BRIDGEWATER — As soon as Lisa Brown saw the ambulance pulling into the parking lot at Bridgewater State Hospital that May evening in 2009, she felt certain something terrible had happened to her son.
Just a few minutes earlier, she’d been sitting with Joshua Messier in the visiting room at the state’s prison for the mentally ill, worrying that he was on the verge of another schizophrenic attack. Messier’s sometimes-violent outbursts in a private psychiatric ward had landed him, much to his mother’s dismay, in the medium-security prison even though he had not been convicted of a crime.
Now, she was buttonholing the EMTs and prison guards converging on the scene, desperate to find out if her 23-year-old son was hurt.
“I could feel him calling me,” she recalled. “That’s how close we were.”
Her intuition proved tragically correct: The ambulance was called after a nurse found Messier strapped hand and foot to a bed, his face turning blue and his pulse nonexistent, while a half dozen guards with almost no mental health training stood idly by, apparently unaware that he had stopped breathing.
In a sequence caught on surveillance video, two of the guards had pushed down hard on Messier’s back as he sat in handcuffs and leg irons on the bed, forcing his chest toward his knees. The tactic, sometimes called “suitcasing,” is banned in Massachusetts prisons because it can cause suffocation, especially for those like Joshua Messier, who had grown overweight from taking antipsychotic medications.
A state medical examiner called Messier’s death a homicide, concluding that his heart stopped during the guards’ effort to strap him down. The autopsy also found injuries consistent with a beating, including internal bleeding on Messier’s brain, and blunt force injuries to his neck, torso, arms, and legs.
‘He was an all-around good kid with a bright future. His biggest thing was he wanted to go to college somewhere near the ocean, which is why he went down to UMass Dartmouth.’ — Kevin Messier, Joshua Messier’s father
Yet, nearly five years after his death, no one at Bridgewater State Hospital has been prosecuted or even punished, and all but one of the guards still works for the Department of Correction. Officially, the department maintains that no excessive force was used and that everything the guards and nurses did that night was “done in accordance with standard procedure.”
Plymouth District Attorney Timothy J. Cruz quietly decided not to prosecute Bridgewater staff in 2010 without convening a grand jury to hear the evidence — and before three other investigations faulted the guards. One of those investigations, by a state watchdog agency, the Disabled Persons Protection Commission, found “sufficient evidence to conclude that [Messier’s] death was caused by the actions of two correctional officers.”
In response to questions from the Globe, Cruz’s office said he dropped the case after medical examiner Mindy J. Hull could not identify a specific moment in the videotape when the guards caused Messier’s death. Cruz’s office said Hull retracted her finding of “homicide,” asserting that Messier was responsible for his own death.
“In her opinion, it was the conduct of Joshua Messier in fighting and maintaining the struggle against the guards that caused his extremely agitated state, and ultimately his death,” according to a two-page statement from the Plymouth district attorney’s office.
Hull, according to Cruz’s office, revealed her changed opinion a year after Messier’s death, at a meeting with an assistant district attorney and State Police investigators.
Neither Hull nor the Office of the Chief Medical Examiner would comment for this article.
Today, Messier’s father and mother — Kevin Messier and Lisa Brown — are pursuing a civil lawsuit against nine guards, two nurses, Bridgewater State Hospital, and the Department of Correction, hoping to learn more about what happened to their son and perhaps save other psychiatric patients from a similar fate. Indeed, were it not for their lawsuit, Messier’s death might have been forgotten by everyone but his family.
“They need to be held accountable,” said Lisa Brown, who has become an advocate for the mentally ill in the years since her son died. The guards and others responsible should also be prosecuted, she added, “so that what happened to Joshua never happens to anyone else.” There is a six-year time limit on filing manslaughter or involuntary manslaughter charges in Massachusetts.
Messier’s death raises broader questions about the role of Bridgewater State Hospital in caring for the mentally ill in Massachusetts. The prison has faced criticism for decades about excessive use of physical restraints and inadequate training of the guards. An inmate died there in 1997 after he was left face down in handcuffs, leading to a private settlement with the man’s family. And, in 2003, administrators promised to rely less on seclusion and physical restraints in order for Bridgewater to win accreditation as a behavioral health care provider.
