In July 2000, New York State agreed to pay the family of Felix Jorge sizable monetary damages.656 Six years earlier, on July 28th 1994, the twenty-four-year-old Jorge had stuffed his mouth full of wet toilet paper and suffocated. His suicide occurred in a mental health observation room in Clinton-Dannemora Prison.
Two years before his death, Jorge had been sentenced to three-to-six years in prison for holding up a woman with a toy gun. Despite a history of hospitalizations for mental illness dating back to childhood, despite a long and documented record of schizophrenia, paranoia, and suicide attempts, it took seven months after his admission for prison officials to realize just how seriously mentally ill Jorge was.657 Only after Jorge had a psychotic attack in September 1993 did the state perform a mental health evaluation on the prisoner. “Mr. Jorge went without correct diagnosis and appropriate treatment for the greater part of his period of incarceration,” wrote Dr. Martin Blinder in an opinion letter presented at the civil trial.658 In the interim, the mental health staff periodically gave him some of the right medications — Haldol, Permitil, Artane — but they did not provide him with any therapy or counseling to ensure he continued taking these medications. In New York State, if patients refuse their medications three times in a row, they can be taken off the medications permanently. And that is what happened to Jorge. Attorney Edward Miller, who represented Jorge’s family in their lawsuit against New York, told Human Rights Watch:
If the inmates who were receiving the service weren’t mentally ill, they’d work fine…. One of the symptoms of mental illness is refusal to take medication, and the system walks away from them once they refuse medication. They decompensate and they attempt suicide. It’s common for them to go out of their minds in silent agony…. You can’t forcibly administer medication unless a prisoner presents imminent risk of harm to self or others. But that’s a red herring. The major issue is provision of therapy so they’ll continue to take medications and not go off them. 659
In late August 1993, in the midst of a psychotic episode, Jorge began banging his head against a window in the prison van in which he was being transported. He was charged with violating “section 123.10 self-inflicted bodily harm” and “refusing direct order,” and received three months in a secure housing unit as punishment. According to prison documents, Jorge was informed that “this disposition is given as punishment for your actions and should serve as a deterrent to future misbehavior of this type by you.”660 In December 1993, Jorge was admitted to the Central New York Psychiatric Center in an acute paranoid, psychotic state. The center did what it is supposed to do: it stabilized Jorge whom the doctors diagnosed with “schizophrenia, paranoid, chronic with acute exacerbation.” He was then returned to the security housing unit, to serve six months for “creating a disturbance” and “refusing a direct order” — both the results of the same paranoid state for which he had been sent to the Psychiatric Center.
According to an investigation by the New York State Commission of Correction, in March 1994 a treatment plan was developed for Jorge, recommending mental health staff see him twice a week and that he be re-evaluated for medication by a physician. The report found, however, that “there is no documentation that indicates he was seen twice a week and he was not provided a medication review.”661
In early April 1994, Jorge swallowed 150 Tylenol (how he obtained this many pills is not documented) and had to have his stomach pumped.662 Once again, the prison system responded to Jorge’s action with punishments rather than treatment. He was given a year in the special housing unit (SHU), was deprived of all commissary, phone calls, and packages for a year, and denied a radio for six months. He was transferred to Clinton-Dannemora prison, to serve his SHU sentence there.663
Despite multiple psychiatric diagnoses, somehow Jorge’s mental health records did not reach Jorge’s new prison. Jorge’s family alleged in its suit that:
In May 1994 the Clinton-Dannemora prison psychiatrist examined Jorge before his placement in the SHU and found no mental illness problems. Under recommended treatment, the psychiatrist wrote “George declines mental health services at this time.”665 Within a few weeks of this evaluation, Jorge had stopped showering, he was wearing soiled clothing, was incoherent and threatening, was talking to himself about people conspiring against him, was starting fires and cutting himself, and finally became unresponsive and hid under his bed. “His records got lost when he was transferred to Clinton,” Miller told Human Rights Watch.
