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Local teen commits suicide in prison

3-20-2010 New York:

A Hudson Falls teen who was serving a prison sentence for child sexual abuse hanged himself Friday in a state prison in Dutchess County, officials said.

Adam D. Wheeler's death came just weeks after he was paroled from state prison, but he was sent back because he didn't find a "suitable" residence after he was paroled, officials said.

Wheeler, 19, died at Downstate Correctional Facility, a maximum-security prison in Fishkill, where he was being held in recent weeks on a 2007 conviction for first-degree sexual abuse.

He was sentenced to 3 years in prison and 5 years on parole in that case, and was paroled in December.

But according to the state Division of Parole, he was charged with violating his parole because he did not find a residence that his parole officer approved of.

Carol Weaver, a spokeswoman for the Division of Parole, said the agency was working with the Washington County Department of Social Services to find some place for Wheeler to live, but parole officials did not believe he was cooperating with them.

He was returned to prison on Feb. 9, and would not have been eligible for release again until December.

Linda Foglia, a spokeswoman for the state Department of Correctional Services, acknowledged Wheeler's death occurred in Downstate Correctional Facility, but said she could not disclose the cause of death because of privacy rules.

But Hudson Falls Police, who investigated Wheeler's sexual abuse case, and the Washington County District Attorney's Office, who prosecuted the case, both said he hanged himself while in prison.

Wheeler was 16 when he was arrested in April 2007 on a charge of first-degree rape. He was accused of having sex with a 10-year-old girl with whom he was acquainted. He also was found to illegally have prescription the prescription drug Concerta, which is used to treat attention deficit hyperactivity disorder, when he was arrested.

He cut a plea deal that included a guilty plea to first-degree sexual abuse, a felony.

Wheeler was deemed a Level 2 sex offender when he was released. ..Source.. DON LEHMAN

Inmate, 19, hanged self after 'grossly inadequate' care

3-6-2011 National:

A 19-year-old inmate at a state prison in Fishkill received "grossly inadequate" mental health care before his suicide and might not have died with appropriate treatment, according to a newly released report by the state Commission of Correction, which investigates prison deaths.

Adam Wheeler, who was imprisoned at 17, hanged himself with a shoelace March 4, 2010, at Downstate Correctional Facility, was revived and died eight days later in St. Luke's Hospital in Newburgh.

"Wheeler received grossly inadequate mental health evaluation, treatment and case management characterized by a nearly complete breakdown in continuity of care," the commission concluded in a stinging report, one of two released to the Poughkeepsie Journal under the Freedom of Information Law. Reports generally take a year or more to complete.

The second report, on the September 2009 suicide at Clinton Correctional Facility of a former correction-officer-turned-inmate, was also harshly critical, concluding that Gary Pfleuger, 38, received "inattentive" mental health care at the Clinton County facility "with multiple changes in treatment regime." It similarly labeled facility care "grossly inadequate."

The findings raise serious questions among prisoner advocates about reforms made to the prison system since the 2007 settlement of a lawsuit over conditions for mentally ill inmates -- a lawsuit that had been prompted by suicides, particularly in solitary confinement. Although 400 treatment beds have been added for seriously ill inmates, the overall number receiving mental health care declined 14 percent from 2008 to 2010, twice as fast as the prison population, the Journal found.

Among other things, the reports called for an investigation of Downstate's care by a separate state agency that monitors treatment of the disabled and a review of all inmates treated by Wheeler's psychologist at another prison.
Officials of the Office of Mental Health, provider of prison psychiatric care, defended their policies and treatment in written responses to the reports. They called psychiatric care at Clinton "satisfactory" and said a second psychiatrist had been hired. But they declined to review the cases of Wheeler's psychologist because she "no longer works" for the agency or to beef up the process to identify troubled inmates at Downstate and elsewhere in response to what they called "one adverse event."

'Quality' care: official

In response to assertions of "grossly inadequate" care, Jill Daniels, an Office of Mental Health spokeswoman, said the agency "provides a wide range of quality services and programs to prisoners in need of mental health care" and is one of "very few" accredited state prison mental health programs. She said she could not discuss individual cases.

Linda Foglia, a spokeswoman for the Department of Correctional Services, said the agency was "committed to improving the efficiency of the process" of identifying potentially suicidal inmates and said that as of mid-January, new inmates at Downstate were seen on their first day by mental health officials. Commission officials, she noted, have "said publicly that mentally ill offenders receive better care while incarcerated than while in the community," adding that "many offenders who commit suicide do not display mental health problems."

In an October article, the Journal revealed that mental health care was harshly criticized in reviews of nine of 21 suicides that occurred after the lawsuit was settled. Significantly, the number of prison suicides doubled to 20 last year from the previous two years, and the 2010 rate was the highest since 1982, the Journal reported in late December. Two inmates have committed suicide in 2011, including one at Great Meadow prison in Washington County, where there were four suicides last year in a five-week period.

