Appendix 6: DOC'S After Action Report of the March 11, 1998 Inmate Homicide

Government of the District of Columbia
DEPARTMENT OF CORRECTIONS
Deputy Director for Institutions
P.O. Box 25
Lorton Virginia 22199

 

 

 

 

 

 

 

 

April 2, 1998
 

 

 

 

 

MEMORANDUM
 

TO :

Margaret A. Moore
Director
 

THROUGH:

John H. Thomas
Executive Deputy Director


 

FROM :

Adrienne R. Poteat
Deputy Director for Institution
 

Lloyd Jones
Acting Chief, Warrant Squad
 

Michael Greene, Sergeant
Drug Interdiction Team
 

SUBJECT:

Audit
 

RE : Northeast Ohio Correctional Center


 

A. INTRODUCTION

 

During the week of March 11-13, 1998 the Team conducted an audit of the Northeast Ohio Correctional Center following a homicide which occurred at the facility on March 11, 1998.
 

We initially met with Warden Willis Gibson and explained the nature of our visit.

We informed him that we intended to v" the unit where the homicide occurred,
 

review written policies and procedures, Interview staff and inmates and obtain documentation for further review. Following our audit, a debriefing would occur and recommendations made to enhance security and improve the overall operation of the facility.
 

Staff were extremely cooperative and spoke freely with the Team. Warden Gibson and staff provided us with all documentation requested.
 

Due to the nature of our visit, there were several issues which raised concern and needed immediate attention. Details regarding our observations will be explained fully in this report. However, inasmuch as the Institution was on a lockdown status, we were only adore to observe areas which are listed below in which, we have submitted recommendations. To ensure that these issues are addressed and compliance is maintained, we recommend the Department of Corrections conduct regular security inspections. A report will be required from the auditor(s) following each visit, which lists areas of concern and proposed recommendations. The Northeast Ohio Correctional Facility will be required to

prepare and submit an abatement plan which will be reviewed during the subsequent audit. We abo recommend that if CCA has issuance to any proposals, they reserve the right to consult and negotiate with the Executive Deputy Director, who is the Contract Monitor.
 

B. EXECUTIVE SUMMARY


 

The following represents a summary of interviews conducted with staff and inmates and the response we received:
 

• Inmates Alphonso White, , and Byron Chisely, , were involved in a serious incident in December 1997, in which both inmates should have been separated from one another and not allowed to be housed or recreate together. This was an incident just waiting to happen which could have been avoided.
   

• Inmate Richard Johnson, , who was recently implicated in a homicide in February 1998 should not have been allowed to recreate with anyone.

•  

  The lack of cell searches and inmate pat or strip searches allows for inmates to feel confident about maintaining weapons in which an unidentified weapon was allegedly used in the commission of an offense. According to staff and inmates, searches only occur when major incidents transpire.

• There is no set policy establishing a limit for the number of inmates authorized for recreation at any given time. Given the status of this unit, inmate movement should be restricted to one inmate out at a time.
   

• The inconsistency for the use of restraints needs to cease and the policy followed governing full restraints for all inmates who enter or depart their cells.
   

• Following a strip search of an inmate, he should not ice subject to exposure outside his cell and paraded in the bay area in front of female staff. This practice is degrading and inappropriate. Staff should make concerted efforts to leave the cells in some sort of orderly fashion upon completion of the cell search.
   

• The use of hand friskers for searches is appropriate but unacceptable if used to conduct cavity searches.
   

• Mandatory unit inspections for both long and short term segregation units needs to occur by the Warden, Deputy Wardens, Major, and Shift Supervisors daily and documented.
   

• Incidents of excessive force while inmates are restrained needs to be investigated as reported by both staff and inmates.

 

 

 

 

C. CHRONOLOGY Of EVENTS
 

 

 

This section represents a detail of the events which transpired in sequential order as reported by the Northeast Ohio Correctional Facility.
 

