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Investigative Report Into the Deaths of Seven Vermont Inmates and Related Issues

NCJ Number
Michael Marks; Philip McLaughlin
Date Published
March 2004
75 pages
This report presents the findings from an investigation into the deaths of seven Vermont inmates that occurred from November 2002 through October 2003, as well as the policies and practices of the correctional facilities that may have contributed to or failed to prevent these deaths.
In one case, an inmate in administrative segregation for 118 days committed suicide after being deprived of adequate support, apparently in retaliation for his filing of grievances and lawsuits. In another case, an inmate died after the facility's inadequate response to his requests for medical services; and in a third case, an inmate died from a drug overdose after consuming prescription drugs she had hoarded due to the facility staff's failure to ensure her consumption of the drugs at the time she received them. In another case of death due to drug overdose, however, the correctional facility was not at fault, because it had engaged in intensive efforts to treat the drug abuse in the course of the management of the inmate's conditional release. In the other cases, a mentally ill inmate committed suicide; an inmate died in custody from AIDS; and an inmate died from an overdose of drugs he obtained during a contact visit. In these cases the actions of the facilities responsible for the inmates were not contributing causes to their deaths. Recommendations offered for consideration by the Vermont Department of Corrections pertain to policies and practices regarding administrative segregation, the timely delivery of all inmate health and medical records after a transfer to a new facility, regular audits of the prescribing of psychotropic drugs, the identification of facilities with a backlog of medical-care requests, sample audits of health care cases, quality assurance reviews of mental health services, prompt responses to inmate grievances, the interdiction of drugs to reduce their accessibility to inmates, staff training in the evaluation of inmate deaths, and certain policies and practices for the housing of inmates.