COMMONWEALTH OF MASSACHUSETTS SUFFOLK, SS. DAVID E. PRADO, as duly appointed PERSONAL REPRESENTATIVE of the ESTATE of DEVON PRADO, Plaintiff V. THOMAS M. HODGSON, as SHERIFF of BRISTOL COUNTY, PAUL B. KITCHEN and JOHN R. MITCHELL and JOHN T. SAUNDERS, as COMMISSIONERS of BRISTOL COUNTY, THOMAS TURCO as COMMISSIONER of the MASSACHUSETTS DEPARTMENT of CORRECTIONS, CORRECTIONAL SERVICES, P.C., and JOHN DOE NUMBERS 1?10, Defendants SUPERIOR COURT (3 Civil Action No. It} COMPLAINT JURY TRIAL DEMANDED INEEQQHQELQN 1. This is an action brought by the Personal Representative of the estate of his deceased daughter, seeking compensation under the Massachusetts Wrongful Death Act, Massachusetts Tort Claims Act, and other statutes, for the death, conscious pain and suffering prior to that death, and other injuries and damages suffered as the result of the death of DEVON PRADO, which occurred while she was an inmate in the custody of the Bristol County House of Correction and Jail, where she died, because of the negligent and/or deliberately indifferent treatment which she received, and the defendants? negligent supervision of Bristol County House of Correction and Jail employees. PARTIES 2. The Plaintiff, DAVID E. PRADO, is an individual residing at 7 Braemore Road, Taunton, Bristol County, Commonwealth of Massachusetts, is the father of the late DEVON PRADO and was duly appointed Personal Representative of the Estate of DEVON PRADO by Order of the Massachusetts Probate and Family Court, Bristol County, Field, J., in the matter of the Estate of Devon Prado, Docket Number BR14P2307EA, on August 28, 2017. 3. The defendant, THOMAS M. HODGSON, is the duly elected SHERIFF of BRISTOL COUNTY having a principal place of business at the Bristol County Sheriff?s Office at 400 Faunce Corner Road, Dartmouth, Bristol County, Commonwealth of Massachusetts, and is sued in his official capacity. 4. The defendants, PAUL B. KITCHEN and JOHN R. MITCHELL and JOHN T. SAUNDERS (collectively COUNTY are the duly elected COMMISSIONERS of BRISTOL COUNTY, having a principal place of business at the Bristol County Commissioners? Office, at 9 Court Street, Room 48, Taunton, Bristol County, Commonwealth of Massachusetts, and are sued in their official capacities. 5. The defendant, THOMAS TURCO, is the duly appointed COMMISSIONER of the MASSACHUSETTS DEPARTMENT of CORRECTIONS having a principal place of business at Central Headquarters, 50 Maple Street, Suite 3, Milford, Worcester County, Commonwealth of Massachusetts, and is sued in his official capacity. 6. The defendant, CORRECTIONAL SERVICES, P.C. is a professional corporation duly organized pursuant to the laws of the Commonwealth of Massachusetts, which has a principal place of business at 35 Braintree Hill Office Park, Suite 301, Braintree, Norfolk County, Commonwealth of Massachusetts. 7. The defendants, JOHN DOE NUMBERS 1?10, are individuals, currently unknown to the plaintiff, who, at all times material, were employed by defendants SHERIFF, COMMONWEALTH, and/or BRISTOL COUNTY COMMISSIONERS, at the Bristol County House of Correction and Jail having principal places of business at the JAIL, at 400 Faunce Corner Road, Dartmouth, Bristol County, Commonwealth of Massachusetts, and who are sued in their individual capacities. EACTS COMMON TO ALL COUNTS 8. At all times material, the defendant BRISTOL COUNTY COMMISSIONERS served as the executive officers of the government of Bristol County, Commonwealth of Massachusetts, exercising all lawful authority, functions, and activities for all purposes, in accordance with the Constitution and laws of the Commonwealth of Massachusetts. 9. Among their lawful authority, functions and activities, the BRISTOL COUNTY COMMISSIONERS traditionally served collectively as executive officer of the BCSO, and exercised lawful authority over the Office, in accordance with the Constitution and laws of the Commonwealth of Massachusetts. 10. At all times material, jails and houses of correction were county correctional institutions, operated and managed by the duly elected sheriff of each respective county, in accordance with the Constitution and laws of the Commonwealth of Massachusetts. 11. At all times material, the operation and management of the JAIL was among the lawful responsibilities and duties of the defendant SHERIFF. 12. Although serving the needs of Bristol County, which continued, at all times material, to exist as a functioning government, pursuant to G.L. c. 348, ?1 and St. 2009, c. 61, the operation and management of the JAIL, along with the other functions, duties, and responsibilities, were transferred to the COMMONWEALTH by St. 2009, c. 61, ?3 and 13. Pursuant to St. 2009, c, 61, ?l3(a) and employees of the BCSO were transferred to the COMMONWEALTH with the SHERIFF, although the SHERIFF continues to act as ?employer? of the employees of the BCSO, retaining the authority to hire, fire, promote, and discipline them, and to organize the operation of the Office. 14. At all times material, the defendant COMMONWEALTH exercised various statutory obligations with respect to county correctional institutions, which included, inter alia, establishing minimum standards for the care and custody of all persons committed to county correctional facilities, inspecting county correctional facilities at least once every six months to determine compliance with minimum standards, and enforcing compliance with standards in accordance with Massachusetts law. 15. Among the obligations imposed upon all of the defendants with respect to county correctional institutions was the obligation to provide for the safety and security of pre- trial detainees and inmates in conformity with constitutional and statutory requirements. 16. To ensure compliance with legal and constitutional standards, Department of Corrections Regulations governing county correctional facilities, at all times material, required the delivery of mental health services by a duly licensed Massachusetts physician; required mental health practitioners to consult with the sheriff/correctional facility administrator before an inmate was housed and before an inmate was subjected to disciplinary measures, and required periodic and medical examinations and treatment under the supervision of the Massachusetts Department of Mental Health for all inmates confined in isolation units. 17. To ensure compliance with legal and constitutional standards, DOC Regulations governing county correctional facilities, at all times material, prohibited the use of ?Awaiting Action Status,? to justify segregated confinement, except ?when necessary to ensure the safety of the inmate, staff or other inmates, or the security of the correctional facility.? 18. To ensure compliance with legal and constitutional standards, DOC Regulations governing county correctional facilities, at all times material, required that cell checks be conducted on an irregular schedule. 19. At all times material, contracts for the provision of services to county correCtional facilities, in existence at the time St. 2009, c. 61 took effect, continued in effect until expired, terminated, or revoked in accordance with the contract terms. 20. At all times material, defendants CPS and SHERIFF had contracted to have CPS provide mental health services to inmates and detainees of the JAIL. 21. At all times material, suffered debilitating mental health problems, which first manifested when she was seven years old. 22. diagnoses included bipolar disorder, attention deficit hyperactivity disorder, and anxiety disorder, compounded by a history of sexual abuse. 23. As early as 2005, when she was only 18 years old, DEVON sought, and continued receiving until a few months before her death, adult continuing care services from the Commonwealth?s Department of Mental Health, and Social Security Disability benefits, relating, inter alia, a history of severe depression, anxiety, and suicidal ideation, for which she had received emergency care at Morton Hospital. 