An independent investigation into the deaths of seven prisoners concludes that Vermont Department of Corrections (VDOC) policies were partly to blame for some of the deaths. The deaths occurred between November 25, 2002, and October 7, 2003. After the suicide death of PLN contributing writer James Quigley, the Vermont Agency of Human Services retained Michael Marks, a Vermont lawyer, and Philip McLaughlin, a former New Hampshire attorney general, to address the issues those deaths appeared to implicate. Those issues included the provision of medical service, mental health service, and the grievance process.
The VDOC can accommodate up to 1,000 prisoners, but is expected to reach 1,900 in the next three years. Some 500 Vermont prisoners are currently housed in a Corrections Corporation of America prison in Kentucky. The report found the VDOC system is rife with communication problems and is under "tremendous stress" from budget cuts and the increased population. The report examined in great depth the circumstances of each prisoner's death and the conclusions to be drawn from those facts. Recommendations for change were included for administrative and legislative action.
The bulk of the investigative report addressed the events that preceded the suicide death of PLN contributing writer James Quigley. On February 11, 2001, after serving 21 years on a life sentence, Quigley was transferred, via Interstate Prisoner Compact, from a Florida prison to Vermont. That transfer was part of the terms of a settlement in a lawsuit against officials of the Florida Department of Corrections, alleging retaliation against Quigley, and law clerks in general, for filing grievances and lawsuits.
That transfer did not extinguish Quigley's activist spirit, for between September 13, 2001, and his departure from NSCF on July 17, 2003, he filed 36 grievances. His vote against Superintendent Kathy Lanman's proposal to buy flowers with canteen proceeds resulted in Quigley's removal from the "inmate recreation committee" in June 2003.
On June 10, 2003, Quigley had a parole hearing with the Florida Parole Commission, who established parole would not be considered for another ten years. Simultaneously, NSCF's Deputy Superintendent received information from an informant that Quigley had a "back-up plan" to parole. Quigley was promptly placed in administrative segregation as an escape risk. Five days later, the Deputy searched Quigley's property and found maps of all Vermont counties, which were cut from a local newspaper. Also found were Florida maps the Deputy learned Quigley received a year earlier. While those maps were not problematic then, they now constituted support for the "back-up plan."
The Deputy recommended Quigley be put in SMU on open status. The compassion Lanman showed for the dying George Sumner [discussed below] did not extend to "a pain in the butt" who "likes to write tons of grievances over petty issues." Lanman disapproved the recommendation, ordering the "legal paper pusher" Quigley to continue in ad seg until review in 15 days. Lanman then took action to have the VDOC send Quigley back to Florida.
Quigley appealed the ad seg decision. The appeal officer, John Murphy, concluded the hearing record was inadequate to support that there was an escape risk because there was improper reliance on a confidential informant and consideration of material outside the record. On July 1, however, a new hearing officer again concluded Quigley was an escape risk.
While an appeal of that decision was pending, Murphy suggested to Lanman that Quigley be transferred to the St. Albans Facility, which is VDOC's most secure prison, because he was considered an escape risk and he had significant grievances with Lanman.
Under VDOC policy, ad seg decisions are to be reviewed every 15 days, and if there is no evidence to support segregation, the prisoner is to be returned to his previous status. On July 17, 2003, Quigley received such a review, which stated: "Facility has no new evidence to present. Recommended remove from ad seg status," Lanman approved that recommendation, but she overrode Quigley's status to close custody, and approved a transfer to St. Albans. Normally, transfers must be approved by VDOC's Director of Classification. No such approval was received here.
Upon arrival at St. Albans, Quigley was placed on D-Wing. Prisoners in D-Wing occupy solitary cells and they do not have access to standard items such as dental floss or standard tooth brushes. Quigley did not have access to standard writing implements with his full legal file even though he had a pending post-conviction relief motion. He was also denied access to outside recreation or exercise.
Quigley described D-Wing conditions as "the worse I've ever seen." With 40 degree temperatures, his cell window would not close. Quigley wrote his mother, Claire Quigley, and said, "There is nothing to do but retreat under the covers and tremble because they won't provide us adequate clothing or allow us to have our own."
VDOC policy directs that Quigley's classification, Close Management Level I, was designed to be a short term of 30 days in duration. Quigley was on D-Wing for 82 days. During that period his regular descriptions were: "quiet" and "no issues."
