The Real Cost of Prisons Weblog

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.

Left in uncertain hands, a haunted life ends tragically

December 10, 2007

Second of three parts

This story was reported by Globe Spotlight Team members Francie Latour, Michael Rezendes, Beth Healy, Jonathan Saltzman, and editor Thomas Farragher. It was written by Latour.

To the teen mother who struggled to raise him, he was slow, abnormal, and often out of control.

To the counselors who tried to steer him from trouble in Springfield, he was a child trapped in the body of a pudgy young man, the charmer who couldn't count the change in his own pocket.

And to prison clinicians who knew him behind bars, he was, above all, a "frequent flier," their code for inmates who require the constant attention of the mental health staff.

By the time Nelson Rodriguez walked through the heavy metal doors of state prison in 2004, convicted in a stabbing case, he had long since been diagnosed as mentally retarded and mentally ill - a man unable to grasp even the most basic concepts.

But as an inmate, the 26-year-old Rodriguez was routinely punished for acting out in ways he could not control. Time and again, his jailers used the same blunt tools - isolation and loss of basic privileges - to deal with him.

The discipline never improved his behavior; in fact, he got worse. It ran directly against warnings by prison clinicians. But it kept coming - for him as for many of the mentally ill who have overwhelmed the prison system.

During 18 months in state custody, the young man with the lazy eye and troubled mind spent a quarter of his time - about 145 days - in solitary confinement.

On Dec. 20, 2005, five days after his last transfer into the forbidding Walpole prison unit known as 10-Block, Rodriguez's isolation was pressed to the extreme. Officers shut an outer solid door over the bars of his cell and walked away.

Sometime in the next four hours, Rodriguez tied a strip of bed sheet to the metal cover around his cell's smoke detector. He wrapped the other end around his neck, and hanged himself.

When it comes to suicide behind bars, it is impossible to expect total prevention, state Department of Correction officials say. With some determined inmates, Associate Commissioner Veronica Madden said, "It seems that they really wanted to die."

But the death of Nelson Rodriguez in cell 49 is not that kind of story. Rather, his is the story of the kind of inmate now flooding the corrections system: the mentally ill for whom prison is increasingly the asylum of last resort. The Globe Spotlight team dwelled in depth on his short life and sorry end as a way to understand why men like Rodriguez wind up behind bars and why too many die there.

Rodriguez was a man-child with a hard-wired inability to learn at the mercy of a system where punishment and more punishment is often the only real response to inmates with little or no ability to control their behavior.

It is a practice that amounts, in some cases, to an invitation to give up on life.

"He is someone who definitely should not have been put in isolation because of his condition. There's no question about that," said Terry Kupers, a national specialist on mental illness in prisons, who reviewed Rodriguez's records. "Putting [mentally ill inmates] in segregation and then closing the solid door to their cell is like asking them to commit suicide."

Madden told the Globe that Rodriguez's suicide was a tragedy, for him, his family, and for her department.

"This was a deeply troubled young man presenting with a very complex set of circumstances in a very noncomplex system that we run," she said.

Madden also said that she had not known that Rodriguez was mentally retarded.

"We hear now that he was mentally retarded," she said. "I don't have any documentation on that. Did that come up in court? Where was that prior?"

In fact, court records and internal reports are peppered with references to Rodriguez's mental retardation. Those records include a 2006 suicide review in which Madden herself was an observer. They stretch back to Rodriguez's first contact with the Department of Correction in 2003, and among those who treated him it was anything but a secret.

"You could talk to him about skills and ways to cope and strategies, but he wouldn't retain it," said one of Rodriguez's former clinicians, who treated him for about a year and who asked not to be named because of department policies that forbid discussing inmates. "He didn't have the skills to say, 'If I'm good for three more days, I'll be out of [solitary confinement].' He just couldn't do that."

Instead, Rodriguez lashed out - and fell apart.

Yet he wasn't on the radar screen of the mental health staff as a high-risk inmate, according to one internal Correction Department review obtained by the Globe.

At Walpole, no one in charge seemed to know anything about a doctor's warning that placing Rodriguez in solitary confinement posed a serious danger to his mental state, and to his safety.