24. DEVON had been prescribed several mental health related medications, and remained subject to extreme mood swings notwithstanding them. 25. DEVON became drug addicted, a victim of Massachusetts?s opioid crisis, and turned to street drugs to satisfy her addictive cravings, heroin and cocaine becoming her drugs of Choice. 26. DEVON was in and out of detoxification and mental health programs from July 2012 until her death, receiving mental health treatment and detoxification services in hospitals, partial hospitalization programs, through outpatient services, and at home, including from High Point Treatment Center, Westwood Lodge Hospital, Arbour Hospital, Bournewood Hospital, Caritas Carney Hospital, ArbourmFuller Hospital, Women?s Addiction Treatment Center, Shepard House, and the Stepping Stone treatment program in Fall River, from the last of which she was administratively discharged in April 2014 because of heroin relapse. 27. drug use led to flights from home, living on the streets and in homeless shelters, and frequent contact with law enforcement. 28. From 2005 until her death, DEVON accumulated a number of criminal charges of varying levels of gravity, including several drug related charges, many of which were accompanied by arrest and/or default warrants. 29. DEVON was never convicted of any of the criminal charges, however. 30. As a result of the various criminal charges, DEVON was held in various jails and houses of correction by the SHERIFF in September 2005, February 2014, May 2014, and September 2014. 31. On February 4, 2014, DEVON was jailed at the JAIL as a pre?trial detainee, pending criminal proceedings. 32. In accordance with JAIL procedures, on February 4, 2014, DEVON was medically evaluated for housing purposes. 33. However, mental health condition was not evaluated before she was released from the JAIL on February 8, 2014. 34. On the night of September 5, 2014, Taunton Police arrested DEVON a short distance away from the site of a possible break in at the Taunton Antique Center in Taunton, Bristol County, Commonwealth of Massachusetts. 35. When DEVON exited the police cruiser at the station on her way to booking, Taunton Police found a bag with pills on the seat where she had been, and questioned her about the pills. 36. DEVON identified the pills as prescribed Percocet, but during booking, DEVON surrendered a bag allegedly containing heroin and a baggy allegedly containing cocaine. 37. DEVON was charged with six offenses, including trafficking in heroin, and possession with intent to distribute both cocaine and Percocet. 38. From September 5 to September 8, 2014, the defendant SHERIFF jailed DEVON at the Ash Street Jail in New Bedford, Bristol County, Commonwealth of Massachusetts. 39. DEVON was arraigned in the Taunton District Court on September 8, 2014, was ordered held without bail on several of the charges, and was so informed in Court. 40. On September 8, 2014, the defendant SHERIFF sent DEVON to the JAIL. 41. At 21:05 on September 8, 2014, Licensed Practical Nurse Meaghan Black, who was employed by or contracted for defendant CPS pursuant to its contract with the other defendants, conducted a medical evaluation and screening of DEVON at the JAIL. 42. LPN Black recorded in CPS/Correctional Health Care Progress Notes that DEVON reported no current medical complaints and denied taking prescribed medications, but admitted to snorting one gram of heroin weekly. 43. On the same date, LPN Black further recorded the following information in her Medical History and Screening record for DEVON: a. DEVON admitted abusing heroin and cocaine, last using heroin on the preceding day (September 7, 2014). b. IDEVON denied then being in a detoxification program. 0. DEVON stated that she had been treated for ?a illness,? specifically ?Bi?polar [disorder],? and had ?been hospitalized in a unit,? identifying her inpatient stay at High Point in January 2014. d. DEVON acknowledged her history of sexual abuse. 44. From the information DEVON provided to LPN Black, defendant CPS knew or should have known of Devon?s mental health illnesses, including, inter alia, bipolar disorder, history of drug abuse and addiction, and did, or could have easily, learned or confirmed that DEVON receiyed DMH services. 45. Based upon her analysis of medical and mental health history, LPN Black concluded and reported that DEVON was 10 to be housed in ?General Population,? and referred DEVON for further mental health review. 46. Notwithstanding the information which DEVON provided to CPS LPN Black, and which LPN Black recorded, the defendants did not transfer the information about mental health and drug addiction histories to her JAIL classification records or booking records, and neither those records nor records concerning the investigation of death identify DEVON as having had any mental health or drug history. 47. Moreover, notwithstanding the information which DEVON provided to CPS LPN Black, and which LPN Black recorded, and LPN Black?s referral for additional mental heath review, as in February 2014, DEVON was not screened concerning her mental health condition before she was removed from the this time on a stretcher, after having been found hanged in her cell. 48. Further, notwithstanding the information which DEVON provided to CPS LPN Black, and which LPN Black recorded, and LPN Black?s conclusion that DEVON should be housed in the general population, the defendants housed DEVON in a segregated unit without even trying to determine whether DEVON had the medical or mental ability to withstand isolation. 49. records indicate that from September 8 through 1605 hours on September 10, 2014, DEVON was placed on ?drug watch? in Female Segregation Cell G4. 11 50. JAIL records indicate that from September 8 through September 10, 2014, DEVON was placed on ?eyeball watch? in Female Segregation Cell G4. 51. Female Segregation Cell G4 was one of eight cells in the female segregation unit. 52. From September 8 through her death on September 12, 2014, DEVON was ?the only inmate living in her cell and no other inmates ha[d] access to her cell,? according to a State Police Investigation Report prepared after death. 53. On September 9, 2014, after her initial booking on September 8, 2014, and CPS LPN Black?s medical evaluation and screening, the defendants made classification recommendations for DEVON. 54. DEVON was classified ?medium security? custody level. 55. According to the defendants? records, at 1605 on September 10, 2014, while she was still in Female Segregation Cell G4, DEVON was alleged to have been found in possession of a ?sheet that had been torn into two pieces,? charged with Offense Code 1~35, ?vandalizing county property,? on a ?Formal Discipline Report? ?use[d] with major offenses only,? and referred for Administrative Segregation. 56. However, at 1525 hours on September 10, 2014, 40 minutes before the time of the alleged disciplinary incident which was used to justify her isolation, DEVON was notified that 12 she was being placed into Administrative Segregation. 57. Moreover, at 1551 on September 10, 2014, still 14 minutes before the ?time of the incident? which purportedly led to her segregation, and after she had been in segregation since September 8, 2014, notwithstanding LPN Black?s assessment that she be placed in the general population, Licensed Practical Nurse Virginia Rego, who was employed by or contracted for defendant CPS pursuant to its contract with the other defendants, conducted an ?initial segregation assessment? on DEVON, purportedly to determine whether DEVON could withstand isolation. 58. LPN Rego did not review LPN Black?s records, made no reference in her own records to the screening performed by LPN Black two days earlier, made no reference to known drug and mental health histories, and simply ?