Investigation Into the Death of Michael Estabrook While In
the Custody of the Vermont Department of Corrections

Vermont Protection & Advocacy, Inc.
Special Investigations Unit
141 Main Street, Suite 7
Montpelier, Vermont 05602
July 9, 2007 Public Report
www.vtpa.org

VP&A is the Protection & Advocacy System for Vermont.

Table of Contents

I.

Introduction………………………………………………………

03

II.

Background………………………………………………………

04

III.

VP&A’s Investigation……………………………………………

05

IV.

Sequence of Events………………………………………………

05

V.

VP&A’s Findings………………………………………………..
Medical Furlough Issues…………………………………….
Worsening Condition and Symptoms……………………….
Infirmary…………………………………………………….
Medication Issues……………………………………………
Do Not Resuscitate Issues……………………………………

17
17
20
21
22
23

VI.

Recommendations………………………………………………..

25

2

I.

Introduction

This report presents the results of an investigation conducted by Vermont Protection
& Advocacy, Inc., (VP&A) into the death of Michael Estabrook on March 7, 2006 at
Fletcher Allen Health Care (FAHC) while in the custody of the Vermont Department
of Corrections.
In April of 2005 Mr. Estabrook was initially detained at the Chittenden Regional
Correctional Facility (CRCF) in South Burlington for failure to appear in court on
August 3, 2004 for a contempt hearing for failure to pay a fine. He was also charged
with possession of marijuana when he was arrested. During his incarceration Mr.
Estabrook was transferred to Northern State Correctional Facility (NSCF), Northwest
State Correctional Facility (NWSCF) and Southern State Correctional Facility
(SSCF).
Mr. Estabrook was a 37 year-old male, divorced with two children, who suffered
from a disabling disease called severe dilated cardiomyopathy. 1 As a result he was
also in congestive heart failure. 2 Mr. Estabrook’s medical condition deteriorated
during the year he was incarcerated resulting in hospitalization on two occasions. He
requested, and was denied, a medical furlough. Mr. Estabrook claimed he was not
receiving adequate medical care while incarcerated and that his housing situation
caused undue stress and exertion on his body. While in SSCF he requested several
times to be transferred back to the jail in South Burlington where, because of the size
and layout of the facility, he was able to ambulate with less difficulty. His request to
be moved was not granted even though the medical provider at the facility
documented that he “…has some effective justification for wanting to be housed at
Chittenden…” Beginning in January of 2006 Mr. Estabrook also requested to be
housed in the infirmary at the Springfield facility to accommodate his deteriorating
physical condition and to make it easier for him to get to areas of the prison. The
Department failed to follow up on this request.

1

Dilated cardiomyopathy (DCM) is a condition in which the heart's ability to pump blood is decreased
because the heart's main pumping chamber, the left ventricle, is enlarged and weakened; this causes a
decreased ejection fraction (the amount of blood pumped out with each heart beat). In some cases, it
prevents the heart from relaxing and filling with blood as it should. Over time, it can affect the other heart
chambers as well. www.webmd.com WebMD Medical Reference in collaboration with the Cleveland
Clinic.
2
Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough
blood to the body's other organs. This can result from *narrowed arteries that supply blood to the heart
muscle — coronary artery disease; *past heart attack, or myocardial infarction, with scar tissue that
interferes with the heart muscle's normal work; *high blood pressure; *heart valve disease due to past
rheumatic fever or other causes; *primary disease of the heart muscle itself, called cardiomyopathy; *heart
defects present at birth — congenital heart defects; *infection of the heart valves and/or heart muscle
itself — endocarditis and/or myocarditis; *The "failing" heart keeps working but not as efficiently as it
should. People with heart failure can't exert themselves because they become short of breath and tired.
American Heart Association Website

3

On January 22, 2006, VP&A met with Mr. Estabrook during outreach at SSCF. He
requested help with possibly being transferred back to CRCF for the reasons stated
above. He expressed concern about being in a single man cell in the Charlie Unit
(medical unit) in the event that he suffered another cardiac event. His main concern
was that no one would find him in time to save him, therefore he asked for a cell
where he could have a roommate. At that time Mr. Estabrook required a wheelchair
to move around.
On February 22, 2006, advocates from VP&A had a scheduled meeting with Mr.
Estabrook at SSCF to prepare an advance directive for health care 3 . At this visit Mr.
Estabrook was extremely fatigued, had swelling in both of his feet and ankles, and
appeared jaundiced. Mr. Estabrook stated that he had not been producing any
significant urine output for several days and that no one from the medical staff was
taking this seriously. Mr. Estabrook required assistance to return to his unit which
was just around the corner. He was not able to open the doors by himself and was
very slow and unsteady on his feet. We discussed his condition with medical staff
and learned that Mr. Estabrook had an appointment scheduled for that same day with
his cardiologist.
Throughout his last 11 months of incarceration Mr. Estabrook had only three visits
with his cardiologist. The third visit was on February 22, 2006, where he collapsed
entering the office and was subsequently transferred to Fletcher Allen Health Care. It
is important to note that in 2004 Mr. Estabrook was also incarcerated for a few
months. During that incarceration he went into renal failure and had to be
hospitalized. He was subsequently released on medical furlough due to the severity
of his illness.
On March 7, 2006, Mr. Estabrook died at Fletcher Allen Health Care from
complications of dilated cardiomyopathy.
II.

Background
A. Vermont Protection & Advocacy, Inc., (VP&A) is a federally-funded, notfor-profit organization mandated to investigate abuse, neglect and rights
violations effecting people with disabilities.
B. Chittenden Regional Correctional Facility (CRCF) is a jail located in
South Burlington, Vermont.

.
C. Southern State Correctional Facility (SSCF) is a prison located in
Springfield, Vermont.
3

18 VSA § 9701 Definitions. (1) “Advance directive” means a written record executed pursuant to section
9703 of this title, which may include appointment of an agent, identification of a preferred primary care
clinician, instructions on health care desires or treatment goals, an anatomical gift as defined in subdivision
5238(1) of this title, disposition of remains, and funeral goods and services. The term includes documents
designated under prior law as a durable power of attorney for health care or a terminal care document.

4

D. Northwest State Correctional Facility (NWSCF) is a prison located in
Swanton, Vermont.
E. Northern State Correctional Facility (NSCF) is a prison located in
Newport, Vermont.
F. At the time of Mr. Estabrook’s death, Prison Health Services was
the contracted medical provider.
G. At the time of Mr. Estabrook’s death, MHM Services, Inc. was
the contracted mental health services provider.
III.

