In 2016, Matthew Tottenham, was transported in chains from his cell at the Souza-Baranowski Correctional Center to the state’s Lemuel Shattuck Hospital for foot surgery — performed by orthopedic surgeon Adriana Carrillo.
Tottenham — now 35 years old — says he’d been told by his surgeon that he was going to have a simple procedure to remove bone spurs. But while he was under anesthesia, he says she did a second procedure on his foot that he did not learn about until months later. He says he woke up in mind-numbing pain and was sent back to prison in a wheelchair.
For months, he says, his foot was infected, swollen and burning with pain. He begged prison officials, and Carrillo, for additional care, he says, and even clean bandages, but was rebuffed. Two months later, he required an emergency surgery to quell the infection.
Now Tottenham, recently released from prison, says he’s never fully recovered, walks to avoid weight on his foot and still suffers from chronic pain.
“She assaulted me and then treated me as if I was nothing,” Tottenham told GBH News in a wide-ranging interview earlier this month. “She shouldn’t be able to operate on prisoners.”
For several years, Tottenham has been trying to hold Carrillo accountable for what he calls medical negligence. He is one of at least 20 people — most, if not all, current and former prisoners — who have filed lawsuits against her in state and federal courts over the last 15 years, an investigation by the GBH News Center for Investigative Reporting has found. Plaintiffs have alleged medical malpractice, botched surgeries — some done without their consent — as well as denial of adequate post-operative care and indifference. In interviews and court records, former patients say that in the wake of their treatment, their hands shake, they walk with a permanent limp or are in chronic pain because of what they describe as failed procedures or lack of follow-up.
Carrillo couldn’t be reached for comment. Her attorney John Cassidy told GBH News that a doctor should not be judged on the number of lawsuits they’ve received, especially when filed by prisoners, most of them without attorneys. He said the legal actions are without merit and she’s never lost a case. He said she can’t be responsible for what happens when incarcerated patients return to their prison cells.
“Dr. Carrillo really should be praised and not criticized,” he told GBH News on Tuesday. “She’s a careful, thoughtful surgeon. She’s doing work that most surgeons are unwilling to do, at least in part because prisoners are notoriously litigious.”
Most lawsuits have been dismissed before getting to a jury, when prisoners were unable to prove their allegations, often lacking medical experts and lawyers to represent them. A handful, like Tottenham’s, are still winding their way through the court system.
But prisoners, their advocates and even some former Shattuck health practitioners say the complaints point to not only a rogue doctor but also a struggling public health system. In its care are some of the state’s poorest patients, including prisoners, people experiencing homelessness and people with mental illnesses.
Many argue prisoners — with few resources, often trying to pursue their legal fights from inside their prison cells — face an uphill battle to hold a doctor accountable. And, generally, prisons offer little choice about where prisoners receive medical care. Most often, those who need care outside their facility are treated at the Shattuck — a place that some former staff say was so poorly managed that they were unable to provide adequate care. They say, too, that the systems built to keep the hospital in check — a state board, state health officials and, more broadly, the justice system — fail to protect the vulnerable population.
Elizabeth Matos, executive director of the nonprofit Prisoners’ Legal Services, says her staff has been so concerned about Carrillo’s treatment of patients that they maintain a spreadsheet of complaints, worry about a call from the next alleged victim, and have repeatedly reached out to prison officials and health care providers about their concerns.
“She stands out in pretty serious botched surgeries that made people permanently disabled,” Matos told GBH News. “This is, of course, something that should have been addressed by the department and by the health care provider already. It’s not something that wasn’t known to the system.”
Reporters from the GBH News Center for Investigative Reporting worked with student journalists at Boston University for months to examine allegations of wrongdoing at the Shattuck, poring through court records and state medical complaints as well as interviewing former and current prisoners and concerned medical staff, many of whom have left the hospital.
Dr. Catharina Armstrong, a former Shattuck employee, told GBH News that Carrillo is not only a “dangerous surgeon” but lacks compassion and treats prisoners with disdain. Armstrong says she reported her concerns to management years ago but nothing was done. She resigned in 2019 from her post as chief of infectious diseases amid wider concerns about care and staffing at the hospital.
Armstrong says she’s appalled Carrillo is still working there.
“It’s a travesty in medical care,” Armstrong said during a recent interview with other concerned former Shattuck doctors. “[Many patients] had more deficits than when they went into the operation. And they were never rectified. And many patients would refuse to ever be seen by her again.”
Officials from the Massachusetts Department of Public Health say that there’s been “no formal patient complaints filed with the Shattuck” related to Carrillo. The lawsuits against her are not surprising, officials said in a written response to GBH News. “You would expect Dr. Carrillo to have greater exposure to malpractice claims based simply on the number of orthopedic procedures performed as orthopedic procedures generally have a higher rate for malpractice claims," according to a written statement released by the department.
