At least 90 people have died in custody in Vermont

How deaths in custody are reported in Vermont

Vermont has no county jails. The Vermont Department of Corrections runs every prison and jail in the state, six facilities holding people awaiting trial as well as people serving sentences, and the U.S. Bureau of Justice Statistics counts them as one integrated system.¹² Only one of the state's 70 law enforcement agencies has a municipal lockup.² The department also holds Vermonters out of state. Since 2018 it has sent men to the Tallahatchie County Correctional Facility in Tutwiler, Mississippi, run by the private company CoreCivic;³ it renewed that contract in 2023 for up to 300 beds,⁴ and 147 Vermont men were held there in May 2026.⁵

State law requires a jailer to notify the nearest medical examiner immediately when a person dies in jail or prison, and the medical examiner and a law enforcement officer must then investigate together. The Commissioner of Corrections may ask for the autopsy report, but reports given to the department stay confidential and are not public records.⁶ The Office of the Chief Medical Examiner releases autopsy reports only with the written consent of the next of kin.⁷ Since 2021, the department's Corrections Investigative Unit has been required by law to investigate every death of a person in its custody,⁸ but the unit became fully operational only in spring 2024.⁹ The department says that it and its contracted health provider, Wellpath, investigate every death, and that the Vermont State Police, the Defender General's Office and the Vermont Program for Quality in Health Care review deaths that are unexpected or suspicious.¹⁰

The department announces deaths in press releases that give the person's name, age, hometown and the facility or hospital, and say that the State Police and the Defender General's Prisoners' Rights Office were notified.¹¹ Its website holds 41 such notices, from December 2020 to March 29, 2026, and none after that,¹² although the department went on announcing deaths in May and September 2026.⁵¹¹ It published one summary of its death investigations, for 2022, listing ten deaths by date, cause and place, without names. The page says the 2023 summaries would be added in February 2025; by October 2026 they had not been.¹⁰¹³ A Department of Health data brief gives yearly totals for 2019 through 2023.¹⁴ The department publishes no named list of deaths and no yearly count of its own.

For the federal Death in Custody Reporting Act, the Department of Public Safety sends a reporting form each quarter to all 70 law enforcement agencies and to the Department of Corrections, and a Vermont State Police detective sergeant posted at the medical examiner's office checks that no death is missed. The state's plan says Vermont has no state law on reporting deaths in custody, and that the Department of Public Safety keeps no public website for the data.²

What has changed

1. 1954On December 8, Vermont carried out its last execution, in the electric chair at the state prison in Windsor. Five people died in that chair from 1919 to 1954, and 26 people were executed in Vermont in all.¹⁵¹⁶
2. 2004Two lawyers hired by the Agency of Human Services reported on the deaths of seven people in or just out of Department of Corrections custody from November 2002 to October 2003. They found that James Quigley, who died by suicide at Northwest State Correctional Facility, had been held in segregation for 118 days in what likely was retaliation for his grievances and lawsuits; that Neil Prentiss did not get timely care despite repeated requests; that Eva LaBounty died of an overdose after the Dale Correctional Facility failed to stop prisoners from hoarding prescription drugs; and that the department did not adequately review deaths, because of a culture that "fails to embrace accountability."¹⁷
3. 2009Ashley Ellis, 23, died on August 16, two days after she arrived at Northwest State Correctional Facility in Swanton. The Chief Medical Examiner listed denial of access to medications among the causes. Disability Rights Vermont found that her potassium supplement was out of stock, that records sent by her doctors were not passed to the prison's medical staff, and that her medical records appeared to have been altered after her death.¹⁸
4. 2017–2018Three people from Vermont died within two months at Camp Hill, a Pennsylvania state prison where Vermont had sent people, one of them of untreated lung cancer. Vermont ended the contract early,¹⁹ and in October 2018 began moving more than 200 men to CoreCivic's prison in Mississippi.³
5. 2019In September, a Vermont man died by suicide at the Mississippi prison, the first Vermonter to die there.²⁰ On the night of December 6, Kenneth Johnson, 60, died at Northern State Correctional Facility in Newport of an undiagnosed tumor blocking his airway.²¹
6. 2020In July, the Defender General's Prisoners' Rights Office reported that Kenneth Johnson had complained of breathing problems for months without seeing a doctor, and that an officer threatened him with solitary confinement after he collapsed.²² The state admitted that the department had never carried out the administrative review of his death that its own policy required, and pledged one after every death.²³ In December, Roberto Vargas, 59, died at the Mississippi prison; his is the earliest death notice on the department's website.²⁴¹²
7. 2021Act 56 created the Corrections Investigative Unit and required it to investigate deaths in custody, and created a Corrections Monitoring Commission to advise on the department's response to them.²⁵
8. 2024In August, the Department of Health reported 33 deaths of people in Department of Corrections custody from 2019 through 2023, with 10 in 2022 and 12 in 2023.¹⁴ The Corrections Investigative Unit became fully operational in the spring.⁹
9. 2025Nine people died in Department of Corrections custody during the year.²⁶ One man, injured in March in a fall from a top bunk during a low-blood-sugar seizure at Northern State, died in April; his mother sued the department and Wellpath in March 2026, saying staff failed to treat his diabetes.²⁷
10. 2026Shawn Sears, 56, was found unresponsive in his cell at the Mississippi prison on May 20, at least the fifth death in Department of Corrections custody that year.⁵ Trevis Gembarowski, 44, died at Southern State Correctional Facility in Springfield on September 27, a day after he entered custody.¹¹

How far the official numbers can be trusted

The official counts do not agree, chiefly over who is counted. For 2019, the Bureau of Justice Statistics has five deaths,¹ the Department of Health six,¹⁴ and the department's own list of names, released to the UCLA Law Behind Bars Data Project, four.²⁸ That list includes only deaths inside Vermont. It leaves out the man who died in Mississippi in September 2019 and Roberto Vargas in 2020,²⁰²⁴ and it also leaves out Kenneth Johnson, who died inside Northern State Correctional Facility in December 2019.²¹²⁸ The Department of Health's totals include five people on medical furlough, and it had no death certificates for four people from out of state who died outside Vermont, so its findings on cause of death cover only 29 of the 33.¹⁴

The state's federal reporting plan says the Department of Corrections does not use contract prisons,² although the department had 194 people at the Mississippi prison in December 2020²⁴ and renewed the contract in 2023.⁴ Out-of-state deaths can also escape review: the 2022 summary records one death in a New Hampshire hospital with no autopsy that, it says, neither the Defender General nor the State Police investigated because it was expected and happened out of state.¹³

The department's own reviews have repeatedly fallen short. The 2004 investigators found it did not adequately review deaths;¹⁷ in 2020 the state admitted it had not reviewed Kenneth Johnson's death at all;²³ and the department publishes summaries of its own and its health contractor's findings, not the reports of the Corrections Investigative Unit, the State Police or the Defender General.¹⁰ What is known about how people died, as in the deaths of Ashley Ellis and Kenneth Johnson, has come mostly from outside investigators and from families who sue.¹⁸²²²⁷