Downstate is one of four state "reception centers" for new inmates, who are considered prone to suicide at a transitional stage in their lives, and ranks fifth among 68 state prisons with 14 suicides since 1995. The facility, with about 680 inmates, is one of eight prisons in Dutchess and Ulster counties that employ nearly 4,400 people and house 7,700 prisoners, 165 sentenced by local counties.

Jennifer Parish, director of criminal justice advocacy for the Urban Justice Institute, said she "cannot imagine a stronger indictment of the prison mental health system" than the Wheeler findings.

"The state must take responsibility for these failings and ensure that the necessary reforms are put in place to prevent similar tragedies in the future," said Parish, who advocates for inmates in solitary confinement.

Sarah Kerr, a lead attorney in the litigation against the state who works for the Legal Aid Society, said the issues cited in the reports are "unfortunately reminiscent of problems" brought out by the lawsuit, including "systematic" changes in inmate diagnoses from seriously ill to not in need of care. Together, they "raise serious concerns about the failure of OMH to provide a continuum of care to their inmate-patients."

Pfleuger and Wheeler both were first-time offenders serving time for child-sex-abuse convictions. Prosecutors declined to reveal the ages or names of the victims of Pfleuger's crimes, for which he was serving 17 to 20 years.

Wheeler, of Hudson Falls in Washington County, was serving three years for having sexual intercourse when he was 16 with a 10-year-old girl he knew, according to a report in the Post Star newspaper of Glens Falls.

In Wheeler's case, Downstate medical officials were unaware when he was returned to prison after a short parole that he had been convicted of sexual abuse, which the commission report called "a well-known, high-risk factor for suicide." That knowledge would have spurred a mental health evaluation — in this case of an inmate with what was termed an "extensive" history of serious mental illness in his previous time in prison, the report said.

The tone of the two new reports is especially harsh, even in a long line of often-critical commission reviews of inmate deaths. Mental health staff members are faulted in both reports; one report refers to the "inadequate availability of psychiatry" at Clinton, which ranks second in the system for suicides since 1995 with 25, while another terms "completely ineffective" a policy not to share conviction information with staff that screens new inmates at Downstate and Clinton — information that is, ironically, readily available on the agency's website.

Suggestions rebuffed

But the responses of mental health officials to the reports point up a long-standing problem with oversight by the Commission of Correction, a three-member board appointed by the governor whose "recommendations" are advisory. Officials can, and often do, reject them — as they did in defending the screening process and calling the criticism "at odds" with previous commission findings.

Also rebuffed were recommendations to "conduct a peer quality review regarding the mental health treatment of patients" of the Clinton
psychologist who treated Wheeler before his transfer to Downstate and, significantly, "to provide the documented results." Officials said the review was "not indicated" because the psychologist had left the prison mental health program.

John Caher, a commission spokesman, disagreed with mental health officials.
"The fact that the psychologist has left the agency does not … render the issue moot because there is a question of whether other cases covered by that person were appropriately handled," he said in response to Journal questions. He said discussions with mental health officials were "ongoing" about that, as well as issues in the Pfleuger case.

But while acknowledging that commission recommendations were non-binding, he said that "chronic refusal" to follow commission directives could result in an enforcement action if officials believe "the facility is not conducting some of its operations in a manner consistent with the health and safety of the inmates."

Along the same lines, mental health officials also rejected a call for better oversight of inmate screenings made by the state Commission on Quality of Care and Advocacy for Persons with Disabilities, which reviewed Wheeler's death at the behest of the Commission of Correction and agreed his care was flawed. Citing "difficult fiscal times," mental health officials said in a letter that they could not revise the system "in response to one adverse event." They did, however, agree to retrain staff at reception centers on screening regimens. ..The rest of the story.. by Mary Beth Pfeiffer

Reports show breakdowns in care at 2 prisons

3-7-2011 New York:

The following are summaries of reports on inmate suicides by the state Commission of Correction, which investigates selected deaths in correctional facilities statewide.

Adam Wheeler Died: March 12, 2010 Downstate Correctional Facility, FISHKILL

Adam Wheeler was 19 years old when he tied a shoelace to the door of his cell at Downstate Correctional Facility in Fishkill and hanged himself between 11:45 a.m. and 1 p.m. on March 4, 2010. By the time a correction officer cut him down with his pocketknife and removed the ligature from his neck, Wheeler had stopped breathing and had no pulse. Revived, he lived eight more days before being pronounced dead on March 12 at St. Luke's Hospital in Newburgh.

