A federally funded watchdog group issued a stinging report Monday on the death of a mental health patient at Bridgewater State Hospital and called on Governor Charlie Baker to transfer control of the troubled facility from the Department of Correction to the Department of Mental Health.
The report by the Disability Law Center followed the organization’s investigation into the April death of Leo Marino, a suicidal father who took his own life by swallowing wads of toilet paper, and concluded that Bridgewater personnel gave Marino the toilet paper he used to kill himself — even though he had attempted suicide by the same means a day earlier.
“In the final hour of his life, Mr. Marino was given [an] arm’s length or more of toilet paper seven times although he did not use the toilet once,” the report said. “Given that Mr. Marino had done this exact behavior just the day before, it is particularly egregious that additional precautions were not in place.”
Marino killed himself on April 8 in Bridgewater’s Intensive Treatment Unit, or ITU, a section of the facility used to hold mental health patients in isolation.
He was supposed to be under the watch of a specially trained observer stationed outside his cell and by correction officers monitoring live video of the inside of his cell.
“Mr. Marino repeatedly and methodically, over a period of time . . . . pushed the toilet paper wad down his throat,” the report said. “This continuous behavior should have been evident to both the [specially trained observer] stationed immediately outside his cell and the [correction officers] watching the monitors of the image from the overhead cameras in the ITU.”
Baker, during remarks to reporters on Monday, said he would make recommendations on the future of the facility over the next six months.
“I certainly think the conversation about the future of Bridgewater is an important one and it’s one that we’ve started to have as an administration,” he said. “I expect that we’ll be making some recommendations on that sometime before the end of the calendar year.”
The report also noted what it said were numerous additional violations of Department of Correction regulations and state law during the nine days Marino was held in the ITU, including a period when, it said, he was illegally placed in four-point restraints, with his wrists and ankles strapped to a bed.
Marino was civilly committed to Bridgewater in January, after he was found incompetent to stand trial on charges he’d assaulted his fiancee. He had previously tried to commit suicide several times while being held at the Essex County Correctional Facility, according to his brother, Joe.
The Law Center said Department of Correction officials have promised to take a series of corrective measures, including installing additional cameras that would allow prison officials to monitor the guards assigned to monitor the video of patients in the ITU.
Those measures are also designed to address “several recent almost fatal suicide attempts,” as well as the case of a mental health patient who almost bled to death while under surveillance, according to the report.
Despite its name, the Bridgewater facility, which houses about 300 patients at any one time, is a medium-security prison that is neither licensed nor accredited as a hospital. Most patients have never been convicted of a crime, though all have been charged, and many have been sent to the facility for psychiatric evaluations.
Department of Correction officials said in a statement that they are attempting to dramatically improve care.
“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,” the statement said.
But the center, citing three previous Bridgewater deaths since 2009, said the new measures are insufficient and asserted that future deaths could be prevented only by the transfer of the facility to the Department of Mental Health.
The report marks the second time in less than two years that the Disability Law Center has called on state officials to assign control of the Bridgewater facility to the Department of Mental Health, and it comes amid publication of a Boston Globe Spotlight investigation into the lack of state-funded care for persons with a serious mental illness who may be dangerous to themselves or others.
The first time was in 2014, after the Globe revealed that three men had died in the ITU from 2009 through 2013 while or after being placed in four-point restraints. One of the men, Joshua Messier, was the victim of a homicide and three correction officers have been charged with involuntary manslaughter in connection with his death.
“It is abundantly clear that Bridgewater State Hospital, as controlled by the Department of Correction, is incapable of providing the appropriate medical and mental health staffing necessary for the care and treatment of patients with mental illness,” the report said. The Department of Correction “is also incapable of effectively changing the prison culture that exists in a correctional facility where patients receive punishment in lieu of treatment.”
As an interim measure, the center proposed placing Bridgewater under the immediate control of a receiver until a transfer can be completed — a proposal echoed by Roderick MacLeish Jr., an attorney representing Bridgewater patients in a class action lawsuit challenging conditions at the facility.
“They don’t have the will, the staff, or the qualifications to be treating people with severe mental illness,” MacLeish said. “Receivership is the only answer.”
MacLeish is also representing members of the Marino family participating in a separate investigation into Leo Marino’s death. That inquiry is by State Police working under the direction of Plymouth District Attorney Timothy Cruz.
Joshua Miller of the Globe staff contributed to this report. Michael Rezendes can be reached at firstname.lastname@example.org. Follow him on Twitter @MikeRezendes. Jan Ransom can be reached at email@example.com. Follow her on Twitter @Jan_Ransom.