The Death of
Timothy Perry

An Investigative Report
State of Connecticut
Office of Protection and Advocacy
for Persons with Disabilities
James D. McGaughey, Executive Director
Susan Werboff, Program Director
Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program

AUGUST 2001

INFORMATION COMPILED BY:
State of Connecticut
Office of Protection and Advocacy for Persons with Disabilities
60B Weston Street
Hartford, CT 06120-1551
1-800-842-7303 (toll-free V/TDD)
(860) 297-4300—(860) 566-2102 (TDD)
e-mail: OPA-Information@po.state.ct.us
with special thanks to Anne Broadhurst, PAIMI Consultant
WWW.STATE.CT.US/OPAPD
This publication may be obtained in alternate format upon request
This publication was made possible by funding support from the Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration and is solely the
responsibility of the grantee. It does not represent the official views of the Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration.

TABLE OF CONTENTS

Introduction
Executive Summary
Investigation Background
Background Information
Psychiatric Hospitalizations and Arrests
Issues and Concerns
Incarceration and Death
Summary of Events
Findings
PAIMI Findings
Recommendations

page 1
page 2
page 7
page 9
page 10
page 16
page 17
page 19
page 24
page 28
page 30

INTRODUCTION
This report summarizes the results of an investigation into circumstances surrounding
the death of Timothy Perry at the Hartford Correctional Center on April 12, 1999. The
investigation was conducted by the Protection and Advocacy for Individuals with Mental
Illness (PAIMI) program of the Office of Protection and Advocacy for Persons with
Disabilities. When he died, Mr. Perry had just turned twenty-one. He had been
incarcerated following arraignment on charges of third degree assault, second degree
assault, threatening, and criminal mischief in the fourth degree. The charges stemmed
from two incidents where staff at Cedarcrest Hospital, a State psychiatric facility where
Mr. Perry was an inpatient, had been injured by him.
Separate investigations into Mr. Perry’s death have been conducted by the Connecticut
State Police and the Department of Corrections (DOC). Additionally, the Office of the
Chief Medical Examiner conducted a post mortem examination, and the Department of
Mental Health and Addiction Services initiated a review of practices for patient arrests.
This investigation reviewed the findings of these other investigations and reviews, along
with information from Mr. Perry’s clinical records. It is intended to examine two sets of
questions: 1) How and why was Tim Perry, a young man with a long established history
of psychiatric disability, sent from a State psychiatric hospital to prison; and, 2) Did he
receive negligent, improper or unsafe treatment while in prison, and if so, did that
treatment cause or contribute to his death? The report concludes with recommendations
for both DMHAS and DOC.
In issuing this report, the Office of Protection and Advocacy hopes that the lessons
learned from Mr. Perry’s tragic death will translate into change within both the mental
health service system and correctional facilities where, unfortunately, an increasing
number of individuals with significant mental illness are being incarcerated.

EXECUTIVE SUMMARY
Who was Tim Perry and how did he wind up in jail?
During his brief life, Timothy Perry had considerable contact with State service systems.
As a child he had been placed into a variety of foster and residential programs, and, at
the age of 18 began a series of stays in adult psychiatric hospitals and supervised
residential programs. Reading his clinical records it is easy to get the impression that he
was a troubled young man whose life was defined by intractable psychiatric and
behavior problems. Indeed, it is clear that many of those who worked with him at
Cedarcrest Hospital came to see him in precisely those terms, growing increasingly
frustrated with his apparent inability to achieve treatment goals, and with what they
interpreted as “self-sabotaging behavior”. Yet, at various times in his life, Tim Perry had
also experienced periods of relative success. He had secured a high school diploma,
pursued his love of music and his religious commitment by singing in his church choir,
had volunteered with children, enjoyed working out and playing sports, and had worked
as a building maintainer.
While he acknowledged that he had problems with
relationships and controlling his temper, and at one point indicated that he preferred to
stay in the hospital rather than leave, Mr. Perry’s records indicate that he saw these
problems as tied in with emotionally traumatic childhood experiences involving abuse
and abandonment by family members.
For all but six months of the last three years of his life, Mr. Perry was an inpatient in
psychiatric hospitals. For most of that time he was at Cedarcrest, a DMHAS facility in
Newington, Connecticut. Hospital records indicate that, at times, he actively participated
in group sessions and other structured programs aimed at assisting patients to assume
more responsibility for their behavior. The records also note the introduction of various
medications intended to reduce impulsive, explosive behavior, although none of these
drugs seemed to have much long-term effect. His diagnoses were initially listed as
schizoaffective disorder and borderline personality disorder, with specific problems
identified as depression, suicidal feelings, impulsive behavior and mood swings. While
the hospital records note Mr. Perry’s frequent references to his unresolved family issues,
and his attempts to reunite with his mother and confront his adoptive father had both
precipitated hospital admissions, there seems to have been little done to help him gain
insight or otherwise resolve the emotional wounds associated with the traumatic events
he consistently reported. In fact, two notable themes emerge from these records: 1) the
consistency with which Mr. Perry’s identity and needs were interpreted not in terms of
his self-reported issues, but rather in terms of the degree of difficulty he experienced
conforming to more or less generic behavioral treatment goals; and, 2) the increasing
frequency with which he was mechanically restrained following struggles with others
whom he perceived as challenging him or denying him something he wanted.
While reviewing records, one cannot help but observe that as hospital staff became
increasingly frustrated with Mr. Perry’s lack of progress toward meeting their treatment
goals, their perspective on who he was and what he needed as a human being grew
narrower, to the point where the types of behavior that had occasioned his
hospitalizations were eventually perceived as criminal in nature. The decision to prefer
charges against him was made following discussions amongst members of his treatment
team. In fact, at his March 31, 1999, arraignment, a representative from Cedarcrest

Hospital (a DMHAS Police Officer) represented to the Court that Mr. Perry was not
mentally ill, but rather had a personality disorder and that Cedarcrest could not provide
the services he needed. The Officer also told the Court that he understood that some
kind of consultation had taken place between Cedarcrest and staff from the Whiting
Forensic Institute (a high security DMHAS facility to which assaultive patients are
sometimes transferred), but that he understood there was some problem with availability
of beds at the later facility.
At that arraignment, the public defender assigned to represent Mr. Perry requested that
the Court order a competency evaluation, as she questioned whether he could
effectively understand the charges against him or assist in his defense. She also
requested that he be remanded back to the custody of DMHAS while the evaluation was
conducted, arguing that holding Mr. Perry in a correctional facility would be
inappropriate. The Judge granted the petition for a competency evaluation, but, having
heard the representations from DMHAS about Cedarcrest’s unsuitability and Whiting’s
unavailability, he ordered Mr. Perry to be held by the Department of Corrections pending
the evaluation.
And so, on March 31, 1999, two days prior to his twenty-first birthday, Timothy Perry was
sent to the Hartford Correctional Center on Weston Street, where he was assigned a cell
in the South Block mental health unit. Notes made by the unit nurse record receipt of a
call “from the court” alerting the facility to expect Mr. Perry, and informing her that “[h]e
had been hitting Cedarcrest staff on a regular basis and was being sent to us to teach
him a lesson.”
What happened to him in jail, and how did he die?
Despite some initial difficulty during his admission processing, it appears that Mr. Perry
presented no major problems to HCC staff until April 12, 1999, the day he died. He had
initially been placed on “KIC” (keep in cell) status, but had been taken off that status by
April 9th, when a DOC Mental Health Treatment Plan was developed. The plan
provided for one-to-one mental health counseling, taking medications (Mr. Perry was
continued on the four medications he had been receiving at Cedarcrest), and follow-up
with outpatient services (mental health services provided to inmates in the general
population) when he was ultimately released from the unit. The unit nurse spoke with
Mr. Perry on a number of occasions during his first week at HCC, and she apparently
developed some rapport with him.
On the evening of April 12th, however, Mr. Perry was in the unit day room with several
other inmates for a recreation period when he asked to speak to the nurse. The officer
on duty (who was new to Mr. Perry), and the nurse both indicated that he could speak to
her later, as she was busy at the time. Mr. Perry then started to pace and began yelling
and banging on the windows. He refused orders to return to his cell. Backup officers
were called in and Mr. Perry was again ordered to go to his cell. According to witness
statements, Mr. Perry then suddenly assaulted the duty officer who, along with three
other officers who had arrived in response to the call for help, subdued him, holding him
face down on the floor while he continued to struggle. A “code orange” (call to assist an
officer who is being assaulted) was initiated. Handcuffs were applied. Mr. Perry
apparently continued to struggle for several minutes while being held, face down, on the
floor. In response to what some witnesses described as “gurgling” or “spitting” noises, a
towel was placed over his head and apparently held in place by one of the officers.

(Witness accounts vary as to how, or even whether the towel was held.) Other officers
arrived, including a lieutenant/supervisor. Mr. Perry was then carried to his cell where
he was placed, again face down, on his bed and leg irons were applied. .
Either just before or shortly after Mr. Perry had been carried to his cell and shackled, the
unit head nurse paged the on-call psychiatrist and obtained an order for tranquilizing
medication and “soft”, four-point restraints. As his own cell was not equipped for the
use of these restraints, Mr. Perry was carried to another cell. As he arrived at this
second cell a handheld camcorder was employed, and a videotape of the incident was
begun. (Taping such incidents is required by DOC policy; failure to videotape the initial
sequence of events was first attributed to dead batteries in the camcorder, although
DOC’s internal investigation later found there was no facility protocol concerning who
was responsible for operating the camcorder.) The tape shows Mr. Perry being held,
face down on the cot in the second cell. The towel is still over his head, although neither
the towel nor the officer holding it are clearly visible until later in the tape when the other
officers begin to leave the cell. The cell is extremely small. The tape shows seven
officers crowded around Mr. Perry, holding him at each ankle and wrist, one of whom is
prepared to apply a pain/control hold to Mr. Perry’s left wrist while another presses his
knee down on the back of Mr. Perry’s upper legs. At the time the taping began Mr. Perry
was naked from the waist down. The nurse them enters along with a health aide, and
quickly administers two injections. Mr. Perry was then rolled onto his back, his shirt cut
off, was loosely covered with a paper gown, and the restraint cuffs applied to his wrists
and ankles.
Throughout the entire tape, Mr. Perry is not seen to resist or even to move. Yet, at one
point, the officer filming the event clearly remarks that, “Inmate Perry is still resisting.”
Indeed, the most notable aspect of the entire scene is the extent to which all involved
seem so focused on maintaining control over particular limbs or on accomplishing
particular tasks, including the administration of injections and application of restraints.
They either do not realize he has ceased to struggle, or attribute no significance to that
fact. No one speaks to, or pays attention to Mr. Perry himself. In the final scene of the
tape, the nurse and correctional supervisor are heard discussing the need to re-enter the
cell to make minor adjustments to the restraints so they will not impede circulation. This
was apparently done, but, again without addressing Mr. Perry or noticing that he was
utterly motionless.
Exactly when Tim Perry died is not clear. While in restraints he was monitored by the
unit supervisor from the unit control station via closed circuit television, and was
observed through the cell door window at fifteen minute intervals by a correctional officer
cadet assigned to the unit. The unit head nurse stated she also observed him “at least
ten times” through the cell window, although none of these observations were
documented. Several hours after he had been placed into restraints, however, another
nurse was assigned to cover the unit. She noticed that Mr. Perry’s feet were cyanotic.
She and the unit supervisor then entered the cell and found him cold and stiff. CPR was
initiated, 911 called, and he was transported to Hartford Hospital where he was
pronounced dead.
What was learned from autopsy and other investigations?
The post mortem examination revealed that the medication injected into his buttocks had
not circulated throughout his body, indicating that Mr. Perry may have already been

