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Vermont Prisoner’s Death Under Investigation: Did Implicit Bias Play Role?

A November 2020 report by Tristam Coffin of the Burlington-based law firm Downs Rachlin Martin, prepared at the request of Department of Health and Human Services Secretary Mike Smith, stated that Johnson repeatedly complained that he could not breathe but was nonetheless denied necessary medical attention, possibly due to his race. His findings closely mirrored a July 2020 report prepared by Matthew Valerio, defender general of the PRO.

Johnson had been admitted to the infirmary at NSCF in fall 2019, complaining of shortness of breath, hoarseness and difficulty swallowing. The preliminary diagnosis was possible chronic obstructive lung disease. He was placed on steroids and scheduled to see a specialist.

On December 6, 2019, Johnson started showing signs of respiratory distress. He began complaining that he could not breathe and was dizzy. He fell on his way to the bathroom and had to be escorted back to his bed by a guard.

Both reports stated that Johnson’s pleas for medical attention were ignored and that guards threatened Johnson with solitary confinement if he did not stop complaining. Johnson died on December 7 due to a cancerous tumor blocking his air passage.

The summary of the Valerio report stated that Centurion staff ignored Johnson’s pleas for medical attention and that Vermont’s DOC was “complicit in covering up its contractor’s gross failure to provide lifesaving medical care.” He condemned Centurion for not conducting a subsequent administrative review and suggested staff actions be reviewed for possible misconduct and discipline. He recommended the DOC cancel its contract with the outside health-care provider and for the Legislature to mandate timely review of all prisoner deaths.

The report said it was impossible to determine if racial bias was a factor in Johnson’s medical treatment but recommended more training in implicit bias when dealing with prisoners, as well as appropriate use of holding cells for medical purposes.

Coffin’s report echoed that of Valerio’s. It said that it could not determine that race played a role in Johnson’s lack of medical treatment, but it was “hard to say that that wasn’t the case.”

Vermont DOC Corrections Commissioner Jim Baker canceled Centurion’s contract and hired a new private health-care corporation to provide services, Kansas-based VitalCore health Strategies. 


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