Death of mentally-ill inmate raises question of care

01:00 AM EDT on Sunday, June 21, 2009
By Steve Peoples

Journal State House Bureau
He banged his head against the wall until his teeth were loose, says one investigator. He clawed at his chest to get the devil out.

So, prison officials moved James Davis-Reed to a special segregation cell within the “Super Max” unit of the Adult Correctional Institutions on March 27.

It is the safest place the prison offers mentally-ill inmates.

The six-cell “observation and stabilization” area is relatively quiet. Prisoners are held in isolation under 24-hour video surveillance. Psychiatrists visit three times a week.

It’s more common for staff to use restraints on suicidal inmates there, as was the case for Davis-Reed that Thursday morning.

His final hours are still under investigation.

Prison officials have confirmed he was locked in four-point restraints — bound to his bed at the wrists and ankles — “for a short period” in the morning. After the restraints were removed, 24-year-old Davis-Reed was left alone and naked — he had stripped off his gown — under motion-activated video surveillance, in a 7-foot by 10-foot cell.

A prison spokeswoman said that Davis-Reed “was on the highest level of observation.” She could not say, however, when guards realized he had stopped breathing.

Just one state official, Mental Health Advocate H. Reed Cosper, has been willing to publicly discuss the young man’s death in detail.

“He rolled himself up into a fetal kind of ball, which is kind of a regressive behavior for a really sick guy. And he managed to roll his head into a crevice between the bed and the wall, and he couldn’t get out,” said Cosper, among those investigating the incident. “He suffocated, kind of like being crucified. He didn’t suffocate in two minutes. He suffocated in 45 minutes, or 30, I don’t know.” It’s unclear if Davis-Reed was trying to kill himself.

The state police are investigating, as is the ACI. The medical examiner has ruled the death was the result of “positional asphyxia.”

No one disputes these basic facts: James Davis-Reed left the prison in an ambulance and was pronounced dead at Rhode Island Hospital on March 27. He died after spending 35 days at the ACI, transferred there after spending the previous 1,273 days in the forensic unit of the state hospital for mentally-ill prisoners.

“There are mentally-ill people for whom prison is toxic,” Cosper says. “This man was too fragile to be in prison.”

Department of Corrections Director A.T. Wall says his staff did the best it could.

“We can never say ‘no’ when a court sentences an offender to us. On any given day we have hundreds of mentally-ill offenders — diagnosed, in treatment, and on medication. The overwhelming majority adjust and are doing fine in the population,” Wall said. “Our staff worked very hard with James and the treating psychiatrist was distraught over his death, as were many of the staff that worked with him. They grieved when he died.”

JAMES DAVIS-REED had largely cooperated with the doctors after his arrest four years ago.

There was little doubt that he was a dangerous man.

He had traveled through the night of June 27, 2005, from Far Rockaway, N.Y., to Rhode Island to find his ex-girlfriend, Tiffany Joiner. He snuck in through her kitchen window at the Oxbow Farm housing complex in Middletown just after 9 a.m., and found a 10-inch kitchen knife in a drawer.

He first attacked Joiner’s 14-year-old brother, who was watching TV on the couch. Davis-Reed stabbed the boy several times in the neck, chest and back before chasing Joiner and her new boyfriend up the stairs.

The couple suffered minor stab wounds as they tried to barricade themselves in an upstairs bathroom.

The police arrived before anyone was killed.

They chased Davis-Reed through the apartment and out the back door before pinning him to the ground.

Middletown police officer Mark Minnella’s narrative described the moment immediately after the arrest: “The subject was crying and covered in blood. I asked the subject why he stabbed the other party, and his reply was, ‘I love ’em like a brother.’ ” Everyone survived the attack, including Joiner’s 5-year-old brother, who was taken to the hospital to be treated for shock.

The State of Rhode Island took custody of Davis-Reed later that day, June 28, 2005, when he was 20 years old.

His first stop was the state prison.

A judge ordered a mental competency exam less than two months later. On Aug. 26, Davis-Reed was deemed incompetent to stand trial and moved to the forensic unit of Eleanor Slater Hospital, the locked unit for mentally-ill criminals.

An incompetent defendant, according to state law, is someone who “is unable to understand the character and consequences of the proceedings against him or her and is unable to properly assist in his or her defense.”

The goal is to restore the defendant to competency through treatment, said Stacy P. Veroni, chief of the criminal division for the attorney general’s office. “Someone can be insane and competent to stand trial. … It doesn’t have to do with his mental state at the time he committed the offense. It has to do with whether the defendant can generally understand the court process.”

Davis-Reed’s public defender, Paul Tondreau, says all involved with the case agreed that his client was not fit for trial. Tondreau said the forensic unit was more appropriate for Davis-Reed. “He was getting treatment there in a setting that was preferable to the prison.”

He responded well in the small hospital unit, where he was medicated and received constant attention. After more than a year of treatment, he was reevaluated and on Dec. 4, 2007, he was deemed competent to stand trial, according to court records. Tondreau did not challenge the competency ruling, but requested that Davis-Reed be allowed to stay at the hospital until the case was resolved in court. The attorney general’s office did not object, and Davis-Reed would spend two more years in Eleanor Slater.