VP&A’s Investigation
VP&A’s investigation of this case included the following:
1. Interviews conducted with Mr. Estabrook before his death
2. Review of medical and mental health records from the Vermont
Department of Corrections
3. Review of core file records from the Vermont Department of Corrections
4. Review of medical records from Fletcher Allen Health Care, Rutland
Regional Medical Center and Regional Ambulance Service
5. Review of American Heart Association information on dilated
cardiomyopathy and congestive heart failure
6. Interview with family member
7. Review of medical examiner’s report
8. Discussions with staff and contracted providers for the Vermont
Department of Corrections
9. Review of Vermont law on “Do Not Resuscitate” orders
10. Review of Department of Corrections Policies and Directives
11. Review of several online sources of medical information
12. Review of PHS Policies and Procedures

IV.

Sequence of Events
Mr. Estabrook was incarcerated in 2004. During that incarceration, he
experienced significant medical problems as reflected in the following
information contained his Department of Corrections records:
May 17, 2004 “New intake – hx dilated cardiomyopathy…feel pt’s needs
would best be served at this time by infirmary housing…” [MD]
June 3, 2004 Medical note at NSCF: “…C.O. called to say that IM was
having chest pain…EKG done. Returned to unit.” [RN]

5

June 4, 2004 Medical note at NSCF: “Chest pain – in neck L shoulder &
upper arm & all sweaty…Diaphoretic + clammy. EKG shows pacer spike on
T wave. Alt comfort, alt health maint R/T pacemaker malfunction. Dr…
paged 911. Orders rec’d to send to E.R.” [RN]
June 4, 2004 “’Scared’ – talking non-stop about unrelated topics.
Ambulance att present – I/M on stretcher [with] 02 on…”
June 4, 2004 1115 “Returned from NCH. ‘I feel lots better.’ … Dr…
notified of I/M return + need for pm ck today. Orders rec’d.” [RN]
June 4, 2004 2200 “At approx 1500 today we were notified that Mr.
Estabrook has been admitted into Fletcher Allen Hospital.” Medical Note.
June 8, 2004
Fletcher Allen Health Care – Nsg [nursing] Note for
discharge of PT [with] CHF: “Pt should be weighed daily at the same time
each day before breakfast. This is to assure the correct dosage of lasix, that
he’s not losing to [sic] much or retaining to [sic] much fluid. Symptoms: He
needs to be watched for shortness of breath [with] exercise or difficulty
breathing at rest or when lying flat, swollen legs, ankles, or abdomen, dry,
hacking cough or wheezing, fatigue, wgt gain, [increase] urination @ night,
dizziness or confusion, rapid or irregular heartbeats. Call MD if gain 2lbs in
one day or 5 lbs in one week. Make sure a good record of his daily wgt is
kept….”
June 8, 2004 Fletcher Allen Health Care Discharge Summary: “Discharge
Diagnoses 1. Acute renal failure secondary to over-diuresis 4 . 2. Dilated
cardiomyopathy….” [MD]
July 16, 2004 Letter to Director of Clinical Services from Superintendent at
NSCF: “I have been informed by Nurse Manager… that Michael Estabrook is
suffering from a terminal medical condition and is in need of a medical
furlough. Michael Estabrook is a 36 year old offender. Mr. Estabrook is
serving a 3 years to 7 years sentence for DWI #6 and DLS #1. His minimum
release date is 04/27/07. According to directive 351.08 The Commissioner
may place on medical furlough any inmate who is serving a sentence,
including any inmate who has not yet served the minimum term of sentence,
who is diagnosed as suffering from a terminal or debilitating condition so as
to render the inmate unlikely to be physically capable of presenting a danger
to society. Due to this current condition Mr. Estabrook is not considered a
risk to the public.”

4

Diuresis is the secretion of large amounts of urine. – Medline Plus Website, U.S.
National Library of Medicine

6

Mr. Estabrook was released on medical furlough approximately on July 21,
2004. VP&A could not find an actual release date due to the insufficient
records provided. After his release on medical furlough, Mr. Estabrook
continued to have serious medical problems. These problems are reflected in
the Probation and Parole case notes quoted below:
January 28, 2005 Probation & Parole Case Notes: “Michael is at
home…Had surgery on Tuesday to reimplant new pacemaker, has two
wounds on chest, states he is already feeling a difference from it…”
February 8, 2005 Probation & Parole Case Notes: “Michael called the
machine to advise he had been admitted to the hospital. He said he is on
McClure 5…and that he would call when he got discharged.”
February 10, 2005 Probation & Parole Case Notes: “Mike called, left a
message that he was released from the hospital…”
April 27, 2005 Probation & Parole Case Notes: “Spoke with [officer] at
Burlington PD. He was looking at the updated Furlough lists we were
bringing in. He believes that Mike Estabrook has an active warrent [sic] out
for his arrest. [officer] calls dispatch and they check and confirm that there is
an active warrent [sic] for Mike dating back to November of 04.”
April 27, 2005 Probation & Parole Case Notes: “…At 2115 hours we went
over to Estabrook’s home…Estabrook was taken into custody, he was very
agitated…”
April 28, 2005 Mr. Estabrook is detained at the Chittenden Regional
Correctional Facility.
April 29, 2005 Probation & Parole Case Notes: “…There was an arrest
warrant for Mike as he failed to appear on 8/3/04 for a contempt hearing for
failure to pay fine. The amount was for $601. Mike was ordered for arrest
until he could satisfy the contempt order by paying the fine in full…”
After he was re-incarcerated in 2005, Mr. Estabrook’s medical condition did
not improve as reflected in his DOC records quoted below:
May 10, 2005 PHS Physician’s Order: “Send to ER via 911 per TVO
[doctor].” This was due to complaint of chest pain.
May 11, 2005 An Outpatient Referral Request Form completed by Prison
Health Services staff read: “To ED [after] CP [chest pain] on 5/10/05. EKG

7

NSR w/pacer spikes. Defib unit did not fire. ED found [change] in kidney
function – probable prerenal azotemia.” 5
May 11, 2005 Note from Fletcher Allen Health Care “patient should be
weighed daily to help manage cardiac condition. He should see [cardiologist]
this week for evaluation of the change in kidney function…”
May 18, 2005 Case note “Met with Michael and he asked what was going on.
I told him that I am wanting [sic] for some answers from central office on his
medical furlough…”
June 1, 2005 Mr. Estabrook had an appointment with [cardiologist] who
noted in a letter to Prison Health Services: “…Mr. Estabrook continues to be
marginally compensated. He needs continued attention to his underlying
congestive heart failure. He needs to watch his sodium and fluid intake…I’ve
asked him to see me in the office in six to eight weeks for repeat ICD
evaluation. Mr. Estabrook has a significant cardiomyopathy and has a
relatively tenuous status…”
June 22, 2005 Email From CWS to DOC Medical Director. “Subject:
Michael Estabrook. Do you know anything about this case? He was on a
Medical Furlough. His current minimum is 4/27/07 which is about 21 months
prior to normal furlough eligibility. An exception can be made for someone
on Medical Furlough. Are you involved in re-assessing his Medical
condition?”
June 23, 2005 Email from DOC Medical Director to CWS: “Hi… Sorry I
don’t recognize your…name. What is your connection to the offender?”
June 23, 2005 Email from CWS to DOC Medical Director: “I am the CWS
at Chittenden. I need to determine what to do with Mr. Estabrook. Should he
be reviewed for a return to a Medical Furlough? Does his current physical
condition warrant being placed on furlough? If the decision is that he remain
incarcerated should he be placed at a facility with more extensive medical
facilities? I suspect that [name removed] was involved in the original decision
which is why I E-Mailed you. I had also heard that you were involved in a
review of the case however that may not be true.”
June 23, 2005 Email from DOC Medical Director to CWS. “Thanks...I did
review his case about a month ago. At that time, I recommended against a
5

