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Nicholas Glisson made the mistake of selling a prescription pill to his confidant, who turned out to be an informant.
The Wayne County judge made the mistake of sending Glisson to prison, disregarding doctors' recommendations for house arrest because of his poor health.
The Indiana Department of Corrections made the mistake of not treating his condition, and Glisson died of starvation and acute renal failure 37 days later.
"'I'm sorry to tell you your son passed," Alma Glisson recalled of a phone call from the prison. "I said, 'Oh my God, you killed my son!'"
You Killed My Son!
Alma Glisson sued the prison for civil rights violations, but a trial judge dismissed the case. A three-judge panel of the affirmed the decision, but an en banc panel reversed. The U.S. Seventh Circuit Court of Appeal said the prison health care providers may well have been indifferent and caused Glisson's death.
"The Corizon providers never took any steps to integrate the growing body of evidence of Glisson's malnutrition with his overall mental and physical health," U.S. Circuit Judge Diane Wood said, writing for the 6-4 majority.
Glisson, 50, had serious health problems that started with cancer in 2003. Surgeons removed his larynx, part of his pharynx, portions of his jawbone and 13 teeth. He was left with a hole his throat to breathe through a tube. He needed a voice prosthesis to speak, and a brace to hold up his head so he could breath and take in some foods.
He developed severe curvature of the spine, and doctors placed a supplemental feeding tube in his abdomen. By the time he was charged, he had been diagnosed with hypothyroidism, depression, and other impairments from smoking and alcohol abuse.
Elephant in the Room
At his sentencing, Glisson's doctors warned that he would not do well in jail. "This patient is severely disabled, and I do not feel that he would survive if he was incarcerated," wrote Dr. Richard Borrowdale.
Nonetheless, Glisson was sent to state prison. Because of his obvious disabilities, officials moved him to Plainfield's Correctional Medical Facilities, also known as Corizon. However, no one reviewed his medical history for almost four weeks.
"Upon reaching Plainfield, Glisson's medical care -- again furnished by Corizon -- began to resemble the blind men's description of the elephant," the appeals court said.
A number of doctors and other health care workers attended to Glisson, but gave conflicting treatments. As he quickly lost weight, they concluded he was not eating because he was psychotic.
"Had Dr. Conant looked at something resembling a complete chart, he would have seen that Glisson had no history of psychosis, and he might have considered, as the post-mortem experts did, the more obvious possibility that lack of oxygen and food was affecting Glisson's mental performance," the judges said and sent the case back for trial.
Glisson was found dead, the coroner said, naked and sitting up in his infirmary cell. The medical personnel never gave him his neck brace.