A state prisoner who’d been losing a dramatic amount of weight began to vomit uncontrollably, and was repeatedly given Ibuprofen that made her internal bleeding worse before she died. 

Another person behind bars waited nearly an hour for a nurse to call an ambulance after he collapsed and had a seizure. 

And one incarcerated man complained of shortness of breath and chest pain for five days, but was never sent to a hospital before he died of a heart attack. 

Those are some of the cases detailed in the 60 death reviews conducted over the past nearly three years by a state oversight commission charged with investigating the state prison system. An estimated 35 of the deaths could have been prevented — or delayed — had the prisoners been given better medical care, the medical reviews indicated. 

THE CITY’s review of the 408 pages of death reports, obtained via a Freedom of Information Law request covering May 2017 to January 2020, shows: 

  • High-profile prisoners and sex offenders were often given inadequate medical care — and were rarely seen by doctors or sent to hospitals, despite serious ailments, according to the medical reviews. 
  • Three prisoners died from asthma attacks that could have been prevented had they been given proper inhalers and other medication. 
  • Four of the 21 suicides logged occurred while prisoners were in solitary confinement. 
  • It took the Commission of Correction an average of nearly 2 ½ years — 883 days — per case to complete its probes into deaths. 

The revelations come as 16 prisoners have passed away due to COVID-19. Juan Mosquero, one of those prisoners, was never tested for the virus or brought to a hospital outside of Sing Sing, according to the HuffPost, which first reported his death. 

Basic Care ‘Lacking’

The commission’s forensic medical unit can prioritize death investigations that appear to involve systemic deficiencies of health care or security, or when multiple deaths with similar fact patterns occur in a single facility, said Kirstan Conley, a commission spokesperson. 

But the cash-strapped commission, with an annual budget of nearly $3 million and a staff of about 30, has not focused on a specific cause of death, like suicide or cancer, or facility in years, records show. 

For instance, there were 18 suicides last year, the highest level in close to a decade since 20 people took their own lives in 2010, according to a report. 

‘Medical care timeliness, quality and just basic patient-provider relations are all lacking.’

“We know that medical care timeliness, quality and just basic patient-provider relations are all lacking across the system,” said Jennifer Scaife, executive director of the Correctional Association prison oversight group.

State prison officials say that all its 52 facilities have medical staff on site and prisoners can access them by making a sick call. Prisoners and the death review reports indicate the facilities are primarily staffed with nurses who can request a telemedicine review with a doctor, if necessary. 

People locked up who are chronic or terminally ill are sent to the state’s Regional Medical Units (RMUs) in selected facilities across the state, according to Thomas Mailey, a spokesperson for the Department of Corrections and Community Supervision (DOCCS). 

‘Something’s Wrong’

None of those steps made a difference for several high-profile prisoners, who reports found were the victims of medical neglect. 

William “Bill” Brennan fatally shot Michael D. Johnson in the back early Christmas Day in 1977. Authorities said that Brennan, who is white, got upset after he saw Johnson, a Black man, kiss a white woman good night. 

Brennan, of The Bronx, was arrested seven years after the crime when a bar buddy tipped off police.

In prison, Brennan, 5-foot-7 and 260 pounds, died from hypertension and heart disease on Nov. 5, 2015, inside Shawangunk Correctional Facility, according to the medical review. 

The 56-year-old was moved in a wheelchair to the facility’s medical clinic after he complained of chest pains at approximately 11:40 p.m.

Instead of being immediately transported to the nearest hospital, the nurse on duty waited until 12:21 a.m. to call an ambulance and failed to perform CPR after Brennan apparently lost consciousness, the death report said. 

That nurse, whose name was redacted in the report, was placed on administrative leave, but later returned to work. 

‘He was one of my favorite patients.’

Another nurse at the facility at the time said that she’s haunted by Brennan’s death. 

“He was one of my favorite patients,” Jeanne Vacca told THE CITY. “If I had been on [duty] that day, he probably wouldn’t have died.”

Afterwards, Vacca said she was careful to never miss any of her shifts, including nights, because she was worried her other patients would die due to mistreatment. 

“These guys are older, they’re sicker,” said Vacca, who worked for DOCCS from 2013 to 2016. “If they complain of something like that and if a diabetic as bad as Bill complains of chest pain, something’s wrong.”

No Call for Help

Stacey Castor, who was dubbed The Black Widow after poisoning two of her husbands with antifreeze, died on June 11, 2016 in Bedford Hills Correctional Facility. 

The 48-year-old, who was serving 47 years to life, died from cardiomegaly, an enlarged heart, shortly after complaining of chest pain to medical staff. 

Castor’s vital signs weren’t taken during one visit to the infirmary after chest pains, “a violation of NYS DOCCS Health Services Policy,” documents show. Not long after, Castor was found unresponsive in her cell, the report said.

The medical review board found that the nurse on call failed to “prompt the use of a telemedicine encounter or consultation with on-call medical provider,” which is standard procedure when a patient complains of chest pain, according to the report. 

‘Grossly Substandard’ Treatment 

Abdul Majid, who was convicted of killing an NYPD cop in 1981, died on April 3, 2016, in the Orleans Correctional Facility. 

The medical review board found that his medical treatment was “grossly substandard with repeated failures to perform adequate assessments.” He was seen 13 times in the facility’s medical clinic for cold symptoms before he was examined by a “medical provider,” the death report said. 

He died from acute cholecystitis, an “inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct,” according to the Merck Manual. He also had a six-centimeter lung mass, the medical review said. 

