1 week Ago By Paul Cuno-Booth
Check back soon for the audio version of this story. That piece was produced by Jackie Harris, and edited by Katie Colaneri and Casey McDermott, with music from Trailhead and Blue Dot Sessions. Pat Borcuk still has three of her son Phillip’s drawings hanging on a wall of her house in Cornish – beautiful, black-and-white sketches of horses.
He was a talented artist, she recalled, who liked to design tattoos for people. He didn’t do well working for others but tried to make it as his own boss, seeking out painting work and other handyman jobs. Pat has fond memories of hanging out with her son at home, listening to Creedence Clearwater Revival, a band they both loved.
“He made my life like a dream, a dream come true, to have a son like that,” she said. But Phillip’s life was up and down. He struggled from an early age with serious mental illness, with inconsistent treatment.
He developed an addiction to drugs, and sometimes got in trouble with the law, mostly for drug and property crimes. Eventually, he ended up at the New Hampshire State Prison in Concord. “I think if it weren’t for the drugs, I think he would have [had] a better life,” Pat said.
One day in December 2017, Pat got a call from the Department of Corrections. Her son had died at the state prison’s Secure Psychiatric Unit, a place where he was supposed to be getting help, after a mental health crisis that escalated into a violent struggle with corrections officers. During that confrontation, the officers handcuffed him and restrained him face down — a position many experts say is unsafe, because it makes it harder to breathe.
Phillip Borcuk’s death was ruled an accident, and the state has denied any wrongdoing. But since then, another man with serious mental illness living in the same prison psychiatric unit, Jason Rothe, has also died after being held down by corrections officers. And this time, the state is bringing charges against one of the officers involved.
The state maintains that the cases are “factually and legally different,” noting that medical examiners determined the men died of different causes. But some advocates say these incidents underscore longstanding questions about how the state cares for some of its most vulnerable individuals: those with a serious mental illness, deemed too dangerous for a hospital setting, who are at risk of harming themselves or others. This reporting was produced in collaboration with NHPR’s Document team.
This longform narrative reporting initiative is driven by the idea that taking the time to tell the whole story leads to bigger impact – opened minds, changed policies – and a more nuanced understanding of the people at the heart of important issues affecting many of us every day. Learn more about Document's work here. The Department of Corrections describes the Secure Psychiatric Unit as a medical facility separate from the prison, though it’s not licensed as a health care facility and isn’t subject to the same kind of oversight as a psychiatric hospital.
People who’ve visited say it looks and feels like a prison, with people living in cell blocks and corrections officers managing security. The SPU has long been controversial , in part because the state sends some civilly committed patients there to be treated in the custody of the Department of Corrections. “When we think of an environment that would be conducive to improving one's mental health, the SPU certainly does not come to mind,” said Francesca Broderick, a senior staff attorney for the Disability Rights Center-NH, an organization that monitors the facility closely.
Both Borcuk and Rothe were there because they needed treatment for a serious mental health condition. But their paths to the facility differed. Borcuk was sent there for treatment while serving a sentence at the state prison.
Theresa Taylor, one of his sisters, said she worried he wasn’t getting the care he needed. “I have a letter from him that said he was struggling,” Taylor said. “He would ask for help, and, you know, they would send him to a psychologist, and it just – they didn't really do anything.
” At some point, records show, Borcuk started refusing medication. “It just wasn't a really good experience in there for him for medical needs,” Taylor said. Borcuk was alone in his cell on the morning of Dec.
6, 2017, when officers said he began trying to hurt himself. Records from the State Police investigation into his death describe a violent and chaotic scene. According to corrections officers, Borcuk, bleeding profusely, was repeatedly hitting his head against a sink.
Officers said he grew combative when they tried to intervene. During the struggle that followed, officers shocked him multiple times with a Taser, wrestled him to the ground and put him in handcuffs. Several officers then continued to hold him face down on the floor as he struggled.
At some point, officers strapped Borcuk onto a stretcher, still face down and in handcuffs. Soon after, he stopped breathing. Officers and nurses who were present told investigators they put Borcuk face down on the stretcher because they worried about blood getting into his airway.
Dr. Brooks Walsh, an emergency room physician at Bridgeport Hospital in Connecticut, said he’s never heard of medical personnel putting someone face down for that reason. “I think every first aid certified person knows that the recovery position isn't placing someone face down,” Walsh said.
“It's placing them on their side.” New Hampshire Chief Medical Examiner Dr. Jennie Duval ruled Borcuk’s death an accident, caused by “Excited Delirium Syndrome due to paranoid schizophrenia” – a controversial diagnosis that major medical organizations have since disavowed.