Officials say Massachusetts “has made significant improvements” at all four state hospitals since 2020.
“Shattuck has also strengthened oversight and accountability and bolstered its internal communications process to improve clinical decision-making,” the spokesperson said in a written statement. “The hospital is deeply committed to treating every patient with dignity and respect. This includes recognizing that every patient has a right to decline our care, if they so choose.”
Prisoners are allowed to refuse treatment unless the situation is “life threatening” and requires the state to seek “a court order for forced treatment,” according to state policy records.
Complaints about Carrillo’s care, specifically, and the Shattuck in general are numerous, inside and outside the courtroom. Several prisoners described to GBH News what they claimed was negligent care, but said they didn’t file suit because they didn’t know how. Others — like Tottenham — have filed legal motions simply for the right to receive care at a different hospital.
Have a tip or a comment about care at the Shattuck hospital? Reach out to GBH Deputy Investigative Editor Jenifer McKim at email@example.com.
Current lawsuits include one by Epiphany Lazarre who is suing Carrillo in federal court, claiming that she administered steroid injections into his lower back in 2017 that left him essentially “paralyzed.” Lazarre arrived at the hospital with back pain and went back to prison in a wheelchair, court records show. He claims she failed to follow up, acting “deliberately indifferent” to his needs. A judge in 2020 denied a request by Carrillo to dismiss the claim, finding Lazarre “had plausibly alleged” his claim of indifference and awarded him pro bono legal representation. The case is pending.
In addition to court filings, Carrillo has been the subject of at least eight complaints filed with the state Board of Registration in Medicine since 2003, according to records obtained by GBH News through several public record requests.
Some of these complaints replicated those in court suits. Some prisoners, like Tottenham, also filed complaints with the state board before filing a lawsuit. Similar to other cases, the board sought a response from Carrillo and then decided not to impose any punishment, instead leaving the complaint in the doctor’s file.
Tottenham first reached out to GBH News in a handwritten letter from prison, saying that the judges, board and hospital “cover for her always.”
“I have found out how crooked this system is, in favor of doctors who do unspeakable things and walk [scot-free] to continue to do it over and over,” he wrote.
An ‘inept’ system
State law requires the board to publish any reports of a malpractice payment online.
Carrillo paid out one medical malpractice claim last year, according to her publicly available state profile. State officials say it was for $45,000 but declined to provide any more information. Cassidy, Carrillo’s attorney, couldn’t confirm the payout amount but said his client voluntarily paid out the claim after she cut into the wrong ankle of a patient and left a scar. “The surgery was started on the wrong ankle, a skin incision was made, it was recognized immediately,” he said.
Court records show Carrillo settled a second medical malpractice claim in 2013 in Springfield. But the state’s online profile of Carrillo does not mention that case and officials told GBH News they had no information the settlement came with a payout.
Andrew Meyer, a leading Boston medical malpractice attorney, says the state board has long been “inept” in living up to its mission to police doctors. The seven-member board, including five physicians, “was created in 1894 to protect the public health safety by setting standards for the practice of medicine,” according to its website.
“They don’t have the funding, nor do they have the will or the desire to investigate these kind of claims,” Meyer said. “In reality, the board of registration is a protection racket for doctors.”
State officials say the board maintains a “robust” public page with profiles of physicians, including malpractice claims against them, investigates all complaints and imposes discipline when necessary. The state has received 2,861 complaints between 2016 and 2020 and disciplined 261 physicians, officials say, with a range of punishments including reprimands, revocations and suspensions.
“Patient safety is of utmost importance to the Board of Registration in Medicine,” a spokesperson for the Department of Public Health said in a written statement. The board “fully investigates all complaints against physicians submitted by patients, family members, healthcare facilities and other healthcare providers and takes action as warranted to protect patients.”
Meyer says the number of lawsuits filed against Carrillo is cause for concern. He says for every person who files a complaint, there’s likely 20 more that didn’t feel empowered enough to state a claim. He compares it to red flags prompted by a driver with speeding tickets.
“If you get stopped speeding once, it’s maybe a mistake; two, three times, you’re probably on the edge,” he said. “You have seven or eight speeding tickets, you’re probably speeding a lot and you probably have been violating the law.”
But winning medical malpractice suits is notoriously difficult, even for people outside the prison system. To succeed, a plaintiff must prove that a physician’s actions were negligent and that negligence caused personal injuries. Those cases require expensive medical experts to support the plaintiffs’ claims.
