This page outlines Department of Corrections (DOC), Defender General's Office (DGO), and Vermont State Police (VSP) findings and recommendations from death investigations completed from January 1, 2022, to January 1, 2023. Ten deaths occurred in this timeframe.
|
Cause of death |
Number of individuals |
Average age at time of death |
|
Suicide |
2 |
32 |
|
Overdose |
1 |
34 |
|
Natural Causes |
6 |
65 |
|
Unknown |
1 |
76 |
|
Total: |
10 |
56 |
|
Date |
Cause of death and contributing factors |
Location of death |
Investigation status |
|
January 1, 2022 |
Overdose – Acute mixed intoxication (methadone, hydroxyzine, sertraline, amitriptyline) Contributing factors: Atherosclerotic cardiovascular disease |
North Country Hospital |
All investigations complete |
|
February 22, 2022 |
Natural Cause – Hypertensive and atherosclerotic cardiovascular disease Contributing factors: Metastatic cancer; chronic obstructive pulmonary disease; obesity; diabetes |
Southern State Correctional Facility |
All investigations complete |
|
April 3, 2022 |
Suicide |
Northeast Correctional Complex |
All investigations complete |
|
April 13, 2022 |
Unknown – Patient died in a hospice setting at a New Hampshire hospital; to the best knowledge of the Department an autopsy was not conducted
|
Dartmouth Hitchcock Medical Center (NH)
|
DOC investigation complete, DGO and VSP did not investigate this death as it was expected and occurred out of state |
|
April 28, 2022 |
Suicide |
Southern State Correctional Facility |
All investigations complete |
|
May 16, 2022 |
Natural Cause – Gastrointestinal bleed of unknown etiology |
Southern State Correctional Facility |
All investigations complete |
|
August 28, 2022 |
Natural Cause – Bacterial pneumonia of the right lung |
Southern State Correctional Facility |
All investigations complete
|
|
October 25, 2022 |
Natural Cause – Small B-cell lymphoma (cancer) Contributing factors: Right inguinal hernia with incarceration of small bowel; bronchopneumonia with abscess formation |
Southern State Correctional Facility
|
All investigations complete
|
|
November 30, 2022 |
Natural Cause – Myocardial infarcts due to arteriosclerotic cardiovascular disease Contributing factors: Obesity; emphysema |
Southern State Correctional Facility
|
All investigations complete
|
|
December 9, 2022 |
Natural Cause – Complications of myocardial infarction due to atherosclerotic stenosis of coronary arteries Contributing factors: Aortic stenosis; diabetes mellitus |
Rutland Regional Medical Center |
All investigations complete |
High-level Findings & Recommendations:
|
Medical Recommendations |
|
|
Recommendation/Finding |
Implementation Status |
|
Recommended additional training in emergency response for contracted medical staff as well as additional training for custody staff regarding DOC Directive 353 Death Response and Review. |
The Department increased the frequency of emergency response training drills across all sites for DOC staff and contracted medical staff. |
|
Highlighted lack of community housing to place individuals who, due to age and medical condition, do not pose a significant risk to the community and require some level of assisted living or nursing home.
|
The Department is working with the Department of Aging and Independent Living (DAIL) to identify increased placement for individuals requiring assisted living or nursing home levels of care. |
|
Mental Health Recommendations |
|
|
Recommendation/Finding |
Implementation Status |
|
Recommended increased frequency of mental health rounds, increased accountability and inventory of allowed items that could be used as ligature, and increased cell inspections. |
Department piloted an enhanced observation and mental health check system for new intakes at Northwest State Correctional Facility – the enhanced check system was implemented statewide in March 2024.
|
|
Operational Recommendations |
|
|
Recommendation/Finding |
Implementation Status |
|
Recommended use of hand-held video cameras during emergencies. |
Department increased consistency in use of hand-held video cameras during emergencies. Department additionally initiated the process of procuring body-worn cameras. This is still in process and has not yet undergone bargaining. |
|
Found a mechanical issue occurred with an Ambu-Bag during one incident (though this did not appear to have contributed to the death). |
Department checked all Ambu-Bags for functionality and increased routine maintenance and checks of Contractor’s emergency equipment. |
|
Found rapid and appropriate response from unit officers. |
Not applicable. |
References
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Investigative partners