U.S. Department of Justice
Civil Rights Division

Assistant Attorney General
950 Pennsylvania Avenue, NW - RFK
Washington, DC 20530

July 11, 2008

Todd H. Stroger
Cook County Board President
118 N. Clark Street
Room 537
Chicago, IL 60602
Thomas Dart
Cook County Sheriff
Richard J. Daley Center
50 W. Washington Street
Room 704
Chicago, IL 60602
Re:

Cook County Jail
Chicago, Illinois

Dear President Stroger and Sheriff Dart:
We write to report the findings of the investigation of the
Civil Rights Division and the United States Attorney’s Office
into conditions at the Cook County Jail (“CCJ”). On February 16,
2007, we notified the Cook County Board of Commissioners
(“County”) of our intent to conduct an investigation of CCJ
pursuant to the Civil Rights of Institutionalized Persons Act
(“CRIPA”), 42 U.S.C. § 1997. As we noted, CRIPA gives the
Department of Justice authority to seek a remedy for a pattern or
practice of conduct that violates the constitutional rights of
inmates in adult detention and correctional facilities.
On June 18-22, 2007, and July 23-27, 2007, we conducted
on-site inspections at CCJ with expert consultants in
corrections, use of force, custodial medical and mental health
care, fire safety, and sanitation.1 We interviewed
administrative staff, security staff, medical and mental health

1

Our fire safety and sanitation experts accompanied us
only on the July on-site visit.

- 2 

staff, facilities management staff, training staff, and inmates.
Before, during, and after our visits, we reviewed an extensive
number of documents, including policies and procedures, incident
reports, use of force reports, investigative reports, inmate
grievances, disciplinary reports, unit logs, orientation
materials, medical records, and staff training materials. In
keeping with our pledge of transparency and to provide technical
assistance where appropriate, we conveyed our preliminary
findings to CCJ officials and legal counsel for the County and
Sheriff’s Office at the close of our July 2007 site visit.
During our July 27, 2007 exit meeting, and by letter dated
August 3, 2007, we notified CCJ officials of life-threatening
deficiencies in sanitation and safety measures at CCJ. In
particular, we indicated that inadequate emergency key
precautions and grossly unsanitary conditions in certain tiers
resulted in a serious and immediate risk of harm to inmates. On
August 6, 2007, counsel for the Sheriff’s Office promptly
responded by indicating that a number of corrective measures were
being implemented to address our concerns.2
We commend the staff at CCJ for their helpful and
professional conduct throughout the course of the investigation.
We received complete cooperation with our investigation, which is
particularly appreciated given that CCJ is the country’s largest
single-site jail. CCJ provided us with unfettered access to
records and personnel, and responded to our requests, both before
and during our on-site visits, in a transparent and forthcoming
manner. We also appreciate the County’s and the Sheriff’s
Office’s receptiveness to our consultants’ on-site
recommendations. Accordingly, we have every reason to believe
that the County and the Sheriff’s Office are committed to
remedying all known deficiencies at CCJ.
Consistent with the statutory requirements of CRIPA, we now
write to advise you of the findings of our investigation, the
facts supporting them, and the minimum remedial steps that are
necessary to address the deficiencies we have identified.
42 § U.S.C. 1997b. As described more fully below, we conclude
that certain conditions at CCJ violate the constitutional rights

2

Counsel for the Sheriff’s Office provided additional
information regarding corrective measures in a letter and
attachments on October 5, 2007. We commend the Sheriff’s Office
on these reported advances and view them as progress toward
improved conditions at CCJ. We look forward to the opportunity
to verify the improvements.

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of inmates. In particular, we find that inmates confined at CCJ
are not adequately protected from harm, including physical harm
from excessive use of force by staff and inmate-on-inmate
violence due to inadequate supervision. In addition, we find
that inmates do not receive adequate medical and mental health
care, including proper suicide prevention. CCJ inmates also face
serious risks posed by inadequate fire safety precautions.
Finally, we find that environmental and sanitation deficiencies
at CCJ result in unconstitutional living conditions for inmates.
As discussed in this letter, these conditions have resulted
in serious harm to CCJ inmates. Three inmates committed suicide
at CCJ in the first four months of 2008. During our
investigation, we identified multiple preventable inmate deaths
and a preventable amputation, due to inadequate medical care. In
2006, separate incidents of unchecked inmate violence resulted in
two inmate deaths. In a one-week period during March 2007, CCJ
documented 35 inmate fights, required 27 uses of force, and found
46 weapons within the facility. The myriad of serious incidents
summarized here, and others discussed herein, indicates that CCJ
is not adequately providing for the safety and well-being of the
inmates.
I.

BACKGROUND

Located on approximately 96 acres in Chicago, Illinois, CCJ
is the largest single-site county jail in the United States.3
CCJ has a daily population of approximately 9,800 adult male and
female inmates, most of whom are awaiting trial in the criminal
court system. In 2006, CCJ admitted 99,663 inmates. CCJ is
staffed by approximately 3,800 sworn law enforcement officers and
civilian employees.
CCJ is separated into 11 semi-autonomous divisions,4 each
with its own superintendent and standard operating procedures.
The majority of the male inmates are housed in three
maximum-security divisions (Divisions I, IX, and X), three
medium-security male divisions (Divisions V, VI, and XI), and one
medium and minimum-security dormitory division (Division II).
Female inmates of mixed security classifications are housed on

3

4

http://www.cookcountysheriff.org/doc/html/facility.html

The divisions are designated by number, one through
eleven. There is no Division VII. The Receiving Classification
Diagnostic Center essentially functions as a separate division,
with its own superintendent.

- 4 

Division III, which also contains male and female medical and
mental health tiers, and Division IV. Division VIII contains
Cermak Health Services and the Residential Treatment Unit. The
Receiving, Classification, and Diagnostics Center (“RCDC”) is
located in the lower level of Division V and handles reception,
classification, and discharge for all CCJ inmates. Division I is
the oldest building, dating from 1929, and Division XI is the
newest, opened in 1995. The divisions range in rated capacity5
from 353 inmates in Division III to 1,536 in Division XI.
All corrections and security functions at CCJ are
administered by the Cook County Department of Corrections
(“CCDOC”) under the Cook County Sheriff. Health care services at
CCJ are provided by Cermak Health Services of Cook County
(“Cermak”), which is part of the Cook County Bureau of Health.
While the health services staff are County employees who are
responsible for the health care of all CCJ inmates, they are not
employed by, or responsible to, the Cook County Sheriff or CCDOC.
Although health care and security issues require a degree of
separation in all correctional facilities, as discussed in more
detail below, the complete division between corrections and
health care operations at CCJ results in serious administrative
problems, including increased frustration, communication
breakdowns, and finger-pointing. Regardless of the
administrative division, Cook County and the Cook County
Sheriff’s Office are responsible for the well-being of CCJ
inmates, including providing adequate care for inmates’ serious
medical and mental health care needs.
In 1982, the County entered into a consent decree in Duran
v. Dart, No. 74-C-2949 (N.D. Ill. Apr. 9, 1982) (“Duran Consent
Decree”) to resolve a class action lawsuit filed by pre-trial
detainees, pursuant to 42 U.S.C. § 1983, regarding overcrowding
of CCJ. The Duran Consent Decree, as amended, is still under the
jurisdiction of the United States District Court for the Northern
District of Illinois. The decree focuses on overcrowding, but
does contain some provisions governing staffing, food service,
personal hygiene, the law library, visitation, physical exercise,
classification, environmental health, and emergencies. CCJ’s
compliance with the Duran Consent Decree is monitored by the John
Howard Association. CCJ is also governed by multiple other
agreements and orders, such as Harrington v. DeVito, No. 74-C
3290 (N.D. Ill. Oct. 19, 1978) (mental health care) and Jackson

5

Actual capacity is often much lower than the rated
capacity due to cells that are inoperable as a result of
maintenance problems.

- 5 

v. Sheriff of Cook County, No. 06-CV-493 (N.D. Ill. July 16,
2007) (STD testing). Despite the existence of these court
orders, a myriad of unconstitutional practices remain at CCJ.
The current court orders applicable to CCJ either do not include
specific provisions governing the constitutional concerns raised
below regarding protection from harm, inadequate medical and
mental health care, fire safety, and sanitation, or have not
resulted in lasting or effective corrective measures.
II.

LEGAL STANDARDS

CRIPA authorizes the Attorney General to seek injunctive
relief to enforce the constitutional rights of inmates subject to
a pattern or practice of unconstitutional conditions in jails and
prisons. 42 U.S.C. § 1997. In defining the scope of jail
inmates’ Eighth and Fourteenth Amendment rights, the Supreme
Court has held that corrections officials must take reasonable
steps to guarantee inmates’ safety and provide “humane
conditions” of confinement. Farmer v. Brennan, 511 U.S. 825, 832
(1994); Bell v. Wolfish, 441 U.S. 520 (1979) (holding pre-trial
detainees protected by Fourteenth Amendment); Cavalieri v.
Shepard, 321 F.3d 616, 620 (7th Cir. 2003). Providing “humane
conditions” requires that a corrections system must “take
reasonable measures to guarantee the safety of the inmates” and
satisfy inmates’ basic needs, such as their need for medical
care, food, clothing, and shelter. Farmer at 832. The
protection of pre-trial detainees’ rights under the due process
clause of the Fourteenth Amendment is “at least as great as the
Eighth Amendment protections available to a convicted prisoner.”
City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983).
When a jurisdiction takes a person into custody and holds
him there against his will, the Constitution imposes upon it a
corresponding duty to assume some responsibility for his safety
and general well-being. County of Sacramento v. Lewis, 523 U.S.
833, 851 (1998) (citing DeShaney v. Winnebago County Dept. of
Social Servs., 489 U.S. 189, 199-200 (1989)).
The duties imposed and rights conferred by the Eighth
Amendment apply to the unreasonable risk of serious harm, even if
such harm has not yet occurred:
We have great difficulty agreeing that prison
authorities may not be deliberately indifferent to an
inmate’s current health problems but may ignore a
condition of confinement that is sure or very likely to
cause serious illness and needless suffering the next
week or month or year . . . . That the Eighth Amendment

- 6
protects against future harm to inmates is not a novel
proposition. The Amendment, as we have said, requires
that inmates be furnished with the basic human needs,
one of which is reasonable safety.
Helling v. McKinney, 509 U.S. 25, 33 (1993) (internal citations
and quotations omitted); Woodward v. Correctional Medical
Services of Illinois, Inc., 368 F.3d 917, 927 (7th Cir. 2004)
(citing Farmer, 511 U.S. at 842).
The “Eighth Amendment prohibition against cruel and unusual
punishment has been expanded under the Due Process Clause of the
Fourteenth Amendment to impose upon both federal and state
correctional officers and officials the obligation to take
reasonable steps to protect inmates from violence at the hands of
other inmates.” Goka v. Bobbitt, 862 F.2d 646, 649-50 (7th Cir.
1988); see also Hudson v. Palmer, 468 U.S. 517, 526-27 (1984);
Swofford v. Mandrell, 969 F.2d 547, 549 (7th Cir. 1992); Anderson
v. Gutschenritter, 836 F.2d 346, 349 (7th Cir. 1988); Archie v.
City of Racine, 847 F.2d 1211, 1222-23 (7th Cir. 1988) (en banc).
The Eighth Amendment forbids excessive physical force
against prisoners. Hudson v. McMillian, 503 U.S. 1, 9 (1992).
This is true even when the use of force does not result in
significant injury. Id. A jail or prison official who inflicts
force maliciously and sadistically to cause an inmate harm
violates the Eighth Amendment. Id.
Inmates also have the right to be free from retaliation for
engaging in constitutionally protected conduct, such as
complaining about conditions of confinement. Walker v. Thompson,
288 F.3d 1005 (7th Cir. 2002); DeWalt v. Carter, 224 F.3d 607,
618 (7th Cir. 2000) (“An act taken in retaliation for the
exercise of a constitutionally protected right violates the
Constitution”).
While low staffing levels do not, by themselves, constitute
due process violations, they provide support for a conclusion
that the inmates are treated “recklessly or with deliberate
indifference” to their safety. Swofford, 969 F.2d at 549.
Similarly, although overcrowding is not a per se constitutional
violation, overcrowding resulting in bunking multiple inmates in
a single cell without adequate safety, space, sanitation,
bedding, or opportunities for activities outside the cells can
amount to unconstitutional conditions of confinement. French v.
Owens, 777 F.2d 1250, 1252-53 (7th Cir. 1985) (holding that
overcrowding was unconstitutional where it led to unsafe and
unsanitary conditions); Wellman v. Faulkner, 715 F.2d 269 (7th

- 7 -

Cir. 1983) (holding that prison was unconstitutionally
overcrowded); see also Nami v. Fauver, 82 F.3d 63, 67 (3d Cir.
1996) (holding that double-bunking coupled with extended in-cell
periods despite safety hazards could constitute a constitutional
violation).
A jailer’s deliberate indifference to an inmate’s serious
medical needs violates the Eighth Amendment. Estelle v. Gamble,
429 U.S. 97, 102 (1976); Maggert v. Hanks, 131 F.3d 670, 671 (7th
Cir. 1997). “Deliberate indifference” involves both an objective
and a subjective component. The objective component is met if
the deprivation is “sufficiently serious.” Farmer, 511 U.S. at
834. Prison officials may not refuse, unreasonably delay, or
intentionally interfere with medical treatment for incarcerated
individuals. Hudson v. McHugh, 148 F.3d 859 (7th Cir. 1998)
(“[T]his is the prototypical case of deliberate indifference, an
inmate with a potentially serious problem repeatedly requesting
medical aid, receiving none, and then suffering a serious
injury.”); Zentmyer v. Kendall County, 220 F.3d 805 (7th Cir.
2000). “Deliberate indifference can be evidenced by ‘repeated
examples of negligent acts which disclose a pattern of conduct by
the prison medical staff’ or it can be demonstrated by ‘proving
there are such systemic and gross deficiencies in staffing,
facilities, equipment, or procedures that the inmate population
is effectively denied access to adequate medical care.’”
Wellman, 715 F.2d at 271 (citing Ramos v. Lamm, 639 F.2d 559, 575
(10th Cir. 1980), cert. denied, 450 U.S. 1041 (1981)). Jail
officials also may not provide an easier but less efficacious
course of treatment nor may they offer only cursory medical care
when the need for more serious treatment is obvious. See
Estelle, 429 U.S. at 104-05. Failure to provide medication can
violate the duty to provide adequate medical care to address
serious medical needs. See, e.g., Zentmyer, 200 F.3d at 811.
The County’s obligation to provide adequate medical care
includes a duty to provide adequate mental health care. Farmer,
511 U.S. at 832; Sanville v. McCaughtry, 266 F.3d 724, 734 (7th
Cir. 2001) (noting that a mentally ill inmate’s condition was
“objectively, sufficiently serious” such that incarcerating him
under conditions that posed a substantial risk that he would
commit suicide subjected him to cruel and unusual punishment).
In addressing the constitutionally minimal standards for mental
health care in a jail or prison, the Seventh Circuit notes:
“When a claim is based upon the failure to prevent harm, in order
to satisfy the first element the plaintiff must show that the
inmate was ‘incarcerated under conditions posing a substantial
risk of serious harm.’” Id. (citing Farmer, 511 U.S. at 832);
see also Estate of Novack v. County of Wood, 226 F.3d 525, 529

- 8 

(7th Cir. 2000); Estate of Cole v. Fromm, 94 F.3d 254, 261 (7th
Cir. 1996). Where a jail’s “actual practice” towards treatment
of mentally ill inmates in general is clearly inadequate, the
facility may be held to be “on notice” at the time of an inmate’s
incarceration that there is a substantial risk of deprivation of
necessary care. Woodward, 368 F.3d at 927 (practice of
inadequate employee training, incomplete intake screening, and
inadequate suicide watch constituted deliberate indifference).
The risk of suicide is an “objectively serious harm” from
which inmates have a right to protection, under the deliberate
indifference standard. Matos v. O’Sullivan, 335 F.3d 553, 557
(7th Cir. 2003). Inadequate suicide prevention may constitute
deliberate indifference. Hall v. Ryan, 957 F.2d 402, 406 (7th
Cir. 1992) (noting that prisoners have a constitutional right “to
be protected from self-destructive tendencies,” including
suicide); Woodward, 368 F.3d at 929 (fact that no previous
suicides occurred in jail did not negate possibility of a
practice of deliberate indifference toward suicidal detainees);
Cavalieri, 321 F.3d at 620 (holding that the right to be free
from deliberate indifference to suicide was clearly established).
Inmates are constitutionally entitled to environmental
conditions that do not pose serious risks to health and safety,
including deficient sanitation, inadequate fire safety,
inadequate ventilation, and pest infestation. Vinning-El v.
Long, 482 F.3d 923, 924-25 (7th Cir. 2007) (holding that
deliberate indifference could be established by inference from
conditions, including floor covered with water, broken toilet,
blood and feces smeared along wall, no mattress to sleep on);
Gillis v. Litscher, 468 F.3d 488, 568 (7th Cir. 2006) (“[A] state
must provide . . . reasonably adequate ventilation, sanitation,
bedding, hygienic materials, and utilities (i.e., hot and cold
water, light, heat, plumbing).”); Board v. Farnham, 394 F.3d 469
(7th Cir. 2005) (requiring adequate ventilation); Isby v. Clark,
100 F.3d 502, 506 (7th Cir. 1996) (“Sanitation, we assume,
includes things like odors and general cleanliness around the
cell.”) (emphasis in original); French, 777 F.2d at 1257 (holding
that fire safety is a “legitimate” concern under the Eighth
Amendment); Antonelli v. Sheahan, 81 F.3d 1422, 1432 (7th Cir.
1995) (requiring adequate pest control).
In addition, detainees have a right to be free of bodily
restraints, such as shackles or a restraint chair, unless the
facility demonstrates a legitimate penological or medical reason
for the restraint. Murphy v. Walker, 51 F.3d 714, 718 (7th Cir.
1995). Where restraints are used, the inmate should be properly
monitored and the length of restraint-time should be limited to

- 9 

ensure the inmate’s safety. French, 777 F.2d at 1253-54.
Restraints imposed by correctional officers that are medically
unjustifiable and have no adequate security rationale infringe on
an inmate’s due process rights. Wells v. Franzen, 777 F.2d 1258,
1263 (7th Cir. 1985) (restraint of a suicidal inmate).
III.