When a close management prisoner demonstrates progress and movement towards self-risk management, he is to be placed on a "movement list," in order of priority, for removal from D-Wing. Despite receiving no disciplinary actions and being "quiet," Quigley was never placed on the movement list. Instead, the D-wing management team had an understanding that "Quigley would stay in D-wing until a transfer to Florida" and "He would stay there indefinitely regardless of his good behavior."
On September 11, John Murphy met with Quigley regarding the accumulation of appeals questioning his D-wing placement and the confinement conditions. After Murphy expressed to his supervisor that it was credible Quigley's placement was retaliatory, the supervisor ordered him to look into the reliability of the assertion Quigley was an escape risk.
During that investigation, Murphy was told by NSCF's Deputy Superintendent that, "The only reason that guy [Quigley] is in ad seg is he pissed off the superintendent." Lanman denied she was angry at Quigley. Nonetheless, Murphy concluded there was "more evidence Quigley was retaliated against than he was an escape risk."
Murphy's conclusion was part of an October 6 telephonic conference between various VDOC lawyers and officials and lawyers acting on Quigley's behalf, who agreed Quigley, would be removed from D-wing. This decision was never communicated to Quigley.
In the early morning hours of October 7, Quigley tied a bed sheet to a grate in the ceiling and hanged himself. He died on the 118th day of confinement in administrative segregation or close custody.
The investigative report concluded the system failed in Quigley's case. The initial decision to remove him from open population was justified. A reasonable investigation, such as Murphy conducted in one day, would have disclosed Quigley did not pose an unusual or heightened risk of escape. His confinement to D-wing was not justified. If the system had worked, Quigley would have been removed from D-wing long before his death.
"Distinguishing which individuals were consciously retaliating from those who were indifferent or ineffective would not affect our ultimate conclusion: Vermont's correctional system treated Mr. Quigley differently because he filed grievances and objected to institutional practices. We can discern no good reason for the different treatment," said the report.
Quigley's family has retained counsel and preparing a wrongful death suit against the Vermont DOC as this issue of PLN goes to press. Lanman was removed from the DOC and is now a supervisor with the Morrisville office of the Department of Children and Family Services. Hopefully she shows more care and less vindictiveness dealing with the children of Vermont than she did with its prisoners.
For several years before his death, forty-eight year-old Neil Prentiss had an institutionally well documented history of serious illness, including but not limited to hepatitis B, hepatitis C, peripheral vascular disease and a traumatic brain injury. In October 2002, Prentiss was received from a Virginia prison at VDOC's Chittenden Facility. Between October 14 and 28, Prentiss submitted numerous medical request forms stating he had not received his medications, he was in pain, and urgently needed medical care.
Over that period, guard Douglas Dinsmore noticed Prentiss' condition deteriorating. Acting outside the scope of medical request policy, Dinsmore called the medical department twice in an attempt to procure care for Prentiss. It was not until October 31 that medical staff did more than examine Prentiss and document his symptoms.
By that date, Prentiss had been experiencing for several days abdominal pain, a swollen tense abdomen, diarrhea, and vomiting. Prentiss was transported to a hospital by ambulance. By November 12, he was being considered for a liver transplant and was on life support and a ventilator. Prentiss died on November 23 at the Leahy Clinic in Burlington, Massachussetts.
Because the report's authors are not physicians, they could not conclude if the quality of response to Prentiss' requests was a factor that contributed to his death. They did conclude, however, that the Chittenden medical staff did not act adequately and in a timely manner to Prentiss' requests for health care that expressed urgency and provided detail to support urgency. The investigative report was highly critical of the fact there was no written report from any governmental agency regarding Prentiss' death. "The government owes a duty of candor and transparency to investigate, to report, to accept criticism, to learn, to improve, to move on in the case of all deaths within VDOC."
While trying to regurgitate a bag of drugs a visitor had brought him, Charles Palmer experienced a drug smuggler's worst fear. The bag holding the drugs broke, resulting in the release of drugs into his system. On April 20, 2003, Palmer died of a massive overdose at the Northeast State Correction Facility (NSCF).
