A report released yesterday by DeVaughn Ward, Connecticut’s Department of Corrections Ombudsman, found DOC to be experiencing “persistent, systemwide breakdowns in the delivery of legally required services,” and to be “operating in a state of sustained institutional failure.”
“Across nearly every core domain evaluated—staffing and operations; medical and mental health care; sanitation, hygiene, and environmental conditions; food services; legal access; communication and visitation; and institutional safety—the OCO [Office of Correction Ombudsman] identified recurring failures that materially affect conditions of confinement,” wrote Ward. “These are not isolated lapses or temporary disruptions. They are structural deficiencies, embedded in daily operations.”
The report spanned Ward’s observations from the time he was appointed to the position by Gov. Ned Lamont in September 2024 to December 2025, and was based upon inmate complaints, site visits, review of records and correspondence, and “sustained engagement” with DOC staff and leadership. Ward, who has previously verbalized the need for increased resources and staff for his office, noted that the report is “conservative rather than exhaustive,” as the report was prepared by him alone. Ward said that his lack of staff constrained the number and depth of investigations that could be conducted simultaneously.”
“That the conditions described herein emerged so consistently, across so many facilities, despite limited oversight capacity, underscores the seriousness and pervasiveness of the issues confronting Connecticut’s correctional system,” wrote Ward.
Altogether, the report found DOC to have provided inmates with inadequate mental health and medical care, persistently failed to ensure a safe or clean environment, provided inmates with inadequate access to legal services, provided low-quality food and did not accommodate dietary restrictions, unfairly restricted visits to family members and was too reliant on using prison lockdowns to make up for staffing shortages. He also cited the financial findings of DOC’s latest audit, saying the DOC’s issues are “further compounded by persistent weaknesses in fiscal and administrative governance.“
Of these problem areas, Ward noted that medical and health complaints “constituted the largest category” of complaints received during the reporting period. Ward noted his office has received more than 143 health services complaints since September 2024.
“The Office documented recurring patterns of delayed diagnosis and treatment, fragmented continuity of care following transfers, inconsistent intake screening, prolonged specialty-care backlogs, and failures to timely identify and accommodate individuals with disabilities,” wrote Ward.
Ward noted that his findings on the topic of healthcare were similarly found in reports done by Disability Rights Connecticut, which found a concerning level of sexual assault at York Correctional Institution, the state’s only prison for women, and a report done by the Office of the Child Advocate (OCA), which criticized DOC’s mental health services and use of solitary confinement for young adults. As noted in the OCA’s report, Ward said DOC had “recurring breakdowns in intake assessment and early intervention processes,” which greatly impacted “treatment timeliness, housing placement, safety, and access to appropriate accommodations.”
Ward included the stories of several complaints regarding DOC’s health services, submitted to him by inmates’ family members. One complaint, received on June 24, 2025, alleged an inmate at Carl Robinson Correctional Institution repeatedly requested medical attention after “experiencing flu or COVID-like symptoms for an extended period,” but was denied care. At one point, the inmate experienced “significant rectal bleeding, which had persisted for some time,” and was told after weeks of requests for care that his “name was not on the list to be seen.”
Another complaint, received on April 4, 2025, said that since December 2024, an incarcerated loved one had been denied proper medical evaluation despite experiencing “persistent chest pain” and having a “palpable lump in the center of his chest.” Instead of being referred to advanced testing or assessment at a hospital, the inmate was given ibuprofen and told their symptoms “might be attributable to heartburn.”
Other complaints said delays in care have prevented one inmate from receiving a needed knee surgery, provided no treatment to a patient with a torn knee cartilage, and required another inmate to undergo two surgeries on their ear that they may not have otherwise needed had earlier intervention occurred. Delays were also observed in inmates in need of optometric and gastrointestinal care. Ward also received complaints regarding mismanagement of psychiatric medication that left inmates to experience “periods of untreated psychosis,” as well as one severely disabled inmate who was not provided proper ADA accommodations.
“The complaints reviewed during the reporting period reflect delays affecting both acute injuries and chronic or routine medical conditions,” said Ward. “Delays across both categories increase the risk of preventable harm, prolong suffering and functional impairment, and may result in more complex and costly interventions over time.”
Ward said that the DOC Health Services Unit “acknowledged that the Department does not maintain a centralized system for tracking sick-call wait times or wait times for outpatient or specialty medical services across facilities.”
Exacerbating the DOC’s inmate health situation was the level of sanitary, environmental and hygiene complaints. Ward received “recurring complaints” regarding “unsanitary living conditions, inadequate access to hygiene facilities and supplies, mold and pest infestations, and environmental conditions exacerbated by extreme heat.”
Ward himself observed black mold and dusty ventilation vents in MacDougall-Walker Correctional Institution and Hartford Correctional Center. At Garner Correctional Institution, Ward experienced “a strong odor of urine” in a housing tier for inmates requiring mental health services and daily living support. Faculty told Ward that “incarcerated individuals on the unit had not been released from their cells to shower for approximately three days.” A similar complaint, made by the father of a female inmate at York, was included in Ward’s report.