Instead, after he cut his arms and throat, he was sent to one of the most restricted and bleak holding units Walpole had to offer: 10-Block.

"He'd never make it there," Rodriguez's former clinician said of Rodriguez's transfer. "I mean, he didn't make it there, obviously."

A troubled child

When he was a little boy, Nelson Rodriguez was haunted by a monster. It tormented his dreams and lurked around corners.

At age 10, he told a psychologist that the monster would kill his friends, eat his mother, and throw him into water burning with fire. Naturally, he gave the monster a name: Freddy, as in Freddy Krueger, the horror movie serial killer.

If Rodriguez's fantasy world was horrific, his boyhood reality was filled with frustration and pain.

His IQ was well below normal. He had a seizure disorder, and tests strongly suggested some form of brain damage. As he approached his 11th birthday, he still wet his bed. And he had no friends. Instead, his peers taunted him mercilessly.

All the while, the mother he dreamed that Freddy would devour was at once the focus of all the boy's devotion, and his rage.

Mildred DeJesus, 18 years old when she gave birth to Rodriguez, couldn't handle her son's violent outbursts, or any of the burdens of raising a child who, in her words, "was not normal." After Rodriguez began exhibiting strange, hypersexual behavior - exposing himself and preying on his toddler stepbrothers - DeJesus grew desperate. Ultimately, she signed over custody of her son to the state.

To his relatives in Springfield, it was clear what had happened. In an interview, Rodriguez's aunt, his grandmother, and his youngest half-brother described young Nelson as a torment, even as they acknowledged that his disability and mental illness were to blame.

"You wanted to trust him," said Dezi Rodriguez, who at 20 has just begun to forgive the brother who once menaced him. "You wanted to give him a chance, but you couldn't."

When told that Rodriguez would speak of his mother with longing to almost anyone he would meet, all three looked up, stared, and fell silent. "Believe me," Mary DeJesus, Rodriguez's aunt, said finally of her sister, who died of AIDS in 1999. "She would try so hard to love that kid."

As Nelson grew into adolescence, little changed. Clinicians still saw traits bordering on psychosis. At 17, he was admitted to a psychiatric hospital for six weeks. He bounced erratically between foster families and group homes.

And in a system already awash with unwanted children who soon grow into unwanted teenagers, Rodriguez became his own worst enemy: He was just smart enough to know he did not want to be labeled "retarded," and just verbal enough to try to convince people that he wasn't.

Jim Nash, a Springfield-area advocate for the disabled, was one of several counselors who took Rodriguez in for short periods of time as a young adult. Rodriguez was 18 at the time, but, with his goofy grin and impossible naiveté, he struck Nash as more like his own two toddlers than as a young man.

"He was able to posture and hold himself and look like some regular dude walking down the street," Nash said. "But in reality, there was nothing below the surface. There was no good framework for how to face the world."

At a critical period, between the ages of 18 and 22, Rodriguez's posturing fooled many of those charged with determining his future. In 1999, clinicians and the courts deemed him competent to care for himself without a guardian.

To the frustration of advocates, Rodriguez was in a social services limbo. He was too old for DSS services and would not ordinarily be eligible for services from the Department of Mental Retardation until age 22, although local DMR caseworkers tried to intervene.

At the same time, no one could force him to accept help. That was key, because Rodriguez was fed up with services, rules, and restrictions.

Jason Nelson, a part-time counselor and Comcast worker who lives in Chicopee, was one of the last people to help Rodriguez, and one of the most determined. In the year he spent as Rodriguez's guardian, he faithfully drove him to his night job washing dishes at a local restaurant and coaxed him to take the medications Rodriguez hated.

But after a year of hostile, unexplained outbursts from Rodriguez, Jason Nelson found himself hitting the same brick wall Rodriguez's mother had reached years earlier.

"I was at my wit's end," he said. "I was emotionally, mentally, and physically exhausted from it."

Rodriguez was spiraling. Between 1997 and 2002, he was in and out of coun ty jail on various misdemeanors - petty larceny, breaking and entering, property damage.