Because Palmer's case is the subject of an active criminal investigation, the report detailed few factual findings. The report concluded, nonetheless, that Vermont prisons suffer a problem common to prisons throughout America: The smuggling of drugs.
The report recommended several steps to dissuade persons from engaging in that activity. First, contact visits for prisoners testing positive for drugs should be limited, contact visits should be more closely monitored, and dogs trained to detect drugs should be utilized. Finally, prisoners and visitors caught with drugs should be prosecuted and that fact published.
On January 9, 2002 George Sumner presented to medical staff that he had not been feeling well and had lost twenty pounds over a two month period. Testing diagnosed Sumner with AIDS.
The medical record and interviews with Sumner's family revealed the staff at NSCF was "very attentive to Sumner and provided him not only with medical care, but empathetic and supportive personal attention." As Sumner's condition deteriorated, infirmary staff questioned the suitability of his continued confinement in the infirmary. Options for transfer were considered.
Sumner, aware his condition was terminal, expressed a desire to die among people he perceived as caring for him. His mother confirmed his desire to die at NSCF. Absent the investigative report, acts of kindness extended to Sumner would not have received the recognition they deserved. Superintendent Kathy Lanman occasionally took lunch with Sumner. Five days before his death, Sumner's family visited with him. He requested pizza, and prison staff ordered out for him. Despite an inability to chew or digest, Sumner's mother said he "just smelled the pizza and smiled."
At approximately 5:30 a.m. on February 14, 2003, an infirmary nurse checked Sumner and found he had no vital signs. Emergency resuscitation was begun. When the supervising physician was presented the vital information, he directed cessation of resuscitative efforts, and transport of Sumner to the hospital.
Prior to leaving the prison, as required by VDOC policy on transporting prisoners, Sumner's leg was shackled to the gurney. When Sumner's body arrived at the emergency room of the hospital, the doctor became angry that an obviously dead person had been brought to him. After the doctor refused to accept Sumner's body, he was taken to the funeral home. Sumner's "body remained shackled at the funeral home for several hours and until the accompanying officer was relieved."
While the report concluded infirmary staff provided competent and compassionate care to Sumner, it recommended VDOC's policies on treating terminally ill prisoners be examined for revisement. However, this report asked what the rationale is for shackling and transporting a "patently dead" prisoner to a hospital. Perhaps, that was done to back up staff boasts that, "no one dies in a Vermont prison."
Upon intake into VDOC on November 6, 2002, to begin serving a sentence of one to five years for aggravated assault and petty larceny, Eva LaBounty reported she was depressed, but not suicidal. The next day, LaBounty submitted a request for medical services that she could not sleep and was stressed over just losing custody of her kids. A clinician recommended medication and support.
Upon arrival at the Dale Facility, LaBounty was placed on medication, which increased in quantity as time passed. Between November 2002 and her May 7, 2003, death, LaBounty participated in two weekly group sessions and she worked with substance abuse counselors. By May 1, 2003, LaBounty was receiving daily doses of 250 mg of amitriptyline, 15 mg of buspar, and 300 mg of wellbutrin. The latter two are psychoactive drugs.
Throughout her incarceration, LaBounty expressed experiencing pain and difficulties in dealing with losing her two children, but said she could not harm herself. LaBounty appeared in court on May 5, where her parental rights were terminated. The next day, she met with her case worker. La Bounty said that losing her children was the hardest thing she had ever gone through, and she had to do it without abusing substances.
Around midnight on May 6, LaBounty went to bed. At approximately 5:45 a.m. on May 7, one of her three cellmates could not rouse LaBounty or detect a pulse. Subsequent toxicology reports disclosed LaBounty died of an overdose of amitriptyline, wellbutrin, and methadone. The amitriptyline was in a concentration four times the lethal range. LaBounty also had elevated levels of nortriptyline, diazepam, and desmythldiazepam.
Obviously, the report could not conclude if LaBounty intended suicide or had accidentally overdosed. The report faulted Dale staff for failing to assure prisoners actually consumed their medications when it was known prisoners horded their drugs to use as intoxicants. Additionally, "The Dale staff erred by failing to control access to Ms. LaBounty's room after the discovery of her body. This failure impeded the investigation by the State Police. The investigating officer documented that at least some cleansing of the scene occurred by inmates. There is no way for us to know the full extent of the lost evidence," the report said.
