After weeks of abuse, a Connecticut brother hopes to bring about change in a system that failed his sibling

Al Shehadi hopes his older brother doesn’t die inside the walls of Whiting Forensic Hospital, where he was found to have been abused for at least two dozen consecutive days by staff.

But Shehadi expects that his brother will be there for life.

Last month, Al Shehadi was awarded $9 million from the state from a settlement connected to the abuse his brother endured while in the custody of the hospital. Though the long-fought legal battle is over, Bill Shehadi remains locked inside the place where he was physically hurt and psychologically tortured.

The younger Shehadi’s fight is not over. Whether he can help his brother finally leave the hospital he entered more than 25 years ago or not, he wants to change the system that has kept him there all these years.

His hope is that he can help rescue future iterations of his brother from facing the same fate, a battle that state legislators, a task force of health care professionals and mental health patients, and a heartbroken Connecticut mother are fighting alongside him.

Bill Shehadi was sentenced to 10 years at Whiting, the state’s only public psychiatric hospital, after being found not guilty by reason of insanity in the death of his father in the mid 1990s. He has been recommitted for years, and remains inside the same hospital where he was seen on video being taunted, hit and forced to wear a diaper on his head as he cowered in his bed, afraid of staff charged with caring for him.

That abuse, his brother said he believes, threw the mentally ill man into a vicious cycle of recommitments.

“He was being continually sent back to this horrible environment because he was being abused, and his behavior was hitting back, not hitting first,” Al Shehadi said.

Bill Shehadi’s longer commitments to the hospital have been handed down by the Connecticut Psychiatric Security Review Board, or PSRB, the state’s governing body that determines whether a person would pose a threat if released.

Over the past several years, a task force of psychiatrists, patient advocates, people living with mental illness and care providers, with legislators, have been taking a hard look at what happens inside those walls.

Some of their main findings, in a lengthy and scathing final report released this year, were that the hospital had a “pervasive atmosphere of hopelessness which is compounded by fear and constraints” in place that was dark, dirty, infested with rodents, not close to a healing environment.

Shehadi’s case blew the lid off of what occurred at the hospital — a branch of Connecticut Valley Hospital Overseen by the state Department of Mental Health and Addiction Services — and led to the firings of more than 30 employees and arrests of at least 10 Whiting staff members.

Whiting is often the first, sometimes the last, stop for people who require mental health evaluations after committing violent crimes and is the facility used for people who are found not guilty by reason of insanity. Such a ruling means the court finds that a person committed the crime they’re charged with, but that their mental state prevents them from being criminally liable for what they did. Instead of prison, they go to Whiting.

About factors that deem a patient ineligible for a step-down to a lower security facility or supportive housing, Art Mongillo, public information officer for the state Department of Mental Health and Addiction Services, said staff considers how patients are responding to treatment, whether or not they’re “becoming clinically stable.”

“We want to make sure that their illness is appropriately managed, etc., etc. We can say that over the past few years that the time involved in this process has grown shorter, and it’s something that we’re always sort of working towards by streamlining,” he said.

The process, he said, “measures the patient’s thoughts of suicidality, any aggressive behaviors and identifying and addressing any stressors that caused them to engage in certain behaviors.”

Mongillo did not answer questions specifically about how a patient’s potential risk is reviewed but did say patients are included in the process and are given the opportunity to advocate for themselves. However, some patients choose to remain in the facility.

“There’s a certain comfort for some people in sort of staying in the setting they’re at,” Mongillo said. “Not everybody necessarily would want to leave or step down.

Mary Kate Mason, director of government affairs at DHMAS, said that patients are more protected now by new guidelines that require any instance of abuse to be reported.

“There’s been a lot of improvements. We’ve made some changes in our reporting of abuse and neglect,” Manson said. “Every single report or allegation of abuse and neglect is investigated. Whether or not the allegation seems improbable, it is still investigated. So that also is a change in the past five years.”

In 2021, the eight member CVH task force made recommendations for Behavioral Health Care Definitions, for CVH, the PSRB and Whiting. Taking the patient’s request into consideration, the Whiting Task Force created “Patient Care Programs,” which plan to give patients more opportunities for growth and enable them to participate in social gatherings. Opportunities for growth are educational, employment and vocational training. Civic, educational and religious gatherings are what the task force considers necessary in order for the patients to gain social skills and a connection to the community once they are released.

The task force report described Whiting as a hopeless place for patients and staff.

“There was unanimous agreement that these aspects of the maximum-security facility are, in part, a reason for hopelessness on the part of patients and low morale on the part of staff,” the final report said.