Inexorably, he was slipping into the growing ranks of the wandering mentally ill, whose outbursts and episodes eventually lead to arrest, prosecution, and prison.

A changing diagnosis

For years, Rodriguez had been fascinated by Teenage Mutant Ninja Turtles.

Something about a cartoon team of mutant reptiles, isolated from society and trained as warriors, clearly spoke to him. And he obsessed over martial arts. One day in the early summer of 2003, while living at a Springfield homeless shelter, he began taking kung fu classes. Then he bought a sword at a local pawn shop.

The next day, Rodriguez used the sword to stab another homeless man in the stomach inside the shelter's bathroom. It's unclear how the conflict began, but, according to police and witnesses, the scene was bloody. The victim, 29-year-old Marcus Roberts, arrived at the hospital holding in his intestines with a towel.

Roberts recovered fully. But despite an unusually passionate appeal by a court-appointed lawyer, this would not be another misdemeanor for Rodriguez. "He wasn't crazy, but he was retarded," said David Burgess of Concord, who asked the judge to send his client to a county jail instead of prison. "He's not as culpable as I would be, or you would be, if we pulled a knife on somebody."

Still, even Burgess could not argue with the judge's bottom line: A person should be able to enter a shelter and not have to worry about being stabbed. The court sentenced Rodriguez to four to seven years.

He was now in the hands of a prison system that struggles to adequately treat or even track mentally ill prisoners and has little capacity to deal with the mentally retarded.

"We don't have enough expertise," said Dr. Kenneth L. Appelbaum, the former mental health director for the UMass Correctional Health, which served the prison population until this summer. "And we don't have the services that those people need in the system. It is, in my opinion, a significant unmet need."

In Rodriguez's case, it was worse than that.

An internal staff review of his death, obtained by the Globe, said clinicians focused far too much on whether Rodriguez was really mentally ill, instead of realizing the danger he posed to himself.

"Despite the fact that his entire mental health history was well documented within the medical record," the report said, "the mental health clinicians at MCI-Cedar Junction seemed to either underemphasize, or simply be unaware of, some of the more critical information contained within his record."

That record, one of distress and breakdown, began even before Rodriguez had been officially sentenced to serve state time.

In November 2003, while still awaiting trial in a county jail in Ludlow, he tried to hang himself, an incident that landed him at Bridgewater State Hospital, the prison system's facility for the mentally ill.

The doctor who evaluated him concluded that while Rodriguez was not profoundly mentally ill, he was a danger to himself. Using italics in her report to stress her point, she noted that clinical staff and correction officers should be aware of the "very real, very substantial" risk of self-harm.

By June 2004, and convicted of the crime, he was an inmate at the Souza-Baranowski Correctional Center, the state's modern maximum-security facility in Shirley. There, his outbursts triggered escalating punishment. He broke his food tray, exposed himself, and repeatedly attacked officers. As a result, he was kept in isolation.

By October 2004, Rodriguez was back for further observation at Bridgewater, where, his relatives say, prison officials should have recognized the severity of his illness and kept him for treatment indefinitely. And for a moment, it looked like that might happen.

In a report correction officials themselves say was crucial, the doctor who evaluated Rodriguez, David W. Holtzen, found that Rodriguez was hallucinating, had thoughts of suicide, was suffering from major depression, and was losing his grip on reality. Holtzen not only wanted Rodriguez admitted, he also wanted a court order to force Rodriguez to take antipsychotic medications.

Then something changed.

About two weeks later, Holtzen evaluated Rodriguez again and deemed him no longer seriously mentally ill but rather "antisocial" and "bored." According to an internal review of Rodriguez's suicide, Holtzen changed his mind after members of Rodriguez's treatment team said they believed Rodriguez was improving.

But Bridgewater's own records show that Rodriguez was still deeply unwell. Shortly after the reevaluation, officers at Bridgewater reported he was punching the cell walls and acting out of control. Despite those warning signs, Rodriguez was back in prison 72 hours after the new diagnosis. And his disciplinary record worsened again.

Through representatives of UMass Correctional Health, Holtzen declined to comment about the change in diagnosis, citing privacy laws of patients. A UMass spokesman called Holtzen's assessment "reasoned."