Yet, less than a decade later, Joshua Messier died in restraints, while being subdued by guards. Far from following “standard procedure,” the guards, members of the Bridgewater medical staff, and prison officials responsible for their training and oversight, appear to have violated more than a half dozen state laws, regulations, and hospital policies in their handling of him, a Globe investigation found. The guards were so poorly trained in dealing with the mentally ill that one admitted afterward he didn’t even know what a “schizophrenic attack” was.
Among the most blatant of the apparent violations: They used the forbidden “suitcase” technique, and placed Messier in “four-point restraints” without getting prior medical approval to do so, as is required in almost all cases.
The guards said they faced an emergency situation and had to use this extreme form of restraint because Messier was out of control after assaulting another guard. But the surveillance video and the guards’ own pretrial depositions in the civil suit are consistent in indicating that Messier was calm and cooperative during the moments before he was strapped down, his schizophrenic attack apparently having passed.
After two of the guards — Derek Howard and John C. Raposo — got off his back and unfolded his body, Messier, the video shows, lay limp and motionless, his head flopping back at a 90-degree angle as guards strapped him to the bed and stripped off his clothes, then casually went about their business for the next 10 minutes.
One former Bridgewater inmate, who was at the prison at the same time as Joshua Messier but did not know him, said rough treatment of inmates was common. The former inmate, Timothy Grabosky, filed numerous abuse complaints against the guards during his nine years at the facility.
“Bridgewater State Hospital is a very dangerous place to be if you’re mentally ill. It’s not a hospital. It's a prison,” he said. “When they put you in four points, they have you in cuffs, they have you in leg shackles, a lot of times they’re pushing you, shoving you from behind. They’ll give you a bop on the head. They’re like bullies.”
Experts in treatment of the mentally ill say patients like Joshua Messier and Grabosky — both charged with assaults that occurred at mental health facilities — should not be sent to prison at all.
Philip W. Johnston, who oversaw Bridgewater State Hospital as state human services secretary from 1984 to 1991, said patients like Messier need treatment outside of prison, but end up at Bridgewater because public and private mental health care facilities are so underfunded that they sometimes dump difficult patients on the state by filing criminal charges against them.
“Assaulting staff goes with the territory,” said Johnston. “These are folks who are troubled and occasionally have fits of anger. Staff are trained, or should be trained, to deal with them without having to resort to incarceration.”
Unfortunately, he added, “In an era of reduced spending on health care, the mentally ill have borne a great deal of the burden.”
A dread diagnosis
It was the second semester of Joshua Messier’s first year in college at UMass Dartmouth in 2004 when Lisa Brown realized something was seriously wrong with her younger son. He began calling with greater frequency, often talking for hours without making much sense.
“He would tell me, ‘The police took my phone.’ And I would say, ‘But Josh, I’m talking to you on your phone,’ ” she recalled.
Finally, Brown drove to Dartmouth to check on Joshua and couldn’t believe what she saw.
“He was jumping up and down like a ballerina. And he wasn’t a feminine kid,” she said. “That’s when I took him out of there” and straight to a hospital.
As a teenager, Messier had gotten into minor legal trouble for marijuana possession and vandalism at a golf course, but his parents said he was basically a happy, ordinary boy growing up with his brother and sister in Charlton, a small town west of Worcester.
“He was an all-around good kid with a bright future,” said his father, Kevin, a chef. “His biggest thing was he wanted to go to college somewhere near the ocean, which is why he went down to UMass Dartmouth.”
Doctors at Marlborough Hospital kept Messier under observation for several days, first suspecting a vitamin deficiency, then considering bipolar disorder. In the end, they gave the family a grimmer diagnosis: paranoid schizophrenia, a disorder often characterized by disturbing auditory and visual hallucinations.
