Last December, as disturbing details emerged about the death of an inmate at a northern Vermont prison, Secretary of Human Services Mike Smith pledged to conduct an internal review of what went wrong.

"We'll have to, obviously, investigate what happened here," he told Seven Days on December 15, a week after Kenneth Johnson died in a prison infirmary, pleading for medical attention.

On Friday, Smith and interim Corrections Commissioner Jim Baker acknowledged that the Department of Corrections had failed to conduct an administrative review of the incident required by the department's own policy.

"There wasn't one," Smith said at a press conference in Montpelier. "And there should have been." In an interview later Friday, he vowed to ensure that such a lapse wouldn't happen again. "From now on, we're going to do one every time there is a death or injury in our facility," the secretary said.

According to a report issued this week by the Office of the Defender General, Johnson died after an undiagnosed tumor blocked his airway. Johnson had complained for weeks about his medical condition and spent his final hours at Northern State Correctional Facility in Newport begging for help, the defender general found. Rather than treat him, prison officials threatened and restrained him, according to the report, and they learned of his death only after another inmate discovered he had stopped breathing.
According to the defender general, the Department of Corrections was "complicit in covering up its [medical] contractor's gross failure to provide live-saving care."

Johnson was 60 years old when he died. He was awaiting trial on charges of human trafficking and sexual assault of a minor.

In their first remarks on the incident since the report's release, Smith and Gov. Phil Scott expressed remorse Friday during one of the governor's twice-weekly press conferences.

"I'm extremely, extremely sorry for the loss to the family members of someone who is in our custody," Scott said. "We had a responsibility to take care of this person, and it appears we may have failed."

Asked if the state was responsible for Johnson's death, Scott said he wanted to learn more before coming to such a conclusion and argued that misdiagnoses happen "every single day." But, he added, "From what I've seen thus far, it appears that we made a tremendous amount of mistakes along the way."

Smith went further. "We are responsible for this, and we should take responsibility," he said. "There is no excuse for this."

The secretary also questioned whether Johnson's race played a role in his death. "Since this prisoner was African American, then we have to ask the hard question and look ourselves in the mirror and say, 'Would we have handled this prisoner differently if he was white?'" Smith said.
After an inmate dies in a prison facility, the Department of Corrections is required to conduct a clinical peer review of the quality of medical care the prisoner received and an administrative review "to ascertain the sequence of events up to and including the inmate’s death."

In recent days, officials have provided conflicting accounts as to whether the latter took place after Johnson's death. Defender General Matthew Valerio said his office had made repeated requests for documentation of such an internal review and, after they went unfulfilled, concluded one had not taken place.

"I cannot explain why there was no internal DOC review," he said. "I could guess, but I don't have the answers."

During a press conference last week, Baker said his department had "done a partial internal review." In an interview Wednesday with Seven Days, he disputed Valerio's assertion and said the department had, in fact, conducted an administrative review.

After Smith, his boss, contradicted that account at Friday's press conference, Baker said in an interview that he had accidentally conflated the clinical peer review, which had taken place, and the administrative review, which had not. Later in the interview, Baker said he had discovered weeks earlier that his staff had failed to conduct an administrative review.

When it became clear that the defender general was poised to release a damning report, Baker said, he worked with Smith to ask the law firm Downs Rachlin Martin to further investigate the matter. Smith had initially hired the firm last December to conduct a broader investigation of the department after Seven Days reported on allegations of wrongdoing at the state's women's prison. In recent weeks, according to Smith, he called on Downs Rachlin Martin to "expand their existing investigation and put more focus on Mr. Johnson's death."

During Friday's press conference with the governor, Smith said that he had instructed the firm to alert U.S. Attorney Christina Nolan and Attorney General T.J. Donovan to any wrongdoing by officials. "We are making sure that we are sharing any of the results with the proper authorities," he said.