AN INVESTIGATION INTO THE DEATH OF
ASHLEY ELLIS

DISABILITY RIGHTS VERMONT
(formerly Vermont Protection & Advocacy, Inc.)

141 Main Street, Suite 7
Montpelier, Vermont 05602
May 13, 2010
Tina Wood
Advocate/Paralegal

A.J. Ruben
Supervising Attorney

DRVT is the Protection & Advocacy System for Vermont

Table of Contents

I.

Acknowledgement………………………………………………

03

II.

Introduction………………………………………………………

03

III.

Background……………………………………………………

04

IV.

DRVT’s Investigation……………………………………………

04

V.

Sequence of Events…………………………………………….

05

VI.

DRVT’s Findings………………………………………………..

12

VII.

PHS Mortality Report………………………………………….

20

VIII. VDH Root Cause Analysis Report…………………………..

20

IX.

DOC Administrative Review of Mortality Report…………

20

X.

AHS Investigations Unit Report……………………………..

21

XI.

Conclusion & Recommendations……….…………………..

21

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I.

Acknowledgement

Disability Rights Vermont (DRVT) would like to acknowledge the
cooperation received from Ashley Ellis’ family and the Vermont
Department of Corrections during the course of our investigation.
II.

Introduction

This report presents the results of an investigation conducted by
DRVT into the death of Ashley Ellis on August 16, 2009 while
incarcerated at the Northwest State Correctional Facility (NWSCF) in
Swanton, Vermont.
Ashley Ellis was a 23-year-old woman incarcerated at NWSCF on
August 14, 2009 to begin a 30-day sentence for a conviction of
misdemeanor negligent operation of a motor vehicle. She had a
history of an opiate addiction, depressive disorder and a severe eating
disorder. According to Ms. Ellis’ family, they knew her as a straightlaced young woman, not a partier. Her family states that her opiate
addiction was the result of a back injury and subsequent treatment
with opiate pain relievers. She was most recently hospitalized at
Rutland Regional Medical Center in June of 2009 for severe
hypokalemia (low potassium) secondary to chronic bulimia. She was
seeing a licensed psychologist and in April 2009 had received
treatment at the Walden Behavioral Care in Massachusetts. She was
also being treated for hypocalcemia (lack of calcium).
She entered Department of Corrections (DOC) custody at
approximately 12:00 noon on Friday, August 14th. She died on
Sunday, August 16th at 07:33 a.m. at the hospital. During her few
days at NWSCF, Ms. Ellis did not receive the potassium as prescribed
by both her outside physician and the Prison Health Services’
physician. Nor did she receive the Suboxone that she was prescribed
to treat her opiate addiction. Prior to Ms. Ellis’ arrival the DOC was in
possession of medical records detailing the conditions for which she
was being treated and the medications that she would require while
incarcerated.
The Chief Medical Examiner for the State of Vermont found that Ms.
Ellis’ cause of death was “Hypokalemic induced cardiac arrhythmia
due to anorexia / bulimia nervosa and denial of access to
medications.”

3

III.

Background
a. DRVT is a private, independent, not-for-profit agency
empowered by federal law to provide advocacy services on
behalf of people with disabilities to ensure their rights are
protected. Under our federal mandate, DRVT has the duty
and authority to investigate allegations of abuse and/or
neglect involving people with disabilities if the incident is
reported to DRVT or if DRVT determines there is probable
cause that an incident of abuse and/or neglect occurred.
DRVT is Vermont’s designated protection and advocacy
system and is a member of the National Disability Rights
Network (NDRN).
b. Northwest State Correctional Facility (NSCF) is a mediumsecurity prison located in Swanton, Vermont which houses
female offenders.
c. Prison Health Services (PHS) was the contracted provider for
medical care at the prison at the time of Ms. Ellis’ death.
d. MHM, Inc. was the contracted provider for mental health
services at the prison at the time of Ms. Ellis’ death.

IV.

DRVT’s Investigation
DRVT’s investigation of this case included the following:
a. Review of Ms. Ellis’ DOC medical and mental health records
which include some of her community medical records;
b. Review of unit logs, end of shift reports, incident reports,
unit videos, e-mails, handheld videos, facility menu, and
core file documents;
c. Review of medical records from Northwestern Medical
Center;
d. Review of Final Report of Autopsy from the Chief Medical
Examiner;
e. Review of PHS Mortality & Morbidity Peer Review –
Confidential;
f. Review of the Vermont State Police investigation report;
g. Review of the AHS Investigations Unit investigation report –
Confidential;
h. Review of DOC Administrative Review of Mortality report –
Confidential;
i. Review of VDH Root Cause Analysis - Confidential;
j. Interview with prisoner(s) at NWSCF;
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k. Review of PHS Policies and Procedures;
l. Review of DOC Policies and Procedures;
m. Review of MHM Policies and Procedures;
n. Online research regarding eating disorders.
DRVT did submit requests to the Department of Corrections,
Prison Health Services and MHM Inc. to interview staff involved
in Ms. Ellis’ case. Our requests for those interviews were
declined.
V.

