Under-medicated and suffering from withdrawal symptoms from the medications that had sustained his life for a decade fighting Parkinson's disease, Brian Tetrault died in 2001, only 10 days after his imprisonment began at Schenectady County Jail in New York.

Previously under the care of the Albany Medical College Parkinson's Disease & Movement Disorders Center, Tetrault received more than a half dozen drugs aimed to control the disease. And until his imprisonment, the drugs had kept him alive.

A recent report by the New York State Commission of Correction states that a disregard for Tetrault's medication regimen by jail doctors contributed to his death.

According to the report, the prison's medical director, W. Duke DeFresne, did not examine Tetrault the day he arrived in jail. But the doctor still drastically altered Tertrault's medication regimen by withdrawing many of the drugs formerly prescribed to Tetrault, drugs that were not in the pharmaceutical formulary for the jail.

Almost immediately, Tetrault started to show signs of under-medication and withdrawal from the drugs his body depended on.

Not until five days later, when Tetrault was so unresponsive that he could not ingest the drugs that DuFresne prescribed for him, was he transported to a hospital. Another five days later, at 2:55 p.m. on Nov. 20, 2001, he died.

The report about Tetrault's death has again ignited a controversy in corrections about whether the private companies that manage inmate health care in many of this country's prisons are more negligent than the public systems.

The report implicates both Dr. DuFresne and the company he works for, Tennessee-based Prison Health Services, Inc., in the investigation of the incident in Schenectady.

It said, "such abrupt reduction and withdrawal was medically reckless, was directly implicated in the neuroleptic malignant syndrome and immobilization that caused Mr. Tertrault's death, and represents flagrantly inadequate medical care by PHS, Inc. and its employees."

But the company says this is a single incident, not a pattern, and it should be judged that way.

Nevertheless, the commission, an oversight committee that guides New York's local corrections facilities, recommended to the Schenectady County Sheriff that he terminate the contract with PHS. And it recommended to PHS that it terminate the services of DuFresne.

Who's to Blame?

Major Robert Elwell, the Schenectady County Correctional Facility administrator, confirmed that when the current contract with PHS expires, as it will in October, the county will formally break ties with the company.

Neither Elwell nor the commission would comment further on the Schenectady incident because of pending litigation.

But while Schenectady plans to resolve the issue by letting its contract with PHS expire, the question of assessing blame for incidents like this is more difficult to answer.

Richard D. Wright, President and CEO of PHS, said, "our view is this incident is isolated and is not indicative of any systemic shortcomings."

He said PHS disputes many of the facts in the commission's 10-page report, and that the company published its own 12-page reaction addressing those facts.

Of the commission, Wright said, "we found their report to be overly harsh, that it condemned the company in a way that we just didn't feel was appropriate or fair."

To help assure quality in their health care coverage, PHS now implements more rigorous screening protocols to determine if entering inmates are too sick to stay in prison, Wright said.

He also said, "we're in a constant state of review of our policies and procedures."

Prison health care experts also agree that all the blame should not be tagged to PHS or other private medical care companies.

Dr. David Thomas, the former director of health services for the Florida Department of Corrections, expressed confidence in the PHS leadership overall.

"I know [PHS' corporate medical director] Carl Keldie. He is a great physician. He is a concerned physician," Thomas said. "And like anybody with a huge responsibility, sometimes things get screwed up."

Thomas explained how a patient can occasionally be neglected in a prison setting, and how he tried to avoid it while working for the Florida DOC.

He said one of the problems that he observed during his tenure in Florida is that prison inmates are difficult people to work with, because many of them fake illnesses. And if they cry wolf enough times, nurses and doctors can become callous to those cries.

"[Many] physicians and nurses-and nurses are key because they are the ones that determine who sees the physicians-become desensitized to patients' needs, because the people they see don't have real needs," said Thomas. "They are malingering."

Thomas said he constantly had to gather together his prison medical staff to "remind them that [the inmates] are my patients and to treat them as though I was there with them every day."

This may also be true with PHS. A company that is that big "is bound to have significant problems, statistically," said Thomas.

Another Case

The Tetrault incident is not the only inmate death case in which the commission has said PHS was negligent.

On Feb. 16, 2002 Victoria Smith-an inmate at PHS-affiliated Dutchess County Jail-died, according to another commission report, because of "a systemic breakdown of health care delivery services." The report says Smith's arthritis went unmanaged. And despite an "abnormality" revealed in an EKG, Smith received no change in medication and went five days before another meeting with the physician.

A note to her father found in Smith's cell the night she died read, "that she had been evaluated by nursing five times relating to 'chest tight and burns,' and she 'needed to get out of jail to get help,'" the report said.

Like in the Schenectady County incident, the commission recommended to the Dutchess County jail administrator that he consider terminating the use of Prison Health Services as the health services contractor for the prison.

But even though the commission suggested the contract with PHS be severed, it also had recommendations for other parties involved in the incident, including the County Office of Community Services, the jail and more for PHS itself.

It recommended to the Community Services office that it discipline the social worker who evaluated Tetrault for not referring a patient on psychiatric medications to a psychiatrist, and that it conduct a quality assurance inquiry into the mental health staff's failure to provide Tetrault with continuity of psychiatric care.

The commission recommended to the Schenectady County Sheriff's Office that it require that a physician be present at the jail at least four hours per day, three days per week.

The commission also told PHS is should maintain a four hour per day, three day per week schedule for its physicians. And it said the company's physicians should examine new inmates "at the time of admission or as soon thereafter as possible," as the law states.

But only time will tell if the implementation of these recommendations will improve inmate health care and siphon the number inmate deaths due to medical negligence.