While still living in the mental hospital, Davis-Reed ultimately pleaded guilty to five felony counts and signed off, in September 2008, on a plea bargain that capped his prison time at 15 years.Tondreau did not raise the insanity defense, which might have kept Davis-Reed out of prison. “The client has the final say,” the public defender said recently. “It’s his decision.”

Superior Court Justice Melanie Wilk Thunberg accepted Davis-Reed’s plea bargain on Feb. 20, 2009, and ordered him to the ACI. Tondreau did not object. After more than three years in a state mental hospital, Davis-Reed was transferred to the prison that day.

Prison officials had less than 24 hours’ notice he was coming.

THE ADULT Correctional Institutions holds Rhode Island’s largest collection of the mentally ill.

One day in mid-May, at least 567 inmates, or 23 percent of the “sentenced male population,” were prescribed psychotropic medication for mental illness, according to figures provided by the Corrections Department. These do not include the intake center or the women’s unit. Of the 567 inmates, 213 were taking antipsychotic drugs for the most serious diagnoses, such as schizophrenia.

Despite the numbers, the prison’s clinical director, Frederic C. Friedman, said the ACI has “a small number of people with serious mental illness. The number of truly psychotic is small.”

It’s unclear if Davis-Reed was among the “truly psychotic.” State officials have refused to discuss his health, citing medical privacy laws. And court records relating to mental competency have been sealed.

After leaving the 20-bed mental hospital, he spent his first 34 days at the intake center — a chaotic, crowded environment that holds 1,148 inmates.

Friedman said Davis-Reed spoke to a “weekend psychiatrist within 24 hours” and visited a psychiatrist and social workers “several times” in the subsequent weeks, typical treatment for inmates.

Cosper, the mental health advocate, has suggested that ACI doctors may have changed Davis-Reed’s medications after the transfer. Citing medical privacy laws, prison officials refused to answer that question.

The ACI has partnered with the University of Rhode Island’s College of Pharmacy to control ballooning medication costs by switching to generic drugs in many cases, a collaboration that prompted a national award less than two weeks after Davis-Reed’s death.

Taxpayers spent $180,857 on antipsychotic medication for prisoners between February and April of this year, according to information Friedman provided.

He said he works to ensure that prison psychiatrists are aware of cheaper drug options, but says that specific prescription decisions are left to inmates’ psychiatrists.

“I’m concerned that in this area of fiscal restraints, the impression is being created that we sacrificed, sent somebody to the bottom line. It simply isn’t true,” said Wall. “The clinical staff was actively working with this guy and he was working with us.”

It’s unclear what triggered Davis-Reed’s deterioration. He went downhill relatively quickly at the ACI — after steadily improving over three years at Eleanor Slater Hospital.

“He had engaged in some self-injurious behavior which called upon us to place him in a smaller setting,” Wall said, declining to describe the behavior. It was Cosper who said that Davis-Reed had been knocking his head against the wall to the point of loosening his teeth, and clawing at his chest “to get the devil out.”

The smaller setting was the ACI’s observation and stabilization unit within maximum security, a special area established roughly three years ago for those with the most serious mental problems.

State law affords prison officials another option. In extreme cases, the corrections director or the director of the state Department of Mental Health, Retardation and Hospitals may file a court petition to have a mentally-ill prisoner transferred to Eleanor Slater Hospital.

Corrections officials could account for a handful of such petitions in recent years; MHRH couldn’t detail any.

The Department of Corrections did not file a petition in Davis-Reed’s case, though they acknowledge that the prisoner had become a danger to himself.

“He is by no means the only inmate who has been self-injurious in our setting. Sadly, we’re accustomed to seeing that behavior. It may not be routine, but it is not particularly rare,” Wall said. “And he had been with us for only five weeks. Lots of mentally-ill inmates have trouble settling down at first whenever there’s a change in circumstance.”

JAMES DAVIS-REED is among dozens of inmates who have died while in the care of Rhode Island’s prison system in recent years.

Altogether, 62 people died at the ACI since Jan. 1, 2000, according to data provided by the Department of Corrections. It’s difficult to say how many were mentally ill.

Davis-Reed is the only one listed as having died from “positional asphyxia.” But the prison details 13 suicides over that time, including 11 by hanging. Four inmates died from drug overdoses or acute drug withdrawal.

Rhode Island is hardly the only state in which prisoners die.

In 2006, 8 inmates died in the Ocean State, 39 died in the Massachusetts’ state prison system, 25 in Connecticut, 7 in Vermont, and 6 each in New Hampshire and Maine, according to U.S. Department of Justice statistics.

“I recognize that our job is, insofar as it’s possible, to keep everybody safe. It’s a very tall order,” Wall said. “Our record is very good. But we work with a very difficult population on a number of fronts, including mental health. Tragic outcomes can and do occur in all kinds of settings, correctional and hospital. I do not think it means that we, or I, am responsible for that outcome.”

speoples@projo.com