NEW YORK STATE COMM:ISSION OF CORRECTION

In the Matter of the Death
of Brian Tetrault, an inmate of
the Schenectady CJ

TO:

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

Sheriff Harry Buffardi
Schenectady County Sheriff's Office
320 Veeder Avenue
Schenectady, New York 12307

FtNAL REPORT OF BRIAN TETRAULT

PAGE 2

GREETINGS:
WHEREAS, the Medical Review Board has reported to the NYS
Commission of Correction pursuant to Correction Law, section
47(1) (d), regarding the death of Brian Tetrault who died on
November 20, 2001 while an inmate in the custody of the
Schenectady County Jail, the Commission has determined that
the following final report be issued.

FINDINGS:
1.

Brian Tetrault died from iatrogenic (physician-induced)
neuroleptic malignant syndrome with bilateral pulmonary
embolism as a complication of inadequately treated Parkinson's
Disease while incarcerated at the Schenectady County Jail. On
11/20/01 at 2: 55 p.m., Mr. Tetrault expired at Ellis Hospital.
At the Schenectady County Jail, he was under the care of
Prison Health Services, Inc., a business corporation which
holds itself out as a medical care provider.
He received
grossly inadequate medical and mental health care which caused
his death, specifically the abrupt withdrawal of medications
prescribed for Mr. Tetrault prior to admission to jail and the
abrupt and sustained diminishment of his carbidopa/levodopa
dosage which precipitated fatal
neuroleptic malignant
syndrome.
Mr. Tetrault's death was preventable had he
received adequate medical and mental health care.

2.

Brian Tetrault was born 12/17/56. He was estranged from his
family.
He was allegedly divorced and had one adolescent
child.

3.

Tetrault was arrested on 11/10/01 and remanded to the
Schenectady County Jail.
His instant offense was Burglary
2nd, Petit Larceny and Harassment. He had two prior arrests,
one on 2/28/01 for Criminal Contempt and on 8/25/01 for
Aggravated Harassment 2nd.

4.

Tetrault was diagnosed with Parkinson's Disease fifteen years
ago and had been under the care of the Albany Medical College
Parkinson's Disease & Movement Disorders Center (AMCH).
He
had a Deep Brain Stimulator (DBS) implanted at Columbia
University Hospital in New York City. He subsequently had the

FINAL REPORT OF BRIAN TETRAULT

PAGE 3

DBS removed secondary to an infection. A DBS was re-implanted
in June 2001.
5.

Upon arrival at the Schenectady County Jail, Tetrault came
under the care of Prison Health Services, Inc. (PHS, Inc.).
On 11/10/01, a registered nurse completed his admission
assessment and noted the following medication regimen:
carbidopa/levodopa 25/100 32 tabs daily on a q2h schedule,
Klonapin 1mg po TID or QID, Zoloft 100 mg po qAM, Comtan 200
mg po QID, Paraton Forte 250 mg tid - QID, Seroquel 25 mg ~
tab q2h (using 4-5 tabs/day) and Ambien 10 mg qhs.
He was
able to ambulate to the clinic area. His demeanor was quiet
and cooperative.
The facility medical director, W. Duke
DuFresne, Me, was contacted for medication orders.
Dr.
DuFresne did not see Tetrault on 11/10/01 and ordered only the
patient's carbidopa/levodopa from among the six medications he
was taking as documented by the Albany Medical Center Hospital
clinic.
No physical exam was conducted, a violation of
§7010.2(b) (1) which states, "Each prisoner shall be examined
by a physician licensed to practice in the State of New York
or by medical personnel legally authorized to perform such
examination at the time of admission or as soon thereafter as
possible, (emphasis added) but no later than 14 days after
admission."

6.