Sequence of Events

On August 12, 2009 two days prior to Ms. Ellis reporting to the DOC
facility Ms. Ellis’ primary care provider in the community faxed 12
pages of medical records on Ms. Ellis to DOC’s Health Services
Director. There was a note by Ms. Ellis’ doctor dated August 6, 2009
which read: “S-Begins a one month prison sentence on 8/20/09.
Continue on Suboxone, 8/2, 2QD. Continue with Potassium...A. – 1.
Suboxone use. 2. Bulemia [sic]. 3. Low Potassium due to bulimia [sic]. 4.
Social situation. 5. Depression. P – 1. Continue current medications. 2. I
wrote a note for her to take that states her dose of Suboxone and
encourages her to continue this in prison; otherwise, recheck in two
months.” Also included was the discharge summary from Ms. Ellis’
stay at RRMC in June of 2009 during which time she was treated with
IV potassium, oral potassium and IV calcium.
According to the Vermont State Police Investigation Report based on
an October 1, 2009 interview with DOC Health Services Director, she
“…verified she received the medical records by fax from [community
physician]…on 08-12-2009. She advised she reviewed the records and
faxed them to [PHS LPN #1]…on 08-12-2009 (the fax date was
incorrect…). [DOC Health Services Director]…advised she had two
further correspondences whereby she sent 2 e-mails to [PHS LPN
#1]…The first e-mail was sent on 08-11-2009 where she told [PHS LPN
#1] …that she would be receiving a complicated patient, whose name
she… did not have at this time. She also included the patients [sic]
diagnosis and medications. The second e-mail was sent the following
day when she…learned of Ashley Ellis’ identity. She also sent a more
detailed diagnosis and medication information.”
There is a fax cover sheet from DOC’s Health Services Director
addressed to PHS LPN #1 on August 12, 2009 indicating that 12
pages of records from Ms. Ellis’ community physician were faxed.
However, the fax date stamp indicates the fax was sent and received
at 2:34 a.m. on August 13, 2009. These records show that Ms. Ellis
was being treated for low potassium as a result of bulimia and for
5

depression. The records also show that Ms. Ellis was being
prescribed Suboxone,1 Lexapro,2 and Klor-Con.3
According to the Vermont State Police Investigation Report during an
interview with PHS LPN #1 on October 1, 2009 they determined “[PHS
LPN #1]…was the third person to have been faxed Ashley Ellis’ medical
records [on August 12, 2009]. [Community physician]…originally faxed
Ellis’ medical records to [DOC Health Services Director]…on 08-122009. [DOC Health Services Director]…faxed Ellis’ medical records to
[PHS LPN #1]…on 08-12-2009 (the fax date and time are not accurate
according to Doctor…as the time on their machine was off. The date
handwritten on the actual fax is correct)…”
The Vermont State Police Investigation Report documented that PHS
LPN #1 stated “…she worked the day shift on Thursday (08-13-09).
She received Ellis’ medical records and reviewed them. In an e-mail
sent to [PHS Regional Director] (who is based out of California), she
[PHS LPN #1] sent her [PHS Regional Director] a summation of Ellis’
medical records…[PHS LPN #1] stated the medications that Ellis was
currently prescribed (from Rutland Regional Medical Center 06-26-09).
[PHS Regional Director] sent an e-mail back giving her…orders to order
the medications for Ellis’ pending arrival (minus the Suboxone).
[PHS LPN #1] went on to state that she then transposed [PHS Regional
Director’s] orders to their medical order form and she…put it on her
desk to continue on Friday (08-14-2009).
[PHS LPN #1] came in to work Friday morning (0700-0730hrs). One of
the two nurses on this shift did not show up. [PHS LPN #1] bypassed
her responsibilities so she could assist the lone nurse by verifying
medications for the 7-8 intakes they had. [PHS LPN #1] stated she was
also scheduled for a meeting in Waterbury with [DOC Health Services
Director]. She called her boss to request postponing this meeting so she
could help the nurse that was at NSCC by herself. [PHS LPN #1] was
contacted by her boss and told to attend the meeting. [PHS LPN #1]
1

Suboxone is used to treat opiate addiction. Generic name: buprenorphine and naloxone. Suboxone can
cause drug dependence. This means that withdrawal symptoms may occur if a patient stops using this
medication too quickly, patients are warned to not stop taking Suboxone without first talking to their
doctor. www.drugs.com
2
Lexapro is a selective serotonin reuptake inhibitor, or SSRI. Lexapro has been proven to be an effective
treatment for depression. www.lexapro.com
3
Klor-Con, Generic name: potassium chloride. Potassium is a mineral that is found in many foods and is
needed for several bodily functions, especially the beating of your heart. Potassium chloride is used to
prevent or to treat low blood levels of potassium (hypokalemia). Patients are warned to not stop taking this
medication without first talking to their doctor as sudden discontinued use may case the patient’s condition
to become worse. www.drugs.com

