By Eric Blaisdell
Staff Writer
MONTPELIER, Vt. — A state official says an independent investigation has found “there’s plenty of blame to go around” after a Black inmate died in December due to an undiagnosed tumor in his throat, despite his repeated calls for medical attention.
Kenneth Johnson, 60, died at the Northern State Correctional Facility in Newport. As part of the response, the state hired the law firm Downs Rachlin Martin to look into the matter. The state is conducting its own investigation.
The state released the law firm’s report Monday and held a briefing with the media about it.
According to the 38-page report, Centurion, the company the state had contracted with for medical services for inmates at the time of Johnson’s death, refused to participate in the investigation. The company did not return a request for comment Monday.
The state has since contracted with VitalCore Health Strategies out of Kansas for inmate health care. That contract started in July.
Tristram Coffin, a former U.S. Attorney who now works for the Montpelier law firm, said Johnson “repeatedly and persistently” reported he couldn’t breathe while at Northern State Correctional Facility in Newport. Coffin said on three instances those at the Department of Corrections called for a “10-25,” or an urgent response to an event, for Johnson.
He said for the first call, witnesses reported Johnson said he couldn’t breathe and he was given medication. Coffin said Johnson still appeared to be in distress.
Coffin said Johnson was later found lying on the floor of a bathroom next to the infirmary. He was still reporting he couldn’t breathe, according to the report, and asked to be brought to a hospital.
Coffin said Johnson was told by DOC and Centurion workers he was not going to the hospital and was told to lie down. He said the surveillance footage showed Johnson was breathing heavily and was gesturing toward his throat.
Coffin said Johnson was checked on by DOC staff every 30 minutes, but it’s unclear how thorough those checks were. He said it didn’t appear any nurses checked on him after the incident in the bathroom.
He said later an inmate in the infirmary got a nurse’s attention because Johnson was unresponsive. Johnson was reported dead on arrival at North Country Hospital in Newport. “First and foremost, looking at the surveillance tape and the factual background for this, the conclusion is inescapable that more could have and should have been done to care for Mr. Johnson,” Coffin said. “It is not sufficient that an inmate complains persistently and credibly of not being able to breath for a period of some hours, does not see a doctor, does not go to the hospital and then later on dies apparently from breathing complications.”
Coffin said it’s “hard to say” if Johnson was treated differently because he was Black, but it couldn’t be ruled out. He said based on interviews with DOC staff, it appeared the department’s implicit bias training needs to be strengthened.
The report stated, “A number of the DOC Officers that (the law firm) interviewed state that they had not received implicit bias training from DOC. A DOC supervisor explicitly disclaimed knowledge of the concept of implicit bias.”
Coffin said it appeared the department could also use stronger policies addressing the culture and attitudes of corrections staff when it comes to treatment of inmates. He noted Johnson was threatened with being moved to a “less accommodating” cell by DOC staff when he was complaining about his breathing issues.
Mike Smith, secretary of the Agency of Human Services which oversees corrections, called the findings a “disturbing report.” Smith said, “there’s plenty of blame to go around,” pointing at the actions of DOC staff and medical staff. He said it was “unfortunate and disconcerting” that Centurion did not participate in the investigation.
“We all hold responsibility for the care of the individuals in our state, especially in our correctional facilities, especially those that are in custody. And the state has taken the responsibility seriously,” he said.
Smith said “without question” those at the department could have prevented Johnson’s death. He said state officials continue to look into the incident and will make results to avoid another incident like this in the future.
He said those at the department have already begun looking into issues of racial equity.
“We have embarked on challenging and self-reflective work and I think this report starts that process and continues that process to change the culture within our facilities,” he said.
eric.blaisdell @timesargus.com
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