Even though Holtzen's interpretation of Rodriguez's behavior had changed radically, the doctor did warn that if Rodriguez was placed in conditions akin to solitary confinement, his mental health would be in jeopardy.

"[Holtzen] clearly puts in the chart: Watch this guy, he's a serious suicide risk," said Terry Kupers, the national specialist on mental illness in prisons. "From that moment on, this is a person who should have been tracked."

Instead, the Department of Correction kept losing track of Nelson Rodriguez.

Off the radar screen

By the spring of 2005, Rodriguez began bracing himself for life inside the state's toughest prison: MCI-Cedar Junction in Walpole.

The clinicians at Souza-Baranowski understood his problems and even found him likeable. But prison officials transferred him after finding themselves overwhelmed by his chronic misconduct.

His state of mind was clear in a letter he wrote to his grandmother, Elsie "Bita" Miranda, and his brother Lorenzo Rodriguez. Using almost no punctuation, he wrote: "I'm trying really hard to survive in jail. . . . My tears been rolling down my cheekbone like crazy. . . . Look I'm gonna be moving to another jail is called Walpole. . . . Pray for me please."

At Walpole, he quickly slipped off the radar screen. His name never appeared on the prison's risk list. And his lengthy mental health history did not catch the attention of the two people at Walpole most responsible for his mental health care: his assigned clinician and her boss, Erika Grandberg, MCI-Cedar Junction's mental health director.

Grandberg would later tell investigators that she knew nothing about the prior warnings that more isolation could hurt Rodriguez or should, at least, trigger more vigilant care. She also defended Rodriguez's absence from the risk list, saying, "At the time, he wasn't somebody who we considered high risk."

But in two months at Walpole, Rodriguez just couldn't follow the rules. He was cited for various outbursts.

Still reasoning like a child, Rodriguez tried to appeal the punishments in the only way he knew how. In November, a month before his suicide, he pleaded to have his television, telephone, and visitation privileges restored. "They don't understand that I'm mildly mentally retarded," records say he told a clinician. "I got a dangerous mind. I can cut myself, hang myself." But nothing came of the appeals.

Rodriguez was 19 months into his prison sentence. He was due for an update on his treatment plan, but the deadline came and went without one, according to the department's review. Rodriguez's clinician told investigators that she had updated it, but that the plan "was not in his chart and she does not know where it went."

In early December, Rodriguez cut his arms and throat, triggering an emergency medical call. He spit on responding officers and bit one of them, records show, and was shackled by his arms and legs. Two days later, he was put on a 15-minute interval watch - a clear sign that he was a high risk for suicide.

And then prison officials decided to send Rodriguez to 10-Block. The prospect led him to further unravel.

On Dec. 14, 2005, a prison psychiatrist discontinued two medications Rodriguez was taking - Remeron, an antidepressant, and Seroquel, an antipsychotic drug - while upping his dosage of a third drug, a mood stabilizer. Department records reviewed by the Globe provide no explanation for the adjustment. The very next day, Rodriguez entered Cell 49 in 10-Block, a foreboding 60-bed, two-story unit where inmates are confined to closet-size cells 23 hours a day.

His brief time in custody had been as volatile as any inmate's. But when Rodriguez underwent a routine assessment as 10-Block's newest guest, the clinician's words had the uneventful tone of a weather report. "Stable, no evidence of psychosis, delusions, or hallucinations. Monitor [patient] per Treatment Plan, [as needed]."

Five days later, officers sounded an alert - Code 99, inmate hanging. They entered Cell 49 and removed the ligature from around Rodriguez's neck. They carried his body down the tier to a landing on the second floor. Chest compressions were begun. An ambulance was called. A Walpole rescue team responded.

He was pronounced dead at 4:44 p.m.

Investigators would later conclude that there were 22 officers assigned to patrol 10-Block that day; 11 of them were responsible for the upper tiers that included Rodriguez's cell. But no one made the required half-hour checks on Rodriguez for four hours, even though the log book for that day contained entries indicating the proper rounds had been made.

