Law firm report: Not enough done to help dying inmate
Vermont Department of Corrections staff should have done more to help an inmate who complained repeatedly that he could not breathe and their response was insufficient to keep the man from dying from a breathing obstruction caused by a tumor, according to a report released by a law firm on Monday.
“That should not have happened,” Downs Rachlin Martin said in its report on the death of Kenneth Johnson, 60, on Dec. 7, 2019, while in custody at the Northern State Correctional Facility in Newport. The department had asked the firm to investigate the death of Johnson. A separate personnel review is being done by the state.
The report recommends policy clarifications and training.
“Looking at the surveillance and the factual background for this the conclusion is inescapable that more could have and should have been done to care for Mr. Johnson,” said the law firm’s Tristram Coffin during a press briefing. “It just is not sufficient that an inmate complains persistently and credibly of not being able to breathe for a period of some hours consistently, does not see a doctor, does not go to the hospital and then later on dies apparently from breathing complications. That is just not as a policy matter how Vermont should be conducting its business.”
In July, the Vermont defender general’s office released a report that said staff at the Newport prison ignored Johnson’s pleas that he could not breathe and threatened him instead of providing lifesaving care. Defender General Matthew Valerio had recommended that the Department of Corrections hold then-medical provider Centurion “accountable for withholding timely life-saving care and conducting no subsequent administrative review.” He also called for the state to look into whether staff actions constituted employee misconduct; review the actions of professional licensees and appropriately discipline; and for the DOC to reinstate an in-house physician as medical director and for the Legislature to mandate that as well as the timely review of all aspects of inmate deaths.
Department Commissioner James Baker, who took over in January, said the state sometimes has a very challenging prison population when it comes to medical care and mental health challenges.
“We have to get better at the way we deal with those who are in our custody and in our care,” he said.
Coffin said Monday that his gut feeling is nothing criminal happened.
“It was just a tragedy that resulted from kind of not strong enough policies empowering people to take the responsibilities that they needed to take, he said. “It just is unconscionable that somebody can complain of not breathing for that period of time and not get the care that he needed. I didn’t see anyone intentionally trying to cause his demise.”
The report from him and lawyer Timothy Doherty said the supervisor and health care staff appeared to have threatened Johnson with a move to a holding cell from the infirmary.
The report recommends additional training and clarification of policy in the use of a holding cell for medical purpose; observation checks; and contact with the superintendent and senior management. It also said the Department of Corrections should train staff in implicit bias, while noting that is impossible to determine if racial bias played a role in Johnson’s death.
“Nevertheless, the fact is that Mr. Johnson — a person of color — was under the supervision and care of an almost entirely white staff, a number of whom apparently disbelieved his persistent and credible claims that he could not breathe and failed to respond to those claims in a manner that ensured safety,” the report stated. Given these circumstances, it(’s) reasonable to conclude that implicit bias likely played a role in shaping staff’s reaction to Mr. Johnson’s medical crisis.”