FINDINGS

We find that CCJ fails to adequately protect inmates from
harm and serious risk of harm from staff and other inmates; fails
to provide inmates with adequate medical and mental health care;
fails to provide adequate suicide prevention; fails to provide
adequate fire safety precautions; and fails to provide safe and
sanitary environmental conditions.
A.

INADEQUATE PROTECTION FROM HARM

Corrections officials must take reasonable steps to
guarantee inmates’ safety and provide “humane conditions” of
confinement. Farmer, 511 U.S. at 832. Providing humane
conditions requires that a corrections system must satisfy
inmates’ basic needs, such as their need for safety.
Additionally, jail officials have a duty to take reasonable steps
to protect inmates from physical abuse.
To ensure reasonably safe conditions, officials must take
measures to prevent the use of unnecessary and inappropriate
force by staff. Officials must also take reasonable steps to
protect inmates from violence at the hands of other inmates. In
addition, officials must provide adequate systems to investigate
incidents of harm, including staff misconduct and alleged
physical abuse of inmates. Finally, a jail has an obligation to
protect vulnerable inmates from harm, such as those who are at
risk of suicide or at risk from other inmates. For the reasons
set forth below, CCJ fails to meet constitutional standards in
all of these regards.
1.
Inappropriate and Excessive Use of Force
Although the violence present in a correctional setting
necessarily permits the appropriate use of force, the
Constitution forbids excessive physical force against inmates. A
determination of whether force is used appropriately requires an
evaluation of the need for the use of force, the relationship
between that need and the amount of force used, the seriousness
of the threat reasonably believed to exist, and efforts made to
temper the severity of a forceful response. Hudson v. McMillian,
503 U.S. 1, 7 (1992). Generally accepted correctional practices
provide that appropriate uses of force in a given circumstance

- 10 

should include a continuum of interventions, and that the amount
of force used should not be disproportionate to the threat posed
by the inmate. Absent exigent circumstances, lesser forms of
intervention, such as issuing disciplinary infractions or passive
escorts, should be used or considered prior to more serious and
forceful interventions.
We found that inmates at CCJ are regularly subjected to
inappropriate and excessive uses of physical force. CCJ officers
too often respond to inmates’ verbal insults or failure to follow
instructions by physically striking inmates, most often with the
active assistance of other officers, even when the inmate
presents no threat to anyone’s safety or the security of the
facility. Moreover, even in cases in which the initial use of
force is reasonable, officers sometimes continue to engage in
physical force after the inmate has been brought under control or
is effectively restrained.
A top security administrator frankly acknowledged to us the
existence of “a culture of abusing inmates” when he came to CCJ
in October 2006. While senior management has taken steps to
reduce the use of force, such as requiring Use of Force Reports
and by subjecting these documents to greater scrutiny, the
excessive and inappropriate use of force has not been brought
under control. We believe that, despite management’s efforts, a
culture still exists at CCJ in which the excessive and
inappropriate use of physical force is too often tolerated.
Our investigation included an intensive examination of
documents provided by CCJ concerning the incidents listed below
and a host of others occurring between January 2006 and July
2007. We also conducted a great many staff and inmate
interviews. In some cases, our findings of inappropriate or
excessive uses of force are in accord with CCJ’s own conclusions.
a.

Use of Force in Response to Verbal Altercations

The use of force, while sometimes necessary in a corrections
setting, must be appropriate to the given circumstances and
proportionate to the threat posed. A verbal taunt from an inmate
to an officer is a rule violation and may appropriately result in
disciplinary action, but it should not require a physical
response. As the examples below demonstrate, verbal altercations
with inmates too often provoke physical responses from CCJ
officers:

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1.	

In July 2007, following his hour of exercise, Alberto
P.6 refused to return to his cell and a female officer
locked the cell doors while Alberto remained outside.
He called the officer a “b----.” When Alberto came out
with his property to be moved to disciplinary
segregation for insulting the officer, he was beaten by
a number of officers. One officer later told Alberto
that he had tried to stop the beating, but he just
“didn’t have enough juice” (apparently explaining his
inability to control the other officers). CCJ records
confirm that Alberto was transferred to segregation and
taken to Cermak for his injuries.

2.	

In June 2007, Dennis L. returned to his cellblock after
a psychological evaluation. An officer refused to give
Dennis a dinner tray. Dennis got into a verbal
altercation with the officer and threw a cup of liquid
at him. A number of officers attacked Dennis in his
cell. Emergency Room records indicate that Dennis
suffered blunt trauma to his head and body, three teeth
knocked loose, and a laceration to his lower lip from
this incident.

3.	

In April 2007, Billy D. wanted to exit his cell and was
accused of pushing his way out. He had a “heated”
verbal altercation with the officer. One officer
struck Billy in the face and other officers joined in.
Medical records show that Billy required internal and
external stitches to close a one-inch laceration that
punctured his lip.

4.	

In September 2006, an officer was handing out extra
lunches to inmates. Malcolm W. asked for one, but was
refused. Malcolm and the officer exchanged verbal
insults. A mental health staff member and another
inmate witnessed the officer slap Malcolm’s face and
drag him from the dorm. CCJ’s Internal Affairs
Division (“IAD”) sustained allegations of abuse, and
recommended that the officer be suspended for 29 days.
The officer was “dedeputized” and prohibited from
carrying a firearm or effecting arrests.

6

To protect privacy, we have used pseudonyms to identify
inmates and officers listed in this letter. Upon request, we
will provide the County with a schedule that cross-references the
pseudonyms with the proper names, where appropriate.

- 12 

5.	

In March 2006, Danny P., who according to CCJ records
was a slight man of 5'1" and 110 pounds, was on his way
to the law library. He got into a shouting match with
the female officer escorting him, which resulted in him
being taken back to his housing unit. Near the secure
staff station, the officer lunged at Danny and began to
slap him. Two other officers grabbed his arms and
pushed him into a dayroom. As he was being handcuffed,
several other officers continued to punch and kick him.
He was hit in the mouth after being handcuffed. CCJ
records show that a sergeant found Danny standing
outside the security office handcuffed and bleeding
about the face. The female officer was disciplined for
failing to report the incident in a timely manner and
also for failing to obtain medical treatment for Danny.
Danny filed a lawsuit against CCJ regarding this
incident, and the parties agreed to settle the case in
March 2008.
b. 	 Use of Force for Failure to Follow Instructions

It is inappropriate and excessive to use force for rule
violations which do not present a threat to safety or security.
At CCJ, inmates’ failure to follow orders too often lead to
physical abuse, even where no security risk is present:
1.	

In June 2007, there was a fight on Thomas K.’s unit, in
which he did not participate. A group of officers came
to the unit, strip-searched the inmates, and sent them
back to their cells. As Thomas started to go up the
stairs to his top tier cell, his hands were on his neck
holding his shirt, instead of on top of his head, as he
had been directed. An officer grabbed Thomas by the
neck, which choked him, and Thomas reacted by grabbing
the officer’s arm. The officer immediately swung and
hit Thomas in the eye with a walkie-talkie, causing a
wound that required five stitches to close. Cermak
medical records confirm Thomas’s injuries and that he
was hit with an “unknown object.” The officer
continued hitting Thomas after the first blow, although
Thomas offered no resistance. We observed Thomas’s
injuries during our on-site visit.

2.	

In February 2007, Matthew S. was ordered to leave the
barber shop for standing up before his turn. When he
tried to explain why he stood up, an officer grabbed
him by the collar and told him to leave the barber
shop. Matthew argued with the officer. Outside the

- 13
barber shop, officers shoved his head into the concrete
after he had been handcuffed. CCJ records confirmed
that Matthew needed stitches to his face and a tetanus
shot following this incident, but he refused treatment.
3.	

In April 2006, Terrence M. was being processed in his
division when an officer noticed that Terrence had an
unauthorized shirt. The officer asked for the shirt,
but Terrence refused to give it to him. After Terrence
was restrained, the officers punched and kicked him.
As a result of the beating, Terrence suffered a broken
jaw that required surgery at an outside hospital. CCJ
found abuse by one officer, and the officer was
terminated.

4.	

In April 2006, Darnell J. refused to go to recreation
when he was told he could not first use the bathroom.
Several officers shoved Darnell into the hallway where
they beat and kicked him. A sergeant watched and then
joined in the beating. Two other inmates in the
hallway were also beaten. Darnell was hospitalized for
neck injuries. CCJ found abuse by the sergeant and
seven officers and also that the sergeant and several
officers had filed false reports. IAD recommended
termination for the sergeant and three officers.

5.	

In March 2006, John S. was being strip-searched prior
to going to recreation. He was tapping on the wall.
An officer ordered him to stop and hit him on top of
the head. John continued to tap. After John was
searched, the officer said: “You’re f------ guilty”
and slammed him on top of a cart and against the wall.
John was pulled into the hallway where other officers
started to beat him. He was hit in the face, dragged
by his hair, choked, and beaten. Photographs of John
in the CCJ files show injuries to his face and body.
IAD found that the officers used excessive force and
recommended that two officers be terminated.

6.	

In March 2006, Jacob D. objected to a tier change and
insisted on speaking with an officer. Three officers
extracted him from his cell. He was handcuffed behind
his back and, while they were taking him to the
segregation unit, the officers pushed his head into the
wall. He was hit in the face, thrown down stairs,
kicked, and punched repeatedly. Photographs of Jacob
from the following day show that his face was badly
bruised and his eye was swollen shut. IAD found that

- 14 

three officers used excessive force and recommended
that they be suspended for 29 days.
7.	

In January 2006, Byron S. was cleaning the dayroom with
other inmate workers when a group of officers accused
Byron and another inmate of planting contraband in the
visiting area, and took both inmates into the hallway.
Byron was beaten by multiple officers. After he was
handcuffed and lying on the floor, Byron received a
blow that broke his jaw. Medical records confirm that
his jaw was fractured. Byron’s jaw was wired shut at
an outside hospital, which required him to eat with a
straw. Three months later, Byron required additional
surgery and his jaw was wired shut for a second time.
Byron filed a lawsuit against CCJ regarding this
incident, and the parties agreed to settle the case in
September 2007.

8.	

In January 2006, Michael A. was resisting going to
disciplinary segregation because he believed he had
already served his time for the infraction in question.
He asked to talk to a sergeant, who said that nothing
could be done. When he continued to resist, stating
that he wanted to talk to a captain, a correctional
officer said: “No,” and struck him in the face. Other
officers were called and joined in beating him. He was
sent by ambulance to an outside hospital. Medical
records show he suffered a fractured nose and two black
eyes.
c.

Use of Force as Punishment or Retribution

We found that inappropriate and excessive use of force also
occurs when officers are angry and upset about inmate violence
against staff. Physical force is also sometimes inappropriately
used at CCJ even after an active dispute between an inmate and
officer has ended, apparently to punish the inmate. Retaliatory
force even occurs when officers are dealing with mentally ill
inmates with limited impulse control, although the inmates do not
present a threat to themselves or others.7 The use of force is

7

According to a division superintendent, a number of
officers assigned to the tiers for inmates with mental illness
have not received training on working with the mentally ill. The
excessive use of force with mentally ill inmates is likely
attributable to lack of, or ineffective, officer training.

- 15 

never appropriate as retribution for previous bad acts and is
inappropriate when an inmate is not a present threat:
1.	

In July 2007, Robert T., who suffers from mental
illness, exposed himself to a female officer. In
response, he was taken to a clothing room where a group
of officers handcuffed him and then proceeded to hit
and kick him after he was restrained. CCJ records
confirm that Robert was sent to an outside hospital
with severe head trauma.

2.	

In June 2007, Russell G.’s cellmate opened the cell
door and Russell got out of his cell. In response, an
officer locked all the inmates in their cells. After
Russell was back in his cell, officers sent his
cellmate downstairs and entered Russell’s cell. The
officers handcuffed Russell, then stomped on his back
and hit him. His eye became swollen and his teeth were
chipped. Before taking him to the dispensary, the
officers threatened to beat Russell again and charge
him with battery unless he told medical staff that he
had hurt himself falling off his bunk. Russell was
sent from the dispensary to Cermak Hospital for medical
treatment.

3.	

In August 2006, an inmate stabbed an officer. Because
Martin S. had argued with the officer earlier in the
day, officers erroneously believed he had committed the
stabbing.8 As a result, officers responded to an “all
available” call and began to beat Martin in the
mistaken belief that he was the inmate who had
assaulted the officer. Besides being punched and
stomped, he was also hit with a radio and kicked in the
groin.

4.	

Inmate Andrew B. was also housed in the unit where the
August 2006 attack on the officer occurred. Andrew had
nothing to do with the attack. A large number of
officers came onto the unit and proceeded to beat the
inmates indiscriminately. Andrew was ordered to lie
down and, while he promptly obeyed, he was stomped and
kicked by the officers.

8

CCJ records confirm that another inmate was charged
with the crime.

- 16 

5.	

In April 2006, Damien H. pushed out of his cell. An
officer escorted him back to his cell. At the door of
his cell, Damien turned and hit the officer, for which
he was charged with aggravated battery. All available
officers were called and, while restraining Damien,
several officers punched, kicked, and stomped him. IAD
found that three officers had used excessive force and
recommended 29-day suspensions for all of them.

6.	