And in its review of his suicide, officials seemed to struggle to explain how an inmate like Rodriguez - mentally retarded with a well-chronicled history of dangerous misconduct - could be described as an inmate "not on the radar screen."

The answer, they concluded, may lie in Cedar Junction's operating ethos.

"Due to the overall culture of the institution, mental health staff at MCI-Cedar Junction have a rather high threshold for how they assess and address an inmate's acting-out behaviors and overall mental health status," the confidential internal review concluded.

Conclusions like that ring hollow for people who still remember Rodriguez as the child trapped in a man's body, the inmate who could never learn the rules.

"He never had a chance to have a childhood," Jason Nelson, his former guardian, told state lawmakers three months after his death. "To place a man in a maximum-security prison that is not equipped or staffed to help or even understand the type of mental illness Nelson was plagued with is beyond my understanding."

Part 3
BREAKDOWN THE PRISON SUICIDE CRISIS
Guards, inmates a volatile dynamic

December 11, 2007

Last of three parts

This story was reported by Globe Spotlight Team members Jonathan Saltzman, Michael Rezendes, Beth Healy, Francie Latour, and editor Thomas Farragher.

It was written by Saltzman and Farragher.

On a damp Saturday last fall, Scott A. Flaherty collected a stack of papers and notebooks that chronicled his decade as a state correction officer and set them ablaze in a cemetery near his home in Randolph.

Flaherty had liked his first eight years at MCI-Cedar Junction in Walpole, but his last two had turned hellish. He hoped the graveyard bonfire would exorcise memories of his work behind the walls of the state's toughest prison.

Especially his memory of what happened there one night in late 2000.

Shortly before 10 that November night, a deeply disruptive inmate lay shackled to a concrete slab in a cramped cell. As Sergeant Flaherty stood watch, a captain and three other officers swept in, the captain grabbing, as he went by, a foam cup that Flaherty had been using to catch tobacco juice and sunflower seeds.

Flaherty said he watched as the captain tilted the cup over the mouth of the prisoner. Sickened, he turned away. But he could hear the parting admonition to the 33-year-old inmate, Hakeem Obba: If you don't behave, my officers will pour [excrement] down your throat.

"Because I can do anything I want to you," Captain Ronald R. Picard told Obba, according to a four-page complaint Flaherty filed with supervisors.

Two months later, Obba hanged himself with elastic from his underpants and bed sheets.

Flaherty, now an investigator for the State Police in Bristol County, said it would be wrong to draw a straight line from the alleged abuse of Obba - which Picard was punished for, but denies - to his suicide. But the larger point was hard to miss: Some correction officers, he said, are unfit to deal with the mentally ill or deeply troubled inmates who are increasingly their charge. The result is an incendiary dynamic between inmates and officers, a climate ripe for abuse.

"The inmate was restrained. He had no way to defend himself," said Flaherty, 37, one of two officers who reported the incident. "It would be akin to a police officer raping somebody. There's no gray area there."

The treatment of Obba - who was in four-point restraints for nearly 40 hours over four days - is one of the most flagrant of the cases examined by the Globe of abuse of inmates whom prison officials or prisoner advocates say had acute mental problems.

But it is hardly an isolated example. A Spotlight Team investigation into a recent surge in prison suicides and suicide attempts found other cases in which correction officers, with scant training in how to handle the burgeoning number of mentally ill in prison, brutalized, mistreated, or neglected inmates.

Indeed, as prisons increasingly become the asylum of last resort for the mentally ill - with the closure of state hospitals and the deinstitutionalization of their residents - desperation, frustration, and violence are rising on both sides of the cell door.

About 50 times a month, according to department statistics, members of its staff are assaulted by inmates. And, at the same time, the correction department has disciplined scores of officers for assault and other misconduct involving inmates.

As the number of inmate suicides has soared to roughly three times the national rate, prison officials say correction officers deserve credit for saving dozens of inmates who attempt suicide. Still, it is not hard to find cases where officers abused mentally ill prisoners.

