Lawsuits claim agonizing, and preventable, death of inmate in Delaware prison
On Feb. 27, 2018, Luis Cabrera wrote to prison medical staff that he was having stomach problems that left him in pain if he didn't take Tums. He wanted to be seen by medical staff.
Months passed. His symptoms didn't improve.
He was shipped from James T. Vaughn Correctional Center, where he once lived inside C Building and witnessed the deadly 2017 prison riot, to Howard R. Young Correctional Institution.
There, he spent his days in solitary confinement.
Less than nine months after he first wrote to medical staff about his stomach pain, he died from a perforated duodenal ulcer in the Wilmington prison's infirmary.
He was never seen by a doctor — all care was performed by a nurse practitioner — nor was he sent to a hospital, according to medical records. More than 2 liters of fecal contents and liquid were found in his abdominal cavity during his autopsy, according to medical records.
Had he been given adequate medical care, the 49-year-old man would have survived, according to a lawsuit filed by his family this week in Delaware courts.
Another lawsuit, filed days later, supports Cabrera's family's allegations that his death was preventable.
In the second suit, a former Connections Community Support Programs employee who directly oversaw Cabrera's care says she was fired for objecting to the "inhumane denial of proper medical treatment to the inmate" and for pushing back against Connections' "subsequent cover-up of the sadistic maltreatment that led to his death."
Both suits give credence to the complaints coming out of Delaware's state prisons about lack of treatment from its contracted health care provider, Connections, already under investigation by the state Department of Justice.
That probe came directly after The News Journal published an investigation into reports that the contractor falsified records to conceal inadequate addiction treatment at Crest South, a taxpayer-funded substance abuse program for drug offenders at a Georgetown facility. The results of that inquiry have not been released.
Both Cabrera's family and former Connections employee Tracy Crews want Connections and some Department of Correction officials held accountable for the death that occurred in their care.
"They had no regard whatsoever for this man's life," said one of the prisons' biggest critics, Dover attorney Stephen Hampton. He is representing the Cabrera family.
"You wouldn't treat a dog like this," he said. "If you treated a dog like this, they'd get you for animal cruelty."
How Cabrera died
Though the lawsuits were filed by separate attorneys for different reasons, together they paint a picture of how Cabrera died and what his final days were like — days spent in agony as an ulcer ate away at his insides and spilled waste into his abdominal cavity.
Both lawsuits zero in on the evening of Nov. 5 when a "Code 4" was called and staff swarmed Cabrera's cell. He was on the floor in a fetal position complaining of "severe abdominal pain."
Medical notes from two nurses show that his stomach was rigid and Cabrera said he was vomiting the day before. A nurse practitioner, Kris Starr, instructed staff to move Cabrera to the infirmary for further observation, according to the lawsuits.
Because he couldn't walk, he was taken by wheelchair, according to the lawsuits.
Throughout the night, Cabrera had screamed and banged inside his cell, according to notes from medical staff cited in the lawsuits. When asked to come to the cell door for an evaluation, he told nurses he was in too much pain and couldn't get up, court filings say.
One nurse, Erlease Freeman, noted in Cabrera's medical files that he did not "appear to be in any acute distress," according to the Cabrera family's lawsuit.
Nurse Practitioner Kathryn Stillman saw Cabrera on Nov. 6. He told her his pain "had been continuous throughout the night," according to the lawsuit by the former Connections' employee. When Stillman tried to touch Cabrera's stomach, he cried out in pain, court papers show.
Hours later, Stillman said she was still performing lab tests on Cabrera but she believed he was "being overly dramatic and faking his illness," according to court documents.
Crews then went and saw Cabrera herself.
He was squatting on the floor, doubled over in pain. Crews helped him to his bed, but the pain continued. He told her he was having "waves of sharp pain, as well as vomiting and diarrhea" since the day before, according to the lawsuit.
An hour later, a urine sample from Cabrera was ordered by Stillman with a straight catheter procedure — the process of inserting a thin tube into a person's urethra and up into their bladder to obtain a urine sample.
Crews offered to do it, but requested some pain medication for Cabrera. According to the lawsuit, he was shivering "due to the obvious pain he was in."
Stillman declined to fill Crews' request for pain medication, claiming she didn't want to "mask" Cabrera's symptoms and noting again that she believed he was faking his pain, court papers show.
Eventually, she agreed to get Cabrera Tums and Zofran, a non-narcotic medication used to treat nausea and vomiting. Crews wasn't able to get the urine sample.
According to the lawsuit, Crews later realized that the decision to catheterize Cabrera "was not based on medical necessity, but rather NP Stillman's vindictiveness."
She called her statewide supervisor, Christine Claudio, and explained that Stillman was refusing to medicate Cabrera. Claudio said Stillman was the "designated health care provider, and it was solely her decision to order pain medication," according to court documents.
Frustrated, Crews called the nurse practitioner to see if she'd consulted with her medical supervisor, Dr. Christopher Moen. Stillman told Crews "she knew what she was doing," according to court documents, and said that Dr. Moen "rolled his eyes" when Stillman talked to him about it.
The back-and-forth continued about Cabrera's care throughout the day. Stillman wouldn't grant pain medication for fear of masking his symptoms, and fought with Crews until Stillman eventually ordered Toradol, a non-narcotic used to treat pain, court papers show.
Crews eventually succeeded in getting a urine sample from Cabrera but found it to be dark brown in color — a signal of a serious medical condition, according to court documents.
When she approached Stillman about giving IV fluids to Cabrera, she was told that he was able to drink on his own, so that shouldn't be necessary, court papers say.