On 11/11/01, Tetrault was seen by the facility medical
director, Dr. DuFresne. Again, no physical examination was
conducted, a second violation of section 7010.2(b) (1).
However, Dr. DuFresne altered Tetrault's medication regime.
He ordered Sinemet, Comtan and Zantax.
Later that morning,
the facility medical director discontinued Comtan and adjusted
the dosage of Sinemet downward.
Zantax was continued.
The
facility medical director's medication orders were a marked
departure from the regimen maintained for Tetrault by the
Parkinson's Disease and Movement Disorders Clinic of Albany
Medical College, which had been treating Tetrault there prior
to his incarceration. Tetrault's last visit to the clinic had
been on 10/26/01, only two weeks prior to admission to jail.
Tetrault's medications were not ordered by Dr. DuFresne or
administered as per the recommendations of AMCH where he was
being treated for his Parkinson's Disease.
The facility
medical director did not examine Tetraul t prior to wi thdrawing
his medications.
There was no consultation with the
Parkinson's Disease and Movement Disorders Clinic which was
managing Tetrault's illness. Klonopin, Zoloft, Seroquel, and

FINAL REPORT OF BRIAN TETRAULT

PAGE 4

pain and sleep medications were abruptly withdrawn without a
credible
rationale.
Dr.
DuFresne's
order
for
carbidopa/levodopa resulted in under medication of Mr.
Tetrault throughout his incarceration, his having been
prescribed less than the 32 pills per day he was required to
take at two (2) hour intervals.
Dr. DuFresne reduced this
regimen, claiming that Mr. Tetrault did not take a 4 a.m.
dose.
The PBS, Inc. nursing staff transcribed even the
reduced order incorrectly so that the most medication Mr.
Tetrault ever received was eight doses, on occasion only 2-4
doses of carbidopa/levodopa daily, at best two-thirds of what
was ordered, at worst 25% of what was ordered.
Such abrupt
reduction and withdrawal was medically reckless, was directly
implicated in the neuroleptic malignant syndrome and
immobilization that caused Mr.
Tetrault's death,
and
represents flagrantly inadequate medical care by PBS, Inc. and
its employees. It should be noted that none of the abruptly
withdrawn medications
were
found
in
the
PBS,
Inc.
pharmaceutical formulary for Schenectady County Jail. When
questioned as to his rationale for abruptly withdrawing all of
the medications except carbidopa/levodopa, Dr. DuFresne
claimed that Tetrault had told him he was not taking Comtan
and that he declined to prescribe any of the other medications
because they were psychiatric medications and should only be
prescribed by a psychiatrist. The Board did not find this a
credible rationale for disruption of this seriously ill
patient' s medication regimen. Moreover, although Tetraul twas
indeed on a psychiatric medication regimen
he was not referred to a
psychiatrist for assessment and appropriate intervention. £

This abrupt cessation represents gross
incompetence by Dr. DuFresne as medical director and
coordinator of Mr. Tetrault's care and by staff of the
Schenectady County Office of Community Services which
contributed to Mr. Tetrault's death.

FINAL REPORT OF BRIAN TETRAULT

PAGE 5

7.

Tetrault's physical condition began to deteriorate on
11/13/01.
Tetrault began having periods of urinary
incontinence
and
changes
in
behavior
(belligerent,
uncooperative, delusional) due to the abrupt cessation of
neuroleptic and anti-depressant therapy.
He exhibited
significant mental status changes beginning 11/15/01.
His
rigidity and spastic movements increased, and he was unable to
pexform ADL's and required assistance with personal hygiene,
both due to a radically reduced carbidopa/levodopa dosage. No
physician was called.

B.

On 11/13/01, the night shift RN was unable to get Mr. Tetrault
to come to the front of his cell for medications. She entered
the cell with an officer to administer medications.
No
physician was called, and in fact Mr. Tetrault was not seen by
Dr. DuFresne or any other physician after 11/11/01.

9.

