I

,

NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death
of Arthur Shawcross, an'inmate
at the Sullivan CF

TO:

Honorable Brian Fischer
Commissioner
NYS Department of Correctional
Services
State Campus, Building #2
Albany, New York 12226

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

FINAL REPORT OF ARTHUR SHAWCROSS

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 Arthur Shawcross
who died on November 10, 2008 while an inmate in the
custody of the NYS Department of Correctional Services at
the Sullivan Correctional Facility, the Commission has
determined that the following final report be issued.
FINDINGS:
1.

Arthur Shawcross was a 63 year old white male who died on
11/10/08 at 9:50 p.m. from a pulmonary thrombo-embolism due to
a large impacted thrombus in the deep iliac vein while in the
custody of the NYS Department of Correctional Services (DOCS)
at the Sullivan Correctional Facility.
He received grossly
negligent, incompetent and inadequate medical evaluation and
treatment which was a contributory factory in his death.

2.

3.

On 2/1/91, Shawcross was transferred to DOCS Wende Reception
from the Jefferson County Correctional Facility. On 2/11/91,
Shawcross was transferred from Wende Reception to Elmira
Reception.

4.

On 3/22/91, Shawcross was transferred to the Sullivan CF where
he remained until his demise.

FINAL REPORT OF ARTHUR SHAWCROSS
5.

6.

7.

8.

9.

PAGE 3

I,

FINAL REPORT OF ARTHUR SHAWCROSS

PAGE 4

Shawcross was placed in cell AS 132.
10.

On 11/7/08 at 8:22 p.m. while in his AS 132 cell, Shawcross
complained to Officer D.W. that his leg was painful and he
could not walk to the medical unit "to receive his medications.
Shawcross reported to the officer that he was overdue for his
4:30 p.m. medication,
The general population inmates' insulin administration takes
place in the Sullivan CF health services unit. Officer D.W.
stated he called the medical unit and spoke to RN K.D.
Officer D.W. stated and documented in the security log that he
requested an inmate to come down to the medical unit to obtain
a wheelchair for Shawcross to receive his medications as the
inmate said he couldn't walk.
Officer D.W. stated he also
reported to RN K. D. that Shawcross had leg pain. According to
the DOCS security log, Officer D.W. documented and stated that
RN K.D. had told him that Shawcross could walk and didn't
require a wheelchair.
Additionally, Officer D.W. stated RN
K.D. said Shawcross did not have a wheelchair permit and if
she sent a wheelchair for Shawcross, he would have to be
admitted to the infirmary. Officer D.W. told Shawcross what
the nurse had told him.
Shawcross said if he couldn't use a
wheelchair to receive his medication, then he wouldn't be
receiving his medication as he couldn't walk.
Per security
log, Sgt. M., who was supervising the AS housing unit, was
notified.
Sgt. M. stated after the Catholic services he
observed Shawcross returning to his housing block and he was
assisted in ambulation by two inmates.
Sgt. M. stated
Shawcross stopped to talk to him and asked the sergeant for
assistance in obtaining his medications as he stated his leg
was painful and he could not walk on it.
Sgt. M. stated he
told Shawcross he would have an officer call the medical unit
for a wheelchair transport.
Upon returning to Shawcross'
housing unit, he asked Officer D.W. if medical was notified.
The officer responded in the affirmative but reported that the
nurse refused to permit Shawcross use of a wheelchair. Sgt.
M. stated he instructed the officer to document the incident
in the security log.

FINAL REPORT OF ARTHUR SHAWCROSS
11.

