REPORT OF
AN INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF
JAMES QUIGLEY
AT THE NORTHWEST STATE CORRECTIONAL FACILITY

Tina Wood
Advocate/Paralegal

A.J. Ruben
Supervising Attorney

Ed Paquin
Executive Director

Vermont Protection & Advocacy, Inc.
141 Main Street, Suite 7
Montpelier, Vermont 05602
(802) 229-1355
www.vtpa.org

May 21, 2004

TABLE OF CONTENTS

I.

Introduction

03

II.

Background

03

a.
b.
c.
d.

03
04
04
04

III.

IV.

James Quigley
Northern State Correctional Facility
Northwest State Correctional Facility
Vermont Protection & Advocacy, Inc.

Circumstances Surrounding the Death of James Quigley

04

a.
b.

Sequence of Events at NSCF
Sequence of Events at NWSCF

04
06

Investigations into the Death of James Quigley

08

a.
b.
c.
d.
e.

08
10
10
10
11

Vermont Department of Corrections
Vermont State Police
Vermont Chief Medical Examiner’s Office
Marks & McLaughlin Report
Vermont Protection & Advocacy Inc.

V.

Findings and Conclusions

12

VI.

Recommendations

16

2

I.

INTRODUCTION

This report presents the results of the investigation conducted by Vermont Protection &
Advocacy, Inc. (VP&A) into the circumstances surrounding the suicide death of James
Quigley on October 7, 2003, at the Northwest State Correctional Facility in St. Albans,
Vermont.
Mr. Quigley was a 52-year old white male serving a life sentence for a conviction of firstdegree murder and attempted murder in Florida. In February 2001 he was transferred
from Florida to Vermont and was housed at the Northern State Correctional Facility
(NSCF) in Newport, Vermont. Vermont participates in the exchange of prisoners with
other states under the Interstate Prisoner Compact. Mr. Quigley was described as a “jail
house lawyer” who helped other inmates with legal issues. Mr. Quigley was also an
outspoken critic of the Department of Correction’s (DOC) system and routinely filed
grievances.
In July of 2002, Mr. Quigley was moved from NSCF to the Northwest State Correctional
Facility (NWSCF) in St. Albans and placed in a segregation cell in the D-Unit. The
move occurred, according to DOC officials, because he was deemed a security risk due to
maps of Vermont that were found in his possession and informants who stated he was
planning an escape.
Mr. Quigley’s caseworker at NWSCF wrote to the Director of Offender Classification
suggesting that Mr. Quigley be sent back to Florida because he was a security risk. The
case worker noted that “[T]his inmate like [sic] to write tons of greviences [sic] over
petty issues. Also a legal paper pusher.”
While Mr. Quigley at the time of his initial incarceration in Vermont was not considered
an individual with a mental illness, his DOC medical and mental health records show that
in the months preceding his death his mental status began to deteriorate, most likely due
to continual segregation and emotional abuse by particular correctional officers at
NWSCF.
Mr. Quigley hung himself in his segregation cell at NWSCF on October 7, 2003,
sometime before 6:10am.
II.

Background
A.

James Quigley

Mr. Quigley was a 52-year old male who was convicted of murder and attempted
murder in 1980 in Florida. He was transferred to NSCF in Newport in February 2001.
Mr. Quigley was never a disciplinary problem, though often at odds with the
administration in Newport. He strived to make the system better for all people
incarcerated and to that end he acted as an advocate for other inmates who needed
assistance. Mr.Quigley was routinely in contact with VP&A via letters with the intent of

3

bringing attention to a wide variety of issues within the DOC. He is survived by his sister
and his mother.
B.

Northern State Correctional Facility

The NSCF is a medium-security prison located in Newport, Vermont. This
facility has no mental health unit. Contracted staff from Matrix Health Systems and
Correctional Medical Services (CMS) provided mental health and medical care during
the time relevant to this investigation.
C.

Northwest State Correctional Facility

The NWSCF is a medium-security prison located in St. Albans, Vermont. This
facility has a mental health unit. Contracted staff from Matrix Health Systems and
Correctional Medical Services provided mental health and medical care during the times
relevant to this investigation. The D-Unit where Mr. Quigley was housed is the facility’s
segregation unit.
D.

Vermont Protection & Advocacy, Inc.