On the 11/14-15/01 night shift, it was noted that inmate
Tetrault had been incontinent of urine.
His buttocks and
sacral areas were noted to be slightly reddened.
His eyes
were noted to be "blood shot" and red.
Dr. DuFresne, the
medical director, was notified at 11:45 a.m. and returned a
call to the RN on duty at 2: 00 p.m.
The RN stated she
directly informed Dr. DuFresne that Mr. Tetrault's condition
was worsening.
The nurse further stated that Dr. DuFresne,
the facility medical director, directed her to request that
the Inmate Service Coordinator seek the release of Mr.
Tetrault from jail.
The nurse stated that she ~d so. Dr.
,DuFresne, the medical director, took no further acuLon to
intervene with Tetrault on 11/15/01 and did not\1\ s.,ee him
t.hereafter.
Moreover, Dr. DuFresne informed nursing staff
that he would see Tetrault on Friday, 11/16/01, then faile« to
~do so.
Tetrault continued to be incontinent throughout the
night of 11/16/01. It was noted that Tetrault was unable to
.situp for medic;aeion delivery and that his eyes remained red
and "draining tears."
Dur*ng an interview with Commission
investigators, the facility medical director, Dr. DuFresne,
claimed that Mr. Tetrault's decline was a period of "off" time
~ typically exhibited by a patient with Parkinson's Disease.
His rationalEt ""as,' based, he claimed, on Health Services
Administrator Clinton Simmons' nursing note of 11/16/03 in
which Mr. Tetrault allegedly ambulated to the medical clinic.
As Mr. Simmons' note was written following Dr. DuFresne's
discussion with the nursing staff on 11/15/01, in which a
registered nurse told the medical director of Mr. Tetrault's
deteriorating condition (whereupon Dr. DuFresne directed the
nurse to seek Tetrault's release), and prior to his contact

FINAL REPORT OF BRIAN TETRAULT

PAGE 6

with nursing staff on 11/17/01, whereupon he ordered
Tetrault' s admission to the hospital, the facility medical
director's basis for assuming that Tetrault's deterioration
was transitory, having not seen Tetrault (or Simmons' entry in
the medical record) in the interim, was invalid. Moreover,
the visit made by Health Services Administrator Simmons to
Tetrault's housing area is without documented rationale.
Health Services Administrator Simmons
told Commission
investigators that he wanted to "assess" Tetrault, yet no
assessment other than vital signs is recorded.
After some
remarks to the patient to the effect that Tetrault had
ambulated
while
claiming
disability
during
a
prior
incarceration, Mr. Simmons escorted Tetrault on a "walk" to
the clinic. Mr. Tetrault later returned to his housing area
in a wheelchair.
The Board found that this conduct
constituted harassment and physical abuse of a seriously ill,
debilitated inmate.
10.

On 11/16/01, Tetrault's episodes of incontinence continued.
There was no intervention to assess Tetrault's condition.
Tetraul t' s sacral and buttock area was again noted to be
reddened and ecchymotic.
At 10:00 p.m., his respirations were
noted as being "heavy" (no respiratory rate is documented).
Tetrault's heart rate was 82, however, it is unknown if this
was an apical or radial pulse. Lungs were documented as being
"clear. "
As noted above, Tetrault was not seen by Dr.
DuFresne, the medical director, as previously planned on
11/14-15/01. The nursing staff failed to again refer Tetrault
to be seen by a physician. No mental health referral was made
despi te a marked change in mental status.
There was no
nursing plan of care inclusive of interventions to address
impending skin breakdown in this bedridden patient.
Vital
signs were not properly measured.
The medical and mental
health evaluation and treatment afforded Tetrault was
inadequate.

11.

On the 11/16-17 night shift, the RN claimed that Tetrault was
"uncooperative" wi th medication adminis tration, incon tinent of
urine f "resistant" to sitting up, "refused" to swallow and
exhibiting a stage I skin breakdown of his coccyx. The Board
found that based upon the evidence developed in the
investigation, Tetrault's condition had deteriorated to the
point where he was unable to cooperate with medication
administration, could not sit up and could not swallow

FINAL REPORT OF BRIAN TETRAULT

PAGE 7

(dysphagia). The nurse's documentation of this as resistance
and refusal is unprofessional to the point of misconduct.
During the early morning of 11/17/01, Tetrault continued to be
incontinent, his speech was garbled and a skin tear was noted
on his coccyx.
Mr. Tetrault was not transported to Ellis
Hospital until 12: 30 p.m., an unwarranted delay which worsened
his condition.
12.

