When Maureen Heatley last saw her son he was crying uncontrollably on the floor of his upstate New York prison.
Todd Heatley was so distraught and confused he didn't recognize his mother despite her weekly visits to the Wende Correctional Facility near Buffalo.
"He was totally disoriented," Maureen, a social worker, recalled of the visit in November 2014.
She cut the visit short and begged correction staff to take him to a specialized medical unit where he could receive proper treatment.
That never happened.
Three days later Heatley, 33, was found hanging from a torn sheet attached to his cell door. He died a few hours later.
A state medical review board charged with probing prisoner deaths concluded that Heatley may be still alive had he gotten proper medical care.
"Facility staff failed to recognize the escalation of symptoms and neglected to initiate appropriate interventions which may have prevented his death," said the board's report, which was obtained by the Daily News through a Freedom of Information Law request.
The reports are not posted online and largely remain hidden from the public and affected family members.
After her son died, Maureen Heatley asked for a copy of the medical review, to no avail.
"I never got any information," she said.
His case is not an anomaly.
All told, the board concluded that the deaths of approximately 50 prisoners statewide over the past five years could have been prevented with simple medical treatment.
Officials with the New York State Department of Corrections and Community Supervision say that even one such case is unacceptable, but that only around 0.02% of the total prison population of nearly 50,000 are referenced in the reports.
Prisoner advocates counter that the reports highlight a much larger issue.
"As these reports illustrate...it is clear people inside are dying due to inadequate medical and mental health care," said Jack Beck of the Correctional Association, one of the nation's oldest inmate advocacy organizations.
"How many more avoidable deaths will occur before the state addresses these serious and persistent problems?" he added.
State Correction Commission review panels repeatedly found medical staff failed to conduct basic checkups and mental health screenings. Doctors and nurses regularly ignored serious ailments until it was too late, according to the reviews.
Multiple deaths involved mentally ill prisoners who committed suicide after they were continually tossed in solitary confinement. At least four prisoners died from asthma-related ailments that could have been prevented had they been given inhalers and other medications.
The scathing death review reports come as Gov. Cuomo pushes for a more robust plan to shut down the jails on the city-controlled Rikers Island.
Mayor de Blasio's 10-year closure plan is "tantamount to saying we have no real plan to close it," Cuomo's counsel, Alphonso David, said in April 2017.
But Cuomo has done little to improve medical care for the 48,132 prisoners his administration oversees, critics contend.
"He really should be looking at his own system and seeing what those problems are," Beck said.
The number of health care practitioners employed by the department has decreased by 3% over the past five years, according to DOCCS. The department currently employees 89 clinical physicians, 18 physician assistants, 849 nurses, and almost 28 nurse practitioners. DOCCS did not provide comparable raw figures for five years ago.
Beck says that state budget documents actually show that figure of full-time medical staff is actually down 17.6% over the past five years.
By all accounts, a part of the staff reduction is tied to a 9% drop in the prison population over the past five years.
DOCCS says that there has actually been a 28% increase in the expenditures for contract medical practitioners and additional services over the past five years. Additionally, all prisoners placed in solitary confinement are evaluated and undergo mental health suicide prevention screenings.
Under a recent legal agreement, prisoners designated as seriously mentally ill are taken out to serve their full sanction in a Residential Mental Health Treatment Unit, where they are offered four hours of out-of -- cell therapeutic treatment and programming.
Prison officials in the state, and throughout the country, have long struggled to hire doctors, nurses, and physician assistants.
At Elmira Correctional Facility in Chemung County, a clinical physician position was open from August 2012 through October 2016, records show. In some prisons, there's only one doctor overseeing the care of more than 500 prisoners, according to the Correctional Association.
Hiring delays are in part due to bureaucratic red tape and a starting salary that is often $10,000 or more below private sector pay.
Overall, the death reports reveal that some of the fatalities involved nurses and doctors ignoring repeated pleas for help. Prison insiders say staff frequently believe prisoners are lying about the severity of their condition in order to get moved to a preferred housing unit or to get drugs.
That wasn't the case for Alfredo Lopez.