Definition: Prerenal azotemia is an abnormally high level of nitrogen-type wastes in the bloodstream. It is
caused by conditions that reduce blood flow to the kidneys. Prerenal azotemia is reversible if the cause can
be identified and corrected within 24 hours. However, if the cause is not corrected quickly, damage may
occur to the internal structures of the kidney (acute tubular necrosis). MedLine Plus, Service of the U.S.
National Library of Medicine

8

medical furlough based on my understanding of the criteria for granting
furloughs. I am happy to review it again if there has been a change in his
condition. Essentially, he has a serious medical condition that is chronic and
stable. At the time of my review, he was not in need of special housing. He
was scheduled for a follow-up with his cardiologist this month which may
shed additional light. His cardiologist did inform us that Mr. Estabrook did
not keep hi [sic] appointments while residing in the community. If you think
this should be reconsidered, please advise as to your rationale and I will ask
the medical staff to re-examine his situation.”
June 23, 2005 Email from CWS to DOC Medical Director: “No. There isn’t
anyone pushing for another review, we didn’t know the results of the original
assessment. I’ll check with medical regarding the date of his next apt. If
there hasn’t been a dramatic change or an on-going need for treatment in this
area, we will consider placement at another facility.”
July 18, 2005 Case note written by CWS “…was placed on a medical
furlough when he was originally sentenced. He was returned to this facility in
April on a warrant. The issue has been resolved however the basis for the
Medical furlough was reviewed by Central Office. A decision has been made
that it is not warranted at this time…”
July 18, 2005 Transferred from CRCF to SSCF.
July 19, 2005 Transferred from SSCF to NSCF for “population
management.” “d/c to medical hsg unit.” PHS Note.
July 29, 2005 Physician at NSCF wrote the following note: “…will consider
transfer to facility [with] higher level nursing care, closer to cardiologist in
FAHC…”
August 9, 2005 Prison Health Services fax sheet to [doctor] from Physician
at NSCF: “…Michael’s care basically remains a guessing game as to how to
adjust his diuretics. During his last incarceration he wound up in acute renal
failure. Thanks…”
August 16, 2005 Physician at NSCF wrote the following note: “…stood +
argued for several minutes that he wanted me to call [cardiologist] about
getting him medical furlough (I told him this had already been d/w Dr.’s…”
September 13, 2005 VT Dept of Corrections Grievance #1 filed by Mr.
Estabrook while at NSCF. “Every night on third shift this unit and [illegible]
are left unattended for extended periods of time. There are chronically ill
individuals (including myself having been described w/a tenuous condition by
my cardiologist I have these docs.) that could not summon help if and when
needed…As w/any other grievance in this system I do so w/great reluctance

9

for fear of retaliation. However, I know my safety and my life are in jeopardy
so I don’t care. Do what you need to do. If DOC or PHS is going to keep
chronically and seriously ill patients in this facility they should be able to
summons [sic] immediate help at all times. What should be [sic] the outcome
be? I believe I will [sic] may my atty. Aware of this situation who will also
make the presiding Superior Court Judge aware of the problem. He will be
unimpressed. This should really help my suit against DOC. The facility is
understaffed and misconduct rampant.”
September 16, 2005 DOC Case Notes: “Michael has left the facility and was
transferred to Southern State.”
September 20, 2005 Mr. Estabrook saw [cardiologist] who noted a 30 pound
increase since June, but that client was reasonably stable.
September 28, 2005 Case note written by [caseworker]: “Met with Michael
Estabrook today. He is here from Newport due to medical issues. From the
casenotes, it seems that Michael has to serve his minimum. It appears that he
is asking me the same questions that he asked of his other CSS in Newport,
for medical furlough…When talking to the Nurse manager here at SSCF…I
was under the impression that Michael quite possibly may not make it to his
minimum with the heart condition that he has…”
September 28, 2005 Licensed Nursing Assistant note about Mr. Estabrook
stating he was a “DNR” and that he wanted to enter into a discussion about his
right to choose.
October 18, 2005 DOC Case Note by case worker: “Met with Michael in the
Infirmary Ward where he remains until a lower room becomes available in the
Charlie Unit. Explained to Michael that he will not be eligible for release to
the community on furlough due to his medical needs have not become more
severe according to medical staff. Informed him that I had reviewed the
casenotes and that at which time that his medical needs become more than the
facility can handle he may be eligible for medical furlough….I spoke to Nurse
Manager…and he stated that there was no reason that Michael could not get
up and around more than what he was doing in the infirmary…”
October 20, 2005 VT Dept of Corrections Grievance Form #2, NSCF
Response to Mr. Estabrook’s Grievance #1. “I/M grieving the fact that there
is only one nurse on at night. Investigative Action Taken: None. Summary of
Facts: Contract between DOC + PHS for this facility only requires one LPN
on night shift. Recommendation: Dismiss. Superintendent’s Decision:
Facility has 24 hour medical coverage. No further action is required.”
October 29, 2005 Mr. Estabrook was admitted to the Springfield Hospital for
chest pain. There was a discussion about putting him back in the medical