Her autopsy report said that “prolonged exertion during physical restraint” contributed to his death, but that there was “no evidence of restraint asphyxia.” More than five years later, Jason Rothe was living in the Secure Psychiatric Unit’s most restrictive ward. Unlike Borcuk, he was civilly committed after being admitted as a patient at New Hampshire Hospital.
In 2022, hospital officials sought a court order to transfer Rothe to the Secure Psychiatric Unit, saying they were concerned he was too high-risk to stay in their care. According to court documents, on April 29, 2023, officers told Rothe to leave a common room because he had overstayed his allotted time there. When he wouldn’t, they tried to forcibly remove him.
During the resulting struggle, officers brought Rothe to the floor and shocked him with a Taser. According to a court affidavit later filed by the state, video footage shows one officer punching Rothe in the head. Once Rothe’s hands were cuffed behind his back, another officer, Matthew Millar, allegedly pinned Rothe face down on the floor for several minutes, with a knee pressed into his back, during which time he stopped moving.
The nurse on duty later testified that she saw Rothe lying prone on the floor and not moving or speaking. She said she did not examine him because she thought he was faking – playing “opossum,” as she put it. Rothe was declared dead later that day at Concord Hospital.
NHPR has been unable to reach his family for comment. The state’s deputy chief medical examiner, Dr. Mitchell Weinberg, ruled Rothe’s 2023 death a homicide, determining that Rothe died from asphyxia from the combination of being restrained face down and having pressure put on his back.
Earlier this year, citing the autopsy findings about Rothe’s death, the state charged Millar with second-degree murder, alleging he recklessly caused Rothe’s death. Millar has pleaded not guilty, and records indicate he intends to argue self-defense when he goes to trial in March. The Department of Corrections also demoted two other guards who were involved in the incident to civilian positions, records show.
In a statement, the New Hampshire Attorney General’s Office said these two deaths are fundamentally different. Michael Garrity, a spokesperson for the office, said it “distorts the reality” of Borcuk’s death to focus solely on restraint. “Mr.
Borcuk’s death was preceded by severe self-injury,” Garrity wrote in an email. “Mr. Borcuk was suffering a mental health crisis, repeatedly hitting his head against a sink, before lashing out at staff who tried to intervene and come to his aid.
” But Eric Jaeger, a New Hampshire-based paramedic and EMT educator, said the two cases do share a troubling similarity: prolonged restraint in the face down or prone position, which can make it harder to breathe. “We see over and over again that people placed in the prone position, they're often described as struggling against police or against EMS providers,” said Jaeger, who trains first responders about the dangers of prone restraint. “The reality is they're not struggling to get up and get into a fight.
They're struggling to get up to breathe.” When someone’s restrained in that position, medical experts say, the chest can’t fully expand, making it hard to take deep breaths. That’s exacerbated if an officer is also putting their weight on the person’s back at the same time.
In some cases – especially when someone’s agitated due to drugs or mental illness, or already out of breath from a struggle with officers – that can cause death within minutes, according to Jaeger and other experts interviewed by NHPR. The law enforcement profession has known about the risks of what’s sometimes called “positional” or “restraint asphyxia” for a long time, and many agencies incorporate it into their training. Even so, a recent Associated Press investigation found hundreds of people around the U.
S. have died since 2012 after police restrained them face down – most infamously, in May 2020, George Floyd. “Anything related to being in the prone position while in handcuffs is not a good idea,” said Shamus Smith, a former NYPD officer and use of force instructor, who now teaches at John Jay College in New York.
Smith said officers should get people off their stomachs as soon as they’re handcuffed, for example by rolling them up on their sides. That’s true even if the person is still agitated or struggling, he said. “I learned this at the police academy as a police recruit in 2005, that this was absolutely not accepted,” Smith said.
The curriculum for new corrections officers at the New Hampshire Corrections Academy has included training on the risks of prone restraint since at least 2013, if not earlier, according to John Scippa, the director of the Police Standards and Training Council. A former nurse at the SPU said she had raised concerns about the use of restraint, even before Borcuk’s death. Beatrice Coulter worked there briefly as a nurse in 2015, before quitting over a range of concerns about how patients there were treated, and has since become one of the facility’s most outspoken critics .
When Coulter worked at the SPU, she said she was shocked to see a patient held face-down in four-point restraints, with their limbs outstretched. As a nurse, she knew that putting someone in that position could stir panic. “People have the sensation of not being able to breathe at times,” she said.
Coulter flagged that in a May 20, 2015 email to a supervisor, which she shared with NHPR. “One of the more troubling practices on SPU for me personally, is the restraining of individuals in the prone position,” she wrote in that email. “This has been shown repeatedly to be wrought with risk and has resulted in positional asphyxia deaths across the county.