6

stated she left the facility around 1045hrs, never having a chance to
follow up on Ashley Ellis’ medication order from the day before.”
Ms. Ellis reported to the correctional facility on August 14, 2009 and
at 1:00 p.m. an officer in the Booking Unit completed a Special
Observation Monitoring Sheet for Ms. Ellis.
On August 14, 2009 at 1:28 p.m. a licensed psychologist who treated
Ms. Ellis in the community, faxed a letter and 13 pages of records to
DOC’s Health Services Director in the DOC Central Office. The letter
recommended that Ms. Ellis be housed “on a medical unit and that
any refeeding efforts be directed by protocols appropriate to refeeding a
severely malnourished individual. She also is quite depressed at this
point in time…”
There is a handwritten note on the original cover sheet of the licensed
psychologist’s fax that states “Fax to…8/14/09.” The fax time stamp
on the document shows that the documents were faxed to NWSCF on
August 18, 2009 at 7:42 p.m. from DOC Health Services. The fax
cover sheet from the DOC Health Services Director to the above
individuals is dated August 18, 2009.
On August 14, 2009 at 2:20 p.m. a MHM mental health clinician met
with Ms. Ellis in the Booking Unit. Her note reads in part: “…Ashley
said she was under the care of a physician, that she was taking
Lexapro + that she had an eating disorder – she is a self-admit and will
be here for 30 days. Inmate is prepared to go to Delta – f/u w/inmate
to complete an evaluation / intake after med + security have completed
intakes.”
On August 14, 2009 at 5:30 p.m. an Initial Needs Survey form was
completed. Ms. Ellis was placed on 15-minute checks.
On August 14, 2009 at 9:00 p.m. a Mental Health Intake form was
completed by a correctional officer in Booking.
On August 14, 2009 an Offender / Inmate Orientation to ADA form
was signed by Ms. Ellis. Boxes on the form obtained from Ms. Ellis’
DOC medical records are checked for “I do request a reasonable
accommodation” and “I have been given a Request Form to complete.”
Upon reviewing this same form that was provided from her DOC Core
File (not the copy from the medical records), the box indicating that
she had been provided a request form was not checked off. Both
copies appear to be of the same form and it is unclear at what point
the box was checked on the version in the medical record.

7

On August 14, 2009 at 9:03 p.m. the PHS Intake Receiving and
Screening form was completed by PHS LPN #2. This form states “HX:
recent medical hospitalizations – yes, low potassium. Pre-Admission
Medications: Suboxone…last dose 8/14/09, Lexapro…last dose
8/1/09, Klor-Con…last dose 8/13/09, Folic Acid…last dose 8/8/09.”
It is noteworthy that there are 2 versions of this form: one
handwritten version completed during the interview with Ms. Ellis,
then a computerized version when the information was entered into
the computer. On the handwritten version, under “Disposition” – it
reads: “Placement: GP, Referral: Routine.” On the computerized
version, under “Disposition” – it reads: “Placement: GP, Referral: H&P
– Expedited (within 3-5 days).” There is no documentation describing
the reason for this difference.
On August 14, 2009 at 9:45 p.m. a PHS Progress Note written by PHS
LPN #2 read: “PPD planted ® arm, needs meds verified at Kinneys,
Bomoseen VT. Also Rutland pharmacy. See empty carton and bottles.”
On August 14, 2009 at 10:50 p.m. there is a note in the Booking Unit
Log that Ms. Ellis was moved to Delta D-40 (segregation).
On August 15, 2009 at 6:14 a.m. there is a note in the Delta Unit Log
that Ms. Ellis refused her meal.
The Vermont State Police Investigation Report documented that
during an interview with PHS LPN #3, on August 26, 2009, she stated
that “…[PHS LPN #2] was [sic] have done Ellis’ initial medical intake on
Friday night (08-14-2009). [PHS LPN #3] advised that she came in to
work on Saturday (08-15-2009) at 0600hrs. She works a 12 hour shift,
leaving around 1800hrs. [PHS LPN #3] went on to say that when she
arrived on Saturday morning there were 5-6 charts on her desk.
Around 0900hrs she was able to verify Ellis’ medications from the
intake chart. [PHS LPN #3] does this by contacting each pharmacy.
After that was complete she called [PHS Physician]…who prescribed the
Klor-Con, Folic Acid and Tums.
[PHS LPN #3] advised that she then called Rite Aid in St. Albans to have
the pharmacy fill a 3 day supply of Klor-Con. [PHS LPN #3] advised the
facility has the Folic Acid and Tums.
[PHS LPN #3] went on to advise that she then called the evening nurse
[PHS LPN #4] to see if she would pick up the inmate’s medications on
her way in to work. [PHS LPN #3] advised she left voice mail for [PHS
LPN #4] and apparently she didn’t get the message as [PHS LPN #4]
came to work around 1740hrs and didn’t have any medications. [PHS

