Defender General Details Failures Leading to Inmate's Death

Jul 23, 2020

The Vermont Defender General has released a summary of findings from an investigation into the death of Kenneth Johnson, an inmate at the Northern State Correctional Facility in Newport. Johnson, a 60-year-old Black man, died in December of 2019 from an undiagnosed tumor which obstructed his airway.  He was awaiting trial on human trafficking charges.

The report details Johnson’s pleas for help in the months and days preceding his death. In fall 2019, it said, Johnson had “told nurses he had shortness of breath; worsening hoarseness; trouble swallowing; feeling of something stuck in his throat.”

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Medical staff employed by Centurion, the prison’s former medical contractor, suspected chronic obstructive lung disease, and prescribed steroids, which aggravated his diabetes and were not effective.  But, the report states, Johnson was never seen by a medical doctor for his breathing problems.

"There's a culture of ignoring medical complaints by inmates that has to be overcome. And in this particular case, I believe that there was a racial component to it as well." - Matt Valerio, Vermont Defender General

The day before his death, according to the report, Johnson “showed many signs of acute respiratory distress.” He was breathing rapidly, rocking back and forth, and “he said outright, repeatedly, that he could not breathe and needed to go to the hospital.” Yet, according to the report, “no one checked Mr. Johnson’s vital signs or listened to his lungs.” 

After Johnson collapsed in the bathroom that evening, the report states, an officer “threatened Mr. Johnson that if he did not ‘knock it off,’ he would be placed in holding - a form of solitary confinement.” It notes Johnson “died after hours of struggling to breathe while nearby nurses did nothing to help,” and that “Nurses learned Mr. Johnson had stopped breathing only when other patients alerted them.”  It goes on to note that Johnson could have been treated with a number of life saving interventions if his tumor had been diagnosed. 

“There’s a culture of ignoring medical complaints by inmates that has to be overcome,” said Vermont Defender General, Matt Valerio. “And in this particular case, I believe that there was a racial component to it as well.” 

Interim Commissioner of Corrections, Jim Baker was not in charge of the DOC at the time of Johnson’s death, but has since taken over the department.  “The failure for our medical providers and the health care providers outside the facility, not to have diagnosed Mr. Johnson's situation, cost him his life — on our watch — inside corrections,” Baker has said. “No one should die in our custody the way that Mr. Johnson passed away.”

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Prisoner’s Rights Office Managing Attorney Emily Tredeau, who led the Defender General’s investigation into Johnson’s death, has called Johnson’s treatment “extraordinarily bad.” 

Dr. Delores Burroughs-Biron, who was Vermont DOC’s medical director from 2007-2015, provided consultation services to the Prisoner’s Rights Office during the investigation. She watched video footage of Johnson’s care, and testified about her findings during a court hearing about Vermont prisons' COVID-preparedness back in April. During her testimony, Burroughs-Biron said Johnson’s care was “not acceptable.” 

"It didn't take many tools to determine that the gentleman was in respiratory distress and needed to go to the emergency room, but it did take the willingness." - Dr. Delores Burroughs-Biron, former DOC medical director

“It didn’t take many tools to determine that the gentleman was in respiratory distress and needed to go to the emergency room,” she said, “but it did take the willingness.” 

Ed Paquin, the executive director of Disability Rights Vermont, previously provided a separate report on Johnson’s death to the Department of Corrections. That report is not available to the public, but Paquin has characterized his findings as amounting to “abuse and neglect.” 

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The Defender General offered a number of policy recommendations in light of their investigation, including a legislative mandate forcing the Department of Corrections to employ an “in-house medical doctor to supervise care state-wide.” 

Matt Valerio, Vermont’s Defender General, noted the state used to employ a doctor in that role, but said the position has been left empty since the Shumlin administration. And, he said, a panel that “reviewed grievances and complaints” has also disappeared over the years. “So one of the things that we recommended is to try to put back in place some of these review and accountability structures,” he said. 

The report also recommends investigations into potential misconduct by DOC staff and licensed professionals by the Department of Human Resources and Office of Professional Regulation.

Update 1:00 p.m. 7/27/20 Centurion, DOC's medical contractor through June of this year, has provided the following statement by email via the communications firm, Marathon Strategies. "We stand by our record of service in Vermont and the quality of care that we have provided to thousands of incarcerated individuals in the state....  While we are not permitted to provide details of the incident — due to privacy laws — we can say that Centurion reported the incident and participated in investigations conducted by the Board of Nursing and the Department of Corrections." 

 

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