Patrick Marley

Milwaukee Journal Sentinel

MADISON - An inmate from Wisconsin's youth prison was transported to a hospital last week after a staff member gave him a psychotropic drug intended for his roommate, marking at least the third time in five weeks the wrong medication had been given to someone staying at Lincoln Hills School for Boys.

The latest incident occurred two days after the Milwaukee Journal Sentinel published a story about a 15-year-old boy who had been given the wrong medication twice in two weeks. That boy's medicine was wrongly given to the other youth, according to family.

A spokesman for the state Department of Corrections said medical privacy laws barred him from discussing the situation, so Gov. Scott Walker's administration can't provide an explanation for how the situation could occur just after similar errors had been publicized. But soon after the latest incident, the Department of Corrections imposed a new policy on distributing medication — though in most cases it still leaves that responsibility in the hands of guards, rather than nurses.

The problems with distributing medication at the juvenile prison come on top of a federal criminal investigation looking into allegations of child abuse, prisoner neglect, excessive use of pepper spray, destruction of records and other crimes.

In addition to the criminal investigation, federal authorities are reviewing whether there has been a pattern of civil rights violations at Lincoln Hills and Copper Lake School for Girls, which share a campus 30 miles north of Wausau.

Under the new policy implemented shortly after the latest incident, front-line staff must have two years of experience before they can distribute medication, according to the Department of Corrections. Staff known as advanced youth counselors are allowed to hand out medication even if they have less than two years of experience.

For years, guards at Lincoln Hills — rather than nurses — have dispensed medication. That's similar to the policy in place at most adult prisons in the state, and it will continue in most cases at Lincoln Hills under the new policy.

The problems with medication documented by the Journal Sentinel occurred in Dubois Cottage, one of several housing units scattered across the prison's campus. Just after the latest incident, nurses were put in charge of distributing medicine for the time being at Dubois Cottage, but not other housing units, according to the Department of Corrections.

"DOC will continue to review practices and implement changes to (Lincoln Hills) medication management policies and practices in the coming weeks," department spokesman Tristan Cook said in a statement.

He said he could not confirm whether any pills were wrongly given out last week because of medical privacy laws, but said department policy requires inmates to be seen by medical professionals if they do take the wrong drugs.

Last week, the Journal Sentinel reported on the case of a 15-year-old boy at Lincoln Hills who was given trazodone intended for another inmate instead of the Seroquel he was prescribed. He took one of those wrong pills and moments later the staff gave him the Seroquel, which he also took, according to his family.

He takes Seroquel for anxiety and to help him sleep. Trazodone is an antidepressant. Both drugs have strong sedative effects and taking them together can lower blood pressure.

The boy's family was not notified of the error, but found out about it the next day when his grandmother visited him and saw him shaking.

Lincoln Hills official Wendy Peterson told the boy's mother she would make sure the problem didn't happen again, according to the family. Peterson was the institution's deputy superintendent at the time and has since been promoted to superintendent.

Two weeks later, the boy was again wrongly given trazodone. That time, staff did not give him his Seroquel, and he reported feeling hung over the next day.

They boy's grandmother visited the school on Saturday and he told her that earlier that week a staff member had accidentally given his Seroquel to his roommate. The grandmother said she was stunned to learn about the incident after similar mistakes had happened twice to her grandson that had been the subject of a news story.

"There is something very, very wrong ethically and morally going on at Lincoln Hills," she said.

The Journal Sentinel is not naming the grandmother to protect the identity of the juvenile.

She said different staff members passed out the drugs in the three incidents she is aware of. The department has not said if any staff were disciplined for the errors.

A source briefed on the situation confirmed a boy was taken from the prison to the hospital after being given the wrong medication last week.

Separately, the family of another inmate has said at times the inmate has been unable to get the prescription medication he takes daily because the institution has run out of it.

Having guards instead of nurses pass out medication in Wisconsin's prisons has long prompted criticism from advocates for inmates — as well as officers responsible for handing out medication.

In 2009, U.S. District Judge Rudolph Randa ordered the state to put medical personnel in charge of distributing drugs in Wisconsin's prison for women, Taycheedah Correctional Institution. That ruling came in response to a lawsuit brought by the American Civil Liberties Union of Wisconsin.

"There is no reason that children, who are less likely to notice errors than adults, should be subjected to a lower standard of care (than those at Taycheedah)," said a statement from the ACLU of Wisconsin's legal director, Larry Dupuis. "Using nurses to distribute medications could prevent the sorts of errors currently being reported at Copper Lake and Lincoln Hills."

Ken Pickett, a retired teacher at Lincoln Hills, said staff at the institution had long opposed having rank-and-file members pass out medication instead of nurses.

"Forty years ago I said, 'Why don't the medical staff dispense the medicine?'" Pickett said. "And the response from the State of Wisconsin was anyone can give this out."