Kenneth Johnson was worried about what might happen to a Black man like him in a northern Vermont prison, according to his younger brother, Gilbert Johnson.
"He told me, 'This is no place for me,'" Gilbert recalled. "'These people are so prejudiced, so racist.'"
When Gilbert told Kenneth in the fall of 2018 that he and a cousin were hoping to visit him at Newport's Northern State Correctional Facility, Kenneth discouraged them from making the trip from New York City to Vermont. "He said, 'It's not a place I want y'all to come,'" Gilbert said. "'It's a place that Blacks are not really welcome in.'"
A little over a year later, Kenneth Johnson died in the infirmary at Northern State — the victim of an untreated and misdiagnosed tumor that obstructed his airway until he could no longer breathe.
According to the summary of a scathing report issued last week by the state Office of the Defender General, Johnson spent his final hours "struggling to breathe while nearby nurses did nothing to help." Instead of providing treatment, a Corrections officer threatened to send him to solitary confinement if he didn't "knock it off," and a nurse "physically forced Mr. Johnson to lie back in bed," the defender general found. Video footage, according to the report, then showed him "in various stages of agony" before a fellow inmate discovered he was dead early on the morning of December 7, 2019.
The care Johnson received was so poor, the state's chief medical examiner concluded it "might rise to the level of criminal neglect," Department of Health spokesperson Ben Truman told Seven Days this week.
To date, nobody has been disciplined, fired or charged.
At the time of Johnson's death, the 60-year-old inmate was being held without bail on charges of human trafficking and sexual assault of a minor. He and another man had been accused two years earlier of plying a 15-year-old girl with drugs and cash, repeatedly assaulting her, and enticing her to engage in sex work. Johnson had pleaded not guilty and was awaiting trial.
Gilbert acknowledged that his brother had been in and out of prison since his late teens — largely, he believes, on robbery charges. "He chose that life," said Gilbert, the first family member to speak publicly about Kenneth's fate. Nevertheless, he said, his brother did not deserve to die a painful, preventable death.
"How could you watch someone die and not do anything?" he asked. "Who's going to be accountable for it?"
In the week since the defender general's explosive report became public, several top state officials have apologized for Johnson's death. "We are responsible for this, and we should take responsibility," Secretary of Human Services Mike Smith said at a press conference last Friday. "There is no excuse for this."
They have also acknowledged that Johnson's race could have contributed to the inadequate care he received. "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.
In the immediate aftermath of Johnson's death, state officials showed much less resolve to get to the bottom of what went wrong.
In a press release disclosing his demise, the Department of Corrections said it appeared to have been the result of "natural causes." Days later, the Vermont State Police echoed that view.
Raymond Gadreault, the Newport inmate who discovered Johnson's lifeless body, said that, soon after the incident, he attempted to tell a state police detective what he had witnessed that night: Johnson "banging on the window," pleading for help. But the detective appeared uninterested, Gadreault told Seven Days last December, and ordered him back to his cell. "He refused to listen to what happened even though I tried several times," Gadreault said.
State police spokesperson Adam Silverman said at the time that the detective was seeking to determine only "whether a crime had been committed, such as an assault, that contributed to the inmate's death." He added, "Whether internal procedures were followed to ensure the inmate received care is a question for Corrections."
Rather than answer that question, according to the defender general, Corrections staffers or contractors appear to have concealed what happened. According to the defender general's report, the department erroneously claimed that Johnson had died at nearby North Country Hospital when, in fact, he had perished at the prison. A log entry described Johnson as "awake" at 2:20 a.m., though video showed he had already stopped breathing by then, suggesting that nurses had failed to check in on Johnson as required — and fabricated official records.
"There was an attempt to not show the full picture," Defender General Matthew Valerio said. He went a step further in his report, calling the department "complicit in covering up its [medical] contractor's gross failure to provide live-saving medical care."
And though Smith pledged in the days after Johnson's death to conduct an internal investigation of what went wrong, Corrections initiated just one of two reviews required by its own policies: It contracted with the nonprofit Vermont Program for Quality in Health Care to perform a peer review of Johnson's medical treatment. What it didn't do was conduct an administrative review of what Corrections staffers might have done differently.
"There wasn't one," Smith said of the administrative review at last week's press conference. "And there should have been one." He added in an interview, "From now on, we're going to do one every time there is a death or injury in our facility."
The peer review, according to interim Corrections Commissioner Jim Baker, drew conclusions similar to the defender general's.
State legislators also appeared unfocused on Johnson's plight. Two panels with jurisdiction over the prison system — the House Committee on Corrections and Institutions and the Senate Judiciary Committee — held hearings this session on another scandal plaguing the department: allegations of sexual misconduct, drug use and retaliation at the state's prison for women exposed by Seven Days. But according to the leaders of the two committees, they took no testimony on Johnson's death.
"There were a lot of issues before us, so we were working through all those issues," said Rep. Alice Emmons (D-Springfield), who heads House Corrections.