10

infirmary at prison so he would not have to walk long distances. Physician
wrote: “I recommend the patient be returned to the correctional facility and
be placed in the infirmary…This plan was discussed with the patient’s escort
who confirmed that these requirements could be fulfilled.”
October 31, 2005 DOC Case Note by caseworker: “…Will
email…regarding what it would take for him to be reconsidered for this
furlough.”
November 2, 2005 DOC Case Note by caseworker: “…Spoke with [LUS]
yesterday about possible medical furlough for Michael. She informed me that
as long as he can be treated by the facility that a medical furlough would not
be an option for Michael at this time…”
November 3, 2005 Mr. Estabrook was transferred from SSCF to CRCF.
November 4, 2005 Mr. Estabrook was transferred from CRCF to NWSCF.
November 8, 2005 Mr. Estabrook was transferred from NWSCF to SSCF.
November 18, 2005 VT Dept of Correction’s Grievance Form #1 filed by
Mr. Estabrook at SSCF: “Nursing staff (not nurse manager) trying to
convince me to come to main bldg. for meds. I thought this issue had been
decided. I am not going to get better. This will cause additional stress on my
heart unnecessarily. Distribute meds in unit bldgs as before.”
November 25, 2005 PHS Progress Note: “I/M complaining of increased
swelling, weakness, shortness of breath…I/M has minimal swelling in lower
legs…Will continue to monitor.” [RN]
November 29, 2005 DOC Case Note caseworker: “Met with inmate * in my
office this pm. He stated to me in regards to his recent medical condition in
which accdng [sic] to him he has severe heart problem. He also requested to
this CSS if he could go back to Chittenden which his regional area and a
smaller faclilty [sic] in terms of everyday mobility. I stated to him that I will
get in contact with our movement.”
December 6, 2005 Mr. Estabrook submitted written request to be transferred
to CRCF.
December 7, 2005 VT Dept of Correction’s Grievance Form #2, SSCF
Response to Mr. Estabrook’s Grievance #1 filed 11/18/05. “I/M complains
that nursing staff are trying to have him come to main med for med. pass. I/M
has been receiving his meds in the Charlie Unit due to a chronic heart
condition as he become short of breath walking to main med. Cont. to
distribute his meds in Charlie unless there is a significant improvement. Only

11

the nurse mgr will make this decision. No further action – inmate is taking his
meds in the unit.”
December 7, 2005 Sick Call Request slip submitted by Mr. Estabrook: “This
sustained tachachardia [sic] continues to be a problem. I have seen no action
taken in this matter. This has occured [sic] approx. 10x in 6 wks. I want to
meet w/the Doc. To discuss this matter.”
December 12, 2005 PHS Progress Note by physician “…thinks he may have
a flu-like illness now…Notes that he hasn’t gotten Lisinopril in recent
days…”
January 3, 2006 PHS Progress Note “…Today’s weight of 172 ½ is
stable…”
January 6, 2006 DOC Case Note by caseworker: “Met with inmate
Estabrook last night and again explained to him his request to be transferred
out of SSCF. I explained to him that acccording [sic] to the Med team that he
is to be remained here at SSCF and such request is denied. Please note that
this CSS did request this transfer to the medical team and was told that inmate
* will reside here at SSCF since this is the medical unit now.”
January 6, 2006 Prison Health Services Memo stating that Mr. Estabrook
had an appointment with his cardiologist on January 25, 2006. There is a
handwritten note on this typed memo that reads: “Canceled. DOC did not
take him. New appt. 2/22 @ 3:30.”
January 9, 2006 Mr. Estabrook submitted a written request to be returned to
CRCF. “I would like DOC + medical to consider transferring me back to my
regional (CRCF) with the provision that I sign a notarized release of liability
absolving DOC + medical of legal liability (that’s what this is really about
after all) in the event of a catastrophic or fatal cardiac.”
A PHS physician met with him and noted: “Discussed above with IM. As
previously, I think he has some effective justification for wanting to be housed
at Chittenden. Will discuss with [doctor]…weight 168#...”
January 17, 2006 Mental Health Progress Note by [clinician name]: “…’I
feel frustrated and powerless and hopelessness.’ Feelings are related to his
efforts to return to Chittenden facility. He is currently on Charlie Unit, is
fearful of the potential difficulty of calling attention to himself if he needs
help (no roommates, door locked) and also feels cut off by his cardiac
condition as he does not have the strength to use a wheelchair and the
distances involved at SSCF are dangerous for him to walk. After discussing
the situation we identified some steps he could take including writing to [DOC
physician] again, talking with LUS…and moving to the infirmary (which he

12

had previously rejected because it was associated with death and dying in his
mind…)…Spoke with LUS…regarding possible transfer to Infirmary. MH
staff will remain available for clinical supports PRN.”
January 22, 2006 VP&A met with Mr. Estabrook for the first time at SSCF
during outreach. Mr. Estabrook was concerned about his placement in the
Charlie Unit in a single man cell. His concern was that if something happened
to him that no one would find him in time to help him. He wanted to be
where he would have someone close by and also wanted to go to CRCF.
February 9, 2006 Mental Health note by [clinician name]: “Mr. Estabrook
seen in response to sick slip request. Today he speaks more openly about the
possibility that he may die before he gets out of prison…He reiterates that he
feels that CSS…is deliberately blocking his transfer to any other facility or his
release…Mr. Estabrook scheduled for medication review 3/1/06 and it is
unlikely that a physician will be able to see him before that date. He is not
experiencing self-harming or suicidal ideation; on the contrary, he is angry
that he is dying.”
February 10, 2006 PHS note “…respond to Charlie Unit. I/M c/o pressure
pain in diaphram [sic] area causing SOB [shortness of breath]…Order
obtained per [DOC physician] by charge nurse to send to infirmary for 24
[hour] observation and juice.”
February 10, 2006 Physician’s Order by [DOC physician]: “Admit to
infirmary for 24 hour observation. Encourage real fruit juice.”
February 10, 2006 PHS note “…WT 171…”
February 11, 2006 PHS note “I/M complaining of feeling faint. Vital signs
92/60 P70, R20, 98% RA. States could not palpate pulse. Radial pulse
palpable upon assessment…”
February 12, 2006 PHS note “80/48, P-45 irregular (radial)…color pale –
continue to monitor present condition.”
February 13, 2006 Discharged from infirmary, placed in Charlie Unit.
February 14, 2006 DOC Case Note by [LUS]: “I met with Michael
Estabrook. He reported that he is concerned about his heart condition and he
thinks that his pace maker / defibrillator needs to be checked. I told Michael
that I would check into this issue for him.”
February 16, 2006 DOC Case Note by [LUS]: “I received a message
from… in medical. She informed me that the request for outside referral for