Officers were escorting five inmates in Dormitory QQ from recreation and removing restraints and placing inmates in their assigned cells. Further investigation revealed that Inmate Alphonso White, stabbed Inmate Byron Chisley, multiple times with a homemade weapon. Inmate Richard Johnson, was also allegedly involved. Inmate Chisley was ordered to the sally port by Officers , at which, time medical assistance was requested from the Medical Department. He was transferred by ambulance to St. Elizabeth Hospital and pronounced dead at 1034 hours. Inmate White was apprehended by correctional staff, ordered to lay on the day room floor and submit to physical restraints and a strip search. A search was also conducted of all inmates in QQ Dormitory but with negative results. The Investigator and Youngstown Police Department responded and the investigation is pending.
 

D. ANALYSIS OF EVENTS
 

We received a preliminary copy of the Incident Report which was reviewed by Supervisors and the Warden. It was recommended that in order to prevent a reoccurrence of this type of incident, the number of inmates escorted by staff in the Segregation Unit would be restricted to one inmate and two staff.
 

After reviewing the report, we elected to establish two interviewing teams to conduct five minute interviews with every inmate housed in the Segregation Unit. The Teams were as follows:
 

TEAM 1

Adrienne R. Poteat, Deputy Director for Institutions, DCDC

Lloyd C. Jones, Acting Chief, Warrant Squad, DCDC

Jay Smith, Deputy Warden, CCA
 

TEAM II

Michael Greene, Drug Interdiction Unit

Michael Gatin, consultant
 

The results of our interviews are as Follows:
 

Inmate White requested to be interviewed by Team I. In summary, Inmate White readily admitted his involvement in the assault of Inmate Chisley. He felt that the facility was at fault for allowing them to have recreation together inasmuch as he had been previously assaulted by this same inmate in December 1997. He indicted that five inmates were being escorted in from the recreation yard. He observed Inmate Chisley with a towel draped over his arm, moving his

hands back and forth as if he was attempting to come out of the restraints. He feared for his life and attempted , with positive results, to remove his restraints. In his words, "I did what I had to do. It was either him or me." He was questioned as to the type of weapon used and only stated that we would not find any weapon in the unit. Inmate White further commented that none of them were strip searched or pat searched when departing or returning from recreation. He complained that medical would not see him to remove his stitches. (A photograph was taken of his wounds).
 

Other inmates were interviewed and the following reflected information provided:
 

The number of inmates who were allowed out for recreation at any given time varied depending on what officers were assigned to the Unit.
 

There was no consistency for inmate searches departing or resuming from recreation.
 

Until the homicide occurred, inmate cell searches were non-existent. This practice is contrary to write policy; Segregation Management, Policy 10-100, dated March 11, 1997, Attachment A under 10-100.5 H Searches, and information contained in the unit log book which reflects that the last search conducted in the unit was on November 12, 1997 (attachment A-1).
 

There was no separation order--between Inmates White and Chisley as a result of the December 1997 assault. Following an interview with the Warden, he acknowledged that one should have been initiated (Attachment B, B-1 through 3), (Attachment B-4 represents the diagram of the housing unit where the incident took place and the emergency evacuation route where Inmate Chisley initially fell alter being stabbed).
 

Based on the information contained in the Post Order, all officers assigned to Segregation Units are required to have a minimum of one year experience. However, when interviewing the Shift Commander, he was not able to provide us with any proof to substantiate this practice.
 

Inmate Richard Johnson, was recently implicated in the murder of another inmate in February 1998, and was housed in this unit. He was allowed to have recreation with other inmates and is allegedly involved in this incident (Attachment C).
 

There appeared to be inconsistency in the amount of restraints used when moving inmates to and from recreation. Both staff and inmates confirmed that inmates were not always fully restrained. Inmates stated that leg irons were often omitted which would expedite their return to and from recreation.
 

Inmates interviewed following the strip search of the unit logged complaints of sexual misconduct involving Officer . In addition, his name was mentioned repeatedly for excessive use of force, both by inmates and staff, which was a concern of the Team. The inmate involved is still at the Northeast Ohio Facility. However, staff and inmates alike indicated that following this incident, he has been involved in several acts of aggressive and abusive behavior which has gone unreported. When this matter was brought to the attention of the Warden, we were concerned at the response that he could not transfer the staff and that the inmate should be transferred. However, we stressed our concern that this officer could be reassigned to any other CCA facility and that we feel was another culprit of an incident just waiting to happen. Unfortunately, the Warden did not appear to take this issue seriously.
 