[m]edically cleared? DEVON for isolation. 59. On September 11, 2014, after a Hearing, the defendants? Disciplinary Officer, John Ledo, found DEVON ?not guilty? of the alleged disciplinary infraction. 60. Notwithstanding her acquittal of the disciplinary charges which allegedly led to her segregation, the defendants kept DEVON isolated in Female Segregation Cell G4. 61. Also on September 11, 2014, the defendants completed initial pre?trial intake, confirming that she was ?medium security custody level,? and reporting that DEVON was 13 cooperative. 62. The defendants gave DEVON an indigent kit, allowed her to place a courtesy call to a friend, and permitted her criminal defense attorney, Albert Cullen, to visit her that day, reportedly conveying no news that she had not already received in the Taunton District Court on September 8, 2014. 63. Although nothing in the defendants? records justified it, the defendants kept DEVON in Female Segregation Cell G4. 64. The defendants did not provide a mental health watch for DEVON after September 10, 2014, despite the fact that they kept her in an isolation cell, and despite the fact that the defendants maintained mental health watches of eight other prisoners during the shift on which DEVON died. 65. Cell checks on Female Segregation Cell G4 were performed, or to have been performed, every thirty minutes, on the hour and the halfnhour. 66. JAIL Correction Officer Tammy Sardinha reportedly saw DEVON standing by her isolation cell window at approximately 0534 on September 12, 2014, not long after DEVON requested and received a roll of toilet paper from C0 Sardinha. 67. At approximately 0601, during lockdown, CO Sardinha saw .Devon hanging from an upper bunk in her cell, a bed sheet tied around her neck. 68. CO Sardinha called a ?Code 99," medical emergency, and 14 reportedly banged on the cell door until responders arrived and opened it. 69. Efforts by various corrections officers, nursing staff, and emergency medical technicians failed to revive DEVON, despite their unsuccessful use of cardio?pulmonary resuscitation, chest compressions, intubation, and an AED defibrillator 70. The AED, which was powered on at 06:06:04 and ended at 06:20:03, repeatedly advised against administering therapeutic shocks to DEVON (twice at 06:07:19, twice at 06:09:34, twice at 06:11:50, twice at 06:14:06, and twice at 06:16:22). 71. Dr. William Zane pronounced DEVON dead from.?hanging? at 07:07 a.m. on September 12, 2014, at St. Luke?s Hospital in New Bedford, where DEVON had been transported for treatment. 72. After Devon?s death, the defendants replaced the AED which had been used to analyze and treat DEVON, and informed the sales representative that the RED needed new batteries and pads. 73. During the Massachusetts State Police investigation of death in custody, the defendants informed investigating State Trooper Phillip Giardino that DEVON ?was recently placed in segregation for bringing narcotics (heroin) inside of the although none of the defendants? records provide any evidence to support that statement and Trooper Giardino cited no supporting evidence. 15 74. The defendants failed to provide DEVON with minimally adequate and timely mental health evaluation, care, and treatment, notwithstanding their constitutional and statutory obligations and knowledge of mental health conditions, constituting deliberate indifference to mental health conditions and needs. 75. The defendants failed to provide DEVON with minimally adequate and timely medical and drug addiction evaluation, care, and treatment, and with properly functioning medical equipment, notwithstanding their constitutional and statutory obligations and knowledge of drug addiction and medical needs, constituting deliberate indifference to medical and drug addiction conditions and needs. 76. The defendants failed to provide DEVON with minimally adequate and appropriate institutional housing, notwithstanding their constitutional and statutory obligations, constituting deliberate indifference to housing needs and rights. 77. The defendants failed to meet, and were deliberately indifferent to their constitutional and statutory obligations to conform to standards for the proper care and custody of persons committed to the defendants? custody in the defendantS' county correctional facilities.? 78. The defendants failed to properly hire, train, and supervise their employees and contractors to ensure that their 16 employees and contractors met their constitutional and statutory obligations and conformed to standards for the proper care and custody of persons committed to the defendants? custody in the defendants? county correctional facilities, constituting deliberate indifference to needs and rights. 79. As a direct and proximate result of the defendants? negligence, and statutory and constitutional violations, the plaintiff?s decedent, DEVON PRADO, suffered severe and permanent emotional and physical injuries, which resulted in her conscious pain, suffering and death. COUNT I WRONGFUL DEATH CLAIM AGAINST DEFENDANTS BRISTOL COUNTY COMMISSIONERS, SHERIFF, AND COMMONWEALTH 80. The plaintiff adopts, repeats, realleges and incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein. 81. The defendants, BRISTOL COUNTY COMMISSIONERS, SHERIFF, and COMMONWEALTH, respectively, are the public employers of defendants, JOHN DOE NUMBERS l?lO, all of whom.were employed as corrections officers, administrators, supervisors, and/or other staff of the respective defendants at the JAIL at all times material, and all of whom are ?public employees,? within the definition of G.L. c. I 82. The defendants, BRISTOL COUNTY COMMISSIONERS, SHERIFF, and COMMONWEALTH, respectively, as "public employer? of their 17 respective public employees, are liable for any injuries caused by the negligent acts or omissions of any of their respective public employees while said employees act within the scope of their office or employment, pursuant to G.L. c. 258, 83. The defendants, BRISTOL COUNTY COMMISSIONERS, SHERIFF, and COMMONWEALTH, are liable to the plaintiff for the negligence of their respective public employees in their care and custody of DEVON at the JAIL, including, without limitation, in the following manners: a. The defendants negligently failed to recognize DEVON as a potential suicide risk, given her history of mental illness and drug addiction; b. The defendants negligently failed to provide proper mental health evaluation, care and treatment to c. The defendants negligently failed to properly record the medical and mental health information obtained from DEVON by CPS LPN Black; d. The defendants negligently failed to take into account the medical and mental health information obtained from DEVON by CPS LPN Black and to factor that information and LPN Black?s recommendations and referrals into the defendant?s housing, segregation, and evaluation, care, and treatment decisions concerning 18 e. The defendants negligently housed DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit, without adequately determining whether she would be able to withstand such isolation; f. The defendants negligently housed DEVON, a mentally ill and drug addicted preutrial detainee, in an isolated segregation unit, despite the well known and well recognized danger of housing such inmates in isolation and segregation units; g. The defendants negligently housed DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit, without conducting an immediate intake screening to determine whether she was a suicide risk prior to her housing assignment, including conducting an inquiry regarding her mental health treatments and hospitalizations; h. The defendants negligently housed DEVON, a mentally ill and drug addicted premtrial detainee, in an isolated segregation unit, without having mental health staff