8

LPN #3] advised that Rite Aid closes at 1800hrs so there would not
have been enough time to go there and get the medication. [PHS LPN
#3] advised that somebody probably would have gotten the medication
on Sunday…”
On August 15, 2009 at 9:15 a.m. a PHS Progress note signed by PHS
LPN #3 documented: “Meds verified @ pharmacy. [PHS Physician]
called. Orders rec’d – suboxone not ordered @ this time due to
uncertainty re: length of stay. Will follow up on Mon for lot.” It is again
noteworthy that when the PHS Progress notes were faxed to the
Northwestern Medical Center on August 16, 2009 after Ms. Ellis was
transported there, the only PHS note on this PHS Progress note form
was the one dated August 14, 2009. However, when DRVT obtained
these medical records from DOC Central Office, this sheet had three
PHS notes on it, dated August 14th, 15th and 16th.
On August 15, 2009 it is documented on the Medication
Administration Record (MAR) that Ms. Ellis received her morning dose
of Folic Acid and Tums.
On August 15, 2009 at 11:00 a.m. there is a Physician’s Order which
states “T.O. [PHS Physician] /[PHS LPN #1]. Klor-Con 20 meq two TID
x5 days, Folic Acid 1mg PO qd x 30 days, Tums two BID x 30 days.”
On August 15, 2009 at 3:00 p.m. it is documented on the Medication
Administration Record that Ms. Ellis did not receive her dose of KlorCon because it was “out of stock.”
On August 15, 2009 at 3:03 p.m. the Delta Unit Log notes that “Nurse
in w/meds for…Ellis,” despite that according to the MAR, Ms. Ellis did
not receive any medication at this time.
On August 15, 2009 it is documented on the Medication
Administration Record that Ms. Ellis received her night-time dose of
Tums, but that she did not receive her night-time dose of Klor-Con
because it was “out of stock.”
According to the Vermont State Police Investigation Report based on
an interview with PHS LPN #4 on September 29, 2009, she stated that
on August 15, 2009 “…she did in fact receive a voice mail from [PHS
LPN #3] with that request. [PHS LPN #4] advised she did not listen to
the message until the following day which usually is the case. [PHS
LPN #4] stated that she works midnights and usually turns her cell
phone off and often times doesn’t get messages until the next
day…[PHS LPN #4] stated that there is no requirement for any of the

9

nurses to pick up inmate’s medications, but that they do it out of
courtesy.” The VSP report goes on to state that PHS LPN #4 “…told
me when we first met that she was no longer employed there. [PHS LPN
#4] advised that she quit as a result of the incident with Ashley Ellis.
[PHS LPN #4] advised that she has been a nurse for approx. 21 years
and did not want to lose her license. [PHS LPN #4] advised it was her
impression that PHS had Ellis’ medical report and her medications
should have been at the prison when she arrived.”
On August 16, 2009 at 6:03 a.m. the Delta Unit Log documents that
the food cart was in the unit and that by 6:20 a.m. the food trays were
all delivered.
On August 16, 2009 at 6:33 a.m. there is a PHS Progress Note which
states “Med responded to M-33 on Delta – upon arrival, CO’s informed
medical that I/M was unresponsive [with] pulse. I/M was in kneechest position [with] food sticking out of mouth, unresponsive [with]
mottling beginning…Skin cool, color pale. Pupils fixed & dilated.
Carotid pulse checked – faint pulse palpated – unable to count. Pulseox applied, low pulse recorded. Food removed from mouth. Heimlick
[sic] procedure done x3 followed by back blows to attempt to dislodge
any blockage [with] no effect. CPR initiated…”
On August 16, 2009 at 10:30 a.m. there is a PHS Progress Note
written, with a time of 6:33 a.m. which states “Nursing staff called to a
10-33 in Delta unit. Upon arrival I/M was not breathing and was
unresponsive…I/M remained unresponsive throughout CPR. Cyanosis
was detected on lower extremities. 911 was called upon arrival. They
arrived at 0650…Emergency team left the building at 0700 [with] I/M in
the ambulance…All management notified of the incident…
Approximately 0805, nursing staff was informed I/M had expired. Time
of death was 0733…”
On August 16, 2009 at 6:37 a.m. the Delta Unit Log states “10-33
Medical call – Ellis, Ashley D-40 non-responsive, on bunk – hunched
over – appears to be choking.”
On August 16, 2009 the Delta Unit video provided to DRVT for review
has a time stamp which reflects that at 6:24 a.m. the 10-33 was
called, not 6:37 a.m. as noted above. It is not clear if the time
reflected on the video was correct, although staff interviews with VSP
indicate the timestamp on the video was not correct.
On August 16, 2009 at 6:57 a.m. the Delta Unit Log states “Ellis,
Ashley D40 out with Amcare @ this time.”

10

On August 16, 2009 the Delta Unit video provided to DRVT for review
has a time stamp of approximately 6:40 a.m. showing Amcare
Ambulance leaving the prison with Ms. Ellis.
On August 16, 2009 a Facility Report form filled out by one of the
correctional officers involved noted “…I then asked staff to get a CPR
mask. None could be found in Delta unit. I left the area to attempt to
get one somewhere else. I looked in Booking, Control, B unit and the
CFSS office and could not find one. I returned to Delta. I observed the
nurse and CO II…performing CPR on the inmate…”
On August 16, 2009 at 7:18 a.m. the medical office at NWSCF faxed
some of Ms. Ellis’ medical records to the hospital. Of note is the PHS
Problem List, which on this date and time listed no identified medical
problems and the PHS Progress Notes page, where only one medical
note is documented for August 14, 2009. On August 30, 2009 when
DRVT received copies of Ms. Ellis’ medical record from the
Department of Corrections, the PHS Problem List had “H/O Low
Potassium” documented on it and the PHS Progress Notes page, which
begins with the identical August 14th note that was faxed to the
hospital, also has a note by PHS LPN #3 dated August 15, 2009 that
was not on the original form faxed to the hospital by NWSCF on
August 16, 2009.
On August 16, 2009 at 7:33 a.m. Ms. Ellis was pronounced dead at
Northwestern Medical Center.
On September 30, 2009 the Chief Medical Examiner issued the Final
Report of Autopsy listing Hypokalemic induced cardiac arrhythmia
due to anorexia / bulimia nervosa and denial of access to medication”
as the cause of Ms. Ellis’ death.
The Vermont State Police Investigation Report documented that on
October 6, 2009 the Detective spoke with an investigator from the
AHS Investigations Unit and “… asked Investigator…if he had the
opportunity to interview [PHS LPN #2]. Investigator…advised he had
only taken a taped statement from [PHS LPN #1]. I advised Investigator
…that the reason I was asking him about interviewing [PHS LPN #2]
was to ascertain whether or not he had any paperwork regarding
Ashley Ellis’ medical issues when she reported to jail on 08-14-2009.
Investigator…advised that [PHS LPN #2] did not receive anything from
[PHS LPN #1] prior to his screening her on 08-14-2009. Investigator…
advised that this information is contained in [PHS LPN #1’s] statement.
Investigator…agreed that Ellis was treated as a typical first time
prisoner and was screened with no prior information.”
11