Vermont Protection & Advocacy, Inc. (VP&A) is a federally-funded, non-profit
whose mission is to advance and protect the rights of individuals with disabilities.
VP&A is mandated to investigate abuse, neglect and rights violations among this
population wherever they may reside, e.g., in the community, private hospitals,
residential care homes, or prisons and jails.
III.

CIRCUMSTANCES SURROUNDING THE DEATH OF JAMES
QUIGLEY
A.

Sequence of Events at NSCF

On May 20, 2003, Mr. Quigley attended a Recreation Committee
meeting of which he had been a member since 2001. According to a letter from Mr.
Quigley, at that May meeting the Superintendent of NSCF made a request to spend $900
from the recreation fund to pay for flowers and seeds. Mr. Quigley and another inmate
on the committee voiced their opposition to this request as they did not feel the
expenditure met the criteria outlined for the fund.
On June 3, 2003, according to a letter from Mr. Quigley, he was informed
by the local Recreation Services Coordinator that the superintendent no longer wanted
out-of-state prisoners on the Recreation Committee. Mr. Quigley and the other inmate
noted above were removed from the committee. Prior to Mr. Quigley’s removal from the
Recreation Committee he had also been arbitrarily removed from his job in the law
library while he was in Newport, a job that provided him with literary enjoyment and
allowed him to help other inmates. From what Mr. Quigley had reported to VP&A, it
would appear the decision to remove him from the law library was a form of

4

administrative retaliation for Mr. Quigley filing grievances and assisting other inmates in
filing grievances.
On June 11, 2003, Mr. Quigley, who had been residing without incident at
NSCF since being transferred there in February 2001, was placed in segregation based on
allegations that he was planning an escape.
In a computerized case note acquired from NSCF, Mr. Quigley’s case
manager wrote on June 11, 2003: “Quigley had a hearing via phone today with the
Florida Parole commission. The call took about 15 minutes where James discussed
possible employment if paroled and circumstances around his crime. James was told by
the commission that he would hear something definate [sic] after the board makes there
[sic] discision [sic] looks like it may be possible Parole in 2013. James was upset with
this discision [sic] and said it was not what he wanted to hear. I placed James on 15
minute check for behavior for his safety [sic].”
A case note dated June 16, 2003 read: “Mr. Quigley was placed in SMU
[Special Management Unit] on Ad. [Administrative] Seg [Segregation] status on
June 11, 2003. He is awaiting an AD seg hearing.”
On June 19, 2003, Mr. Quigley submitted a CMS Health Services Request
Form stating: “Since I was placed in SMU, I have been unable to get any quality sleep.
It seems like every little sound, including my heart beat, awakens. I also have no
appetite, and it appears as though I’ve lost a lot of weight.”
On June 21, 2003, Mr. Quigley was seen by a registered nurse who noted,
“[A]lteration in coping r/t SMU housing. Refer to MH [mental health].” Mr. Quigley
was put on sleep checks by the mental health contracted clinician on June 24, 2003.
A case note dated July 16, 2003 states: “…Mr. Quigley is currently on
Administrative Segregation status at the NSCF with a review date of July 17, 2003. Mr.
Quigley has been placed on the Administrative status due to a potential risk of flight and
possible retribution to what Mr. Quigley believes is a confidential informant in the
facility. Discussion was had in regards to placement of Mr. Quigley should the
Administrative Review allow him to return to general population and/or not. The plan
from this group was for inquiry to movement to NWCF if the Due Process Hearing
allows Mr. Quigley to return to general population status. If the decision is for continued
Administrative status then he will be reviewed for continued placement in the SMU
Unit.”
A case note dated July 17, 2003 states: “James Quigley has been
reviewed by the Administrative Due Process this morning and the determination has
been to discontinue the Administrative Segregation. The Superintendent has concured
[sic] with this decision. The case plan has now been reviewed and Mr. Quigley has been
overridden to close custody and is currently being moved to the NWCF for close custody
housing. Further case planning will be developed through the NWCF and be determined

5

by Mr. Quigley’s behavior.”
B.

