Investigators who probed the recent deaths of three Vermont prison inmates have found little blame to assign in two of the three incidents.
But the state did seriously mishandle its treatment of the third inmate — a man who committed suicide last spring — the lead investigator told a legislative oversight committee on Wednesday.
Defender General Matt Valerio doesn't hesitate to say when he believes officials have done wrong by his clients, who include inmates sent to out-of-state prisons.
But he says fault for the death of 65-year-old James Nicholson in April can't be laid fully on the private prison contractor which ran the Kentucky institution where the Vermonter died weeks after suffering severe head injuries during a fight in a prison bathroom.
"If I am making a conclusion and I'm going to point fingers at somebody, I have to have evidence," Valerio said.
Valerio was referring to a Kentucky medical examiner's report which showed Nicholson also suffered from heart disease, hypertension and diabetes. Valerio says the report is not clear if the injuries he received during the altercation in the bathroom contributed to his death a month and a half later.
"I've read a lot of autopsy reports and have handled many murder cases in the course of my career. And sometimes when you read those you have to read a little bit between the lines," Valerio said.
"It looked to me like the medical examiner was trying to figure out a way to link the two, but couldn't do it scientifically."
Valerio was much more definitive about the death of another inmate in state custody. Patrick Fennessey was 34 when he died in April, two days after he hung himself at the Southern State Correctional Center in Springfield.
The investigation is continuing, Valerio says.
"But it's pretty obvious to me that the Department of Mental Health, the Agency of Human Services, Health Care Rehabilitation Services and the Department of Corrections all contributed to in some degree in failing to prevent (Fennessey) from committing suicide," Valerio says.
Fennessey did not receive the mental health care he needed, Valerio says, and he was transferred back to prison after his insurance ran out to pay for his treatment at the Brattleboro Retreat.
"They didn't have a caregiver or a place to put him outside that would satisfy his needs, so they just brought him in," Valerio says.
The third inmate who died this year was 43-year-old Annette Douglas. She refused treatment for diabetes and other conditions. Valerio says officials failed to focus on her mental conditions that led her to make the choice to end her medical care.
Gordon Bock, state director of CURE Vermont, which advocates on prisoner issues, says Douglas and Fennessey probably should not have been incarcerated at the time of their deaths.
"It doesn't make sense for us to keep simply incarcerating people who have mental health issues, substance abuse issues or both," he says.
The treatment of prisoners with mental illness has long concerned Bennington Senator Dick Sears, co-chairman of the legislature's justice oversight committee.
"I'm hoping that... one of the things that come out of our committee's work is recommendations about how we deal with seriously functionally impaired (people) that have mental illnesses that are not being addressed in a correctional setting," Sears said.
Sears says the committee will hold its next hearing at the Springfield correctional center and will ask more questions about mental health care in the prison system.