The Task Force conducted a confidential employee climate survey to measure the work environment at CVH and WFH. In the results listed under “Staff Perspectives,” 80% of 417 respondents to the survey answered that staffing shortages were a common issue within their units. The survey also revealed that within the previous six months nearly 90% of workers reported seeing bullying of their peers by their managers and/or supervisors.

State Rep. Jonathan Steinberg, D-Westport, said he sees Whiting more like a prison than a hospital.

“We are effectively incarcerating people with severe mental health issues,” he said.

The problems at Whiting, said Steinberg, who has been championing changes at the hospital, are not easily solved. There is no straightforward shortcut or solution. But the legislature has made some progress.

Steinberg chairs the General Assembly’s Public Health Committee, which introduced Senate Bill 450, an act concerning Connecticut Valley and Whiting Forensic hospitals. The bill, among other measures, reestablishes “Whiting Forensic Hospital’s 11-member advisory board as an oversight board, removes the DMHAS commissioner from the board’s membership and expands the board’s duties,” records show.

It was signed into law by Gov. Ned Lamont in May and includes a proposed $3 million remodel of the hospital. It also requires the board to make recommendations “to the hospital and DMHAS on necessary actions to improve staff work, hospital conditions, or patient or staff treatment needed to address any complaints or staff concerns.”

Steinberg said in crafting the bill he and his colleagues aimed to carefully consider recommendations from the task force and then ask for continued conversations and continued change. He said “nobody should have any illusion” the needed changes can happen overnight.

“We really are asking is that this bill is for further exploration, further dialogue, to come up with a solution that reassures the public and family members of the victims that these that the people who were involved are going to be kept away, so others are kept safe, yet at the same time, we want to be humane with them as well,” Steinberg said.

Steinberg said he thinks creating a new hospital is the best thing lawmakers can do to right the wrongs that have been done to patients such as Bill Shehadi.

“Putting us on a path to have a new facility that creates a better environment and a more humane environment for those who are obliged to be kept there is perhaps the most significant thing we can do,” he said. “That’s the thing that gives me the greatest hope that there will be a very different environment at some point down the road.”

State Sen. Heather Somers, R-Groton, said the bill set forth changes that will hopefully change the system at Whiting. There have been a lot of improvements since the time of Shehadi’s abuse, said Somers, “but there’s still a long way to go.”

One of the changes is that patients committed to Whiting can now seek a step-down to a lower security hospital, via an inter-hospital transfer, as a medical decision with their doctor, rather than having to go to a PSRB review. The PSRB will also now consider the wellbeing of the patient, not just entirely risk, when considering a patient’s future.

The bill also changed the definition of abuse of patients to include harassment and bullying, rather than just physical abuse. It also is trying to empower patients to know their voices can be heard.

Even amid changes they have fought for, family members like Al Shehadi say they live with the pain of how their loved ones were treated.

Bill Shehadi was a recent college dropout with severe mental illness who weighed about 250 pounds when his parents came to visit one winter day in 1995. Aside from thrice daily visits from aides who ensured he took his medications, Shehadi was living in a normal apartment, “alone with a TV set and his thoughts,” his brother described it, after bounding between public and private mental health care facilities following his return to Connecticut from Pennsylvania, where his brother said his mental health had deteriorated quickly.

On that fateful day, his parents came to bring groceries and visit with him, despite his not wanting visitors.

Al Shehadi said even after all these years he isn’t entirely sure what happened. Somehow, whether there was a lunge or a slip, Bill Shehadi ended up on top of his frail 89-year-old father at the bottom of a stairwell.

Their father died at a hospital two weeks later, and Bill Shehadi was charged with manslaughter. Soon after, he was sentenced to what his brother now calls “the never never land of Whiting” where he would be “recycled through the system,” recommitted repeatedly by a board whose sole charge for years was to determine one thing: whether a person poses a risk to society if they’re released. Connecticut is one of few states with such a board.

Al Shehadi said that he has desperately hoped his brother would be deemed eligible for a step-down, for a chance to live in the type of supportive housing he thinks would have changed the trajectory of his life.

Despite all his efforts, he thinks his brother will die before he gets out of Whiting.

Colleen Lord said that her son, Carl “Robby” Talbot, died in a state-run facility where she feels he was mistreated.

Talbot, 30, died in March 2019, 33 hours after he was brought into the New Haven Correctional Center. He was mentally ill, diagnosed with anxiety and bipolar disorder with schizoaffective features, according to his mother.

Talbot, whose family described him as mentally ill, died inside the jail following an altercation with correction officers. Jails and prisons are run by the state Department of Correction, a different entity than DMHAS, which runs CVH and Whiting.

