That is the assessment of interim Corrections Commissioner Jim Baker, who said on Monday that multiple investigations into last year's death of inmate Kenneth Johnson have revealed significant failures within the state prison medical system, ranging from a failure to diagnose tumors blocking Johnson's airways to an apparent disregard among nursing staff for his life-threatening symptoms.
"Mr. Johnson repeatedly told staff that he could not breathe," Baker said. "I don't know why the reaction was not different."
"I have not read all the reports yet, but I've been briefed, and I've been briefed enough to know that no one should die in our custody the way that Mr. Johnson passed away," Baker said at a virtual press conference announcing that the department has hired a new health care contractor. "The failure for our medical providers, and health care providers outside the facility, not [to] have diagnosed Mr. Johnson's situation cost him his life on our watch."
Baker's comments come as the Vermont Prisoners' Rights Office prepares to release a report that will conclude prison staff could have done far more to help Johnson. Supervising attorney Emily Tredeau said Monday that she expects the report will be published within the next several days.
"We’ve done an exhaustive investigation — including looking closely at all the security video, interviewing witnesses and examining medical records — and run all this past a very experienced physician with experience in correctional health care," Tredeau said. "Absolutely, the DOC prison health care system failed him."
Johnson was awaiting trial after pleading not guilty to charges of human trafficking and sexual assault of a minor. He had been having trouble breathing for more than a week before he died, according to Raymond Gadreault, a fellow inmate who recounted the events leading to Johnson's death for Seven Days last year.
Johnson, Gadreault and a third prisoner spent the night of December 6, 2019, in a locked infirmary at the Northern State Correctional Facility in Newport. Gadreault said Johnson spent at least four hours that night "knocking on the window, telling the nurses he was having trouble breathing and needed to go to the hospital."
Nursing staff ignored Johnson and then threatened him, according to Gadreault. He said one nurse entered the room shortly before Johnson's death and "ordered him to lay down with his feet up in the air and keep quiet and stop bothering them because he was faking it."
The nurse then threatened to move Johnson to a cell without a bed in another part of the prison, Gadreault said. Early the next morning, Gadreault found Johnson was not breathing. Johnson was then transported to the hospital, where he was pronounced dead.
DOC officials said at the time that Johnson appeared to have died from natural causes. A noncertified copy of his death certificate from the Vermont Department of Health lists his cause of death as "Laryngeal Squamous Cell Carcinoma," a type of throat cancer.
Mike Touchette, then-commissioner of the DOC, told Seven Days last December that, in the hours before Johnson died, nurses at the facility had "fairly frequent interactions" with him about "some level of uncomfortableness he was having."
Touchette resigned that same month in the wake of Seven Days' prison investigation. On Monday, his replacement said that he did not understand why the nurses ignored Johnson's pleas.
Prisoner advocates called the incident yet another tragic example of the woefully insufficient medical service provided by the DOC and its contractor, Centurion.
In early 2019, nine months before Johnson's death, the estate of inmate David Bissonnette sued the DOC and Centurion, alleging that they had contributed to his November 2016 death by placing him in a segregated unit while he suffered from opioid withdrawal.
Just like Johnson, Bissonnette had complained of chest pains and difficulty breathing during his short prison stay. The lawsuit said a medical provider responded by giving him a book of word search puzzles "to help distract him from his perceived 'anxiety.'" Bissonnette died days later from bacterial endocarditis.
Three Vermont inmates held at a Pennsylvania prison died in late 2017, including one who suffered from metastatic cancer, which reportedly went untreated.
Speaking about Johnson's death, Baker cast blame on medical professionals outside the prison system as well, saying Johnson had been transported for "at least one" checkup during which he also failed to receive a proper diagnosis.
"Our system failed — not only our internal system, but our external system," Baker said.
It is unclear when and where Johnson was treated. A DOC spokesperson could not immediately provide details of Johnson's treatment history, though a news story from the Caledonian Record published two months before his death said he was hospitalized at Northeastern Vermont Regional Hospital for chest pains after a court hearing.
S. Lauren Hibbert, director of the Vermont Secretary of State's Office of Professional Regulation, which licenses medical professionals, confirmed that her office received a complaint connected to Johnson's death. But she said state law allows her to release complaint details only if prosecutors in her office decide to charge a license holder with unprofessional conduct. She said the investigation is ongoing.
Vermont State Police spokesperson Adam Silverman said the agency also has an ongoing investigation into the case. So does the corrections department, Baker said. And the state has retained the Burlington law firm Downs Rachlin Martin for an independent probe separate from the one it is already running on the prison system as a whole.
Baker, meantime, has already received one report about Johnson's death, from Disability Rights Vermont.
A.J. Ruben, the office's supervising attorney, said the report was not made public because Disability Rights does not have authorization to release details provided by Johnson's family or estate. But he said deaths related to inadequate health care have been a "constant problem" within the prison system, and Johnson's case reflects the same systemic issues that have allowed other inmates to unnecessarily suffer and die over the years.
The report recommends that the department increase oversight and develop a "cultural demeanor" among staff that teaches inmates deserve the same quality of health care as the general population, Ruben said.
"We raised some pretty serious concerns with the commissioner in the report," Ruben said. "We are hopeful the state will take our recommendations to heart."
Baker called Johnson's case a key motivator in his efforts to revamp the DOC's approach to health care and professionalism. To that end, the interim commissioner on Monday detailed two recent changes.
First, he announced the creation of the Office of Professional Standards, which will seek to increase diversity among prison staff and facilitate interactions with people who have concerns about their loved ones in the system, among other tasks. The office has been up and running for a few weeks and will seek to "bring equity, fairness and impartiality into everything we do," Baker said.
Second, Baker announced that the state is contracting with a new health care provider, VitalCore Health Strategies, and is partnering with the Department of Vermont Health Access to monitor the contract and provide clinical oversight. VitalCore CEO Viola Riggin said at Monday's press conference that the Kansas-based company works in about 20 other prisons around the country. She said Vermont will be the company's first statewide contract.
Baker said the state put the contract out to bid after declining to extend its relationship with Centurion. VitalCore was the lowest of three bidders, DOC officials said, beating out both Centurion and Wellpath for a new three-year contract worth some $20 million annually.
Asked whether Johnson's death prompted the state to cut ties with Centurion, Baker said that the decision to put the contract out to bid occurred before he took over in January. But Johnson's case has motivated him to rethink the way the state provides health care in its prison system, he said, particularly in light of his own ongoing battle with cancer.
"I was able to get health care at one of the leading health care facilities in the country, Sloan Kettering in New York. That saved my life," the commissioner said. "Mr. Johnson didn't get that opportunity. And that, for me, is a failure of the system"