dead or at least close to death at the time the injections were administered. Small
hemorrhages were noted in his eyelids, tongue and facial muscles. According to the
Deputy Chief Medical Examiner who conducted the autopsy, this finding is consistent
with either asphyxial death, or death during a state of “excited delirium”. Based on
conflicting statements to police concerning the extent to which Mr. Perry was still
struggling as he was carried between cells, the medical examiner could not determine
with certainty when, or exactly how he had died. The adrenaline coursing through his
body while he struggled so intensely (e.g. in a state of “excited delirium”) in the day room
area or in the first cell to which he had been brought may have produced a fatal cardiac
arrythmia. Alternatively, compression applied to his chest area while he was being
physically held in a face down position by a number of correctional officers may have
prevented him from inhaling. The final cause of death was listed as “Sudden Death
During Restraint”, but the Medical Examiner could not determine the exact manner in
which it occurred. (An independent pathologist commissioned by PAIMI to review the
autopsy results determined that asphyxial death was the more likely scenario, but, could
not rule out the other possibility.)
However, the post mortem also noted a number of other irregularities, including the
presence of a third, non-prescribed psychotropic drug, (to which Mr. Perry was known to
be allergic) at the injection site.
A subsequent analysis of stomach contents also
revealed high concentrations of oral medications in his stomach – concentrations that
were inconsistent with the time that unit records indicated he had supposedly last
received them. Neither the Medical Examiner’s Office nor the independent pathologist
employed by PAIMI believe that these irregularities caused Mr. Perry’s death. But, they
do raise questions regarding the accuracy of unit records, the veracity of statements by
nursing staff, and the overall quality of health care in the unit. (Health care, including
mental health care in DOC facilities is provided through a contract with UCONN Health
Care Center. Doctors and nurses who treat inmates are employed by UCONN, not
directly by DOC.)
Both the State Police and the Department of Corrections conducted comprehensive
investigations into Mr. Perry’s death. A number of HCC staff were disciplined for failures
to adhere to DOC policies. The police investigation (which occurred first), determined
that several of the corrections officers had initially made misleading statements
concerning their actions during the incident. The nurse who had obtained the doctor’s
order for restraints and administered the injections, claimed to be unaware of any
requirement to check vital signs prior to administering medication or applying restraints,
She indicated that she thought she had felt a pulse when adjusting the restraint cuffs.
(DOC referred the question of discipline for nursing staff to its health care subcontractor,
UCONN Health Care Center. The nurse subsequently resigned.) The DOC policy
requiring physical assessments while inmates are restrained was found to be missing
from the unit policy manual, and there was no record that staff had received training in
its requirements.
In addition it was noted that supervisors had observed the
unauthorized placement of the towel over Mr. Perry’s head, but did nothing to cause its
removal. Upon reviewing the medical examiner’s report and the findings of the police
investigation, the State’s Attorney declined to pursue criminal charges against any of
those who participated in the incident.
In the wake of Mr. Perry’s death, DMHAS convened a committee to review its practices
with respect to seeking arrest and prosecution of its clients. After determining that
practices varied considerably between different elements of its system, the committee

developed a draft policy. At the time of the completion of this report, that policy is still in
draft form.
What should be done to prevent similar tragedies from occurring in the future?
Based on its findings, OPA has offered recommendations to both DMHAS and DOC. In
addition, the Office is requesting the Chief State’s Attorney to review the investigations
generated by Tim Perry’s death to determine if stronger statutory language is necessary
or desirable to provide criminal penalties for those who make misleading statements to
police agencies investigating deaths or allegations of mistreatment of individuals in State
custody.

Recommendations for DMHAS:
1. Develop a formal mechanism to initiate multi-disciplinary, external review and
consultation regarding the treatment of individuals whose behaviors are
proving to be especially challenging despite efforts of clinical staff of a
particular facility. Particular attention should be paid to those individuals
whose treatment goals are consistently not realized despite the use of various
therapies and interventions, and whose behaviors are deteriorating and
potentially dangerous, as evidenced by an increase in the use of physical
interventions, seclusion, and the use of PRN medication.
2. Review current guidelines regarding the arrest of clients, to ensure that
decisions to arrest clients are made only under very limited circumstances
and only when the alleged criminal conduct is clearly not a manifestation of a
client’s mental illness.
Recommendations for DOC:
1. Review current policies and procedures regarding both custodial restraint
practices and the use of physical and chemical restraints as psychiatric
interventions, in order to ensure that both conform to accepted medical
standards and do not place individuals at risk of injury or death. It should
be clear that in both custodial and medically-ordered restraint situations
that inmates are not to be held face down; that breathing may not be
impaired by physical holds; that covering of a restrained inmate’s head or
face is not permitted; and that both the reasons for using the restraints,
and conditions necessary for their discontinuation should be explained to
the inmate. These policies should also make clear that, especially when
dealing with inmates known to have psychiatric involvement, genuine
attempts must be made to de-escalate the situation prior to employing
physical force or restraints. Procedures for the use of emergency or
involuntary administration of psychoactive medication should also be
modified to require qualified personnel to assess the physical status of the
inmate prior to administration of the drugs and at regular intervals
thereafter.

2. Establish a protocol for assigning objective supervision to manage
physical interventions for inmates with psychiatric disabilities, and the
investigation of problematic events and practices. This protocol should
include the designation of a staff person who has not been involved in the
development of a particular intervention to act as an objective evaluator of
the situation and provide guidance to staff, as needed, in order to ensure
that appropriate and safe approaches are followed.
3. Establish a protocol to ensure that when unprofessional acts and
omissions by health care professionals are suspected by DOC
investigators, they are directly reported to appropriate licensing agencies
for review.
4. Establish a protocol for ensuring that advocacy services are made
available to inmates with mental illness.

INVESTIGATION BACKGROUND
The Office of Protection and Advocacy for Persons with Disabilities (OPA) operates in
accordance with State and federal statutory mandates that have been established to
protect and advance the civil rights of people with disabilities in Connecticut. In keeping
with its federal mandate under the Protection and Advocacy for Individuals with Mental
Illness (PAIMI) Act of 1986, as amended (Title 42 U.S. Code section 10801 et. seq.),
OPA has the authority to investigate allegations of abuse and/or neglect of persons with
psychiatric disabilities, including the death of such individuals, which occur in psychiatric
facilities, or facilities such as prisons or jails.

This report chronicles the circumstances leading up to and surrounding the death
of Mr. Timothy Perry, a young man with a psychiatric disability whose life ended
prematurely during the application of a four-point restraint at the Hartford
Correctional Center on April 12, 1999. It results from an extensive review of
records and reports obtained by the Protection and Advocacy for Individuals with
Mental Illness (PAIMI) unit at OPA following Mr. Perry’s death, including expert
opinions and collateral materials acquired by PAIMI as recently as May 2001.
The purpose of this report is to examine issues and concerns regarding Mr.
Perry’s treatment during the course of his psychiatric hospitalizations and
subsequent incarceration and to offer recommendations related to specific
aspects of his care and custody.
Materials reviewed for purposes of this report include:

•

Inpatient records of Mr. Perry’s most recent psychiatric hospitalizations at
Cedarcrest Hospital
(Dates of Admission and Discharge: 8/17/98
to10/6/98, 10/7/98 to 1/21/99 and 1/26/99 to 3/31/99)

•

Medical records of Mr. Perry from Capitol Region Mental Health Center
(Dates of Admission and Discharge: 1/21/99 to 1/26/99)

•

Department of Mental Health and Addiction Services Guidelines on the
Arrest of Clients (Effective: 3/1/00)

•

Transcript of Mr. Perry’s appearance before the Honorable William L.
Wollenberg, Judge, New Britain Superior Court (3/31/00)

•

Department of Correction Incident Report Package
4/12/99)

•

Connecticut State Police Investigation Report, including witness
statements and reports of witness interviews (Report Date: 4/16/99)

•

Report prepared by Ronald Cilyo, Captain/Investigator, Department of
Correction (Report Date: 9/24/99)

•

Report from the American Medical Response of CT Ambulance Company
(Date of Transport: 4/12/99)

•

Medical records of Mr. Perry from the Hartford Hospital emergency room
(Date of Service: 4/12/99)

•

Medical records of Mr. Perry from the Department of Correction (Dates of
Admission and Discharge: 3/31/99 to 4/12/99)

•

Videotapes (2) labeled “4 Point Restraint of I/M Perry” and “Code White
Timothy Perry” (Dated: 4/12/99)

•

Department of Correction Administrative Directive 6.5 on the Use of Force,
including Authorized Use of Restraints and Video Recording (Effective:
8/3/98)

•

Department of Corrections Administrative Directive 8.14 on Suicide
Prevention (effective 8/26/99)

•

Department of Corrections Administrative Directive 8.5 on Mental Health
Services (effective 6/19/00)

•

Department of Corrections Administrative Directive 8.8 on Psychoactive
Medication (effective 8/16/99)

(Incident Date:

•

Department of Correction Training Curriculum on Use of Restraints

•

A copy of the Memorandum of Understanding between the Department of
Correction and University of Connecticut Health Center (Dated: 8/11/97)

•

Report of the postmortem examination and findings performed by Edward
T. McDonough, M.D., Deputy Chief Medical Examiner of the State of
Connecticut Office of the Chief Medical Examiner prepared from Mr.
Perry’s autopsy (Dated: 7/26/99)

•

Report of postmortem toxicological studies and supplemental report
prepared by Sherwood C. Lewis, Ph.D., Director of Toxicology of the State
of Connecticut Office of the Chief Medical Examiner (Dated: 8/4/99 and
2/8/01, respectively)

•

Report of Barbara C. Wolf, M.D., Forensic Pathologist (Dated: 10/23/00)

•

Forensic Toxicology Report and Supplemental Report regarding the death
of Mr. Perry prepared by Thomas G. Rosano, Ph.D., DABFT, DABCC
(Dated: 11/30/00 and 3/17/01, respectively)

•

“What Killed Timothy Perry?” by Jayne Keedle, Hartford Advocate (Dated:
11/16/00)

BACKGROUND INFORMATION
Timothy Perry was born on April 2, 1978 in Hartford, CT. By Mr. Perry’s own
account, and, as reported in his hospital records, he was the victim of neglect,
and physical and emotional abuse since early childhood. Mr. Perry’s records
state that for the first three years of his life he was under the care of the
Department of Children and Youth Services. He lived in various foster homes
until the age of three, when he was placed in a home for adoption. According to
his records, Mr. Perry had a history of aggression in school and, at the age of
ten, was removed from school and placed on homebound instruction.
Although no court charges against his (adoptive) parents were ever filed, the
Department of Children and Families removed Mr. Perry from their care at the
age of eleven. For the next seven years, Mr. Perry moved in and out of a
number of foster homes, institutions, and other residential programs and,
according to hospital records, his behavioral and emotional problems continued.
In 1996, at the age of eighteen, Mr. Perry entered into a series of frequent
psychiatric hospitalizations. Between April 1996 and March 31, 1999, Mr. Perry
spent approximately six months outside of inpatient mental health facilities.