Left without medication for his mental illnesses or medication that prevented him from the throes of withdrawal from a substance use disorder, Talbot experienced a mental health crisis and was brought to the jail’s medical unit, according to his mother and reports.

Talbot was brought into the shower after screaming in his cell and throwing feces and smearing it on himself, according to the inspector general’s report on his death. He was kicked and sprayed with a chemical agent while lying naked on the shower floor, refusing to get up.

He died sometime over the next few hours, strapped to a bed in his cell.

His exact cause of death, according to officials, was sudden death due to a physical struggle, with restraint, as well as atherosclerotic and hypertensive cardiovascular disease and morbid obesity

His death was ruled a homicide, but an inspector general’s report found his death was not the specific fault of any officers who interacted with him. One officer was charged with third-degree assault for kicking Talbot in the upper torso while Talbot lay on his back on the floor after being sprayed with a chemical agent.

Lord said she can still recall the sound of her own screams when she got the call that he was dead.

The saga of what happened to Bill Shehadi also started with a late night phone call Al Shehadi can’t forget.

A doctor told him his brother had been moved to a different unit. There was no explanation, no detail offered, he said. But that call unraveled into a scandal that revealed his brother had been doused with liquids, hit, kicked and psychologically tortured by multiple staff members. Mark Cusson, a nurse, is serving a sentence for multiple counts of intentional cruelty to persons for what he did; a jury convicted him in 2019 and he was sentenced to five years in prison, according to DOC records.

Al Shehadi said that the fact that his brother’s abuse was caught on camera outraged him.

“Nobody even tried to hide it,” said Shehadi. “It was completely out in the open. Because they knew there was no oversight, no internal control, there was no system in place to make them do what they were supposed to do.”

He attributes that apathy to the fact that, in his opinion, “mentally ill people are still treated as second-class citizens in this state.”

Both Shehadi and Lord watched videos of what occurred with their loved ones. Talbot’s ordeal was captured on jail surveillance video and Department of Correction cameras.

Shehadi said watching the videos of his brother’s experience was “like a slow motion train” that stopped at many emotions: “anger, profound sadness, grief, fear, overwhelm and just disbelief.”

Lord said not a day goes by that she doesn’t cry over her son, over what she saw him endure on that tape. And she feels the same emotions Shehadi does.

“He was treated like he wasn’t even human, there was a real lack of any acknowledgement that he was a human being when he was there,” she said. “He was in an agonizing, excruciating, painful state of body and mind, and there was no care for him. It was like he was an animal that they just had to keep in a cage.”

Talbot also was caught in a cycle. He’d been in and out of private, public, out-of-pocket paid hospitals and treatments centers for years.

He had been in jail for misdemeanor offenses in fall 2018 and released the following January. He was returned to jail for violating conditions of his release on a Tuesday in March 2019. By that Thursday, he was dead.

If her son lived, Lord said, she would have left the state to find adequate help for him.

“I would have moved to another state to get better care for my son, that’s how bad the state of Connecticut is for this segment of the population, and it’s a big segment of the population,” she said. “Nothing’s going to bring my boy back, and the only thing that was going to bring me peace … I just want things to be better, and I want for people to stop denying that things are going wrong.”

She hopes to advocate for changes to laws through which chemical agents are allowed to be deployed and wants to fight for more accountability for all state employees who work with the mentally ill.

“Once this happens all you can think is: Don’t let this happen again. Don’t let this happen to somebody else,” Lord said.

Another concern Lord had about her son’s treatment was that he was put into a five-point restraint. The OIG’s report confirmed use of this restraint.

He lay there restrained until someone noticed that he was dead. By the time he was brought to the hospital, according to reports and his mother, rigor mortis had set in.

In their final report, the Whiting task force also had concerns about similar restraints at the hospital. The task force found staff at Whiting had “a long history of violations in the standard of care” including an overuse of restraint and seclusion.

Another one of Lord’s goals is to have better accountability and training for all employees, such as DOC guards, that work with the mentally ill.

Lord said that though she already lost her son, it doesn’t mean there’s nothing to fight for. She wants to fight for the lives of everyone like him.

“Just because it’s already happened to me, I still think of people that are still in there. I think of Bill,” she said.

Bill Shehadi’s brother also thinks of the others, of the next version of his brother.

The money won in the Shehadi lawsuit against the state goes into a trust for Bill Shehadi for the rest of his life. When he someday dies, it goes to his brother, who plans to use all the money to help organizations create supportive housing — the type of supportive housing that he thinks could have saved his brother from what appears to be a life sentence at Whiting.

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