Sequence of Events at NWSCF

On July 17, 2003, Mr. Quigley arrived at NWSCF. He was initially
housed the first night in booking. On July 18, 2003, he was moved into the D-Unit. A
Mental Status Evaluation was completed on July 18, at which time a note was made on
the top of the form which read: “Admits to suicidal thinking at times, no risk at this
time.”
On July 22, 2003, Mr. Quigley submitted a grievance #1 stating that since
his arrival on July 17 he had no opportunity to exercise. The response to his grievance by
a correctional officer on July 23, 2003, read: “Mr. Quigley arrived at NWCFS on
7/17/03. On 7/18/03 Mr. Quigley was moved to Delta Act #3 due to lack of bed space.
On 7/20/03 Mr. Quigley was moved into D-46 and was allowed full privileges of Delta
Unit…Recommendation: None needed. Mr. Quigley has from approx. 0800 hours until
1800 hours with the exception of meal times to be out of his cell for various reasons. Mr.
Quigley has ample time to exercise.” Mr. Quigley submitted grievance #3 on July 25,
2003, stating that being allowed time out of his room does not equate to meaningful
exercise. Mr. Quigley wrote: “The lack of exercise is injurying me mentally and
physically. This situation must be promptly rectified. Enough of the lies, please.”
A case note dated July 28, 2003: “…Inmate Qiglet [sic] is a ISC inmate
who was transferred from Newport for Close Custody --- overridden from medium—per
Newport---Security issue---Maps in his possession and informants stated that he was
going to Escape. I have written Ray Flum and made a case that this inmate should return
back to Florida as he is a security risk—no word back yet. This inmate like [sic] to write
tons of greviences [sic] over petty issues. Also a legal paperpusher.”
In July and August of 2003, VP&A submitted grievances on behalf of
certain inmates to the DOC outlining complaints regarding abuse and neglect on the DUnit.
In a letter to VP&A from Mr. Quigley dated August 11, 2003, he wrote:
“…The chainings and the sprayings are almost daily occurrences on D-Wing, and it
seems like prisoner’s are constantly attempting suicide back here, and I can see why.
There is an atmosphere of malevolence, and the conditions are punitive…there are two
cells on my wing whose windows are welded closed and have no water (37 and 38)
except for the toilets.”
In a letter to VP&A from Mr. Quigley dated August 15, 2003, he wrote:
“…this place is absolute bedlam, and many of the guards are brutally callous, particular
[sic] [officer], who is the regular 2nd shift shift supervisor…Perhaps the worst aspect, is
he routinely fabricates misbehavior reports about the prisoner’s in D-Wing, which result
in their missed recreation and prolonged segregation. I strongly suspect he has been
prolonging my tenure back here. Can you imagine, if these people can abuse someone as

6

sophisticated as me, the way they are treating me, what can they get away with the
mentally ill? The constant use of chemical sprays, and the routine chaining to bunks that
I have observed is horrifying. The systematic denial of out-of-cell exercise is both a
violation of DOC Policy 411 and the 8th Amendment, but it’s been approved by…[the]
Superintendent.”
In a letter to VP&A from Mr. Quigley dated August 17, 2003, he wrote:
“You know something, not once did a guard enter my wing after 7:30, even though DOC
policy requires checks of each cell every 30 minutes, and this is an every night routine
when [officer] on duty.”
On August 20, 2003, Mr. Quigley submitted a handwritten note to mental
health which read: “For some reason, I cannot seem to read effectively anymore. It’s as
though my mind is wanting to adsorb the information at a faster pace than is physically
possible. This has been going on for about a week and it’s terribly frustrating because
there is nothing else to do in segregation, and I have a lot on my agenda, but it all
involves reading. Is this a common problem and if it is, can it be [illegible].”
On August 27, 20031, Mr. Quigley was seen by a mental health clinician
who noted on the bottom of Mr. Quigley’s handwritten request above, “Anxiety, exercise,
increase psychosocial.” This clinician also noted in the Mental Health Progress Notes:
“Patient reported having problems with reading which is his main source of activity.
Stated that during this process he will lose his place, experience a tightening in his chest,
and not be able to think clearly. These conditions are typically temporary but
disconcerting. Acknowledged increase in psychosocial stress, goal oriented. (A) No
obvious major mental illness – r/o adjustment disorder. (P) Discussed about move out of
D-Unit…”
In a letter to VP&A from Mr. Quigley dated September 10, 2003, he
wrote: “Today is my 92nd day in segregation for no legitimate reason, and with no end in
sight…A month ago or so I began to notice my ability to read was becoming impaired by
what appears to be a psychological impediment that I suspect is directly related to a lack
of exercise, a transition that would likely be more pronounced in my case because I have
been almost hyperactive most of my life…about a month ago I sent a request to mental
health for an assessment, and a man came to interview me on August 27, but I don’t know
his name…In any event, this mystery mental health worker left me with the impression
that he was going to: (1) discuss the situation with [clinician] and (2) the D-Wing case
worker... It’s now been two weeks with no response…Suppose the condition was driving
me nuts? Perhaps it is!”
In a letter to VP&A from Mr. Quigley dated September 25, 2003, he
wrote: “I am in receipt of your letter, dated Sept. 23, 2003 along with an authorization
1