During those six months, he received day treatment services and lived in a
supervised apartment in Middletown, CT. According to his records, Mr. Perry did
fairly well in the community when provided with a lot of supervision and
supportive services.
Mr. Perry claimed that due to his long history of
institutionalization and abuse, he had “lots of difficulties relating to and
understanding people.”
According to his records, Mr. Perry completed high school, did maintenance
work, and volunteered with children. He also sang in the church choir and
attended services on a regular basis. He enjoyed listening to music, playing
sports, and exercising.
At the age of eighteen or nineteen, Mr. Perry attempted to reunite with his
biological mother, who also has a history of mental illness. According to inpatient
progress notes, his unresolved relationship with her was the source of much
distress and grief. Mr. Perry expressed a deep resentment towards his
(adoptive) father, due to his self-reported history of abuse. There is no evidence
of contact with other family members in Mr. Perry’s records, with the exception of
an aunt whom he regularly visited in Hartford.

PSYCHIATRIC HOSPITALIZATIONS AND ARREST
Third Admission to Cedarcrest
Prior to his incarceration at the Hartford Correctional Center on March 31, 1999,
Mr. Perry had five admissions to psychiatric facilities, four of which were to
Cedarcrest Hospital. This report begins with his third admission to Cedarcrest
Hospital, which occurred on August 17, 1998. At that time, Mr. Perry was
admitted on a fifteen-day emergency certificate from the Institute of Living, where
he had been an inpatient for one week. Mr. Perry had been accused of fondling
a woman he believed to be his girlfriend. The police had been notified and the
case was being investigated, along with three complaints of a similar nature. Mr.
Perry expressed a fear that he might, “end up in jail – I was depressed and
having suicidal thoughts – I requested hospitalization.”
At the time of this admission to Cedarcrest Hospital, Mr. Perry had diagnoses of
schizoaffective disorder, borderline personality disorder, and asthma. Problems
related to his interaction with the legal system were also noted. His admission
notes indicate an allergy to Thorazine in the form of a skin rash or hives and
below average/borderline intelligence. According to Mr. Perry’s self-assessment,
“I’m not suicidal, I’m only very anxious because this girl is accusing me of
touching her…I don’t know why she’s doing this, as to me, she was
consenting…I don’t know how to cope with this problem.”
Mr. Perry’s problems, as identified in his individualized treatment plan, were
depression, suicidal feelings, impulsive behavior, and mood swings. Long-range

treatment goals were that he would no longer feel suicidal and would have
control of his impulses. Specific treatment approaches identified to meet these
goals were that Mr. Perry’s psychiatrist regularly assess his level of
dangerousness to himself or others, that his medication be assessed and
adjusted as needed, that he be assessed for medication understanding and
compliance, and that he be referred to a dialectical behavior therapy (DBT)
program, related skills groups, and weekly sessions with a DBT therapist.
Established discharge criteria for community placement were that Mr. Perry be
stable in mood with adequate control of his suicidal thoughts and impulsive
behavior. In addition, that he maintain DBT, a day program, and anger
management support services.
During this hospitalization, Mr. Perry regularly attended group activities and was
an active participant in them. Progress notes indicate that he seemed committed
to the DBT program, worked hard on his skills and interpersonal effectiveness,
maintained a diary, and was compliant with his medications. At the same time,
he also experienced frequent setbacks and episodes of unpredictable behavior.
During this hospitalization, Mr. Perry was physically restrained and/or placed into
seclusion a total of seven times. Precipitating factors included discussion of his
discharge, being accused of looking at a female patient while she was taking a
bath, fighting with other patients, and becoming angry when his requests for PRN
(as needed) medication were not satisfied. In addition, on October 2, 1998, three
days before his discharge, Mr. Perry requested to be placed in physical restraints
because he felt like hurting someone “and I will.”
There is evidence in the progress notes that Mr. Perry was trying to gain insight
into his emotional and psychological problems and that he had, in general, a
positive attitude towards his treatment. Of note, however, was Mr. Perry’s
anxiety about his discharge plans. On September 9, 1998 he told his psychiatrist
that he didn’t want to live alone in his own apartment. On September 10, 1998
he told his treatment team that he was afraid of being back in his apartment and
needed a roommate. On October 2, 1998 he told his treatment team that he
didn’t want to return to Middletown and expressed an interest in living in Hartford.
On October 6, 1998 Mr. Perry was discharged back to his supervised apartment
in Middletown to receive outpatient follow-up at River Valley Services. According
to his psychiatric discharge summary, his prognosis was “guarded, in view of the
chronicity of his illness and marginal response to medications.”
Fourth Admission to Cedarcrest
On October 7, 1998 Mr. Perry was re-admitted to Cedarcrest Hospital one day
after his discharge. According to hospital notes, Mr. Perry became “enraged”
after seeing his (adoptive) father allegedly “look at him, laugh, and walk away” on
the streets of Middletown. Mr. Perry “lost control, threatened to kill his (adoptive)
father, and caused damage to a parked State vehicle.” A medical note on
October 8, 1998 reports the following:

Patient was discharged from CRH on 10/5/98; he had no desire to leave
the facility, was telling other patients that he likes it here and wants to
stay. During interview patient was told that he did not have to threaten
other people, destroy property in order to come back to the hospital.
When asked to identify the problems and goals he needed to address while
hospitalized, Mr. Perry reported his problems to be “anger, patience, depression,
frustration, and confusion with how to deal with stress.” His goals were “to move
to Hartford and to work on anger.”
At the time of his fourth admission, Mr. Perry had diagnoses of schizoaffective
disorder, borderline personality disorder, and asthma. Problems related to
conflicts with service providers and his (adoptive) father were also noted. Mr.
Perry’s problem, as identified in his individualized treatment plan, was poor anger
management. His long-range treatment goal was to maintain control of angry
feelings through means other than acting out. Specific treatment approaches
identified to address this goal were that Mr. Perry’s psychiatrist meet with him
regularly to assess risk factors, that his medication be monitored and adjusted as
needed, that he be offered medication as needed for increased agitation, that
mental health staff members interact with him individually and in group settings to
build therapeutic relationships, that the use of DBT skills be encouraged and
reinforced, and that alternative living arrangements in other towns be explored.
In addition, Mr. Perry’s treatment plan addressed his tendency to touch and hug
people inappropriately by having mental health staff remind him of its
inappropriateness upon occurrence, stress the importance of boundaries, and
emphasize the risk of his behavior interfering with another patient’s progress and
his own treatment. Established criteria for discharge were that Mr. Perry be free
of aggressiveness and self-harmful behavior. In addition, that he agree to and
obtain a placement that meets his needs.
While initially quite stressful, the first month of Mr. Perry’s treatment team
reviews report a positive response to treatment. On October 20, 1998 Mr. Perry
reported that he needed to be away from his (adoptive) father in Middletown. He
stated, “I’ll get more support from my Mom’s family in Hartford…I want to be part
of a family.” Records from this time period report that Mr. Perry was working
daily to control and manage his frustration without the need for “time out” or
physical restraint, and was meeting with staff members to discuss “anger
management, more patience, and minding my business.” There was one
incident of sexually inappropriate behavior reported during this time period.
By the second month of treatment, Mr. Perry’s treatment team reviews and
progress notes reflect a shift in his behavior. Mr. Perry reports that he doesn’t
know what works to manage his anger. He states that while he believes the
behavioral interventions he has been taught will be useful and helpful to him, he

continues to have difficulty remembering the interventions when his anger
escalates. Staff also report that he conveys a sense of being overwhelmed and
needing help in managing his feelings of abandonment and rejection. Mr. Perry
acknowledges that he struggles daily with issues of anger and rejection. On
December 14, 1998 the treatment team review contains the following note:
Tim presents increased violence when he is unable to have a desire met
or when told he has to wait and he disagrees that he should. He admits
that his patience is limited. Timothy has identified that when he gets angry
he is unable to consider the consequences for his anger. He reports
difficulty recalling past conversations, questions, or issues previously
addressed. He can only think about his current desire or issue at that
time.
During this hospitalization, Mr. Perry was physically restrained and/or placed into
seclusion a total of fifteen times. Examples of precipitating factors include his
wanting to smoke, wanting courtyard privileges, a telephone call to his mother,
altercations with other patients, and the imposition of unit restrictions.
On December 20, 1998 Mr. Perry was seen by staff from the Capital Region
Mental Health Center (CRMHC) and accepted for outpatient services there. As
in the case of his previous hospitalization, Mr. Perry expressed ambivalence
about his pending discharge. On December 14, 1998 Mr. Perry reports looking
forward to his discharge and placement into a supervised apartment. On
January 13, 1999 he tells his social worker that he feels he is ready to go to the
respite program at CRMHC. On January 20, 1999 he reports periods of some
anxiety. While he likes the idea of leaving the hospital, he indicates that he has
an attachment there. Nursing notes written on January 21, 1999, the day of Mr.
Perry’s discharge, report that he continues to have increased anxiety over his
pending discharge, having difficulty with his anger management.
Also noted during this hospitalization are frequent references to Mr. Perry’s
unresolved relationship with his biological mother. Progress notes report periods
of tearfulness, depression, suicidal feelings, and anger due to her refusal to talk
with him and eventually changing her phone number.
On January 21, 1999 Mr. Perry was discharged to CRMHC to receive respite and
intensive outpatient services while awaiting acceptance into the Center for
Human Development (CHD) Connecticut Outreach program. According to Mr.
Perry’s psychiatric discharge summary, his prognosis was “guarded, in view of
the chronicity of his illness and poor impulse control.”
A comprehensive assessment was completed by CRMHC on December 17,
1998. At that time, Mr. Perry’s diagnoses are major depression, recurrent,
borderline personality disorder, and history of asthma.
A mental status
examination reports that Mr. Perry’s “thinking is concrete to bizarre, with
inappropriate/nervous
laughter
when
he
didn’t
understand
the