Schizophrenia commonly strikes men and women in their late teens or early 20s, said Newton psychiatrist Dr. Stuart Grassian, upending life for entire families as the schizophrenic begins to confuse interior voices and visions with reality.
“They’re paranoid, fearful, and they can become agitated and assaultive as a result,” Grassian said. “When they do, it’s the result of this internal, chaotic, unreality-based thinking.”
Messier’s mother put it another way: “When your child gets schizophrenia, it’s like a death because you’ll never have that same child back again.”
Over the next few years, Messier cycled in and out of psychiatric hospitals, his life punctuated by eruptions of violence — smashing himself in the head with drinking glasses, punching his father in the jaw — as doctors tried in vain to find a combination of drugs that worked.
He spent more than a year at Worcester State Hospital, one of the few remaining state-operated mental health institutions, where officials said he assaulted staff and patients more than 70 times. In perhaps the most serious attack, a state psychologist wrote, Messier “struck a mental health worker on his hands, groin, and face causing damage to the victim’s dentures and resulting in a six-week medical leave of absence from work.”
Brown believes Worcester State clinicians often made her son’s agitation worse by confining him to a small room as punishment, leaving him with nothing but the voices in his head.
“I kept telling them it’s not a behavioral thing,” she said. “He hit people because he thought they were the devil coming at him.”
Eventually, Messier was released from Worcester State, but his psychotic attacks began again almost immediately. In early 2009 alone, Messier’s parents checked him into Harrington Memorial Hospital, the small community hospital near their home, several times.
On Messier’s last visit to Harrington, his schizophrenic episodes became a criminal issue. After he allegedly assaulted three staffers on two separate occasions, misdemeanor assault and battery charges were filed against him and a judge sent him to Bridgewater for a psychiatric evaluation.
On April 1 of that year, Joshua Messier was admitted to the medium-security prison. He would never go home again.
Grassian, the psychiatrist, has studied the effects of incarceration on the mentally ill, and he said he believes Harrington Hospital officials had an ethical duty to care for Messier without allowing charges to be filed, noting that many mental health clinicians, himself included, have been assaulted by patients.
“If his violent behavior is the product of an illness, you don’t put him in jail, because it’s certainly going to make him worse,” he said.
Officials at Harrington declined to discuss their care of Messier, citing patient confidentiality.
But Lisa Brown said the first time she saw the high chain-link fencing topped with razor wire at Bridgewater, she knew it was the wrong place for her son, a paranoid young man from a small town who had never been imprisoned with seasoned criminals.
“He was scared,” she said. “He would tell me, ‘Mom, there are people in here who have killed their grandparents.’ ”
Inmates, not patients
The guards who stood around Joshua Messier’s bed as he died did not pretend to have any expertise in caring for the mentally ill. At least four of the seven who were in cell 13 that night — including Howard and Raposo — had only a high school or high school equivalency education, and most of them candidly admitted that they saw themselves as prison guards, not as guards in a mental health facility.
“I don’t even know what a schizophrenic attack is so that wouldn’t have meant anything to me,” said Correction Officer Clifford M. Foster in his deposition in the lawsuit filed by Messier’s parents. “I don’t recall any training in mental health.”
Another guard in cell 13, Timothy M. Soares, said he made no distinction between criminals and patients even though many of Bridgewater’s 350 inmates are there for psychiatric evaluations — not because they have been convicted of committing crimes.
When the guards receive their training, Soares said, “you don’t really learn about patients too much, you learn about inmates.”
Guards also said that although they did receive training in how to use force to subdue inmates or to protect themselves, they received no hands-on instruction in how to put an inmate in four-point restraints. And one of the two guards who “suitcased” Messier by pressing down hard on his back said under oath that he was not aware the practice is barred because it’s too dangerous.
“I did not know that,” John Raposo said during his deposition. “I understand that now.”
In addition, at least three of the seven guards had faced prior work-related disciplinary action or complaints, according to their depositions. Officer James P. Barker had been suspended for three days in 2008 after claiming to be absent from work for medical reasons when, in fact, he was dealing with an assault and battery charge filed against him by a former girlfriend.
