The ombuds for the state Department of Corrections (DOC) have issued a report detailing maddening bureaucracy, staff confusion and unexplained delays in medical care that contributed to the death of an inmate diagnosed with breast cancer at the Monroe Correctional Complex in March 2018.

The report, signed by Ombuds Director Joanna Carns and provided to Corrections in November, said the inmate died in June 2019, “fifteen months after the lump was discovered having never been treated.”

The Department of Corrections, in a 12-page response attached to the report when it was issued publicly Monday, said the “primary provider” for the inmate resigned, and that sweeping policy changes were implemented to address the ombuds’ concerns.  The DOC noted that an internal mortality review also identified “significant process failures” and that other employees involved have been placed on “corrective action plans.”

“Following an internal review of this tragic situation, the Department identified and is implementing significant process changes to address failures identified in the review,” said DOC spokeswoman Janelle Guthrie in a statement Monday. “The Department of Corrections remains committed to operating a safe and humane corrections system, and to continually improving how we care for individuals in state custody.”

The ombuds, an independent public office that investigates citizen and inmate complaints against the DOC, do not identify the inmate or the crime he was serving time for. Their report focuses on the care he should have received, but didn’t, while in the state’s care. The inmate was scheduled for release from prison in December 2020.

The ombuds’ report notes that the office learned of the circumstances surrounding the inmate’s illness after a friend of the dying inmate complained in March 2019. By then, the dying inmate had signed a do-not-resuscitate order and was terminally ill with the cancer, which had spread throughout his body.


The ombuds’ investigation revealed the department acted lackadaisically in the face of the inmate’s health emergency.

The lump was discovered in the man’s breast in March 2018 by a nurse during an unrelated medical appointment. The nurse notified her superiors, but no action was taken and no follow-up scheduled, the ombuds’ report says. The inmate wasn’t seen by another health professional for two months, and then only after he asked to go to a medical clinic. Another month passed before the inmate was seen for the first time by a physician’s assistant, who identified in June an “urgent” need for a mammogram and an ultrasound of the lump. According to the ombuds, “It takes another month for these ‘urgent’ needs to be satisfied.”

Six months after the lump was first discovered, a biopsy was completed in August that showed an invasive carcinoma. That report, from an outside provider, stated that DOC had been notified and that the corrections caretakers would “arrange for surgical and oncological follow-up.” However, it took DOC staff 15 days to sign off that they had received that report, according to the ombuds.

The inmate was not told he had cancer for 13 days after the diagnosis, according to the report.

“The surgical follow-up was never scheduled,” the ombuds found. It took nearly a month for an oncological consultation to be completed. Meantime, the outside consultants recommended an emergency CT scan of the inmate’s chest and abdomen. “This ’emergency’ request was not approved by the Monroe medical director for 10 days and it will be a further 60 days before the procedure is done,” the ombuds wrote.

The investigation found that the DOC failed to follow up on a number of the specialists’ recommendations, including failing to schedule consultations with a surgeon and an oncologist.


“Eight months after the lump was discovered, and almost three months after the oncologist recommends treatment ASAP, no treatment has been done,” the ombuds found. At that point, the inmate signed a do-not-resuscitate order and requested “comfort measures only.”

The ombuds reported that throughout the ordeal, the inmate repeatedly asked for information and sought medical treatment. He filed several grievances and official requests to see a medical provider, only to have them ignored, dismissed or returned to the inmate to be rewritten for bureaucratic reasons, the report says. Even after the diagnosis in August, the inmate complained he could not get any information.

“I do not have long to live,” the inmate wrote in a grievance filed in September. He said the specialist “told me I needed to start chemo aggressively right away or would not live nine months,” he wrote. “That was two months ago. What is taking so long?” The response, according to the ombuds, was for DOC officials to point out that the grievance window was 20 days, and that two months exceeded that time period. The grievance was sent back to be rewritten and resubmitted. It never was, the report says.

The ombuds also found that the Monroe medical staff was confused regarding DOC procedures dealing with urgent medical needs, and that the inmate’s files lacked documentation, including specialist reports and treatment recommendations.

One thing the DOC said it is clarifying in its policies is the need to act within certain time frames in urgent situations, and to require notification of prison medical officials of recommendations made by outside consultants. If the prison doctor chooses not to follow that advice, it must be noted in the patient’s file with an explanation.

Correction: Due to an editing error, an earlier headline for this story referred to the Monroe Correctional Complex as a jail. It is a prison.