13

Michael to see the cardiologist has been approved by [doctor] and he is
scheduled to see a cardiologist on 02-22-06.”
February 16, 2006 PHS note “’I’m cold. I know I see the cardiologist soon.
I’d rather be in the infirmary because if something was to really go down.’ …
Enc. I/M to return to bed and elevate feet. Notified charge nurse…Orders
came from MD via charge nurse…enc. Fluids of juice…I/M reports [increase]
SOB when lying flat on back. And [increase] dizzieness [sic] when
ambulating to bathroom. Other wise comfortable and taking in significant
amt. of fluids. [decrease] cardiac output R/T hx heart failure. Cont. to
monitor per MD orders.”
February 16, 2006 DOC Case Note by LUS: “I met with Michael this
afternoon. He reports that he is very low on energy and has difficulty
breathing. I told him that he will see the cardiologist soon. He would like to
move back to the infirmary. I told him that I would consult with medical staff
about this request. I am also asking for him to be reevaluated and considered
for another medical furlough.”
February 17, 2006 PHS Physician’s Order: “DNR” 6 written, signed by
physician (unable to read name).
February 17, 2006 PHS Physician’s Order: “Encourage juice / Gatorade.
Vital signs every 2 hours x3. Then every 4 hours. T.O. [DOC physician].”
February 19, 2006 PHS note “I drank 60oz and my output was only 15oz
stunk up my room + was the color of the apple juice here…f/u [with] MD
[with] regards to above matter.”
February 19, 2006 PHS note “IM request v/s [vital signs] to be taken c/o
pain – sternum + up to shoulders…”
February 22, 2006 VP&A met with Mr. Estabrook and discussed physician’s
order dated 2/17/06 which read “DNR” and signed by PHS physician. Mr.
Estabrook was unaware that the physician had written this order and stated
that he was not consulted prior to this order being written. Mr. Estabrook
further stated he did not wish to be a DNR until he made up his mind that he is
ready to do that. Mr. Estabrook wrote a statement rescinding the physician’s
DNR order on this date and VP&A assisted him in completing an Advance
Directive document. Both the Advance Directive document and the statement
rescinding the DNR order were hand delivered to the nurse manager. During
discussion with the nurse manager about Mr. Estabrook’s desire to be moved
to the infirmary she stated that she did not feel he needed to be in the

6

18 VSA § 9701 Definitions (6) “Do-not-resuscitate order” or “DNR order” means a written order of the
principal’s clinician directing health care providers not to attempt resuscitation.

14

infirmary as the infirmary was for sick people. But if his condition were
deteriorating she would reconsider moving him there.
At this visit Mr. Estabrook was extremely fatigued, had swelling in both of his
feet and ankles, and appeared jaundiced. Mr. Estabrook stated that he had not
been producing any significant urine output for several days and that no one
from the medical staff was taking this seriously. Mr. Estabrook required
assistance in returning to his unit that was just around the corner. He was not
able to open the doors by himself and was very slow and unsteady on his feet.
We questioned his condition with medical staff who indicated that Mr.
Estabrook had an appointment scheduled for that same day with his
cardiologist.
February 22, 2006 PHS Physician’s Order: “Patient is now a full code per
directive written on 2-22-06. T/O [physician name]”
February 22, 2006 PHS note “Spoke [with] [cardiologist] @ Rutland
ER…[cardiologist] state I/M collapsed in office. [Cardiologist] stated class 4
CHF, kidney failure, renal insufficient…[Cardiologist] stated that they would
be transferring him to Fletcher Allen Hospital…”
February 22, 2006 PHS note “[Physician] informed of situation…informed
[physician] of code [change].” Then noted “Late entry. [Cardiologist]
informed of I/M [change] of code status from DNR to full code.”
February 22, 2006 Regional Ambulance Service Run Form” “While
walking into the doctors office the patient became lightheaded and had a near
syncopal episode, falling to the floor. Also had chest pain that he described as
10/10 crushing pain in the left side of his chest. Since sitting and relaxing the
main decreased to 6/10. Placed patient on the stretcher and loaded into the
ambulance. Patient stated that he has been feeling poorly during exertion
lately and has had hypotensive episodes…Patient stated that he did not get his
Amiodarone a couple of time during the past week. Patient transported to
RRMC ED and turned over with a verbal report.”
February 22, 2006 Rutland Regional Medical Center Emergency
Department Report: “Patient is a 37-year-old who was inadvertently in
[doctor’s] office when he had sudden unexpected syncope, that he was
actually on his way for an outpatient cardiology appointment with
[cardiologist] when this occurred. Mr. Estabrook states that he has constant
left anterior chest discomfort, this is more of a pressure and is not acutely
worsened at present. This is nonradiating. There is no jaw, neck or shoulder
pain. Mr. Estabrook notes that his health has been deteriorating for several
years…Mr. Estabrook notes that he has gained some 20-30 pounds during the
last 3 weeks. He has begun having increasing pedal edema and notes that he
has never had swelling of his ankles to this degree. He also notes that he has

15

not been urinating very much in the last 2 weeks…Patient is an inmate in the
correctional system and when he began to pass out the guard was able to catch
him and gently lower him to the floor. By the time EMS had arrived Mr.
Estabrook had come back to consciousness…[Cardiologist] has actually
arrived to see patient and has assumed his care. I am relinquishing care.
Preliminary diagnosis of acute syncope and hypotension. Must rule out renal
failure…” [MD]
February 22, 2006 Regional Ambulance Service Run Form: “Patient was
transferred to FAHC due to renal failure/CHF. Patient was on the cardiac
monitor for the transport showing a paced rhythm in the 70’s…Patient is in
custody and is accompanied by a guard. TOT FAHC staff with a verbal
report.”
February 22, 2006 FAHC History and Physical Examination completed by
[cardiologist]: “This is one of several Fletcher Allen Health Care
hospitalizations for Michael Estabrook, an unfortunate 37-year-old gentleman
who is transferred emergently from Rutland Regional Medical Center
emergency room with worsening congestive heart failure and renal
insufficiency…He has dilated cardiomyopathy complicated by multiple heart
rhythm abnormalities and arrhythmias. The patient has been hospitalized
multiple times in Burlington. Mr. Estabrook has been in and out of difficulty
with the law and is presently incarcerated. The patient reports a two to three
month history of worsening shortness of breath, fatigue, lightheadness [sic]
and edema. I last saw the patient in September of 2005…Over the last few
months, Mr. Estabrook has had multiple symptoms of worsening shortness of
breath, orthopnea 7 , and worsening edema…Medications at this time include
amiodarone 200 mg twice daily, Lasix 80 daily, carvedilol 12.5 twice daily,
warfarin as directed, Klonopin 3 mg twice daily, lisinopril 10 mg daily, nitro
patch…Assessment/Plan:…4. Hypothyroidism: This is likely drug-induced
and related to amiodarone…5. LFT abnormalities: The patient has elevated
bilirubin, which undoubtedly is related to his amiodarone. Amiodarone will
be held for the time-being. Overall, the patient is in very poor health and may
well need a cardiac transplant in the near future if that is possible.”
February 22, 2006 FAHC Admitting History & Physical “…Over last 2
weeks he had [increased] SOB and wt gain around 15 lbs has also noticed
[increased] fatigue and leg edema. He thinks this started when his prison ran
out of lisinopril…”
February 23, 2006 FAHC Nursing Acute Care Flow Sheet “…weight 83.1
kg…” [Note: 83.1 x 2.2 = 182.8 weight in pounds]
7

Orthopnea: The inability to breathe easily unless one is sitting up straight or standing
erect. Medicine.Net, Owned and Operated by WebMD.