In January 2006, an officer wanted Jerry M. to return
to his cell, which Jerry resisted, and the officer
rolled the door over Jerry’s foot. Jerry called the
officer a “b----.” The officer then beat Jerry with
handcuffs wrapped around his hand like brass knuckles.
A CCJ internal investigation of this incident found
that excessive force had been used and recommended that
the officer be terminated. The Sheriff’s Merit Board,
which hears CCJ termination cases, ruled against CCJ
and reinstated the officer to duty.
d. 	 Use of Force at Intake

The pattern of inappropriate and excessive use of force is
distributed throughout the CCJ divisions, and not confined to the
areas where the use of force is most likely to occur in a
correctional setting: the maximum security units and intake
area. However, an especially high number of abuse of force
allegations do emerge from CCJ’s RCDC intake unit.
There is unanimity of opinion among those familiar with CCJ,
including administrators and staff, the County, the Sheriff’s
Office, and the court monitors, that conditions in RCDC are
unacceptable and must be changed. As discussed in more detail
below, the RCDC is chronically overcrowded, cramped, chaotic, and
insufficiently staffed. The impact of these conditions on the
use of force is considerable. In the RCDC, inmates who request
attention for various needs run the risk of becoming victims of
physical abuse. Inmates are especially vulnerable to abuse when
they are taken in large groups to be strip searched in an
isolated area out of the view of non-security intake staff. Many
inmates report that those who are old, mentally ill, or do not
understand English, are struck by officers for undressing or
dressing too slowly. Finally, inmates may also be targeted for
physical abuse because of the charges for which they were
arrested.
1.	

In September 2006, Pedro S. was arrested on a sex
charge brought by his niece. While in the intake area,

- 17
three officers who had read his charge began taunting
him, yelling threats in Spanish, and asking if he knew
what was about to happen to him. The officers struck
him many times and called him a “f------ Mexican.” The
other inmates were ordered to turn and face the wall
“or else.” Because the officers threatened to kill
Pedro if he said anything about the incident, he did
not seek medical attention. Pedro was released four
days later and immediately saw a doctor and reported
the incident to the Chicago Police Department. The
Police Department contacted CCJ. Medical records
confirm that Pedro’s injuries included a broken rib and
damage to his jaw and knee.
2.	

In July 2006, Lonnie L., 59-years-old, was leaving the
medical area of intake and heading to the bullpen.
When he turned around to get more medication, an
officer told him not to return to the medical area.
Lonnie did not obey the order. The officer came into
the medical area and hit Lonnie on the mouth. When
Lonnie fell to the ground, the officer kicked him and
again struck him in the mouth, knocking out a tooth.
The officer dragged Lonnie by the pants out of the
medical area. During Lonnie’s intake strip search, the
same officer hit him in the back with a cane. Three
inmates testified that they witnessed the incident.
Medical records indicated injury to Lonnie’s ribs and
lung. CCJ found abuse and recommended that the officer
be terminated.

3.	

While being processed into CCJ in May 2006, Antonio R.
was wandering around the intake area asking for his
methadone. An officer told him to return to his
holding pen. Antonio apparently did not obey quickly
enough, as the original officer and others proceeded to
beat him, first in the main open area and then in an
adjoining tunnel. They hit Antonio with a radio,
knocked out his dentures and smashed them under a boot.
As a result of this incident, Antonio suffered multiple
fractures and a collapsed lung. After being returned
from one outside hospital, he was sent to another in
acute respiratory distress. He was transferred to a
Level 1 trauma center, where he needed to be placed on
a ventilator. Medical records confirm Antonio’s severe
injuries.

4.	

In February 2006, while being processed into the CCJ
for driving on a suspended license, James W. would not

- 18
(and could not) remove jewelry embedded in a piercing
because it was permanently soldered. The officer
conducting the strip search attempted to strike James,
who blocked the blow. The officer then called over
other officers, who hit James in the face multiple
times. One officer hit him repeatedly with a handcuff
wrapped around his hand. James later stated that the
officers had used his head as a “bongo drum.” Medical
records confirm that James was diagnosed with a
perforated ear drum and blood in his right ear at
Cermak Hospital the next day. Additional records show
that the incident resulted in diminished hearing in one
of James’s ears. James filed a lawsuit against CCJ
concerning this incident and the parties agreed to
settle the case in March 2008.
e.

Inadequate Oversight of Use of Force

Effective measures to prevent excessive and inappropriate
uses of force start with the adequate reporting of information to
permit the identification of potential problem cases and
effective internal investigations. We find that CCJ fails to
elicit adequate information about use of force incidents, making
management review ineffective. We also find that, in most cases,
internal affairs investigations of use of force are undertaken
only when a lawsuit is filed, rather than when a serious incident
occurs.
i.

Management Review

In order for CCJ to provide adequate oversight of officers’
use of force, management must have adequate information to review
incidents and reach a conclusion as to the propriety of a use of
force. While all officers involved in a use of force incident
fill out a Use of Force Report, in most cases these reports
provide very little information because they are written in
generalities. For example, numerous Use of Force reports fail to
describe, in factual terms, the type and amount of force that
officers used. Many Use of Force Reports merely describe the
force used with phrases such as, “used the least amount of force
necessary to gain control of the inmate” or “faced inmate to the
floor.” Although most shift commanders review Use of Force and
Incident Reports to ensure that reports are completed, some
commanders reported that they do not review the reports for
substantive content. Although copies of Incident Reports are
forwarded to CCJ’s Executive Director, Assistant Executive
Directors, Superintendents, and the official file, it is unclear

- 19 

if the administration routinely conducts any additional review of
these reports.
Moreover, while in most cases there are both Incident
Reports and Use of Force Reports, the reports generally do not
indicate the nature or extent of an inmate’s injuries, arguably
the most telling indication that there may have been an
inappropriate use of force. The reports usually conclude with an
inmate being taken for “medical attention,” but with no
indication of why medical attention was required. The reports
also fail to capture the time the inmate received medical
attention, which makes it difficult to assess whether medical
attention was promptly provided. In the May 2006 case of Jacob
D., there is no indication of any injury in the CCJ reports, but
when Jacob was transferred the next day to the Illinois
Department of Corrections (“IDOC”), his facial bruising and
swelling was so severe that the IDOC contacted CCJ immediately to
report the physical condition of the incoming prisoner. In the
case of John S., there is also no indication of injury in the CCJ
reports about a March 2006 incident. The reports simply state
that John was taken for medical attention and released from the
dispensary, with no mention of any injuries. In fact, as photos
taken later show, John suffered two black eyes and a swollen lip,
among other injuries. In both of these cases, CCJ eventually
found excessive use of force by the officers, but the reports
themselves were devoid of helpful information.9
Because the information contained in Use of Force and
Incident Reports is insufficient for management to determine
whether the incident raises suspicions concerning use of force,
review by management, when it occurs, usually does not result in
identifying cases for investigation. There can be no effective
oversight if necessary information is not put forth when the
incident happens. For example, a report indicating that an
inmate sustained a black eye after an inmate-officer altercation
should raise concern, but management will never know about the
black eye under the current system.
In addition to the lack of information contained in CCJ
reports, we discovered that the Incident Reports did not contain
a tracking number or source of issuance until a July 2007
initiative by the Executive Director. This initiative is
consistent with generally accepted correctional practice.
Previously, it was extremely cumbersome to track any one incident

9

In both of these cases, investigations were initiated
as a result of external complaints.

- 20 

(for use of force and other serious incidents) and, in all
likelihood, impossible to ascertain if all incidents were being
reported and processed. Incident tracking numbers are now to be
issued by External Operations staff. Serious incidents and uses
of force should also be tracked by each division with a uniform
logging system for recording serious incidents at all levels of
CCJ.
Finally, CCJ has no tracking or early warning system to
identify those officers who are the most frequent users of
physical force and those whose actions have elicited the most
complaints of excessive force, grievances, or injuries. An
appropriate early warning system is an accountability tool that
allows for early intervention by alerting a facility to a need
for retraining, problematic policies, supervision lapses, or
possible bad actors. In 2004, CCJ hired an external consulting
firm to review its policies and procedures regarding the use of
force after a special grand jury concluded that a 1999 incident,
in which correctional officers beat and terrorized 49 inmates at
CCJ, constituted “gross, if not criminal, misconduct.” The
consulting report recommended that CCJ institute an early warning
system “as soon as possible.” The 2004 recommendation was never
implemented.
ii.

Investigations

To ensure reasonably safe conditions for inmates,
correctional facilities must develop and maintain adequate
systems to investigate staff misconduct, including alleged
physical abuse by staff. Beyond management review, the avenue
for oversight at CCJ is the Internal Affairs Division (“IAD”).
Generally accepted correctional practices require clear and
comprehensive policies and practices governing the investigation
of staff use of force and misconduct. Adequate policies and
practices include, at a minimum, screening of all Use of Force
and Incident Reports, specific criteria for initiating
investigations based upon the report screening, specific criteria
for initiating investigations based upon allegations from any
source, timelines for the completion of internal investigations,
and an organized structure and format for recording and
maintaining information in the investigatory file. The
investigation must also be and appear to be unbiased. CCJ’s
investigatory practice fails on multiple levels.
To be effective, investigations must be undertaken promptly.
A jail, by its nature, has a tremendously high turnover of
inmates. An inmate whose incident is being investigated may well
have left CCJ if the investigation does not occur soon after the

- 21 

incident, and the same is true for inmate witnesses. Because CCJ
does not initiate many use of force investigations, most use of
force investigations are not opened until long after an incident
has taken place. Instead, investigations are undertaken because
the inmate has filed a lawsuit, which can be up to two years
after an incident occurs. For example, the investigation of
Michael A.’s January 2006 beating did not begin until 16 months
after the incident, despite the fact that Michael was treated at
an outside hospital, suffered a fractured nose, and had,
according to the medical records, “raccoon eyes.” The
investigation of the incident in which Byron S. suffered a broken
jaw did not start until Byron filed suit seven months later, even
though Byron’s visible injuries required him to eat through a
straw with his jaw wired shut. Because of the delay, inmate
witnesses to the occurrence will likely have left CCJ by the time
an investigation begins. IAD’s only attempt to reach an inmate
witness who has left CCJ is a form letter to a last known
address, which rarely elicits any response. We found that many
investigations are simply undertaken far too late to be
effective.
Perhaps even more troubling is the fact that investigations
are reactive and suffer from the appearance of bias. The vast
majority of IAD files we reviewed stated that the investigation
of use of force was opened at the request of CCJ’s attorney in
response to an inmate lawsuit CCJ is defending in court. It is
almost impossible for IAD to appear fair and unbiased when the
investigation is undertaken only because CCJ is defending an
inmate lawsuit. All uses of force should be appropriately
reviewed through the chain of command. Whenever Incident
Reports, Use of Force Reports or other information raise the
possibility that excessive force was used, such incidents should
be thoroughly investigated by IAD. In particular, incidents
involving suspicious inmate injuries, such as black eyes or blunt
head trauma, and incidents requiring medical care at an outside
hospital should be investigated by IAD. An appropriate
evaluation of incidents for investigation will require more
detailed Use of Force and Incident Reports and a more thorough
management review than CCJ’s current practice.
IAD also reported a backlog in resolving use of force cases
and incidents involving inmate-on-inmate assaults because it is
difficult to obtain medical releases from Cermak, CCJ’s on-site
health care provider, in a timely manner.10 Obtaining medical

10

IAD is under the Sheriff’s Office while Cermak is part
of the Cook County Bureau of Health.

- 22 

records from Cermak can take anywhere from six to 12 months,
which prevents IAD from bringing prompt closure to an
investigation. This type of delay is totally unacceptable, and
is devastating for any investigation.
We also found that there are attempts by officers or other
staff to conceal the inappropriate or excessive use of force.
CCJ officials found that the officer involved in the January 2006
beating of Jerry M. had attempted to persuade a sergeant on the
tier to change his story as to what had happened. In another
case, Russell G. reported that the officer who caused his
injuries in June 2007 threatened him with worse treatment unless
he told the medical staff that he had hurt himself by falling out
of his bunk. We found two accounts of senior division staff
attempting to dissuade inmates from complaining about the use of
force, in one case by the offer of a favor and in the other by
the threat of criminal charges. CCJ’s administration and IAD
must take action to ensure that inmates are not intimidated into
concealing excessive use of force and that information received
is accurate and credible.
Finally, we also found flawed investigatory techniques at
CCJ. For example, investigators often do not give sufficient
attention to the inmate injuries that are known. When
investigators question officers accused of using excessive force,
the officers are generally not even questioned as to how an
inmate’s particular injury might have occurred. For example, IAD
opened an investigation of the March 2006 case of Antonio R.
after a doctor at an outside hospital reported that Antonio was
in serious condition with “blunt trauma all over his body.”
Although the investigator was aware of Antonio’s injuries at the
time he questioned both of the officers involved, he never asked
the officers about the nature of Antonio’s injuries or how they
occurred. While there may sometimes be tactical reasons to avoid
discussing inmate injuries when an officer is first questioned,
the investigation is incomplete if the officers are never asked
to address the inmate’s resulting injuries.
We found other examples of investigatory techniques that are
unlikely to result in complete or credible information. For
example, on March 9, 2006, an investigator interviewed inmate
Gabriel M. about a use of force incident involving another inmate
in his tier. The investigator then attempted to interview
Gabriel’s cellmate about the same incident but, since the
cellmate could not speak English, the investigator utilized
Gabriel as the Spanish interpreter to provide his cellmate’s
statement. Relying on one inmate to translate for another inmate
in an investigation involving both of them is a poor

- 23 

investigatory technique that calls into question the credibility
of the information gathered by CCJ investigators.11
iii. Videocameras and Overhead Cameras
When properly utilized, cameras in a correctional setting
can augment inmate safety and security and provide essential
information for investigations. Certainly video surveillance
should never be used to substitute for direct officer supervision
of inmates, but it often is helpful to supplement supervision and
for incident reconstruction. CCJ has limited and antiquated live
feed overhead cameras in some divisions, but the cameras do not
have the critical capability to record and replay, and most do
not capture activities outside of the housing unit dayrooms.
Moreover, while there are two small monitors in the RCDC intake
area, we discovered that the officers in the Security Office were
unaware that the monitors could view various parts of the intake
area. The cameras, installed to monitor activity in a part of
CCJ that had experienced among the highest number of allegations
of excessive and inappropriate uses of force, were not being
used.
Procedures at CCJ require that a handheld videocamera be
brought to the scene of any use of force and that the use of
force be recorded. While this policy is helpful for review of
cell extractions and other planned uses of force, it is not
surprising that the use of handheld videocameras has not been an
effective means of oversight for unplanned uses of force. None
of the numerous videotapes we reviewed captured an unplanned use
of force in progress. Improvements and additions to CCJ’s video
surveillance system, including the ability to record for
retrieval following an incident, would be a much more effective
oversight mechanism.
2.

Deficient Inmate Safety and Supervision

CCJ does not provide adequate inmate supervision, which
exposes inmates and staff to unsafe conditions. Lack of adequate
11

Title VI of the Civil Rights Acts requires that
recipients of federal funds take reasonable steps to provide
meaningful access to limited English proficient communities.
Given Cook County’s growing Hispanic population, CCJ should
ensure that some investigators and correctional officers are
familiar with rudimentary Spanish. In addition, CCJ staff would
benefit from receiving diversity training. See Title VI of the
Civil Rights Act of 1964, 42 U.S.C. § 2000d et seq.

- 24 

security staff, insufficient direct supervision in the majority
of the housing units, a dilapidated physical plant, inadequate
policies and procedures, and an overcrowded environment combine
to result in an unsecure facility that is dangerous for everyone
on the premises. On April 9, 2007, the John Howard Association
found that the rates of injuries to CCJ inmates and staff have
increased significantly in the past decade, despite a substantial
decrease in inmate population.12 In 2006, inmate injuries
occurred at the highest rate since the John Howard Association
began gathering data, and staff injuries reached the third
highest rate since 1991.13 Our review of CCJ documents revealed
that between January 1, 2007 and June 19, 2007, IAD opened
approximately 254 cases involving inmate assault and/or battery
and five cases of sexual assault. In 2006, IAD opened
approximately 357 cases involving inmate assault, battery, or
sexual assault.
Insufficient inmate supervision has been a serious problem
at CCJ for decades. Inmate supervision is seriously compromised
by chronic overcrowding and under-staffing. The federal district
court monitoring the Duran Consent Decree has repeatedly cited
CCJ for failing to provide adequate security staff to ensure safe
and secure conditions at the facility.14 In September 2006,
then-Sheriff Michael Sheahan admitted that the Jail is “severely
understaffed.”15 The John Howard Association’s April 9, 2007
report found that CCJ would require an additional 189 new
correctional officers and suitable replacements for the 130 to

12

Court Monitoring Report, Duran v. Dart, No. 74-C-2949,
at 115-16 (N.D. Ill. Apr. 9, 2007) (“2007 Court Monitoring
Report”). Monthly averages for staff injuries have risen from
6.6 in 1996 to 28.3 staff injuries per month in 2006.
13

Id. at 116. Monthly averages for inmate injuries
increased from 14.7 injuries per 1000 inmates in 1996 to 27.8
injuries per 1000 inmates1 in 2006.
14

Leonard N. Fleming, “Federal Judge Warns County to Fix
Overcrowding at the Jail,” Chicago Sun Times, Dec. 1, 2007;
Jonathan Lipman, “Judge Blasts Staffing at Jail,” Daily
Southtown, Dec. 29, 2005.
15

Joint Status Report, Duran v. Dart, No. 74-C-2949, at 8
(N.D. Ill. Sept. 29, 2006).