In a 2004 episode at MCI-Cedar Junction, a correction officer twice punched a handcuffed inmate in the head as the prisoner lay face-down on the floor, giving him a bloody eye. The incident was captured on videotape, and the state fired the correction officer. But a civil service panel reduced the punishment to a 90-day suspension, in part because the prison superintendent was merely demoted for using excessive force in an unrelated incident. The prison system is appealing the reduced punishment in the courts.

In September 2006, prison officials sustained a complaint by an inmate that correction officers at the Souza-Baranowski Correctional Center locked him in a shower cell overnight in 2004 and shoved feces and urine into the stall with a mop. The prisoner -who suffers from panic disorder, depression, and possible bipolar disorder, according to medical records - has cut his own Achilles tendon and repeatedly swallowed razor blades, batteries, and push pins.

"I understand that when people do bad things, they have to go and pay for them," said Amelia Bargoot, the sister of the inmate, Eric R. Bargoot, a convicted bank robber. "But there's a difference between torture and rehabilitation."

Well-trained correction officers are crucial for recognizing suicidal inmates and preventing many deaths, according to Lindsay M. Hayes, a national specialist in prison suicide prevention hired by the state in 2000 to study Bridgewater State Hospital. Because many suicides take place at night and on weekends, when mental health clinicians have gone home, correction officers are the only ones who can intervene.

However, when Hayes returned to the prisons late last year for a follow-up study, he found that the state had ignored his recommendation to increase suicide-prevention training for new officers from two and a half to eight hours. Prison officials said they have since complied.

Still, the volcanic cellblock dynamic scares relatives and friends of prisoners.

"Between mental illness and the fact that these people have committed crimes, they're going to throw them away," said Kathleen Connolly, who worries that her boyfriend and father of her two children, mentally ill inmate John Nowell, will never make it out of Walpole alive.

"We'll take his dead body out of there," she said. "He's not going to make it. He does not belong in there. Either someone is going to kill him or he's going to kill himself."

The DDU

The place where Hakeem Obba died and where John Nowell now lives, sits at the extreme end of the gone-to-seed Walpole complex, just minutes and a world away from Gillette Stadium, the gleaming home of the New England Patriots.

It is a walled-off, cinder block bunker where inmates are locked up 23 hours a day. From a glass-paneled, high-tech silo at its inner core, correction officers monitor the inmates' every move on video screens. Prisoners can leave their cells for an hour of exercise in cages that are the human equivalent of small, fenced-in dog runs.

Prison officials call the bunker the Departmental Disciplinary Unit, or DDU for short.

The solitary confinement inmates who live there have a nickname for it, too: the hole.

Its 124 cells are reserved for "the worst of the worst," inmates who earn their spot in the system's most secure unit by assaulting correction officers or other inmates, or by committing other serious misconduct. It is a place, some officers say, where inmates feel they have nothing to lose by lashing out, because there is no place worse to go.

Correction officers who spoke to the Globe under the condition of anonymity, citing department rules that restrict their ability to speak to the media without permission, said a thick emotional callous is a virtual job prerequisite.

"It's a survival tool," one officer said. "That's exactly what it is."

But the officers did not hesitate to confirm what many maximum-security prisoners in solitary confinement told the Globe: Sometimes, in anger and frustration, they taunt inmates who threaten to kill themselves, telling them: "Hang it up!"

"You can't help it, it just comes out," said one Walpole officer who guards prisoners in an isolation block. His message to inmates he feels are using threats of suicide to gain leverage? "You know what? Do it!"

Or, said a Cedar Junction colleague assigned to a segregation unit where some of the toughest cases are confined, frustrated officers will respond to a threat of imminent suicide this way: "I'll be back in 10 minutes. Twenty maybe."

The officers, three 20-year veterans from a medium-security facility in Bridgewater and two relative rookies who work at MCI-Cedar Junction, said they are easy scapegoats when something goes wrong. They said they have become marginalized by mental health clinicians who no longer listen to what they have to say. They do stressful work that, they said, almost nobody wants.

"Morale has never been this low," one veteran officer said in an interview. "I've never seen guys despise coming to work. . . . They treat you like you're a guard at a mall."

A good night at Walpole, they said, is when everyone on the cellblock is breathing when they walk in, and everyone is breathing when they walk out.