Lopez, 54, was found hanging by an electrical chord in Great Meadow Correctional Facility on Jan. 13, 2015, at 6:48 a.m. Lopez, from Sunset Park, Brooklyn, spent years trying to convince officers that a medical condition made it difficult for him to urinate within three hours for drug tests.
The department keeps a "shy bladder" list of inmates who have that problem. Those prisoners are given a private room and water to drink. But Lopez, a diabetic who had extensive and painful nerve damage, was never placed on that roster.
Instead, he was repeatedly tossed into solitary confinement due to his inability to produce urine -- deemed a failed drug test.
His haunting suicide note was addressed to state health staff.
"I can't take the abuse anymore," he wrote. "The mental anguish being locked up for urinalysis, while ALL along my system has been clean. Check my blood, DNA, anything."
The approximately 10 urine samples he was able to produce all came back clean during his time in the Great Meadow prison, the report states.
His suicide note also pointed out that his pain medication for the nerve damage was taken away while in solitary.
"I haven't slept since the 26th of December 2014," he wrote. "And combined with my nerve damage and the cold cell with which I'm forced to be in 24 hours a day it's as if I were dead already."
Some of the prisoner deaths tied to shoddy medical treatment involved high-profile cases, the review panel found.
Julio Gonzalez, the arsonist who killed 87 people trapped inside the Happy Land nightclub in the Bronx in 1990, died of heart disease that was never properly treated for years.
Gonzalez, 61, suffered a fatal heart attack inside a stairwell at Clinton Correctional Facility on Sept. 13, 2016, at 8:30 a.m. The medical review board concluded that the "chronic care" for his "hypertension was systemically deficient."
"His last documented physical was in 2010," the report said, noting he should have been checked every two years.
Medical staff also failed to make sure he took his medication, the review said. He was serving 87 simultaneous 25 years to life sentences for starting the blaze.
In approximately 50 of the close to 80 death review cases, the medical review board ordered prison and health officials to change or update procedures. But those orders seem to do little to improve matters, especially for several inmates with asthma.
William Stewart, 56, died after a major asthma attack at the Groveland Correctional Facility on Oct. 6, 2013. During his time in prison, medical staff failed to do everything from record his vital signs to document medications. No one realized his asthma was "progressively worsening" despite multiple emergency sick calls.
His medical care "was grossly substandard and did not meet acceptable standards of care," the review board concluded. If he received proper care "his death may have been prevented," the review added.
Stewart, who was serving a four-year sentence for selling drugs and assault, was seen at least three times by a nurse who failed to take his condition seriously.
As for Heatley, he was sentenced to 25 years in prison for stabbing to death 19-year-old Jacob Herbert during a fight outside a party in Buffalo.
During his five years in prison his mother visited over 100 times. Initially, Heatley, who worked as a DJ before his arrest, studied and got his GED and read everything he could get his hands on.
"I was amazed at how well he did and how much he had grown as a person and intellectually," his mother recalled. "We'd sit there and talk about Tesla's theory of electricity and different philosophers.
"Those are conversations I never had with him in high school," she added.
But weeks before his suicide his mental health drastically deteriorated and he repeatedly talked of harming himself. He begged to be put in protective custody away from the general population prisoners who he thought wanted to harm him.
During his last visit with his mother, he kept on repeating he was in the wrong seat and couldn't even remember her, according to department records.
"I don't know if you've ever seen a hamster readying to die," she said. "They run around frazzled in their cage. That's what he was doing."
Before she left, Maureen Heatley said a correction sergeant promised to make sure her son was immediately evaluated and placed in a protected unit. But the unnamed sergeant reportedly concluded it wasn't an emergency case and could be handled by a medical staffer within 14 days.
So Todd Heatley was placed back in his general population cell.
"This referral was not documented," the medical board concluded. The staff "failed to recognize the symptom of confusion as a sign of mental illness and institute interventions to provide safety to Heatley until he was evaluated by mental health staff."
After his death, prison officials shipped two cardboard boxes of his belongings to his mother. She has never opened them.
(c)2018 New York Daily News