Derek Howard, one of the guards seen “suitcasing” Messier in the video, had been suspended or reprimanded three times, once for insubordination, he said during his deposition.
And Sergeant George A. Billadeau was the subject of a 2008 complaint by a mental health worker who said he used a racial slur while referring to a Bridgewater patient. In his deposition, Billadeau, now a lieutenant, said he could not recall details of the incident.
Department of Correction officials declined to speak with the Globe about any of the issues raised by Messier’s death, citing the lawsuit filed by Messier’s father and mother. The office of Attorney General Martha Coakley, which is defending the guards, Bridgewater, and the department, also declined to answer questions.
But mental health care experts say Messier’s plight recalls a troubled era during the 1980s, when violent but noncriminal mental health patients were routinely sent to Bridgewater for extended stays until five preventable inmate deaths and a lawsuit led to reforms that included an end to the practice.
The reforms included creation of a psychiatric unit specially designed to house up to 50 violent noncriminal patients. But in 2003, the state closed the specialized unit at Taunton State Hospital to save money, contending that hospital clinicians at private and public hospitals generally had become better equipped to prevent mental health patients from becoming violent, making the specialized unit unnecessary.
“Times have changed since we opened the unit,” said one Department of Mental Health official at the time.
Today, Roderick MacLeish Jr., the attorney who filed the landmark lawsuit on behalf of Bridgewater inmates, argues that Messier’s incarceration at Bridgewater represents an end run around the state’s agreement to stop holding noncriminals indefinitely at the prison.
“There’s no way [Messier] should have been sent to a facility that is primarily a correctional facility,” he said.
Despite its name, Bridgewater State Hospital is a prison first — the facility is not accredited as a hospital — and it has long faced criticism for sacrificing mental health care to security concerns.
In 1996, an outside psychiatrist who reviewed operations at the facility put it bluntly: “The security vs. treatment issue at Bridgewater seems to permeate the operating atmosphere, with security being clearly dominant and treatment a secondary consideration.”
A fist fight with guards
Lisa Brown felt shaken after leaving her son in Bridgewater’s visiting room at about 8 p.m. on the night he died. During their conversation, she said, her son told her that guards had advised him he could hit people to protect himself, or to prevent other patients and inmates from taking advantage of him.
Though Brown couldn’t tell whether Messier was imagining the guards’ advice, she worried that they were trying to goad him into lashing out so that they could punish him.
“He wasn’t feeling well. He had anxiety, maybe because the guards told him that,” she recalled.
Worried that her son was on the verge of another schizophrenic episode, she told him to ask Bridgewater staffers for extra antipsychotic medications and said goodbye, never suspecting it was the last time she would see her son alive.
Minutes later, Messier was strip-searched — standard procedure for Bridgewater inmates and patients after receiving visitors — and made his way back to the residential unit where he was staying. Because it was late, an admitting officer sent him to a break room used by guards to ask for an escort to his room.
But once Messier entered the break room, which is not equipped with surveillance video, he suddenly punched Correction Officer Christopher J. Rego in the head, hard enough to make him spill his coffee, according to the State Police report on the incident.
Sergeant John A. Pupek, who was in the break room, told State Police that Messier’s expression was blank, his mouth agape. When Rego ordered Messier to turn around so he could put him in handcuffs, Pupek said, Messier refused and hit Rego again, prompting Rego to punch Messier “three to five times in the shoulder and the head.”
As a growing number of guards wrestled Messier into handcuffs and leg irons, Messier shouted, “I’m having a schizophrenic attack!” Pupek recalled.
The guards then led the shackled Messier across the prison courtyard to what is known as the Intensive Treatment Unit, crossing a 600-foot stretch with no functioning video cameras. The guards said Messier spat blood at them on the way, prompting one of them to pull Messier’s shirt over his head.
But in their depositions and statements to State Police, guards also said Messier seemed to calm down during the off-camera walk, apologizing for what he had done.