prepare a written assessment of her suicide risk before assigning DEVON to a segregation unit; i. The defendants negligently housed DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit; 19 j. The defendants negligently housed DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit that was not suicide resistant; k. The defendants negligently housed DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit that did not contain suicide resistant bunks; l. The defendants negligently housed DEVON, a mentally ill and drug addicted premtrial detainee, in an isolated segregation unit without providing close supervision at intervals no greater than 15 minutes; m. The defendants negligently conducted cell checks on a regular, predictable schedule, rather than on an irregular schedule; n. The defendants negligently failed to purchase, inspect, maintain, and operate properly functioning life? saving emergency medical equipment, including, without limitation, an AED defibrillator; o. The defendants negligently failed to enact and implement procedures to enhance communication between and among corrections staff and medical and mental health personnel; p. The defendants negligently failed to train their staffs in suicide prevention, including, without limitation, 20 identifying suicidal inmates despite their denial of the risk, potential predisposing factors to suicide, high?risk suicide periods, and warning signs and of suicide; q. The defendants negligently failed to supervise their staffs in suicide prevention, including, without limitation, identifying suicidal inmates despite their denial of the risk, potential predisposing factors to suicide, high?risk suicide periods, and warning signs and of suicide; and r. The defendants negligently failed to hire, train, supervise, and discipline their staff to ensure that staff complied with their constitutional and statutory obligations to provide proper care and custody to pre?trial detainees in county correctional facilities. 84. As a direct and proximate result of the defendants' negligence, DEVON, and the plaintiff, suffered the damages aforesaid. 85. On Monday, September 12, 2016, in compliance with G.L. c. 258, the plaintiff made timely written demand for relief upon each of the defendants, a copy of which is hereto annexed. 86. None of the defendants timely responded to the plaintiff?s written demand for relief, thus constituting a denial of said demand by each defendant. 87. The plaintiff has complied with all of the conditions 21 precedent for commencement of this action. 88. The plaintiff pursues this Count for the wrongful death of DEVON PRADO, pursuant to G.L. c. 229, COUNT II CONSCIOUS PAIN AND SUFFERING CLAIM AGAINST DEFENDANTS BRISTOL COUNTY COMMISSIONERS, SHERIFF, AND COMMONWEALTH 89. The plaintiff adopts, repeats, realleges and incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein. 90. The plaintiff pursues this Count for the conscious pain and suffering before her death of DEVON PRADO, pursuant to G.L. c. 229, COUNT WRONGFUL DEATH CLAIM AGAINST DEFENDANT CPS 91. The plaintiff adopts, repeats, realleges and incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein. 92. By virtue of its contract to provide mental health services to the inmates and pre?trial detainees incarcerated in the JAIL, the defendant, CPS, owed a duty of care to properly and adequately provide such mental health services to those inmates and pre-trial detainees, including, without limitation, DEVON. 93.? At all timeS'material, the defendant, CPS Was the employer and/or principal of Licensed Practical Nurses Black and Rego. 94. The defendant, CPS, is liable to the plaintiff for its 22 negligence, and the negligence of its employees and agents, in their care and custody of DEVON at the JAIL, including, without limitation, in the following manners: a. The defendant negligently failed to recognize DEVON as a potential suicide risk, given her reported history of mental illness and drug addiction; b. The defendant negligently failed to provide timely, proper mental health evaluation, care and treatment to c. The defendant negligently failed to properly record and convey the medical and mental health information obtained from DEVON by CPS LPN Black; d. The defendant, including, without limitation, CPS LPN Rego, negligently failed to take into account the medical and mental health information obtained from DEVON by CPS LPN Black and to factor that information and LPN Black?s recommendations and referrals into the defendant?s housing, segregation, and evaluation, care, and treatment decisions and recommendations concerning e. The defendant negligently authorized the housing of DEVON, a mentally ill and drug addicted pre?trial .detainee, in an isolated segregation unit, without adequately determining whether she would be able to withstand such isolation; 23 f. The defendant negligently authorized the housing of DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit, despite the well known and well recognized danger of housing such inmates in isolation and segregation units; g. The defendant negligently authorized the housing of DEVON, a mentally ill and drug addicted pre?trial detainee, in an isolated segregation unit, without conducting a proper intake screening to determine whether she was a suicide risk prior to her housing assignment, including conducting an inquiry regarding her mental health treatments and hospitalizations, and factoring into its analysis the information obtained by its employee/agent, CPS LPN Black; h. The defendant negligently failed to enact and implement procedures to enhance communication between and among corrections staff and medical and mental health personnel; i. The defendant negligently failed to train its staff in suicide prevention, including, without limitation, identifying suicidal inmates despite their denial of the lrisk, potential predisposing factors to suicide, high?risk suicide periods, and warning signs and of suicide; j. The defendant negligently failed to supervise its 24 staff in suicide prevention, including, without limitation, identifying suicidal inmates despite their denial of the risk, potential predisposing factors to suicide, high-risk suicide periods, and warning signs and of suicide; and k. The defendant negligently failed to hire, train, supervise, and discipline its staff to ensure that staff complied with their obligations to provide proper evaluation and care to pre?trial detainees at the JAIL. 95. As a direct and proximate result of the defendant?s negligence, DEVON, and the plaintiff, suffered the damages aforesaid. 96. On Monday, September 12, 2016, in compliance with G.L. c. 258, the plaintiff made timely written demand for relief upon the defendant, a copy of which is hereto annexed. 97. The defendant did not timely respond to the plaintiff?s written demand for relief, thus constituting a denial of said demand. 98. The plaintiff has complied with all of the conditions precedent for commencement of this action. 99. The plaintiff pursues this Count for the wrongful death of DEVON PRADO, pursuant to G.L. a. 229, COUNT IV CONSCIOUS PAIN AND SUFFERING CLAIM AGAINST DEFENDANT CPS 100. The plaintiff adopts, repeats, realleges and 25 incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein.. 101. The plaintiff pursues this Count for the conscious pain and suffering before her death of DEVON PRADO, pursuant to G.L. c. 229, -COUNT VIOLATION OF FEDERAL CIVIL RIGHTS BY DEFENDANTS JOHN DOE NUMBERS 1?10 102. The plaintiff adopts, repeats, realleges and incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein. 103. At all times relevant, DEVON had the rights afforded to her by the Fourth and Eighth Amendments to the United States Constitution, applied to the Commonwealth of Massachusetts through the Fourteenth Amendment of the United States Constitution, inter alia, not to be deprived of her life or liberty without due process of law; not to be subjected to cruel and unusual punishment; and not to be unreasonably denied necessary medical and mental health evaluation, care and treatment. 