PAGE 5

On 11/7/08 at 8:30 p.m., RN K.D., who stated she was working
in the medical unit from 2:00 p.m. to 10:00 p.m. that day,
received a telephone call from the AS housing officer (Officer
D.W.). The officer asked if an inmate could come down to the
medical unit to obtain a wheelchair for Shawcross to be
~ e d to the medical unit
. . . . . . . . . . as the inmate said he couldn't walk. In interview,
RN K.D.
stated that she would not allow Shawcross a
wheelchair, as "Shawcross was walking in the morning and he
did not have a wheelchair permit." RN K.D. stated Shawcross
did not declare a "code blue" which is an emergency sick call.
RN K.D. stated she did not g9 to the housing unit to assess
the situation herself as the nurses do not go to the inmate
housin units unless a "code blue" is formall
called.

In the course of the investigation, it was verified
that the Sullivan CF has inmate helpers, usually two inmates
per housing block who have been specifically trained to be
wheelchair transporters.
Addi tionally, the facility nurse
administrator stated she also keeps a list of trained. inmates
available to call u on if needed.

Per Sullivan Correctional Facility policy #5008 dated 5/18/05
entitled Sick Call Procedures for Population, (IV,8) which
states:
"Emergency
Sick
Call-Whenever
inmate
or/and
facility employee has reason to believe that a
medical/dental
condition
has
risen
that
is
life/limb threatening,
and warrants
immediate
attention, they are to arrange notification of the
Health Unit and advise the RN on duty of the
inmate's name, DIN number, exact condition, current
situation, and are to receive instructions as how
to proceed to the Health Unit. Employee on duty is
to provide, to the extent·of his/her knowledge and
abilities, sufficient emergency treatment as to
sustain life and limb until inmate can be either
transported to Health Care Unit or appropriate
medical personnel arrive on scene."
This is a violation of
Correctional Facility policy #5017 dated 10/17/08

FINAL REPORT OF ARTHUR SHAWCROSS

PAGE 6

Distribution of Medication to Inmate Population (C,7) which
states:
"Any inmate refusing to .take . one to one
medication will fill out a refusal form and
have the same properly witnessed.
Should an
inmate refuse to complete the form,
the
medication nurse and correction officer will
so note the observation that the inmate has
refused to accept the medication.
A copy of
this form will be placed in the inmate's
health care ambulatory record."
12.

On 11/9/08 at 7:35 a.m" Officer L. documented in the security
log book that he made a telephone call to the medical unit
reporting Shawcross had told him that he could not walk to
receive his medications. RN C.C. called the officer back and
instructed the officer to find an inmate to obtain a
wheelchair to bring Shawcross to the medical unit for his
medications.

13.

infirmary nurse's
responsibility to provide nursing care to the admitted inmate
and to call the physician on call, if needed.
14.

FINAL REPORT OF ARTHUR SHAWCROSS

Services #7.1,
states:

PAGE 7

This is a violation of DOCS Division of Health
(B) dated 9/3/03 entitled Infirmary Care which

"Inmates will be admitted to an infirmary only upon
the order of a primary care provider (i.e.,
physician,
physician
assistant
or
nurse
practitioner). The Nurse Administrator or designee
may admit upon obtaining the specific approval of
the primary care provider on-call."
15.

All registered nurses interviewed for this investigation
stated that they could admit inmates into the infirmary for
twenty-four hours for nursing observation without notifying or
having a physician order. However, in DOCS Health Policy 7.1,
entitled Infirmary Care, dated 9/3/03, there is no difference
cited between a' twenty-four hour infirmary admission and a
regular infirmary admission.

16.

On 11/9/08 at 3:00 p.m., RN B.B. came on duty at 3:00 p.m. as
the evening infirmary nurse.

17.

FINAL REPORT OF ARTHUR SHAWCROSS

PAGE 8

18.
This is a violation of DOCS Health Services Policy
entitled Infirmary Health Record (3,a) which states:
"Following are the minimum nursing documentation
time frames: New Admission: once per shift for a
period of 48 hours."
Additionally stated in DOCS Health Services Policy $4. 2A dated
7/17/91 entitled Infirmary Short Form Health Record (D):
"Health provider's Progress Notes-Notations are
made according to progress (positive or negative)
as required."
19.

