Police: Lawyers shut down death probe
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Ashley Ellis of Rutland died Aug. 16 while an inmate at the Swanton prison. File Photo |
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By Gordon Dritschilo and Brent Curtis
Staff Writers - Published: March 7, 2010
A medical corporation stonewalled the police detective investigating the death of an inmate last year at the Swanton prison.
A state police report on the investigation into the death of Ashley Ellis includes revelations that lawyers for the private company that provided medical care in Vermont prisons instructed its employees not to talk to police, that Ellis might have gotten medication she needed were it not for a missed phone call, and that Ellis was smuggling contraband into the prison at the time of her death.
Ellis died Aug. 16, two days into a 30-day sentence for a traffic offense that seriously injured a man. A medical examiner's report found that she died in part because prison medical officials did not supply her with potassium pills used to treat complications from anorexia.
The 10-page report, released after a public records request, lists Vermont State Police Detective Edward Meslin's findings before lawyers for Prison Health Service, which had a contract to provide health care in Vermont prisons, put an end to its employees' cooperation.
The Vermont Department of Corrections did not renew the contract when it expired in January.
A spokesman for Tennessee-based Prison Health Services declined to comment Friday.
In the past, the company has denied responsibility for the death of Ellis, who was from Rutland.
"Based on the information available at this time, PHS is confident that during the less than 48 hours that Ashley Ellis was in state custody, she
received care that met applicable standards. … We can state emphatically that PHS did not deny her access to medications," the company said in a Sept. 30 statement.
But while the company and its employees have faced neither criminal charges nor civil litigation as a result of Ellis' death, there is plenty of blame directed at it and its employees.
"PHS broke down, that's where the breakdown was," said Vermont Defender General Matthew Valerio. His office oversees the Prisoner Rights Office, which handles legal affairs on behalf of Vermont inmates. "The bottom line is, they had an obligation to get her medications. How they did so is almost an irrelevance."
"I'd have to say in my view, there is sufficient evidence to bring a criminal charge against the company itself," Valerio added. "I almost guarantee if this were an elderly person who checked into a nursing home and someone failed to provide for them, it would be looked at in a whole different way."
Franklin County State's Attorney Jim Hughes said in October he would not pursue charges in Ellis' death because he could find no one person whose negligence rose to a criminal level.
A.J. Ruben, an attorney for Disability Rights Vermont (formerly Vermont Protection and Advocacy), said his organization, which safeguards the rights of individuals with physical or mental disabilities, hadn't found evidence of a crime in the case, but believed that civil liability on the part of the company or PHS employees involved may exist.
"There's no individual or corporation here who should be held responsible," Ruben said. "There were individuals who made poor choices when taken all together."
'Poor choices'
The state police report, completed Oct. 9, describes several "poor choices" and failures in the system that should have provided for Ellis' health.
Ellis, 23, was convicted last year of misdemeanor negligence in a 2007 crash that left a motorcyclist partly paralyzed and in a wheelchair. Her sentence also included community service and indefinite loss of her driver's license.
Ellis had been diagnosed with depression and an eating disorder since the crash and was on medications, including potassium chloride.
On Aug. 12, a Wednesday, two days before Ellis was to report to Northwest State Correctional Facility, her doctor faxed her medical records to Dr. Delores Burroughs-Burron in the Department of Corrections' health services office, who in turn faxed them to a nurse working at the prison.
The nurse, Renee Trombley, reviewed the records the next day and e-mailed a Dr. Cody in California, identified in the report as Prison Health Services' regional director. Cody authorized Trombley to order Ellis' medications, the report said, but they were not ordered then because it was the end of the day.
Arriving between 7 and 7:30 a.m. the next morning, Trombley found one of the two other nurses scheduled that day had not come in. Trombley wound up skipping her own duties to cover the missing nurse's.
Trombley told police she tried to have a meeting in Waterbury postponed but was instructed by a superior to go, and left the jail in mid-afternoon. She never ordered Ellis' medication.
Ellis reported to prison that same day — Aug. 14, a Friday — at 1 p.m. As she sat in booking, Ellis wrote a two-page letter, later found under her bed. Detective Meslin said she described going from a healthy, 120-pound 21-year-old to a depressed, 86-pound 23-year-old.