Asked why his Judiciary Committee hadn't addressed Johnson's death, Sen. Dick Sears (D-Bennington) said, "Good question. I don't know. I can't answer that question."
Other entities have probed Johnson's death. Disability Rights Vermont concluded its own investigation last month, according to executive director Ed Paquin, and came to "substantially the same conclusions" as the defender general. Paquin said he could not release his organization's report without permission from Johnson's family.
Earlier this month, Smith also asked the Vermont law firm Downs Rachlin Martin to expand an existing investigation into the women's prison scandal to include a close look at Johnson's death. If the firm's lawyers, led by former U.S. attorney Tristram Coffin, uncovered any criminal wrongdoing, Smith said, they would turn over the evidence to state and federal law enforcement officials.
After initially dismissing Gadreault, the state police appear to have taken a renewed interest in the matter. "When I saw the autopsy, I contacted the state police and asked them to look at it very carefully — and they have," said Orleans County State's Attorney Jennifer Barrett, who is also collaborating with the Secretary of State's Office of Professional Regulation. "I have had a lot of communications with state police, and there's a significant amount of information that's been collected."
Silverman declined to comment on the state of that investigation.
Attorney General T.J. Donovan said he got involved in June after chief medical examiner Dr. Steven Shapiro contacted the head of the AG's criminal division. According to Truman of the Department of Health, "Dr. Shapiro wanted to ensure that office was aware of the case, due to the possibility that the care, or lack of care, given to Mr. Johnson might rise to the level of criminal neglect."
According to Donovan, his office is exploring potential criminal liability "for individuals or corporations," as well as potential civil liability. That raises the possibility that the state may have its former medical contractor, Centurion Managed Care, in its sights. Until this month, Centurion ran the prison system's infirmaries and employed the medical personnel who staff them.
The Virginia-based company did not respond to multiple requests for comment, but it told the Associated Press this week that it stands by its "record of service" and "quality of care" in Vermont.
Donovan said he is also preparing for the possibility that Johnson's family may sue the state. Ordinarily, his office would be tasked with defending Corrections, but if it were already pursuing criminal charges, it might have to hand over that job to an outside law firm in order to avoid a conflict of interest.
Federal prosecutors could also get involved, if they haven't already. U.S. Attorney for Vermont Christina Nolan said she could not confirm or deny the existence of any ongoing investigations, but she noted that her office was empowered to prosecute systemic constitutional violations within a correctional system.
Earlier this month, as the findings of the defender general and Disability Rights Vermont became clear, Corrections sought to get out ahead of the story and demonstrate a commitment to preventing such failures of care in the future.
At a July 13 press conference, Baker announced that his department had declined to renew its contract with Centurion and had hired Kansas-based VitalCore Health Strategies to take over prison medical care. Johnson's death, he suggested, had played a role in the change.
"That caused me to rethink the way we should be providing health care in our system," the Corrections commissioner told reporters.
In fact, the two events were entirely unrelated. According to Baker's spokesperson, Rachel Feldman, the department put the contract out to bid in December 2018 and selected VitalCore in October 2019 — two months before Johnson's death.
"I would say the death of Kenneth Johnson reinforced our decision that VitalCore was the right move," Feldman clarified.
Whether the move will result in better care for inmates remains to be seen. At the July 13 press conference, VitalCore CEO Viola Riggin said her company had "scoured the U.S." for "top-of-craft professionals" to dispatch to the prisons it serves.
But in an interview this week, Riggin acknowledged that 89 percent of its initial Vermont hires came directly from Centurion's ranks — including Dr. Steven Fisher, who served as Centurion's in-state medical director and now plays that role for VitalCore.
Lia Ernst, a senior staff attorney for the American Civil Liberties Union of Vermont, is skeptical that the new contractor will be an improvement over the old one.
"You paint a new logo and a new name on the service provider, but the individuals at the ground level are largely the same," she said. "Time will tell, but if you have all the same people who've been involved in what has been, without question, a failing system, it's hard to be overly optimistic."
Others argue that what's really missing is adequate oversight of the system's medical contractor. As the defender general noted in his report, Corrections hasn't had its own full-time, in-house medical director since 2015. Currently, according to Baker, Dr. Scott Strenio of the Department for Vermont Health Access is spending 10 hours a week moonlighting in the role.
"I think [Corrections] would be much better served having their own medical director," said Paquin of Disability Rights Vermont.
According to Riggin, VitalCore is just getting started reforming prison medical care in Vermont and is evaluating every one of its new employees. She said the company has already parted ways with a handful of them since taking over the contract this month, reducing the number of Centurion alums to 84 percent, and she suggested that major leadership changes were in the works — including to the medical director position.
"I just want to say that we're different," Riggin said.
Gilbert Johnson, Kenneth's brother, said that what bothers him the most is that professionals ostensibly dedicated to helping others failed to help his brother. As an assistant cook at a New York City homeless shelter, Gilbert has seen "the good, the bad and the ugly," he said. "Our job is to save them no matter what."
He added, "So how could you just let my brother just die like that and stand there and don't do anything?"