This story has been updated.

A report by Disability Rights Connecticut released on Tuesday accused the Department of Correction of failing to provide the correct medical care to an incarcerated man who, suffering from ALS and opiate withdrawal, died within 24 hours of being admitted into the correctional facility. 

The 2 1/2-year investigation, which began not long after the incarcerated man’s death on June 25, 2022, alleges that the nurses and correction officers who responded to his death ignored his ALS-driven dietary needs, did not actively monitor his ongoing opiate withdrawal and delayed trying to revive him for nearly 20 minutes after finding him unresponsive, according to the report. 

The nurses and correction officers at the Bridgeport Correctional Center also falsified documentation regarding their actions leading up to the man’s death, the report alleges. The man was not identified by name.

In response to the report, the Judiciary Committee on Tuesday modified a bill that increases penalties for falsifying police records to extend those penalties to detention records. Under the revised bill, anyone who falsifies these records can be charged with a class D felony. 

Sen. Steven Stafstrom, D-Bridgeport, said during a meeting of the Judiciary Committee on Tuesday that the allegations in the report needed to be taken “very seriously.” 

“We place a lot of trust in both the internal affairs of our police department, our correction department, as well as the Office of the Inspector General, to make sure when there’s an untimely death in custody, that that is appropriately investigated. And where members of those very law enforcement units or the Department of Correction are themselves the ones impeding those investigations, it needs to be punished, and it needs to be punished severely,” he said.  

Both Stafstrom and State Rep. Craig Fishbein, R-Wallingford, also referred to the death of Carl “Robby” Talbot at the New Haven Correctional Facility in 2019. An investigation alleged that corrections officers had falsified documents regarding use of force and the regularity of checks being made on Talbot. 

“ We, as a society, take people into our care and custody based upon a conviction. We do have a level of requirement to do things properly, and I would hope that the Department of Correction would investigate … what’s been brought to our attention, as well as at some point let us know what actually happened [with the falsification of records in the case of Talbot],” said Fishbein. 

According to the report, when the man came into the Bridgeport facility, the nurses noticed that he was “extremely frail.” His body mass index was 18 — slightly below normal — and he was struggling to eat and swallow. He was admitted to the facility’s hospital unit. 

ALS, also known as Lou Gehrig’s disease, is a progressive neurological disorder that slowly takes away a person’s ability to control their own muscles. The disease is fatal and affects a person’s ability to move, speak, eat and perform other voluntary functions.

The man was also in withdrawal from heroin, and a nurse noted that he was nauseated and vomited while being admitted into the facility. Although an order was issued to screen the man for withdrawal, he was never evaluated. The nurse later entered a screening score into the man’s medical record after his death, the report alleges. 

A different nurse — one who “never spoke with John Doe about any withdrawal symptoms, never made face-to-face contact with him, and did not conduct any physical assessment” — entered a second, different screening score into the man’s medical record after his death that indicated that he was not in withdrawal, according to the report.  

The report also alleges that, the morning after the man was admitted, he received the same food as the other incarcerated people, including crackers that he was unable to chew. They also gave him milk without the thickening agent that he needed to help with his difficulty swallowing. Staff found a half-consumed milk carton in the man’s cell after his death, along with vomit on the floor, the report claims. 

The Office of the Chief Medical Examiner ruled the man’s death the result of  “complications of acute and chronic opioid use.” 

According to department policy, correction officers were supposed to check on the man every 15 minutes because of his medical condition. But the investigation reported that three correction officers each recorded multiple “safety tours” that never actually happened. 

The report also criticized the failure of both nurses and correction officers to perform CPR on the man when they found him unresponsive. According to the report, it took 19 minutes before a nurse began to perform CPR on the man. 

It took over two years for the Department of Correction to discipline the people involved, the report states. Two lieutenants received suspensions that were later reduced. One correction officer was dismissed but later had the dismissal reversed and was able to receive back pay for the four months she was not working. 