Department of Corrections Protocol 361.01.03 Mental Health Intake Assessment. There is a 3 working
day response requirement once an inmates submits a slip requesting medical or mental health treatment.
This rule was not adhered to as Mr. Quigley submitted his request on August 20th, and was not seen until
August 27th, 2003.
7

and consent for release form…I must caution that I do not agree with your premise that
the named individuals ‘are not fully aware of how inmates are being treated’ in D-Wing.
Plus I would remind you that the reason I have been in segregation since June 11 is
because I have spoken out against prison conditions in Vermont, and help other prisoners
to do the same…Certainly the only reason I am still confined to D-Wing is because I filed
10 grievances related to D-Wing conditions or my confinement thereto. This was made
unequivocally clear to me by the Delta Unit case worker… at my one and only status
review on July 28…Indeed, it’s all about repression, which is why I close by cautioning
you that I have no doubt that I will be tortured further, if you show my letters to any
prison official…I enjoy helping people in need, and I would very much like to help
improve the system, but look where it’s gotten me.”
In the week before Mr. Quigley’s death, Ed Paquin, Executive Director of
VP&A, discussed with Janice Ryan, Deputy Commissioner – DOC, the various
complaints that VP&A was receiving about the D-Unit conditions.
In a letter to VP&A from Mr. Quigley dated October 1, 2003, he wrote:
“…I suspect they intend to send me to Springfield next week to inaugurate their new 48bed ‘close custody’ unit. This means I’ll be locked in a cell for 23 hours a day for who
knows how long. This is more punitive treatment than prisoner’s receive for actually
breaking the rules, and they get ‘due process hearings’. I’ve done nothing wrong and
they think they’re going to torture me until their sadistic, malevolent souls have had their
fill. No way…There is no question I have been singled out for abuse, and it’s got me
livid…This is a corrupt system, and it’s getting worse. I’m looked at as a whistleblower,
and the only thing I’ve changed is my circumstances – for the worse.”
In a letter to VP&A from Mr. Quigley dated October 4, 2003, he wrote:
“Who says Vermont does not have a death penalty. Simple commitment to the Vermont
DOC care an implicit death penalty element, I suppose. At least the dead no longer have
to endure the torture.” VP&A did not receive this letter until after Mr. Quigley’s death.
On October 7, 2003, at approximately 4:30 am, three other inmates housed
in the D-Unit near Mr. Quigley’s cell reported hearing what sounded like a
gagging/choking noise coming from Mr. Quigley’s cell.
On October 7, 2003, 6:10 am, Mr. Quigley was found hanging in his
segregation cell. He was transported via Amcare Ambulance to Northwestern Medical
Center in St. Albans where he was pronounced dead at 7:16 am.
IV.

INVESTIGATIONS INTO THE DEATH OF JAMES QUIGLEY
A.

Vermont Department of Corrections

The Vermont Department of Corrections conducted their own internal
investigation into the death of James Quigley. Their report does not offer any conclusion
and lacks objectivity. It ignores factual information available to the Department such as a

8

memo from John Murphy, Hearings/Deputy Compact Administrator to Lawrence
McLiverty, Director/Security & Supervison, dated September 11, 2003, which read, “The
purpose of this memo is to apprise you of the possibility that Mr. Quigley is being
retaliated against for his grievance activity.” The memo went on to read, “[I] believe
that a determination needs to be made about possible employee misconduct before I can
craft a response to his most serious issues regarding retaliation. Please advise.”
Despite this and copies of other documents provided in the Department’s own report, the
impression the report leaves the reader with is that Mr. Quigley exhibited behavior over
the course of the past few years that warranted being housed in segregation for almost
four months.
Mr. Quigley’s allegation of possible retaliation is further supported by review of
the Hearing Officer’s Report dated June 11, 2003, completed at NSCF. The officer’s
findings were: “After reviewing the information presented at the hearing, I find there to
be insufficient documentation to place James Quigley on Administrative Segregation
status. There doesn’t seem to be adequate documentation for me to believe that James
Quigley had any intention to escape from this institution.”
The Department’s report ended with a ‘case analysis’ section that outlined the
following recommendations, none of which addressed the issues of psychological abuse
by correctional staff, lack of mental health follow up by the contracted providers,
retaliation, or the effectiveness of the hearing process, all issues relevant to Mr. Quigley’s
untimely death.
1.
2.