Following the completion of interviews and the information provided, we elected to inspect other areas of the facility in which the following is provided:
 

Culinary Unit
 

At the present time, the facility is under contract with Aramark. The menu on Thursday consisted of half smokes, beans, salad, and cookie. Inmates and staff complained about quality and quantity of food.
 

Inmate were questioned about the procedure used for washing dishes it the dishwasher was malfunctioning. It was indicated that rubber trashcans were utilized for scraping garbage, washing dishes and two for rinse cans before placement back on the line. The Warden acknowledged this practice and indicated that solutions were used for sanitizing. He suggested that we speak with the Chief of the Culinary Unit before we cited this deficiency.
 

Casemanagement
 

Random flies were reviewed from a caseworker and found to be incomplete. Inmates who have been housed in the facility for months had files with no contact logs, profile or program prescriptions.
 

Legal logbooks revealed no calls since December 2, 1997, although a caseworker indicated that calls were made on a regular basis by request. Inmates routinely complained about staff refusing to honor requests for calls.
 

No file cabinets were in the office and files were kept in a file box with absolutely no organization.
 

Mail Room
 

There is currently a backlog of undelivered mail which dates back to February 1996. There is no record of legal mail being issued. Staff complained of the facility policy to allow inmates to receive sexually explicit magazines and photographs as long as it was not an unnatural sex act. Postal money orders or settlement checks are only authorized, however, staff are required to post all transactions and complained about their inability to keep up, creating a back log.
 

Receiving and Discharge
 

Several months ago, arrangements were made with the Warden to transfer property to Youngstown for inmates housed at the facility and the excess property to be sent home. Currently, there are approximately 65 bags which, need to be returned to the District of Inmates who are no longer housed in the facility.
 

Recreation
 

The recreation cages for the long-term segregation unit were sufficient or with a suggestion to add some type of exercise equipment in each yard.
 

Property
 

Property allotment for Segregation Units was excessive.
 

Inspections
 

Supervisory inspections are not well documented. In fact, a review of the unit inspection logs does not reflect visits by the Warden and Executive Staff. Inmates indicated that they rarely see Management unless an incident occurs, (see Attachment D).
 

Staffing
 

Staffing in the Long-Term Segregation Unit appeared to be inadequate. One officer in the bubble and two roving officers for the three pods. If recreation occurs in one unit, everything must cease in all other units.
 

Security
 

Information regarding separation orders, restrictions, or other pertinent information in the Special Management Unit is only available to staff by reviewing the unit files. Therefore, a shadow board, in which the tags are color coded, needs to be implemented which would also reflect an inmates status. Offices were questioned as to they would evacuate the unit if there was a major fire only to realize that possibility would exist that inmates would be removed, housed in a secure area, and restrained later. The possibility of an inmate staging an incident to effect removal from the unit and involvement in a serious incident is likely. Unless officers have a mechanism to immediately identify separatees, could very well happen.
 

Disciplinary Proceedings

(Short-Term Segregation Unit)

(Attachment E, E-1, and E-2)
 

Inmates were being held in the Special Management Unit past their time. Example: An inmate was found guilty for possession of bleach, and sentenced to seven days, but we found once his time was up, he remained on lockdown status for what was determined as "pending investigation of housing classification".
 

Appropriate documentation was non existent. An inmate who was punished for flooding in the unit had his water turned off completely for an extended period of time. There was no evidence that the water was even turned on for periodic, supervised toilet usage. This practice is understandable, but appeared to unsanitary.
 

An inmate was placed in the shower as a holding cage pending a decision from the Shift Commander when vacant cells were available. This inmate was fully clothed, remained in the cage for approximately four hours with no provisions for toilet use.
 

Officers indicated that after 5:00 p.m., once the Adjustment Board Supervisor departs, no releases occur from the Adjustment Unit and they have no idea who can be released in an emergency situation. Information in the flies in not complete.
 

Evidence revealed that inmates housed in the Segregation Units had separations which were not recorded in both files.
 