The Vermont State Police Investigation Report concludes: “It appeared
that Ashley Ellis’ medical records never left [PHS LPN #1’s] desk.”
VI.

DRVT Findings

Ms. Ellis’ death is an undeniable tragedy that could have been
prevented by the Department of Corrections and Prison Health
Services. It is evident that Ms. Ellis, her family, and her community
providers did what was reasonable and sufficient to alert the
Department of Corrections to her very serious medical needs and
what medications she would require while serving her 30-day
sentence. Unfortunately, despite these efforts, the Department and
its contracted providers failed to keep Ms. Ellis safe while she was in
their custody.
With that said, DRVT would also like to commend the NWSCF
correctional officers who were on duty when Ms. Ellis was found on
August 16th. Based on reports from other prisoners and
professionals and DRVT’s review of relevant documentation, the
correctional staff acted in accordance with policies in performing their
duties under very difficult circumstances. DRVT recognizes and
acknowledges that Ms. Ellis’ death has been a traumatic event for all
involved.
DRVT identified the following specific areas of concern regarding Ms.
Ellis’ death:
1. Lack of communication between medical providers.
Despite the fact that three different physicians (DOC Health
Services Director, PHS Regional Director, and PHS physician]
were made aware of Ms. Ellis’ condition to varying degrees and
at different times, it is not clear from the record that any of the
various physicians actually shared information during the
relevant time period.
DOC’s Health Services Director received medical records related
to Ms. Ellis on two separate occasions, once before her
incarceration and once on the day of her incarceration. One set
of records was faxed to the health office at NWSCF on August
12th, two days before Ms. Ellis arrived. There is no
documentation in Ms. Ellis’ DOC or PHS records to show (1)
when those documents were received (2) who received them (3)
who reviewed them, and (4) any medical decisions or
discussions with the physician about the content of the records.
12

DRVT also found that the DOC Health Services Director sent
two e-mails to PHS staff and MHM staff regarding Ms. Ellis’
medical records, but again there was no documentation in Ms.
Ellis’ DOC medical record to indicate this information was
received.
PHS LPN #1 received Ms. Ellis’ medical records as faxed by DOC
Health Services Director on August 12th as evidenced by e-mail
correspondence that did occur between her and PHS Regional
Director regarding the information in those records. Aside from
the e-mail to the PHS Regional Director in California it appears
PHS LPN #1 did not share the information from the August 12th
faxed records with other providers at the facility. Neither PHS
LPN #2 nor PHS LPN #3 had the information about Ms. Ellis
that her community providers had intended them to have by
sending that information to the DOC Health Services Director in
the DOC Central Office. PHS policies did require that pertinent
information be shared between health and custody staff when
dealing with a special needs individual, which Ms. Ellis was.
The PHS physician was the local onsite physician in charge of
Ms. Ellis’ care. It is not clear why neither PHS LPN #1 nor
DOC’s Health Services Director did not notify the PHS physician
of the information sent by Ms. Ellis’ community providers or
why PHS LPN #1 elected to contact the PHS Regional Director
on August 13th regarding Ms. Ellis’ special medical needs rather
than the local PHS physician.
The second set of records, those that the licensed psychologist
faxed to the DOC Health Services Director at the DOC Central
Office on August 14th were not faxed to the medical office at
NWSCF until August 18th, 2 days after Ms. Ellis’ death, even
though the DOC Health Services Director had written a fax
cover note indicating those records should have been faxed on
August 14th. DRVT was unable to identify who was responsible
for actually faxing these documents and why they were not sent
until 2 days after Ms. Ellis died.
DRVT concludes that PHS LPN #1 violated specific standards
identified below by not accurately updating Ms. Ellis’ medical
records to reflect records received and her e-mail
correspondence with the PHS Regional Director and by not
sharing the information about Ms. Ellis that she had in her
possession with other nurses on duty.

13

VT DOC Medical Health Services Contract 2007, Page 35:
The Contractor must ensure that health records are kept current.
Each encounter between a health care provider and an inmate
must be documented in the health record by the end of each staff
shift to ensure that the providers coming onto the next shift are
aware of the medical status of any inmate treated during the
prior shift.
PHS Policy P-A-08 Communication on Special Needs
Patients
To ensure communication occurs between the facility
administration and treating clinicians regarding inmates’
significant health needs that must be considered in classification
decisions in order to preserve the health and safety of that
inmate, inmates, or staff.
1.

