The Defender General’s Office’s investigation into the death of David Mitchell, who died in the Springfield, Vt., prison last April, revealed that medical staff did not recognize the seriousness of his condition in the months before his death and did not respond sufficiently on the day he died.

In a recent interview, Matt Valerio, Vermont’s defender general, described topline findings from his office’s investigation. The office investigates every death in Vermont’s prisons, and the reports, which take months to compile, are not public record.

In the days after Mitchell died, five people incarcerated near him detailed to VtDigger the hours leading to his death. At the time, he was the 12th person to die at Southern State Correctional Facility in 16 months, far outpacing previous years.

In on-the-record interviews conducted over the phone, as well as using video and messaging apps, all five men described the 46-year-old Mitchell begging for help before and after he was briefly seen by medical staff on the morning of his death on April 17. All five also said a correctional officer told Mitchell he would be sent to segregation if he didn’t stop complaining.

Four of the men said Mitchell used an oxygen tank and three said he had been removed from buprenorphine, which is commonly used to treat opioid dependency, in the days before his death.

Mitchell suffered from chronic obstructive pulmonary disease, or COPD, and also contracted strep throat, pneumonia and COVID-19 in the months leading up to his death, Valerio said.

“The medical provider didn’t seem to recognize the seriousness or progression of his COPD,” Valerio told VTDigger.

As part of the report, investigators consulted with medical professionals to review Mitchell’s medical history as well as video footage from within the prison on the day he died.

Valerio said a senior-level emergency medical technician who was involved in the review was “very critical of the way the medical staff performed.”

“He said that the LPNs (licensed practical nurses) and RNs (registered nurses) did not appear to be trained to the same standard as like local EMS,” Valerio recounted. “They didn’t seem to know what to do with CPR. They didn’t seem to know how to attach the defibrillator.

“They bumbled around with the equipment. They didn’t know what they were doing,” he said.

A medical doctor also reviewed Mitchell’s autopsy and toxicology, Department of Corrections medical records, community medical records, and a video of the resuscitation event.

Valerio, reading from the doctor’s review, said Mitchell’s death “was not sudden, as the record demonstrates a picture of unfortunate yet predictable clinical deterioration over the preceding months.

“Although it is understandable for a diagnostic uncertainty to exist, opportunities were afforded to those caring for Mr. Mitchell to recognize the severity of his pulmonary disease, lack of durable improvement, and need for judicious specialty care.

“I cannot predict if any intervention would have changed the outcome of the case. But it bears mention that Mr. Mitchell suffered from potentially treatable conditions. His death illustrates several areas for improvements which should not go unrecognized, and the need for greater health care advocacy to vulnerable populations.”

Valerio said that correctional officers “responded well” to the emergency, and that previous investigations have shown that corrections staff are at times “better at doing CPR than the nurses.”

But the defender general also described a feedback loop between medical staff and corrections staff that could be to the detriment of Vermont’s incarcerated population.

Correctional officers and medical staff develop an “attitude” toward people with chronic health issues, Valerio said, labeling them “complainers” or “the boy who cried wolf.” Because corrections’ staff take health-related direction from medical staff, officers may treat a health issue as a behavioral issue, as was the case with Mitchell, according to Valerio.

“From (Correctional officers) lay observations, they kind of acknowledged the shortcomings of the medical staff. But they don’t feel like they’re in any professional position to make any judgments,” he said.

At the time of Mitchell’s death, Vermont contracted with VitalCore for health services in its prisons. Last summer, the state switched the contract to the private-equity-owned firm Wellpath.

“It doesn’t matter what contractor it is,” Valerio said. “Fundamentally, they end up hiring the same people to do the work.”

VitalCore did not respond to messages on Friday to discuss the findings of the review.

In an interview, Corrections Commissioner Nick Deml acknowledged a lack of trust in medical staff raised by the investigation.

“In this case, if an individual has a longstanding issue that either is not improving or not being treated properly — is not being addressed — then I think it’s difficult for correctional officers to say, ‘I would treat them differently,’ because they’re not medical providers,” Deml said. “We need to have that level of faith and trust in our medical provider. I think it’s one of the reasons we put our contract out for bid last year.”

The state’s contract with Wellpath included enhanced training requirements, according to Deml.

“We have very carefully structured the contract that governs our health provider to ensure that, you know, you’re not going to get paid until you’re hitting the benchmarks that we need you to hit,” he said. “If we’re not getting the outcomes we want, we can kind of force that to happen. And by doing that, by building that infrastructure on the front end, that helps hold them accountable.”

Deml also acknowledged the “reputation, the perception” of Wellpath, the current provider, which has faced criticism both in Vermont and elsewhere for issues ranging from staffing levels to alleged employee misconduct.

“Wellpath isn’t pulling the wool over our eyes. We’re aware of those things,” he said. But he praised the company for filling staff vacancies. In testimony this week, a Wellpath regional leader told lawmakers the company had cut its reliance on traveling staff, including at the Springfield prison.

“Since this tragic event happened, we have transitioned vendors,” Deml said, “and they’ve been receptive to our need that they provide better emergency medical response training, and training in other areas.”

For Valerio, his office’s investigations serve to create change in the Department of Corrections. He said he has seen improvements under Deml’s leadership, such as better health screenings people receive when entering Vermont’s prisons.

Still, he said, more progress is needed.

“When the state takes custody of somebody in a prison, they also take with them the duty to make sure that they have medical care consistent with — this is what the law says — consistent with what you would get if you’re on the outside,” Valerio said. “What we’re seeing with the medical contractors in the cases that we’ve investigated, they’re not meeting that standard.”

As for the solution, Valerio said he hasn’t figured that out yet.

“The hard part is that I don’t know the answer.”