In the hours before Kenneth Johnson died in the Northern State Correctional Facility in Newport late last year he repeatedly complained that he couldn’t breathe.
A correctional officer responded that if he “did not knock it off” he would be placed in the holding area at the prison, a form of solitary confinement.
That exchange is among the many new details provided in the summary of a report prepared by the state Defender General’s Prisoners’ Rights Office investigating the death of Johnson, a Black inmate, in the Newport prison the night of Dec. 6-7.
The document sketches out a timeline of the lack of care and hostility Johnson endured in his final hours, and provides a damning account of those who were supposed to be responsible for his well-being while he was in their custody.
“This is one that calls into question whether race played a factor,” Matthew Valerio, Vermont’s defender general, said Tuesday. “I can’t conclusively say that, but in my heart I believe that.”
He talked about how the case mirrors other deaths of Black men at the hands of those in authority, which have sparked protests around the nation over the past weeks following the police killing of George Floyd, a 46-year-old Black man, in Minneapolis in May.
“It’s about not listening when they tell you, ‘Look I can’t breathe here, there’s something really wrong here’ and they say, ‘Go back to your bed or I’ll put you in the hole,’” Valerio said.
The report summary into Johnson’s death presented a charge to the Vermont Human Rights Commission: “Investigate the role that implicit racial bias in officers and nurses” had in ignoring “Mr. Johnson’s pleas that he could not breathe.”
Bor Yang, executive director of the Vermont Human Rights Commission, couldn’t immediately be reached Tuesday for comment.
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It was just last week that James Baker, who took over as interim corrections commissioner about a month after Johnson’s death, cited “failures in the system” from the corrections department to its contracted prison medical provider, Virginia-based Centurion Managed Care.
Baker also said at the press conference last week he didn’t know why the corrections staff or the medical providers acted as they did toward Johnson, but added that an internal investigation as well as other probes are underway.
“No one should die in our custody the way” he did, Baker said at that time.
On Tuesday, Baker offered a similar assessment.
“It should not have happened on our watch, it should not have happened,” the commissioner said. “The report is hard to read.”
Baker added, “Our systems, both internally and externally, failed.”
He said changes are underway, including partnering with the state Department of Vermont Health Access to allow a doctor to monitor a new health care contractor, VitalCore Health Strategies, moving forward. Baker also talked of initiatives in place to help recruit and hire a more diverse workforce.
“At the end of the day, the Vermont Department of Corrections is responsible for the individuals that are in our custody,” he said. “Our responsibility is to give them the best medical care we can, both statutorily and morally.”
The Prisoners’ Rights Office investigation included interviews, record reviews, and video from surveillance cameras at the prison. “We have reams of documentation,” Valerio said. The full 22-page report was recently provided to the corrections department.
Valerio said he was only publicly releasing an “executive summary,” rather than the full report, due to the several reasons, including that the Prisoners’ Rights Office within his department has an attorney-client relationship with inmates in Vermont’s prisons. In addition, he said, the full report includes confidential personnel and medical records.
“What I try to do is put out as much I can to get the story across without disclosing specific sources,” he said.
The summary report by the Prisoners’ Rights Office and obtained this week by VTDigger levels harsh criticism at the state Department of Corrections, highlighting that ultimately it is that state’s responsible to provide the oversight of the care of those in its custody.
“DOC is complicit in covering up its contractor’s gross failure to provide live-saving medical care,” the report summary stated.
“DOC has provided no internal administrative review, which both DOC policy and the medical contract require,” the document read. “DOC has claimed that Mr. Johnson died at the hospital, but he was dead on arrival.”
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Among those interviewed for the report, according to Valerio, was Raymond Gadreault, 71, of Coventry.
Gadreault was an inmate who had been in the same prison infirmary as Johnson at the time of his death as well as the days leading up to it. In an interview Monday night with VTDigger, Gadreault gave a similar account to the one laid out in the Prisoners’ Rights Office summary report.
He talked about how Johnson repeatedly told corrections and medical staff that he couldn’t breathe on the night he died and pleaded to be taken to the hospital. Gadreault had also talked to Seven Days shortly after Johnson’s death providing a similar description of that night.
Speaking Monday evening, Gadreault said he could only offer one explanation for the lack of medical care at the prison for Johnson, “I’ll tell you straight up, it was racism.”
Gadreault said while he didn’t hear anyone making racist comments, prisoners in the infirmary who were white had received much better care than Johnson. “If he were white this wouldn’t have happened,” Gadreault added of Johnson.