2.

Inmates received into the facility will be assessed and
reassessed as needed by healthcare staff. The medical
information will be reviewed for special needs that may
affect housing, programs, and work assignment. This
information will be shared as needed with the jail
administration, and such communication will be
documented.
Health and custody staff will communicate about inmates
who are:
●
●
●
●
●
●
●
●
●

Chronically ill,
On dialysis,
Adolescents in adult facilities,
Physically disabled,
Pregnant,
Frail or elderly,
Terminally ill,
Mentally ill or suicidal, or
Developmentally disabled.

In addition to PHS LPN #1’s negligent conduct noted above,
DRVT suggests additional review be made regarding the lack of
communication between the DOC Health Services Director, PHS
Regional Coordinator and local PHS physician regarding the
imminent arrival and eventual treatment of Ms. Ellis. The
failure of those leaders in DOC’s medical provider system to
assure that providers on duty and caring for Ms. Ellis had the
14

relevant information about her fragile condition illuminates a
problem that should also be specifically addressed.
2. Medications
The Department had sufficient warning to plan for and obtain
the needed medication for Ms. Ellis, but failed to do so.
According to the medical examiner’s report, the lack of KlorCon, a drug to treat low potassium, was identified by the
Medical Examiner as having a significant role in Ms. Ellis’
death. Rather than following an adequate process to acquire
the medication from a community pharmacy once they realized
they needed it but didn’t have it in stock, PHS staff used an
informal voicemail process to obtain the needed medication, an
informal process that failed to work.
PHS staff violated the following contractual requirement and
national standard by not having Ms. Ellis’ required critical
medication on hand when she arrived:
VT DOC Medical Health Services Contract 2007, Page 18:
W. Pharmaceuticals – Contractor shall provide a total
pharmaceutical system in compliance with NCCHC standards
that is sufficient to meet the needs of the DOC inmates. Contract
shall also be responsible for the acquisition, storage and
administration of pharmaceuticals.
NCCHC Page 61, P-E-02: Receiving, Screening: #9.
Prescribed medications are reviewed and appropriately
maintained according to the medication schedule the inmate was
following before admission.
3. Documentation in medical record after Ms. Ellis’ death
Both the PHS Problem List and PHS Progress Notes from the
time period between Ms. Ellis’ admission on August 14th and
her transfer to the hospital on August 16th were obtained from
various sources by DRVT. DRVT received a copy from the
hospital indicating that on August 16th at 7:18 a.m. the medical
office at NWSCF faxed the PHS Problem List to the hospital.
That document listed no identified medical problems. However,
a copy of the same form received from DOC on August 30, 2009
had “H/O Low Potassium” documented on the Problem List.

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Similarly, the copy of the PHS Progress Notes supplied to DRVT
by the hospital had only one medical note documented for
August 14th. When DRVT received copies of Ms. Ellis’ medical
records from the DOC, the PHS Progress Notes page now also
had a note by PHS LPN #3 dated August 15th which was not on
the form when faxed to the hospital.
These conflicts between the copies of the forms could mean that
the hospital did not receive the most current information from
NWSCF medical department regarding Ms. Ellis’ care and
conditions.
PHS medical staff violated the following contractual requirement
by not making timely notes in Ms. Ellis’ medical record:
VT DOC Medical Health Services Contract 2007, Page 35:
The Contractor must ensure that health records are kept current.
Each encounter between a health care provider and an inmate
must be documented in the health record by the end of each staff
shift to ensure that the providers coming onto the next shift are
aware of the medical status of any inmate treated during the
prior shift.
4. Communication between mental health and medical
staff.
The MHM mental health clinician at NWSCF met with Ms. Ellis
while in booking on Friday, August 14, 2009 at approximately
2:20 p.m. DRVT could find no evidence that this clinician
discussed any of Ms. Ellis’ medical issues with the medical
staff, even though she documented in her note that Ms. Ellis
had an eating disorder and stated she was currently under the
care of a physician for that eating disorder, and was taking a
mental health medication. Nor is there any evidence that this
clinician did any kind of follow up on Ms. Ellis’ status after the
medical and security intakes were completed on August 14,
2009.
It is thus likely that this clinician violated the following
standards as outlined in the contract for services between DOC
and MHM:
State of Vermont Contract for Services between
AHS/Department of Corrections and MHM Services, Inc.