3.

4.
5.
6.

The Department review its criteria for Interstate compact selection.
Vermont sends its long term offender out of state because its facilities are
not well suited for them but takes similar cases in return.
A training should be conducted for the casework and security staff at
facilities that would receive Interstate Compact offenders to ensure that
they are clear on the criteria and governing directives on how these cases
should be handled.
A separate directive should be drafted that details the Interstate Compact
case planning process. This directive should detail lines of authority and
time frames for the case planning process, to include return of the inmate
to the sending state.
Training and a description of the governing parole statutes be provided to
casework staff to ensure they understand what individual Interstate
Compact inmates are facing in their respective states.
The Department continue its training for all hearing officers and
investigators on the process for managing confidential information and
informants.
The Department needs to continue to develop various types of housing for
those requiring restrictive housing. The opening of Springfield should
provide that opportunity. D unit in St. Albans should not contain both
segregation and Level 1 offenders. Level 1 or close custody should be
housed in a separate unit.

9

7.

The Department continue to work with the Department of Buildings and
General Services to ensure that all such cells are free of possible means of
self-harm.

B.

Vermont State Police

The Vermont State Police conducted an investigation into the death of Mr.
Quigley. Upon review of the scene of the death, interviews with witnesses and DOC staff
and the assistant medical examiner, the Vermont State Police concluded that he had
committed suicide by hanging. The police report did not address to what extent the DOC
and its contractors complied with policies relevant to Mr. Quigley’s care and treatment
prior to his death. Nor did it discuss the verbal harassment by DOC staff reported by Mr.
Quigley.
C.

State of Vermont Chief Medical Examiners Office

The State of Vermont Chief Medical Examiner’s Office conducted an
investigation into the death of Mr. Quigley. It was concluded to be a suicide by hanging.
D.

Report Completed by Michael Marks and Philip McLaughlin

On March 13, 2004, Michael Marks and Philip McLaughlin, special investigators
contracted by the Governor’s Office to investigate issues in DOC, released their findings.
Their report documents that not only were correctional officers involved in the abuse of
Mr. Quigley, but higher level DOC officials were also involved, and condoned the
continued retaliation and mistreatment that subsequently contributed to Mr. Quigley’s
untimely death. Their report shows that on October 6, 2003, the decision was finally
made to remove Mr. Quigley from D-Unit as soon as possible. That decision was never
shared with Mr. Quigley, and he subsequently hung himself in the early morning hours
on October 7, 2003. Had that information been shared with him, it potentially could have
saved his life. The following are just a few excerpts from this report.
“There is no evidence of any behavior by Mr. Quigley in St. Albans that would
have justified the conclusion that Mr. Quigley was an escape risk. Nor is there any
evidence of any behavior that would have justified keeping Mr. Quigley in D-Wing
beyond his initial thirty days there. The record establishes that the staff in St. Albans was
determined to keep Mr. Quigley in D-wing until Vermont would transfer him back to
Florida.
Mr. Quigley’s correspondence in the last days prior to his death documents
profound dissatisfaction with his circumstances. His condition deteriorated markedly
during the 118 consecutive days he spent in segregated or close custody status.
We have concluded that Mr. Quigley’s continued placement on D-Wing was not
justified. If the system had worked correctly, it should have moved Mr. Quigley from DWing long before his death.

10

Vermont’s correctional system treated Mr. Quigley differently because he had
filed grievances and objected to institutional practices…Retaliation for the filing of
grievances is a significant mistake.
It is also significant that on the night of his death there was a violation of the
regulations requiring the guard to check inmate cells every thirty minutes and see the
inmate’s skin. The guard should have conducted further investigation once he could not
see Mr. Quigley’s skin. It is impossible to say whether adherence to this policy would
have prevented Mr. Quigley’s death. There is no way of knowing whether Mr. Quigley
took his life just after a thirty minute check and would have been dead by the next check
even if the guard had made the check and observed his skin. We do know that this failure
lost a potential opportunity for preventing his death.”
E.

Vermont Protection & Advocacy, Inc.

