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Ralph “Phil” Grenon was killed by a police officer in Burlington in March 2016. Photo courtesy Niki Carpenter

A state report has determined that the death of Phil Grenon, the 76-year-old man shot and killed by a Burlington police officer in 2016, was preventable.



The Vermont Mental Health Crisis Response Commission concluded after a two-year investigation that Grenon’s death “was the result of a breakdown in services and communication.”



The report scrutinizes decisions made by the Burlington Police Department, Burlington Housing Authority and Howard Center in the months leading up to and the day of Grenon’s death. The lack of action by Howard Center is particularly called into question.



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Grenon was shot by BPD officer David Bowers on March 21, 2016, after an extended standoff between Grenon and officers at Grenon’s apartment at South Square Apartments.



Grenon was living in a subsidized apartment owned by the Burlington Housing Authority and was a client of Howard Center, the county’s mental health agency. Grenon had missed two of his last three appointments and stopped taking his medication in the months leading up to the shooting.



Grenon received an eviction notice on March 15, 2016, after “escalating conflicts with his neighbors” and had called and left a message for his treating psychiatrist at Howard Center saying he would protect himself with knives if police came to his apartment.



“The Howard Center did not notify BPD of the threat and did not contact Mr. Grenon to attempt to engage him in treatment,” the report states.



When police arrived at the apartment, Grenon did not respond to the officers’ knock on his door, and the officers were let into the apartment using the resident manager’s key. Grenon was standing near the door holding two knives, and closed the door just as Bowers shot his taser at Grenon.



After three hours of unsuccessful attempts to communicate with Grenon using a crisis negotiator, then-Police Chief Brandon del Pozo decided to have officers enter the apartment as del Pozo was concerned Grenon would kill himself.



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Officers found Grenon in the bathtub holding the two knives, and shot him with a taser that did not subdue him. Bowers then shot Grenon as Grenon advanced toward the officers, according to the report.



While the Burlington Housing Authority and BPD reacted to Grenon’s death by implementing changes in programming, training and resources, the commission found that there was “no evidence” that Howard Center has made any changes in policies, practices or procedures after Grenon’s death.



In a statement, Howard Center CEO Bob Bick said that the center would review the report but criticized the way the commission conducted its investigation.



“I will note that one of the recommendations made, consistent with legislative intent, was to improve communications among community partners; we believe that the way the investigation was conducted, hampered rather than helped this process,” Bick said. “The nature of mental health care and treatment in Vermont and across the country is complex, demanding, and requires collaboration among multiple partners and systems.”



Bick’s statement did not address whether the center had made any changes in response to Grenon’s death, and Howard Center spokesman Adam Brooks said the center would not be providing further comment on the report.



[Related: The 2010s were the deadliest decade in Vermont history for killings by police.]

The report found that Grenon was likely experiencing psychosis leading up to his death.



“Mr. Grenon’s mental health began to deteriorate at least one year before his death,” the report states. “He believed that people, including the police, were coming to his apartment to kill him.”



Grenon’s deterioration followed the departure of his long-time Howard Center case manager, and the center did not have an adequate plan to support Grenon during that change, the report states.



“Mr. Grenon’s treating psychiatrist consistently recommended an increase in anti-psychotic medication without ever recognizing that Mr. Grenon had stopped re-filling his prescription for anti-psychotic medication three months before his death,” the report states.



Howard Center also did not use any avenues available to treat Grenon involuntarily after the center determined he posed a serious risk to others, according to the report.



The BPD “had false and incomplete information, and inadequate resources” to properly respond to Grenon, the report states. Officer Durwin Ellerman incorrectly told his sergeant that Grenon threatened to kill himself, and Howard Center did not inform BPD that Grenon believed officers were going to go to his apartment to kill him.



“In addition, BPD did not take into account how Mr. Grenon’s mental illness affected his ability to comply with their commands or how his mental state might affect his reaction to pepper balls or Tasers,” the report states. “BPD also did not take advantage of the Howard Center’s mobile crisis clinician who was standing by during the encounter. “



The BHA realized that Grenon’s mental health was deteriorating in the months before his death, and contacted Howard Center to alert the center to its concerns. But BHA did not follow up when it did not hear back from Howard Center, according to the report.



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“The communications lacked the sense of urgency that the Commission believes the circumstances required,” the report states.



The report lays out a series of suggestions for community mental health agencies, providers of public housing and law enforcement, including recommendations to improve communication and training.



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