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II. Mental Health Services
3.1 A qualified mental health professional must conduct
structured interviews with all inmates who screen positive
for mental illness during the intake screening processes or
who are referred for mental health services in accordance
with referral guidelines. The mental health assessment will
be conducted in coordination with the Responsible Health
Care Authority (Medical Vendor’s Medical Director or
designee) at each site, according to timeframes that insure
the safety and timely treatment of all inmates who have been
triaged as follows:
emergent – Inmates in need of immediate medical /
psychiatric attention are either transferred to a specialty unit
capable of providing twenty-four (24) hour observation and
care, or are placed on suicide watch until more suitable
arrangements can be made and/or a complete mental health
assessment is conducted.
Likewise, there is no documentation to reflect that PHS nursing
staff initiated any discussion with mental health about Ms.
Ellis.
PHS staff violated the following contractual agreement by not
communicating with the mental health providers upon Ms. Ellis’
intake.
VT DOC Medical Health Services Contract 2007, Page 40:
G. Interface with DOC’s Mental Health Services Provider –
Contractor shall establish procedures to ensure an ongoing active
interface with the DOC’s Mental Health Provider system…The
purpose of the interface between the parties is to ensure
coordination of care occurs for inmates being treated for both
physical and mental health problems.
It seems clear that medical staff and mental health staff in the
facility had only very limited knowledge about Ms. Ellis’ complex
treatment and safety needs as evidenced by the lack of
documented and informed interchange between all relevant
service providers within the DOC system in this case.
Furthermore, had the licensed psychologist’s record been sent
to the MHM mental health clinician when they were received,
she would have had them before meeting with Ms. Ellis on

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August 14th and that could have changed the outcome for Ms.
Ellis.
5. Lack of consideration of potential for detoxification
issues related to not providing opiate addiction drug as
prescribed in the community.
DOC and PHS medical staff, specifically the DOC Health
Services Director, PHS Regional Director and local PHS
physician, were all aware that Ms. Ellis was actively being
treated with Suboxone for her opiate addiction. Both the local
PHS physician and PHS Regional Director gave orders to
discontinue the Suboxone because of the “uncertainty” in Ms.
Ellis’ length of stay. From the records DRVT reviewed there was
no uncertainty found regarding the length of Ms. Ellis’ stay.
Neither PHS physician attempted to contact the DOC Health
Services Director or other DOC officials to inquire about the
length of stay issue. The records reviewed by DRVT did not
include any documentation of consideration by Ms. Ellis’ DOC
medical providers about the impact on Ms. Ellis that the
decision to halt her suboxone prescription may have had on
her, nor any discussion about the need or advisability of
beginning detoxification monitoring protocols given the decision
to halt the suboxone prescription.
PHS medical staff violated the following contractual agreement
by not properly monitoring Ms. Ellis for withdrawal, given the
fact that they were discontinuing her Suboxone treatment:
VT DOC Medical Health Services Contract 2007, Page 19:
b. Medication Assisted Therapy for Opiate Addiction – Contractor
shall comply with DOC policy on Suxobone [sic], Methadone,
Buprenorphine and other medication-assisted therapies for opiate
addiction.
Contractor shall work with DOC to ensure that medication
assisted therapy for the treatment of opiate addiction is
available to inmates, as determined by and in agreement with
DOC policy. Contractor shall also be expected to participate in
the identification of potential candidates and coordination of
such treatment.

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6. Placement in segregation rather than in the infirmary.
Based on the suggestion of her community treatment providers,
Ms. Ellis should have been placed in the infirmary after her
medical and security intakes were completed. Instead she was
placed in the Delta Unit, a segregation unit, apparently due to
lack of bed space in general population. DRVT found
insufficient documentation in the medical records to determine
that medical staff assessed and agreed with this placement
decision.
PHS medical staff violated the following policy by placing Ms.
Ellis in Delta Unit with no written documentation to indicate
that this placement and Ms. Ellis’ medical condition was given
due consideration.
Prison Health Services Policy, Segregated Inmates P-E-09,
#1.
Upon notification that an inmate is placed in segregation a
qualified health care professional reviews the inmate’s health
record to determine whether existing medical, dental, or mental
health needs contraindicate the placement or require
accommodation. Such a review is documented in the health
records.
7. Lack of adequate nursing coverage at facility.
The contract between PHS and DOC required having a
registered nurse (RN) on duty during the evening shift at
NWSCF every day of the week. From records reviewed there is
no documentation that an RN was on duty when Ms. Ellis
entered DOC, or at any other time during her incarceration. It
is possible that had the contract been fulfilled in this area and a
higher practice level of professional such as an RN had been on
duty and available to assess Ms. Ellis upon intake, a different
course of treatment or evaluation of the impact of the treatment
provided would have occurred and changed the outcome for Ms.
Ellis.
Also concerning is that PHS LPN #1 did not fulfill her job duties
on Friday, August 14, 2009 in part because another nurse did
not come to work. PHS LPN #1 told the VSP that due to being
shorthanded, she made the decision to not process Ms. Ellis’
medical information and instead assisted PHS LPN #3 with
other new intakes. DRVT found no evidence that PHS or DOC
19

had a plan in place to assure that when a medical staff person
was out sick that another staff person would be called in to fill
that open position nor that any such effort was made for the
shift in question.
PHS medical staff violated the following contractual obligation
by failure to adequately cover a nursing shift:
VT DOC Medical Health Contract 2007, Page 46:
e. Staffing Standards and Coverage: It shall be the Contractor’s
final responsibility to fill all posts in accordance with the staff
standards and coverage schedules per Attachment G…Contractor
must also ensure that no shift is left uncovered. Attachment H
reflects the minimum staffing required by facility, by shift, by
type of clinical staff for Contractor to avoid a penalty under this
provision. Contractor may, at its discretion and cost, fill clinical
positions with lower or higher practice level professionals without
penalty provided that clinical staff are not asked to operate
outside of their scope of practice to cover a shift.
The following sections identify information that was
available to DRVT under our federal access authority that
cannot be shared with the public in this report due to the
confidentiality requirements of our access authority.
VII.