Family members for Johnson could not be located for comment.
The three-page summary document, in bullet point fashion, outlines the following steps leading up Johnson’s death:
Johnson, 60, of Staten Island, New York, had been held without bail awaiting trial since September 2017 when he was charged with sexual assault and human trafficking.
It was in fall 2019 that Johnson told nurses of his shortness of breath, while also informing them of worsening hoarseness, trouble breathing, and the feeling of something stuck in his throat, the document stated.
Prison medical staff suspected chronic obstructive lung disease, or COPD, and prescribed Johnson steroids, which failed to improve his breathing but aggravated his diabetes.
Johnson, still in the infirmary on Dec. 6. 2019, showed many signs of acute respiratory distress and nebulizer treatment wasn’t working, according to the document.
As a result, the summary stated, “he was panting, restless, rubbing his chest, splashing water on his face, rocking back and forth; and he said outright, repeatedly, that he could not breathe and needed to go to the hospital.”
The on-call provider prescribed him cold medicine and nurses told him to stay in bed. His vital signs were never checked and neither were his lungs.
“Prison nurses can and do send patients to the ER,” the document stated. “However, the night Kenneth Johnson died, nurses either failed (to) recognize that he was dying or were unwilling to help.”
In the bathroom later that night Johnson collapsed, asking for oxygen and to go to the hospital. Instead, a corrections officer walked him from the bathroom to his bed.
“The officer observed that Mr. Johnson was ‘flailing all over and would not sit still, stating he was getting dizzy … He kept panting and making a fuss saying he couldn’t breathe,’” the document stated.
“The officer threatened Mr. Johnson that if he did not ‘knock it off,’ he would be placed holding — a form of solitary confinement,” the summary added. “A nurse physically forced Mr. Johnson to lie back in bed.”
Video from inside the prison showed Johnson in agony, the document stated, adding, “He died after hours of struggling to breathe while nearby nurses did nothing to help.”
Additionally, the medical documentation and the facts didn’t add up. An entry reported Johnson awake at 2:20 a.m. on Dec. 7. However, by then, according to the video, Johnson was no longer breathing.
“This suggests that nurses were not performing checks,” the document stated. “Nurses learned Mr. Johnson had stopped breathing only when other patients alerted them.”
Johnson had no pulse by the time nurses checked on him and it took several more minutes before they unsuccessfully tried CPR. When emergency medical technicians arrived, Johnson hadn’t had a breath or a pulse for 20 minutes.
He was taken to North Country Hospital in Newport where he was pronounced dead on arrival.
A later autopsy, according to the document, revealed that Johnson died from an undiagnosed tumor in his throat that had blocked his airway.
A death certificate from the Vermont Department of Health stated Johnson’s cause of death as airway obstruction by laryngeal squamous cell carcinoma, with the onset of death within “minutes/week.”
In addition, the certificate stated that the manner of death “Could not be determined.”
Baker, the corrections commissioner, announced last week that Centurion, which had been contracted to provide health care services in Vermont’s prisons for the past five years, was no longer doing that.
Instead, following a request for proposals, the state selected Kansas-based VitalCore Health Strategies to perform the task and the change took place July 1.
Asked at the press conference announcing that change if Johnson’s death was the reason for the switch in health care providers, Baker responded, “What I would say is that that case was an example for me coming in after the fact, being briefed on it, that caused me to rethink the way health care is provided within the system.”
In addition to conducting its own internal investigations, Baker said Tuesday the state has contracted with the Vermont-based law firm, Downs Rachlin Martin, to investigate.
That is the same law firm the state contracted with earlier this year to investigate corrections misconduct allegations at the Chittenden Regional Correctional Facility in South Burlington, the state’s only women prison.
Michael Touchette, who had been corrections commissioner, resigned from the position in mid-December following a Seven Days expose on the women’s prison, outlining a series of allegations of sexual misconduct and drug use.
The summary document from the Defender General’s Office includes a list of policy recommendations and calls on various state departments, agencies, and offices to look at the actions, or the lack thereof, of those involved.
The report also calls for a review by the corrections department of the training protocols for correctional officers on implicit racial bias and recognizing medical emergencies.
“The thing that has to be overcome at some time is a change in culture at how medical complaints are addressed and evaluated in our prison facilities,” Valerio, the defender general, said Tuesday. “Something has to change.”
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