Michael Barton died in the Oregon State Penitentiary last year after catching the flu.

In the course of a month, Barton, 54, became sicker and sicker; he stopped eating and witnesses reported he could not stand or walk. Barton eventually suffered from a MRSA infection, resulting in a collapsed lung and organ failure.

Portland-based legal nonprofit Disability Rights Oregon (DRO) investigated Barton’s death and, in a new report out Monday, stated it was caused by neglect from nursing and medical staff due to ignorance regarding his mental illness.

Barton was sentenced to prison for bank robbery in 2017. He arrived with a “long history of serious mental illness,” including a mood disorder diagnosis, DRO’s report states, and he also had exhibited “significant signs of dementia.”

Throughout his time at the penitentiary, prison employees detailed Barton’s symptoms of mental illness and dementia, but, DRO’s report states, prison staff repeatedly ignored serious issues and requests from Barton regarding them as unfounded.

“He didn’t get the help he needed because his mental illness and dementia led staff to dismiss his complaints,” said Joel Greenberg, a staff attorney with DRO. “It was clear that the nursing staff in particular didn’t do what they needed to do.”

At one point, Barton had believed the water in his cell was poisoning him. Nurses “argued with him because they interpreted his irrational resistance to drinking the water in his cell as malingering or an obstinate refusal to follow medical advice,” the report states.

This pattern continued during Barton’s stay. During multiple visits to the medical infirmary, and additional requests to be admitted, “he was continually returned to his cell.”

One employee with the Oregon Department of Corrections, said he witnessed Barton’s weakness and lack of ability to stand or walk as his illness persisted and requested that Barton be readmitted to the infirmary.

“[The witness] was told by the responding nurse that he ‘just needs to rest,’” the report said.

“Instead of inquiring further or getting someone with a little more expertise on how to talk with a person with those issues, they just dismissed his complaints as whining, as malingering, and essentially watched him die,” DRO’s Greenberg said.

Oregon Department of Corrections physician Reed Paulson reviewed Barton’s death, stating that more care should have been taken and that Barton’s “mental illness may have been a confusing or distracting factor” to staff members.

Paulson concluded his review stating, “the fault does not lie in one person’s mistake, but rather highlights system failure that has affected many staff.”

Greenberg agrees there’s a systematic issue and said the prison culture around mental illness needs to change.

“There may be other causes such as understaffing or poor training or poor supervision,” Greenberg said. “But at the bottom of all those things, the through line is there’s a culture that simply doesn’t treat people like Mr. Barton as human beings.

“Any unnecessary death is a tragedy, but an unnecessary death that’s been driven by the dehumanization of people who really can’t advocate effectively for themselves, can’t communicate effectively, is particularly tragic.”

DRO’s report concludes that the Oregon Department of Corrections should hire an “Independent Prison Health Expert” who has experience in systematic reform of correctional healthcare and extensive knowledge of mental illness and developmental disabilities.