Stillman determined that Cabrera would not be sent to the hospital, according to the lawsuit.
At this point, Cabrera told medical staff the pain medication wasn't working anymore, according to the lawsuit.
An ultrasound of Cabrera's abdomen showed fluid in his stomach, "which could have been 'ascites,' an abnormal buildup of fluid in the abdomen," court papers say. A technician couldn't see his spleen or liver, so based on the inconclusive results, Stillman reiterated that Cabrera was faking it, according to court documents.
Stillman and Mitchell White, a physician assistant, examined Cabrera later that day, where he reported a 10 out of 10 on the pain scale, according to court documents.
A nurse, Cori Greene, noted in Cabrera's medical records that "all hell broke loose" since he arrived at the infirmary and he hadn't been sleeping.
This nurse would be the one to later pen details about finding Cabrera unresponsive.
Early on the morning of Nov. 8, nurse Greene made her rounds to check patient vital signs.
According to a late entry charted in Cabrera's medical record, Cabrera was "observed hunched over with his back to the cell door," according to court documents. He was having a hard time getting to his feet, so Greene moved on to the next cell, court papers say.
About 10 minutes later, an officer called inside the cell to see if Cabrera was alive, according to the notes in the medical file. When the officer got no response, he or she pushed open the door and found Cabrera on the ground unresponsive with no pulse, the medical file said.
The nurse was called and pulled Cabrera from his position on his side to flat on his back, where she began CPR. Cabrera was taken to Wilmington Hospital shortly after, where he was pronounced dead at 4:54 a.m.
At the time of his death, the prison issued a press release noting that foul play was not suspected.
"The documentation in (the former employee's) lawsuit is very supportive of what we put in ours," Hampton said. "I think our case was very strong before and is even stronger now. It baffles me beyond belief why people would think this man is faking it and why this man shouldn't go to the hospital."
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An autopsy revealed his cause of death: a perforated duodenal ulcer that turned the inside of his abdominal cavity a green-yellow color.
Cabrera's family says in its lawsuit that Connections' medical providers were "deliberately indifferent" to his condition and "callously watched him die slowly in excruciating pain from a medical condition that could have been successfully treated with proper medical care."
Fallout after Cabrera's death
The whistleblower, Crews, says in a filing by Wilmington attorney Chris Johnson that she was fired after objecting to Cabrera's treatment and raising further concerns in meetings after his death.
She then said she began to receive retaliatory behavior from her supervisors, according to the lawsuit.
Crews sat through multiple meetings in which she got the impression that all Connections and DOC employees needed to get "the story straight" about what happened to Cabrera, according to the lawsuit. She was told "she could be honest, but cautioned against 'finger pointing.'"
This "Root Cause Meeting" held with Connections employees and administrators in the days after Cabrera's death, "confirmed her (Crews') suspicions that Connections' management actively engaged in a cover-up and had no intention of admitting that any Connections' employee engaged in misconduct attributable to the death of Luis Cabrera," the lawsuit states.
Crews began to feel the effects of Cabrera's death on a physical and psychological level. She sought out treatment at Christiana Hospital on Nov. 27 because she feared she was having a stroke.
The following month, Crews was part of a group of Connections employees who met with prison administrators about Cabrera's death.
During that December meeting, Stillman was questioned about why she didn't send Cabrera to the emergency room, according to court documents. Other inmates had been sent "for symptoms far less serious than those presented by Mr. Cabrera," the lawsuit says.
It was at this meeting that Crews learned nurse Greene had been fired by Connections after failing to enter Cabrera's cell and give him care when she saw him there the morning he died, according to court documents.
In the subsequent weeks, Crews was placed on a "performance improvement plan" and then transferred to Baylor Women's Correctional Institution near New Castle. Staff told Crews the transfer had nothing to do with Cabrera's death, according to the lawsuit, and Crews was directed to use her paid time off until her new start date at the women's facility.
“When Ms. Crews complained about what she believed to be blatant inmate maltreatment, she was silenced and ultimately fired,” said Johnson, partner at the Igwe Firm's Wilmington office, in a written statement. “Ms. Crews was a model employee prior to complaining about Mr. Cabrera’s lack of proper medical care. Our lawsuit is intended to clear her name and to hold Connections accountable for the alleged misconduct as detailed in our complaint."
Crews ultimately lost her job, despite completing an outpatient treatment program at MeadowWood Behavioral Health Hospital where she was diagnosed with major depression and post-traumatic stress disorder stemming from the events around Cabrera's death.
How many other deaths go unchecked?
These lawsuits filed against the Department of Correction staff and Connections point to a larger question within the state prison system — who is holding these organizations and agencies accountable and how does the general public know what's really going on inside?
The DOC rarely says how someone died, other than to note that foul play was not suspected. Occasionally, it is noted that someone died from a long battle with an illness, but suicides and other causes of death typically aren't released.
Take last week, when two Delaware inmates died on the Fourth of July inside the James T. Vaughn Correctional Center.
Joseph Jackson, 55, died at 3:44 a.m. Julius Johnson, 31, died at 10:59 p.m.
Foul play was not suspected in either death, according to the prison, but further details weren't released.
Connections quietly settled a lawsuit against them by Steven Sipple, a man who developed colorectal cancer while in the prison's care but didn't receive treatment.
He died last year before his lawsuit was settled.
"By no means do I feel like (prison) should be the Taj Mahal," the then-48-year-old man said, "but you should be treated like a human being."
Brittany Horn is an investigative reporter digging into Delaware's biggest issues. Got a story that needs telling? Contact her at (302) 324-2771, firstname.lastname@example.org or on Twitter at @brittanyhorn.