Given the frustrations and dangers the correction officers confront, there is little reservoir of empathy for inmates who arrive with or descend into psychosis.

"We do have a lot of frequent fliers who swallow nails, spikes, glass," said Steve Kenneway, president of the 5,000-member Massachusetts Correction Officers Federated Union. "If you leave a light bulb laying around, they'll eat that, too. I mean they will just put everything in their system and then they'll tell you because it's their way of manipulating where they're going to be housed. There are definitely some inmates who are crazy, and they need help. They need treatment."

But treatment is not the responsibility of Kenneway's union members. They are trained to maintain safety and security.

"Let's think about why the person's sitting in the cell for 23 hours a day locked down," he said. "Because he murdered somebody. Stabbed an officer. Did something so egregious inside the prison system that now he has to be locked away even from the inmate population. So I'm never going to sympathize with the inmate. That's not my job."

Lack of sympathy is one thing. Urging self-destruction is something else.

Prison officials said such conduct is not tolerated and would be met with swift discipline if substantiated. Staff members have been suspended for making "derogatory comments" to inmates, they said. But the department could not supply an instance in which action was taken against an officer for encouraging an inmate's suicide or expressing glee after a hanging.

Correction officials say they do want to know who posted a jubilant message on a website used by MCI-Cedar Junction officers after a former inmate was found dead of a drug overdose shortly after he left prison earlier this year.

"Released last Thursday and found dead in Somerville Saturday. Hooray!" the Aug. 14 anonymous message read.

Prison management has disciplined staff for a wide array of other offenses.

From January 2003 to June 2007, the prison system's Office of Investigative Services investigated 1,126 allegations of serious misconduct by employees, some of which remain open cases, department statistics show.

Most of the cases involved correction officers. The alleged offenses ranged from 73 assaults - on inmates, employees, and civilians - to 98 cases of sexual misconduct with inmates, female and male.

Prison investigators sustained 312 allegations, more than a quarter of the 1,126. Because of the gravity of the offenses, the vast majority of those cases then went to hearings before the commissioner, who has the authority to issue significant punishments, ranging from an unpaid suspension of more than a week to termination.

The prison system ultimately fired 112 correction officers from January 2003 to June 2007, according to department statistics. But correction officers often appeal firings to the state Civil Service Commission or arbitrators - and some win back their jobs.

Sometimes correction officers have been found to be neglectful rather than abusive.

In 2005, for example, prison investigators found that correction officers failed to make required checks on three inmates who killed themselves at prisons in Walpole, Concord, and Shirley. Two of the inmates were severely mentally ill, and the third was undergoing withdrawal from a heroin addiction.

In two of the deaths, officers said they had made required checks but were contradicted by prison videotapes.

One of the suicides was that of Andrew Armstrong, who was serving 15 years for assault with intent to murder after a home invasion, and who had been diagnosed with bipolar disorder. He had made two previous suicide attempts and was discharged from Bridgewater State Hospital four days before his death.

Before he hanged himself, he used a bar of soap to scrawl a message near the stainless steel mirror in his cell.

"Dust in the wind," it read.

'I'm not an animal'

No episode more starkly illustrates the toxic relationship between seriously troubled inmates and correction officers than the encounter between Obba and Picard.

And none more boldly underscores what can happen when the officers' cellblock code of solidarity is violated than what happened later between Picard and Flaherty.

Obba was one of the most disruptive prisoners at Cedar Junction, records show. He urinated on the floor. He spread feces on his walls. He was cited 210 times for misconduct in the hole.

But he never received a thorough mental health evaluation in prison, a psychiatrist retained by his family to advise them on a wrongful death suit said. He said Obba's behavior was so extreme it should have raised red flags for prison mental health staff.

Once, when a correction officer was passing out coffee to inmates in solitary confinement, Obba reached through the grill of his cell and stabbed him in the neck.

"There, deal with that, mother [expletive]," he said, according to department records. For that attack, he received 13 to 15 years on top of his sentence, three to five years for breaking and entering.

On Nov. 12, 2000, after officers said they saw Obba smear the door and window of his cell with feces, they received permission to shackle his wrists and ankles until he agreed to stop his disruptive behavior.

