Yesterday, I told the gentle reader about the life of Alexander Orlowski, a young man that died while incarcerated at the House of Correction.
But the question now is this: How was Alexander allowed to die? The long answer short is that he was caught in the perfect storm of personal problems, bureaucratic incompetency and political influences.
The Milwaukee Journal Sentinel reported in April 2008 that another inmate, Samuel M. Fitzpatrick, sold some methadone pills to Alexander, who eventually overdosed on these pills. The article goes on to mention that Alexander and Fitzpatrick were both drug addicts, but does little else to give the reader any further in-depth look at why Alexander died.
As I mentioned yesterday, Alexander was a drug addict. To complicate the matter, he also had Attention Deficit Hyperactivity Disorder. This meant that Alexander really never had a chance to fight his addiction unless he had some enforced sobriety and a lot of support.
Due to his addiction and mental illness, Alexander was often in trouble with the law. He was caught a number of times burglarizing houses and businesses to pay for his habit. He has a criminal history that includes burglary, breaking and entering, trespassing, resisting arrest and possession of a controlled substance.
When he was finally sentenced to the House of Correction, his parents report that they actually felt relief. They thought that at least they knew where he was, and that he would be relatively safe, as opposed to be out on the streets somewhere, doing God knows what, to support his habit.
At first, the Orlowskis were correct. Alexander responded well to the forced sobriety. He became more of his old self and would often write or call home. He became more focused on improving his life and earned his GED just weeks before he died. He kept telling his parents that he missed them and couldn't wait to get home. He asked them to delay Christmas until he came home.
Alexander, due to going to school, and then getting a job in the kitchen, was put into a dorm know as Z-2, or Zebra 2. When I worked at the HOC, I worked in that dorm. It was one of the hardest dorms to work in. Most dorms at HOC are large rooms where the correction officer would have an unobstructed view of almost the entire dorm. Z-2 is different than the rest. It is two smaller rooms divided by a hallway. The dayroom is behind the officer, instead of in front of him or her. The shower is off the dayroom and cannot be seen from the desk at all. Even if the officer was constantly patrolling the entire dorm, there would be plenty of opportunity for the inmates to get into all sorts of mischief. On top of it all, at night, when the main lights are off, it is very dim and difficult to see.
When I worked there, all but the most strictly controlled medications were kept in a locked footlocker and the officer was responsible to administer the medications. I believe that since I worked there, the policy was changed and a nurse was supposed to administer the medications, but rarely with the officer there to help supervise to make sure the inmate took the medicine, and didn't palm it or cheek it. Due to the bustle, the poor supervision and the dimness, it would still be easy for an inmate to cache his medication, either for later use, or more commonly, to sell for canteen (chips, soda, candy, etc.)
When the powers that be transferred Fitzpatrick into Z-2, Alexander was doomed. According to what the Orlowskis learned from the investigation, Fitzpatrick was known to deal his medication. As the paper reported, Fitzpatrick somehow was able to get a doctor to prescribe a large dose of Methadone. Methadone is commonly used to treat heroin withdrawal, but has become the drug of choice to replace Oxycontin as a pain reliever. Oxycontin was replaced due to its high demand as a way to get high among inmates.
Fitzpatrick was being given 14 tablets of Methadone, twice a day. It makes me wonder if there was any safety mechanism in place for medication review. While I am not a doctor, that seems like an unusually large amount of Methadone to give anyone, just for pain.
Anyway, it did not take long for Fitzpatrick to declare himself open for business and found a more than willing customer in Alexander. Likewise, it did not take Alexander long to build up a supply for himself. A supply large enough to turn out to be lethal.
On the day that Alexander died, he was supposed to get up for work, but when the officer went to wake him, he sat up, then quickly fell back in his cot and back to sleep. The officer sent an alternative in his place. Later that morning, Alexander was snoring loudly enough to have other inmates complain to the officer, and still nothing was done. Some even expressed concern that something was wrong with Alexander, but it still took hours before the officer called for medical help to come to the dorm.
Without being privy to the actual investigation reports, or talking to those that were there, I am hesitant to state definitively why there was such a long delay in summoning help. The officer might have thought that Alexander was malingering, wanting to take the holiday off from work. Maybe the officer wasn't trained very well. Maybe the officer was just not a good officer. We all work in fields where some people are better at their jobs, and some are worse at them. At that time, due to Scott Walker's budget cuts, officers were being forced to work many hours of overtime, and maybe the officer was just extremely tired and not performing his duties as he should have.
I don't know if we will ever know for sure what else happened that night. Fitzpatrick is scheduled to go to trial in January, and maybe some answers will come out then.
What I do know is that not only did the HOC not give the necessary care and supervision to Alexander was alive, they dropped the ball after his death.
The Orlowskis told me that they were notified of Alexander's death by a detective with the Milwaukee County Sheriff's Office. Then they heard nothing again until the detective came back a few weeks later with Alexander's personal effects. Not once did they hear from Ron Malone, the superintendent of the HOC. Nor did they hear from any of the assistant superintendents or any other staff member of the HOC. Nor did any of these people return their phone calls.
Nor did they hear from Scott Walker, who is Ron Malone's boss.
County Board Supervisor Mark Borkowski, whose district includes the HOC, did talk to me about this case. He told me that he felt terrible about what happened to Alexander, but that "the damage was done and no magic will bring him back." He did add that if this is "how the County deals with grieving parents, he is ashamed to part of it."
The Orlowskis did hear from the inmates. Many of the inmates called and wrote to the Orlowskis. The told them how Alexander was respected among the others, not only for his art talents, but because he was just a likable kid. They told them how they tried to get help for Alexander, but had their efforts rebuffed by the correction officer.
Were the inmate lying to the Orlowski, just to make themselves look better or to assuage their own feelings of guilt? Maybe. Or maybe they felt that Alexander was definitely treated unjustly, and wanted someone to know. Either way, it is not often that inmates will go to that kind of effort for another inmate. That alone tells me that Alexander was one of those people that could reach out and affect people, no matter who they were.
The Orlowskis have filed a claim against the county, stating that "the county was grossly negligent in the hiring, training and supervision of employees at the House of Correction." A claim is the precursor to a lawsuit. Borkowski told me that from what he has learned of this case, he thinks that they have strong grounds and a good chance of winning.
Tomorrow, we will look at the future of the HOC, and what some pending changes could mean.