To win a “deliberate indifference” claim in federal court, a prisoner needs to prove that a doctor’s care was so “clearly inadequate as to amount to a refusal to provide essential care at all,” as a judge laid out last year when she dismissed one of the complaints against Carrillo.
Meyer says the vast majority of cases that go to trial are won by doctors — and people without an attorney have little chance of success. “They are expensive, and they are difficult to bring,” he said. “That’s why very few people even do it.”
A ‘workhorse’ who’s ‘prolific’
Carrillo is seen as a “workhorse” at the Shattuck, carrying out at least 10 or more procedures a week, according to Kathryn Noonan, a former Shattuck employee who served as director of information technology until last year.
Noonan said she’s not surprised by the number of lawsuits — which average just over one a year — particularly because of the number of procedures Carrillo performs. “Most people sort of admired her work ethic, she saw a lot of patients,” Noonan said. “She was very, very prolific.”
Carrillo graduated from the University of Javeriana Faculty of Medicine in Colombia in 1987, according to a state physician lookup site. There, she completed a residency in orthopedic surgery, completed in 1994, and then a second residency in physical medicine and rehabilitation at Boston Medical Center.
She is not board certified as an orthopedic surgeon. Her attorney says that’s because she did her training outside of the country. Certification is not required by law, but most major Boston hospitals told GBH News that they don’t allow surgeons to work without it following several years of hire.
Carrillo is not directly employed by the state but works for the Shattuck through an independent company called Orthopedic Trauma, P.C. She’s also affiliated with the Beth Israel Deaconess Hospital in Milton through the same company. But a Beth Israel spokesperson says Carrillo is not qualified to practice at the hospital because of her lack of certification.
Carrillo’s lawyers have repeatedly defended her work in lawsuits as complying with the “standard of care” required by physicians.
Among those who lost their legal cases against her, state prisoner Treas Carter filed suit in 2011 claiming Carrillo “failed” a hip surgery that left him with one leg two inches shorter than the other. Carter claims that he was permanently disabled and struggles with chronic pain.
His case was dismissed after a judge denied his request for a pro bono attorney and he was unable to produce an expert witness to support his claim. “No attorney wants to take on a medical malpractice against a [Department of Correction] medical provider,” Carter told GBH News in an email from prison earlier this month, saying the department’s legal team is too well resourced and can drag out court cases. “Dr. Carrillo should be removed.”
There’s also state prisoner Joseph DeLong, who claims that Carrillo left metal in his knee during a 2016 surgery and then attempted to cover it up.
DeLong — a stocky, muscular man who has spent most of his life in prison — says he exited surgery feeling much worse than when he went in, like a knife stabbing him at the spot he had been operated on.
After months of complaints, Carrillo took X-rays and recommended that he get a full knee replacement. But when DeLong read his report, he realized the doctor had failed to give him a key piece of information: Carrillo had left metal fragments in his leg.
A federal court judge found there was enough merit to DeLong’s story to approve a pro bono attorney. The judge also awarded him money to hire an expert to better understand what happened to him.
But the review wasn’t what DeLong hoped for.
The expert hired to examine the case reported in a letter to the attorney that Carrillo deviated from the standard of care by “not recognizing that a drill bit approximately 1.4 cm in length had broken off during the procedure.” He also said that Carrillo erred when she “failed to observe, note and inform the patient of, or ignored, the presence of the foreign body on X-ray.”
However, the expert also concluded that the half-inch long piece of metal “embedded in bone,” was not the source of DeLong’s suffering.
DeLong disagrees. He maintains the excruciating pain in his knee occurred after the surgery. “She’s a butcher, and she needs to be held to account,” he said.
In late February, a three-judge panel in the 1st Circuit Court of Appeals affirmed a lower court’s decision to dismiss the case.
DeLong wrote in an email from prison that he was disappointed by the decision. “I tried to the best of my ability to have them held accountable for their wrongful conduct,” he said.
DeLong was so upset about his care at the Shattuck that he filed a legal motion to force the state to allow him to have a follow-up surgery on his knee at a private hospital.
Advocates say it’s next to impossible to get treatment elsewhere. DeLong says in his case, a sympathetic prison administrator helped him arrange for a full knee replacement at a different hospital — treatment he felt was like night and day.
At the Shattuck, he said, “they treat you so inhumane that you literally feel like you’re not a human being.”
Shattuck doctors ‘not being heard’
The facility with roughly 250 beds is run by the state Department of Public Health in conjunction with the Department of Mental Health and the Department of Correction.
Doctors who work there describe a sense of mission in caring for some of the poorest and most troubled patients in the state. But a group of former staff members — including Armstrong — say they left several years ago, deeply concerned about treatment of patients and worried about retribution from administrative leadership if they spoke up.