abstractions…Client states that he hears voices in his head; when he does, it is
always his father’s voice making degrading statements.” In addition, Mr. Perry
reported that he experienced flashbacks and nightmares due to his history of
victimization.
Fifth Admission to Cedarcrest
On January 26, 1999, just four days after being discharged, Mr. Perry was readmitted to Cedarcrest Hospital on an emergency certificate from CRMHC for
assaulting another resident and reportedly pushing a female staff member.
At the time of this admission to Cedarcrest Hospital, Mr. Perry’s diagnoses were
impulse control disorder, borderline personality disorder with antisocial traits, and
asthma. Problems concerning his conflicts in the respite program were also
noted. Mr. Perry’s problems, as identified in his individualized treatment plan,
were poor impulse control and an inability to control anger. Long-range
treatment goals were that he would maintain control of his anger through the use
of learned skills when faced with stressful situations. Specific treatment
approaches identified to meet this goal were that Mr. Perry’s psychiatrist would
regularly meet with him to assess his risk to others and level of impulsivity, that
his medication be assessed and adjusted as needed, that he be offered
medication as needed when showing signs of “bravado, paranoia, and
aggression,” and that mental health workers and medical staff interact with him
individually and in group settings to review DBT skills, assist him to identify
triggers to his losing control, and with the development of interpersonal skills.
Mr. Perry’s treatment team reviews and progress notes during the first month of
hospitalization indicate that he was demonstrating improvement in controlling his
behavior. By February 24, 1999 Mr. Perry had moved from the most to least
restrictive level on his unit. A transition plan was developed for Mr. Perry
involving Cedarcrest Hospital and the CHD Connecticut Outreach program and a
discharge date of March 5, 1999 was set. The transition plan included a
behavioral contract that Mr. Perry agreed to follow in order to be accepted for
services in the community. The contract stipulated that Mr. Perry take his
prescribed medications, continue his participation in DBT classes, not physically
injure himself or others, and maintain a structured day by attending Life Skills
programming at CRMHC with a gradual transition to the Chrysalis program. In
addition, the contract included the provision that support staff would be instructed
to notify the police and press legal charges should Mr. Perry injure someone.
On March 3, 1999 Mr. Perry became combative during a discharge group.
According to hospital records, Mr. Perry threatened a staff member, and when
two other staff members attempted to intervene, he threw one of them to the
floor.

Following this episode, Mr. Perry’s discharge date was postponed and he
experienced almost another full month of “incident free” behavior. A new
discharge date of March 30, 1999 was established. On March 27, 1999 Mr.
Perry complained of foot pain. He was examined by a physician on-call, who
recommended cold compresses and Motrin for treatment. Mr. Perry requested to
be taken to the emergency room, but was advised to wait and try what the doctor
had recommended. Initially, Mr. Perry agreed to this plan, but after exiting the
treatment room, he approached the on-call physician and threatened to kill him.
Two staff members sustained injuries in an effort to intervene. A psychiatric
emergency was called and Mr. Perry was placed in physical restraints with a net.
On March 28, 1999 Mr. Perry met with a staff psychiatrist for an evaluation of his
condition. Mr. Perry was informed that, due to his behavior on March 27th, he
had been placed on continuous observation and needed to remain in his room.
He was also informed that he would be transferred to Whiting Forensic Institute
perhaps as soon as the following Monday. Records indicate that as soon as the
staff psychiatrist left his room, Mr. Perry walked out and yelled, “I have nothing to
lose if I’m going to Whiting.” As a result, Mr. Perry was again placed into
physical restraints with the use of a net. Later that same day, Mr. Perry was
placed in locked ambulatory restraints on a 1:1 status.
On March 29, 1999 Mr. Perry’s DBT therapist noted the following:
Patient continues to give only lip service to DBT – At the beginning of the
month, patient did one set of behavioral alternatives over an incident in a
discharge group – after that, however, patient has failed to submit even
one diary card and has resisted initiating and completing one – in recent
attempts to do a behavioral alternative, patient was very resistant. Patient
has made some efforts when happier and more “stable” to do skills, but
there has been little observable change when any more emotional stage
exists. There is serious question whether DBT treatment should continue
– patient will be approached to ascertain commitment for the remainder of
his time at Cedarcrest.
Hospital staff injured in the March 3, 1999 and March 27, 1999 incidents filed
complaints against Mr. Perry with the agency police officer and an application for
an arrest warrant was filed on March 29, 1999. Mr. Perry was charged with thirddegree assault, second-degree assault, threatening, and criminal mischief in the
fourth degree. A consultation was requested by Cedarcrest Hospital of the
Whiting Forensic Institute Team regarding the possible transfer of Mr. Perry to
Whiting Forensic Institute or to the criminal justice system.
On March 30, 1999 the assistant director and staff from Whiting Forensic Institute
met with Mr. Perry’s treatment team, Cedarcrest administrative staff, Mr. Perry’s
CRMHC case manager, and their hospital liaison. According to written progress
notes, the Whiting Forensic Institute team “agreed that Mr. Perry should face

legal charges and recommended that, if full consultation was desired, the director
of Whiting Forensic Institute should be contacted.” There is no written evaluation
report on file.
On March 30, 1999 a telephone consultation was completed between medical
staff at Cedarcrest Hospital and Whiting Forensic Institute. According to medical
notes, Mr. Perry’s psychiatric history, medication regimen, treatment approaches,
and most recent behavior were discussed. The response reported from medical
staff of Whiting Forensic Institute was that, “I cannot think of what else to do, it
looks like everything is tried, unfortunately I do not have any wisdom.”
On March 30, 1999 Mr. Perry’s medical records contain the following notation
made by his psychiatrist:
Patient was made aware that he sabotages his discharge plans. He knew
that he was going to be accepted by CHD (Center for Human
Development) and would start looking for an apartment as of today.
Patient has been ready for discharge for several weeks; placement has
been very difficult because he acts out a few days before his discharge.
During this hospitalization, Mr. Perry was physically restrained and/or placed into
seclusion a total of four times prior to the March 27, 1999 incident, which resulted
in his being physically restrained twice with a net and then being placed into
locked ambulatory restraints for the remainder of his stay at Cedarcrest Hospital.
Examples of precipitating factors include his wanting another cigarette,
altercation with patients, general agitation, and becoming angry when his request
for outside medical attention was not satisfied.
According to Mr. Perry’s psychiatric discharge summary, his final diagnoses were
impulse control disorder, personality disorder, with antisocial, narcissistic, and
borderline features, borderline intellectual functioning, and bronchial asthma. His
prognosis was “guarded, in view of poor response to medications and poor
impulse control.”
On March 31,1999 Mr. Perry was escorted to New Britain Superior Court by the
agency police officer and a caseworker to face charges.
According to a transcript of the court proceeding, the judge was informed by the
agency police officer that Cedarcrest Hospital’s position with regard to Mr. Perry
was that “he was not mentally ill but suffering more of a personality disorder.” In
addition, the agency police officer reported that the hospital believed that “they
cannot provide the services he needs at that particular setting.” Mr. Perry’s
public defender petitioned the court for an evaluation for Mr. Perry as she
questioned whether he could effectively understand the charges against him or
assist with his defense. She reported that her interest was in securing further
treatment for Mr. Perry. She stated, “I do believe that he (Mr. Perry) has a
number of problems and that’s one of the reasons, the main reason that he was

hospitalized…I would certainly argue that Corrections is not the place for him but
a treatment facility…and, unfortunately, there is no phone that we can pick up
and just have something available today.” According to the transcript, the
agency police officer was unsure as to what the Whiting Forensic Institute
treatment team recommended in Mr. Perry’s case, “but there was something
about availability of beds, his space, at that facility.”
In closing, the presiding judge granted the defense attorney’s request for Mr.
Perry to undergo an evaluation. A future hearing date was arranged and Mr.
Perry was remanded to the Hartford Correctional Center.

ISSUES AND CONCERNS
1. Mr. Perry’s records reveal that while a patient at Cedarcrest Hospital, he
experienced intermittent periods of progress toward recovery. Although it is
not clear which of the different combinations of medications, behavioral
therapy, physical interventions or “time out,” strategies was most helpful in
this regard, it is clear that he was, at times, able to assume responsibility for
his behavior and improve his relationships with others. However, it also
seems apparent that he was unable to sustain the kind of continuous growth
and stability necessary to succeed in a typical community based program. As
his hospitalization(s) progressed, there is significant evidence of an increase
in both the number and intensity of aggressive episodes requiring physical
intervention, seclusion, and the use of PRN medication. His records also
reflect a concurrent rise in the frustration level of his treaters. Yet, there does
not appear to have been a mechanism in place for Mr. Perry’s treatment team
to step back and ponder what was not working; to seek an external
consultation from a source that was both sufficiently expert in behavioral
analysis, and sufficiently independent, to look objectively at what was really
going on. While Cedarcrest staff did seek the opinion of Whiting Forensic
Institute, the consultation was informal, and occurred only after an incident
where Mr. Perry had threatened a physician and injured two staff members
who were trying to restrain him. When Whiting staff indicated they were
unable to offer treatment alternatives, the decision was made to seek Mr.
Perry’s arrest and ultimately his transfer to the Department of Corrections.
2. There does not appear to have been a programmatic response to Mr. Perry’s
recurring ambivalence and anxiety just prior to and immediately following
discharge. While mention is made in Mr. Perry’s medical records that he
“undermined” his discharge plans, his treatment team reviews do not reflect
discussions of alternative interventions. Mr. Perry’s statements about his
issues and concerns were apparently not given much credibility, especially
during his later admissions. Hospital staff had a treatment plan in mind and
insisted that Mr. Perry conform to it even when it was clear that, at that time in
his life, he couldn’t. Mr. Perry may have been told that he didn’t have to

threaten other people or destroy property in order to stay in the hospital, but
that wasn’t really true. In the face of other alternatives, it appears as if Mr.
Perry’s experience taught him how to work a system that was leading him in a
direction about which he was reporting, and demonstrating, he felt
ambivalent.
3. One of the themes that emerges from reviewing Mr. Perry’s records is that,
despite their efforts to help him succeed, his treaters seemed to lose sight of
what it was like to be him. The whole treatment plan was built around his
achieving self-control, and when he did not do so, it is apparent that the
interpretation of who he was and what he needed began to change.
Nowhere in the hospital records is there a sense that the system might be
failing Mr. Perry. Instead, the reports are more about how he failed to meet
the standards of the system. In this context, Mr. Perry’s arrest seems to
reflect a hopelessness on the part of staff – partly a “we give up,” statement of
frustration, partly a punishment imposed for violently rejecting the help they
had offered.
4. There is evidence in Mr. Perry’s records that he was eligible to participate in
the Department of Mental Health and Addiction Services (DMHAS)
Specialized Services for Transitioning Youth, also known as the Special
Populations Project. The project’s purpose is to assist young people like Mr.
Perry to make a successful transition to adulthood. Services available
through participation in this project include housing, vocational support,
treatment, and supervision. There is no indication in Mr. Perry’s records that
these services were ever made available to him.
5. According to PAIMI records, Mr. Perry received advocacy services from the
Connecticut Legal Rights Project (CLRP). There is, however, no record of
Mr. Perry having any contact with a CLRP advocate during his
hospitalization(s) or arrest.
6. At the time of Mr. Perry’s arrest, DMHAS had no policies or procedures in
place to ensure that decisions to pursue arrest of clients were made in a
consistent manner, according to objective criteria.

