The Agency of Human Services and several departments all played a part in the circumstances that led to the suicide of a Springfield inmate earlier this year, Defender General Matt Valerio told lawmakers Wednesday.
Patrick Fennessey, 34, died in April, two days after he attempted to hang himself in his cell at Southern State Correctional Facility.
Valerio summarized the investigation into Fennessey’s death, which is still ongoing, as part of a presentation to the Joint Legislative Justice Oversight Committee on the deaths of the three people in DOC custody this year.
The committee of 10 lawmakers meets outside of the legislative session to follow developments in the criminal justice system.
Annette Douglas, 43, was an inmate at the Chittenden Regional Correctional Center, the state’s only women’s prison, when she died in January. James Nicholson, 65, died in the infirmary at a Corrections Corporation of America prison in Kentucky in May.
Valerio said that of the three deaths, he found Fennessey’s to be the most “troubling.”
Fennessey had several mental health issues, as well as a history of alcohol and substance abuse, that complicated his ability to live independently in the community. He was classified as seriously functionally impaired (SFI), a designation that exists only in the correctional system that indicates an individual may respond differently a correctional setting.
Because of the acuteness of his mental heath issues, Fennessey required support from community-based mental health services in order to live in the community on probation or parole.
“It’s pretty obvious to me that the Department of Mental Health and the Agency of Human Services, Health Care and Rehabilitative Services and the Department of Corrections all to some degree contributed to failing to prevent this guy from committing suicide,” Valerio said.
Following a minor criminal charge in 2007 with a two-year minimum prison sentence, Fennessey had been in and out of prison several times. Most recently he had been released in December 2013 with a plan for community-based mental health support, as VTDigger reported in June.
Before Fennessey returned to prison in August 2014, he resided in an apartment in Springfield with a support plan coordinated by the local designated agency, HCRS, Valerio said. The plan included a full-time, live-in caregiver who helped oversee Fennessey’s health and medication regimen.
According to the investigation by the Defender General’s office, Fennessey’s living situation was deemed unacceptable when a DOC field service unit stopped by his apartment and found that the HCRS-appointed caregiver was intoxicated.
At that time, Fennessey was sent to the Brattleboro Retreat for treatment. Once he had stayed in the mental health facility for the full length of time he could on his insurance, he was returned to the custody of the DOC and placed in Southern State Correctional Facility, Valerio said.
“As a practical matter, you didn’t have AHS, DOC, DMH working on the same page with this guy, and when they don’t know what to do they bring him back into a facility,” Valerio said.
According to the Defender General’s investigation, before Fennessey’s death he told many people, including fellow inmates and correctional officers, that he was going to attempt suicide, Valerio said.
“It wasn’t taken seriously, or as much as it should have been,” Valerio said.
The investigation into Fennessey’s death is still ongoing. Valerio expects investigators will need several more months to finish going through paperwork, he said.
No fault in other deaths
Investigations by the Defender General’s office into the other two deaths did not find strong indications of fault.
James Nicholson died in the infirmary of the Corrections Corporation of America facility in Kentucky that housed hundreds of Vermont inmates until the end of June, when the GEO Group took over the out-of-state contract.
Nicholson died May 18 of cardiac arrest and other medical complications, according to an autopsy that was completed in late July.
A month and a half before his death, Nicholson was so severely injured in a fight in the prison that he was hospitalized. Upon his return to the prison, he was placed in the infirmary unit where he remained until his death.
According to the Defender General’s summary report, there are no clear links between the injuries Nicholson sustained in the fight and his death.
Gordon Bock, who heads the Vermont chapter of the national prisoners’ rights group CURE, testified that the months-long wait for clear conclusions about the cause of Nicholson’s death illustrates challenges with the out-of-state prison program.
“To us, the Nicholson death demonstrates one of the sundry reasons not to send our prisoners out of state,” Bock said.
From an investigation into the death of Annette Douglas, the Defender General’s Office concluded that she died because she refused medical treatment.
The summaries of the investigations are available online here.
Mental health and the correctional system
Sen. Dick Sears, D-Bennington, who chairs the committee, hopes that lawmakers will work on finding ways to better address serious mental illness in prisons.
“I’m hoping one of the things that will come out of our committee’s work is how do we deal with the seriously functionally impaired who have mental illnesses that aren’t being addressed in a correctional setting,” Sears said.
Dr. Dee Burroughs-Biron, DOC health services director, told the committee that reform of mental health treatment and the correctional system needs to be done thoughtfully.
“We need to be doing this every single day until we find a solution,” Burroughs-Biron said.
After the hearing, DOC Commissioner Andy Pallito said that he agrees with the Defender General’s assessment that the various players across the AHS failed to respond sufficiently to Fennessey’s needs.
Pallito said that the relationship between the correctional system and mental health needs to be further evaluated.
“I think the oversight committee needs to put some thought into how that shakes out,” Pallito said.