By the time Messier appeared on camera in a dorm room at the Intensive Treatment Unit, where he waited while the four-point bed in cell 13 was prepared, he seemed completely calm, his schizophrenic attack apparently over. But the guards began putting him in four-point restraints anyway, something that Grassian, the psychiatrist, said should not have happened.
“Once he’s calm, what’s the point of putting him in four-point restraints?” said Grassian. “You do that and you can’t expect anything but that he will become more paranoid and more agitated. It’s obvious.”
Some of the guards said that’s precisely what happened. While Messier was sitting on the bed with his hands cuffed behind him, they said, he began to resist, arching his back toward Correction Officer Howard.
Howard said he began pushing against Messier’s back to hold him upright and prevent him from falling backward onto his handcuffs, then lost his balance, according to his deposition.
But the video shows that Howard pushed against Messier until Howard was lying on Messier’s back while Raposo, in turn, pushed down on Howard’s back, forcing Messier’s chest toward his knees. Messier stopped moving after that.
When nurse Shawn E. Whinery finally arrived with a vital signs machine, precious minutes passed as he trouble-shot the balky apparatus and finally checked Messier’s carotid artery manually, finding he had no pulse.
“I wasn’t expecting to go in and find an expired patient,” he later explained.
By the time a doctor and another nurse arrived to begin chest compressions and mouth-to-mouth resuscitation, 10 minutes had passed since the guards laid out Messier’s body — long enough to end his life.
Although the Department of Correction has publicly defended the conduct of the guards and medical staff, its own Internal Affairs Unit reached a different conclusion. On May 25, 2011, two years after Joshua Messier was killed, Internal Affairs specifically cited Howard and Raposo for violating a policy that prohibits guards from putting pressure on a restrained inmate’s back, even if the inmate is resisting.
“If an inmate continues to struggle once restrained, staff shall never sit on or put their weight down on an inmate’s back,” the report said, quoting the policy.
Then, in July 2011, the state’s Disabled Persons Protection Commission found that Howard and Raposo were responsible for abusing Messier and recommended discipline “up to and/or including termination.” The commission’s report said the video showed that Howard and Raposo had pushed Messier over far enough so that his “chest appeared to make contact with the front of [his] legs.”
Nonetheless, department administrators decided to support Howard and Raposo, ignoring the findings of their own internal affairs investigator.
In her review of the internal affairs report, Assistant Deputy Correction Commissioner Karen Hetherson wrote that “no misconduct was found against staff.” She also recommended that Howard and Raposo “attend refresher retraining in the use and application of restraints.”
A month later, department officials appealed the Disabled Persons Protection Commission advisory opinion, to no avail, as the commission upheld its initial conclusion that, “there was sufficient evidence to conclude that [Messier’s] death was caused by the actions of two correctional officers.”
Finally, in January 2013, the Department’s Special Operations Division, which is responsible for reviewing all uses of force in the department, faulted the guards.
Without mentioning anyone by name, Special Operations director Steven P. Ayala said the guards were wrong to press on Messier’s back. He also said they violated a provision requiring them to be alert to breathing difficulties or loss of consciousness in a restrained inmate, and to take special care with obese patients and those who appear psychotic.
Nearly a year after Ayala’s finding should have reached Commissioner Luis S. Spencer’s desk, the department has yet to take any public action in Joshua Messier’s homicide.
Legal experts say Cruz, the district attorney, could have considered a variety of criminal charges, including involuntary manslaughter, in which a defendant engages in “wanton and reckless conduct” that leads to a person’s death, or in a “wanton and reckless failure to act,” including instances where the defendant had a “duty of care” for the victim.
“If you took this out of Bridgewater State Hospital and put it in a school or outside a bar or at Massachusetts General Hospital, there’s no doubt there would be criminal prosecutions,” said Benjamin R. Novotny, an attorney with the Boston law firm of Lubin & Meyer who is representing Messier’s parents.
At a minimum, Cruz should have called a grand jury to weigh the evidence or asked for another outside legal entity to review the matter to avoid the appearance of a conflict of interest, said R. Michael Cassidy, a Boston College Law School professor and former head of the state attorney general’s criminal bureau.
