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Administrative Errors and Poor PHS Medical Care Precede Chronically Ill Vermont Prisoner's Death
by David M. Reutter
A Report by the Vermont Protection and Advocacy System (VP & A) has found breakdowns by staff of the Vermont Department of Corrections (VDOC) in its furlough procedure and troubling care provided by VDOC's medical provider, Prison Health Services (PHS). The July 2007 report focuses on the treatment of VDOC prisoner Michael Estabrook.
The subject of the report has been unable to read it. That is because while in custody of VDOC, Estabrook died at Fletcher Allen Health Care (FAHC) on March 7, 2006. The report is based upon Estabrook's medical and classification file notes. At the time of his death, Estabrook was 37 years old, divorced with two children.
In May 2004, he entered VDOC a very sick man. He suffered from a disabling disease called severe dilated cardiomyopathy, which is a condition that decreases the heart's ability to pump blood because the heart's main pumping chamber, the left ventricle, is enlarged and weakened. He also had congestive heart failure.
Recognizing his condition was "terminal and debilitating," VDOC around July 21, 2005, granted Estabrook a medical furlough because he was physically incapable of presenting a danger to society. His furlough, however, was revoked on April 27, 2005, due to an outstanding warrant for a failure to pay a $601 fine. He was to remain imprisoned until he fully paid that fine.
After detailing the chronological facts from Estabrook's files, the VP & A made its findings. It began with "Medical Furlough Issues." It found Estabrook should have been granted a medical furlough "during his last incarceration based on his deteriorating state and need for strict and careful medical monitoring."
In July 2005, a PHS physician noted that Estabrook should be transferred to a prison with a "higher level of nursing care, closer to cardiologist in FAHC." That doctor also found his care "basically remains a guessing game" that resulted in renal failure during his last imprisonment. VDOC's Medical Director reviewed Estabrook for medical furlough. She recommended against furlough based on outdated, inaccurate or erroneous information, and that did not accurately reflect the severity of Estabrook's medical situation.
Despite saying she reviewed his case, the Medical Director never compiled all the documents required under VDOC's Medical Furlough Directive and submitted them to the clinical director and director of security and operations for their review. Between August 2005 and February, there are six different notations that reflect Estabrook was requesting a medical furlough, but no one took official action to act on that request despite their reassurances otherwise.
Starting in November 2005, there are at least eight notes that indicate Estabrook's condition was deteriorating and no appropriate medical response occurred. In June 2004, FAHC outlined for VDOC medical providers conditions that merited medical follow up. The greatest concern for Estabrook was fluid retention, which required daily weighing and action if a gain of 3 to 4 pounds or more occurred over 1 to 2 days. After January 1, 2006, the daily weighing stopped. Between February 11 and February 22, 2006, Estabrook gained 11 pounds, meaning medical providers failure to monitor his condition contributed to his deteriorations. Most strikingly, he was ordered by VDOC doctors "to take lots of fluids."
On January 17, 2006, Estabrook requested to be placed in the Infirmary.
Under PHS policy, that request should have been granted. Estabrook, however, was only told by PHS staff they would follow up on the request, but none did. Unsurprisingly, "PHS ran out of a few of Mr. Estabrook's critical medications" between November 2005 and February 2006. Finally, a PHS physician entered a Do Not Resuscitate order in Estabrook's file without consultation. Not only did this violate Vermont law, it was against Estabrook's wishes. The order was later rescinded and did not contribute to his death.
The VP & A report concludes with 9 common sense recommendations to prevent the administrative failures leading up to his death. The report, entitled Investigation Into the Death of Michael Estabrook While In the Custody of the Vermont Department of Corrections is available on PLN's website.
A Report by the Vermont Protection and Advocacy System (VP & A) has found breakdowns by staff of the Vermont Department of Corrections (VDOC) in its furlough procedure and troubling care provided by VDOC's medical provider, Prison Health Services (PHS). The July 2007 report focuses on the treatment of VDOC prisoner Michael Estabrook.
The subject of the report has been unable to read it. That is because while in custody of VDOC, Estabrook died at Fletcher Allen Health Care (FAHC) on March 7, 2006. The report is based upon Estabrook's medical and classification file notes. At the time of his death, Estabrook was 37 years old, divorced with two children.
In May 2004, he entered VDOC a very sick man. He suffered from a disabling disease called severe dilated cardiomyopathy, which is a condition that decreases the heart's ability to pump blood because the heart's main pumping chamber, the left ventricle, is enlarged and weakened. He also had congestive heart failure.
Recognizing his condition was "terminal and debilitating," VDOC around July 21, 2005, granted Estabrook a medical furlough because he was physically incapable of presenting a danger to society. His furlough, however, was revoked on April 27, 2005, due to an outstanding warrant for a failure to pay a $601 fine. He was to remain imprisoned until he fully paid that fine.
After detailing the chronological facts from Estabrook's files, the VP & A made its findings. It began with "Medical Furlough Issues." It found Estabrook should have been granted a medical furlough "during his last incarceration based on his deteriorating state and need for strict and careful medical monitoring."
In July 2005, a PHS physician noted that Estabrook should be transferred to a prison with a "higher level of nursing care, closer to cardiologist in FAHC." That doctor also found his care "basically remains a guessing game" that resulted in renal failure during his last imprisonment. VDOC's Medical Director reviewed Estabrook for medical furlough. She recommended against furlough based on outdated, inaccurate or erroneous information, and that did not accurately reflect the severity of Estabrook's medical situation.
Despite saying she reviewed his case, the Medical Director never compiled all the documents required under VDOC's Medical Furlough Directive and submitted them to the clinical director and director of security and operations for their review. Between August 2005 and February, there are six different notations that reflect Estabrook was requesting a medical furlough, but no one took official action to act on that request despite their reassurances otherwise.
Starting in November 2005, there are at least eight notes that indicate Estabrook's condition was deteriorating and no appropriate medical response occurred. In June 2004, FAHC outlined for VDOC medical providers conditions that merited medical follow up. The greatest concern for Estabrook was fluid retention, which required daily weighing and action if a gain of 3 to 4 pounds or more occurred over 1 to 2 days. After January 1, 2006, the daily weighing stopped. Between February 11 and February 22, 2006, Estabrook gained 11 pounds, meaning medical providers failure to monitor his condition contributed to his deteriorations. Most strikingly, he was ordered by VDOC doctors "to take lots of fluids."
On January 17, 2006, Estabrook requested to be placed in the Infirmary.
Under PHS policy, that request should have been granted. Estabrook, however, was only told by PHS staff they would follow up on the request, but none did. Unsurprisingly, "PHS ran out of a few of Mr. Estabrook's critical medications" between November 2005 and February 2006. Finally, a PHS physician entered a Do Not Resuscitate order in Estabrook's file without consultation. Not only did this violate Vermont law, it was against Estabrook's wishes. The order was later rescinded and did not contribute to his death.
The VP & A report concludes with 9 common sense recommendations to prevent the administrative failures leading up to his death. The report, entitled Investigation Into the Death of Michael Estabrook While In the Custody of the Vermont Department of Corrections is available on PLN's website.
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