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Connecticut’s Office of the Inspector General concluded in a report released Monday that “significant medical errors” occurred when methadone was prescribed to two incarcerated men at Garner Correctional Institution, leading to their deaths. The report said the department failed to manage dosing carefully and did not sufficiently account for other prescribed medications that can intensify methadone’s respiratory-suppression effects.
The Inspector General said the state Department of Correction has administered medication assisted treatment, or MAT, since 2013 for people addicted to opioids or heroin. The department contracts with Recovery Network of Programs Inc. in Shelton to distribute methadone at Garner.
For Ronald Johnson, the report said he was transferred from Rikers Island to Garner in July 2024, after having been found at Garner to have “moderate to severe” opioid use and a history of other drug use. The report said Johnson tested negative for opioids on July 10, 2024, and that he was prescribed 30 mg of methadone, which was increased to 40 mg after two days.
The report said Johnson’s case involved additional warning signs that should have changed the methadone dosing approach. It said Johnson had written on an inmate request form that he believed he was having a bad reaction to methadone because his feet were “very swollen till the point that it is noticible,” and that he had discussed swollen feet with a friend the day before he died.
The report also described drug interaction concerns tied to other medications Johnson was receiving. It said investigators found a white pill near Johnson that they identified as Vraylar, an antipsychotic, while the state Medical Examiner’s office later contended the drug was Prozac. The Inspector General said Johnson was prescribed neither medication.
The Inspector General’s report cited medical guidelines warning doctors not to increase methadone doses too quickly and to lower initial doses for patients considered “high risk.” It referenced guidance from the College of Physicians & Surgeons of Manitoba advising that for high-risk patients the first methadone dose should be between 5 mg and 20 mg, including for patients on sedative medications or antipsychotics or those who have not taken opioids for a significant period.
The report said those “high risk” considerations should have applied to Johnson because he had been incarcerated for nearly two months at the time of his death and was being prescribed an antipsychotic. The Inspector General wrote that it was likely Johnson’s body could not handle the methadone amount he was receiving each day, that the drug accumulated to a toxic level, and that combined with the antipsychotic medicines he was receiving, it caused him to stop breathing. The report said the deaths should have prompted immediate “red flags” about whether other inmates were being given medically appropriate methadone doses. (It also said doctors or other medical professionals who prescribed the methadone did not meet in person with Johnson.)
The report said Tyler Cole died later under similar circumstances involving methadone and antipsychotic and other drugs. It said Cole was given MAT at Garner after an intake at Bridgeport Correctional Center on June 13, 2024, when he told medical staff that he had used heroin and drank Hennessy cognac that day. The report said he was transferred to Garner and that more than a month passed before methadone was first given on July 19, when he received an initial dose of 30 mg; the report said his dose was raised to 40 mg the next day.
The Inspector General said Cole, like Johnson, would have been considered high risk because he had not taken an opioid for over a month and because he was being prescribed both a sedative and an antipsychotic medication. It cited guidelines from the College of Physicians & Surgeons of Manitoba saying methadone doses should be increased by 5 mg every 3 to 5 days, or 10 mg every 7 days, and it also cited guidance from the American Society of Addiction Medicine advising increases “no more than 10 mg approximately every 5 days.”
Cole’s family has pursued state action. The report said a lawyer for Cole’s family, Ken Krayeske, filed a claim with the state’s Claim Commissioner in 2025 seeking permission to sue the Department of Correction and requesting $25 million in damages. Krayeske characterized the change from 30 mg to 40 mg within 24 hours as “pretty outrageous,” according to the report, arguing it did not give Cole time to build tolerance.
The Inspector General said it was likely methadone accumulated in Cole’s system, and it described interactions with antipsychotic drugs and with clonazepam, a benzodiazepine, as depressing respiration to the point where Cole could not breathe. The report also said those prescribing doctors or medical professionals did not meet in person with Cole.
In response to the deaths and the findings, the report said the Inspector General did not find that the medical professionals who prescribed methadone engaged in any “criminal action.” The report cautioned against eliminating methadone programs in prisons overall, saying allowing incarcerated people who are detoxing from opioids to access methadone can improve their ability to reenter communities after they leave prison. The report said, however, the Department of Correction should take “immediate and substantial steps” to address how the methadone program was being run.
Andrius Banevicius, the spokesperson for the Department of Correction, said in a statement to the Connecticut Mirror that after Cole and Johnson’s deaths, the department conducted a review of its MAT program “to ensure that it is being administered as effectively and safely as possible.” The report said the department plans to hire an addiction medicine specialist to work across prison facilities, and that it will stop starting patients at Garner Correctional Institution on methadone because of the risk of combining methadone with antipsychotic medications.
Cole’s mother, Tracy Ciccone, and his stepfather, Jason Ciccone, said they wanted the Department of Correction and medical professionals involved in Cole’s death held responsible. In comments relayed in the report, Jason Ciccone said, “This can’t happen again to other people,” adding, “It’s a tragedy, and going forward they’ve really got to clean things up.” Tracy Ciccone said she felt those involved should lose their jobs and that Cole’s son should receive monetary compensation, and she criticized the Inspector General’s finding that action could not be taken against individuals.