The report concluded Superintendent Rowe was to be commended for trying to discover what went wrong in LaBounty's death and making "responsive, effective changes." The changes included: Guards may no longer dispense medications; they may only be dispensed by nurses, who must physically verify they were consumed. Because amitriptyline is lethal if overdosed, it was removed from the list of approved drugs. All prisoners who have parental rights are automatically placed on mandatory 15 minute checks, and only a mental health professional who has examined the prisoner can discontinue those checks. The report found, further, that the medication level at the Dale Facility is the highest in Vermont. This warrants a systematic audit by a medical expert to determine its appropriateness.
Lawrence Bessette had been in jail on pending assault charges for just over two months when he hanged himself in his cell at NSCF on May 22, 2003. During that period, he had expressed to mental health staff his desire to "string myself up." As a result, Bessette was maintained on a mandatory 15 minute check. By May 14, Bessette's attitude changed because his sentence was not going to be as long as expected. He "report[ed] futuristic thinking, hopeful about release, and spending time with his wife and children." Mental health staff considered Bessette a non-threat to himself and removed him from the mandatory checks.
A telephone call on May 22 made Bessette decide to forfeit his future. He had a lengthy conversation with the mother of his two children, who was also the victim in his assault charge. The woman told Bessette that she was with another man and she would not marry Bessette. When the woman refused to change his mind, Bessette threatened to kill her. He then said he was going to kill himself.
At 3:07 p.m., Bessette returned to his cell. He placed a sign in his window signifying bathroom use. At 3:57, his cellmate found Bessette's body suspended by a belt tied to the bunk bed.
Because of the change in Bessette's behavior, the report did not fault staff for removing him from periodic checks. Staff could not foresee the telephone call or change its affect on Bessette. The report found, however, that there was a delay in transmitting mental health records between facilities that requires immediate attention. That delay had no affect on Bessette's treatment course.
While on furlough status, twenty-five year old Jeremy Garcia died at an appointment in Winoski, Vermont, of an overdose on October 1, 2003. His December, 2002, release plan required, among other things, that he avoid substance abuse. Garcia was unable to do so and he failed twelve drug tests up to his reincarceration in March 2003. At that time, VDOC incarcerated Garcia for 15 days as a sanction for the failed tests.
Subsequently, on May 9, 2003, Garcia was reimprisoned after failing yet another drug test. While in prison he failed several more drug tests. VDOC refused to release him until he entered an approved residential treatment program.
On September 29, 2003, VDOC furloughed Garcia so he could enter the Maple Leaf Farm treatment center. The next day, Garcia called his parole officer and said he felt threatened at the center. He then left Maple Leaf Farm. Sometime on October 1, Garcia died of an overdose of oxycodone.
"Garcia's death depicts the destructive power of drug additional," the report said. State officials used all the tools in their power to dissuade Garcia from using drugs, but not even incarceration prevented him from doing so. The only issue presented for state officials to act on in the matter is the availability of drugs in prison.
The investigative reports authors did a commendable job of establishing the facts and conclusions in an impartial manner. They recommended changes on issues related to these prisoners' deaths.
In the mental health area, there needs to be a quality assessment system to grade the services rendered to prisoners. The grievance procedure should assure a prisoner's complaint is acted upon or rejected in a timely manner. The authors also suggested that the state or VDOC provide more funding for the Prisoner's Rights Office of the Vermont Defender General because it may provide quicker and more reliable adjustment of VDOC errors.
In his last letter, Quigley said, "They're all full of crap. Spin is everything to these prison officials. It's all a front." The report's authors agreed when they lambasted VDOC's written reports into the deaths of Bessette, Quigley, Palmer, and LaBounty. Those reports did not address in depth the circumstances surrounding the deaths, and they provide no basis for assessing or improving VDOC practices. Instead, they emphasize facts that would be favorable to the VDOC in subsequent litigation while ignoring potential errors that warrant correction.
The question that now arises in these prisoners' deaths is now that VDOC's facade has fallen, will administrators and legislators act to correct the problems or will the philistines spin a new front?
A copy of the report is posted on PLN's website at www.prisonlegalnews.org.
Sources: Investigative Report in the Deaths of Seven Vermont Inmates and Related Issues; Brattleboro Reformer; New York Times.
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