104. Defendants John Doe Numbers 1*10 violated rights, as aforesaid. l05. As a direct and proximate result of the defendants? violations of civil rights, DEVON suffered the damages aforesaid, for which the plaintiff may recover pursuant to 42 26 U.S.C. ?l983 and ?l988. COUNT VI VIOLATION OF FEDERAL CIVIL RIGHTS BY DEFENDANTS BRISTOL COUNTY COMMISSIONERS, SHERIFF, AND COMMONWEALTH 106. The plaintiff adopts, repeats, realleges and incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein. 107. The defendants, BRISTOL COUNTY COMMISSIONERS, SHERIFF, and COMMONWEALTH, were responsible for supervising their respective employees, staff and contractors at the JAIL. 108. The defendants, BRISTOL COUNTY COMMISSIONERS, SHERIFF, and COMMONWEALTH, developed and maintained policies or customs exhibiting deliberate indifference to the constitutional rights of pre?trial detainees and inmates of the JAIL, which caused the violations of rights. 109. It was the policy and/or custom of these defendants to inadequately train, supervise, and discipline their respective employees, staff, and contractors at the JAIL, thereby encouraging violations of the constitution and laws, as aforesaid, and failing to discourage such constitutional violations. 110. The aforementioned policies and/or customs of these defendants to inadequately train, supervise, and discipline their respective employees, staff, and contractors at the JAIL demonstrated deliberate indifference on the part of these 27 defendants to the constitutional rights of pre?trial detainees and inmates of the JAIL, and were the cause of the violations of rights alleged herein. 111. As a direct and proximate result of the defendants? violations of civil rights, DEVON suffered the damages aforesaid, for which the plaintiff may recover pursuant to 42 U.S.C. ?1983 and ?1988. COUNT VII BREACH OF CONTRACT BY DEFENDANT PARTY BENEFICIARY LIABILITY 112. The plaintiff adopts, repeats, realleges and incorporates by reference the allegations set forth in the preceding paragraphs as though they were fully set forth herein. 113. As a pre-trial detainee of the JAIL, DEVON was an intended third party beneficiary of the contract for the provision of mental health services at the JAIL between defendants CPS, SHERIFF, BRISTOL COUNTY COMMISSIONERS and/0r COMMONWEALTH. 114. The defendant CPS breached its contract with the defendants by failing to provide proper and timely mental health evaluations, care and treatment to pre?trial detainees at the JAIL and by failing to make proper recommendations to the defendants concerning housing and other services required by pre? trial detainees at the JAIL. 115. As a direct and proximate result of defendant 28 breach of contract, DEVON suffered the damages aforesaid. 116. The plaintiff brings this claim against defendant CPS to collect damages for breach of the contract between defendants CPS, and SHERIFF, BRISTOL COUNTY COMMISSIONERS and/or COMMONWEALTH as a third party beneficiary of that contract. RELIEF SOUGHT WHEREFORE, the plaintiff respectfully demands judgment against the defendants, jointly and severally, in an amount to be determined by a jury to serve as compensatory damages, plus a multiple of that amount or as otherwise permitted by statute and common law to serve as punitive and/or as multiple damages in addition to the compensatory damages, plus costs, interest and reasonable attorney?s fees as allowed by law, plus such other and further relief as this Court deems equitable and just. JURY TRIAL DEMAND THE PLAINTIFF RESPECTFULLY DEMANDS A TRIAL BY JURY ON ALL COUNTS OF HIS COMPLAINT. Respectfully Submitted, The Plaintiff, By his Attorney, MM MARK F. ZKOWI (BBO #248130)? 175 eral eet Suite 1425 Boston, MA 02110?2287 (617) 695m1848 MFItzkowitz@hotmail.com September 10, 2017 29 ark I tzkowitz Attorney at Law I 75 Federal Street Telephone: 61 7-695-?1848 Suite 1425 Facsimile: 61 7-426- 7972 Boston, Massachusetts 02110-2287 . Also Admitted In New York Email: cam 2% - September 11, 2016 (5 .M we. 1/ 53,1. babe" EMAIL DELIVERY 9: Honorable Commissioner Paul B. Kitchen Honorable Commissioner Thomas Turco V157 Honorable Commissioner John R. Mitchell Department of Corrections Q: Honorable Commissioner John T. Saunders Central Headquarters at. Bristol County Commissioners? Of?ce 50 Maple Street 9 Court Street, Room 48 Suite 3 Taunton, MA 02780 Milford, MA 01757 Honorable Sheriff Thomas M. Hodgson Honorable Attorney General Maura Healey - Bristol County Sheriff?s Of?ce Of?ce of the Attorney General . 400 Faunce Comer Road One Ashburton Place 015 Dartmouth, MA 02747 Boston, MA 02108?1518 5d) 1 "9 Honorable Secretary Daniel Bennett Jorge R. Veliz, M.D. i A: it?? Executive Of?ce of Public Safety Security Correctional Services, P.C. One Ashburton Place, Suite 2133 35 Braintree Hill Of?ce Park, Suite 301' Boston, MA 02108 Braintree, MA 02184 Re: Da vfd?'ado a Maria Hado, Representatives oftlze Estate of De van CYaim Pursuant to Massachusetts General La ws 0. 258 Honorable Commissioners, Sheriff, Attorney General, Secretary, and Dr. Veliz: I represent David Prado and Maria Prado, of 7 Braemore Road, Tamiton, Massachusett, Representatives of the Estate of their daughter, Devon Prado, and JoAnne V. Davidson, Esquire, of 5 Lafayette Road, Salisbury, Massachusetts, Guardian adsz?em of Devon Prado?s daughter, Kinley Prado (hereafter referred to jointly as ?the Estate?), in claims arising from the wrongful death of Devon Prado, While she was in the custody of the Bristol County House of Corrections in Dartmouth on September 12, 2014. The clairns arise from the negligent misconduct, comp'ensable pursuant to G.L. c. 258, and civil rights violations caused by the misconduct and negligence of administrators, staff, corrections of?cers, contractors, and other personnel who were responsible for the care and custody of Devon Prado during her incarceration. This demand is sent to you in a good faith effort to resolve the Estate?s claims without the need for protracted litigation. By making demand in this fashion at this time, the Estate does not waive any claims, theories of liability, or 701% 71/27 Q/n/aO/e @Q7s/a7?e/ (been; 09M mam {144/19 Page 1 of 9 evidence not expressly set forth herein. STATEMENT OF THE FACTS Devon Prado was a victim of Massachusetts? opioid crisis before she entered the Dartmouth House of Corrections and while she was there. She also suffered debilitating mental health problems, which ?rst manifested when she was seven years old. Her diagnoses included bipolar disorder, attention de?cit hyperactivity disorder, and anxiety disorder. She had a history of sexual abuse. As early as 2005, when she was only 18 years old, she sought adult continuing care services from the Department of Mental Health and Social Security Disability bene?ts, relating, Inter alia, a history of severe depression, anxiety, and suicidal ideation, for which she had received emergency care at Morton Hospital. She received DMH services until a few months before her death. Devon had been prescribed several tnental health related medicatiOns, and remained subj ?ct to extreme mood swings notwithstanding them. She became drug addicted, heroin and cocaine becoming her drugs of choice. Devon was in and out of detoxi?cation and mental health programs from July 2012 until her death. During that time, she received mental health treatment and detoxi?cation services in hospitals, partial hospitalization programs, through outpatient services, and at home, including from High Point Treatment Center, Westwood Lodge Hospital, Arbour Hospital, Bournewood Hospital, Caritas Carney Hospital, Arbour?Fuller Hospital, Women?s Addiction Treatment Center, Shepard House, and