A month later, one correctional officer was fired for not making rounds of the observation cell on a regular basis, for falsifying logbooks, for failing to video Jorge, and for failing to notify his sergeant when Jorge failed to respond to his pounding on the cell door when he finally did do his rounds. Three weeks later, however, the dismissal was reversed, and the correctional officer was reinstated and only ordered to pay a fine.668
In a scathing report the state’s Medical Review Board found “the continuity of mental health care in this case deficient. In addition, the Board found the supervision of the observation room in the Mental Health Satellite Unit deficient on the night of George’s death.”669
From January 1995 until March 2002, the New York State Commission of Correction found a total of eighty-three people had committed suicide while prisoners of New York State. At least twenty-five of these were in SHUs at the time of their deaths.670
656 In internal prison documents, and court documents, George’s name is sometimes spelt “Jorge,” sometimes “George.”
657 Ana Luisa Jorge v. The State of New York, Claim No. 92210 (Court of Claims, N.Y., August 27, 1999). Page two of claimant Ana Luisa Jorge’s Trial Brief states that “after Felix Jorge was incarcerated in May, 1993, New York State did not perform a mental health evaluation of Felix Jorge until September 23, 1993 and then, only after Felix Jorge had a psychotic attack involving auditory hallucinations and paranoia.”
658 “Expert Report of Dr. Martin Blinder,” Ana Luisa Jorge v. The State of New York, Claim No. 92210 (Court of Claims, N.Y.), exhibit Q.
659 Human Rights Watch interview with Edward Miller, attorney, New York, New York, June 12, 2002.
660 In the trial, this document was presented by Attorney Miller as Exhibit A, Bates Stamp #3. See memorandum from Collie Brown to Edward Miller, Esq., December 16, 1999, p. 1; on file at Human Rights Watch.
661 In The Matter of the Death of Felix George, an Inmate of Clinton Correctional Facility, New York State Commission of Correction report to Glenn Goord, acting commissioner, New York State Department of Correctional Services, April 17, 1996; on file at Human Rights Watch. The information quoted is in Finding 7, p. 3. The report also found that, at Clinton, Jorge was supposedly seen on a daily basis by a psychologist. However, investigators could find no written evidence that these meetings had in fact occurred.
662 Jorge was treated at Auburn Memorial Hospital.
663 The forms filled in at the hearing list Jorge being charged with violent conduct, interference with employee, refusing direct order, unauthorized medication, self-inflicted bodily harm. The punishments listed were SHU confinement for 365 days, no commissary for 365 days, no packages for 365 days, no earphones for 180 days, and no phone calls for 365 days. The hearing also recommended the loss of six months good time.
664 Ana Luisa Jorge v. The State of New York, Claim No. 92210 (Court of Claims, N.Y., August 27, 1999), p. 3.
665 This is documented under Finding 10 of the New York State Commission of Correction’s Final Report into the death of Felix George. Submitted by Commissioner Thomas Goldrick, April 17, 1996.
666 At trial, psychiatrist Florence Kaufman confirmed the practice of discontinuing medication for a prisoner who refuses it. Question: “If Central Psychiatric issued a blanket order for medication for a psychotic patient, under what if any circumstances could that prescription or order ever be discontinued?” Answer: “If the inmate refuses, that’s pretty much the reason. Sometimes when they come, they will ask to sign off medication and we’ll have them sign a medication refusal form. Sometimes they just never show up for the medication and that’s their way of stopping it.”
667 Human Rights Watch interview with Ed Miller, attorney, New York City, June 12, 2002.
668 The letter of dismissal was sent out on August 15, 1994, under the signature of Thomas Testo, Special Assistant to the Commissioner for Labor Relations. The Disciplinary Settlement Agreement, superceding the initial letter, was sent out September 8, 1994, and was signed and accepted by the correctional officer the next day.
669 This was documented as Finding 14 in New York State Commission of Correction’s Final Report into the death of Felix George. Submitted by Commissioner Thomas Goldrick, April 17, 1996.
670 Information collated by the Legal Aid Society, based on data from the New York State Commission of Correction, and some additional information provided by the New York State Department of Correctional Services.