CT DOC report sheds light on overdose death and raises questions

An internal investigation conducted by the Connecticut Department of Correction concluded the agency bears responsibility for the fatal methadone overdose suffered by Tyler Cole, who died while incarcerated at Garner Correctional Institution.

But the report also states Cole may have ingested more methadone than he was prescribed.

Cole was one of two young men who died within days of each other in 2024 while receiving methadone at Garner. Methadone is one of the medications approved by the U.S. Food and Drug Administration to treat opioid use disorder. It works to reduce cravings and prevent painful withdrawal.

According to the state Office of the Chief Medical Examiner, Cole’s death was caused by a combination of methadone and antipsychotic drugs he was prescribed, which were being administered while he was at Garner.

The DOC has administered medication assisted treatment, or MAT, since 2013 for patients addicted to opioids or heroin. As of last year, some type of MAT program existed in 10 of Connecticut’s 13 correctional facilities. The department contracts with Recovery Network of Programs Inc. in Shelton, which is responsible for distributing methadone at Garner.

The October 2025 security division investigation, conducted by a nurse consultant for DOC and obtained by the Connecticut Mirror through an attorney for Cole’s family, sheds more light on Cole’s death, but it also raises questions. 

The internal investigation concluded that “based on the collected evidence obtained during SD investigation, CTDOC is responsible for the death of I/M Cole.” The investigation revealed “a multi-system failure and poor communication” between DOC and Recovery Network of Programs Inc., or RNP. 

Correction Ombuds DeVaughn Ward said he’s seen cases in which DOC took responsibility for a death but “can’t think of an instance where it’s been explicitly stated like this.”

The report outlined the “multi-system” failure that contributed to Cole’s death. For example, RNP did not have the ability to update DOC electronic health records, and DOC did not have access to RNP’s electronic health records. There was also no documentation found indicating that DOC and RNP met to discuss the methadone treatment course for Cole, in accordance with DOC policy. 

The investigation recommended several “opportunities for improvement,” including documented meetings between vendors and DOC staff before an inmate begins medication assisted treatment and granting healthcare vendors the ability to update DOC’s electronic health records.

“Since the regrettable loss of Tyler Cole, the Department of Correction has made and will continue to make significant changes to their Medication Assisted Treatment (MAT) programs to improve their safety and efficacy,” DOC spokesperson Andrius Banevicius said.

Banevicius said the agency has suspended the MAT program for new patients at Garner, has employed a doctor with a specialty in addiction medicine and “is closely evaluating all medications an incarcerated individual is taking as part of their consideration for participation in the MAT program.”

DOC continues to use RNP as a contracted MAT provider, Banevicius confirmed. RNP did not respond to a request for comment. 

Raising doubts

But even while placing responsibility with DOC, the report also states that Cole had more methadone in his system than expected based on the doses he received. The report concludes that it was “very likely that I/M Cole took more methadone than what was prescribed to him as evidence by his toxicology report.”

However, the report does not provide any evidence as to how Cole would have ingested more methadone.

“The document is conflicting,” Ward said. “In portions it says CT DOC is responsible, but it also says that Mr. Cole is responsible.”

DOC did not respond to questions about the conflicting messaging in the report or the conclusion that Cole had taken more methadone than was prescribed, citing the active litigation. 

A January investigation by the Connecticut Office of the Inspector General into the methadone overdose deaths of Cole and another person incarcerated at Garner, Ronald Johnson, also acknowledged that the level of methadone in Cole was “elevated after just two doses.” The investigation concluded that Cole died from the combined effects of methadone and other prescribed medications.

The OIG investigation found that Cole’s methadone doses started out too high and were increased too rapidly for a high-risk patient. Cole should have been considered high risk because he had not taken an opioid for over a month and was being prescribed both a sedative and an antipsychotic medication, which puts patients at greater risk of methadone toxicity, the report stated. 

Ken Krayeske, a lawyer for Cole’s family in a case against the state and RNP, said he finds DOC’s conclusion that Cole took more methadone than prescribed unlikely, given how “tightly controlled” the delivery of methadone is in the prison system.

And illicitly obtaining methadone is difficult, said Marc Stern, a physician and researcher focused on correctional healthcare. Methadone most commonly comes in liquid form, as opposed to a tablet that could be easier for someone to hide in their mouth.  

“It’s not impossible,” Stern said. “But it is hard to divert.”

Krayeske said he believes the conflicting messaging in the security division investigation is an attempt to minimize the state’s financial liability.

“DOC has written a report that accepts liability but then casts doubt and blame so that it doesn’t have to pay as much,” Krayeske said.

“The state needs to be held accountable,” said Cole’s mother, Tracy Ciccone, when reached by phone. “They were responsible for keeping him safe.”

Elizabeth Benton, spokesperson for the Office of the Attorney General, declined to comment further, also citing the pending litigation.