the Stepping Stone treatment program in Fall River, from the last of which she was administratively discharged in April 2014 because of heroin relapse. Her drug use led to ?ights from home, living on the streets and in homeless shelters, and frequent contact with law enforcement. From 2005 until her death, Devon accumulated a number of criminal charges of varying levels of gravity, from disorderly conduct to receiving stolen preperty to larceny to malicious destruction of property to breaking and entering in the nighttime to drug possession to drug distribution to traf?cking in heroin, and many motor vehicle license related infractions. Many of the charges were accompanied by arrest and/or default warrants. She was held in various jails and houses of correction by the Bristol County Sheriff?s Of?ce in September 2005, February 2014, May 2014, and September 2014. However, she was never convicted. On February 4, 2014, pending criminal proceedings, Devon was jailed at the Bristol County Jail and House of Corrections. On February 4, 2014, she was medically evaluated for housing purposes. However, her mental health condition was not evaluated before she was released on February 8, 2014. . On the night of-September 5, 2014, Taunton Police responded to reports of a possible break in at the Taunton Antique Center. Witnesses provided a description of the suspect. Devon Prado was arrested a short distance away, matching the description provided by witnesses. She was arrested for an outstanding warrant, and driven back to the scene. Witnesses identi?ed her as the person who broke into the store. She was arrested and taken to the station for booking. When she exited the police cruiser, Taunton Police found a bag with pills on the seat where she had been. Page 2 of 9 Devon identi?ed the pills as prescribed Percocet. During booking, Devon surrendered a bag containing heroin and a baggy containing cocaine. Police located several cases containing jewelry in the pocketbook she was carrying. Devon was charged with six offenses, including traf?cking in heroin and possession with intent to distribute both cocaine and Percocet. From September 5 to September 8, 2014, Devon was jailed at the Ash Street Jail in New Bedford. She was arraigned in the Taunton District Court on September 8, 2014, and sent to the Bristol County House of Corrections in Dartmouth. She was held without bail on several of the charges, and was so informed in Court. At 21 :05 on September 8, 2014, Licensed Practical Nurse Meaghan Black of Correctional Services, which provided contract health care services for the Bristol County Sheriff?s Of?ce, conducted a medical evaluation and screening of Devon Prado. See CPS/Correctional Health Care Progress Notes (09?08?14, 21 She reported no current medical complaints. LPN Black recorded that Devon denied taking prescribed medications, but admitted to snorting one gram of heroin weekly. She recorded ?States to have na [sic] MH hx of Bipolar. No complaints at this time.? Nurse Black?s note is speci?c enough to indicate that she knew or should have known of Devon?s mental health history of bipolar disorder, whether Devon admitted it or not. Additional detail was provided in Nurse Black?s Medical History and Screening record for Devon Prado of the same date. In that record, Nurse Black recorded Devon as admitting abusing heroin and cocaine, last using heroin on the preceding day (September 7, 2014). She denied then being in detoxi?cation. Devon stated that she had been treated for ?a illness,? speci?cally ?Bi- polar [disorder],? and had ?been hospitalized in a unit,? identifying her inpatient stay at High Point in January 2014. She did not acknowledge having received DMH services, a matter which the BCSO could have determined. Devon. also acknowledged her history of sexual abuse to Nurse Black. The Medical History and Screening record concluded with a notation that Devon was to be housed in ?General Population.? CPS/Correctional Health Care?s Patient-History of Entry Lines note of September 8, 2014 indicates that Nurse Black referred Devon for further mental health review on September 8, 2014, because of at least one of her responses to Nurse Black?s questions. However, as in February 2014, Devon was not screened for her mental. health condition before she left the jail; this time on a stretcher, after having been found hanged in her cell. Notwithstanding Nurse Black?s screening, BCSO classi?cation records, booking records, and records concerning the investigation of Devon?s death do not identify Devon Prado as having any mental health or drug history. The ?Mental Health Concerns? box on page 2 of the BCSO Initial Classi?cation Review orm was not marked or checked. ?No? was the entry next to ?Drug/Alcohol Dependence? in the BCSO Book Memo. ?No? was the entry next to ?Drug Addict? and ?Drug Intoxicated?.in the Massachusetts State Police ACISS Homicide/Death Report (No. 2014?1 04-5 5 7), prepared on September 12, 2014 by Trooper Phillip Giardino after he reviewed BCSO records. After her initial booking on September 8, 2014, classi?cation recommendations were made for Devon Prado on September 9, 2014. She was considered ?medium security? custody level. At Page 3 of 9 that time, BCSO records indicate that she was on ?eyeball watch,? and reportedly remained so on September 10. BCSO Initial Classi?cation Review Form Page 2. A BCSO Formal Discipline Report, prepared on September 10, 2014 by Kayla Botelho, and reviewed that day at 2110 hours by Watch Commander John Laws, indicated that Devon had been on ?drug watch? until 1605 on September 10, 2014. From September 10, 2014 until she was removed from the Dartmouth House of Corrections by emergency medical technicians on September 12, 2014, Devon Prado?s conditions of incarceration, at best, were of questionable propriety, and the reports concerning her con?nement were of questionable veracity. BCSO Formal Discipline Report (?for use with major offenses only?) Number 09-128?14 indicates that at 1605 on September 10, 2014, while she was in Female Segregation Cell G4, Devon Prado was found to have been in possession of a ?sheet that had been torn into two pieces.? She was charged with Offense Code 1?35, ?vandalizing county property.? However, 40 minutes before the time of this incident, at 1525 hours, Devon was noti?ed that she was being placed into Administrative Segregation. At 1551 on September 10, 2014, still 14 minutes before the ?time of the inciden which purportedly led to her segregation, and after she had been in segregation since September 8, 2014, notwithstanding Nurse Black?s assessment that she be placed in the general pepulation, Correctional Services Licensed Practical Nurse Virginia Rego conducted an ?initial segregation assessmen on Devon Prado. Nurse Rego?s notes make no reference to the screening performed by Nurse Black two days earlier. They make no reference to Devon?s drug or alcohol history. Rather, Nurse Rego simply ?[m]edica11y cleared? Devon for isolation. Apparently, BCSO had already been housing Devon in a segregated unit since September 8, without even trying to determine whether she had the medical or mental ability to withstand isolation. On September 11, 2014, after a Hearing, Disciplinary Of?cer John Ledo found Devon ?not guilty? of the alleged disciplinary infraction. Notwithstanding her acquittal of the charges which led to her segregation, Devon Prado remained in cell G4 in the female segregation unit. BCSO Initial Classi?cation Review Form Page 2 indicates that Devon? 