“This type of case raises concern about law enforcement protecting law enforcement if the district attorney doesn’t look to some neutral factfinder to make a determination, such as an inquest or a grand jury,” he said.
Cassidy also said that, except in cases of clear self-defense or other rare circumstances, “it’s unusual to have a homicide listed as the cause of death and not have any additional judicial proceedings.”
But Cruz’s office insisted it was right in dropping the case without presenting evidence to an independent factfinder, saying that the office has the authority to investigate all deaths in Plymouth County.
“There was no conflict of interest, nor has any conflict of interest ever been suggested or raised by the victim’s family or their civil attorneys during any of the meetings or correspondence with this office since Joshua Messier’s death,” the office said in a statement.
Cruz’s office said there was “insufficient evidence” to make criminal charges because the medical examiner, Hull, could not identify a specific cause of death during an extensive review of the videotape of Messier’s death.
“Input from the ME was absolutely critical,” the statement said.
Cruz’s office also said prosecutors did not believe the guards were criminally liable for failing to care for Messier, saying there was no evidence that the guards “specifically decided not to seek medical assistance for him.”
In addition, Cruz’s office said the medical examiner concluded there was no evidence that Messier was beaten with any weapons, saying that a deep gouge on top of Messier’s head — visible in autopsy photos — could have been caused by a fall after his fight with Rego.
However, Cruz’s statements on the case do not address in detail the extensive injuries found in the autopsy report, including the “contusions and abrasions” on Messier’s back, as well as the “contusions and abrasions of all extremities.”
In addition, Cruz did not address an abrasion on Messier’s neck that an emergency room doctor at Brockton Hospital, where Messier was pronounced dead, described as “ligature or straight laceration marks” — or signs that someone had tied something around Messier’s neck. The video in cell 13 shows nothing of the kind.
Joshua Messier’s mother said she did not observe any of these injuries when she saw her son just minutes before his encounter with Correction Officer Rego, adding that she is sure he would have told her if he’d been hurt or injured before her visit.
“Something happened to cause all those injuries,” said Novotny, the Lubin & Meyer attorney. “Where is the most likely place? In the courtyard where there are no cameras.”
The guards denied mistreating Messier in their depositions, though they did not receive medical approval to put him in four-point restraints until after nurse Whinery finally discovered he had no pulse. Bridgewater policy requires prior approval except in emergencies.
The nurse who filled out the belated approval, Carla M. Tornifoglio, checked off a box that said it was not possible to consider alternatives before guards placed Messier in four-point restraints — as normally recommended — such as talking to him about the incident in the break room. She also said that Messier’s vital signs were being checked while he was being placed in the restraints, though the video shows that didn’t happen.
The guards insisted they were not using four-point restraints to punish Messier — which would be a violation of explicit rules — but one of them, Officer Barker, said the guards put Messier in the restraints because “he attacked someone.”
Novotny believes what happened is simple: Guards were trying to teach Messier a lesson and make an example of him.
“There’s nothing that can justify what the guards did,” he said. “But are there things that can explain it? Sure. That he hit a guard. That they were retaliating, that they wanted to make an example of Josh, who was relatively new there, that they were going to teach him a lesson.”
Eight days after Joshua Messier was killed, Brian D. Frye, then director of security at Bridgewater, sent an e-mail to top prison staffers letting them know that guards would no longer be allowed to put prisoners in four-point restraints on their own authority. And internal e-mails indicate that guards are now receiving hands-on instruction in the use of four-point restraints.
But the lawsuit filed by Kevin Messier and Lisa Brown may be the last chance to learn the full story of Joshua Messier’s final moments. Already, the lawsuit has turned up the video of his death — evidence that Kevin Messier still can’t bear to watch.
“As his father, I’m the one that’s responsible for protecting him,” he said, explaining that he wasn’t there for his son when he was killed in cell 13. “I don’t know if I can deal with that.”Michael Rezendes can be reached at Michael.Rezendes@globe.com. Follow him on Twitter @RezGlobe.