INCARCERATION AND DEATH
On March 31, 2001 Mr. Perry was transferred to the South Block Unit at the
Hartford Correctional Center (HCC). South Block Unit is a mental health unit that
is staffed by both custody and medical/mental health staff and managed by the
University of Connecticut Health Center (UCHC) in partnership with the
Department of Correction (DOC). In a Memorandum of Understanding signed
and dated August 11, 1997, UCHC agreed to manage a comprehensive health
care delivery system that includes the provision of medical, mental health, dental,

and ancillary services to inmates in DOC correctional facilities. While delivery of
health care and clinical services to inmates is managed by UCHC, the DOC
retains the authority for the care and custody of inmates and has responsibility
for the supervision and direction of all DOC facilities. UCHC, however, assumes
full responsibility for correctional health care personnel under this agreement.
The South Block Unit at HCC consists of two tiers which house “exclusively
mental health inmates.” Each tier contains twelve single cells for a total of
twenty-four inmates.
Mr. Perry was admitted to the South Block Unit on a Psychiatric Watch (PW) and
Keep In Cell (KIC) status. According to the Mental Health Initial Assessment
completed by the Correctional Head Nurse on March 31, 1999:
This 20-year-old black male is transferred to jail from Cedarcrest Hospital
after assaulting a staff member. He is on Clozaril, Depakote, Prozac,
Klonopin. He is angry with an angry, irritable affect. Got into a situation
with an officer while awaiting his intake and was escorted back to the unit
without his intake. He is explosive with no impulse control. Denies
voices. Admits to being adopted and beaten by father two times a day
until placed by the state.
In a statement to DOC investigators on September 7, 1999, the same
correctional head nurse made the following statement:
The day of Timothy Perry’s admission, I received a telephone call from the
court, apprising me of his admission status. I was informed that Perry was
assaultive and was a patient at Cedarcrest. He had been hitting
Cedarcrest staff on a regular basis and was being sent to us to teach him
a lesson.
On April 5, 1999 the following note was made by the South Block Unit psychiatric
social worker:
Inmate has been well behaved in his cell on PW and KIC status. I let him
out of his cell this evening to speak to me. He expressed remorse
regarding the assault (alleged) on staff at Cedarcrest Regional Hospital.
Stated he has a temper problem. Stated he hopes he will be allowed out
of his cell soon. States he intends to be well behaved because jail is a
terrible place.
According to a DOC Mental Health Treatment Plan developed on April 9, 1999,
Mr. Perry’s problem was identified as “inmate has been aggressive with his
behavior towards others.” The treatment goal established was to “decrease and
cease aggressive, assaultive behavior.” Interventions included 1:1 mental health

counseling, taking medications as prescribed, and follow-up outpatient services
when discontinued from the court.
By April 9, 1999 Mr. Perry had been removed from KIC and PW status and on
April 12, 1999 he was cleared for Unit C-2 status. Unit C-2 houses inmates with
mental health needs, but their problems are less acute. Mr. Perry’s clinical
records report that a social worker from the public defender’s office was due to
visit him on April 13, 1999.
On April 12, 1999, approximately two hours after being placed into 4-point
restraints, DOC and UCHC staff discovered Mr. Perry to be unresponsive.
Resuscitative efforts were initiated and Mr. Perry was transported to Hartford
Hospital by ambulance. Within minutes after arriving at the hospital, Mr. Perry
was pronounced dead. The following chronology of events and witness
statements are taken from comprehensive State Police and DOC investigative
reports, which were conducted in response to the untimely and suspicious death
of Mr. Perry.

SUMMARY OF EVENTS
On April 12, 1999, prior to 7:45 PM, Mr. Perry was in the South Block west
dayroom for evening recreation. Prior to this date, the unit rover (correctional
officer on duty) had never worked with or seen Mr. Perry. According to
statements provided to DOC investigators, the unit rover’s first interaction with
Mr. Perry was when Mr. Perry let him know that he wanted to see the nurse. The
unit rover told Mr. Perry that he would see her when she came around. In a
statement provided by the nurse, she indicated that she had the opportunity to
speak with Mr. Perry on a number of previous occasions and had developed a
rapport with him. She reported that on the evening of the incident, she was very
busy in her outpatient area with new admissions. At one point, she walked past
the dayroom and Mr. Perry asked to talk with her. She told him that she would
speak with him later, but she never had the opportunity.
7:45 PM
According to all witnesses present, at approximately 7:45 PM, on that same
evening, Mr. Perry began pacing around the dayroom, yelling and banging on the
windows, and standing on the table and chairs. Both the correctional head nurse
assigned to the South Block Unit and the unit rover spoke to Mr. Perry, urging
him to calm down. Mr. Perry remained anxious and uncooperative and
subsequently refused several orders to return to his cell or “lock up.” There were
two inmates in the dayroom at this point and they returned to their respective
cells without incident.

The unit officer contacted the control center officer, who dispatched three
correctional officers to assist the unit rover. All three officers and the unit rover
entered the dayroom and attempted to convince Mr. Perry to return to his cell.
After a short time, Mr. Perry looked as if he had calmed down and appeared as if
he was going to return to his cell without further incident.
According to witness reports, Mr. Perry began walking towards the dayroom door
when suddenly, apparently without warning or provocation, he charged the unit
rover. The unit rover then pushed Mr. Perry backwards and he and the other
correctional officers began struggling to restrain Mr. Perry. The unit officer then
called a code orange, alerting facility personnel that an officer was being
assaulted and needed additional back up.
A fourth officer arrived on the scene and witnessed Mr. Perry thrashing around
on the floor. This officer assisted in turning Mr. Perry on to his stomach.
According to witnesses present, with a struggle and the help of other officers, this
officer then handcuffed Mr. Perry behind his back. According to most of the
facility personnel present, Mr. Perry stopped speaking once the use of force
began.
8:00 PM
By this time, other facility staff had arrived, including another correctional officer
and the scene supervisor, who was a lieutenant, both of whom directly assisted.
By this time, Mr. Perry was face down on the dayroom floor, handcuffed behind
his back. Several minutes had elapsed and Mr. Perry was still described as
“actively resisting.” Four correctional officers and the unit rover then carried Mr.
Perry face down to his cell, which was Cell #10, and placed him face down on to
his bunk. The lieutenant/scene supervisor supervised the staff throughout this
portion of the incident, and, while in Cell #10, also applied leg irons to Mr. Perry.
One of the correctional officers was maintaining control of Mr. Perry’s head. He,
along with several other facility staff, stated that Mr. Perry was either spitting or
making “gurgling noises” as if he was about to spit. While in Cell #10, the officer
maintaining control of Mr. Perry’s head called out for a towel. A towel was
passed to him and the officer either placed the towel over Mr. Perry’s mouth or
his entire face, as witness accounts differ concerning the exact placement of the
towel.
The correctional head nurse, in her statement to DOC investigators, reported that
from the time the unit rover and Mr. Perry struggled in the dayroom to the time
Mr. Perry was in Cell #10 appeared to have been approximately ten minutes.
According to her statements, the correctional head nurse, who was in charge of
the medical and mental health areas for the 4:00 PM to midnight shift, informed
the lieutenant/scene supervisor, who identified himself as the officer in charge,
that she was going to contact the staff psychiatrist.

The correctional head nurse contacted the staff psychiatrist via pager. According
to her statements, the staff psychiatrist called back quickly. The correctional
head nurse gave the staff psychiatrist a brief history and summarized Mr. Perry’s
actions. According to her statements, the staff psychiatrist ordered Mr. Perry to
be medicated with 2 milligrams of Ativan and 10 milligrams of Haldol and that he
be placed into 4-point restraints. The correctional head nurse then relayed this
information to the lieutenant/scene supervisor. It should be noted that the
lieutenant/scene supervisor indicated in statements to DOC investigators that it
was hard for him to believe that they were placing Mr. Perry in 4-point restraints.
He felt that Mr. Perry’s behavior didn’t warrant 4-point placement, only cell
restraint. In a statement to DOC investigators the lieutenant/scene supervisor
reported the following:
The correctional head nurse was making the calls and other staff in the
immediate area was confirming this is how it is done here. I was not used
to medical staff calling shots in incidents such as this and this to me was a
custody issue.
It should be noted that the 2nd shift commander reported to DOC investigators
that he also didn’t feel comfortable with “this 4-point restraint and I questioned
who made the decision…the lieutenant/scene supervisor informed me that the
nurse stated that a doctor ordered the 4-point restraint and that was the policy for
this facility.”
In the South Block Unit, Cell #13 and Cell #24 are designated for 4-point
restraints. Each cell has a surveillance camera that is monitored at the unit
officer’s station. The cameras do not have recording capability, nor are they
monitored from any other location in the facility. Both Cell #13 and Cell #24 were
occupied at this time, but neither inmate was in restraints.
According to statements provided to DOC investigators, the correctional head
nurse and a second lieutenant on the scene assisted in preparing Cell #24 for
Mr. Perry’s transfer. After the inmate in Cell #24 was moved, Mr. Perry was
carried face down from Cell #10 to Cell #24. At this point, witness accounts still
place the towel over Mr. Perry’s head/face. It should be noted that, according to
witness accounts, Mr. Perry’s level of resistance decreased to “minimal” as the
incident progressed.
8:20 PM
Immediately after being placed face down on the bunk in Cell #24, the unit officer
began filming the incident. When the filming begins, Mr. Perry is on his stomach
and correctional officers are removing his leg irons, pants, and underwear. Both
lieutenants are actively supervising the officers. Mr. Perry is quiet and does not
appear to be resisting in any way. Medical staff informs the lieutenants that Mr.