Two of the nurses, meanwhile, are being investigated by the Department of Public Health. Petitions against the nurses are pending action, the report states.

Brittany Schaefer, a spokeswoman for the Department of Public Health, said they could not comment on any investigation but noted that investigations can be delayed for “a variety of reasons, including challenges in identifying expert consultants who can objectively review a case and provide an expert opinion.”

The Department of Correction fired one of the nurses in July 2024. 

Ashley McCarthy, a spokesperson for the Department of Correction, said in an email that the department was in the process of “reviewing the findings and the recommendations” of the investigation.

“The Department of Correction takes the health and well-being of all those under its supervision very seriously and continuously strives to ensure that the incarcerated population receives the best level of care possible,” the statement reads.

The report noted that the Department of Correction had no formal plan to improve its operations in response to the man’s death. According to the investigation, the department has not been running CPR drills since 2018. The two nurses who allegedly falsified medical records did not complete a 13-week orientation program for new employees, the report claims. 

Disability Rights Connecticut called for a series of changes, including requiring the Department of Correction to report annually on death investigations in all its facilities and any corrective measures they are taking in response. It also called on the Department of Correction to establish a “death investigation task force” to make recommendations regarding department operations. It also asked for evaluations of the Department of Correction’s disciplinary procedures and the delays at the Department of Public Health. 

Sen. Gary Winfield, D-New Haven, chair of the Judiciary Committee, told The Connecticut Mirror that he “generally” supported the recommendations that Disability Rights Connecticut had made. He said some of what they were recommending was already included in legislative proposals. He noted that the committee was trying to strengthen the power of the Correction Ombuds, who can investigate all complaints made against the Department of Correction.  

Interim Correction Ombuds DeVaughn Ward told CT Mirror that he saw the situation as “tragic” and that he was “all too familiar” with situations in which people enter correctional facilities without a proper assessment. 

“ I think the most concerning things, aside from the actual manner of death, are the fact that the employees never faced any discipline for being derelict in their duties. I think that’s really concerning,” said Ward. 

Like Winfield, Ward said there were proposals already in the legislature that would address some of the recommendations made by Disability Rights Connecticut. Specifically, he mentioned a bill that passed through the legislature’s Public Health Committee that would require the Department of Correction and the Department of Public Health to annually evaluate the quality of physical and mental health care provided in the state’s correctional facilities, and would require the ombuds to report on the health care that inmates were receiving. 

Ward said he was also troubled by the long delays that Disability Rights Connecticut faced when it sought documentation from the Department of Correction. The report noted that the Department had taken “weeks or months” to grant the organization documentation it requested despite a federal law requiring agencies to provide documentation within 24 hours of a request from certain investigators. 

“ I also think it’s a question for William Tong and the Attorney General’s office, who defends them,” he said. “DOC didn’t do that in a vacuum. They didn’t do that without legal counsel.” 

Elizabeth Benton, spokesperson for the attorney general’s office, told CT Mirror that the office has tried to make sure these records are available “whenever possible” and referred any further questions to the Department of Correction.

In a statement, Sen. John Kissel, R-Enfield, and Sen. Stephen Harding, R-Brookfield, called the report “highly concerning.”

“Its findings are alarming. DOC must address them with full transparency and accountability as soon as possible,” the statement reads. 

Sen. Herron Gaston, D-Bridgeport, expressed his frustration with what the report revealed and said that anyone who falsified records should be “prosecuted to the full extent of the law.” 

“ I think that for people who already have skepticism about our criminal legal system, this only fuels that skepticism, and it only energizes that distrust,” he said.  

Gaston proposed creating an oversight committee of lawmakers, attorneys or law students and law enforcement to investigate similar claims. He said he envisioned such a committee as working in tandem with the ombuds office. 

“We don’t want anything like this to ever happen again,” he said.

This story has been updated to include a comment from the Department of Correction.