5 initial pre?tiial intake was completed on September 112014. Again, she was reported to be of ?medium security custody level.? She was reported to be cooperative. She was given an indigent kit and allowed to place a courtesy call to a friend. Her criminal defense counsel, Albert Cullen, visited her that day, reportedly conveying no news that she had not already received in the Taunton District Court on September 8. Although nothing in the BCSO records justi?es it, Devon Prado remained in female segregation cell G4. The last person to see Devon alive reportedly was Correction Of?cer Tammy Sardinha. According to CO Sardinha, at approximately 0534 on September 12,2014, she last saw Devon standing by her isolation cell window, not long after having requested and received a roll of toilet paper from that CO. At approximately 0601, during lockdown, CO Sardinha saw Devon hanging from an upper bunk in her cell, a bed sheet tied around her neck. CO Sardinha called a ?Code 99,? Page 4 of 9 medical emergency, and reportedly banged on the cell door until responders arrived and Opened it. The Bristol County Sheriff?s Of?ce Daily Shift Report for that night/morning indicates that there were allegedly eight mental health watches of prisoners. One was an ?eyeball? watch of a male prisoner and another of a female prisoner. Two Were ?ve minute watches of male prisoners, and four were 15 minute watches of male prisoners. None were of Devon Prado. CO Melanie Thibault, who had been assigned to eyeball watch, was reassigned to escort the unconscious Devon Prado to St. Luke?s Hospital in the ambulance. Efforts by various corrections of?cers, nursing staff, and emergency medical technicians failed to revive Devon Prado. Cardio?pulmonary resuscitation, chest compressions, intubation, and the use of an AED de?brillator were unsuccessful. The ABD, which was powered on at 06:06:04 and ended at 06:20:03, repeatedly advised against administering shocks to Devon Prado (twice at 06:07: 19, twice at 06:09:34, twice at 06:11:50, twice at 06:14:06, and twice at 06:16:22). After Devon?s death, Correction Of?cer Robert Mates informed the sales representative that the BCSO needed new batteries and pads for the machine. The ABD which was used on Devon Prado was replaced with the AED used for training. Dr. William Zane pronounced Devon Prado dead at 07:07 am. on September 12, 2014. The cause of death was ?hanging.? Massachusetts State Police began a homicide/death investigation that day. Among the evidence they reviewed and collected were photographs of Devon Prado?s cell and corpse, surveillance videos from the segregation unit, written logs from the segregation unit, ABD readings and notes, written statements and interview notes, Devon?s medical history, and notes relating to the criminal charges which were pending against her when she died. Trooper Phillip Giardino investigated Devon Prado?s cell and housing conditions at the Dartmouth House of Corrections. He reported that cell G4 is one of eight cells in the female segregation unit. ?Prado is the only inmate living in her cell and no other inmates have access to her cell.? Cell checks were to have been performed every thirty minutes, on the hour and the half?hour. Reportedly, CO Sardinha found Devon hanging during the 0600 rounds, and found her alive, awake, speaking, and during the 0530 rounds. Trooper Giardino reported that ?Prado was recently placed in segregation for bringing narcotics (heroin) inside of the jail. There is no suspected criminal No evidence was cited in support of those statements. No BCSO records provide any evidence to support them. LIABILITY The Massachusetts Tort Claims Act, G.L. c. 258, provides that: ?Public employers shall be liable for personal injury or death caused by the negligent or wrongful act or omission of any public employee while acting within the scope of his of?ce or employment, in the same manner and to the same extent as a private individual under like At the time of Devon Prado?s incarceration and death in 2014, operation and management of the Bristol County House of Corrections in Dartmouth were among the functions, duties, and Page 5 of 9 responsibilities of the Bristol County Sheriff. St. 2009, c. 61, Although serving the needs of Bristol County, which continues to exist as a functioning government, G.L. c. 34B, St. 2009, c. 61, the operation and management of the jail, along with the Bristol other ?mctions, duties, and responsibilities, were transferred to the Commonwealth by St. 2009, c. 61, ?3 and Employees of the Bristol County Sheriff?s Of?ce were transferred to the Commonwealth with the Sheriff. St. 2009, c. 61, ?13(a) and The Sheriff continues to act as ?employer? of the employees of his of?ce, retaining authority to hire, ?re, promote, and discipline them, and to organize the operation of the Sheriff?s Of?ce. St. 2009, c. 61, ?16. The Tort Claims Act requires that written notice of a claim he presented ?to the executive of?cer of [the] public employer within two years after the date upon which the cause of action G.L. c. 258, ?Public employer? is de?ned to include ?the commonwealth and any county,? among other government units. G.L. c. 258, ?1 (?Public employer?). The ?[e]xecutive of?cer of a public employer? is de?ned as ?the secretary of an executive of?ce of the commonwealth, or in the case of an agency not within the executive of?ce, the attorney general,? and ?the country commissioners of a county,? among others. Id. (?Executive of?cer of a public employer?). Courts have held that the county commissioners constituted the ?executive of?cer? of the Bristol County Sheriff?s Of?ce before the adoption of St. 2009, c. 61, Baptiste V. Shen?of Bristol County, 35 Mass. App. Ct. 119, 127 (1993), and that the executive of?cer of sheriff?s of?ces of ?abolished counties? is the sheriff himself. Garcia V. Essex County Sheriffs Deparnnenzf, 65 Mass. App. Ct. 104, 108 (2005). The purpose of the notice requirement, inter alfa, is to ?ensure that the designated individual has the opportunity to protect the public employer?s interests by investigating the circumstances of a claim and instituting measures to prevent similar claims in the future.? Bellantt V. Boston Public Health 70 Mass. App. Ct. 401, 408 (2007). Devon Prado?s Estate is particularly invested in ensuring that the appropriate authorities undertake the ?loss prevention? function of the statute, id, 70 Mass. App. Ct. at 409, so that no other inmates die in circumstances similar to Devon?s, although others already have. For that reason, the Estate tenders presentment to all of the of?cials who were, are, or may have been involved in the operation of the Dartmouth House of Corrections, including contractors who are not?required to receive notice IDevon Prado was found hanging, and died, on September 12, 2014. That is when "the cause of action arose." Bellanzi V. Boston PubJJ'c Health Commission, 70 Mass. App. Ct. 401, 404 n.5 (2007). Presentment must be made by September 11, 2016, which is a Sunday. Several statutes provide, and cases con?rm, that when "the last day for the performance of any act authorized or required by statute falls on Sunday the act may, unless it is speci?cally authorized or required to be performed on Sunday .. be performed on the next succeeding business day." G.L. c. 4, sec. 9 (general provision, quoted); G.L. c. 34, sec. 16 (same provision speci?c to counties, and including acts required to be performed on Saturdays when county of?ce is closed on Saturday, as is Bristol - County's); Maboney V. Dematz?eo?Flan'ron, 66 Mass. App. Ct. 903 action ?led timely on Monday when limitations period ended preceding Saturday); Miller V. City of Boston, 25 Mass. App. Ct. 997 (198 8)(rescript) (defective road notice timely served on Monday when due preceding Saturday and city of?ces were closed Saturday). The Tort Claims Act, G.L. c. 25 8, sec. 4, does not speci?cally require notice to be provided on Sundays. The deadline for serving notice, therefore, is Monday, September 12, 2016. Page 6 of 9 under the Tort Claims Act. G.L. c. 258, ?1 (?Public employer?) (?but not a private contractor with any such public employer?). See Souza V. Shen'??ofBJisto] County, 455 Mass. 573, 580?82 (2010) (explaining respective responsibilities of counties and Commonwealth with resPect to jails and prisons, and overlapping responsibilities of Commissioner of Correction with respect to both). The circumstances of Devon Prado?s death demonstrate the negligence of of?cials, of?cers, and employees of the Bristol County House of Correction in Dartmouth, and, more broadly, of the of?cials, of?cers, and employees of the state, county, and local of?ces that were responsible for securing the welfare of incarcerated inm?es. Devon Prado should have been an obvious suicide risk to the persons who investigated her mental and medical histories and who incarcerated her. She had a long?standing history of debilitating mental health conditions, compounded by drug addiction, which she acknowledged, and which should have been obvious to her jailers. She was being held in pre-trial custody for serious drug offenses. She admitted her heroin and cocaine abuse to the nurse who conducted her medical screening, acknowledging that she was not in ?detox? and that she had used heroin the day before the screen. Despite her forthrightness, and Nurse Black?s recording of her conditions, BCSO records failed to note those conditions on her intake and booking forms, and those conditions did not play a role in her housing within the jail. Devon Prado should not have been housed in an isolation/segregation unit. The dangers of housing inmates suffering mental health and drug conditions in isolation/segregation have been noted in many studies and publications over many years. Lindsay M. Hayes, Project Director of the National Center on Institutions and Alternatives, conducted two such studies for the Commonwealth in 2007 and 2011, following a rash of imnate suicides in 2006: ecJInica] Assistance Report on Suicide Pre ven tion Practices Within the Massachusetts Department of Correction (January 2007), and Follow?Up Report on Suicide Prevention Practices Imam the Massachusetts Department of Correction (February 18, 2011). Among the Hayes Reports? recommendations which were not followed in Devon Prado?s case are: Immediate intake screening for suicide risk prior to housing assignment, including inquiry regarding mental health treatments?iOSpitalizations; - Written assessments for suicide risk by mental health staff prior to assignment to a special housing unit; - Avoiding housing isolation; House in suicide resistant cells; Use suicide resistant bunks in cells; - Close observation at intervals not to exceed 15 minutes; - Staff training in suicide prevention, including in particular, identifying suicidal Page 7 of 9 inmates despite denial of the risk, potential predisposing factors to suicide, high-risk suicide periods, and warning signs and and - Procedures to enhance communication between and among corrections staff and medical and mental health personnel. Department of Corrections Regulations governing county correctional facilities, 103 CMR ??900.0l, 900.08, 901.01, required the delivery of mental health services by a duly licensed Massachusetts physician. 103 CMR ?932.01( 1), Mental health practitioners were required to consult with the Sheriff/facility administrator before an inmate was housed and before an inmate was subjected to disciplinary measures. 103 CMR ??932. (0). So clearly dangerous is the housing of mentally impaired inmates in isolated units that the General Court required periodic and medical examinations and treatment under the supervision of the Department of Mental Health for all inmates so con?ned. G.L. c. 127, ?39. Devon was never provided mental health screening, let alone mental health care. Over two separate incarcerations, February and September 2014, the Bristol County Sheriff?s Of?ce failed to performed a mental health screening of Devon Prado. No consultations or even mental health evaluations were ever conducted before she was housed in a segregated/isolation unit in September 2014. Regulations prohibited the use of ?Awaiting Action Status,? the classi?cation used to house Devon Prado in segregation on September 10, 2014, except ?when necessary to ensure the safety of the inmate, staff or other inmates, or the security of the correctional facility.? 103 CMR ?902.01 (?Awaiting Action Status?), ?943.03. Possessing a torn bed sheet did not justify such con?nement. Moreover, when Devon was found not guilty of the alleged disciplinary in?ection, she should have been released into the general population, as the medical screen suggested. Alternatively, had the jail suspected that Devon tore the bed sheet to use as a ligature, a suspicion not documented in any record and a charge of which she was found not guilty, she should have been placed on suicide precautions immediately, and monitored far more frequently than occurred. Cell checks should not have been conducted on the hour and half-hour, as noted in the State Police report. Regulations required that checks be ?on an irregular schedule.? 103 CMR As suggested by the Hayes Reports, DOC Regulations required more frequent checks of mentally disordered inmates, like Devon Prado, and should have been conducted. 103 CMR Similar legal requirements existed for inmates con?ned in state correctional facilities. See 103 CMR Staff, including medical staff, should have inspected to be certain that required medical . equipment was operating properly. The AED de?brillator which was used to? revive Devon Prado apparently was not. Failure to inspect and maintain life?saving medical equipment constitutes negligence. The State Police report concluded that Devon Prado committed suicide, and that no one had access to her in cell G4. Should the facts later reveal that someone else did gain access to Devon Page 8 of 9 Prado and either kill her or create circumstances that led to her suicide, the failure to secure her cell from intrusion by other persons, whether or not fellow inmates, would constitute negligence by the jail staff The Department of Corrections,'the Executive Of?Ce of Public Safety and Security, the Bristol County Sheriff, the Bristol County Commissioners, and Correctional Services, P.C. failed to ensure that the Dartmouth House of Corrections staff was obeying the law and meeting their legal duties. Failures to comply with legal obligations, including the hiring, training, disciplining, and retention of staff, all of which are implicated in the instant action, constitute negligence, and are compensable under the Tort Claims Act. DAMAGES The defendants? negligence proximately resulted in the wrongful death of Devon Prado. Devon left a young daughter, Kinley (born August 10, 2013), and her parents. Their losses exceed the maximum amount which the Estate may recover under the Tort Claims Act: One Hundred Thousand Dollars. Of course, the Estate may recover more for the defendants? violations of Devon?s civil and constitutional rights. A?ga V. Holyokq 398 Mass. 343, 352 11.10 (1986). DEMAND The Estate?s tort claims are limited by the Massachusetts Tort Claims Act to a maximum value of One Hundred Thousand ($100,000) Dollars. G.L. c. 25 8, 2. Its civil rights claims are not so limited. The Estate intends to pursue them. Its civil rights claims are not covered by this demand. In an effort to resolve the Estate of Devon Prado?s tort claims without litigation at the present time, demand is hereby made for payment by each of the identi?ed government defendants of the amount of One Hundred Thousand Dollars. We are willing to discuss resolving all of the Estate?s claims against all of the defendants, as well. Please direct your response to this demand to my attention at the above address within the time permitted by the Massachusetts Tort Claims Act. Do not contact the Prado?s or Attorney Davidson directly. Thank you for your consideration of this matter. Very truly yours, MFlzel cc: Mr. David Prado/Ms. Maria Prado JoAnne V. Davidson, Esquire Page 9 of 9