Perry must be placed on his back, but will first be given medication by injection.
The correctional head nurse and a correctional medical attendant enter Cell #24
and Mr. Perry is given two injections in his right buttocks. Mr. Perry is silent and
doesn’t appear to react at all when the injections are administered. In her
statements to DOC investigators, the correctional head nurse reported that “Mr.
Perry did not move or flinch when I injected him like most patients do.”
Next, Mr. Perry is turned over onto his back, leg and wrist restraints applied and
his shirt and t-shirt are cut/torn off. The scissors don’t cut very well and
correctional officers manipulate Mr. Perry’s body to remove his shirt and t-shirt.
Finally, they actually end up tearing the shirts off of him. Throughout this time,
correctional staff maintains controlling techniques, ready to apply pain
compliance if necessary. One correctional officer can be seen on the videotape
applying a bent wrist technique to Mr. Perry at 8:24:54 PM, and looking for some
type of response. Throughout this time period, Mr. Perry does not appear to
resist in any way. Mr. Perry does not utter a sound and no one present, neither
the correctional officers nor the lieutenants, give instructions to Mr. Perry or
advise him to stop resisting.
Of note is that the unit officer filming the incident can be heard commenting on
the videotape that Mr. Perry is still resisting when, in fact, no resistance can be
seen. After reviewing the tape, the unit officer acknowledged that Mr. Perry was
not resisting and offered that he thought he had seen movement out of the corner
of his eye as he looked between the viewfinder and the top of the camera.
Although the videotape doesn’t show Mr. Perry’s face, at various points during
the film a correctional officer is observed continuing to hold a towel over Mr.
Perry’s mouth/face. At 8:29 PM, this same correctional officer is clearly seen
holding a towel over Mr. Perry’s face. Immediately before exiting the cell, this
same correctional officer can be seen removing the towel from Mr. Perry’s head.
The videotape never shows Mr. Perry’s face or eyes.
Just before the correctional officers exit the cell, a paper gown is loosely placed
over Mr. Perry’s body, obscuring any view of his face. According to the DOC
investigation report:
Significant is that during the entire videotape, Mr. Perry is silent, appears
motionless, and totally unresponsive. No one is talking to Mr. Perry or
giving him instructions. The involved staff consistently state that Mr. Perry
ceased resisting but none of them found his behavior peculiar.
8:30 PM
After the correctional officers exit the cell, the lieutenant/scene supervisor briefly
summarizes the incident and signs off the videotape. As the videotape ends, the
correctional head nurse is seen informing the lieutenant that she must check the

4-point restraints. The videotape did not remain on for the restraint check, but
according to statements provided to DOC investigators, both lieutenants entered
the cell with the correctional head nurse. She determined that one or both of the
wrist restraints required adjustment, which was accomplished by the lieutenants.
During her final restraint check, the correctional head nurse “believed” she
detected a pulse at each restraint location. She also could not recall any
problems with Mr. Perry’s respirations. She did not remember Mr. Perry
speaking or looking at her. The lieutenant/scene supervisor, in a statement
provided to DOC investigators, reported the following:
I checked his left restraints. While checking his wrist restraint I do recall
Mr. Perry’s eyes were open. I just glanced at him and it appeared as if he
looked at me. Throughout the incident it was hard for me to believe that
we were placing him in 4-point restraints.
After Mr. Perry’s cell was secured, everyone left the unit, except for the unit
officer and a correction officer cadet. Cadets are assigned to the units for
training and are instructed to observe, not become directly involved in incidents.
The unit rover, in direct contradiction to a recent notice requiring the unit rover to
remain in the unit at all times, left the South Block Unit to report to the medical
unit to be examined.
After the unit rover left the unit, the unit officer monitored Mr. Perry from the
officer’s control station camera. According to statements provided to DOC
investigators, the unit officer never saw any indication of trouble over the monitor.
He reported that “Mr. Perry had been sedated and appeared to be sleeping.”
The correction officer cadet conducted the 15-minute checks of Mr. Perry and
documented them on a Close Observation Checklist. In statements provided to
DOC investigators, the correction officer cadet reported the following:
I knew to look for living, breathing flesh. I thought I saw living, breathing
flesh. He (Mr. Perry) had a paper gown thrown over him and I thought I
saw the paper gown moving. I did not expect to see much movement
from Mr. Perry due to the fact that he was sedated. He remained in the
position he was in, on his back and I think his face was turned to the right.
The inmate’s face was partially covered by the paper gown that was laid
on top of him.
The correctional head nurse reported to DOC investigators that she did “check in
on Mr. Perry periodically and he appeared to be okay.” She also reported that
the last time she “peeked into his cell was about 9:15 PM.” The unit officer and
the correction officer cadet both stated that they never observed the correctional
head nurse conduct these checks, nor was there documentation of them.
At approximately 10:05 PM, the correctional head nurse left the South Block Unit
in order to tour Unit C-2. When she left, she informed the correctional head

nurse assigned to the outpatient area that she was leaving. At this point, the
correctional head nurse assigned to the outpatient area was responsible for the
South Block Unit.
Earlier in the evening the correctional head nurse assigned to the outpatient area
told DOC investigators that at around 8:30 or 8:40 PM, when she found out that
Mr. Perry had been “4-pointed and medicated,” she went to Cell #24 “and peeked
in and saw ankles and feet with a puffed up gown blocking my view of his face…I
didn’t look long enough to see the rise and fall of his chest…I was afraid he
would see me and I would have to spend time with him, which I couldn’t because
of other duties.”
10:30 PM
At approximately 10:30 PM the unit officer returned to the South Block Unit. He
had been gone approximately two hours. As he entered the unit, he spoke with
the correctional head nurse about how strong Mr. Perry was earlier. After
speaking briefly, they went to check on him. When the correctional head nurse
looked through the cell door window, she observed Mr. Perry’s feet to be
discolored. In a statement to DOC investigators, she reported the following:
I saw Mr. Perry’s feet discolored – they were blotchy and mottled. Mr.
Perry was in the same position that I had seen him in earlier. I had the
unit officer open the door. I went inside and tried to take his pulse. Mr.
Perry was cold and stiff – he had been dead for some time.
A code white was then called, CPR was initiated, and an ambulance was
summoned. According to the American Medical Response of CT ambulance
report, rigor was noted in Mr. Perry’s jaw and arms. Mr. Perry was transported to
Hartford Hospital where he was pronounced dead at 11:10 PM.

FINDINGS
Office of the Chief Medical Examiner Postmortem Report
The report of the postmortem examination performed by Edward T. McDonough,
M.D., Deputy Chief Medical Examiner, revealed the following evidence of injury:
The presence of a thin superficial abrasion on the right side of Mr. Perry’s
neck, a compression band around the left wrist and a 3/8” abrasion over
the right ulnar process. Internal examination revealed no hemorrhage in
the soft tissues of the neck or injury to the laryngeal structures other than
a 0.8 cm hemorrhage in the right piriform sinus. There were hemorrhages
in the anterolateral aspects of the tongue bilaterally. Hemorrhages were
also present in the temporalis muscle.
Three pinpoint petechial
hemorrhages were also present on the lower lid of the left eye. No other

injuries were noted, and there was no evidence of pre-existing natural
disease which would have contributed to Mr. Perry’s death.
Dr. McDonough concluded the following:
There are two main possibilities for this gentleman’s death. One would be
an “excited delirium” type of death where during a struggle a
hyperadrenergic (adrenaline) response would cause an abnormal heart
rhythm even to a grossly or microscopically unremarkable cardiac tissue.
This would cause a cardiac arrest. Secondly, in any situation involving
multiple person restraint, the possibility of an asphyxial death is raised.
This could occur by compression of an individual’s chest, causing an
inability to inhale air. Also, a form of neck or airway blockage could be
accomplished. The autopsy examination did show three tiny petechial
hemorrhages in the eyes. While these are seen in asphyxial deaths,
these are nonspecific findings and can also be found in sudden cardiac
deaths. A careful internal examination of the neck structures revealed no
evidence of hemorrhage that would be consistent with a strangulation and
no injury to the mouth suggestive of an oral airway blockage was
identified. None of the investigative information allows for an accurate
reconstruction in a second by second, moment to moment fashion that is
required in order to make a diagnosis of a traumatic, or other type of
asphyxial, death. Therefore, no specific diagnosis is able to be made at
this time.
Of note, a corrections nurse gave the deceased an injection in the right
buttock reported to be lorazepam (Ativan 2 mg) and haloperidol (Haldol 10
mg). The toxicologic results revealed the presence of the lorazepam and
also the haloperidol in the area of the injection site. Of note, the presence
of chlorpromazine (Thorazine) was also detected in the area of the
injection, which is not supported by the medical records.
Final Cause of Death:
Final Manner of Death:

Sudden Death During Restraint
Undetermined

Department of Corrections Investigation Findings
DOC investigators, in the summary section of their investigation report, made the
following statements:
From the time inmate Perry assaulted the unit rover until the 4-point
placement was completed, approximately 20 minutes elapsed.
Throughout this period, staff had their “hands on” Perry. Initially, Perry
actively resisted. His level of resistance diminished as the incident
progressed. When the filming began (approximately 10 minutes into the
incident), Perry appears to be totally unresponsive.
There is

consistency in their statements that Perry was mute during the entire
incident and no one is talking to him, for any reason. Disturbing is that not
until the videotape was reviewed by some of the involved staff that they
realized Perry was unresponsive, including the unit officer who states on
the tape that Perry is still resisting. When the unit officer reviewed the
tape, he realized Perry wasn’t resisting at all and offered that he thought
he saw resistance through his peripheral vision as he picked his head up
from the camera viewfinder. No one, either custody or medical staff,
thought Perry’s actions were unusual.
After being placed into restraints, Timothy Perry was monitored via
camera by the unit officer at the unit officer’s station. The correction
officer cadet checked him every 15 minutes from the cell door observation
window. In addition, the correctional head nurse claims she observed
Perry from the cell door observation window at least 10 times between
8:30 PM and 10:10 PM.
At approximately 10:30 PM, when the
correctional head nurse originally assigned to the outpatient area
discovered Perry unresponsive, she noted his feet were discolored and
that he was cold and stiff. The correctional medical attendant (medic),
who administered CPR, also described him the same way. The medical
examiner’s report did not establish the time of death. However, there is
indication that he was deceased for some time.
In addition to the investigative summary, DOC investigators issued a number of
findings, which resulted in disciplinary action being taken against DOC facility
employees involved in the incident. DOC investigators also issued findings
concerning the actions of the correctional head nurse and correctional medical
attendant. However, as UCHC employees, UCHC assumed responsibility for
determining whether any disciplinary action should be taken against them as a
result of their involvement in the incident.
DOC findings included the following:
1. Although the incident lasted approximately 20 minutes, only the latter half is
documented on videotape. During the course of the investigation it was
learned that the HCC did not have a procedure designating staff responsible
for videotaping incidents. A policy/procedure was not developed until after
inmate Perry’s death.
2. That initially, Perry resisted with great force. After about 10 minutes, when
the videotape begins, Perry appears to be totally unresponsive. Careful
review of the videotape fails to produce a single voluntary movement by
inmate Perry. Staff observed this behavior yet none thought it to be unusual.
3. That Perry was mute from the point where he attacked the unit rover. No one
is heard talking to the inmate or giving him any instructions, especially when

they turned him over or he was given the injections. No one ever tells Perry
to stop resisting.
4. Throughout the videotape, the lieutenants actively supervised the officers.
The lieutenants never give any instructions to Perry, only staff.
5. One correctional officer used a towel as a spit shield, which was observed by
both lieutenants and allowed, although not authorized.
6. The incident videotape was not handled as evidence and the facility captain
should not have allowed correctional officers to review the tape following the
incident without a supervisor present.
7. That although the HCC Post Order 8.7, regarding the use of 4-point restraints
for psychiatric intervention was in effect since 1994, the required checks of
the pulse, respiration, circulation, blood pressure, and temperature were not
conducted, and were not a matter of protocol. The medical staff claim they
were never issued the post orders. Some acknowledged they were aware the
post orders were located at the nurse’s station. Review of their files failed to
produce any documentation that the post orders were issued. (Note: On
April 13, 1999, the day following this incident, it was discovered that a copy of
Post Order 8.7 was missing from the policy manual at the South Block Unit
nurse’s station).
8. That the correctional head nurse failed to provide proper medical care for
inmate Perry. She failed to conduct physical assessments (described in Post
Order 8.7) and document them in the progress notes section of the inmate’s
medical chart.
Furthermore, between 8:30 PM and 10:00 PM, the
correctional head nurse claims she conducted visual checks of inmate Perry
from the cell door window, but she did not document these checks in the
medical chart, nor did she observe anything unusual. Furthermore, as the
correctional head nurse monitoring inmate Perry, she was responsible to
determine when inmate Perry’s behavior warranted the removal of the 4-point
restraints. According to everyone who observed him, Perry was calm since
he was placed in Cell #24, thereby raising the question as to whether the 4point restraints were necessary for as long as they were used.
9. The videotape depicts significant deficiencies in the overall condition of Cell
#24. The cell is filthy with layers of paint peeling from the walls. This
condition is unacceptable and far below DOC standards.
10. The stationary unit surveillance cameras do not have recording capability nor
can they be monitored from the control center.
Independent Toxicology Findings

