State officials have agreed to pay $1.65 million to the family of Karon Nealy Jr., a 19-year-old who died in 2015 of complications from lupus while he was in prison. “Nothing’s gonna bring this kid back. It’s certainly less than what we had it valued at, but it gives resolution to his mom and his 7-year-old daughter,” said DeVaughn Ward, one of the attorneys representing Nealy’s estate in a federal lawsuit that has taken three years to resolve. “It’s a small down payment on some restorative justice for his family.”
The money is important, said Kenneth Krayeske, who also represented Nealy’s estate, “but the information we uncovered about how poorly the entire system is run should be the wake-up call for investigating how we provide health care to people who have lost their liberty.”
The state, which did not admit liability in Nealy’s death, agreed in the settlement not to seek funds to cover the cost of Nealy’s incarceration or medical costs, which together totaled $72,067.95.
The Department of Correction and the Attorney General’s Office declined to comment this week.
Nealy, who was imprisoned while UConn Health’s Correctional Managed Health Care oversaw medical care for those in state prisons and jails, submitted an array of complaints to medical staff after he was admitted to Manson Youth Institution in October 2014, about nine months before his death. Staff ordered lab work, gave him Motrin, and told him to do low-impact exercises, according to his lawsuit. His hands were cold to the touch and his fingernails were gray or blue. He stayed in bed most days, complaining that all the bones in his body hurt.
Gerald Valletta, the doctor assigned to Manson Youth Institution at the time of Nealy’s death, was scheduled to see Nealy during his next visit to Manson in June 2015 but didn’t keep the appointment because nurses at the prison failed to give the doctor Nealy’s full chart, which listed his medical issues, according to the lawsuit. Valletta never saw Nealy again.
Medical personnel took Nealy to the University of Connecticut Health Center on June 25, 2015, after his cellmate told a corrections officer that he needed medical attention. There, Nealy was diagnosed with systemic lupus.
He died on July 27, 2015, from lupus, organ failure and a lung infection. About three years later, the DOC took over medical care for its incarcerated population.
The case had been scheduled to go to trial this December.
Another matter potentially adding pressure to settle the case: the threat of a lawsuit in state court, where, Krayeske and Ward claimed, the plaintiff’s lawyers would have had to clear a lower legal standard than one they had already met in the federal suit.
Ward and Krayeske asked legislators for permission to sue in state court during the last legislative session. Lawmakers approved the request in a House Joint Resolution that passed unanimously through both chambers.
The attorneys released the state claim as part of the agreement in the federal lawsuit. In other words, the federal lawsuit’s settlement “resolves not only the federal claim, but also the state claim,” said Ward.
‘Call for them’
Krayeske and Ward have brought a number of lawsuits that revealed systemic under-staffing of medical personnel at state correctional facilities. One of their main arguments in the Nealy lawsuit is that systemic under-staffing of medical personnel at Manson Youth Institution contributed to Nealy’s death.
The last deposition in the Nealy lawsuit occurred in May 2021, when Krayeske spoke with Chad Greenwood, a DOC head nurse who worked at Manson at the time of Nealy’s death and, as the attorneys understand it, is the only health care professional besides Valletta who treated Nealy.
Greenwood said he has frequently been “floated” between Cheshire Correctional and Manson Youth institutions due to low staffing levels.
“Our minimum staffing levels usually are met, and I would say that’s like a really strong majority of the time. It’s an infrequent event when we fall below minimum staffing,” Greenwood said. “How we get to the minimum staffing is more the frustrating experience when it comes in the form of, say, a mandatory overtime, which is you’re not going home at the end of your shift or you have to tell somebody that they’re not going home.”
In his questioning of Greenwood, Krayeske brought up a report, authored by DOC employee Jennifer Benjamin, that presented an internal medical analysis of Nealy’s case. Greenwood corrected what he felt was a misinterpreted comment he made to Benjamin about insufficient staffing levels resulting in staff being unable to meet patients’ needs.
“What I mean by that is we’ve never not been able to address an emergency situation,” he said, clarifying that he wasn’t saying patients were suffering the consequences of inadequate staffing. Rather, he said, being short-staffed hindered the ability to respond to sick calls.
“So I would disagree with ‘patients suffered,'” he said. “The productivity is less when you have to look for the necessary staffing to ensure continuity of care in a facility because you can’t go down to zero, zero nurses. That would be a far worse experience for everybody and really put people at risk.”
During the time CMHC was in charge of prison medical care, Greenwood said, they would occasionally fall below minimum staffing ratios at Manson Youth while working the day’s second shift, only scheduling two nurses from 3 to 11 p.m. “That third nurse would be tasked to report to Cheshire. And we were told, ‘Well, if you need them to come back, then call for them,’” said Greenwood.
The nurses stationed at Manson had a walkie-talkie to communicate with the third nurse, who was assigned to Manson but was actually at Cheshire, a little over half a mile away.
Staff would also use the walkie-talkie during overnight work hours. A nursing shift at Cheshire had been “dissolved and vacated” over that timeframe, “So during the 11 p.m. to 7 a.m. shift at Manson Youth, a nurse would be the first responder to report to Cheshire if there was an emergent need.”
The layout of Manson Youth Institution — the grounds are dotted with “cottages” instead of one central building — made it difficult to zip back and forth between the two correctional facilities.
“It would be difficult to just up and discontinue patient care, to then begin patient care in another location,” said Greenwood.
He recalled how he was once chastised by a supervisor for taking too long to get to Cheshire after having finished a shift at Manson. He’d been mandated to work a second shift to relieve a nurse at Cheshire who had also just worked a double. In 15 minutes, he managed to leave Manson, clean the snow off his car, drive to Cheshire, park and report to work.
“I thought that was pretty good,” Greenwood said of his pace.
He wound up having to file an incident report about what took him so long to get to Cheshire Correctional Institution during a snowstorm so that he could work mandated overtime.
Greenwood said the walkie-talkie system was discontinued after a few years, once officials brought back the third nursing shift at Cheshire.
Krayeske said the walkie-talkie system speaks to the “disregard for inmate heath care.” He said the use of a walkie-talkie so that nurses can cover multiple prisons was “not a recipe for success, and that it was allowed to occur and no one has been reprimanded or investigated, is why litigation like Mr. Nealy’s is important and vital.” He also called for an investigation into what Greenwood revealed in his deposition.
“The Attorney General’s Office has a responsibility to not just defend defendants, but recognize when there’s a situational injustice occurring,” said Krayeske.
At the time of Nealy’s death, there were about 1,300 people incarcerated at Cheshire Correctional Institution. Ward said spreading medical staff between prisons leads to a delay in providing emergency care to patients.
“This is, plain and simple, medical malfeasance,” he said. “It’s a way to triage medical care, but it’s a way that would not be accepted in any community standard, from what we understand.”
In the last month of Nealy’s life, Greenwood recalled hearing reports from UConn Health Center that he was improving from the care there. He remembered how for a long time at Manson Youth it wasn’t clear what was causing his symptoms, and it took UConn Health some time to figure out what it was.
“What I thought about that is there’s quite a lot more resources in that environment than we have at Manson,” Greenwood said. “I was glad that he was there to get that perspective and get that level of care. I just remember that the shifting — just seems like we didn’t really land on the lupus for a while.”
