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New York Jail Doctor Put on Probation After Wrong Prescription Kills Detainee

by John E. Dannenberg

The former medical director for Rensselear (New York) County Jail was put on probation for three years by state health authorities for improper treatment of alcohol withdrawal syndrome that caused the death of a pre-trial detainee. Additionally, the director was permanently banned from practicing medicine at any correctional facility. The county settled the ensuing wrongful death suit for $150,000 in 2004. the discipline took place after the lawsuit was settled. It is rare that the medical neglect murder of prisoners results in any medical discipline.

Ray Valigorsky, 46, was an alcoholic well known to Rensselear County Jail personnel. On July 19, 2002, he was arrested on disorderly conduct and open-container charges. Homeless for the previous ten years, Valigorsky had been treated for alcohol withdrawal at the jail nine previous times between 2000 and 2002.

On this latest arrest, he was prescribed Ditropan, even though Valigorsky showed signs of delirium tremens (DTs, a severe alcohol withdrawal symptom). Medical director Dr. Morteza Naghibi prescribed the drug without ever even seeing Valigorsky, and the prescription was improperly filled by contract nurses from Adept Health Care Services, Inc. (Adept). Only after four days did one nurse tell Dr. Naghibi that Valigorsky was not doing very well." Naghibi then changed the prescription to the sedative Librium, but Valigorsky lost consciousness a few hours later and was pronounced dead shortly thereafter at Samaritan Hospital.

Investigation into the death revealed a sorry continuum of negligence. Naghibi, who was paid $42,000 a year for a two-hour jail visit every Tuesday, plus on-call responsibilities, failed to review Valigorsky's records, see him personally or communicate with jail staff.
In a 42 U.S.C. § 1983 civil rights lawsuit filed by Valigorsky's daughter Rachel McCrea against Dr. Naghibi, numerous sheriff's office administrators, Adept, Nurses Sherry McIsaac, Mary Malatino and LPNs Barbara Cicognani, Rosemary Sorel and Peter Rice, the accusations were legion. Dr. Naghibi was charged with willful neglect of his duties by prescribing Ditropan (not safe or effective for DTs), failure to review the patient's records, failing to see or monitor the patient and failure to hospitalize him.

Sheriff's administrators were charged with failing to intercede to gain proper medical care for Valigorsky, as well as failure to properly train their staff to do so.

Nurses were charged with violation of prescription distribution regulations wherein drugs were improperly ordered in bulk rather than in individualized sealed packets for specified patients.

All defendants were charged for their negligence in full well knowing Valigorsky's medical history, but simply ignoring it when giving him inappropriate medication and lack of direct medical attention for four days. Valigorsky died naked in his cell, lying on his side, skin warm, moist and blue. His death was plainly preventable. See: McCrea v. County of Rensselear, U.S.D.C. (N.D. NY), No. 03-CV-0892 FJS/DPH.

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Related legal case

McCrea v. County of Rensselear