The results of post-mortem forensic toxicology reports prepared by Thomas G.
Rosano, Ph.D., DABFT, DABCC, Forensic Toxicologist, dated as recently as
March 17, 2001, revealed the following findings:
The result of postmortem toxicologic studies reveals the presence of
fluoxetine (Prozac) and clozapine (Clozaril) in Mr. Perry’s blood. The
postmortem level of fluoxetine (Prozac) in gastric content indicates recent
oral ingestion of the drug that has not had sufficient time to distribute
throughout the body. (Note: DOC medical records show that Mr. Perry
was dispensed a 40 mg dose of Prozac at 12 PM on 4/12/99) The
postmortem level of clozapine (Clozaril) is consistent with oral therapeutic
use of Clozaril and is also consistent with the medication plan. (Note:
DOC medical records show that Mr. Perry was dispensed a 300 mg dose
of Clozaril at 10 PM on 4/12/99) The postmortem level of valproic acid
(Depakene) is consistent with the oral use of Depakene and with the
medication plan. (Note: DOC medical records show that Mr. Perry was
dispensed a 1000 mg dose of Depakene at 10 PM on 4/12/99) The
postmortem level of lorazepam (Ativan) is consistent with a perimortem
intramuscular injection of Ativan. The undetectable level in iliac blood
indicates insufficient time or insufficient circulation for systemic distribution
of the drug. The postmortem level of haloperidol (Haldol) in iliac blood
and tissue from the injection site are consistent with a local injection of the
drug near or after the time of death. The elevated level of haloperidol
(Haldol) in iliac blood indicates insufficient time or insufficient circulation
for systemic distribution of the drug to body tissue. The postmortem blood
and tissue studies of chlorpromazine (Thorazine) in this case are
consistent with a perimortem intramuscular injection of chlorpromazine
(Thorazine). The trace level of chlorpromazine (Thorazine) in iliac blood
with high concentration at the injection site indicates insufficient time or
insufficient circulation for systemic distribution of the drug.
Based on the drug treatment information and toxicology studies reviewed
in this case, the findings are consistent with oral therapeutic use of
clozapine (Clozaril) and valproic (Depakene) as prescribed. The tissue
and blood determinations of lorazepam (Ativan), chlorpromazine
(Thorazine), and haloperidol (Haldol) indicate administration of these
drugs at or around the time of death. The toxicology findings do not
indicate a fatal drug overdose.
Independent Forensic Findings
The results of an independent forensic report prepared at the request of PAIMI
by Barbara C. Wolf, M.D., Forensic Pathologist, dated October 23, 2000, reveal
the following findings:

It is my opinion, to a reasonable degree of medical certainty, that the
placement of Mr. Perry face down in a prone position with his hands
restrained behind his back and his legs restrained, and with a towel held
over his mouth, placed the inmate at a significant risk of death. It is my
further opinion that these actions were more likely than not indeed the
cause of his death. Such a position inhibits chest wall motion and
compromises breathing. When restraint is required, an individual should
not be left in a prone position once subdued. In this case the videotape of
Mr. Perry’s restraint shows him making no motion, suggesting he
succumbed prior to his being placed in the supine position. Furthermore,
the rigor mortis noted by ambulance personnel indicates that he had been
dead for longer than indicated by the correctional head nurse, since rigor
mortis usually requires at least a period of up to two hours before it
becomes first detectable, indicating that Mr. Perry was not adequately
monitored while under the observation of the correctional head nurse.
The term “restraint asphyxia” refers to deaths occurring under these
circumstances, when an individual is restrained, usually in the prone
position following a state of physical and emotional exertion. Extreme
emotion and physical exertion increases the individual’s requirement for
oxygen. Clearly a multitude of factors can contribute to the sudden death
of an individual during restraint, including physical compromise of
breathing and hormonal responses of the body. Correction officers and
other law enforcement officials should be trained in the proper methods of
restraint, transport and monitoring of individuals when such restraint is
necessary. An individual under restraint should not be left in the prone
position but should be seated or placed on his side or back as soon as
possible. The individual should be monitored for adequacy of air
exchange and level of consciousness.
The detection of Thorazine in Mr. Perry’s system at the time of his death is
also a source of concern. His medical records indicate that he was
allergic to Thorazine. Although the postmortem findings do not suggest an
allergic or anaphylactic reaction as being a contributory factor in his death,
his prescribed medications and the medications allegedly given during the
inmate’s restraint do not account for the presence of Thorazine.

PAIMI FINDINGS
In addition to the findings reached by the Office of the Chief Medical Examiner,
DOC investigators, independent toxicology, and forensic reports, and based
upon a review of all the available medical and investigative materials, PAIMI also
concludes the following:

1. That Mr. Perry’s medical records reveal that the correctional head nurse who
was responsible for monitoring Mr. Perry the evening of his death initialed on
his medication sheets that she dispensed prescribed doses of Depakene,
Clozaril and Ativan to him orally at 10:00 PM on April 12, 1999. However, it is
clear that documentation is in error, as at that time Mr. Perry was in cell # 24,
in four-point restraint, and very likely had already expired.
2. That while the independent toxicology report concludes that Mr. Perry’s
postmortem level of Prozac in gastric content indicated recent oral ingestion
of the drug (i.e. not very long before the occurrence of death), Mr. Perry’s
medical records indicate that his last dose of Prozac (40 mg) was dispensed
at 12:00 PM on 4/12/99. There is no documentation in Mr. Perry’s medical
records to suggest that Prozac was dispensed orally at any later point in time.
3. That while the independent toxicology report reveals that Mr. Perry’s
postmortem blood and tissue levels of Thorazine are consistent with a
perimortem intra-muscular injection of Thorazine, there is no documentation
in Mr. Perry’s medical records to suggest that Mr. Perry received an intramuscular injection of Thorazine at any time. In fact, Mr. Perry’s medical
records clearly document an allergy to Thorazine.
4. That while independent toxicology studies and forensic reports determined
that intra-muscular injections of Ativan and Haldol were administered to Mr.
Perry just prior to, or even possibly after his death, and that by that time he
appeared to be totally passive (indeed unresponsive), neither nursing nor
custody staff considered whether the conditions which had precipitated the
staff psychiatrist’s initial order for the use of medication were still warranted,
and whether, as Mr. Perry was no longer struggling, a change in the order
should be sought.
5. That according to HCC Post Order 8.7, Restraints as a Psychiatric
Intervention, dated May 1994, restraints are to be used only in situations in
which a patient’s behavior presents an imminent danger to himself or others
and LESS (emphasis in the original) restrictive methods have either been
unsuccessfully tried or cannot be safely implemented. Neither custody nor
medical staff attempted to implement less restrictive measures with Mr. Perry
once handcuffs and leg irons had been applied in Cell #10 and he had been
effectively immobilized.
6. That according to HCC Post Order 8.7, Restraints as a Psychiatric
Intervention, dated May 1994; the correctional head nurse is required to
explain the restraint procedure and reasons for the restraint to the patient.
There is no evidence to indicate that any of the custody or medical staff
present attempted to communicate with Mr. Perry over the course of the
entire incident.

7. That while the DOC investigation report states that the correction officer cadet
conducted 15-minute checks of Mr. Perry between 8:45 PM and 10:15 PM,
and documented such checks on the Close Observation Checklist, an
examination of the checklist reveals that the 15-minute checks are not
initialed.
8. That based upon the position of the paper gown used to cover Mr. Perry
following the removal of his clothing and the application of 4-point restraint,
the only part of his body that is likely to have been visible to custody or
medical staff checking on his condition through the cell door window were his
ankles and feet.
9. That while, as the postmortem report indicates, it is impossible to establish
the exact time and nature of Mr. Perry’s death, independent toxicology
studies and forensic reports have determined that intra-muscular injections
were administered to Mr. Perry just prior to or possibly even after his death.
As many as ten custody and medical staff either had their hands directly on
Mr. Perry or were present in Cell #24 just prior to, during, and immediately
following his death, yet they neglected to, in any way, attend to his most basic
physical and/or medical needs. In addition to significantly compromising his
life during the application of restraint, they took no action to ensure that his
life, once fatally threatened, had a chance of being saved.

RECOMMENDATIONS
The following recommendations are organized into two sections: one specific to
the Department of Mental Health and Addiction Services (DMHAS), the other
specific to the Department of Corrections (DOC). They are intended to stimulate
discussion, and urge clarification of policies and procedures related to issues
identified in the report.
Recommendations for DMHAS
1. Develop a formal mechanism to initiate multi-disciplinary, external
review and consultation regarding the treatment of individuals
whose behaviors are proving to be especially challenging despite
efforts of clinical staff of a particular facility. Particular attention
should be paid to those individuals whose treatment goals are
consistently not realized despite the use of various therapies and
interventions, and whose behaviors are deteriorating and potentially
dangerous, as evidenced by an increase in the use of physical
interventions, seclusion, and the use of PRN medication.
It is clear in Mr. Perry’s case, as noted in his records, that as his hospitalizations
progressed, there was a significant increase in both the number and intensity of

behavioral episodes. These were met with more restrictive levels of physical
restriction and various pharmaceutical interventions, neither of which seemed to
diminish the impulsive behavior. While Mr. Perry’s case notes describe his
behavior as unstable and lacking self-control, his treatment team reviews do not
reflect any discussions of alternative courses of treatment or modifications to
plans to discharge him to a community program. Nor do they explore how his
cognitive limitations (noted in his final discharge summary) may have influenced
his ability to fully participate in, and derive benefit from, the type of behavioral
programming and other therapeutic interventions being provided. (For instance,
dialectical behavior therapy requires that individuals keep extensive diaries, yet
writing fluently may be difficult for someone with cognitive impairments.) As Mr.
Perry’s needs became more critical and his failure to meet the objectives
established in his treatment plan became more pronounced, his treatment goals
and discharge plans remained essentially unchanged.
When it became clear that Mr. Perry could not conform to the treatment plan
hospital staff had in mind, bringing a discussion of his treatment history to
objective, outside evaluators for consultation and review, could have created the
opportunity for a greater understanding of his needs and an examination of other
treatment approaches. Having an objective, outside evaluation could also have
ensured that all of the services available to Mr. Perry were being offered. For
instance, he might have benefited from a program established to assist youth
with mental health needs transition to adulthood (Specialized Services for
Transitioning Youth)
While Cedarcrest Hospital did informally seek the opinion of a psychiatrist at
Whiting Forensic Institute, that discussion occurred following the incident which
precipitated Mr. Perry’s arrest. When that discussion failed to produce additional
insight or treatment alternatives, no further outside opinions were sought.
2. Review current guidelines regarding the arrest of clients, to ensure
that decisions to arrest clients are made only under very limited
circumstances and only when the alleged criminal conduct is clearly
not a manifestation of a client’s mental illness.
In order to ensure that consistent standards are being applied, it is vital that there
be a mutually agreed upon set of underlying principles to guide the response of
mental health professionals across individual facilities whenever a client arrest is
being considered. Although DMHAS has developed draft guidelines since Mr.
Perry’s death, the following issues need to be emphasized:
•