Inmates complained about their inability to receive showers on a regular basis. Interviews from the Warden indicated that showers were conducted on any three days of the week. The Unit Post Orders reflect Monday, Wednesday, and Friday. Documentation in some cases revealed inconsistency in procedures.
 

E. INMATE INVOLVEMENT
 

This section provides you with a list of all inmates allegedly involved in the incident.
 

(See Attachment)
 

F. SECURITY AUDIT RESULTS
 

While facility was on lockdown, the Special Operations Response Team conducted a search of the facility. In addition, there are certain security practices which should be followed. Listed below are those policies which occurred:

 

• The unit in which the homicide occurred was immediately locked down and searches were conducted.
   

• The Special Operations Response Teams from various CCA Facilities were called in to conduct a facility search.
   

• Inmates were restrained with their hands behind their backs and in leg irons.
   

• Inmates were strip searched and hand friskers used prior to removing them from their cells.
   

• Inmates were placed outside their cells, completely nude and restrained, while in a kneeling position, ordered to lean forward with their heads against the wall.
   

• Cell searches were conducted with a ratio of four of officers to one inmate.
   

• Order was maintained while the searches were being conducted.
   

• Supervisors were present during the search.
   

• Medical staff were present during the searches.
   

• The Executive team conducted period checks of the searches.

 

 

 

 

G. CONCLUSIONS
 

 

 

The Team is of the opinion that relative to the homicide, had staff at the facility followed sound correctional policy and procedure, this incident would have been avoided. This is based safely on interviews conducted with staff, inmates, and a visual inspection of the unit.
 

During our inspection, members of the Team were approached by employees who asked to speak with us away from the facility and off the record for fear of reprisal or termination. Contact was made with these employees who reported incidents of staff mistreatment of inmates and cover-ups.
 

Conclusions are that Post Orders are too vague and do not give officers enough guidance to perform their duties properly. Some orders need to be rewritten, especially those dealing with the Segregation Unit, and others implemented.
 

Inmates need to be reclassified and housed accordingly. Unit operations need to be restructured to deal with both long- and short-term felons.
 

The facility needs to revisit the staffing levels to alleviate the possibility of compromising security.
 

Officers need additional training.
 

Seasoned and experienced staff need to be reassigned from other CCA Facilities to deal with this population.
 

The facility needs to enhance the intelligence network deal allegations of staff/inmate improprieties reported by both inmates and staff.
 

Staff need to feel a part of the decision making process.
 

Officers were very receptive to new ideas and some cognizant of sound penology practices, however, they have been placed in positions to compromise security. They feel that failure to follow instructions from their Supervisors create a posture of insubordination and removal.
 

H. RECOMMENDATIONS

 

• All Inmates in the Northeast Ohio Correctional Center need to be reclassified using the instrument developed by James Austin.
   

• Inmates classified and viewed as high risk need to be housed in a unit identified for that purpose.
   

• Post Orders for operating a high-custody unit need to be developed which, include level of supervision, recreation, movement, programs, staffing, etc.
   

• The use of televisions for a long-term housing unit needs to be explored especially if the inmates are not a disciplinary problem and only housed in the unit based on custody levels .
   

• Long-Term Segregation Units should be utilized for major disciplinary problems with proper documentation regarding the reason for their placement in the unit, classification reviews, restricted privileges to include but not limited to: canteen, visiting, recreation, telephone, etc., and other pertinent information.
   

• As an added security measure, implement a rotation of cell policy for inmates who remain confined for an extended period of time. This can be used as a deterrent for escape attempts.
   

• Identify a step-down unit for inmates being released from the Long-Term Segregation Unit which allows a period of adjustment before restoring full privileges and movement.
   

• Inmate handbooks and orientation should include policies and procedures for both long-term and short-term segregation units.
   

• Staff assigned to both long- and short-term segregation units should undergo specialized training. Seasoned staff should be assigned in accordance with written policy. There should also be an increase in staff assigned to the Long-Term Segregation Unit to ensure proper operation.
   

• CCA may want to implement the Zone Concept for Supervisors which identifies areas of responsibility for response and inspections.
   

• If the Adjustment Board Officer is a Lieutenant or above, he or she shall be responsible for overseeing the day-to-day operation of both long- and short-term segregation units.
   

