OFFICE OF THE DEFENDER GENERAL
6 Baldwin Street, 4th Floor
Montpelier, Vermont 05633
Telephone (802) 828-3168
Fax (802) 828-3163
Matthew F. Valerio, Defender General
EXECUTIVE SUMMARY FOR DISTRIBUTION
FROM:
RE:
DATED:

Matthew Valerio, Defender General
Executive Summary / Investigation of the Death of Kenneth Johnson while in
Vermont DOC Custody, Date of Death: December 7, 2019
July 20, 2020
INTRODUCTION

Kenneth Johnson was a black man who died in VT DOC custody on December 7, 2019. Medical
and correctional staff ignored his pleas that he could not breathe—an undetected tumor blocked
his airway. Instead of providing life-saving care, staff threatened him. Fellow inmates, not
nurses, discovered that he had stopped breathing. Mr. Johnson could not be resuscitated and died
in DOC custody.

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FACTUAL FINDINGS
Kenneth Johnson was a black man detained awaiting trial at Northern State Correctional
Facility in Newport, Vermont, from 2017 until his death in 2019.
In fall 2019 Mr. Johnson told nurses he had shortness of breath; worsening hoarseness;
trouble swallowing; feeling of something struck in his throat.
Prison medical suspected chronic obstructive lung disease (COPD) and prescribed steroids,
which did not help his breathing but did severely aggravate his diabetes. Mr. Johnson was
never seen by an MD for his breathing problems.
When the steroids didn’t help, medical staff referred Mr. Johnson to an outside specialist for
further diagnosis. That appointment was scheduled for a time subsequent to Mr. Johnson’s
death.
On December 6, still in the infirmary, Mr. Johnson showed many signs of acute
respiratory distress: nebulizer treatment was insufficient; he had rapid breathing and trouble
sitting up; 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.
Medical staff failed to recognize the urgency of the situation. The on-call provider
prescribed cold medicine. Nurses told him to stay in bed. No one checked Mr. Johnson’s vital
signs or listened to his lungs. No one informed the on-call provider that nebulizer treatment
was not working as prescribed—a red flag. Prison nurses can and do send patients to the ER.
However, the night Kenneth Johnson died, nurses either failed recognize that he was dying
or were unwilling to help.

 • Later that evening Mr. Johnson collapsed in the bathroom and again said he couldn’t
breathe. He asked for oxygen and hospitalization but was refused both.
• A correctional officer walked him from the bathroom back to 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 officer threatened
Mr. Johnson that if he did not “knock it off,” he would be placed holding—a form of solitary
confinement. A nurse physically forced Mr. Johnson to lie back in bed.
• Subsequent security video shows Mr. Johnson in various stages of agony. He died after
hours of struggling to breathe while nearby nurses did nothing to help.
• DOC’s medical documentation conflicts with the facts. One log reported Mr. Johnson
“awake” at 2:20 a.m. on December 7. By then, video shows, he had stopped breathing. This
suggests that nurses were not performing checks. Nurses learned Mr. Johnson had stopped
breathing only when other patients alerted them.
• By the time nurses checked Mr. Johnson, he had no pulse. Several more minutes passed
before they started CPR, unsuccessfully. By the time EMTs arrived, Mr. Johnson had not
breathed, nor did he have a pulse for twenty minutes. His remains were brought to North
Country Hospital where he was pronounced dead on arrival.
• Autopsy showed that Mr. Johnson died because a tumor in his throat had blocked his
airway—which an ear, nose, and throat doctor could have detected if the appointment had
ever been scheduled. Mr. Johnson could have been treated by intubation, supplemental
oxygen, and surgical removal of the tumor.
• Even afterward, nurses blamed their victim. One claimed she did not perform adequate
checks “because he was so fidgety”—itself a sign of respiratory distress.
• DOC is complicit in covering up its contractor’s gross failure to provide live-saving
medical care. DOC has provided no internal administrative review, which both DOC policy
and the medical contract require. DOC has claimed that Mr. Johnson died at the hospital, but
he was dead on arrival.
POLICY RECOMMENDATIONS
To the Legislature:
• Mandate that DOC hire an in-house medical doctor to supervise medical care statewide, a
function not performed since 2015.
• Mandate that DOC timely review of all aspects of the death of any inmate.
To the Department of Human Resources:
• Investigate whether DOC staff’s actions constituted employee misconduct.
To the Office of Professional Regulation:
• Review the actions of and appropriately discipline all involved professional licensees.
To the Department of Corrections:
• Reinstate the position of an in-house DOC physician as medical director to supervise the
medical contractor.
• Reinstate an independent panel of experts to periodically review the provision of medical care
by the DOC contractor and medical director
• Hold Centurion accountable for withholding timely life-saving care and conducting no
subsequent administrative review.

 • Review training protocols for correctional officers regarding implicit racial bias and
recognition of medical emergencies.
• Revise staffing matrix to ensure facilities have regular accessible on-site medical doctors to
provide timely review of complex cases occurs.
To the Vermont Human Rights Commission:
• Investigate the role that implicit racial bias in officers and nurses had ignoring a Mr.
Johnson’s pleas that he could not breathe.
REPORT CONTRIBUTORS:
• Emily Tredeau, Managing Attorney, Vermont Prisoners’ Rights Office, ODG
• Hillary Reale, Investigator, Vermont Prisoners’ Rights Office, ODG
• Dr. Delores Burroughs-Biron, M.D., Medical Consultant, Fmr. VT DOC Medical Director,
2007–2015