Phil Grenon should still be alive.
That's the message in a new report from Vermont's mental health commission, which examined the shooting death of the 76-year-old Grenon by Burlington police in 2016 and found that it was preventable.
Grenon, whose mental health had been deteriorating for many months, was shot and killed in his apartment following a four-hour standoff with police on March 21, 2016. He had charged at officers swinging two knives after they tried unsuccessfully to subdue him with a Taser. The shooting was featured prominently in the APM Reports investigation "When Tasers Fail," which found the devices played a role in 258 fatal police shootings in the U.S. between 2016 and 2018.
While Burlington prosecutors quickly ruled the shooting justified, the Vermont Mental Health Crisis Response Commission also found it could have been prevented if Burlington's mental health system, public housing agency and police department had approached the situation differently. The commission's 63-page report released on Wednesday makes frequent reference to the APM Reports investigation. It also draws on hours of police body camera videos and thousands of pages of Grenon's medical records.
In an interview, commission Chair Wilda White said Grenon's shooting could have been avoided. "If all the recommendations were followed, we feel that they would have made a difference," she said.
The commission's report notes that "Mr. Grenon advanced on the officers only after he was struck by the Taser, leading the Commission to conclude that Mr. Grenon wanted to live and thought he was acting in self-defense at the time he was killed."
Grenon had left a voicemail message for his psychiatrist about a week before the shooting predicting that police would come to his apartment to try to kill him. Investigators later found a note in his apartment vowing to "kill them before they kill me."
The commission determined that police may have stoked Grenon's paranoia by discussing their plan to use the Taser, saying within his potential earshot that they would "light him up" and "hit him" with the device. The report found Grenon could have misconstrued these terms as threats of deadly force. "Under these circumstances, it becomes understandable why Mr. Grenon left the bathroom wielding the knives after Officer [Durwin] Ellerman fired his Taser," commissioners wrote.
The report cautioned that police should not assume Tasers "will work effectively or in a typical manner on people in crisis," and that officers should decide ahead of time on a contingency plan should the devices "not achieve the desired effect." The recommendation also applied to another less-lethal technology that proved ineffective on Grenon, a device called a PepperBall. The report found a "misplaced reliance" on these tools "played a role in Mr. Grenon's death."
Tasers are ubiquitous in American policing. Most patrol officers carry them. But data obtained by APM Reports last year show officers in major police departments rate them as effective between 55 and 80 percent of the time. The same datasets show that, in many departments, the use of Tasers has declined substantially over time.
In Grenon's case, the ineffective Taser was just the last in a series of events that led to the shooting. The report documented numerous other factors that contributed to the tragic outcome long before the police arrived. At the time of the incident, Grenon's longtime psychiatrist was out of the country on vacation. Though Grenon's mental condition was clearly declining, his treatment center didn't have an "adequate plan" for care in her absence, the commission reported.
Grenon was also facing eviction at the time of the incident, though the commission did not believe that was a major factor in escalating his behavior. APM Reports' own review of Grenon's medical records found his paranoia often focused on fears of losing his housing.
Following the shooting, the Burlington Housing Authority adopted a "compassionate eviction policy" that provides additional time and assistance for tenants before they are removed from their apartments. The mental health commission recommended other public housing agencies adopt similar policies.
A 2019 analysis by The Washington Post found about 25 percent of the roughly 1,000 people fatally shot by U.S. police each year were in "mental distress" at the time.
The commission was created by the Vermont Legislature in 2017 in response to Grenon's death. Its job is to investigate cases in which police officers kill or seriously injure someone who appears to be experiencing a mental health crisis. Its two-year investigation into Grenon's death was its first.
Most states do not conduct such wide-ranging investigations into police shootings. Inquiries are typically limited to determining whether the use of deadly force was legally justified. Local prosecutors almost always conclude it was, as they did in Grenon's case, based on the threat officers faced in the split second before they pulled the trigger. But the Vermont commission's job is to look more broadly at the factors that led up to the shooting in the prior days, weeks and months, and to make policy recommendations to prevent similar incidents from happening in the future.
The commission has between two and five cases awaiting investigation, White, the commission chair, said. But she did not believe those inquiries would necessarily take as long as the first one did.
The Burlington Police Department did not respond to a request for comment. The chief at the time of the shooting, Brandon del Pozo, resigned in December after admitting he had created a fake Twitter persona to ridicule a critic of his department.
The Howard Center, where Grenon had received mental health treatment for many years, did not provide a comment, either.
Grenon's daughter, Niki Carpenter, applauded the recommendations and said she was happy that her father's death was leading to positive change. "I am proud," she wrote in an email to APM Reports, "and he would be too."