An inmate who committed suicide inside a Newport prison in August was not subjected to adequate medical monitoring after he was prescribed an anti-depressant that can prompt extreme emotional swings, the Vermont Defender General's Office concluded in an investigation released yesterday.
Robert Mossey, a 38-year-old Burlington man who hung himself in the Northern State Correctional Facility on Aug. 30, was placed on medication while an inmate, but was not subjected to the strict follow-up reviews received by patients who aren't incarcerated, Defender General Matt Valerio told lawmakers yesterday.
"Some of those medications can make you suicidal, instead of stopping you," Valerio said. "There's no indication from the records that (appropriate monitoring) occurred."
Valerio declined to specify the medication used or provide other details, and he said it was unclear if more follow-up exams would have made a difference in Mossey's case. But he said the lack of monitoring was worrisome.
"It hurts me to know that the simplest directions can't be followed," Valerio said. "I'm not putting cause and effect (together) here, because I don't know that. But ... that's what I'm concerned about."
In a letter sent to lawmakers hours after the hearing, Department of Corrections Commissioner Andy Pallito did not respond to Valerio's concerns about the medication, though he addressed other aspects of Valerio's report.
The Defender General's Office investigation looked at whether anything that happened in the Mossey incident pointed to problems that would jeopardize the ongoing safety of Vermont inmates. The Vermont State Police conducted a separate inquiry and determined that no laws were broken. And the state just launched an internal inquiry, to see if DOC policies were violated.
Valerio said his office did not uncover any problems that pointed to major concerns throughout the DOC.
"There's not some huge systemic issue," Valerio said.
However, Valerio told committee members that other details surrounding Mossey's death and the immediate aftermath raised flags.
Once Vermont State Police were finished examining the scene, other inmates were assigned to clean up the mop closet where Mossey took his life, a task that involved significant "blood and tissue" cleanup, Valerio said. But the inmates — who are routinely called upon to clean-up messes inside the prison — were not wearing gloves and other protective equipment, and do not have medical training.
"They're not trained to protect themselves from any kind of fluid or blood-borne pathogens," Valerio said.
Valerio recommended inmates no longer be tasked with such cleanups.
In his letter to the committee, Pallito said inmates assigned to cleaning crews usually receive training and specialized equipment to deal with "biohazards."
"These inmates receive specialized training as well as equipment to deal with sites deemed by Corrections staff as bio harzadous," Pallito said. "This is a long standing practice of the DOC and allows for the swift cleanup of areas within facilities. Speed is essential to maintaining the security and safety of facilities. We are working with DHR on their investigation to determine if proper procedures were followed."
Additionally, Valerio said the inquiry was hindered by a refusal of some prison guards to talk to investigators. Valerio said that lawyers from the Department of Human Resources had apparently instructed the guards to not talk, which Valerio said was a departure from how previous inquiries into prison cases have been conducted.
"We've seen a bit of a shift in that paradigm relatively recently," Valerio said. "In the past we've had conversations with corrections officers regarding incidents, and that has not been accommodated in this case."
In later testimony, DHR Commissioner Kate Duffy said her department was hesitant to have prison guards to speak because anything they said could have jeopardized a possible criminal case, if the Vermont State Police had found reason to make an arrest, and put the guards in legal jeopardy.
"There are Fifth Amendment issues that arise around that, so we are very careful to make sure that a criminal investigation ... has complete integrity," Duffy said.
Vermont State Police Lt. Robert Cushing told lawmakers that Mossey gained access to the mop closet, which is normallly locked, after one of the few inmates with a key left it open at Mossey's request. (The inmate who left the door open believed Mossey was simply trying to access cleaning supplies, which Cushing said is a fairly regular occurrence for inmates in that population block.)
Once inside, out of view of other inmates and guards, Mossey jammed the lock with an ink cartridge and hung himself with a bedsheet. He left behind notes and journal entries that discussed suicide.
His family has said Mossey struggled with drug addiction.
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