VP&A first learned of Mr. Quigley’s death as a result of a phone conversation
with another inmate at NWSCF on October 7, 2003. VP&A opened its own
investigation, which included the following:
Î

Review of Mr. Quigley’s medical and mental health record.

Î

Review of Vermont Department of Correction’s Protocols regarding
medical and mental health treatment and NWSCF D-Unit policies.

Î

Review of the Vermont State Police investigation report and supporting
documents.

Î

Review of the Chief Medical Examiner’s autopsy report.

Î

Review of records from the Northwestern Medical Center.

Î

Interview with several of the inmates on D-Unit at the time of Mr.
Quigley’s death.

Î

Review of letters written by Mr. Quigley.

Î

Review of Vermont Department of Correction’s incident report forms.

Î

Review of records from Amcare Ambulance Service.

Î

Review of the Investigative Report into the Deaths of Seven Vermont
Inmates and Related Issues by Michael Marks and Philip McLaughlin,
March 13, 2004

11

Î

V.

Review of the Department of Correction’s Internal Investigation into Mr.
Quigley’s Death Completed February 13, 2004

FINDINGS AND CONCLUSIONS

VP&A’s investigation found no evidence to suggest that Mr. Quigley’s death was
anything other than a suicide. This was also the conclusion of investigations conducted
by the Vermont State Police, Chief Medical Examiner’s Office and by Marks &
McLaughlin.
VP&A’s investigation did find evidence that DOC and its contracted agent,
Matrix Health Systems, knowingly contributed to the untimely death of Mr. Quigley.
The DOC allowed continued psychological abuse and punitive segregation by
administration and correctional officers. DOC and Matrix did not follow up on mental
health services for Mr. Quigley after he reported having difficulties on August 20, 2003,
directly attributed to being housed in the D-Unit in St. Albans. DOC failed to
immediately make changes in the facility after a report submitted by Jeffrey Metzner,
M.D., P.C., to Thomas Powell, Ph.D., Director of Clinical Programs for the DOC that
detailed problems in the D-Unit. DOC failed to heed warnings given by VP&A and Mr.
Quigley.
A.

Segregation

Mr. Quigley was not a disciplinary problem as evidenced by the lack of any
disciplinary reports while he was housed in the D-Unit in St. Albans. It is
unconscionable that Mr. Quigley was held in segregation for approximately 118 days, a
status typically reserved for inmates who exhibit severe disciplinary problems or are high
security risks. This is especially so in light of the note in a grievance response to Mr.
Quigley that he was only in that unit due to lack of bed space elsewhere in the facility. A
correctional officer who routinely worked in the D-Unit stated in his sworn statement to
the Vermont State Police, referring to Mr. Quigley, “…[H]e’s always quiet and got a
long with everybody.”
B.

Suicide Prevention

Dr. Metzner completed a psychiatric consultation “…concerning issues relevant
to the mental health system in the Vermont Department of Corrections.” On August 13,
2003, Dr. Metzner met with key employees of the Department of Corrections, Matrix
Health Systems, and Correctional Medical Services regarding this consultation. His
report, dated August 16, 2003, was then sent to Dr. Thomas Powell. The report noted
that “Suicide prevention issues are difficult to assess due to the lack of adequate written
QI review as required by the August 20, 1997 suicide prevention directive
(361.01.13)…The 1997 suicide prevention protocol is not being followed relevant to the
required QI written report. It is my recommendation that such a report continue to be
required and actually performed…An adequate review process is necessary in order to

12

identify potential system problems and make appropriate corrections. Based on lack of
implementation of the quality improvement report requirement, I have concerns whether
other aspects of the suicide prevention directive are being followed. This question should
be reviewed and corrective action steps implemented as appropriate.” Furthermore,
despite Dr. Metzner’s warning, there is no evidence that the Department of Corrections
did anything to correct the problems identified in St. Albans prior to Mr. Quigley’s death.
Mr. Quigley was not placed on suicide watch2 after the Mental Status Evaluation
which noted he had suicidal thinking at times. Neither Authorization for Suicide Watch
nor Suicide Watch Observation Log forms could be found in his medical record3.
C.

Transfer Between Facilities

Staff at NSCF failed to have a mental health provider review and sign off on the
transfer of Mr. Quigley to NWSCF as indicated by the fact that the transfer form was
blank under ‘cleared by mental health’.4
D.