- 25 

152 correctional officers on inactive status16 to comply with the
Duran Consent Decree and “good correctional practices.”17 CCJ’s
Post Analysis Reports and Divisional Staffing Reports for April
through June 2007 revealed that at least 172 correctional officer
positions at CCJ were vacant or inactive. Although the External
Operations Unit, which is responsible for the security of the CCJ
perimeters, the Emergency Response Team, the Canine Unit, and the
transportation of 800 to 1500 inmates to and from court daily,
has an authorized security staffing complement of 420 positions,
on May 1, 2007, the actual External Operations manpower
availability comprised 352 positions. Our expert consultant
found that the level of correctional staff available to supervise
housing units at CCJ is woefully inadequate.
The lack of adequate staff is magnified by the fact that CCJ
is chronically overcrowded. In fact, every day from June 2006
through April 2007, numerous inmates were required to sleep on
the floor of two-person cells that housed three inmates.18
Divisional reports for the period of February 26, 2007 through
June 17, 2007 reflect that an average of 485 inmates were forced
to sleep on the floor each night. During our site visit on July
23, 2007, Division VI held 1268 inmates in space with a rated
capacity of 992 inmates.19 Dormitory Four in Division II is
operating at twice its design capacity.20 However, we did not
observe any increase in security staffing levels or enhanced
supervision practices within the overcrowded divisions.
Overcrowding has an impact on security at CCJ. For example,
the week of March 19, 2007, CCJ had more inmates sleeping on the
floor (591) than any other week in the four-month period of March
through June 2007. During that week, CCJ also had the most
fights (35), the most uses of force (27), and found the third
most “shanks” (homemade knives) (34) and second most weapons

16

Correctional officers on “inactive status” include
persons on disability, suspension, leave of absence, military
leave, or leave for a duty injury.
17

2007 Court Monitoring Report at 84.

18

Id. at 12.

19

The actual capacity of Division VI was much lower than
992 on July 23, 2007, due to numerous cell closures because of
maintenance problems, which further exacerbated the overcrowding.
20

2007 Court Monitoring Report at 15.

- 26 

(12), of any other week during the same period.21 On November
30, 2007, Judge Virginia Kendall for the United States District
Court for the Northern District of Illinois apparently chastised
the County and Sheriff’s Office for failing to ease overcrowding
at CCJ, stating: “This is no longer a budget problem. It is a
constitutional violation.”22 Despite the fact that CCJ has been
subject to the Duran Consent Decree for 25 years, the County and
the Sheriff’s Office have been unable to solve the problems of
overcrowding and inadequate supervision at CCJ.
CCJ has taken some unusual steps to try to deal with the
problems of overcrowding and inadequate staffing. The practice
of cross watching, discussed below, is an unacceptable and
dangerous approach. A recently instituted policy of extended
lockdowns is similarly unacceptable. In the spring of 2007, CCJ
implemented extended lockdown periods for all general population
inmates. Under this system, only half of the inmates in each
housing tier were allowed out of their cells during each shift.
Generally, this meant that half of the inmates were allowed out
of their cells for a period in the morning, half of the inmates
were allowed out of their cells for a period in the afternoon and
evening, and all of the inmates were locked in their cells during
the night. Because the groups of inmates rotated on a shift by
shift basis, the result was that every other day each group of
inmates spent a continuous 26-hour period locked inside the
cells. This practice was applied indiscriminately to all general
population inmates, except those housed on the medical units. As
discussed in further detail below, in addition to constituting an
unjust restriction on pre-trial detainees, the extended lockdown
practice interfered with medical and mental health care,
programs, and the grievance system. Moreover, deficient
maintenance in many cells (no lighting, plumbing failures, etc.)
resulted in inhumane conditions for an extended lockdown.
Therefore, as a result of CCJ’s inadequate supervision, inmates
are subjected to unjustified, prolonged periods of in-cell
confinement. Following our July 2007 visit, the Sheriff’s Office
informed us that CCJ had revised the lockdown policy to decrease
the length of the in-cell periods. This would be an improvement

21

Weekly averages for March through June 2007 were:
fights, 17 uses of force, 23.5 shanks, and 6.6 weapons.
22

23.5

Staff Writer, “Judge Orders Cook County to Fix Jail
Overcrowding,” PR Newswire Europe, Nov. 30. 2007; Leonard N.
Fleming, “Federal Judge Warns County to Fix Overcrowding at the
Jail,” Chicago Sun Times, Dec. 1, 2007; Notification of Docket
Entry, Duran v. Dart, No. 74-C-2949 (N.D. Ill. Nov. 30, 2007).

- 27 

and a welcome change, and we look forward to assessing the new
lockdown system.23
As discussed below, the result of CCJ’s inadequate inmate
supervision is that inmates and staff are exposed to unsafe
conditions, an increased risk of violence and an abundance of
dangerous and illegal contraband.
a.

Assaults on Inmates and Staff

The severity and frequency of inmate-on-inmate assaults
demonstrate that CCJ is not providing for the safety and
well-being of the inmates. In a period of less than two months
in the spring of 2006, inmates reportedly engaged in at least
seven separate knife fights that resulted in serious injuries to
at least 33 inmates and seven correctional officers, including
one inmate death.24
Weekly Divisional Reports from February 26, 2007 through
June 17, 2007 show an average of 23.5 inmate fights and 3
incidents of “battery to staff with injury” per week at CCJ.
Many of these incidents occurred in CCJ’s maximum security
divisions, where inmates should be supervised at the highest
level, and extra precautions should be taken to minimize access
to, and creation of, shanks and other weapons. Clearly CCJ
cannot be expected to prevent all altercations between inmates.
Nevertheless, the Constitution requires correctional officers and
Cook County officials to take “reasonable steps to protect

23

CCJ’s latest attempt to deal with overcrowding involves
a “hot bunking” pilot program whereby inmates volunteer to take
turns using the same bed in eight-hour shifts. See Sheriff’s
Supplemental Report, Duran v. Dart, No. 74-C-2949, at 2 (N.D.
Ill. Jan. 15, 2008). Although each inmate is reportedly using
his or her own bedding, the hot bunking procedure could result in
serious sanitation and infection control problems, as well as
possible inmate-to-inmate intimidation regarding potential
volunteers.
24

See e.g., William Lee, “Two Cook County Jail Inmates
Were Stabbed During a Fracas in a Maximum-security Division
Monday Night,” Daily Southtown, May 2, 2006; Lori Rackl, “2
Inmates in Hospital After Jail Brawl,” Chicago-Sun Times, Apr.
24, 2006; William Lee, “Seven Inmates at Division 11 are Injured
by Homemade Knives in a Gang-Related Fight,” Daily Southtown,
Apr. 24, 2006; Staff Writer, “Knife Fights in Cook County Jail
Injure 17,” Chicago Tribune, Mar. 13, 2006.

- 28 

inmates from violence at the hands of other inmates.” Goka v.
Bobbitt, 862 F.2d 646, 649-50 (7th Cir. 1988). The level of
inmate-on-inmate and inmate-on-staff violence that is occurring
within CCJ is so unacceptably high that it is clear that inmates
are not adequately supervised, in accordance with generally
accepted correctional standards. Notably, just as the Court and
CCJ staff have recognized the shortage of staff supervision,
inmates are also aware that they could engage in violence with
little to no supervision. Much of the violence at CCJ involves
group attacks, which reflect some degree of planning and
coordination by the inmates, without the staff’s knowledge or
intervention.
As the following examples demonstrate, CCJ is not meeting
its constitutional obligations to provide for the safety and
well-being of its inmates:
1.	

On December 29, 2007, multiple inmates suffered stab
wounds during a fight in a Division IX dayroom. Six
inmates required treatment from outside hospitals and
two inmates were admitted to the hospital with multiple
stab wounds and other serious injuries. Officers were
required to use Oleoresin Capsicum spray (“OC spray”)
to break up the fight. CCJ recovered four shanks, some
of which measured six inches in length, and another
weapon in the tier. Despite the severity of this
incident, IAD did not open an investigation file.

2.	

On June 26, 2007, an officer delivering breakfast trays
found inmate Louis J. unconscious on the floor of his
cell in Division IX. Louis J. was admitted to the
hospital for trauma and died on July 8, 2007, as a
result of his injuries. Hospital records showed a
hematoma with fractures and wounds to the face and
head. Although the Incident Report related to this
incident states that Louis J. may have suffered a
seizure, Louis J.’s cellmate was promptly transferred
to CCJ’s highest level of disciplinary segregation, the
Level IV Special Incarceration Unit in Division IX.
However, CCJ could not produce a disciplinary citation,
hearing record, or investigation documentation on the
incident.25 Louis J.’s cellmate was still in the

25

We requested all documentation related to this incident
on multiple occasions. We never received any disciplinary or
investigation records. CCJ did not complete a mortality review
for Louis J., allegedly because he was no longer in custody at

- 29
Special Incarceration Unit a month after the incident,
during our July 2007 site visit.
3.	

On June 26, 2007, officers noticed that several inmates
from Tier 4B were running as they returned from the
Division X gymnasium. Officers found several inmates
with stab wounds and other injuries in the corner of
the gymnasium. One inmate was hospitalized with a stab
wound to the neck and another inmate had a broken jaw.
The fight was apparently the result of different gang
affiliations mixed within the tier. Upon
investigating, officers recovered three shanks. CCJ
placed the entire 48-inmate tier on extended lockdown
from June 26 through July 8, 2007, wherein each inmate
was allowed out of his cell for only one hour per day,
and only one inmate was allowed out at a time. No
other obvious precautions were taken to address the
gang problem on the tier. When the lockdown ended on
July 8, another fight broke out involving some of the
same inmates and the same gangs as the June 26
incident. One inmate was stabbed and officers
recovered another shank.

4.	

On June 20, 2007, inmates Auben J. and Sam D. suffered
injuries to their heads and faces following a fight in
the outdoor area of Tier A-H in Division IX. Because
no officers witnessed or responded to stop the fight,
it was eventually broken up by another inmate, Roger R.
Officers only learned of the fight after observing
Auben J. bleeding from the head when he returned from
exercise. Because Roger R. admitted that he helped
separate the fighting inmates and injured Auben J. in
doing so, he was transferred to disciplinary
segregation along with Auben J. and Sam D.

5.	

On May 10, 2007, seven inmates were treated for stab
wounds after a gang-related fight involving
approximately 25 inmates in the Division IX, Tier 3C,
dayroom. Inmates Mark V., Alex W., and Arthur A. had
to be transferred to outside hospitals for medical
treatment. CCJ staff found a shank in the dayroom.

6.	

On December 5, 2006, 31-year-old Marcus K. was found
dead in his cell. His cellmate was charged with
first-degree murder for allegedly strangling Marcus K.

the time of his death.

- 30
after the two were heard arguing. The two men were
locked in their cell at the time, and other inmates in
the common area alerted a correctional officer that an
inmate needed help during the altercation.
7.	

On April 22, 2006, inmate Izzy J. suffered a fatal stab
wound to the head during a gang-related fight involving
approximately 20 inmates in Division XI. Six other
inmates were hospitalized after the brawl; five of the
inmates were stabbed with shanks.

8.	

On April 2, 2006, inmates Tyson D. and Freddy R. were
seriously injured during a gang-related fight involving
at least six other inmates in Division XI. Both Tyson
D. and Freddy R. were admitted to the hospital with
multiple stab wounds to the back.

In addition to the inmate-on-inmate violence, CCJ’s security
failings put staff in danger as well:
1.	

On March 22, 2007, maximum security inmate Reed W.
stabbed a correctional officer, a nurse, a hospital
patient, and a bus driver during an unsuccessful escape
attempt at Stroger Hospital, where he had been taken
for a doctor’s appointment. CCJ officials reported
that Reed W. may have smuggled a shank out of CCJ
Division IX in his rectum.

2.	

On August 16, 2006, correctional officer Ben W. was
hospitalized for five days and required 30 stitches
after being attacked by inmate Daniel M. in Division V.
The inmate was able to run from the scene before any
other officers could come to Officer W.’s aid.

3.	

On April 15, 2006, six officers received medical
treatment, and at least four inmates were hospitalized
for stab wounds, after a multiple-inmate fight broke
out in a Division XI dayroom. Officers recovered
several wooden sticks and at least one metal shank
following the fight.
b.	

Inadequate Security Staffing

As a result of insufficient security staffing, CCJ is not
providing adequate supervision of the inmate housing areas. As
discussed above, a major concern surrounding inmate supervision
is the practice of “cross watching.” Cross watching refers to
the practice of having one correctional officer simultaneously

- 31 

supervise two tiers of cells as opposed to one.26 The
correctional officer monitors the second tier on camera while
stationed in the first tier’s control center. By policy, the
officer supervising a housing unit is supposed to conduct
security rounds inside the unit every 30 minutes, which allows
him to check on inmates in their cells and in the shower and
bathroom areas. These areas are not visible on the security
monitors or from the officer’s standard post inside unit’s
control center. However, if or when the officer conducts a
security check inside the first housing unit, the second housing
unit is unsupervised. If the officer leaves the control center
of the first housing unit to conduct a check of the second
housing unit, the inmates in the first housing unit can see that
there is no officer supervising their actions.27 Although we
recognize that CCJ has made efforts to increase staffing levels
in housing units and decrease cross watching, we observed
numerous instances of cross watching during our June and July
2007 visits to CCJ. The practice is highly utilized during lunch
periods, but we also observed cross watching throughout the day.
As noted earlier, because inmates are aware when there is
not an officer in the housing unit, there is a higher risk for
illicit inmate behavior, including inmate assaults, production of
weapons, and gang and drug activity. For example:
1.	

On May 15, 2007, an officer was cross watching two
tiers in Division IX, a maximum security division.
Inmate Carson T. was assaulted by five or six inmates
in the tier dayroom. He received multiple wounds to
his shoulders, back, face, and was admitted to the
hospital. The cross watching officer did not notice
anything amiss until he saw inmate Carson T. pacing by
the tier door. CCJ documents noted that Carson T. had
“injuries resulting from being attacked with a homemade
knife” and that a “small piece of metal was sticking
out [his] back.” During the subsequent investigation,
security staff found two shanks in the tier. No
officer observed the dayroom assault.

26

Cross watching is prohibited by the Duran Consent
Decree and the John Howard Association has cited CCJ for the
practice, but it continues to occur. See 2007 Court Monitoring
Report at 86.
27

The number of inmates per housing unit varies across
divisions, but it is not unusual for one cross watching officer
to be responsible for more than 90 inmates in two units.

- 32 

2.	

On May 10, 2007, also in Division IX, an officer was
cross watching two tiers when a disturbance involving
25 inmates occurred. Seven inmates received injuries
including multiple lacerations and puncture wounds.

3.	

On December 24, 2006, the assigned officer was cross
watching two tiers in Division VI when inmate George W.
assaulted inmate Otis F., causing a head injury.

4.	