PHS Mortality Report
DRVT received the PHS Mortality Review relevant to this
investigation pursuant to our federal access authority and an
agreement with PHS.

VIII. VDH Root Cause Analysis Report
DRVT received the VDH Root Cause Analysis Report relevant to
this investigation pursuant to our federal access authority.
DRVT will be providing comments regarding that review to DOC
and VDH directly.
IX.

DOC Administrative Review of Mortality
DRVT received the DOC Administrative Review of Mortality
Report relevant to this investigation pursuant to our federal
access authority. DRVT will be providing comments regarding
that review to DOC directly.

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X.

AHS Investigations Unit Report
DRVT received the AHS Investigation Unit Report relevant to this
investigation pursuant to our federal access authority. DRVT
will be providing comments regarding that review to the AHS
Investigations Unit directly.

XI.

Conclusion and Recommendations
DRVT concluded that Ms. Ellis’ death would have been avoided
had appropriate communication and planning occurred
between medical providers working for DOC. Due to identifiable
failures by DOC and its contractors to communicate and plan,
Ms. Ellis’ community providers’ efforts to insure adequate
medical treatment of their patient once she came with the
DOC’s control and custody proved insufficient. Areas of
significant concern and suggested for further review and
remedial action include the lack of adequate communication
between the DOC Health Services Director and facility medical
staff and PHS physicians specifically. Clearly the DOC Health
Services Director received important information about Ms. Ellis
and made an effort to forward this information to the facility
medical staff. The failure to follow up and assure that the
information arrived and was reviewed by the appropriate facility
personnel, as well as the failure to access PHS physicians to
assure that this complicated new patient was treated
appropriately should be reviewed and systems put into place to
avoid this kind of miscommunication in the future.
PHS medical providers’ failure to communicate with other
facility staff and to assure that medication was obtained, either
prior to Ms. Ellis’ admission or soon thereafter, also contributed
to her death. The failure of PHS to have adequate medications,
specifically Klor-Con, in stock or to know to order it when they
had knowledge it would be needed is also an area needing
improvement. Finally, the decision by PHS doctors to
discontinue Suboxone without initiating detoxification
procedures was also a relevant omission in Ms. Ellis’ death.
There was a staffing deficiency within the medical department
at NWSCF during Ms. Ellis’ stay that contributed to poor
decision making and failure to follow through with physician’s
orders, a situation that should not be allowed to be repeated.
In addition, as noted by other commentators on Ms. Ellis’
death, the lack of a registered nurse on duty during Ms. Ellis’
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admission and stay appears to be a contributing factor to the
failure to properly identify the risk and needs presented by Ms.
Ellis.
Finally, it appears that documentation was added to Ms. Ellis’
medical records after she died based on the differences between
the documentation faxed to the hospital and those provided by
the DOC from Ms. Ellis’ medical file. Any decision to augment
such medical records after the fact deserves added scrutiny and
appropriate disciplinary action.
Recommendations
1. Department staff and contractors should receive verifiable
and ongoing staff training in recognizing and reporting
behaviors that are potentially life threatening for the individual
experiencing them;
2. The Department should assure, through repeated testing,
that policies, directives, and procedures are taught to all staff
and contracted employees and that these rules are followed
consistently;
3. The Department should assure, through repeated training
and random record reviews, that nursing staff are correctly
documenting medication administration times and that
physician’s orders are properly written and carried out;
4. The Department should assure that physicians follow up on
their orders for prisoners who have complicated and potentially
life-threatening medical and/or mental health conditions when
they enter DOC and that the physicians adequately supervise
the medical staff;
5. Department staff and contracted providers who violated
policies or standards of care should be terminated and
complaints should be filed with the appropriate licensing
agencies;
6. The management of severe withdrawal and detoxification
should no longer be done in the correctional setting. The
Department should develop a policy whereby this type of
treatment is conducted only in a licensed acute care facility in
order to prevent future deaths from the failure to adequately
monitor and treat life-threatening withdrawal situations;

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7. The Department should strictly monitor the care provided by
the contracted medical provider and consider changing the
manner by which medical care is provided within the Vermont
system, i.e., making it a not-for-profit venture.
8. The Department should create a policy that clearly identifies
the process to follow when medical information about an
incoming or current prisoner is received at the DOC Central
Office. This policy should require that, in cases where the
medical information received is important to adequate patient
care, the information is promptly, and at least within 2 hours,
forwarded to both the medical department at the appropriate
facility and the contracted physician in charge, with verification
that the information is received and reviewed. In addition, a
policy should be created that requires facility contracted
medical providers and mental health providers to document
their review of community provider information and information
received from the DOC Central Office relevant to patient medical
care. This policy should also require any medical decision to
discontinue medication be accompanied by a detailed
description of what risks are involved and whether or not, and
on what basis, detoxification protocols will be implemented if
applicable.
9. The Department and its contracted providers should assure
that registered nurses rather than licensed practical nurses are
on duty during nights and weekends at each facility in order to
provide for adequate assessment and evaluation of all medical
needs and circumstances.

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