Other DOC Procedural Failures

Several procedural steps were not adhered to upon Mr. Quigley’s arrival and
subsequent stay at NWSCF. According to DOC protocol5, a mental health intake
assessment is supposed to be completed within 7 days of an inmate’s admission to a
central facility. No Mental Health Intake Assessment form could be found in Mr.
Quigley’s medical record after his transfer to NWSCF.

2

Department of Corrections Protocol 361.01.13, Suicide Prevention, Definitions, Suicide Watch: defines a
level of increased supervision and observation of inmates believed to be at risk of suicide. Two levels of
watch are possible: constant (continuous) and close. Watch may be authorized by mental health staff or
supervisory correctional personnel.
3

Department of Corrections Protocol 361.01.13, Suicide Prevention, VI. Protocol, F. 4. Copies of the
Authorization for Suicide Watch and Suicide Watch Observation Sheet forms shall be filed in the inmate’s
medical chart.
4

Department of Corrections Protocol 361.01.07, V. A., 2.a.(1): All inmates who are transferring to another
facility within VDOC will have their mental health records reviewed by the designated mental health staff
prior to transfer.
5

Department of Corrections Protocol 361.01.03 Mental Health Intake Assessment, V. Procedure, A. A
Mental Health Intake Assessment will be administered to all inmates by medical staff within 14 days of
admission or earlier upon referral. At central facilities, this assessment must be administered within 7
days.

13

The mental health clinician at NWSCF failed to document in Mr. Quigley’s medical
record that he reviewed his prior mental health evaluation and related documentation6.
E.

Failure of Supervision at NWSCF

Aside from the lack of adequate mental health follow up that may have
contributed to the death of Mr. Quigley, there is disturbing evidence that the correctional
officer on third-shift duty at the time of Mr. Quigley’s death did not follow the Northwest
State Correctional Facility procedure that requires “seeing skin”7 when doing the unit
tour checks every 30 minutes. According to the State Police interview with the
correctional officer, he reported that he did not remember at what point he stopped seeing
skin while doing the 30-minute checks. This same correctional officer also noted in his
incident report, “I try to alternate my checks so that the inmates do not get a pattern of
what I am doing at night. I did see I/M Quigley at the beginning of the shift and a few
times after that. I do not remember when I did not see skin. It gets cold down there at
night so a few of the inmates bundle right up under their covers to stay warm…Everytime
a checked I/M Quigley, it appeared to be a body laying down on the bunk. I did my last
check at approx. 0520hrs before the first shift officers took over the unit.” After Mr.
Quigley was found hanging, it was discovered that his bed was full of books that were
positioned to resemble a body lying under the covers. It is also noteworthy that this
correctional officer reported in his statement to the State Police that he had a television
playing in his work area. That noise could have muffled out the sounds that were very
clearly heard by at least two other inmates in the unit at the potential time that
Mr.Quigley hung himself.
In a letter dated September 25, 2003, Mr. Quigley wrote: “By the way, after 5
p.m., the Delta Unit ‘activity rooms’ become a guards’ lounge. Whether it’s Monday
Night Football, WWF Smackdown, or a movie, that’s where the guards will be. Someone
could be dying on one of the wings and they wouldn’t find out until rigor mortis set in.”
Several inmates who were interviewed for this report stated that the correctional
officers did not perform the mandated 30-minute checks, even though the Unit Log
indicates the checks were completed. One inmate stated he felt Mr. Quigley’s death
could have been prevented, or the attempted interrupted, if the officer on duty actually
performed the checks.
The Marks/McLaughlin report shows that the Superintendent at NWSCF was well
aware of and condoned Mr. Quigley’s continued segregation in the D-Unit.
6

Department of Corrections Protocol 361.01.04 Mental Health Evaluation, V. 2. a. due to the fact that a
majority of inmates admitted to central facilities are sent from regional facilities where the mental health
evaluation may already have taken place, it need not be repeated if it has been done within the preceding
three months. b. in such cases, the sending facility must document on the transfer form that the mental
health evaluation is present in the inmate’s medical chart and mental health staff at the receiving facility
must document that they have reviewed the evaluation and related documentation.
7

Northwest State Correctional Facility, Procedure 300.80, Delta C/O I Post Orders, General Orders #1.
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Superintendent…wrote that Mr. Quigley could earn his way out of D-Wing and into the
general population by ‘appropriate behavior’ and ‘cooperation’.” Given the evidence
discussed previously, this statement can only be considered an intentional falsehood.
F.

