A state panel has concluded that Department of Corrections doctors breached professional standards of care in the case of a mentally ill prison inmate strapped to a restraint board for three months.
The three-member pre-litigation panel for the state Division of Professional Licensing unanimously determined the inmate's claims of medical malpractice by three prison doctors have merit.The April 14 ruling, made public this week, opens the way for inmate Steven LeRoy Nelson to sue the state.
The panel of two medical doctors and a layman said the department was justified in restraining Nelson, a diagnosed schizophrenic who was suicidal and prone to self-mutilation.
But the circumstances under which Nelson apparently was held - nearly naked atop a stainless steel plank in a lighted room for 12 weeks - were found wanting, according to the ruling.
"Strapping a mentally healthy inmate to a board for weeks on end, clad in nothing but a pair of boxer shorts and no blanket would be bad enough," said attorney John Pace, who is representing Nelson in cooperation with the American Civil Liberties Union and the Disability Law Center.
"But to do it to someone who already has a darkness in his soul, who is mentally ill, is simply barbaric," Pace said Friday.
Nelson's hnotice of intent to sue names Dr. Robert Dennis Jones, Corrections' clinical director; Jones' assistant, Dr. Richard Garden; and Dr. Van O. Austin, prison psychiatrist.
A telephone message left for prison spokesman Jack Ford was not returned Friday afternoon. An officer who answered the telephone at the clinic at the Utah State Prison said Jones and Austin were not in Friday morning. Garden responded to a message, but referred inquiries to Ford.
Todd Utzinger, spokesman for the Utah attorney general's office, said the doctors will invoke the Utah Governmental Immunity Act, which restricts lawsuits against state employees acting in their official capacities.
The ruling by the state panel comes at a time when the Department of Corrections is under fire for the quality of its treatment of mentally ill inmates and the prison's routine use of restraints to subdue them.
Last month, another schizophrenic prisoner, Michael Valent, died after spending 16 hours in a restraining chair. Corrections officials, after first having said the chair was rarely used, have since admitted that 150 inmates have been restrained in the chair some 200 times in the past two years.
Corrections officials stopped using the chair following Valent's death, but they told a legislative committee earlier this week they were preparing to resume. Terry Bartlett, who heads the department's Division of Institutional Operations, told lawmakers that the chair was considered more humane and less dangerous than the board, which has been used at the prison for years.
Bartlett said the chair usually was used for just a few hours at a time but that some inmates had been strapped into it for up to five days.
According to Nelson's complaint and the state panel's decision, the inmate was restrained on the board for three months, taken off his medications "cold turkey" and let up just twice a day, but handcuffed. One hand was freed at mealtime.
Clad only in boxer shorts, Nelson was strapped hand and foot to the pallet, which is stainless steel so feces and urine can be easily hosed off. A light in the room was kept on around the clock, and Nelson was left alone, without observation and in apparent violation of prison policy, for long periods.
The state panel, while agreeing Nelson needed to be restrained to be kept from injuring himself, found the doctors "breached the standards of care" in regard to the medications, the 24-hour light, an absence of padding resulting in bed sores, lack of adequate supervision and failure to properly document the use of restraints.
Nelson had a long history of mental illness that manifested itself in bizarre efforts to hurt himself. Over the years he had injected saliva into his arm, set his leg on fire, pushed a paper clip through his chest wall and disemboweled himself to the extent that he required a colostomy.
In January 1995, Nelson - despite receiving several powerful medications - cut his abdomen open with a razor while housed in the prison's mental health unit. He was hospitalized for nine days and returned to prison, where the infirmary doctors decided he was not mentally ill and took him off his medications.
Four days later, Nelson again cut himself. He was sent to the Utah State Hospital in Provo for observation, where he cut himself yet again, seriously enough to require hospitalization. Transferred to the University Hospital, he was treated and placed back on his medications.
On Feb. 23, 1995, Nelson was returned to the state prison infirmary, where the doctors again decided he was not mentally ill. They discontinued his medications and strapped him to the board, where he stayed until released by court order on May 18. He has resided at the state mental hospital since.
The ACLU and the Disability Law Center, a federally mandated advocate for the mentally ill, are conducting investigations into numerous allegations involving the use of restraints at the state prison. Carol Gnade, ACLU for Utah executive director, said they have contacted 35 inmates and that a class-action lawsuit is planned.
"It is encouraging that we've been given substantiation about yet another tragic incident involving the use of restraints at the prison," Gnade said of the panel's ruling.