On July 25, 2006, inmate Andrew K. committed suicide in
Division I while the assigned officer was cross
watching two tiers. The Medical Examiner reported that
inmates discovered Andrew hanging by the cell bars,
alerted officers, untied his noose, and initiated chest
compressions before staff intervened. Although staff
reported that sight checks occurred in the tiers on a
frequent basis, it is not clear if the officer actually
saw Andrew in his cell at the times reported.
Inexplicably, the CCJ investigation of the incident did
not include the results of interviews of the other
inmates who were present in the tier at the time of
Andrew’s death.

5.	

On March 19, 2006, inmate John M. was attacked by two
other inmates in Tier D-B of Division XI, which at the
time was a maximum security division. Because the
officer assigned to Tier D-B was at lunch, and the two
closest officers were cross watching Tiers D-B and D-C
and Tiers D-A and D-D, the officers had to wait for
back-up to arrive before anyone could enter Tier D-B to
break up the fight. John M. suffered two puncture
wounds to his neck and one puncture wound under his
arm. After the fight, officers recovered two steel
shanks, a broken cane, and three razors from the tier.
c.	

Contraband and Vandalism

Another indicator of inadequate supervision is the amount of
dangerous contraband that is being recovered from the housing
units and the ease by which inmates can fabricate homemade
weapons. Due to the dilapidated condition of scores of cells,
shower areas, and various dayroom features, inmates have ample
material for fabricating weapons, including floor tiles, metal
from light fixtures, metal from the ventilation system, glass
from cell light bulbs, electrical wiring, and plumbing fixtures.
It is virtually impossible for any correctional facility to
completely deter inmates from obtaining materials for weapons due
to the condition of the physical plant, but the problem at CCJ is

- 33 

further exacerbated by the lack of direct supervision in most of
the divisions.
Even though the CCJ administration has recently made efforts
to curtail the creation of shanks and other weapons through the
establishment of a “Weapons Committee,” a severe contraband
problem still exists. For example, IAD’s Contraband Log reveals
that, between January 1, 2007 and June 19, 2007, security staff
found approximately 484 weapons and shanks. Many of these
weapons and shanks were found in inmate cells and dayrooms after
a stabbing incident. The Weekly Divisional Reports from February
26, 2007 through June 17, 2007 show an average of 23.5 shanks and
6.6 weapons found each week at CCJ. In just one week, April 2-8,
2007, CCJ staff recovered 55 shanks and 12 weapons. In 2006, IAD
opened approximately 590 cases involving shanks, 77 involving
weapons, and 115 cases involving other contraband. The number of
weapons and shanks is extremely high, even considering CCJ’s
large inmate population.
During our site visits, we noticed scores of opportunities
for inmates to fabricate shanks and other weapons. We found
broken and jagged floor tiles laying exposed in dayrooms without
raising the notice of staff. In some instances, inmates are
using the absence of ventilation grates in their cells to rig a
“dumbwaiter” system that allows them to transmit drinking water
between the housing unit’s upper and lower tiers from within
their locked cells. However, the inmates can also use these
passageways to pass contraband. Shower and bathroom walls in the
Residential Treatment Unit (“RTU”) that had been damaged by
inmate vandalism provided ample opportunity for weapons
production and concealment of contraband. We observed numerous
vandalized cell lighting fixtures and missing and vandalized cell
vents, which are commonly used to create shanks. Inmates’ access
to the lighting fixtures can lead to additional dangers. For
example, on June 14, 2007, an inmate attempted suicide by cutting
himself with a broken light bulb.
In addition to the troubling, unchecked proliferation of
weapons at CCJ, it is clear that there is a serious narcotics
problem. Between January 1, 2007 and June 19, 2007, IAD opened
approximately 110 cases related to narcotics/drugs. In 2006, IAD
opened approximately 160 cases involving narcotics/drugs.
The lack of adequate supervision at CCJ is further
highlighted by the frequent and flagrant rule violations that are
evident in almost every tier throughout the facility, including
special management units that should have a higher degree of
supervision. For example:

- 34 

1.	

Scores of cells have been vandalized and are rife with
gang and general graffiti.

2.	

Scores of cells contain homemade clothes lines. The
hanging linens prevent adequate visibility into the
cell. Also, the clothes lines can be used by inmates
as potential weapons or suicide implements.

3.	

Small in-cell fires are common. Many inmates use the
cell lighting fixtures as an ignition source for
warming food and starting fires. Numerous inmates
covered the cell light bulb with a milk carton that
serves as a lamp shade and an ignition source. In
scores of cells, the bottom bunk has evidence of having
been heated. Inmates and staff reported that inmates
use the bottom bunks as hot plates for warming food by
setting a fire underneath them.

4.	

Scores of cells contain dozens of empty milk cartons
and other stored debris that can be used by inmates for
improper purposes and provide a potential fuel load in
case of a fire.

5.	

Numerous shower areas have been vandalized, resulting
in exposed ceilings and materials that can and are used
to fabricate weapons.

6.	

Numerous inmates use extra blankets as carpets or room
dividers for their cell, while other inmates claim a
shortage of blankets.

7.	

Scores of cells, shower areas, bathrooms, and dayrooms
have exposed electrical wiring.

8.	

Scores of vents, window sills, stairwells, and screens
throughout the tiers are plugged and covered with
debris.

9.	

As discussed below, many in-use cells are so unsanitary
or have such severe maintenance problems that it is
clear that adequate security checks are not occurring.

It is common for inmates to try to engage in vandalism or
rule infractions, and CCJ could not be expected to prevent all
such inmate activities. However, it is not generally accepted
correctional practice to allow these violations to occur so
flagrantly and with such prevalence throughout the facility.

- 35 

The sheer frequency of these issues demonstrates that inadequate
supervision is common at CCJ.
d.

Inadequate Visibility

Inmate supervision is further hampered by CCJ’s physical
layout, which does not allow for direct supervision in most
divisions. With the exception of the Division II and RTU
dormitory units, correctional officers are not stationed inside
the housing units. In most divisions, the housing units are
supervised by an officer from a tier control center or security
entrance post that only allows for observation of the dayroom and
some common areas of the housing unit. This is the case even in
the special management units, such as disciplinary segregation
and protective custody, which is a grossly atypical corrections
practice. The officer cannot see into the individual cells while
in the control center and is therefore required to conduct
frequent physical checks of inmates in their cells. However,
security check documentation at CCJ is spotty. For example,
during our on-site visits we discovered pre-recorded security
checks on housing unit logs and also security checks that were
suspiciously logged at precise intervals throughout a shift
without any deviation. In addition, numerous inmates throughout
the facility reported that officers commonly only enter the
housing unit during shift change or meal times, but not on
regular rounds throughout the day. This is not surprising, as a
single officer may be cross watching two housing units
simultaneously from one control center.
Even if security rounds within the housing units are
occurring as scheduled, lack of visibility into cells is a major
safety concern. Scores of cells are dark due to inoperable
lighting fixtures, missing light bulbs, or inmate vandalism of
lighting fixtures. We also observed the results of rampant
vandalism of the lighting system in the RTU dormitory units,
despite the fact that an officer is purportedly posted inside
each RTU dormitory at all times. In fact, one RTU dormitory had
no working lights and another had only two or three working
lights, out of 24 light fixtures. Lack of operable lights makes
the entire unit dangerous both for inmates and officers. This
problem is compounded by the fact that correctional officers
cannot replace broken or burned out light bulbs, but must issue a
work order and wait for Facilities Management to handle the
request. In addition, we observed many cells and shower areas
with “privacy curtains” and with the celldoor windows obscured by
cardboard, paper, towels, and other materials. It is very
difficult, if not impossible, for officers to provide adequate
safety and security checks of inmates when they cannot see into

- 36 

the cells and shower areas. Compounding the lack of adequate
inmate supervision within the housing units is the fact that
cells are not equipped with intercoms or emergency call buttons,
which are useful safety and security features designed to allow
for a locked inmate to alert an officer in an emergency
situation. Intercoms or emergency call buttons are especially
important for special management units, where the inmates spend
approximately 23 hours of the day locked inside their cells,
often alone.
Of particular concern for inmate and officer safety is the
lack of visibility in the Special Incarceration Unit of Division
IX. As these cells house CCJ’s highest risk offenders and
inmates with demonstrated behavior problems, the celldoor windows
have been modified to prevent inmates from throwing liquids or
objects at officers. However, instead of installing a protective
covering that would allow for observation, such as safety glass,
CCJ welded a metal plate with small holes in it on to the cell
windows in the Division IX Level 4 tier. As a result, it is
virtually impossible to see into the cell, especially at night.
In addition to inadequate interior security visibility,
during a night time tour of CCJ, we observed approximately 22
external post and building lights that were not functioning in
the area between Division I and Division V. This is unacceptable
and a significant security risk.
e.

Inadequate Security Policies and Procedures

At CCJ, each separate division has Standard Operating
Procedures (“SOPs”) that cover all the necessary components for a
security program, such as key control, cell locking procedures,
incident reporting, and search procedures. During our review, we
found that while some CCJ policies and procedures were up to
date, many were not. Generally accepted correctional practices
require that post orders should be reviewed on a quarterly basis.
CCJ policy requires that post orders be reviewed annually. We
reviewed the post orders available at various security posts
throughout CCJ and found many post orders that had not been
reviewed in multiple years. For example, in Division XI, we
inspected a manned gun tower. The post order for the tower was
dated January 1996 and was last revised on January 15, 2003. In
addition to being outdated, the post order did not contain
essential information for an armed post, including instruction on
when and under what circumstances the weapon should be used.
CCJ is also lacking in proper policies regarding inventory of
security equipment, including the newly introduced OC spray,
which could allow for unaccounted misuse by correctional

- 37 

officers. When post orders are not updated regularly and do not
address vital information, facility practices will develop in an
ad hoc nature and will not account for current needs. Outdated
policies, procedures, and post orders are inconsistent with
generally accepted correctional standards and contribute to a
failure of the overall security system.
Although CCJ policies must adapt to some extent to account
for the different security levels and different physical layouts
in the various divisions, there is widespread policy variation
from division to division on issues ranging from the handling of
grievances to incident reporting. This can be confusing for
correctional officers, who rotate posts every 90 days and may be
transferred from one division to another without adequate
training on division-specific SOPs. Policy discrepancies abound
division to division, which result in widely different security
practices. There is no standardized format in use throughout CCJ
for division Roster Staffing Reports and Post Analysis Reports.
Even CCJ’s top level administration is unclear how security
procedures are implemented throughout the facility. For example,
a high level security official told us that each and every inmate
should be patted down when he or she returns from the recreation
yard. However, Division I supervisors reported that inmates are
only subjected to pat downs at random upon their return from the
yard.
An additional area of policy concern is with regard to
special management units, which include the Special Incarceration
Units, disciplinary segregation, and protective custody units.
Generally accepted correctional practices require that officers
who are assigned to these types of units possess a higher level
of detention experience, receive focused training in special
management operations, and are regularly assigned to these units
for stability purposes. Correctional officers in CCJ’s special
management units rotate on a regular basis and do not receive
specialized training for working with high risk inmates. This
practice should be changed at the policy level.
f.

Disciplinary Process

CCJ operates the inmate discipline component with a policy
and procedure that appears to be adequate and provides sufficient
due process to inmates. However, we did note some concerns with
regard to the disciplinary process. First, hearings are not
consistently conducted in a private, confidential manner and
secure setting in accordance with generally accepted correctional
standards. During our observation of the disciplinary hearings
in Division II, 12 inmates were brought into a large room and

- 38 

seated together for their individual disciplinary hearings,
including inmates whose disciplinary charges involved incidents
of violence against each other. The proceedings were conducted
within hearing of the other inmates. This process certainly
presents safety and security issues because there may still be
animosity between inmates who were involved in an altercation.
For example, on July 26, 2007, two inmates began fighting during
a disciplinary hearing in the Division VI library, and required
medical care. Also, the victim may be reluctant to be truthful
during the hearing for fear of retaliation by the aggressor. In
addition, we noted that the statements made by the inmates during
the hearing are written down by the disciplinary board in a very
abbreviated fashion that may not adequately represent the
inmates’ statements.
3.

Deficient Classification Procedures

All inmates admitted or discharged from CCJ are processed in
the RCDC. The RCDC is located in the basement of Division V, and
was originally designed as a storage area. Instead of storage,
it holds several hundred inmates as they are strip searched,
processed through booking, fingerprinted, photographed, screened
for medical and mental health problems, and assigned to a bullpen
until they can be transferred to their appropriate divisions.
Almost every evening, the RCDC bullpens hold hundreds of inmates,
for several hours at a time, who are crowded shoulder-to-shoulder
behind chain link fences so tightly that there is insufficient
space for them to sit or lie down. There is one female bathroom
and only one male bathroom, with two toilets, and no hand washing
facilities, for hundreds of male inmates to share.28 While the
RCDC overflows with hundreds of inmates, a surprisingly small
number of correctional officers attempt to perform a multitude of
duties, including the supervision of inmates. In addition to the
natural stress resulting from admission to jail, inmates upon
booking, who may have been held for multiple days in various
police departments before arriving at CCJ, can be medically and
mentally unstable. Newly admitted inmates are very
unpredictable. The overcrowded, disorganized, and understaffed
RCDC is a major security and safety risk to staff and inmates.

28

On January 14, 2008, the Sheriff’s Office sent us
photographs of recent renovations to the RCDC bathroom, including
six new sinks and five new urinals. This is a vast improvement,
but the single bathroom and limited toilets is still problematic,
given the immense number of inmates in the RCDC each evening.

- 39 

The John Howard Association found the RCDC “grossly
inadequate in size, design, and virtually every other respect.”29
We concur. The Sheriff’s Office and the County concede that the
RCDC physical plant is inadequate and we understand that funds
have been allocated for construction of a new RCDC and RTU, but
the new facility will not be completed until late 2009, at the
earliest.30
Classification problems do not end with the physical plant
of the RCDC. The Sheriff’s Office admits that the present
classification system is “extremely obsolete.”31 The system was
purchased in 1991 and last updated in 1993. It is an antiquated
inmate tracking system that is incapable of tracking basic
information, such as the number of empty beds in each CCJ
division at any time. The RCDC Superintendent is required to
make telephone calls on a constant basis to the other divisions
in order to ascertain the bed availability. Although the RCDC
Superintendent has access to e-mail, the superintendents of the
other divisions do not.
The classification system contains provisions for initial
custody assessment and for custody re-assessments. However,
although CCJ uses a Special Incarceration Unit “level system” to
manage high risk inmates and security threat groups, that
information is not contained within the classification policies
and procedures manual.
Perhaps more troubling than the obsolete nature of the CCJ
classification system is the fact that many supervisors do not
understand how to properly utilize the system. Midway through
our second site visit to CCJ, we learned that information on each
inmate’s classification status and history is readily available
from terminals in every division. However, many CCJ supervisors
and even division superintendents had previously reported to us
that they could not access such information on the system. The
superintendent who revealed the broader tracking capabilities to

29

2007 Court Monitoring Report at 67.

30

President Todd H. Stroger and the Cook County Board of
Commissioners’ Status Report, Duran v. Dart, No. 74-C-2949, at 8
(N.D. Ill. June 11, 2007).
31

Sheriff’s 2007 Status Report and Response to John
Howard Association Court Monitoring Report, Duran v. Dart, No.
74-C-2949, at 22 (N.D. Ill. June 11, 2007).

- 40 

us acknowledged that many CCJ supervisors are not proficient with
the CCJ system.
Given the high level of inmate assaults and gang-related
violence at CCJ, it is clear that inadequacies of the
classification system are contributing to CCJ’s security
deficiencies.
4.