While the current draft DMHAS guidelines state that “arrest is to be
considered only when (a full array of clinical) interventions are either
inadequate or inappropriate,” it is critical that DMHAS ensure that clients
are not arrested for exhibiting behaviors for which they are specifically
being provided treatment. While it is true that Mr. Perry’s aggressive

behavior presented particular challenges, and that staff members
sustained physical injuries in their attempts to manage his behavior, his
impulsivity and inability to utilize the behavioral alternatives that had been
presented to him, as well as his lack of patience and admitted inability to
cope with his anxiety, make it unlikely that at this point in his life he was
capable of controlling his impulsive responses or assuming full
responsibility for his behavior. There is no evidence that Mr. Perry’s
aggressive episodes were premeditated. Rather, the pattern of Mr.
Perry’s assaultive behavior indicates an almost reflexive response to
certain stressors, and are characterized by an inability to form appropriate
judgments when confronted by those stressors. (This is further evidenced
by his inability to assess the danger he was placing himself in by
antagonizing officers at the Hartford Correctional Center.)
•

Before a client is arrested, or if an application for an arrest warrant is
being sought, DMHAS should ensure that an external advocacy source,
such as OPA or the Connecticut Legal Rights Project (CLRP) is notified.
In Mr. Perry’s case, although his records indicate that he received
advocacy services from the CLRP, there is no evidence that he was
provided with an opportunity to meet with his advocate regarding his
impending arrest and appearance in court.

•

If a client is transferred from a DMHAS facility to a correctional facility, as
in the case of Mr. Perry, DMHAS should ensure that the treatment team
responsible for providing mental health services in the correctional facility
is accurately apprised of the client’s treatment history and needs, and that
contact by DMHAS staff is maintained with the client to ensure an
appropriate level of care and support is being provided.

Recommendations for DOC
1. Review current policies and procedures regarding both custodial
restraint practices and the use of physical and chemical restraints as
psychiatric interventions, in order to ensure that both conform to
accepted medical standards and do not place individuals at risk of
injury or death. It should be clear that in both custodial and
medically-ordered restraint situations, inmates are not to be held
face down; that breathing may not be impeded; that covering of a
restrained inmate’s head or face is not permitted; and that both the
reasons for using the restraints, and conditions necessary for their
discontinuation should be explained to the inmate. These policies
should also make clear that, especially when dealing with inmates
known to have psychiatric involvement, genuine attempts must be
made to de-escalate the situation prior to employing physical force
or restraints. Procedures for the use of emergency or involuntary
administration of psychoactive medication should also be modified

to require qualified personnel to assess the physical status of the
inmate prior to administration and at regular intervals thereafter.
Subsequent to Tim Perry’s death, DOC issued new or revised policies on mental
health services for inmates (Administrative Directive 8.5, dated 6/19/00), Suicide
Prevention (Administrative Directive 8.14, dated 8/26/99), and Psychoactive
Medication (Administrative Directive 8.8, dated 7/23/99). The policy on suicide
prevention also contains a section addressing the use of “Emergency Mental
Health Intervention”, including use of restraints. That section sets fairly
comprehensive requirements for medical orders, documentation, and a schedule
of checks for vital signs at regular intervals. It also prescribes the use of “soft”
restraints in a face-up position only. However, these requirements apply only
when on-site Health Services staff is on site. In situations where Health Services
personnel are not present, correctional staff is to be initially guided by DOC’s
policy on Use of Force (Administrative Directive 6.5).
The Use of Force policy (Administrative Directive 6.5) covers a range of
interventions up to and including the justifiable use of deadly force to protect life
and prevent escape. While the policy requires supervisory authorization for the
use of in-cell or full stationary restraints, and requires medical observation of
restrained inmates every two hours, it does not provide specific directions
regarding positioning nor detail regarding the specific requirements for medical
monitoring. Especially with respect to inmates with mental health needs, this
bifurcation of rules invites problems and confusion. It must be remembered that
the initial response to Tim Perry’s non-compliant behavior on the evening of April
12, 1999, was from custodial staff, apparently using customary custodial restraint
techniques. These techniques included multiple staff members holding Mr.
Perry, face down, for an extended period – possibly resulting in severe
respiratory compromise and “restraint asphyxia”. DOC should review the
interplay between these two distinct restraint policies to ensure that, to the
maximum extent possible, both are subject to the same limitations and
requirements, stated in the same terms. For instance, it should be explicitly
stated in both that face-down holds are prohibited, that physical holds may not
impede breathing, and that inmates’ faces and heads may not be covered during
any restraint. Both custody and medical staff should be trained in methods of
restraint that call for individuals to be seated or placed on their sides or backs as
soon as possible after control is achieved. Staff should also be trained to
specifically monitor adequacy of air exchange and level of consciousness. Most
importantly, however, staff that work in mental health units should be trained in
techniques for de-escalating and redirecting inmates who are becoming agitated.
It would also be useful for policy to direct that the circumstances under which
inmates with mental health treatment plans might be subject to restraint be
discussed with the inmate as part of the development of the plan. In that way,
specific de-escalation strategies could also be identified, and pre-existing

medical conditions which might compromise an inmate’s health and safety during
restraint (e.g. asthma), could also be clearly identified.
DOC’s policy on Psychoactive Medication (Administrative Directive 8.8)
establishes procedures for obtaining inmate consent for the use of psychoactive
medications, and for use of such drugs without consent in response to
emergencies. (The policy also provides procedures for documenting medical
justification for, and obtaining official review of, decisions to involuntarily
administer drugs in non-emergency circumstances. Inmates who wish to contest
decisions to involuntarily medicate them are to be provided notice and an
opportunity for a hearing.) However, the policy does not require medical staff to
check vital signs prior to administering medication on an emergency basis. Nor
does it require subsequent assessments of the inmate’s physical condition at
regular intervals. These requirements should be added to the directive.
2. Establish a protocol for assigning objective supervision to manage
physical interventions for inmates with psychiatric disabilities, and
the investigation of problematic events and practices. This protocol
should include the designation of a staff person who has not been
involved in the development of a particular intervention to act as an
objective evaluator of the situation and provide guidance to staff, as
needed, in order to ensure that appropriate and safe approaches are
followed.
It is clear that something is profoundly wrong when one views the videotape of
Mr. Perry’s restraint and sees the discrepancy between what was actually going
on and what was reported by staff in witness statements. The correctional
officers restraining Mr. Perry in Cell #24 were so completely focused on particular
tasks that they paid no attention to the fact that Mr. Perry had ceased struggling,
and perhaps had even ceased breathing. As indicated in the DOC investigation
report, custody staff displays signs of physical exertion on the videotape,
coinciding with their statements as to the level of intense resistance initially
offered by Mr. Perry. However, by the time he was moved to Cell #24, Mr. Perry
appeared totally unresponsive (emphasis in original report).
Although custody and medical staff bring different perspectives to interventions in
mental health units, when both become involved in the evolution of an
emergency situation, and each has responsibilities for carrying out specific tasks,
it is possible for both to lose perspective on “big picture” issues. (Like whether
an inmate who struggled with great strength and intensity has quieted down, and
if so, whether restraints and/or medication are still warranted.)
In such
circumstances it would be useful for a supervisor who is not involved in the initial
eruption to assume overall direction of the intervention. This individual would
also be well positioned to ensure that required reporting, debriefing and evidence
preservation occur following the incident.

3. Establish a protocol to ensure that when unprofessional acts and
omissions by health care professionals are suspected by DOC
investigators, they are reported to appropriate licensing agencies for
review.
To its credit, DOC investigators conducted a commendably thorough
investigation into the circumstances surrounding Tim Perry’s death. DOC then
took a variety of disciplinary measures with respect to HCC staff. However,
because Health Services staff was employed by DOC’s subcontractor, UCONN
Health Center, and not by DOC itself, disciplinary action with respect to nursing
staff was deferred to UCONN. While such deferral may make sense with respect
to employer/employee disciplinary matters, it should not bar DOC from directly
reporting questionable conduct by health care professionals to appropriate
licensing review bodies. In Mr. Perry’s case, reviews of autopsy results, unit logs
and individual medical records revealed apparent errors in medication
administration and documentation, failure to conduct even a rudimentary physical
assessment prior to injecting major tranquilizers, the unexplained presence of
Thorazine at the injection site (a drug that was not ordered by the on-call
physician, and to which Mr. Perry was known to be allergic), and other apparent
irregularities (e.g. claimed follow-up assessments were neither observed by other
staff nor documented in medical records or logs). Acts and omissions such as
these by a licensed health professional may justify disciplinary actions not only
by employers, but by responsible licensing agencies mandated to protect the
public from practitioners who do not meet professional standards.
These
reviews only occur, however, if suspected deviations from professional standards
are reported.
4. Establish a protocol for ensuring that advocacy services are made
available to inmates with mental illness.
According to the recent Report of the Governor’s Blue Ribbon Commission on
Mental Health, rates of “serious mental disorder” among the United States jail
and prison population are considerably higher than in the general population.
The report cites various studies conducted over the past decade which indicate
that approximately one-tenth of all inmates in U.S. jail and prison have serious
psychiatric disabilities. The correctional system was not designed to provide
mental health services and treatment to individuals with significant mental illness.
As a result, inmates with serious psychiatric disabilities are often at greater risk of
experiencing abuse, neglect and other forms of harm within correctional facilities.
They also tend to have higher rates of recidivism, perhaps due to difficulties
securing post-release supports. These facts all argue for increased availability of
advocates for inmates with psychiatric disabilities.
OPA has received an increasing number of telephone calls from inmates with
mental illness, as well as mental health providers, regarding care and treatment
within various correctional facilities.
In addition, DOC’s new policy on

Psychoactive Medication provides a mechanism for inmates to contest decisions
to administer non-emergency medication. That mechanism allows inmates to be
represented at hearings by patient advocates. The provision of advocacy
services to inmates with psychiatric disabilities (whether or not they are being
considered for involuntary administration of psychoactive drugs) could help
protect them from abuse and neglect, safeguard their rights, and facilitate
appropriate treatment and coordination of services and support upon their
release from incarceration.