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Disability Rights Vermont Report Faults Staff for Disabled Prisoner’s Death

In June 2010, the advocacy group Disability Rights Vermont (DRV) released a report faulting the staff of the Chittenden Regional Correctional Facility (CRCF) in South Burlington, Vermont in connection with the death of a disabled prisoner.

Michael Crosby, 49, was arrested after he turned himself in on charges of selling prescription drugs. Crosby, who was on parole at the time, had a lengthy history of minor criminal misconduct that was mostly related to drug abuse and misbehavior while under the influence of drugs or alcohol. He also had a documented history of accidentally overdosing on his prescription medications and at least two serious suicide attempts. At the time of his arrest he was receiving outpatient mental health, psychopharmacological and substance abuse services. He was also obese, sedentary and receiving Social Security benefits for his disabilities.

Crosby was taken to CRCF, a minimum-medium security facility in the Vermont Department of Corrections’ (VDOC) integrated jail/prison system. One of the guards who transported Crosby to CRCF noticed that he was sweating profusely. When asked about the sweating, Crosby allegedly replied that he was a “big guy” and “not in very good shape.” It was undocumented whether the arresting and transporting guards adequately conveyed to CRCF personnel the extent of Crosby’s drug abuse history or that he had been arrested on drug charges.

Crosby was kept in a holding cell with other prisoners, then moved to a cell by himself without receiving a proper health evaluation. He was discovered unresponsive in his cell ten-and-a-half hours later and transported to a hospital where he was pronounced dead. His death, on August 26, 2009, occurred ten days after the death of another Vermont prisoner, Ashley Ellis, who was denied medication by medical staff at the Northwest State Correctional Facility. [See: PLN, April 2010, p.32].

Under CRCF policies, as a recent drug user who could experience dangerous withdrawal symptoms, Crosby should have been referred to medical staff for a health evaluation immediately upon his admission to CRCF. He was not. Instead, a Licensed Practical Nurse (LPN) who had no credentials to assess patients’ health, but whose duties included “contributing to the assessment of the health status of individuals,” spoke with him briefly. She noted that Crosby was “a bit sweaty” and slurred his speech, signs of intoxication.

The LPN was an employee of Prison Health Services (PHS), a private prison medical care contractor. PHS policy required that a physician be contacted if a prisoner appeared to be intoxicated or in withdrawal; however, no doctor was called in regard to Crosby. Further, in violation of another PHS policy requiring immediate documentation, the LPN failed to document her informal evaluation of Crosby for 22.5 hours. By that time Crosby had died. A separate PHS policy instructing night shift PHS employees to defer all non-critical health care to the day shift may have contributed to Crosby’s death.

Delaying prisoners’ health evaluations was contrary to the contract between the VDOC and PHS, which required immediate health evaluation by a qualified health care provider (registered nurse or physician) upon intake. However, a PHS health assessment policy indicated that PHS considered it sufficient if the screening was performed within 24 hours and a physical examination within a week of admission. 
Guards at the prison also contributed to Crosby’s death. One guard who filled out Crosby’s intake form failed to notify her supervisor even though the information on the form regarding Crosby’s prior suicide attempts and appearance of intoxication required her to do so. While Crosby was supposed to be observed at staggered intervals not to exceed 15 minutes, and guards were supposed to check for signs of life, documentation and videotapes showed that the guards falsified time entries and did not spend enough time at his cell door to check for signs of life when they did check on him. The DRV report concluded that the guards’ behavior indicated they were accustomed to a lax environment with little oversight of their compliance with the VDOC’s policy on cell checks.

An autopsy revealed that Crosby died due to “Acute mixed (Diazepam, Methadone, Oxycondone, Tramadol and Citalopram) intoxication” with “hypertension, atherosclerotic cardiovascular disease, obesity (body mass index 34.0) and chronic substance abuse” as contributing factors. Of the drugs in his system, only Citalopram had been prescribed to Crosby by a physician.

DRV found there were numerous policy violations by VDOC and PHS staff, and “the most egregious of these violations involved the lack of any formal medical assessment of Mr. Crosby upon his admission to CRCF.” This failure led to other medical deficiencies which, combined with the ineffective cell checks, likely contributed to his death. DRV recommended revising several policies and improving training to clearly require proper health assessments using properly-trained health care professionals immediately upon admission. It also recommended disciplinary action against the health care and security personnel who contributed to Crosby’s death. Since Crosby died, the VDOC has contracted with a different prison medical care provider.

Rob Hofmann, Secretary of Vermont Human Services, disagreed with the report. “Those checks were done,” he said. “The offender was seen by a nurse.”

Hofmann added that saving people from themselves was not the job of the state, noting that the medical examiner listed substance abuse and an unhealthy lifestyle as a cause of death.

“People who come into prison are distinctly more overweight, more apt to smoke, more apt to have substance abuse problems, more apt to have a host of chronic conditions,” said Hofmann. Unfortunately, he did not make the connection that such people might need medical care for those conditions, and that it is the prison system’s responsibility to provide such care. The DRV report is available on PLN’s website or at

Sources: “Investigation into the Death of Michael Crosby at the Chittenden Regional Correctional Facility on August 26, 2009” (Disability Rights Vermont, June 2010);

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