“She told me that the air ducts in her unit are clogged and dirty, releasing constant dust and creating an unhealthy environment,” reads the complaint. “Furthermore, she reported that bed linens have not been changed for over a month, leading to unsanitary conditions, particularly due to heat, perspiration, and basic feminine hygiene needs”.
At York, Ward heard from inmates that “only one or two operational showers were available for approximately twenty-five residents,” despite the fact that the facility has been making capital improvements to its showers for almost a year. The women also told Ward that there were “recurring shortages of women’s hygiene and sanitation projects,” requiring women to use toilet paper.
Rodent infestation was also reported at Cheshire Correctional Institution and Hartford Correctional. During the summer of 2025, Hartford’s rodent problem got so bad that food for the facility had to be prepared at MacDougall-Walker. Ward said Cheshire staff indicated that the building’s “age and porous infrastructure” made rodents “an ongoing challenge.”
On the subject of food, Ward “received complaints alleging that food services were unsafe, nutritionally inadequate, or inconsistently administered across multiple facilities.” One inmate at York reported receiving moldy food and rotten milk, and even “alleged the presence of rodent feces in meals,” calling it “dehumanizing.” Another inmate at Osborn Correctional Institution complained that portions were “insufficient to meet the caloric needs of an adult male,” and the daughter of an inmate at Bridgeport Correctional Institution reported that the food provided to her father was incompatible with his diabetes and food allergies.
During site visits, Ward found “visibly unclean kitchen equipment and food preparation areas.” He noted that while DOC menus “reflect intended dietary standards,” allegations of “spoiled food, improper storage, insufficient portions and insufficient substitutions” hamper the ability to assess DOC’s food services based solely on menu analysis. He recommended DOC officials to strengthen coordination between food and medical staff.
Ward received numerous complaints surrounding the issue of facility lockdowns. DOC officials admitted to having 387 lockdowns last year, and have attributed their frequency to a lack of proper staffing, an assertion which Ward agreed with. Ward said that “staffing shortages have had a substantial and recurring impact on facility operations during the reporting period.” Complaints commonly alleged that lockdowns led to cancellation of family visits, and one complainant, the mother of an inmate at Cheshire, alleged lockdowns to have coincided with Easter Weekend, Super Bowl Sunday, and Mother’s Day. Another complaint alleged that MacDougall correctional officers placed the prison on lockdown in order to allow staff members to attend a “piano and violin musical performance,” in October 2025.
“Modified and full lockdowns were frequently used as a management response to insufficient staffing, resulting in the suspension of visitation, recreation, education, medical services, hygiene access, and other core activities,” said Ward. “These conditions affected not only incarcerated individuals but also staff, who were required to work extended hours under increasingly strained conditions.”
Ward recommended that DOC explore the use of temporary reemployment to alleviate staff shortages, develop contingency staffing and lockdown mitigation plans, and “assess opportunities” to let qualified mental health service staff help reduce “the operational burden” on correctional officers and limit lockdowns.
Ward’s report also noted significant complaints regarding access to inmate legal services. He received complaints from inmates at both MacDougall-Walker and Corrigan Correctional Institution alleging that the facilities’ Inmate Legal Assistance Programs (ILAP) to be unhelpful. Ward greatly questioned the efficacy of the ILAP, and included statistics to validate his doubts. Per ILAP’s Year-End Reports, Ward noted that 355 new inmates had reached out to ILAP in 2022-2023, and 471 new inmates reached out to ILAP in 2023-2024. From 2023 to 2024, ILAP reported making and receiving thousands of phone calls and sending and receiving thousands of letters, yet only initiated litigation in four cases from 2024 to 2024, and two cases from 2023 to 2024, none of which have resulted in a court appearance.
“While recognizing that court representation is not constitutionally mandated, the OCO notes that the extremely limited number of cases initiated, when viewed alongside the volume of requests for assistance and recurring complaints, raises questions regarding whether the current service model meaningfully supports access to the courts in practice, particularly for individuals housed in restrictive settings or seeking to challenge conditions of confinement,” said Ward.
In response to numerous complaints, Ward said he began a comprehensive review of the ILAP in 2024. This review led to Ward filing a suit against Bansley Law LLC, the law firm contracted to oversee ILAP, in October 2025, after Bansley refused to comply with his subpoenas for records and staff testimony regarding ILAP’s administration.
“The initiation of litigation to obtain basic oversight records from a state contractor performing constitutionally significant services was an extraordinary step and materially delayed completion of the OCO’s review,” said Ward.
