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He told the investigator that if someone needed medical attention or had disabilities, they had a special cell with a working intercom, but otherwise inmates “get ahold of us by yelling, banging, waving their towels…”

The investigator quoted the cellmate as saying he shouted to ask other inmates to use the emergency intercom to get the attention of guards. “They were trying to press buzzers … I think the intercom only in the handicap cell works,” the investigator quoted the inmate saying.

The investigation report says a follow up email from the correctional officer several days after the death indicated that the intercom in the specialized health cell also wasn’t working, and there was no record on the reason for that.

I can tell you since we implemented the strip search and the longer period of time (of observation) there hasn't been any methadone that's made its way back to the unit

The Department of Justice declined all comment on whether the lack of intercom may have caused a delay in response to the dying prisoner and whether changes have been made in response, citing an ongoing lawsuit from his family.

Devin Maxwell, the lawyer representing Cromwell’s family, said in an interview he feels the disconnected system played a role.

“Disabling the intercom system removed a level of security from the inmates that could have allowed Clayton’s cell mate to contact correctional officers before he died. Nuisance was not a sufficient reason to take that option away,” he wrote in an email.

The report contains disputed versions of when inmates first attempted to get the attention of correctional officers, with some reporting they’d been trying since 6 a.m., three hours before the official time of death.