Shawcross
was not evaluated by a medical provider in a timely manner.
This is a violation of DOCS Division of Health Services
#7.1(c) entitled Infirmary Care which states:
"Within 24 hours of admission, all inmates will be
evaluated by a primary care provider and written
treatment and nursing care plans will be developed
and implemented."
20.

FINAL REPORT OF ARTHUR SHAWCROSS

PAGE 9

PA G.S. stated that she thought an ambulance would have been
called
She was unaware
that he didn't go to AMC by ambulance, and that a wheelchair
van was being located for transport instead. According to the
documentation, there was a nearly four hour wait for the
wheelchair-accessible van to become available from another
correctional facility in the hub which precipitated an
untimely transfer.
There was a lack of communication
regarding how Shawcross was to be transported.
21.

On 11/10/08, Officers B . M., M. P., and J. H. transported
Shawcross by a wheelchair accessible state van to AMC arriving
at 8:40
.m.

RECOMMENDATIONS:
TO THE NYS DEPARTMENT OF CORRECTIONAL SERVICES, DIVISION OF
HEALTH SERVICES:
1.

The Division shall provide in-service education colloquium to
the professional nursing staff at the Sullivan Correctional
Facili ty regarding the assessment and treatment of common
post-operative complications.

2.

The
Division
shall provide
an educational
in-service
colloquium to the professional nursing staff at the Sullivan
Correctional Facility for the purpose of complying with the
DOCS Division of Health Services #7.1, dated 9/3/03, entitled
Infirmary Care, and the infirmary admission process.

3.

The Division shall provide written educational guidelines to
its professional medical staff regarding the timely and
appropriate
medical
transfer
of
inmates,
specifically
ambulance versus wheelchair-accessible van for the purpose of
facilitating timely medical emergency transfers.

FINAL REPORT OF ARTHUR SHAWCROSS

PAGE 10

4.

The Division shall reinforce compliance with Sullivan
Correctional Facility Health Services with DOCS Health Service
Policies $4.2 entitled Infirmary Health Record and #4. 2A
entitled Health Record Services Infirmary Short Form Health
Record regarding documentation guidelines for both 24 hour
admissions and regular infirmary admissions.

5.

The Division shall reinforce compliance with procedures for
accurate physician orders transcription by the professional
nursing staff at the Sullivan Correctional Facility.

6.

The Division shall take administrative action against RN K.D.
who on 11/7/08 did' not assess Shawcross and prevented his
transport to the facilit infirmar, an inmate at the Sullivan
Correctional Facilit ,
Additionally, the RN
did not comply with Sullivan Correctional Facility policy
#5008 Sick Call Procedures for Population by failing to
provide direction to a correction officer and policy #5017
entitled Distribution of Medication to Inmate Population by
failing to obtain a Refusal of Treatment/Care from Shawcross.
administrative action
examine and assess a

7.

TO THE NYS
DISCIPLINE:

EDUCATION

DEPARTMENT,

OFFICE

OF

RN M.L.

PROFESSIONAL

1.

That the Office of Professional Discipline investigate RN K.D.
for gross negligence and gross incompetence, specifically, for
failure to respond to, evaluate and arrange for medical
intervention

2.

That the Office of Professional Discipline investigate RN M.L.
for gross negligence and gross incompetence, specifically for
failure to adequately examine and/or refer to a physician a
patient

'PAGE 11

FINAL REPORT OF ARTHUR SHAWCROSS

WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner,
NYS Commission of Correction, SO Wolf Road, 4 th Floor, in the City
of Albany, New York 12205 this 1S th day of December, 2009.

Harrison-Ross,
Commissioner
PH-R:mj
OS-M-149
S/09
cc:

Superintendent James Walsh, Sullivan CF
Dr. Lester Wright, Chief Medical Officer
Nancy Lyng, Director of Health Services

M.D~