Inmate Grievance Procedure

An inmate grievance system is a fundamental element of a
functional jail system, intended to provide a mechanism for
allowing inmates to raise conditions of confinement related
concerns and issues to the administration. If viewed as credible
by inmates, it can also serve as a source of intelligence to
staff regarding potential security breaches as well as staff
excessive force or other misconduct. The grievance system should
be readily accessible to all inmates. Inmates should be able to
file their grievances in a secure and confidential manner and
without the threat of reprisals. Staff responsible for answering
inmate grievances should do it in a responsive and prompt manner.
Unfortunately, we noted a number of serious concerns with the
inmate grievance process at CCJ.
The primary responsibility for coordinating and responding
to inmate grievances lies with the Correctional Rehabilitation
Workers (“CRWs”). Each of the approximately 40 CRWs, if evenly
distributed throughout CCJ, has a caseload of well in excess of
200 inmates, which is extremely ambitious. Although management
staff expect that the CRWs conduct at least two visits to each of
their assigned units per week to collect grievances and to
perform other duties, this is not occurring on a consistent
basis. Moreover, numerous inmates complained that they do not
have access to the CRWs (and consequently, the grievance process)
if they are locked in their cells when the CRWs conduct rounds,
which is a common occurrence.
At the divisional level and by divisional policy and
procedure, there are supposed to be locked grievance boxes in the
housing units for inmates to place their grievances in. The CRWs
are supposed to collect the grievances from the locked boxes each
weekday. However, the grievance system functions differently in
practice, and varies from division to division and even from tier
to tier. Although it is not reflected in the written policies,
the prevailing current practice is for the inmate to give the
completed grievance to the CRWs when they conduct rounds. Staff
reported that inmate grievances are to be inserted in
confidential envelopes and sealed by the inmate, which is also

- 41 

not written in the divisional policies. In some divisions, an
inmate can also give the completed grievance to a security
supervisor, who will record it in a log and give it to a CRW. In
other divisions, security staff refuse to handle any grievance,
to avoid conflicts and the appearance of impropriety. In yet
another version, inmate grievance forms are kept and passed out
only by the CRWs and completed forms are collected by the block
sergeant and brought to the CRWs’ office. Although most of the
divisions are not using the grievance boxes, many staff members,
including the Program Services Administrator, were under the
impression that inmates were using the boxes. There is an
extremely high level of confusion regarding the grievance policy
and practice at all levels of CCJ.
In addition, access to grievance forms by inmates is a
universal problem. Although many management staff believe that
the grievance forms are available on the tiers, this is simply
not the case. The vast majority of the units that we visited
during our June and July 2007 site visits did not have inmate
grievance forms or confidential envelopes available on the
housing units. Grievances forms are not available in Spanish
language, despite the fact that many CCJ inmates can only speak,
read, and understand the Spanish language.32
We also found that inmates believe the grievance process is
unreliable and repeatedly complained about its effectiveness,
with reason. For example, inmates stated that grievances related
to the use of force generally result in one of two inadequate
responses. Sometimes an investigator will speak to inmates after
they file use of force grievances, but the inmates stated that
they never heard back about their grievances. Most inmates
complained that they heared nothing at all in response to a use
of force grievance or received a summary denial. Inmate Byron S.
filed a grievance approximately one month after an officer broke
his jaw in January 2006. Thirteen days later he received a one
sentence response to his grievance stating that there would be no
IAD investigation because Byron had been found to have “assaulted
and battered staff . . . as detainee was combative.” In fact,
although the officer initially reported that he was attacked by
inmates, the officer admitted he had fabricated the story weeks
before Byron filed the grievance. IAD filed a complaint against
the officer for falsification of a report, yet the response to
Byron’s grievance, over a month later, was factually inaccurate
according to CCJ’s own records. Moreover, the grievance did not

32

See Title VI of the Civil Rights Act of 1964, 42 U.S.C.
§ 2000d et seq.

- 42
trigger an investigation. CCJ opened the investigation seven
months later, after Byron filed a lawsuit.
5.

Access to Information

Generally accepted correctional practice requires that newly
admitted inmates are given an opportunity to learn about the
facility rules and regulations, services that are available,
policies and procedures that affect the inmate, and facility
schedules. Each inmate should receive a facility handbook,
containing all the relevant information, and should have an
opportunity to have the information explained to him or her if
the inmate cannot read. Most facilities have a formal
orientation procedure as a part of the intake processing. At
CCJ, officers reported that they offer inmates a copy of the
inmate handbook in the RCDC. There is no documentation as to
whether a handbook is offered or accepted. Although there was a
small stack of inmate handbooks behind a counter in the RCDC
strip search area, we did not observe a single inmate of the
hundreds present in the RCDC area with a CCJ handbook during
either of our site visits.
B.

INADEQUATE MEDICAL CARE

Jail officials are responsible for providing adequate
medical care to inmates. Moreover, a jail may not deny or
intentionally interfere with medical treatment. A delay in
providing medical treatment may be so significant that it amounts
to a denial of treatment. Our investigation revealed that
medical care provided at CCJ falls below the constitutionally
required standards of care. We found the following deficiencies:
(1) inadequate medical staffing; (2) inadequate intake screening;
(3) inadequate health assessments; (4) inadequate acute care;
(5) inadequate chronic care; (6) inadequate emergency care;
(7) inadequate record keeping; (8) inadequate medication
administration; (9) inadequate management of communicable
diseases; (10) inadequate access to medical care; (11) inadequate
medical facilities; (12) inadequate dental care; and
(13) inadequate quality assurance.
1.

Inadequate Medical Staffing

CCJ lacks the medical staff necessary to provide adequate
medical services. Generally accepted correctional standards of
care require that facilities maintain adequate staffing to
provide inmates with necessary medical care. Many of the
problems identified below are exacerbated by the inadequate
medical staffing. In early 2007, there were significant health

- 43 

care cutbacks at CCJ, including 23 clinical positions (four
physicians and three dentists), nine management positions, and 16
other health care positions. These cutbacks have severely
impacted the quality and timeliness of medical care at CCJ. Most
notably, the nursing staff shortages, which have left many
divisions understaffed during periods of the day, and the dental
staff shortages have caused or aggravated inadequate medical
services.
2.

Inadequate Intake Screening

CCJ fails to adequately identify inmates’ urgent and/or
ongoing health needs through appropriate intake screening.
Adequate intake screening is essential for ensuring that inmates
are receiving proper care for acute or chronic needs. Generally
accepted correctional medical standards require that incoming
inmates be screened by staff trained to identify and triage
serious medical needs, including drug and alcohol withdrawal,
communicable diseases, acute or chronic needs, mental illness,
and potential suicide risks. CCJ’s intake screening fails to
identify such needs and increases the risk of serious harm.
At CCJ, correctional medical technicians are responsible for
conducting intake screenings. If an inmate’s intake screening is
positive for a possible acute or chronic condition, the inmate
should be referred to a physician assistant for an evaluation.
Nationwide, more than 30 percent of inmates have acute or chronic
conditions that would require a medical or mental health
evaluation on the first day at a correctional facility.33 In
contrast, only 15 percent of the 100 intake screening records we
reviewed during our June 2007 on-site visit resulted in a
referral for evaluation. During our July 2007 on-site visit, we
reviewed 120 intake screening records and found that only six of
the inmates were referred to the physician assistant. These
numbers depart significantly from what would be expected in CCJ’s
inmate population, which strongly suggests that the CCJ intake
screening process is incomplete and inadequate.
Screenings take place in an area of the RCDC that is
chaotic, noisy, and crowded. The screening interviews often
occur while inmates are handcuffed together, resulting in a total
lack of privacy, which compromises the quality of information
received. Further, CCJ’s screening form is deficient because it

33

National Commission on Correctional Health Care, The
Health Status of Soon-to-be-Released Inmates: a Report to
Congress (May 2002). http://www.ncchc.org/pubs/pubs_stbr.html.

- 44 

lacks sufficiently specific questions regarding acute and chronic
illnesses, including drug and alcohol withdrawal. We found
several instances where acute and chronic medical needs were not
recorded on intake. These practices contravene generally
accepted correctional medical standards, and place inmates at
significant risk of harm.
For example, we identified the following cases of intake
screening deficiencies:
a.	

Nadia H. died in late 2006, one day after being booked
into CCJ, likely of withdrawal syndrome.34 During
intake, she reported a history of heroin addiction, yet
staff failed to document her drug use and history of
addiction. Despite knowledge that Nadia had a history
of addiction, staff disregarded her emergent condition
and placed her in general population. The next day she
was found dead in her cell.

b.	

Julia G. was booked into CCJ in 2007 with a history of
alcoholism and a dangerously high blood pressure. The
screening process failed to identify that she was at
risk of developing delirium tremens, a potentially
life-threatening, but preventable, complication of
alcohol withdrawal. Instead of evaluating and treating
her medical condition, she was transferred to general
population, where she developed delirium tremens and
had to be admitted to the hospital. She also had co
morbid hyperthyroidism, which should have been detected
during the intake screening. Because of CCJ’s
inadequate screening, Julia was at a very high risk of
death.

c.	

In June 2007, David M. was booked into CCJ with a
history of heart disease, deep vein thrombosis,
depression, and recent trauma. Despite his serious
medical history, he was neither examined by a physician
assistant nor did he receive any medical care. Even
after informing CCJ personnel on several occasions that
he was currently taking a prescription for Coumadin (a
blood-thinner prescribed for those at high risk for a

34

We reviewed the medical records of 20 inmates seen by
the physician assistants in the intake area on June 18, 2007, and
found that none of the inmates were asked about a history of
alcohol withdrawal syndrome, a life-threatening condition that is
common among inmates.

- 45
blood clot and for some heart conditions), it took
staff over three weeks before David finally received
his first dose of Coumadin.
d.	

In June 2007, Lyle P. was booked into CCJ. At intake,
Lyle reported his HIV infection and his strong
adherence to his medication regimen, but he did not
receive his medication prescription. Nearly two weeks
passed before he was finally seen by an infectious
disease specialist. Because of the two week lapse in
medication, the specialist chose to delay treatment,
which further enhanced the risks for Lyle to develop
potentially-fatal drug resistance.

e.	

During our July 2007 on-site visit, we encountered an
inmate who suffered from a recent facial trauma,
including redness, swelling, and abrasions on the left
side of his face. He complained of visual disturbances
and discomfort over the entire left side of his face
during intake, yet he was not examined by medical
staff. It was only after we brought his condition to
CCJ personnel that he was re-evaluated by medical
staff.

3.	

Inadequate Health Assessments

CCJ does not give its inmates an adequate health assessment
within a reasonable period after admission. The generally
accepted standard of care is to conduct a health assessment
within fourteen days of admission, or sooner when medically
indicated. This assessment typically includes a review of intake
information, a complete medical history, a physical examination,
and screening for tuberculosis (“TB”) and sexually transmitted
diseases (“STDs”). Appropriate and timely health assessments are
particularly critical should screening procedures fail to
identify an inmate’s serious health needs and improves the
facility’s ability to provide efficient and adequate care.
The great majority of inmates admitted to CCJ do not receive
a health assessment within a reasonable period after admission.
Many inmates never receive a physical examination at all. Even
inmates who were appropriately referred to the physician
assistants upon intake did not consistently receive appropriate
referrals for follow-up or assessment.35 The necessity for a full

35

The physician assistants in intake spend approximately
five minutes per patient and conduct very cursory examinations

- 46 

health assessment is underscored by the grossly inadequate intake
screening process. In addition to the risk to individual inmates
with untreated conditions, CCJ’s failure to conduct health
assessments puts all inmates and staff at risk from the spread of
disease.
4.	

Inadequate Acute Care

CCJ fails to provide adequate and timely acute care to
inmates with serious or potentially serious acute medical
conditions. CCJ’s acute care services substantially depart from
generally accepted correctional medical care standards. We
identified grossly inadequate acute care that led to prolonged
suffering and premature deaths of inmates at CCJ. Acute care was
so deficient that inmates suffered needlessly because medical
staff failed to ensure that inmates met scheduled appointments,
failed to monitor acute conditions, and failed to
timely treat inmates’ conditions. We found numerous instances
where CCJ’s failure to adequately assess and treat inmates likely
contributed to preventable deaths, amputation, hospitalizations,
and unnecessary harm.36
The following examples highlight CCJ’s deficiencies in
providing acute care:
a.	

In early 2006, Gloria D. died after not receiving
adequate care for an emergent and life threatening
condition. Gloria, who suffered from human
immunodeficiency virus (“HIV”), was admitted to CCJ in
early 2006. After one month in the facility, staff
ordered an x-ray after Gloria complained of persistent
cough and shortness of breath. Although her x-ray was
abnormal, Gloria did not receive any follow up care.
Less than three weeks after her abnormal x-ray, Gloria
developed a fever, tachycardia,37 and low oxygen

without privacy or an appropriate facility.
36

Our medical chart review was hampered by CCJ’s highly
disorganized and incomplete medical records. For example, 72
percent of the records we requested for inmates sent to hospital
emergency rooms were unavailable. While the medical records
deficiencies hindered our review, we were still able to document
serious lapses in medical care.
37

Tachycardia is a rapid heart rate, over 100 beats a

minute, which can be caused by cardiac arrhythmia.


- 47
saturation. Gloria was hospitalized and died of
untreated Pneumocystis carinii.38
b.	

In July 2006, Manuel M. was admitted to CCJ with a
life-threatening blood pressure reading, an elevated
pulse, and a history of alcohol use. Although he was
medicated and monitored daily for hypertension, he was
not treated for alcohol withdrawal and, on his third
day at CCJ, exhibited tremors and an altered thought
process, signs of delirium tremens. He should have
been hospitalized at this point, but was not. On his
sixth day at CCJ, when his blood pressure decreased
some from its previously high levels, he was put in
general population. He was never treated for delirium
tremens and committed suicide while delirious.

c.	

In August 2006, inmate Aaron B.’s leg was amputated as
a result of a bone infection resulting from CCJ’s
failure to provide adequate acute care. On August 8,
2006, Aaron was admitted to CCJ. He arrived at CCJ
with a soft cast on his leg. Medical staff removed the
soft cast and replaced it with a hard cast. Aaron
complained of constant pain for nearly a week before he
was finally seen by a physician on August 14. The
physician scheduled an immediate orthopedist
appointment for August 16. Unfortunately, Aaron never
saw the orthopedist because the orthopedist refused to
treat Aaron without his medical chart, which CCJ staff
did not provide. After complaining of discomfort and a
malodorous discharge dripping from his hard cast, on
August 31, he was admitted to Cermak infirmary with
osteomyelitis (an acute or chronic inflammatory process
of the bone). His leg was later amputated because the
severe infection had destroyed substantial soft tissue.

d.	

In late 2006, Aidan A. died after suffering from
sepsis.39 He was admitted to CCJ after suffering from a
gunshot wound in his arm. His wound was surgically
repaired and he had metal inserted in his arm to set
the bone. The orthopedist scheduled an appointment so

38

Pneumocystis carinii is an opportunistic but
preventable infection that occurs in immunosuppressed
populations, primarily HIV patients with advanced infection.
39

Sepsis is the presence of bacteria or other infectious
organisms or their toxins in the blood or in other tissue.

- 48 

that the metal insert could be removed, but CCJ failed
to take him to the hospital for his scheduled
appointment. After seven weeks at CCJ, Aidan developed
a deep tissue infection which elevated his respiratory
rate and his pulse rate became dangerously high. By
the time he was finally taken to the hospital, it was
too late to contain the infection and Aidan died at the
hospital of sepsis two months after his admission to
CCJ. This was a preventable death.
e.	

Five days after his 2007 intake to CCJ, Henry H. had a
new, on-set seizure and suffered a fractured jaw during
the incident. It took six days for him to be seen by
an oral surgeon and he was never evaluated for the
cause of his seizure, as he should have been.

5.	

Inadequate Chronic Care

CCJ fails to provide adequate care to inmates with serious
medical needs that require monitoring and follow-up medical care.
Inmates who suffer from chronic medical illnesses must be
regularly monitored by medical professionals to prevent the
progression of their illnesses. Monitoring should occur on a
regular basis to ensure that symptoms are under control and that
medications are appropriate based on generally accepted
correctional medical standards. However, we found that CCJ was
deficient in ensuring that patients are seen on a regular basis,
that medications are timely distributed, and that inmates are
monitored and treated to prevent the progression of illnesses.
Specifically, in examining a sampling of medical records of
inmates with chronic conditions, we found the following instances
of deficient chronic care:
a.	

