New York State says poor care preceded teen's hanging at county facility

From Rochester, NY. Just my opinion, but it looks like another case of where an industrial outsource firm for psychiatric care has dropped the ball for profit. from this report.

A state commission has concluded that a private company gave inadequate mental health treatment to a teenager who hanged himself in Monroe County Jail.

A report by the state Commission of Correction stopped short of saying that Correctional Medical Services Inc. of St. Louis, which contracts with the county to provide medical care to jail inmates, was responsible for the death of 16-year-old Javon Leggett on Aug. 29, 2004.

But the report charged that:

• A Correctional Medical Services employee who wasn't trained to deal with high-risk inmates or depressed adolescents was assigned to Leggett after what might have been a previous suicide attempt six weeks before Leggett's death.
  
  
• Leggett wasn't referred for follow-up mental health care or medication even though he was interested in both, and was removed from suicide watch three days after the apparent suicide attempt.
  
  
• The company was at fault for failing to provide properly trained mental health providers and recommended that Monroe County review whether it should continue to retain the company.

Despite the report, however, the county renewed its contract with Correctional Medical Services on Jan. 1. The one-year extension was for $7.5 million.

The report marks the second time that a state investigation into an inmate death at the jail has sharply criticized private companies for inadequate medical or mental health care.

In May 2002, the Commission of Correction said inmate Candace Brown died in September 2000 when she received "grossly and flagrantly inadequate care" from Prison Health Services Inc. after her opiate withdrawal was untreated.

Prison Health Services of Brentwood, Tenn., provided care in the jail from 2000 to 2004, when Correctional Medical Services replaced it with a three-year, $17.7 million contract approved by the County Legislature. Prison Health Services agreed to pay $450,000 to Brown's family to settle a lawsuit.

The report on Leggett's death, issued in March 2005, was kept private until it was filed earlier this year as part of a lawsuit against the county and Correctional Medical Services by Leggett's mother, Loretta Leggett.

Rochester lawyer Van Henri White, who represents Loretta Leggett, said the critical report has prompted him to seek a settlement with the county and the company.

"They've refused to talk about settlement," he said. "I've tried everything to convince these people that this is a case that should be settled."

A spokesman for the county declined to comment about the case because it involves pending litigation. A spokesman for Correctional Medical Services said he couldn't comment about the case because it involves confidential mental health records.

Both the county and the company have filed legal papers seeking to have the lawsuit dismissed on the grounds that they acted properly.

In its papers, Correctional Medical Services said its care to Leggett met or exceeded the standard of care and maintained that it's uncertain whether Leggett committed suicide or accidentally hanged himself while attempting to get transferred from the jail to Rochester Psychiatric Center.

Leggett was charged in May 2004 with assault and robbery. He pleaded guilty on Aug. 20, 2004, and was expected to receive five years' probation and six months in jail. But a deputy found him dead in his cell, hanging from a sheet tied around his neck, on Aug. 29, 2004.

Six weeks earlier — on July 16, 2004 — Leggett was found under his bunk in what was documented in medical records as an attempted hanging. Leggett, who had a sheet around his neck, said he was stressed out but denied a suicide attempt.

Correctional Medical Services assigned an employee who had a master's degree in social work — but was unlicensed — to perform a "lethality assessment" of Leggett to determine whether Leggett was in danger of committing suicide. Leggett was watched constantly as a suicide risk until July 22, when the social worker decided Leggett was feeling better.

After seeing the social worker again on July 26, Leggett had no more mental health follow-ups, the Commission of Correction said in its report.

"Overall, the evolution and treatment afforded Leggett was inadequate," the report said. "There was no referral to a psychiatrist, psychologist and nurse practitioner to evaluate Leggett for medication. There was no treatment plan, no follow-up for release after constant supervision, no monitoring, no medication."

After being involved with altercations with other inmates in the week before he killed himself, Leggett was punished by being assigned to "administrative segregation," the report said.

On Aug. 27, two other teen inmates who were found with sheets around their necks said they were feigning suicide in an attempt to get transferred to Rochester Psychiatric Center, where they believed they would have more privileges. Leggett was part of that plan, the other inmates told deputies.

Two days later, Leggett hanged himself in his cell. He died despite attempts to resuscitate him at the jail and at Strong Memorial Hospital.