Four workers at Bridgewater State Hospital have been banned from all Department of Correction facilities during an investigation into the April suicide of a Bridgewater patient, according to officials.
Leo Marino, a 43-year-old father, died April 8 after swallowing wads of toilet paper that had been given to him by Bridgewater’s staff, despite the fact he had tried to kill himself the same way a day before.
According to an investigation by the Disability Law Center, a federally funded watchdog group, several specially trained observers gave Marino “[an] arm’s length or more of toilet paper seven times” within his final hour of life.
Marino was to have around-the-clock supervision, which included a trained observer stationed outside his cell and correction officers monitoring live video of the inside of his cell, according to the report, released Monday.
The four workers who are the subject of the “administrative separation” are contract employees and are not subject to disciplinary action by the Department of Correction, according to spokesman Christopher Fallon. All are trained observers who were “involved at some point with monitoring Mr. Marino,” Fallon said.
The agency’s investigation is ongoing, and no other staff have been disciplined, Fallon said.
“The Department of Correction recognizes the challenges at Bridgewater State Hospital, we are working on a strategy to ensure the quality of care and level of safety patients at Bridgewater receive matches what patients would receive at any mental health facility,” Fallon said Wednesday in a statement.
Roderick MacLeish Jr., an attorney representing Bridgewater patients in a class-action lawsuit, called the suicide “a failure of multiple levels.”
“This was a loaded gun they handed to him,” MacLeish said. “The [correction officers] and the specially trained observers were facilitators.”
An investigation by the Plymouth County district attorney’s office is ongoing.
Marino was committed to Bridgewater in January, after he was found incompetent to stand trial on charges he assaulted his fiancee. His brother, Joe, said he tried to kill himself several times at the Essex County Correctional Facility prior to being transferred to Bridgewater for an evaluation. In the weeks before his death, Marino, in the Intensive Treatment Unit, tried to commit suicide three times. He slit his wrists, tried to hang himself with a sheet, and swallowed wet toilet paper, according to his family.
Bridgewater, a medium-security prison, is not licensed or accredited as a hospital. And while all patients have been charged with a crime, most have not been convicted. Many have been sent to the facility for psychiatric evaluations.
The Disability Law Center’s report was the second time in less than two years that the organization urged state officials to give the Department of Mental Health control of Bridgewater, where between 2009 and 2013 three men died in the ITU while being placed in four-point restraints, or after.
Following Marino’s death, the Department of Correction said it would install cameras.
In a letter to MacLeish, Bridgewater’s supervising counsel wrote that observers have received additional training, and new briefings have been initiated to ensure staff are aware of a patient’s needs and restrictions.
MacLeish said the changes will not be enough. “There were ample opportunities to see what [Marino] was doing,” he said. “These people are dying, and it’s totally preventable.”Jan Ransom can be reached at firstname.lastname@example.org.