Vietnam Veteran Died Of Thirst In Prison

Another Victim Of The Broken Promise

By Ted Sampley
U.S. Veteran Dispatch
December 1997 - January 1998

The tragic death of Glen Raeford Mabrey in Raleigh, North Carolina's Central Prison last year is an all too evident example of another needless death of a veteran. Mabrey, who a prison hospital doctor had pronounced "reasonably healthy" when he entered the prison system, died of thirst.

Mabrey's death was caused by neglect not just by the state's prison system but more importantly by the failure of the United States government to live up to a promise to take care of war veterans injured in the line of duty - no matter what.

When he died, Mabrey was 47 years old. A native of Roanoke Rapids, North Carolina, he had been diagnosed as suffering from PTSD (Post Traumatic Stress Disorder) as a direct result of his combat service in Vietnam.

"Uncle Sam wants you to join the armed forces. Spend an exciting tour of duty traveling the world fighting to free the oppressed. After you are honorably discharged, Uncle Sam will pay for your education, and if you have been injured in the service of your country, he will take care of all your medical needs," the armed forces recruiter smilingly pitches to a potential recruit.

Most politicians do the same. In public, they do a lot of chattering about how much America owes the men and women in uniform who risk their lives and limbs during times of war. In most cases, the politician's words, like the recruiter's, are ritual and hollow — spoken to humor.

In an exclusive investigative report for the Raleigh News & Observer published November 2, 1997, reporters Joseph Neff and Wade Rawlins wrote about Mabrey's Vietnam experience and made public the previously secret circumstances surrounding his death.

Drafted after high school and sent to Vietnam in 1968, Mabrey served escorting convoys, setting up ambushes in the Ia Drang Valley until 1970.

Melvin Tharrington, a boyhood friend of Mabrey who served with him in Vietnam, told the reporters about a night he and Mabrey spent pinned down under enemy fire. "It was rough… Glen was good as gold. He was like a brother to me. He wasn't the same Glen I had known after he got back. I think it really got to him."

Mabrey's mother told the reporters that a week after he returned home, she heard noises in his bedroom. She said she found him in a closet crying, banging his head against the wall.

Mabrey's sister said he had told his mother about his friends being sent home in body bags and that it was too much for him to take.

According to Mabrey's friends and relatives, he began to have numerous run-ins with the law resulting from drug and alcohol abuse. In 1994, he was sent to prison to serve a fourth sentence for drunk driving. By the end of February 1996, Mabrey was dead.

The reporters gave the following account: "In prison, Mabrey was a frequent client of mental health services, receiving treatment for depression and other illnesses.

"When he became incoherent and disoriented, officials at Umstead [Correctional Institute] involuntarily committed him to Central Prison's psychiatric hospital. That was Feb. 21, 1996.

"He was put in a cell with a mattress, a blanket, a toilet and a sink.

"Dr. James Smith, medical director of the psychiatric hospital, noted that Mabrey was `acutely psychotic.'

"Mabrey repeated the word `raisins' over and over. At night, he yelled and banged his head on a door, as he did when first home from Vietnam. He piled up his mattress and clothes and poured food on them.

"Smith ordered that Mabrey be put in restraints and given Thorazine, an anti-psychotic medicine sometimes referred to as a `pharmaceutical straitjacket.' The Thorazine continued daily while he was in the mental health ward.

"Two days after admission, Mabrey flooded his cell at 5 a.m. by stopping up his toilet and repeatedly flushing it. He said he smelled smoke.

"Someone turned off the water to his cell. Prison officials don't know who. But cutting the water off is standard practice, Smith said. `If an inmate is flooding his cell, we'll cut the water off so other patients aren't disrupted.'

"With the water off for nearly five days, Mabrey's health depended on the meals delivered three times a day. His medications increased his body's need for fluids.

"Mabrey was uncooperative and paranoid, according to the medical staff. At times he refused to come to the door, telling one nurse, `You just want me to come over there so you can push medicine and kill me!'