• All records and files on inmates currently housed in segregation must be reviewed and releases activated on all inmates who have surpassed their disciplinary time unless extenuating circumstances exist with supporting documentation.
   

• The files of inmates entering the unit should include, but are not limited to, date of entry, results of the disciplinary board hearing, release date, special conditions (if any exist). The justification for placement in segregation units must be clearly defined.
   

• Implement policy to only allow one inmate to move at any given time, fully restrained and accompanied by two officers.
   

• Daily shakedowns must transpire for inmates, housing units and cells which are recorded in the unit log book.
   

• Contraband log reports should be prepared to include: Name, DCDC # (if applicable), items found, when and where. Depending on the types of contraband found, what action has been taken by Management to correct a deficiency and possibly prevent these items from reoccurring.
   

• Random cell searches occur utilizing the use of dogs and metal detectors Periodically, these searches should include maintenance staff for the removal of light fixtures, plumbing devices and water valve shut off. All other areas are equally important.
   

• All major shakedowns that mandate strip searches should be supervised by a Senior Correctional Supervisor and videotaped.
   

• Shadow boards need to be placed in the units and mounted on the walls that are easily visible to correctional staff. These boards should include the name, DCDC # of Inmates, cell, status, special conditions/restriction and separatees. Color coding the tabs would reflect the status.
   

• Intake unit needs to be established which allows for all inmates to be on complete lockdown for an established period of time. This allows for record review, classification, medical review, and housing designation.
   

• Develop a form for inmates who have animosity with one another and require separations. These forms must be placed in the institutional file, case management file, and unit file. All other documents which list separations must have up-to-date, complete and accurate information. Forms should be filled out and signed by Supervisory Staff.
   

• Establish a Special Handling Status for inmates who are involved in serious incidents such as homicides, escape attempts, etc. Inmate Richard Johnson, who was recently involved in a homicide, would fit the criteria and require total separation from all inmates pending investigation, prosecution or transfer to a more secure facility. At no time should he have been allowed to recreate with other inmates. Inmates on this status can only be removed by the Warden.
   

• Review the procedure for the transport and preparation of food for inmates inmate's in segregation units to alleviate contraband being placed in the food trays and delivered to the inmates. Staff do not inspect all of the food trays before delivery.
   

• Laundry for the segregation units needs to be searched thoroughly before they are redistributed to the inmates.
   

• An investigation needs to be conduced into the allegation of alleged sexual misconduct that has already been forwarded to Warden Gibson.
   

• An investigation needs to be conducted into the allegations of excessive use of force involving inmates and staff. According to staff reports, there is a substantial amount of incidents for Use of Force. To avoid legal implications, these incidents should be videotaped.
   

• Incidents which require the facility be remain on a lockdown status for several weeks should include provisions for inmates showers. The Warden did not see this as a problem since each inmate had access to a sink.
   

• Identify a task force to process the backlog of regular and legal mail, and post money orders. If necessary, additional staff need to be trained and assigned to assigned to avoid this from occurring again.
   

• Recreation for the segregation units should be done in accordance with written policy.
   

• Ensure that casemanagement staff review the daily movement sheets for inmates and establish contact with all new inmates assigned within an established time. Had this transpired, information pertaining to the last stabbing incident between Inmates White and Chisley may have been seen and acted upon if it was documented in the file.
   

• Daily inspections must occur by the Warden and Executive Staff for the Segregation Units, Culinary, and Medical. All other areas should be done on a weekly basis.
   

• The policy which governs strip searches needs to be revised to disallow inmates to lay on cold floors, remain naked, and be paraded through the unit completely nude in presence of female staff. This practice appears to be demoralizing and inappropriate.
   

• The use of mental hand friskers must not be used for cavity searches.
   

• Establish a policy which identifies and limits the amount of property for inmates confined in segregation.
   

• Casemanagement files must be reviewed on a random basis by the Unit Manager.
   

• Ensure that if trashcans are used for washing dishes, sanitizing agents are utilized, cans are properly labeled and not used for other things, water temperatures are sufficient. It was recommended that styrofoam trays be utilized but the Warden indicated this was too costly.
   

• CCA needs to consider reassigning seasoned officers into this facility.