40

In reviewing the records of ten CCJ inmates with
diabetes, we looked for seven nationally accepted
interventions.40 Inadequately monitored diabetes can
lead to stroke, vision loss, diseases that effect the
feet and muscles, kidney damage, coma, and death. In a
gross departure from generally accepted correctional
standards, none had a documented urinary microalbumin

These interventions are: measurement of sugar levels
upon intake, measurement of urinary microalbumin, dilated
examination of the retina, cholesterol measurement, measurement
of A1c hemoglobin, chronic care visit with physician, and aspirin
therapy.

- 49
within the last 12 months; only two had a measurement
of A1c hemoglobin within the past three months; four
had a cholesterol measurement within past year; two
were on aspirin prophylaxis; and two had a dilated
retina exam. Our review of these files revealed that
CCJ was not adequately monitoring these inmates through
chronic care visits or consistently screening them from
the conditions that they are at risk of developing.
b.	

We reviewed the treatment of 14 inmates suffering from
moderate or severe asthma. Chronic follow-up care and
regular monitoring of peak expiratory flow (a test that
measures how well the airways are working) are critical
in the proper care for persons with asthma. We found
five of the 14 inmates had not been seen for chronic
care within the last three months and only seven of the
14 had any measurement of their peak expiratory flow.
We also requested records of 13 inmates seen in the
Cermak emergency room for acute asthma between March 5
and May 2, 2007. None of these patients had follow-up
to see if they were improving.41

c.	

Similarly, we requested the records of 15 inmates at
the facility who are on the blood thinner Coumadin.
This medication has very narrow therapeutic range; if
an inmate is given too little, the medication will be
ineffective, but if the medication is given too much,
he or she will experience substantial detrimental
effects. Accordingly, frequent measurement of the
blood-clotting ability of patients taking Coumadin is
critical. Of the records we requested, two were lost,
one inmate was not scheduled for follow up for eight
weeks, instead of the typical one to two weeks, and
another inmate did not have necessary laboratory tests
at intake. Inmates who are taking Coumadin but who are
not monitored appropriately are placed at risk for a
potentially life-threatening blood clot or a
hemorrhage.

d.	

We also reviewed the records of five paraplegic inmates
who suffered skin breakdowns, skin ulcers (bed sores),
or wound infections. Our expert consultant found
patterns of egregious failures of care regarding wound
care in each of these cases. In one startling example,

41

Only 23 percent of the records requested were available
and only one of those charts contained the emergency room record.

- 50
we reviewed the chart of inmate Wallace G., who
suffered a skin breakdown. An x-ray revealed that his
initial skin breakdown caused a soft tissue infection
which likely caused a bone infection. Despite the
abnormal x-ray, we were unable to find any follow-up
care, treatment for the condition, or assessment by the
physician. These failures are gross deviations from
generally accepted correctional medical standards.42
6.

Inadequate Emergency Care

CCJ fails to provide adequate emergency care. We observed
an emergent incident during July 2007 on-site visit, when we
encountered a male inmate who was known by CCJ staff to have a
history of heart disease. While we were on his housing unit,
inmate Mitchell H. experienced severe heart complications and
lost consciousness. Although the dispensary nurse responded to
the emergency call, it took 15 minutes for the ambulance and EMT
to arrive. While the dispensary nurse was struggling to revive
Mitchell, the EMTs were chatting and inattentive to Mitchell’s
needs. After nearly 45 minutes of suffering severe chest pains,
Mitchell was finally placed in the ambulance. CCJ’s slow
response does not comport with generally accepted correctional
medical standards and placed this inmate at risk of serious harm.
We found additional instances of deficient emergency care
that put inmates’ health and lives at risk. As part of our
review, we randomly selected five inmates who were seen in the
Cermak emergency room for alcohol withdrawal symptoms in the
spring of 2007 and concluded that CCJ’s treatment and assessment
was deficient in four out of five cases. Two of the inmates were
sent to the emergency room because of their significant
elevations of blood pressure. In both cases, CCJ staff neither
treated their high blood pressure nor adequately monitored their
condition. Rather, CCJ sent both inmates back to general
population without a thorough examination. Two other inmates
were seen in the emergency room, but we were unable to find
emergency room notes that documented any treatment.43 The last

42

Our expert consultant advised CCJ of this patient’s

inadequate care during our July 27, 2007 exit conference.

43

CCJ has a responsibility to obtain discharge summaries
or notes from the hospital when inmates are treated at outside
facilities in order to adequately assess and treat inmates upon
their return to CCJ.

- 51 

inmate received no treatment because he suffered from asthma and
did not require treatment for alcohol withdrawal.
7.	

Inadequate Medication Administration

We found numerous systemic problems with medication
administration and management. CCJ frequently fails to:
(1) verify identification of inmates receiving and ingesting
medication; 2) provide critical medications to inmates without
delay or lapses; and (3) maintain inmate medication
administration records (“MARs”) concurrently with distribution.
Generally accepted correctional medical standards require
that facilities administer medication and maintain adequate
medication records to meet the medical needs of the inmates and
to prevent medication errors and other risks of harm. Regular
and systematic reviews of medication usage is also required to
ensure that each inmate’s prescribed medication regimen continues
to be appropriate and effective for his or her condition.
During our on-site visits, we observed the distribution of
medication in each of the CCJ divisions. In every instance, we
found nurses throughout the facility who failed to verify
inmates’ identification before administering medication. This
deficient practice increases the chances of dispensing
medications to the wrong inmate or dispensing medication to an
inmate who may have an adverse reaction to medication. Also
problematic was the failure of nursing staff to observe inmates
swallowing prescribed medication. This failure prevents nursing
staff from accurately recording administered medications and
creates an unsafe and potentially dangerous environment where
medication could be hoarded, sold, or result in overdoses. The
nurses’ failure to verify identification and observe inmates
swallowing medications is inconsistent with generally accepted
professional standards of correctional medical care and greatly
increases the risks for error and harm.
Our investigation also revealed significant delays, errors,
and lapses in medication administration, all of which have
contributed to needless suffering and inmate hospitalizations.
The following examples illustrated the medication administration
deficiencies:
a.	

As discussed above, David M. was booked into CCJ in
June 2007 with a prescription for the blood thinner
Coumadin, but there was a 22-day delay before he
finally received his first dose of Coumadin.

- 52 

b.

In May 2007, Roy H. was booked into CCJ. He was
admitted after a kidney transplant. He was prescribed
medication to prevent his body’s rejection of his
kidney transplant. After 16 days without his
prescribed medication, he had to be hospitalized
because his body began to reject his kidney and he
developed metabolic acidosis, a potentially
life-threatening condition.44

c.

In 2007, Gregory T. was booked into CCJ after a
hospitalization for deep vein thrombosis. Although he
had a prescription for Coumadin, CCJ staff failed to
order his prescription. For nearly 20 days, he
needlessly suffered. He developed a blood clot in his
leg and had to be hospitalized because of CCJ’s failure
to order his prescribed medication.

d.

In 2007, Stella R. had a prescription for Coumadin and
a prescription for hypertension medication, yet CCJ
staff failed to order her prescriptions. Stella went
nearly 20 days without her prescriptions. It was only
after we brought this medication error to CCJ’s
attention that Stella had her prescriptions ordered.

e.

In 2007, Rebecca N., an HIV-positive inmate, had a
prescription for antiretroviral medication, but CCJ
staff failed to administer her medication daily as
prescribed. There was a five-day lapse in her
medication, which is especially dangerous for inmates
with HIV.

f.

In 2007, Grant P. suffered head trauma during seizure,
which was likely caused by his not receiving 11 of his
31 prescribed doses of his anticonvulsant medication.

We also found deficiencies in CCJ’s MARs. Contrary to
generally accepted correctional standards, numerous MARs were not
contemporaneously completed or signed as medication was
distributed. CCJ medical staff often left records blank or
failed to log critical clinical information upon distribution of
medication to inmates. We spoke with a medication technician who
told us that because of staffing problems in several divisions it
was virtually impossible to distribute medications and document
MARs at the same time. This practice is inconsistent with

44

Metabolic acidosis is a clinical disturbance
characterized by a relative increase in total body acid.

- 53 

generally accepted professional standards of correctional medical
care and greatly increase the risk of error.
We also reviewed a sampling of MARs during our on-site
visits and found that approximately 15 percent of the MARs were
blank which made it difficult to determine if inmates were
receiving medications as prescribed. In Division IV, we found
particularly high level of blank MARs. When we spoke to the
nursing staff on the division, we learned that Division IV was
severely understaffed. Further, we learned that staffing
shortages had resulted in the division and nurses being unable to
dispense medications in the afternoon or evening. Inmates were
forced wait until the morning before they were able to get their
medications. Similarly in Division III, we learned that
medications were not delivered because of staffing shortages and
inmates were not receiving medications as prescribed. Blank MARs
are indicative of inadequate training, supervision, and staffing.
8.

Inadequate Infectious Disease Control

CCJ fails to adequately treat, contain, and manage
infectious disease. This failure is dangerous and places
inmates, staff, and the community at unnecessary risk of serious
health problems. CCJ’s management of TB, Methicillin-resistant
Staphylococcus aureus (“MRSA”),45 and other infectious diseases
deviates from generally accepted correctional medical standards.
Inmates with infectious diseases are not appropriately contained,
treated, or managed. The overcrowding, poor ventilation, and
constant exposure of inmates to each other and CCJ staff are
conditions conducive to the spread of disease. CCJ’s containment
and management of infectious disease substantially departs from
generally accepted correctional medical standards.
CCJ fails to ensure adequate containment of TB. Once TB has
been identified, treatment must be initiated and monitored.
Inmates believed to have infectious TB should be placed in
specialized respiratory isolation (“negative pressure”) rooms to
reduce the risk of transmission through airborne particles.
Isolation rooms are essential to the prevention of contagion.
These isolation rooms should be tested to ensure proper
ventilation. In addition, staff who are potentially exposed to
the risk should wear masks and be trained in the use of

45

MRSA is a potentially dangerous drug-resistant bacteria
that can cause serious systemic illness, permanent disfigurement,
and death.

- 54 

specialized respirators. We found that CCJ does not comply with
these generally accepted correctional standards.
The most egregious example of CCJ’s failure to provide
adequate containment of TB is inmate Wallace G. Wallace was
housed in a respiratory isolation room because of his abnormal
chest x-ray and a history of TB. The room purportedly had
negative pressure to contain any TB organisms. However, we
inspected the respiratory isolation room and discovered that the
room did not contain negative pressure. A correctional officer
was stationed outside the hallway to the negative pressure rooms,
in order to ensure that people entering the area wore proper
masks, but the doors to the area were propped open. Immediately
following our discovery of the possible inadequate containment,
we informed CCJ personnel of our finding and the potential health
risks. CCJ staff later moved Wallace to another respiratory
isolation room that contained negative pressure.
Thereafter, we inquired into whether CCJ was following the
Centers for Disease Control and Prevention’s recommendations for
containment of TB. The recommendations require facilities to
check respiratory isolation rooms monthly, and daily when rooms
are occupied.46 We found that neither CCJ, Cermak, nor Facilities
Management Department inspect the isolation rooms. This
oversight exposes staff and other inmates to a high risk of TB
infection.
Similarly, CCJ fails to provide adequate management of skin
infections. Consistent with generally accepted correctional
practices, jails should adopt a skin infection control plan to
guide the prevention of transmission of skin infections,
including drug-resistant infections such as MRSA. MRSA
transmission can be prevented by early identification, effective
treatment, wound care, follow-up, environmental controls, and
efficient laundry practices. We found serious deficiencies in
these critical areas at CCJ.
CCJ lacks an adequate tracking system to ensure that skin
infections are properly treated. We learned that CCJ had a nurse
practitioner responsible for wound care and tracking patients
with skin infections, but she did not record any of her findings
in inmates’ medical records. Without an adequate tracking
system, inmates with infections are not properly treated and the
risk of transmission increases significantly. Similarly, we
found that the CCJ laboratory did not report diagnostic cultures

46

http://www.cdc.gov/mmwr/PDF/rr/rr5509.pdf

- 55 

of skin infections to the nurse practitioner. A culture, which
is an examination of a sampling of cells taken from the affected
area, may be done to identify the microorganism causing the skin
infection and to determine the antibiotic or other treatment that
will effectively treat it. Without wound cultures, it is
impossible to recommend appropriate antibiotics and increases the
risks of harm.
Laundry is also an important component to prevent the
transmission of infection. Inmates should have access to clean
underwear and regular changes of uniform. CCJ launders inmates’
clothing once per week, thereby increasing the risk of infection
transmission. Inmates informed us that the only way to maintain
clean underwear is to wash it themselves in sinks and toilets in
the cell area. We observed uniforms, underwear, and linen
hanging to dry throughout the cell area and on railings and
dayroom window ledges on every division. These deficient
practices greatly increase the risk of intramural transmission of
skin infections.
9.

Inadequate Record Keeping

CCJ fails to maintain complete, accurate, readily
accessible, and systematically organized medical records. CCJ
lacks an adequate medical records system to ensure that inmates’
records are correct and accessible so that physicians can provide
appropriate care.
CCJ’s medical records system is strained and overflowing
with unfiled and inaccurate medical records. For example, there
is a three month backlog of unfiled medical records in the
central medical records room; a two month backlog of unfiled
emergency room records; and a three to 14 month filing back log
of medical records in various CCJ divisions. The backlog of
unfiled records seriously interferes with the continuity and
coordination of care at CCJ. This inefficient filing system
greatly increases the risk of error in treatment, assessment, and
care. Further, the current system does not facilitate a system
for coordinated treatment by multiple providers because inmates’
records are not accurate, organized or timely filed.
We found records throughout the facility with critical
medical information missing. For example, as discussed above,
although inmate Aaron B. was scheduled to see the orthopedist for
his serious knee injury, the physician refused to treat Aaron
because CCJ could not find his medical chart. Aaron’s leg was
subsequently amputated because of a serious infection that

- 56 

developed due to inadequate care resulting from a chart that was
missing in the medical record.
The inadequate record system is further impeded by
clinicians who created “shadow charts.” Physicians kept lists,
logs, or filed copies of progress notes and diagnostic reports in
their desks so that they could properly monitor their patients’
progress. While the concept of creating shadow charts might seem
to enhance continuity of care, they actually create another
barrier for maintaining accurate, complete, and accessible
medical records. In most instances, physicians maintained notes,
lists, and logs that were not updated in central records, which
further created a gap in maintaining complete records.
Our investigation also revealed that medical records were
not readily accessible. For example, we found that clinicians
did not have access to inmates’ records maintained in the
divisions after 3:00 p.m. because the medical records rooms were
locked at that time due to staffing problems. This lack of
medical continuity and coordination of care seriously interferes
with the clinician’s ability to manage medical emergencies
outside of the Cermak units.
10.

Inadequate Access to Medical Care

The CCJ sick call process fails to provide adequate access
to medical care. CCJ inmates access medical care by completing
sick call requests. Although CCJ correctional staff are
responsible for collecting sick call requests, inmates reportedly
make multiple requests before receiving medical care. Our review
of medical records confirmed that many inmates made several
requests for care before receiving treatment. For example, on
July 25, 2007, inmate Jackson E. requested medical treatment for
staples that had been left in his scalp and sutures that had been
left in his arm. Although he made several requests to have the
staples and sutures removed, he did not receive treatment, even
after our consultant alerted CCJ staff to his condition. He
reportedly was placed in lock down for ten days for making
repeated requests for medical care. It is inappropriate to
punish inmates for requesting medical care. Similarly, inmate
Donald C. made repeated unanswered requests for medical care for
eye hemorrhages and lacerations he sustained in an altercation
with custody staff.
Also of concern, inmates reported that they were limited in
their ability to access medical care by the practice of extended
half-tier lockdowns, discussed above. When inmates are confined
to their cells for extended periods, they have limited access to

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custody staff and can be denied access to medical and mental
health care. For example, inmate Chester H. reported that he had
a seizure during the 26-hour lock down period and he was unable
to receive medical care and was unable to attract the attention
of CCJ personnel. He needlessly suffered while he waited for
medical care. Because the nurses do not go onto the units to
deliver medications to inmates who are locked in their cells,
inmates who are on lockdown status during medication
administration do not receive their prescribed medications. The
extended lockdowns interfere with implementation of prescribed
treatment plans and continuity of care for inmates.
11.