I have restrained many individuals in my career, and have never used that position.” The state’s official diagnosis in Borcuk’s death — “excited delirium” — has been used to explain many deaths in police custody over the years, attributing them to a potentially life-threatening state of severe agitation caused by drugs or mental illness. Since 2020, major medical organizations – including the American Medical Association – have rejected excited delirium as a diagnosis or cause of death, saying it’s not supported by scientific evidence.
Research has found the vast majority of deaths attributed to excited delirium involve people who were restrained by law enforcement. NHPR spoke to five forensic pathologists about Borcuk’s death. Based on the autopsy report, most thought restraint likely played at least some role, whether as the main cause or one of several factors.
Dr. Victor Weedn, a former chief medical examiner in Maryland who has published research on restraint-related deaths, said the way he was restrained would have prevented him from taking deep enough breaths to recover from the exertion of the struggle. He said that could have caused a fatal buildup of lactic acid within minutes.
Based on Borcuk’s autopsy report, Weedn said he believed that was the most likely cause of death. “What people don't understand is, one, how fast this metabolic acidosis can build up, and two, how quickly it just causes somebody to just flat die,” said Weedn. Dr.
Thomas Andrew viewed the case as more complicated. He spent two decades as New Hampshire’s chief medical examiner and was retained as a consultant by a lawyer representing Borcuk’s family. Andrew said this case involved a confluence of variables beyond restraint alone, including surging adrenaline due to agitation, deployment of a stun gun and underlying health issues.
In his view, the state’s autopsy basically got it right in accounting for those different factors, even if a different term than “excited delirium” might be used today. “I saw this as much more complex than simply a death due to prone restraint,” Andrew said. Garrity, the spokesperson for the attorney general’s office, said the medical examiner’s use of “excited delirium” was appropriate in this context.
“Although not recognized as an underlying cause of death, excited delirium is a well-known term used to describe a life-threatening clinical condition most often resulting from stimulant drug use and/or psychiatric illness,” Garrity said. In a statement provided through an unidentified spokesperson, the Department of Corrections denied the two men’s deaths are evidence of systemic issues. “Any loss of life is devastating and felt deeply by those who knew and cared for them,” the statement said.
“The department extends its condolences to the families and loved ones of Mr. Borcuk and Mr. Rothe.
” Borcuk’s death prompted an investigation from the Disability Rights Center-NH, which is empowered under federal law to look into potential cases of abuse and neglect in facilities housing people with disabilities. Broderick, the senior staff attorney there, said confidentiality rules prohibit her from saying what that investigation found, though it did lead to a meeting with the Department of Corrections. She said their initial concerns were prompted by news reports about his death, which said only that Borcuk had died after “self-injurious” behavior.
Broderick said that raised questions about how someone in a mental health unit had been able to injure themselves so significantly, and what kind of treatment he received leading up to that. “We were concerned about the circumstances of his death that were public at that time,” she said. Broderick said her organization remains concerned about conditions at SPU, including staffing shortages and patients spending long hours isolated in their cells, which could exacerbate their mental illness.
The Department of Corrections said it has expanded training on responding to and de-escalating mental health crises, including partnering with the mental health organization NAMI-NH. The agency also said all officers also get training on the risks of prone restraint that includes “a scenario-based opportunity where officers experience exertion and are handcuffed in the prone position so they recognize first-hand the need to immediately roll handcuffed individuals on their side.” The department noted that it updated its use of force policy in early 2024, equipped corrections officers with body cameras and started using a new restraint tool in the SPU that immobilizes people in an upright position, to minimize risks to breathing.
“We hear and take seriously the concerns raised by advocates about the intersection of mental health care and corrections,” they said. “The New Hampshire Department of Corrections is committed to ensuring that all individuals in our care receive the treatment, support, and respect they deserve.” Borcuk’s family, meanwhile, is still looking for accountability.
They tried to bring a wrongful death lawsuit against the state, but that petered out this year with a nominal settlement – about $4,000 – and no admission of wrongdoing. They say it wasn’t about the money, they just didn’t want what happened to their son to happen to anyone else. “I don't know if I've ever been told what actually happened, or I don't think we'll ever know what really happened,” said his sister, Theresa Taylor.
They’re doing their best to move forward without that closure. Borcuk’s father, Fred, still thinks about some of the good times he had with his son, throwing horseshoes in their yard. “I didn't see a lot of those a lot of those times with him,” he said.
“But once in a while, on a Sunday afternoon, he would have it together and he would want to come out and shoot some horseshoes ...
And, you know, that was when the dad and son really – we really got a little closer at that particular moment.” Fred has since taken the horseshoe pit down. He doesn’t have anyone to throw with anymore.
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