At 12:30 p.m. on 11/17/01, Tetrault was transported via
ambulance to Ellis Hospital ER.
He was admitted to
Neurological Critical Care (NCCU). His vital signs in the ER
were T-100.4, P-100, R-24, and a BP of 140/90.
His 0 2
saturation was 96-97% on room air.
He was not verbally
responsive .
There was a large 2" open area on his left
buttock. He exhibited conjunctivitis OU and he was severely
dehydrated which, taken together with the decubi tus ulcer, was
indicative of grossly inadequate nursing care by PHS, Inc. at
the jail. An IV was started, a Foley catheter was inserted
and he was given 1 gm of Rocephin. The neurology consul tation
performed at Ellis Hospital for Mr. Tetrault on 11/17/01 after
his admission from the jail documented that Mr. Tetrault had
been under-medicated while in~Jail and the lack of medicatio~
-as well as its abrupt withdrawal was responsible for his
deteriorating condition.

13.

On 11/19/01, the consultant's diagnosis was apparent septic
shock,
sudden
hypotension
and
respiratory
distress.
Tetrault's temp was 102, CK had increased, rigidity noted with
decreased responsiveness. Later in the day, his temperature
elevated to 104, his BP was 60/40 and respirations were
labored.
His oxygen saturation was 86%, he became nonresponsive with bilateral rhonchi.
He was intubated and
placed on vent.
Large amounts of stomach contents were
suctioned from his lungs.
He remained febrile.
he was
transferred to ICU.

14.

On 11/20/01, seizure activity was noted. His hospital course
continued on a steady decline.
He remained febrile with a
temp of 102.2 and 103-104, respectively. There was no corneal
response, limbs were flaccid.
Asystole was noted at 2: 44
p . m., CPR and ACLS measures were taken.
Tetraul twas
pronounced dead at 2:55 p.m.

15.

On 11/20/01 at 6:13 p.m., a "Release of Prisoner" order was
received by fax from the Niskayuna Town Court by the
Schenectady County Sheriff's Department, clearly indicating
that Mr. Tetrault was in the custody of the Schenectady County

FINAL REPORT OF BRIAN TETRAULT

PAGE 8

Sheriff at the time of his death at 2:55 p.m. The record of
the official release of Tetrault from custody filed pursuant
to New York State Correction Law 500-f was altered from
showing a (false) release time of 3:07 p.m. 11/20/01 to 2:45
p.m. on that date (also false), ten (10) minutes before
Tetrault was pronounced dead, in an effort to evade the
mortality reporting requirements set forth in Correction Law
§47 and 9 NYCRR §7022.4.
The Schenectady County Jail
administration failed to report Tetrault's death as required
by law until 5/8/03, twenty and one-half months later when it
was ordered to do so by the Commission.
RECOMMENDATIONS:
TO PRISON HEALTH SERVICES, INC.:
1.

PHS, Inc. should terminate the services of W. Duke DuFresne,
M.D., facility medical director, for malpractice and gross
incompetence, specifically his unwarranted disruption of Mr.
Tetrault's treatment regimen for Parkinson's Disease planned
and implemented by recognized specialist experts,
for
dangerously abrupt withdrawal of psychiatric medications
prescribed as adjunct therapy for his Parkinson's Disease and
radical underdosing of carbidopa/levodopa causing fatal
neuroleptic malignant syndrome, and for failure to attend to
a patient with a life-threatening neurological disease as his
condition deteriorated to a critical medical emergency.

2.

PHS, Inc. should discipline six (6) of the Schenectady County
Jail nurses who encountered and were responsible for caring
for Tetrault from 11/13-17/01 for failure to adequately assess
his deteriorating condition,
failure to provide basic
supportive nursing care which hastened his deterioration and
caused additional medical problems resulting from neglect, and
in one case, harassment of the patient followed by a coerced
or forced walk by the patient an extended distance to the
ambulatory clinic, constituting physical abuse.