16

February 23, 2006 FAHC Clinical Record – General Progress Notes:
“…1500 cc fluid restriction, strict I/O’s, daily wghts…”
February 24, 2006 PHS note “Called Fletcher Allen – spoke with inmate’s
nurse...She stated that he would be in at least a week for tests and [decreased]
BP, diuresing…”
February 24, 2006 VP&A spoke with Living Unit Supervisor at SSCF, on
the telephone. We were informed of Mr. Estabrook’s status. VP&A inquired
if his Advance Directive document went with him to the hospital. LUS said
she would check with medical and let VP&A know. She called back later this
same day and informed us that the nurse manager stated that his Advance
Directive did go with him to the hospital.
March 6, 2006 FAHC Records: “’Still don’t feel well.’ Tired, feels ‘out of
it’, funny dreams. Shortness of breath unchanged…”
March 7, 2006 FAHC Records: “…Feeling poorly…abdomen
distended…twitching.”
March 7, 2006 DOC Case Note by Assistant Superintendent at CRCF:
“Received a phone call from CO…at 1811 hours reporting that Mr. Estabrook
passed away at 1808 hours. On 2/23/06 Mr. Estabrook was transferred from
the Rutland hospital to FAHC due to his medical needs exceeding their ability
to meet them. He had a heart condition that was deteriorating. I spoke with
Nurse…at FAHC who said they expected him to pass away given his
deterirating [sic] health condition. [Nurse] also reported that the attending
Doctor was on the phone as we spoke notifying his 2 sisters that were listed
for family contact in MA. His cause of death was heart failure…”
May 2, 2006 Final Report of Autopsy, Office of the Chief Medical Examiner:
“Cause of Death: Multiple complications of dilated cardiomyopathy.”
V.

VP&A’s Findings
VP&A found several areas of concern with regard to Mr. Estabrook’s medical
care while incarcerated. Those areas of concern, which are detailed further in
this section, include – but are not limited to - medical furlough status, his
worsening condition and symptoms which went unaddressed, his housing
assignment, medication problems and end-of-life decisions.
Medical Furlough Issues
Mr. Estabrook should have been granted a medical furlough by the
Department of Corrections during his last incarceration based on his
deteriorating state and need for strict and careful medical monitoring. He

17

would have been able to receive this quality/level of care in a community
setting. Instead the medical providers at SSCF apparently ignored his
worsening condition and serious symptoms for weeks leading up to his acute
episode and hospitalization on February 22, 2006. The fact that, in 2004, Mr.
Estabrook was granted a medical furlough because, at that time, he had
experienced renal failure while incarcerated should have been considered in
favor of granting the medical furlough he requested earlier in 2005. A DOC
physician in July of 2005 wrote a medical note stating that she would
“…consider transfer to facility [with] higher level nursing care, closer to
cardiologist in FAHC…” This physician also noted on a fax coversheet she
sent to another DOC physician in August of 2005 that “Michael’s care
basically remains a guessing game as to how to adjust his diuretics. During
his last incarceration he wound up in acute renal failure…”
The Department of Corrections and its contracted providers should have
realized that they could not manage his complicated medical condition and
should have furloughed him soon after his incarceration again in 2005.
Mr. Estabrook was clearly a candidate for medical furlough. It was discussed
during his 2005-2006 incarceration at various times but, in the end, no one
took responsibility to insure the appropriate consideration was given to his
request.
In June of 2005 DOC Medical Director noted in an email that she had
reviewed Mr. Estabrook’s case “about a month ago” and at that time she
recommended against medical furlough based on her understanding of the
criteria for granting furloughs 8 . She stated that he had a serious medical
condition that is “chronic and stable”. According to the cardiologist’s medical
note of June 1, 2005 “…Mr. Estabrook has a significant cardiomyopathy and
has a relatively tenuous status.” VP&A identifies that the DOC Medical
Director’s statement was based on outdated, inaccurate or erroneous
information and did not accurately reflect the severity of Mr. Estabrook’s
medical situation.
The DOC Medical Director did say that she would ask medical staff to reexamine his situation if staff felt she should. At that time the case work
supervisor indicated there was no one “pushing for another review, we didn’t
know the results of the original assessment.”

8

Department of Corrections, Medical Furlough Directive #351.08 effective date 5/01/01: “Authority for
this directive is derived from VSA Title 28, Chapter 11, §808(f). The Commissioner may place on medical
furlough any inmate who is serving a sentence, including any inmate who has not yet served the minimum
term of the sentence, who is diagnosed as suffering from a terminal or debilitating condition so as to render
the inmate unlikely to be physically capable of presenting a danger to society.”

18

According to the Medical Furlough Directive, if an inmate is considered for
medical furlough such as what the DOC Medical Director described above,
the following process will take place:
“7. After receipt of the furlough investigation report from the CCSC, the
facility superintendent shall gather the medical, caseworker and furlough
investigation materials and submit them with a cover letter concerning the
proposed medical furlough to the clinical director and the director of security
and operations. They shall review the plan and recommendations and either
approve or disapprove same.”
VP&A could find no evidence in the records provided that this process took
place even though the DOC Medical Director stated she reviewed Mr.
Estabrook’s case.
In August of 2005 Mr. Estabrook discussed his request that the physician
discuss with his cardiologist a medical furlough. The physician told Mr.
Estabrook that that decision had already been made by the DOC Medical
Director. It appears there was insufficient effort made by the contracted
medical providers to assure that accurate and complete information was
provided to the DOC Medical Director.
On September 28, 2005 a case worker at SSCF noted that Mr. Estabrook was
asking her about medical furlough. She wrote that she “…will need to look
into this a little more.” She also noted that when she spoke to…the PHS nurse
manager at that time, he indicated Mr. Estabrook would probably not make it
to his minimum because of his heart condition. VP&A found no evidence in
Mr. Estabrook’s records that the case worker followed up on this request.
According to the Department’s Medical Furlough Directive, “The Responsible
Health Authority and Regional Health Authority will determine that an
inmate’s medical condition is either terminal or debilitated to the point of
needing a higher level of care than can be realistically provided within the
confines of a correctional facility.” The nurse manager is defined as the
person who is typically the Responsible Health Authority. The PHS nurse
manager made no notes or recommendations regarding Mr. Estabrook’s
continued incarceration or medical furlough request as is required by this
directive.
On October 18, 2005 a case worker also noted that she “met with Michael in
the Infirmary Ward…Explained to Michael that he will not be eligible for
release to the community on furlough due to his medical needs have not
become more severe according to medical staff…at which time his medical
needs become more than the facility can handle he may be eligible for medical
furlough…”