On Oct. 9, one day after filing the suit, Ward recommended DOC officials temporarily suspend their contract with Bansley. On Nov. 17, the DOC responded to this recommendation with a letter, which Ward said disputed his “interpretation of performance metrics,” despite acknowledging “deficiencies in ILAP’s reporting practices.” The letter said DOC had advised Bansley to “begin including additional data points, including response times, case opening and closing intervals, and breakdowns of attorney and paralegal services.” On Dec. 9, DOC told Ward it had “received documentation from the contractor responsive to the OCO’s records requests and declined to suspend the contract or withhold payments.” Ward noted his investigation into ILAP “remains ongoing.”
Ward also noted that York, as well as four other facilities, lacked law libraries entirely, and that their absence was “repeatedly identified by incarcerated individuals as a barrier to accessing legal information and pursuing legal claims.”
“At present, four county correctional facilities and York Correctional Institution—the State’s only women’s correctional facility— do not have law libraries,” said Ward. ” The absence of a law library at York raises particular concern regarding equitable access to legal resources and potential differential treatment.”
Ward recommended, again, that the DOC terminate its ILAP contract “subject to completion of ongoing oversight and contracting review,” expand its access to legal materials through inmate tablets, establish or restore law libraries at the facilities that lack them, and “reevaluate the structure and administration of inmate legal services.”
Ward also found inmates’ access to communication with family to be unduly restricted. He noted inmates have to wait “extended periods to receive a tablet,” which are used to send messages to friends and family via Securus, an e-messaging service used by prisons nationwide. He noted the presence of inoperable Securus kiosks at Cheshire and MacDougall, a lack of ability for inmates to use tablets to submit grievances or file medical requests, an absence of digital legal resources, and frequent disruptions in phone and e-messaging services between inmates and families. In April 2025, technical issues with Securus created a “systemwide disruption,” leaving inmates unable to message family.
“DOC later confirmed that the restriction resulted from a manual system configuration change that propagated statewide through the Securus platform,” said Ward. “The incident demonstrated that a single staff action was capable of materially restricting communication access across all facilities without immediate detection, notice to incarcerated individuals or families, or redundancy safeguards.”
Lastly, Ward received several complaints regarding the conduct of correctional officers, with one complaint alleging retaliation against an inmate after they contacted Ward. Ward said that off-record conversations with DOC staff confirmed the presence of retaliatory action taken against inmates seeking external assistance.
“DOC staff have confidentially conveyed to OCO that incarcerated individuals are often retaliated against—both overtly and subtly—for speaking with OCO or seeking external oversight,” said Ward.
Additionally, Ward took issue with correctional officers’ display of “political and ideological symbols,” such as “Don’t Tread on Me” and “Blue Lives Matter” flags, and staff’s conduct on social media following the November 2025 suicide of an inmate who had previously assaulted a correctional officer.
“Following an incident involving a staff assault, OCO directly observed protected health information concerning the staff member’s injuries being posted and circulated within correctional facilities to solicit financial contributions,” said Ward. “OCO also became aware of social media posts by DOC staff following a death by suicide in November 2025 that celebrated deaths in custody or expressed derogatory views toward incarcerated individuals.”
Ultimately, Ward said that the report doesn’t intend to ascribe blame, but to evaluate DOC’s performance, and thanked DOC staff for their “professionalism and cooperation” in providing him with the information and conducting the site visits necessary to author the report. At the same time, Ward also noted that the report shows the need for greater DOC oversight, standards and legislative intervention.
“This report is not an indictment of individual dedication; it is an evaluation of systemic performance,” said Ward. “The Office of the Correction Ombuds submits this report as both a record and a warning: absent decisive intervention, Connecticut risks entrenching a correctional system defined by instability, isolation, and preventable harm.”
In response to the report, DOC Commissioner Angel Quiros said that DOC “strongly objects to [the] grossly overstated and unsupported generalization,” that the correctional system is operating in a state of “sustained institutional failure.” Quiros said the report contains “a number of allegations which are unsupported in either fact or law and appear to serve only to foster an extremely negative perception of the agency,” and of citing “several issues that are based solely on a singular occurrence, from which Attorney Ward has drawn unfounded and wide-ranging inferences.”
“The report also fails to indicate that the department proactively brought to the Ombudsman’s attention many of the issues raised in the report,” said Quiros. “Any implication that the DOC has disregarded any of the concerns raised is simply not true.”
Quiros said that “there is always room for improvement in any enterprise that houses, feeds, clothes, ministers to the physical, emotional, spiritual, medical and psychological needs, provides reentry and counseling and programming, addiction treatment services, educational services and vocational, and employment readiness training to approximately 11,000 incarcerated individuals on a 24-hour/365-days-a-year basis,” and that DOC “strives for continuous improvement.”
“The administration of the Department of Correction strongly believes a collaborative approach with the Office of Correctional Ombudsman is in the best interest of the incarcerated population,” said Quiros. “The DOC is working on (and will submit to the Ombudsman by February 20) a thorough and detailed response to the 2025 Conditions of Confinement Report.”
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