The Connecticut Office of Inspector General found that “significant medical errors” were made in relation to two inmates who died of overdoses at the Garner Correctional Institution in Newtown in July 2024 shortly after both men were put on the facility’s methadone program.
The report detailing the findings of the investigation into the deaths of 30-year-old Ronald Johnson and 32-year-old Tyler Cole was released Monday. It was authored by Inspector General Eliot Prescott and his predecessor, Robert Devlin, Jr.
The investigation looked into the in-custody deaths of Johnson and Cole.
Johnson was found unresponsive in his cell on July 19, 2024, just before 2 p.m. He was given medical attention from Department of Correction staff and medics before being pronounced dead at 2:33 p.m., the report said. In his pocket, investigators found an inmate request form on which Johnson had written that he believed that he was having a negative reaction to methadone.
Two days later, Cole was found unresponsive in his cell at 9:16 a.m. He had foam coming from his mouth and was cold to the touch.
Cole was given CPR, and staff used an automated external defibrillator. He was later given Narcan before medics arrived. He was pronounced dead at 10:03 a.m., according to the report.
Illicit drugs are getting into CT prisons. People are dying; families and others want answers.
The investigation found that both men were receiving daily methadone doses after recently beginning in the methadone program at Garner, according to the report.
“Significant medical errors were made in this case,” Prescott and Devlin said in the report. “The investigation suggests that both Johnson and Cole received initial doses of methadone that were too high for them, and their doses were increased too rapidly.”
According to the report, investigators also reportedly found that “insufficient attention” was given to the medications both men were receiving which “enhanced the respiratory suppression effects of methadone.” They each died within the first two weeks of methadone therapy.
Johnson, who was in DOC custody for 56 days before his death, had tested negative for opioids, the report said.
“He met the criteria for an opioid naïve patient,” the report said.
Investigators found that Johnson was receiving the antipsychotic medications Quetiapine and Olanzapine, both of which have sedating effects, according to the report.
Recovery Network of Programs, which administered the methadone program at Garner and another correctional center, had access to his medication records, the report said.
“These factors should have counseled against starting Johnson on a dosage of methadone of 30 mg per day and quickly increasing the dosage to 40 mg per day,” according to the report.
“In Johnson’s case, it is likely that his body could not handle the amount of methadone that he was receiving each day, and it accumulated to a toxic level that (along with the Seroquel and Zyprexa) caused him to stop breathing.”
“His death should have raised immediate red flags in DOC regarding whether other inmates were receiving medically appropriate doses of methadone,” Devlin and Prescott said in the report.
At the time of his death, Johnson was being held on a $100,000 bond on a violation of probation charge, the report said. He was arrested in New York and held at Rikers Island before waiving extradition to Connecticut. He received methadone daily for nine days before his death, the report said.
Cole, who was in DOC custody for 37 days, was being held on a $25,000 bond after being charged with assault. He was given methadone twice in two days before he died, according to the report.
Johnson’s cause of death was found to be “acute intoxication due to the combined effects of methadone, olanzapine, and quetiapine.” The manner was listed as “accidental (took drugs),” the report said.
A toxicology analysis suggested that Johnson may have been a “non-tolerant user of methadone,” according to the report. When he was taken off his bed after being found unresponsive, officials reportedly found a pill that was identified as Vraylar, the report said. He had not been prescribed the medication, according to the report.
Cole was transferred to Garner on June 20, 2024, after reporting a 20-year history of using recreational drugs, according to the report. He told a nurse he used heroin and drank liquor daily, the report said.
Cole was detoxing from alcohol and Xanax and appeared to be experiencing auditory hallucinations, according to the report. When he was prescribed methadone, Cole was prescribed seven different medications, including those for antipsychotic purposes, bipolar disorder and seizures.
At the time he was prescribed methadone, Devlin and Prescott said the report, “he also tested negative for opioids” and “should have been considered an opioid naïve patient.”
“Recovery Network of Program had access to Cole’s medication list,” according to Devlin and Prescott. “All of these risk factors counseled against him receiving a starting methadone dose of 30 mg per day.
“Certainly, his dose should not have been increased to 40 mg after only one day in the program,” Devlin and Prescott continued in the report. ”It is likely that methadone was starting to accumulate in his system; but the methadone’s interaction with the antipsychotic drugs and the Clonazepam depressed his respiration to the point where he could not breathe.”
Johnson’s cause of death was found to be “acute intoxication by the combined effects of methadone, clonazepam, diphenhydramine and olanzapine.” The manner of death was listed as “accidental (ingested medications),” the report said.
“The investigation establishes that the deaths of Ronald Johnson and Tyler Cole were the result of acute intoxication caused by the methadone and other medications that both were taking,” Devlin and Prescott said in the report. “While tragic, it was not criminal.”
According to the report, the DOC held a meeting in January after receiving a draft of the investigative report. The changes the department has made include employing a medical doctor who is an addiction medicine specialist, reviewing methadone induction protocols at all facilities and the suspension of methadone induction at Garner.
“DOC has made the judgment that the antipsychotic medications that many Garner inmates receive pose too high a risk of a negative interaction with methadone,” the report said.
“The leadership of the DOC agrees with the Inspector General’s opinion that this … report should not be read to advocate for the cessation of this beneficial program,” a spokesperson for the DOC said. “The evidence demonstrates that the availability of methadone to incarcerated individuals improves their chances of a successful reentry into their communities when they are released. Such persons tend to stay in treatment, avoid street drugs and are less likely to return to prison than opioid addicted inmates who do not receive methadone.”
The department also indicated it would closely evaluate all medications that an inmate is taking as part of the evaluation for their participation in the medication-assisted treatment (MAT).
The changes that were implemented came after a “comprehensive and thorough review” of the MAT program, a DOC spokesperson said.