19

Then on October 31, 2005 a case worker made a case note that she would
email [redacted name] regarding what it would take for him to be reconsidered
for this furlough. VP&A found no evidence in Mr. Estabrook’s records that
this communication took place.
On November 2, 2005 a case worker made another case note that she had
talked with the LUS about the possible medical furlough for Michael. “[LUS]
informed me that as long as he can be treated by the facility that a medical
furlough would not be an option…”
Then on February 16, 2006 the Living Unit Supervisor made a case note
which stated that she was going to ask for Mr. Estabrook to be re-evaluated
and considered for another medical furlough. VP&A could find no evidence
in Mr. Estabrook’s records provided that this request was ever made.
Worsening Condition and Symptoms
Mr. Estabrook was displaying serious symptoms that were not acted upon by
the medical staff or the correctional staff at SSCF. The June 2004 Fletcher
Allen Health Care nursing note outlined conditions for the DOC providers
that, if displayed by Mr. Estabrook, would need medical follow up. Those
conditions were: shortness of breath, swollen legs, ankles or abdomen, dry
hacking cough, wheezing, fatigue, weight gain, increased urination at night,
dizziness or confusion, rapid or irregular heartbeats.
There were at least 8 notes found in Mr. Estabrook’s records starting in
November of 2005 indicating that his condition was starting to deteriorate and
the warning signs listed above were clearly noted. There was no appropriate
medical response to these worsening signs that were identified in Mr.
Estabrook’s records.
November 25, 2005 minimal swelling was noted in Mr. Estabrook’s lower
legs. On January 13, 2006 Mr. Estabrook submitted a sick call request
reporting that he has filed sick call slips that have gone unanswered and even
filed a grievance about his shortness of breath. On February 10, 2006 Mr.
Estabrook was admitted to the infirmary at SSCF for 24-hour observation as
he was having chest pain and shortness of breath. On February 11, 2006 Mr.
Estabrook was complaining of feeling faint. On February 12, 2006 a nurse
noted that Mr. Estabrook’s pulse was irregular, his color pale. On February
16, 2006 a PHS progress note indicates Mr. Estabrook was complaining of
shortness of breath and an increase in dizziness. Also on February 16, 2006
the Living Unit Supervisor made a note that she met with Mr. Estabrook and
he complained of being low on energy and having difficulty breathing. On
February 19, 2006 a PHS progress note recorded that Mr. Estabrook stated he
drank 60 oz and his urine output was only 15 oz and it was foul smelling and
colored. Later that same day he was complaining of chest pain.

20

On February 22, 2006 VP&A advocates met with Mr. Estabrook and
witnessed the swelling in both of his lower legs, his fatigue, jaundice
appearance and inability to go from one unit to another without assistance.
Staff was made aware of these observations and we were told that Mr.
Estabrook had an appointment scheduled for that very day with his
cardiologist.
On November 12, 2005 the physician wrote an order that Mr. Estabrook’s
weight be checked every other day. That weight check did occur every other
day until January 1, 2006. After that it ended even though there was no new
physician’s order rescinding the order. After January 1, 2006 Mr. Estabrooks’
weight was checked only occasionally: January 3, 2006 -172.5 lbs; January 9,
2006 – 168 lbs; February 11, 2006 – 171 lbs. Part of the treatment
recommended for patients with dilated cardiomyopathy is “Daily monitoring
of body weight may be advised. Weight gain of 3 of 4 pounds or more over 1
or 2 days may indicate fluid accumulation.” 9
On February 22, 2006 when Mr. Estabrook was taken to the Emergency
Department at Rutland Regional Medical Center, part of that record reflected
that he told the physician that “…he has gained some 20-30 pounds during the
last 3 weeks. He has begun having increasing pedal edema and notes that he
has never had swelling of his ankles to this degree…”
Mr. Estabrook’s hospital records reflect that on February 23, 2006, one day
after being admitted to FAHC, his weight was 182.8 lbs. That is an
approximate 11 lb gain in the same number of days. Had the medical staff
been following the physician’s written order this symptomatic weight gain
would have been recognized and Mr. Estabrook could have potentially
received adequate medical care before his condition deteriorated.
In addition, medical orders on February 16, 2006 indicated that Mr. Estabrook
was encouraged to take in a lot of fluids. This order was given without any
documented check of Mr. Estabrook’s current weight. Had his weight been
monitored carefully, as is the standard of care for his illness, the course of
treatment for Mr. Estabrook could have been corrected. Upon his admission
to FAHC Mr. Estabrook was actually placed on fluid intake restrictions.
Infirmary
On January 17, 2006 Mr. Estabrook discussed with a mental health clinician
the possibility of moving to the infirmary. On this same date this clinician
spoke with the Living Unit Supervisor about the possibility of transferring
him to the infirmary. A month later on February 16, 2006 the Living Unit
Supervisor noted that she met with Mr. Estabrook and he once again asked to
9

American Heart Association’s website www.americanheart.org 9/22/06 “Cardiomyopathy”

21

be moved to the infirmary due to his worsening symptoms. She noted that she
would “consult with the medical staff about his request.”
VP&A could find no evidence in Mr. Estabrook’s records that any actions
were taken by either the mental health clinician or the LUS in response to Mr.
Estabrook’s request.
Prison Health Services, Health Services Policy and Procedures Manual, Title:
Infirmary Care, No. P-G-03: Policy. 1. The scope of care provided in the
infirmary may include, but is not limited to such illnesses/diagnosis/conditions
as: … b. Long-term care for inmates with chronic medical conditions that
occasionally need medical services that cannot be supplied in general
population…”
Mr. Estabrook should have been moved to the infirmary when he made this
request in January of 2006. He had a chronic medical condition which
required a higher level of care when his symptoms worsened. The fact that
various staff kept saying they would follow up and never did is very
disturbing in what is supposed to be the medical prison for Vermont.
Medication Issues
On February 22, 2006, the day Mr. Estabrook collapsed, he mentioned to the
ambulance personnel that he had not received one of his medications a few
times that week. Upon reviewing the Medication Administration Records
(MAR) for Mr. Estabrook, VP&A discovered that PHS ran out of a few of Mr.
Estabrook's critical medications for a few days in February.
Mr. Estabrook was prescribed Amiodarone 200mg once per day. Amiodarone
is only used for treatment of the following documented life-threatening
recurrent ventricular arrhythmias that do not respond to other antiarrhythmics
or when alternative agents are not tolerated; recurrent ventricular fibrillation,
recurrent hemodynamically unstable ventricular tachycardia. 10
According to DOC and PHS records Mr. Estabrook did not receive this
medication on December 23, 2005 and February 18 & 19, 2006. The MAR
reflects that the medication was out of stock on those dates.
Mr. Estabrook was also prescribed Lisinopril, an antihypertensive and ACE
inhibitor drug used for the treatment of hypertension alone or in combination
with thiazide-type diuretics. It is also used for adjunctive therapy in CHF for
patients unresponsive to diuretics and digitalis alone. 11