“I do believe there is a feeling of bullying and retaliation if you do speak up for things that would make the hospital look bad or the administration look bad,” Armstrong said. “And many people didn’t speak up.”
Armstrong and two other former Shattuck physicians spoke with GBH News in early March in the hopes of shining a light on the facility, one that they all dedicated many years of their lives to.
They said they did speak up — but felt they weren’t heard. In 2019, after Armstrong left, a group of employees sent a letter to Monica Bharel, then-commissioner of the Department of Public Health, detailing complaints including “unsafe staffing” and a “punitive” work environment.
“This is a plea from the majority of Shattuck Hospital staff for a reexamination of the hostile and toxic work environment,” the letter said.
The department met with staff, but doctors who spoke with GBH News say nothing changed.
Medical personnel sent a follow-up letter in 2020 saying things had only gotten worse. “We believe that things have deteriorated significantly since our initial communication with the public health mission at Shattuck Hospital even more at risk than it was six months ago,” they wrote. Many staff members eventually left.
Later that year, then-Chief Executive Officer Joel Skolnick retired. While some say he departed under pressure, Skolnick told GBH News he left on his own accord. He defended his leadership and said many of the medical personnel who departed were not sufficiently dedicated to the hospital’s mission.
“The physicians, even though some of them were very good, weren’t showing up, they weren’t writing in the patient records,” Skolnick said.
State officials say the physician complaints were investigated and “resolved.” They also noted that another group of doctors sent a 2019 letter in support of new leadership.
But Dr. Salah Alrakawi, who headed the residency program at the Shattuck before leaving in 2020 after 23 years in the system, is dubious that improvements were made.
“We completely lost trust in the system, that there’s any transparency in the system and there’s any real investigation or holding people accountable,” he said. “There was really no action that shows that someone is taking our complaint seriously.”
Dr. Jack Cadigan, who left his post as chief of cardiology in 2020, says he’s proud of his work at the Shattuck but left because the environment became too difficult to continue. “Some of the finest doctors I know left the facility — and they could work anywhere.”
They also said there are many health practitioners still there who need support.
“Why is Dr. Carrillo continuing to operate when she is causing such damage?” Armstrong said. “Why is there not more oversight with the needs of the hospital? Why? Why are we not being heard?”
Complaints from prisoners focus on the hospital’s correctional unit located on the Shattuck’s eighth floor. It’s a medium security unit operated in conjunction with the Department of Correction, at an annual cost per person of about $436,000, according to a recently released state report. About 17 people generally are treated there each day.
Tottenham didn’t sue only Carrillo. Like many plaintiffs, he names a list of defendants, including prison staff and medical personnel. But he told GBH News that it was his treatment by Carrillo that prompted him to file suit, writing out his claim by hand from his prison cell.
The tall, tattoo-covered man says it wasn’t until two months after his surgery that he learned Carrillo had performed a second procedure on his foot — a bunionectomy — that he hadn’t approved or been aware of. He says he also read in his medical records that Carrillo claimed he later had mishandled his bandages, which may have contributed to his poor recovery.
“I felt betrayed when I got my medical records,” he said. “You are not going to treat me like a dog and then blame me.”
Carrillo says in court records that when he signed his consent forms, he understood “that conditions may develop during the procedure which would require modifying or extending” the scope of the surgery. She says she performed the surgeries “consistent with the standard of care applicable to the average qualified orthopedic surgeon in 2016.”
In 2018, a three-member Medical Malpractice Tribunal ruled in Tottenham’s favor, a key step to a case moving forward. But in June, a Suffolk Superior Court Judge dismissed his case, claiming he hadn’t been able to prove his claims with the help of an expert witness or had taken a deposition of Carrillo.
Tottenham says he wasn’t able to access X-rays of his foot or arrange a deposition of Carrillo from his prison cell. He is preparing his appeal from his temporary housing in a motel room in Connecticut, set up with a new printer and a computer gifted by a family member. He’s hoping a new judge will support efforts to get him a pro bono attorney and funds to hire an expert.
“I went to prison. I didn’t sign up for torture,” he said. “I gave them consent to do the surgery that she explained, and she did another surgery which resulted in the altering of my entire life.”
Research for this story was launched in a Boston University College of Communication investigative journalism class. Contributors include then-students Hannah Green, Luciano Cesta, Claudia Chiappa, Kayla Dungee, Hannah Edelman, Luna Echeverria, Sravan Gannavarapu, Bilin Lin, Alex Scheinberg, Shannon Sollitt, John Terhune, Saumya Rastogi, Jesse Remedios and David Zong. Former GBH News intern Ashley Belanger also contributed to this report.