversaw the opening of the supermax prison, Northern Correctional Institution and, at the same time, appeared uninterested in strengthening oversight of the DOC.

“It was clear that their ability to do what they did was progressively undermined,” Lawlor said of the ombudsman. “The minute Rowland arrived, they were working, among other things, to undermine and ultimately jettison this whole approach, (such as) independent people going in and talking to prisoners.”

Before he was appointed DOC commissioner by Gov. Dannel P. Malloy, Scott Semple served as the agency’s legislative liaison during the Rowland administration and was instructed to try to gather support for eliminating the ombudsman office.

“It really had to do with cost,” said Semple.

In 1999, Correction Commissioner John Armstrong tried to eliminate funding for the position. Legislators wound up appropriating about $150,000 — roughly half the office’s budget.

Engel said Armstrong “made it his mission to get rid of us,” because he didn’t think the ombudsman added any value to the prison system. But in the prisons themselves, Engel said, wardens and directors of regions were supportive of the office.

“They saw the value to the incarcerated people, they saw the value to staff, they saw the value to the atmosphere,” Engel said. “It was very, it was pretty low money to be able to tell those incarcerated, ‘Listen, if you’re not happy with how we responded to your complaint, you’ve always got the ombuds.'”

Sen. Gary Winfield, D-New Haven, listens to the proponents of the PROTECT Act at the Connecticut State Capitol on the last day of the special session. Yehyun KIm / ctmirror.org

Legislators enshrined the ombudsman’s services into statute in 2001, part of an ongoing effort to preserve the office. The statute was repealed in 2010, eliminated in a budget revision passed during that year’s legislative session.

What made the ombudsman program so important, Engel said, was that the investigators were independent of the DOC. They served as an outlet for prisoners frustrated with the system in which they were confined.

“There were a lot of unsatisfied incarcerated people who wrote and didn’t get the response they wanted. But what they did get was the opportunity to complain to me, to complain to my colleagues, to sit down and talk to us,” Engel said. “We didn’t blow them off. We listened to what they had to say, and that can be a very valuable thing in an environment like this.”

The incarcerated weren’t the only ones reeling from the loss of the program. Legislators like former state Rep. William Dyson, D-New Haven, used the office as an information source for crafting policy. Having an objective fact-finder meant lawmakers didn’t have to rely on the Department of Correction to police itself, Dyson said. Engel was in the prisons four days a week. He was a part of the fabric of the system.

“In retrospect what has happened is we have to dig for the information ourselves now, from within, to ascertain what conditions are like and what’s going on, and how things are being done, and how the place is being run,” said Dyson, who was chair of the Appropriations Committee from 1989 to 2005. “What we had was a person who understood the system, its temperament, who had a depth and breadth of knowledge about the system.”

When it closed, lawmakers like Dyson wondered: “Now what?”

“That had not been something we had ever anticipated,” he said, “that you’d have a system without an ombudsman.”

Grieving internally

An administrative grievance system replaced the ombudsman office, but for some it felt woefully inadequate.

“In order to grieve someone, you have to first of all, ask a guard to give you the grievance form, so they know you’re gonna grieve,” said Tracie Bernardi, who was in prison from 1993 to 2015. “And it’s such a joke to the guards they will spell their names, like dare you, because they don’t care that you’re writing them up because they know it goes nowhere.”

In 2010, a corrections officer wrote Bernardi up for “disobeying a direct order” and refusing to get dressed after she’d showered, according to a disciplinary report. Bernardi said she’d been locked out of her cell and the correction officer wouldn’t let her in to change, so she remained outside her cell in her bathrobe.

Bernardi planned to plead not guilty but said she ultimately decided to abandon the fight because she didn’t want to lose privileges, like being able to attend college classes.

That experience, and many others during the 22 years she spent in prison, didn’t give her a lot of faith in the grievance process.

“A grievance is within their own system,” Bernardi said. “They’re not going to go against their own because then they have to admit something’s wrong.”

Leighton Johnson didn’t trust the grievance system, either. Sometime around 2011, about halfway through his decade-long sentence, Johnson filed a grievance against the grievance system. He believed it was biased against the incarcerated.

Leighton Johnson spent 10 years in prison. At the halfway point of his sentence, he brought a complaint against the grievance system. Yehyun Kim / ctmirror.org

“I was basically saying we needed somebody that was unaffiliated with the DOC, that was unbiased in their findings,” he said, outlining the need for an ombudsman office. “They told me I had no merits, and they denied it.”

Semple defended the administrative grievance process, however. DOC management monitors the complaints, he said, looking for trends and conducting their own internal audits.

“If you get a bunch of grievances that are specific to a specific facility, that should be a red light that you need to pay attention to that,” he said.

If incarcerated people disagree with the way their grievances were handled, Semple said, they can appeal.

“I think some people would be disappointed if the finding wasn’t in their favor, but there was many times where the process was remedied and in favor of the person who put in the complaint,” Semple said. “It wasn’t like, ‘OK, we got your administrative remedy, and we’re going to deny it no matter what.’”

Moving forward 

A fiscal analysis of the PROTECT Act estimated it would have cost $677,277 this fiscal year to hire an ombudsman and six support staff. That’s roughly double the amount spent on the program in 2008.

DOC Commissioner Angel Quiros, a 32-year veteran of the department, told members of the Judiciary Committee at a March public hearing that he supported reinstitution of the office, a position later clarified by his spokeswoman after the governor vetoed the PROTECT Act earlier this month.

Kevnesha Boyd, a former social worker at New Haven Correctional Center, worked the afternoon that Robby Talbot died. Boyd said there was no debriefing to prevent death like Talbot’s in the future. “That conversation never was had. It never was had, ever, ever, ever,” she said. “The next day everything just went back to normal.” Yehyun Kim / ctmirror.org

“The language now does not mirror the language that the Ombudsman used to operate under, and there were concerns about access to records and things of that nature,” said Karen Martucci, the DOC’s director of external affairs. “But, we supported the Ombudsman philosophy and practice.”

Winfield, whose desk often has tall stacks of mail from incarcerated people who write to him from prison, said the system needs an ombudsman. He said he will likely introduce legislation in future sessions to get the office up and running.

Colleen Lord sat outside the Capitol for nine hours the day the House passed the PROTECT Act, a Saturday in the waning days of the session. Boyd was with her.

The two women connected after Boyd became a board member of Stop Solitary CT, which advocated for the PROTECT Act throughout the session. Getting to know Lord helped Boyd process her feelings. Before, when she still worked at the jail, she grieved Talbot’s death alone.

“When you care about incarcerated people, they label you an ‘inmate lover,'” Boyd said. “That becomes really, really isolating when your co-workers are teasing you. You’re being ostracized for caring when your role as a mental health counselor is to care.”

Boyd swears Lord looked lighter the night the House passed the PROTECT Act, like she was finally getting justice for her son’s death.

Lord had a framed picture of her son beside her as she listened to the arguments from outside the building. She felt him there with her.

“To me, this bill represented that no one would ever die or be killed the way that my son was, and it just felt really important to me, that I had to be there when it crossed the finish line,” Lord said. When it passed, she cried tears of relief. “To me it seemed like maybe Robby didn’t die for nothing.”

Kelan is a Report For America Corps Member who covers the intersection of mental health and criminal justice for CT Mirror. Before joining CT Mirror, Kelan was a staff writer for City Weekly, an alt weekly in Salt Lake City, Utah, and a courts reporter for The Bryan-College Station Eagle, in Texas. He is originally from Philadelphia.