10
11

2002 Lippincott’s Nursing Drug Guide
2002 Lippincott’s Nursing Drug Guide

22

According to DOC and PHS records Mr. Estabrook did not receive this
medication on November 6, 7, 8, 9, 10, 2005; December 10, 11, 12, 13, 14,
15, & 16, 2006; February 18 & 19, 2006. The MAR reflects that the
medication was out of stock on these dates.
The frequency and length of time that critical medications were not available
in the facility is unconscionable. PHS and DOC are required to have a system
in place to assure that inmates are not suffering because prescribed
medications are not effectively monitored to assure availability. If an inmate
is prescribed a medication for daily use, DOC and PHS are required to provide
those medications daily or move the inmate to an adequate treatment
environment. DOC does have the option of using a local pharmacy to obtain
critical medications if they run out. It does not appear that anyone did this for
Mr. Estabrook during the dates outlined above. The lack of prescribed
medications just prior to Mr. Estabrook’s collapse and eventual death cannot
be overlooked as a potential contributing factor in the series of medical and
administrative failures identified leading up to his death.
DNR Issues
The unethical issuance of a written DNR by a Prison Health Services
physician for Mr. Estabrook is shocking. While not contributing to Mr.
Estabrook’s death it is an example of overall questionable medical practices
by DOC and its contracted providers. According to Vermont law 12 , a
physician must document that they consulted with, or made an effort to
consult with, their patient. There is no evidence that anyone within the
medical system took time to discuss what a DNR is and how it is carried out
with Mr. Estabrook, even at the point when he wrote what he thought was a
DNR order for himself on November 30, 2005 and asked that it be placed in
his medical record. The document he wrote did not conform to legal
requirements, yet PHS staff placed it on the front page of his chart and there is
no evidence of any discussions with Mr. Estabrook about this. On February
17, 2006 the PHS physician wrote a physician’s order that read “DNR” and
there is no evidence that he discussed this order with Mr. Estabrook before he
wrote it. There is also no evidence in Mr. Estabrook’s records that any
mental health clinician took the time to discuss this DNR order or Mr.
Estabrook’s own handwritten document with him.
The PHS physician’s written DNR did not meet either the requirements of
Vermont law or PHS policy.

12

18 VSA § 9709 Authority and obligations of health care providers, health care facilities, and residential
care facilities regarding do-not-resuscitate orders. (a) A do-not-resuscitate (“DNR”) order must: (1) be
signed by the patient’s clinician; (2) certify that the clinician has consulted, or made an effort to consult,
with the patient, and the patient’s agent or guardian, if there is an appointed agent or guardian.

23

18 VSA § 9708 (3) include either: (A) the name of the patient, agent, or other
individual giving informed consent for the DNR and the individual’s
relationship to the patient; or (B) certification that the patient’s clinician
and one other named clinician have determined that resuscitation would
not prevent the imminent death of the patient, should the patient
experience cardiopulmonary arrest.
Prison Health Services, Health Services, Policy & Procedures Manual, Title:
Care of the Terminally Ill. Do Not Resuscitate (DNR) Orders, No. P-G-12.01
Effective Date February 1, 2005:
Purpose: To allow the terminally ill inmate to participate in the medical
care decisions during the terminal stages.
Policy:
1. Inmates will be provided the treatment options available in the
community, including “Do Not Resuscitate Request”.
2. Mental Health Staff and Clergy will be requested to discuss the
decision with the inmate to evaluate the inmate’s understanding of the
decision.
3. The Responsible Physician will document in the progress notes the
desire of the terminally ill inmate not to have cardio-pulmonary
resuscitation performed. The progress note will contain the issues
discussed with the inmate and will be signed by the Physician and the
inmate.
4. If the inmate has completed a Living Will in the state, the inmate will
be required to provide a copy for placement in the Medical Record.
5. If the inmate has not completed a Living Will, or if a copy cannot be
obtained, a representative providing inmate legal services will be
requested to meet with the inmate to discuss this option.
6. The Institutional Authority will be notified of any terminally ill inmate
who has requested a “no cardio-pulmonary resuscitation order”.
7. Orders for “DO NOT RESUSCITATE” do not preclude other
indicated medical and nursing care. “DO NOT RESUSCITATE”
orders can be rescinded by the inmate at any time.
8. “DO NOT RESUSCITATE” orders will be discussed with the inmate
monthly and renewed or changed to reflect the desires of the inmate.

24

The medical progress notes are very clear that the physician made no attempts
to have a discussion with Mr. Estabrook about his DNR status at any time.
And the one note made by a Licensed Nursing Assistant in September of 2005
demonstrates that Mr. Estabrook wanted to engage in a discussion with
medical staff about being a DNR. No effort was made by anyone to have this
discussion with Mr. Estabrook, even when he went as far as to write his own
DNR statement.
Prison Health Services, Health Services, Policy & Procedures Manual. Title:
End of Life Decision Making No. P-I-04 Effective Date: February 1, 2005.
Purpose: To ensure that inmates approaching the end of life are permitted
to execute advance directives including living wills, health care proxies, and
“do not resuscitate” (DNR) orders. These directives are signed only after the
patient receives appropriate information regarding the meaning and
consequences of such decisions.
4.

DNR orders are reviewed by a medical professional who is not
directly involved in the patient’s treatment.

5.

Mental Health Staff and Clergy will be requested to discuss the
decision with the inmate to evaluate the inmate’s understanding of
the decision.

Again, there is no documentation in the records provided to VP&A that the
physician or any other medical or mental health provider made any effort to
discuss this issue with Mr. Estabrook. In fact, it wasn’t until VP&A met with
Mr. Estabrook and explained to him what a DNR order meant that he seemed
to fully understand the difference between a DNR order and what he actually
wanted. What Mr. Estabrook wanted directly conflicted with having a DNR
order in place. Without VP&A’s intervention it is likely this unwanted DNR
would have remained in place.
VI.

Recommendations
Due to the number of policy violations in this case, VP&A recommends the
following actions be taken by the Department of Corrections and its
contracted providers immediately:
1. The rights of terminally ill inmates must be clearly discussed with the
inmate and accurately documented in the medical record.
2. Contracted staff must be trained in Vermont law and their own policies
and procedures about end of life decisions and what is required of them as
medical providers.

25

3. Contracted staff who violate Vermont law and policies and procedures
shall be disciplined accordingly.
4. Reassess all recent requests for medical furlough to assure the decision to
refuse medical furlough was arrived at with sufficiently current and
accurate medical information.
5. Implement independent review and quality assurance for medical furlough
decisions.
6. Develop a system to ensure that medications are stocked and are available
each day they are prescribed for an inmate.
7. Develop a system for access to infirmary or other correctional facilities
that are appropriate for the medical condition.
8. Develop a system whereby inmates with serious and/or terminal illnesses
are able to access their outside specialist in a timely fashion consistent
with the medical necessity identified by the specialist for their patient.
9. Develop and implement a system for documentation and peer review of
untimely deaths in corrections and assure that a review is done on every
death, even when the inmate dies in a hospital.

26