3.

PHS, Inc. should establish and maintain a schedule whereby a
physician is present at the facility to see patients a minimum
of four (4) hours daily, three (3) days per week.

4.

PHS I Inc. should comply with the requirements of 9 NYCRR
7010.1(b) for a physical examination of inmates at the time of
admission or as soon thereafter as possible.

FINAL REPORT OF BRIAN TETRAULT

PAGE 9

TO THE SCHENECTADY COUNTY OFFICE OF COMMUNITY SERVICES:
1.

The Director of Community Services should discipline the
Certified Social Worker who evaluated Tetrault for failure to
refer a patient on psychiatric medications for evaluation by
a psychiatrist.

2.

The Director of Community Services should conduct a quality
assurance inquiry into the failure of the mental health staff
to maintain continuity of care for a patient dependent upon
multiple psychiatric medications as an adjunct to control of
the psychiatric manifestations of his advanced Parkinson's
Disease and its therapy.
TO THE SCHENECTADY COUNTY SHERIFF:

1.

The Sheriff should consider terminating the contract with PHS,
Inc. for cause, specifically an inability or refusal to
oversee and require their employees to provide adequate care
to a patient with a life threatening neurological disorder
whose condition had deteriorated to a medical emergency.

2.

The Sheriff shall immediately comply with New York State
Correction Law §47(2) and with 9 NYCRR 7022.4, Reporting
Inmate Deaths, and provide written assurance of same.

3.

The Sheriff should require the presence of a physician at the
Schenectady County Jail at least four hours per day, three
days per week.
TO THE DEPUTY COMMISSIONER,
OFFICE OF THE PROFESSIONS:

NYS DEPARTMENT OF EDUCATION,

That the Office of the Professions investigate the business
practices of PHS, Inc., a business corporation engaged in
unlawful corporate medical practice.
TO THE NYS DEPARTMENT OF HEALTH,
MEDICAL CONDUCT (OPMC):

OFFICE

OF PROFESSIONAL

That the OPMC investigate the professional conduct of W. Duke
DuFresne, M.D. as to his treatment of Brian Tetrault at the
Schenectady County Jail in November 2001.
TO THE NYS
DISCIPLINE:

EDUCATION DEPARTMENT,

OFFICE

OF

PROFESSIONAL

FINAL REPORT OF BRIAN TETRAULT

PAGE 10

That the Office of Professional Discipline investigate the
unprofessional conduct of the Health Services Administrator
during his encounter with Brian Tetrault on 11/16/01 beginning
at 9:55 a.m. The Medical Review Board has reason to believe
that the Health Services Administrator verbally harassed the
patient, directly implied he was malingering, then required
him to walk an extended distance when in fact the patient was
wheelchair-bound, was rapidly deteriorating, and would be
admitted to the hospital in critical condition the following
day.
TO THE OFFICE OF THE DISTRICT ATTORNEY OF SCHENECTADY COUNTY:
That the Office of the District Attorney investigate the
alteration and filing of the official record of admission and
release of Brian Tetrault to and from the Schenectady County
Jail in November 2001 and take such action as is deemed
warranted. In addition, the Office of the District Attorney
should inquire into the circumstances of the patient abuse set
forth herein also referred to the State Office of Professional
Discipline.

WITNESS, HONORABLE FREDERICK C . LAMY, Commissioner, NYS
Commission of Correction, 4 Tower Place, in the City of Albany, New
York 12203 this 23rd day of June, 2004.

~/
Commissioner

FCL:mj
01-M-235
2/04
cc:

Karen Rapoch, RN, CCHP, Prison Health Services,
Region 1
Jack Cadalso, Jr., Director of Community Services,
Schenectady County Office of Community Services
Robert M. Carney, Esq., Schenectady
County District Attorney
Frank Munoz, Office of the Professions,
NYS Education Department