"This is cruel," he said in comments captured on videotape provided to the Globe by the correction officers' union. "This shouldn't be for a dog. . . . I'm a human being. . . . I'm not an animal."

Flaherty came on duty at 3 p.m. on Nov. 14 and volunteered to relieve an officer who had Obba on an "eyeball watch." Flaherty said his job was to monitor Obba through the window of his cell and to note his condition in a log every 15 minutes.

Flaherty, a Randolph native, had joined the department in 1992 at the age of 21. Like many correction officers, he hoped to use the job as a stepping-stone to a career as a police officer. But he said he ended up enjoying the rigors of the work - it required a combination of firmness, common sense, and fairness - and the camaraderie with other officers.

His view of correction, he said, was influenced by his granduncle, George F. McGrath, who was former governor John A. Volpe's correction commissioner in the early 1960s.

"He believed that inmates are going to get out some day, and you've got to give them programs to prepare them for when they get out," Flaherty said. "He was progressive, and I wanted to be like that."

Instead, what Flaherty found at Walpole, he said, was a bureaucracy that crushed idealism and muzzled dissent. Officers who cozied up to top prison officials enjoyed choice job assignments and got away with abusing inmates and staff, he said. Those without influential benefactors struggled for years to get off the night shift.

"We used to call it the Department of Corruption and Favoritism," he said.

Picard joined the Department of Correction in 1987 after working about a year as a part-time Bellingham police officer. He was ultimately promoted to captain, a job in which he oversaw about 20 officers.

Around 9:50 p.m., the captain and three other officers entered the observation ward, according to the incident report Flaherty filed. As the three underlings surrounded the inmate, Flaherty said, Picard tipped the cup of spit over Obba's mouth.

"It actually sickened me," Flaherty recalled in a sworn deposition he gave in April in the wrongful death lawsuit filed by Obba's family. "I turned away. I couldn't look."

The four officers left the cell, and Picard handed the cup back to Flaherty. One of the officers bragged, "You could hear [Obba's] jaws clenching," Flaherty wrote in his complaint to supervisors.

After Picard and his coterie were gone, Obba shouted to Flaherty, "Tell the Captain if he pours [expletive] in my mouth, I'll kill him and his family," Flaherty recalled in his complaint. He could have disciplined Obba for the threat but opted not to. "I probably would have said the same thing," he said in his deposition.

Flaherty said he agonized about whether to report the alleged abuse.

He had filed a complaint about Picard only four months earlier because the captain accused him of faking an illness when it turned out that Flaherty had a fever of 103 and strep throat, he said. Picard retaliated by giving him lousy assignments, leading scores of shackled inmates to showers and mopping the hallways, Flaherty said.

Flaherty got so uneasy that he began carrying a small notebook to record any problems with Picard and his allies.

But Flaherty said he felt he had no choice but to report the treatment of Obba.

"Picard was just sadistic," Flaherty said in an interview. "He thought this was the way to rule. Sometimes you have to use force in the prison. It's just the dynamics. But the way I was schooled, once you're in restraints, it's over."

In response to Flaherty's complaint, prison officials began an internal investigation. Picard and two officers who accompanied him into the cell, Lieutenant Edward Marvelle and Sergeant Edward Mack, denied that anyone threatened Obba or poured anything on him. Marvelle told the investigator that Flaherty had been overheard in the past saying he was out to get Picard, according to the investigator's report.

But another officer, James E. McParlin Jr., who was assigned to the control room and said he could see Obba through the window, backed Flaherty's account. He said in his own incident report that he saw Picard extend his arm and tilt a foam cup over Obba's head.

"What happened that day was totally wrong," McParlin told the Globe. "You're in four-point restraints. You can't do anything. That's torture."

The department, citing internal records, said Obba confirmed Picard's threat but told investigators the cup's contents did not enter his mouth.

Before the Department of Correction completed its internal investigation, Obba hanged himself in his cell on the observation ward in the DDU.

Not long afterward, the inquiry into the alleged abuse concluded that Picard had threatened Obba and interfered with the investigation