"Although Mabrey was locked in a cell without water, his charts show no evidence that the staff monitored his eating or drinking. There are just two notes mentioning food or water: He ate one dinner and drank 18 ounces of water while the cell's water was turned off.

"Mabrey was checked hourly by the staff, but the checks often were done by correctional officers with no medical training. Officers also delivered his food and picked up his trays, a policy changed after Mabrey's death. Officers aren't trained to monitor an inmate's intake of fluids and food or to look for signs of dehydration."

The nurse checked on him every 30 minutes - by kicking his door, shining her flashlight on his eyes through the door and seeing if he moved.

On the fifth day after Mabrey's water was cut off, a nurse grew concerned about his emaciated condition. She suspected he was dehydrated. He had a high pulse and extremely low blood pressure.

She called for a doctor who referred Mabrey to Central Prison's hospital emergency room.

Mabrey was carried into the emergency room on a stretcher. A nurse there noted that he was "curled up, emaciated and unconscious. He had a green crust around his eyes and cracked skin around his mouth. His tongue was so dry it had furrows in it."

Although no attending physician issued written orders or provided any documentation on Mabrey's chart, someone ordered lab tests. A registered nurse administered intravenous fluids (an IV) and oxygen. Neff and Rawlins couldn't nail down what happened to the supposed attending physician.

Ironically, the nurse was later disciplined for "exceeding her scope of practice" by administering the IV in the absence of orders from a doctor. There is no record of disciplinary action taken against any physician involved in this miscarriage of medical care.

When another doctor came on duty, he did order an IV and a transfer to an acute care room. The order for the IV was never carried out

When test results arrived showing kidney failure and life-threatening levels of sodium in

Mabrey's body, the registered nurse on duty never reported his condition to the attending physician. No doctor inquired about the test results.

When he awoke, Mabrey was taken to an isolation room that was used to "seclude disruptive patients" rather than an acute care room.

How could this happen when one of the emergency room physicians had ordered him moved to an acute care ward on another floor where nurses could monitor him and administer the IVs?

Neff and Rawlins ascertained that someone had scratched through the original order and had written in the new destination in the isolation room. They think it may have been a corrections officer. No one knows for sure.

The prison hospital has since changed its policy and does not allow correctional officers to make room assignments based on custody concerns. Nursing supervisors assign beds based on the level of care that is needed. That's very caring. It's too late, however, for Mabrey.

Records show that the nurse on duty did not check Mabrey's vital signs when he arrived in the isolation room. Nor did she review his charts or reports.

The nurse who followed her on duty checked on him every 30 minutes - by kicking his door, shining her flashlight on his eyes through the door and seeing if he moved. She did not so much as enter the cell or read his records.

By the time he was found unconscious and rushed to Wake Medical Center's emergency room, his file was either missing or of no use to the attending medical staff there. Written documentation was too incomplete.

Unsure of what was going on with him, doctors suspected a drug overdose and treated him for that - not dehydration. After eight days of "care," the Vietnam vet was dead. An autopsy found dehydration to be the "sole cause" of his death.

Mabrey's family told the reporters that they had tried for months to find out what happened to him but were stonewalled by the prison hospital staff. They said the only way they discovered how and why Mabrey died was after the reporters called. Mabrey's sister told the reporters that she had called the prison hospital and asked what happened. All they told her was that they could not "release that information."

Hospital officials claimed staff shortages of qualified health care professionals was the cause of Mabrey's death. Was it?

Why was Mabrey in prison in the first place? The Veterans Administration had already concluded that he suffered from PTSD, and it is common knowledge that alcohol and drug abuse can result from the disorder.

Instead of a prison psychiatric ward, why wasn't Mabrey being treated in a veterans' hospital under involuntary commitment if necessary?

Vietnam veteran Glen Raeford Mabrey died in the prison system because the U.S. government's promise to take care of its war veterans "no matter what" is a big lie.