VP&A’s Concerns About D-Unit

In addition to Mr. Quigley’s own correspondence that went to many different
individuals and agencies, including DOC, expressing his concerns about the treatment
inmates were receiving in both D-Unit One and D-Unit Two, Vermont Protection &
Advocacy, prior to and around the time of Mr. Quigley’s death, had brought it’s concerns
to the attention of DOC officials to no avail. VP&A had been receiving numerous
complaints from different inmates in the D-Units regarding abuse, both physical and
emotional, being inflicted upon them by certain correctional officers who worked there. It
is disconcerting that the Department ignored these serious warning signs and failed to
investigate and correct problems that existed. If they had, there may have been a very
different outcome for Mr. Quigley.
G.

Welfare of Inmates Affected by Mr. Quigley’s Death

According to DOC protocol8, whenever there is a death of an inmate in a facility,
both staff and inmates are to be given the opportunity for a debriefing session to address
their emotional needs, as many inmates develop close bonds and friendships while
incarcerated and can suffer emotional distress when a suicide occurs. VP&A staff
conducted interviews with inmates who lived in the same unit as Mr. Quigley, and these
inmates were specifically asked if the Department provided any kind of counseling or
debriefing for them. The unanimous answer was no. This is very disturbing as many of
the inmates interviewed were visibly upset over Mr. Quigley’s death.
H.

Other Findings

In addition to the DOC protocols already noted as having been violated in this
case, VP&A also finds the following were violated as well:
■
DOC Directive 361.01 Mental Health Directive II. Purpose: The mission of the
Vermont Department of Corrections’ (VDOC) mental health services is three-fold: (1) to
provide comprehensive clinical services to alleviate symptoms and reduce suffering; (2)
to enhance the safety of the correctional facility environment for inmates, staff and
visitors; and (3) To ready inmates with mental illness for participation in risk reducing
programs through direct services, case coordination, and research evaluations.”
This directive was violated as evidenced by the fact that Mr. Quigley did not
receive adequate mental health follow up after he was initially evaluated by a clinician
8

Department of Corrections Protocol 361.01.13, Suicide Prevention, VI. Protocol, H. 6. All staff and
inmates affected by serious or completed suicide attempts shall be provided with crisis intervention
services. In addition, all affected parties shall be subject to the requirements of the Critical Incident
Debriefing directive.
15

after reporting symptoms of possible adjustment disorder and anxiety, which may have
contributed to his untimely death.
■
DOC Protocol 361.01.02 Referral for Mental Health Services, V., B: Mental
health referrals by staff members (1) Any staff member who believes that an inmate may
be in need of mental health services shall complete a Mental Health Referral form.
This protocol was violated when medical staff at NWSCF failed to complete the
appropriate mental health referral form even though it was documented that Mr. Quigley
had reported suicidal thoughts.
VI.

RECOMMENDATIONS

Based on its findings and conclusions, VP&A recommends the following actions
that should be taken by the Department of Corrections:
1.

Any and all correctional employees involved at any level in the retaliation and
mistreatment of Mr. Quigley should be immediately dismissed from employment.
The Department needs to establish a no tolerance policy with regard to employee
misconduct.

2.

Review of quality of follow up services being provided by the contracted mental
health providers.

3.

Improvement and renovation of the physical plant and living conditions in DUnit.

4.

Staff training in recognizing and reporting behaviors that are potentially life
threatening for the individual experiencing them.

5.

Mandatory training on policies, directives, and procedures for all staff and
contracted employees, including the psychiatrist, with an oversight mechanism
that assures that these rules are followed consistently.

6.

Review and revision of the current hearing process, including procedures to be
followed when a hearing officer’s recommendations are overridden by the
Superintendent.

7.

Review and revision of the current grievance process to assure timely and
unbiased investigation into inmate complaints.

8.

Develop a protocol to provide in depth, unbiased investigations into deaths that
occur within Corrections. Quantifiable recommendations need to be provided, as
well as corrective actions, including employee sanctions.

16

9.

Develop a procedure whereby misconduct of administrative staff, i.e., assistant
superintendents and superintendents, is reviewed and addressed when allegations
of retaliatory acts are made.

Cc:

Claire Quigley
Honorable Governor James Douglas
Steve Gold, Commissioner
Janice Ryan, Deputy Commissioner
Charles Smith, Agency of Human Services
David Sleigh, Attorney for Mr. Quigley’s Estate

17