A report by the state Commission of Correction criticized the care Wheeler received prior to his death, stating: "Wheeler received grossly inadequate mental health evaluation, treatment and case management characterized by a nearly complete breakdown in continuity of care between two successive incarcerations … in which his mental health status changed from seriously mentally ill to not in need of services with an associated failure to examine extensive documentation of his history and prior courses of treatment. Had Adam Wheeler received adequate and appropriate mental health care and treatment, his death may have been prevented."

Wheeler was first incarcerated August 2007, when he was 17 years old, as a child-sex offender, according to the report. In August 2008, he was transferred to the sex offender program at Mid-State Correctional Facility in Oneida County, where he remained until paroled in October 2009. He was returned to prison a month later for failing to find adequate housing, according to the commission's report. His parole officer had tried, to no avail, to find Wheeler housing, and the Salvation Army program in Glens Falls, where he was living, would not accept sex offenders.

When returned to prison, Wheeler went to Clinton Correctional Facility in Clinton County, where the nursing staff screened him to assess if he was at risk for suicide. He did not disclose the child-sex-abuse crime, and the report notes that the "nursing staff at the correctional facilities, including the reception centers, do not have the knowledge or access of the incoming incarcerated populations' crimes," making them unable to properly assess suicide risk.

If officials had known of Wheeler's crime when he was returned to Clinton and later transferred to Downstate, they would have referred him for mental health care, the report states, since sex offenders have a higher suicide risk than the general prison population. According to the report on Wheeler's suicide, the nurses' lack of information "skew[ed] the results of Wheeler's suicide screen" and reflected a "completely ineffective" procedure.

Richard P. Miraglia, associate commissioner of forensic services at the Office of Mental Health, which provides prison mental health care, defended the agency in response to the commission's assertions, saying that it had previously revamped suicide screening and that "the nature of the crime … is only one of many risk factors" considered.

"In all candor, I find the commission's recommendation to review this risk assessment at odds with the favorable comments the commission made regarding our revised approach to suicide prevention," he wrote. He declined a recommendation to review all other cases handled by the psychologist who saw Wheeler, stating that the "psychologist no longer works for (the agency); therefore a quality assurance review is not indicated under the circumstances."

On the day Adam Wheeler hanged himself, the officer on duty had spent only two days as a housing officer. At 11:45, the officer conducted an inmate count and reported that Adam was "healthy and breathing" at that time.

About half an hour later, the officer announced "chow" time. He counted 28 inmates, but left without Wheeler, a violation of protocol. When the officer and inmates returned 45 minutes later, Wheeler was hanging from the ceiling of his cell.

Wheeler left no suicide note, although a letter addressed to his correction counselor asked for a transfer to "a unit with less inmate traffic or protective custody."

"He had indicated in the note that other inmates from his county knew of his crime," the commission report stated.

Gary Pfleuger Died: Sept. 22, 2009 Clinton Correctional Facility, Dannemora

Gary Pfleuger had fallen a long way in the world by the time he hanged himself with a bed sheet in Clinton Correctional Facility in Clinton County on Sept. 18, 2009, and died in a hospital four days later. He had been married 19 years and had three sons. He had been a state prison correction officer. He had been to outward appearances a law-abiding family man. And then he was sentenced to 17 to 20 years on a conviction for child-sex crimes. A native of Buffalo, he was 38 at the time of his death and in the midst of a divorce.

According to a report on his death by the state Commission of Correction, at the time of his death, Pfleuger was a mental health patient who did not receive adequate care.

"His mental health status was characterized by inattentive case management with multiple changes in treatment regime at a distance without clinical encounters," the report stated. It said there was only one psychiatrist assigned to Clinton, a facility with 2,900 beds and the system's second-highest number of suicides since 1995.

"The clinical staffing deployment to the facility is grossly inadequate and argues strongly for adjunct services such as telepsychiatry," to supplement the care they provide, according to the Commission of Correction.

In response to the commission's recommendations, the Office of Mental Health defended what officials called "satisfactory psychiatric services," saying that they had "utilized telepsychiatry services in the past and will continue to do so as needed" and that a second full-time psychiatrist had been added to the staff.

At the same time, the commission called for a "quality assurance / improvement study" of both a psychiatrist's and a psychologist's care of Pfleuger.

Mental health officials said in response that they had "met with the involved psychiatrist and discussed at length the need, and requirement, to personally see the patient when medications are started, changed, or discontinued, as well as the need to document in the record these encounters and the pertinent discussions regarding the medications, risks and benefits involved, and the clinical response to them."

On the morning of Pfleuger's suicide, a porter found him tied to the front bars of his cell by a sheet and in a kneeling position. The porter thrust his arms through the bars to hold the inmate, while calling for help, the official report reads.

"Pfleuger had no incident reports or disciplinary infractions during his incarceration," according to the report. He was in protective custody at the time of his suicide "due to his employment as a correction officer." ..Source.. by Mary Huber, Journal intern

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