The letter said she had been sitting in booking for six hours, that she had spoken to "a lady from mental health" three hours ago and that she needed her medication. She described being served a peanut butter and jelly sandwich, chips and a peach before writing "well that didn't take long for all that to come up."
At 9 p.m. Ellis was screened by another nurse, Wayne Hogaboom. She listed low potassium as a chronic medical problem. At about 11 p.m., she was taken to her cell.
Missed opportunity
On Saturday, Aug. 15, nurse Connie Hall arrived at 6 a.m. for a 12-hour shift. Ellis' chart was one of five or six waiting on her desk. Hall verified Ellis' medications, then called a PHS doctor to issue her new prescriptions, including one for potassium chloride.
The prison did not have the potassium in stock, so Hall called in the prescription to the Rite Aid pharmacy in St. Albans and left a message for a nurse on the night shift, asking her to pick it up.
The night nurse, Karen Hough, didn't listen to the message until the following day. She told police she didn't usually check her messages until then. Hall said that while nurses would often pick up prescriptions on their way to work, it was "strictly a courtesy thing."
Hough arrived at work at 5:40 p.m. without the medication. Hall told police the Rite Aid closed at 6 p.m., so there was not time to get the medication, and that "someone probably would have gotten the medication on Sunday."
Hough later told police she left the company because of the incident. She could not be reached for comment for this story.
Corrections officer Mike Wall brought Ellis breakfast in her cell a few minutes after 6 a.m. that Sunday. Wall said they exchanged pleasantries. Another inmate said Ellis appeared groggy.
Wall returned about half an hour later and found Ellis face-down on her bunk, unresponsive. Medical personnel cleared food from her mouth and performed the Heimlich maneuver before taking her to the Northwestern Medical Center in St. Albans.
She was pronounced dead at 7:33 a.m.
Detective Meslin arrived at 8:45 a.m. He interviewed prison officials and found the letter under Ellis' bunk, along with a casework request form under her bed. Filled out in pencil, the form said, "On Tuesday I'd like to meet my case worker to discuss my meds and get everything straightened out."
She also had a sick call request, dated Aug. 15, that did not appear to have been handed in to prison officials.
An autopsy found the cause of death to be complications from low potassium, blaming anorexia and lack of access to medication. It also found a package in Ellis' vagina containing 17 hand-rolled cigarettes and five and a half pills of Suboxone, a painkiller prescribed to her before entering prison.
Gag order
Meslin wrote that an interview with Trombley in October was interrupted by a knock on the door, after which she left the room for a moment. When she returned, according to the report, she said an attorney for Prison Health Services had instructed her not to speak with him.
Five days later, on Oct. 6, an attorney for the company contacted Meslin, saying he represented not just PHS but all its employees, who asked him not to speak with any of the company's employees regarding the incident.
Both Valerio and Ruben said that denying investigators access to employees was normal practice for a business trying to limit its legal liability.
But both lawyers said they saw lots of room for improvement in the system.
Ruben said his group is completing an investigation of Ellis' death that will include not only the nonprofit group's conclusions about what went wrong but also pages of suggestions that will be turned over to the Department of Corrections.
At least some action has already been undertaken by the state, which replaced Prison Health Services with another private contractor, Correct Care Solutions. It has been providing health and mental health services at Vermont's prisons since the start of February.
Corrections Commissioner Andrew Pallito said Friday that he made it clear early on to the new company's president that he had high expectations.
"I met him face to face because I wanted to tell him what I expected and what wouldn't be tolerated," Pallito said, adding that problems like those experienced in Ellis' case were part of the conversation.
For his part, Pallito characterized the breakdowns that led to Ellis' death as a case of human failure.
"In the end, what we have is a good system but not enough follow through," he said. "I would say it wasn't even so much a breakdown in communication as it was a failure to follow through."
An attorney with a Rutland law firm representing Ellis' family in the investigation of a possible lawsuit declined to comment on the case Friday.
gordon.dritschilo@rutlandherald.com
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