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The 65-year-old was serving a 25-years-to-life sentence for gunning down Officer John Scarangella and for the attempted murder of Officer Richard Rainey.

State Assemblyman Charles Barron (D-Brooklyn) called Majid a “political prisoner” who was never given a chance at freedom by the parole board. 

“I think it’s part of a plan to make sure [political prisoners] never see the light of day and die in prison,” he said.  “We must fight that.” 

Not Enough Doctors 

The medical reviews found that some of the alleged mistreatment of patients is due to an over reliance on telemedicine. 

William Cullen died from a heart attack after a nurse sought an off-site doctor’s take on what to do after he collapsed and seized on the floor on April 3, 2016, in the Clinton Correctional Facility, according to the death report. The nurse took an hour to call an ambulance, the review found. 

“There has been an inordinate reliance on telemedicine use for critical patients,” the death report said. 

The 40-year-old mechanic from Syracuse was serving a 12-to-15 year sentence for raping a young relative. 

‘He suffered every f—–g night.’ 

Lexcy Cullen, his twin sister, charged her brother was abused by guards due to the nature of his crime. 

“They beat the hell out of him in handcuffs,” she alleged, noting he suffered from chronic pain since a car partially fell on him. 

“They did not help his pain at all,” she said. “He suffered every f—–g night.” 

DOCCS records do not indicate any incidents involving use of force by staff while he was incarcerated at Clinton Correctional Facility, according to DOCCS spokesperson Rachel Connors. 

The family was unable to conduct an independent autopsy because state prison officials took 11 days to hand over his body, Lexcy Cullen said.

DOCCS blamed the delay on Champlain Valley Physicians Hospital where William Cullen was pronounced dead. 

“When individuals pass away at outside hospitals, the body is not in DOCCS’ custody, but rather the custody of the hospital and, ultimately, the coroner,” Connors said. 

Diagnoses Delayed

As for the death reports, the commission does not post its reviews online and they are only obtainable via Freedom of Information Law requests that typically take months to process. 

Advocates have long argued that people in prison receive deficient medical care and that state prison officials are reluctant to have them checked by specialists or sent to nearby hospitals. 

The oversight commission did not thoroughly review a single death directly caused by cancer since at least May 2017, records show.

Some 720 people with cancer diagnoses were in DOCCS custody as of December 2019, according to the Correctional Association. Scaife says the prison oversight organization has heard of multiple cases of people in prison being diagnosed with cancer too late for successful treatment. 

The oversight commission did not thoroughly review a single death directly caused by cancer since at least May 2017.

DOCCS has also long struggled to fill vacant medical posts — from nurses to doctors to physician assistants.

Vacca said that when she worked at the Shawangunk Correctional Facility there were typically only two on-call nurses per shift, one for the 20-bed infirmary and another for the clinic. 

“If we were really lucky, we would have three of us on but that didn’t happen very often,” she said. 

Vacca routinely performed medicine runs alone during her 3 P.M. to 11 P.M. shift, tending to upwards of 100 prisoners. The only doctor in the facility worked days and was reachable by phone. “It was implied that we not call him on evenings,” she added. 

Untimely Death Reports

The review commission says it takes years for the reports to be completed because staff must sometimes wait until a pending criminal probe is finished. 

The death reports are frequently not made public until the statute of limitations for lawsuits runs out, according to Katie Rosenfeld, a civil rights attorney who represents multiple state prisoners. 

“People wait for years to find out what happened to their family member who died behind bars,” she said, noting most lawsuits must be filed within two to three years.  “The commission’s pace insulates the prison system from necessary lawsuits to bring pressure for humane medical care.”

The case of Dana Brown, who died in Wende Correctional Facility on Feb. 2, 2016, due to a drug overdose, languished for more than three years before a death report was issued. 

Similarly, it took the board more than three years — 1,183 days — before the commission completed its review into Karen Eason’s death from a blood clot in her lung and complications of peptic ulcer disease. 

It took more than three years to review some prisoner deaths.

The 53-year-old suffered from a host of medical ailments and required frequent hospital visits. 

But she was rarely sent out of Albion Correctional Facility before she died on June 29, 2016, the review noted. 

Her treatment was “inadequate with serious departures from acceptable standards of care,” the medical review panel said. Eason was repeatedly prescribed Ibuprofen and another medication “which based on her diagnosed conditions, were wholly contradicted,” according to the death review. 

Prison officials claimed that she was repeatedly seen remotely by a doctor, yet none of those records exist, the report said.  

She was being held on a probation violation because she failed to pay a $500 fine after she was arrested when she attempted to fill a forged prescription. 

Grievances Pour In

The Inmate Grievance Program utilized by the state Department of Correction allows inmates to file complaints about specific facilities and services. According to the agency’s 2018 Annual Report, inmates filed a total of 34,198 grievances, 19% of which cited issues with medical services. 

Maximum security facilities account for the majority of grievances in the state. In the same year, Southport Correctional Facility, averaged 699.2 health service grievances per 1,000 inmates.

Four of the 18 suicides in 2019 reviewed by the commission happened while people were being held in solitary. 

Criminal justice reform activists call for a plan to end the use of solitary confinement during a news conference on the steps of City Hall, Oct. 21, 2019. Credit: Ben Fractenberg/THE CITY

In one case,  a 26-year-old man serving time for robbery and drugs was found on the floor of his solitary cell with his head suspended by a piece of torn sheet tied to the bars on March 4, 2017 inside Wende Correctional Facility. 

His suicide note apologized to his mother and said “he could not live like this anymore,” according to the death review report. 

“He also apologized to the security staff … for all the paperwork that would be caused as a result of his suicide,” the report said.