Inadequate Medical Facilities

Medical facilities at CCJ lack adequate space, privacy,
lighting, and sanitation to provide inmates with medical care
consistent with generally accepted correctional standards.
Approximately 300 inmates receive face-to-face medical care
daily.
Inadequate space is especially significant because it limits
CCJ’s ability to provide medical services such as intake
screenings, sick calls, and health assessments as well as care
for inmates with specialty, chronic, and acute needs. The RCDC
intake area is inadequately equipped to manage the daily volume
of inmates during the essential intake screening process. The
area is constantly congested and overcrowded.
Generally accepted professional standards of correctional
medical care require that for a proper clinical evaluation
inmates be examined in a clean and private setting with
sufficient lighting and access to necessary diagnostic tools. We
found mouse droppings in dispensaries and medication rooms
throughout the facility.
Moreover, some of these rooms lacked
accessible hand-washing sinks or disinfectant, and contained
unsecured syringes and other sharp implements, which can be
potentially dangerous. Further, the floors and work surfaces of
all of the medical units and intake screening area were filthy.
12.

Inadequate Dental Care

CCJ fails to provide adequate dental care to its inmates.
Dental care is an important component of overall inmate health
care. Poor oral health has been linked to numerous systemic
diseases. Contrary to generally accepted correctional standards,
dental care at CCJ is not timely and does not include immediate
access for painful or urgent conditions. During our June 2007
on-site visit, we found that there was only one dentist

- 58 

responsible for over 9,500 inmates.47 We further learned that the
dentist was unable to perform any restorative care. The
dentist’s services were limited to extractions and it usually
takes about two weeks before the dentist was able to perform any
necessary follow-up care. More alarming, we learned that over 25
percent of the extractions performed at CCJ resulted in chronic
infections such as osteitis (inflammation/disease of the bone) or
dry sockets.
We also found that the dentist typically was unable to treat
inmates with serious or urgent dental needs. We found many
instances where inmates complained of tooth abscesses, but the
dentist was unavailable to treat their serious dental needs. For
example, inmate Derek B. was admitted to CCJ on June 17, 2007,
with a tooth abscess. Although Derek requested dental care, the
CCJ dentist did not provide treatment for his tooth abscess.
Without proper treatment, Derek is at risk of serious deep tissue
infection, pneumonia, sepsis, septic shock, and possibly death.
As a result of the dentist’s inability to treat serious
dental needs, the Cermak emergency room and sick call are
inundated with dental emergencies. Despite having Cermak
physicians treat these serious dental emergencies, inmates
continue to suffer needlessly because they do not receive
appropriate follow-up care.
13.

Inadequate Quality Assurance and Performance Measurement

CCJ fails to engage in consistent, effective quality
assurance reviews in order to monitor and assess the quality of
medical care offered at the facility. An adequate quality
assurance and performance measurement instrument is necessary to
examine the effectiveness of health care delivered at CCJ, to
discuss medical care results, and to implement corrective action
so that the quality of care is improved. During our on-site
visits, we found that CCJ had discontinued many of its
performance measurements in February 2007 because CCJ lost
accreditation by the National Commission on Correctional Health
Care. As a result, CCJ discontinued its review of chronic
disease care, acute and chronic care, completion of treatment for
STDs, and access to care. Performance measurements are a
critical component to ensure that polices and procedures are in
place and to ensure adequate care. Without performance measures,
the quality of medical care will suffer.

47

Three dentists, one dental hygienist, and seven fulltime equivalent dental assistants were cut in February 2007.

- 59
We also found that CCJ failed to conduct self-critical
mortality reviews. Our expert reviewed mortality reviews and
autopsies of 13 inmates who died while in custody at CCJ and
found that none of the mortality reviews were self-critical. The
absence of self-critical review creates a barrier for proper
review that will ensure that proper policies and procedures are
in place to correct failures and ensure adequate care,
prospectively.
Finally, staff involved in the inmate grievance process are
frustrated that once a medical or mental health related grievance
is referred to Cermak, a response is not forthcoming. The inmate
grievance system should alert medical staff to possible
weaknesses in the provision of medical care. We reviewed
numerous grievance files that alleged the need for medical
services, some of an emergent nature, that showed a referral to
Cermak, but contained no actual response to the grievance. For
example, inmate Steve S. filed a grievance on March 19, 2007
alleging that he was taken off his psychotropic medication
without seeing a doctor, that he had been experiencing nightmares
that prevented him from sleeping at night, that he was hearing
voices, and that he was contemplating taking his own life and
desperately needed help. The CRW acknowledged receipt of the
grievance on March 23, 2007, but did not mark the grievance as an
emergency and referred the grievance to Cermak with a statement
that Steve S. merely alleged he was not getting proper medical
attention. On April 2, 2007, Steve S. received a response
stating, “Referred to Mental Health Services.” The grievance
file does not contain any information indicating whether Steve S.
ever received mental health treatment.
C.

INADEQUATE MENTAL HEALTH CARE

CCJ fails to provide inmates with adequate mental health
care that complies with constitutional standards. CCJ fails to
address the specific needs of inmates with mental illness,
including: (1) failure to timely and appropriately evaluate
inmates for treatment; (2) inadequate assessment and treatment;
(3) inadequate psychotherapeutic medication administration; and
(4) inadequate suicide prevention.
Mental health services at CCJ are provided through a
combination of County Cermak employees and a contract with the
Isaac Ray Center (“IRC”) for psychiatric services. Cermak mental
health services are directed by a Chief Psychologist who
supervises a staff of approximately 50 individuals, including two
medical social workers, three activity therapists, one mental
health specialist supervisor, and approximately 40 Mental Health

- 60 

Specialists (“MHSs”). County mental health services have
recently experienced specific cuts in staffing. The result is an
inadequate number of trained staff to provide adequate
programming and coverage in the mental health areas.
1.

Failure to Timely and Appropriately Evaluate Inmates

CCJ fails to properly identify inmates with mental illness
through adequate screening. Adequate screening of incoming
detainees for mental health care needs is instrumental to a
facility’s ability to identify inmates in need of mental health
services, to provide appropriate mental health care, and to
reduce potential harm to those whose conditions would otherwise
go unrecognized. Mental health screening should comport with
generally accepted correctional standards of care to aid in
classification, identification of emergent mental health care
needs, provision of continuous care, and management of
medication.
Follow-up of known or new mental health problems is a key
focus of intake screening. Mental health screening information
should be incorporated into an inmate’s medical record. This
ensures the prompt continuation of necessary medication for all
inmates with chronic or newly identified mental health
conditions. Persons with potentially serious and/or chronic
mental health illness (i.e., active psychosis, suicidal ideation)
should be referred from screening for prompt mental health
evaluations and examinations by a psychiatrist.
As indicated, CCJ’s medical screening and follow-up care
procedures deny necessary care to inmates. The policy governing
the CCJ mental health screening process is completely inadequate.
Insufficiently trained MHSs perform mental health initial intake
screening at CCJ. This screening is not accomplished under
appropriate medical supervision. The system allows technicians,
who are not adequately or appropriately trained in detecting
mental illness, to query inmates and detainees regarding their
mental health history.
For mental health screening, CCJ staff utilize a form
entitled “Department of Mental Health Services Brief Primary
Psychological Screening Tool” which is not then incorporated into
the medical record. This is a one page form that is used to
collect brief demographic information and answers to 11 general
questions. No mental status exam is completed at that time. At
the end of this brief interview, which lasts for less than five
minutes, the MHS makes a decision whether to refer the inmate to
general population, refer the inmate for admission to psychiatric

- 61 

services, or to conduct a secondary interview. The screeners do
not ask questions beyond those on the form, and do not appear to
understand when additional questions were indicated or what those
questions might be, especially relating in the area of assessment
of suicide risk. Thus, mental health symptomatology that is
associated with past hospitalizations, current treatment, or
suicidal ideation, is unlikely to be uncovered.
Consequently, our expert consultant found that less than
five percent of inmates screened are identified as having
psychiatric problems. The County’s Director of Psychiatric
Services acknowledged that the screening process was flawed and
one would expect the percentage of inmates identified with
psychiatric problems to be as much as ten percent. No
psychiatrists are assigned to supervise or support the RCDC
intake area where the initial mental health screening is
conducted. In addition, we found that even for those inmates who
screen positively for serious mental illness, the subsequent
referral process to mental health treatment providers is flawed.
2.

Inadequate Assessment and Treatment

CCJ fails to appropriately assess and treat inmates with
mental illness, including those inmates on the acute care units
and in the RTU. Our investigation revealed two principal
problems. The first is the lack of attention to past mental
health treatment records including previous psychiatric
hospitalizations. Virtually no collateral mental health care
information is requested or utilized in the assessment process.
The second problem is that medical information already collected
is not available for review or utilization in the continued
assessment and treatment process. Our review of records
indicates that this leads to multiple, often conflicting
diagnoses, potential over prescription of antipsychotic and
antidepressant medications, and medication dose adjustments
without clear rationale. These failures have resulted in mental
health deterioration and unnecessary suffering.
We noted that there are significant problems with the mental
health treatment records. CCJ fails to maintain complete,
accurate, and systematically organized mental health treatment
records. CCJ’s medical and mental health records system is
completely inadequate and mismanaged. We observed numerous
incomplete, unfiled, and inaccurate records. This flawed record
system greatly increases the risk of error in assessment,
treatment, and care. The County Director of Psychiatric Services
described the medical record operation within CCJ as “grossly
inadequate.”

- 62 

The following examples are illustrative of the assessment
and treatment failures at CCJ:
a.	

Seth P. was seen for a psychiatric consult during our
July 2007 on-site visit. Seth had been admitted to CCJ
three to four weeks prior to the consult and, after
initial screening, had been placed in the general
population. No records were available or requested48 at
the time of the consult. The psychiatrist evaluated
Seth and assessed him as exhibiting grandiose thinking
and hyperactivity, prescribed medications, and ordered
Seth to be admitted to CCJ’s acute psychiatric unit for
further evaluation. Immediately following the
psychiatric consult, Seth was sent to an outside
emergency room for evaluation for a possible fracture
of his right hand. Upon his return to CCJ, the intake
MHS,49 who was not aware of the recent psychiatric
assessment due to the inadequate record keeping,
determined independently that Seth was to be admitted
to the general population. The result was that Seth
received no further psychiatric evaluation and did not
receive the prescribed antipsychotic medication ordered
by the psychiatrist.50

b.	

Melanie O. had a miscarriage at CCJ on May 25, 2007,
was depressed, and had not received any psychiatric
follow-up even though she was taking psychotropic
medications. During our June 2007 on-site visit, we
observed Melanie sitting in a hallway, having what
proved to be an acute allergic reaction. No medical
records for Melanie were available at that time.

48

The Director of Psychiatric Services indicated that to
request such records would be fruitless. When we insisted that
the records be requested, none were available nor could they be
located. Eventually Seth P.’s medical records were located, two
days later, and the record was found to be incomplete.
49

Each time an inmate is transferred or leaves the
facility for a consult, he is returned to the intake area for a
housing classification. In this case, the housing classification
was conducted by the intake MHS.
50

The psychiatrist was not aware of the mixup and the

situation was rectified only after we brought the matter to his

attention. The Director of Psychiatric Services indicated that

this was typical of what happened at CCJ on a daily basis. 


- 63
Eventually, Melanie’s medical record was obtained and
the record reflected that she had been sent to the
emergency room two days earlier because of symptoms of
allergic drug reaction. Medication was prescribed, but
Melanie had not received the medication because there
was no record of the prescription order from the
hospital. No medical evaluation had been completed to
determine the cause of her allergic reaction and no
psychiatric assessment of her mental state occurred.
c.	

Kyle N., who had been assigned to CCJ’s acute
psychiatric unit, had a medical record which contained
misfiled medical record information belonging to
another inmate.

d.	

Anthony G. was housed on a Division IX segregation
unit, with limited out-of-cell time, and had not had
any access to psychiatric care in over six months. He
reported setting fires to get access to medical and
mental health care. The officers’ log verified
Anthony’s fire setting.

e.	

Drew E. was also housed in Division IX and admitted
that he also set fires to get access after repeatedly
receiving no response to his grievances over lack of
access to medical and mental health care.

As demonstrated, CCJ fails to provide essential, generally
accepted components of an adequate treatment programs in a
correctional mental health system. The crisis level of care
lacks the capacity for necessary short-term treatment. There is
not adequate physical space for evaluating and treating inmates
in the emergency or RCDC areas. At present, psychiatrists do not
go to the general population to see inmates or conduct clinics.
In addition, psychiatrists do not make rounds in any segregation
areas. Rather, all inmates are brought to the emergency room
area to be seen. The result is that inmates who for security
reasons or lack of escort correctional staff cannot be brought to
the emergency room area, are not seen.
In addition, CCJ does not have access to an acute care
program that would provide appropriate access for inpatient
hospitalization. For example, mental health staff have no
involvement in substance abuse assessment or treatment and make
no referrals for substance abuse assessment or treatment. Also,
a chronic care program for inmates with serious mental illnesses
does not exist. While CCJ does provide segregated housing units
for inmates with serious mental illnesses, these housing units

- 64
lack an adequate treatment program, which is an essential
component of an adequate chronic care program.
3.

Inadequate Psychotropic Medication Administration

CCJ fails to timely and appropriately evaluate inmates for
the administration of psychotropic medications and to monitor
their continued administration. Many CCJ inmates require
psychotropic medications to avoid the unnecessary suffering of
acute and chronic episodes of mental illness. Generally accepted
correctional mental health care standards require that a
physician see an inmate usually before, but clearly shortly
after, a prescription for psychotropic medication is written in
order to evaluate whether the medication should be maintained and
to evaluate the continued administration for proper dosage and
effectiveness. Inmates who remain untreated, or who are treated
without being seen by a physician, may suffer from a worsening of
their symptoms, including suicidal and homicidal thoughts, or
from the potentially lethal side effects of medication. CCJ
consistently fails to follow this practice.
We found significant problems with regard to medication
management, which include the following: (1) delays ranging from
days to weeks for inmates having their psychotropic medications
started after their admission to CCJ; (2) breaks in receiving
their medications after their prescriptions were initiated at CCJ
related to housing changes and nurse unavailability for
medication administration; (3) inmates not receiving their
prescribed medications due to being locked down for extended
periods of time and unable to receive medications when called;
(4) numerous medication errors appeared to be common;
(5) psychotropic medications being prescribed or reordered
without any clear medical rationale or justification; and
(6) lack of monitoring for side effects, or potential toxicity,
particularly with regard to the psychotropic drugs Lithium,
Depakote, and Clozaril.
As confirmed by our investigation and acknowledged by the
Director of Psychiatry, inmates routinely do not receive
medications as prescribed or have lapses in medication
administration. Medication errors were common due to nurses
being overwhelmed and failing to observe inmates taking their
medications or to assure that the medication was delivered as
prescribed.
Medication administration problems are compounded by the
fact that psychiatrists do not utilize any formal practice
guidelines or protocols with regard to the psychiatric care being

- 65 

provided at CCJ. No routine lab work, weights, measurements, or
screenings are conducted regardless of the medication being
prescribed. Generally accepted professional standards require
regular blood draws and lab work whenever certain psychotropic
drugs are prescribed to ensure that the patient is receiving
therapeutic levels of the medication. Metabolic syndrome which
is characterized by the presence of risk factors including
obesity, abnormal lipid profiles (high LDL cholesterol, low LDL
cholesterol, and high triglycerides) is not tracked. Screening
for the side effects of antipsychotic medication is not routinely
done. The result is that CCJ is providing medication management
that significantly departs from generally accepted professional
standards. Illustrative examples from 2007 include:
a.

Salazar F. did not receive his antipsychotic medication
after his transfer to Division IX from CCJ’s acute
psychiatric unit.

b.

Although Raul G. was housed in the Division V medical
unit, he did not receive his prescribed antipsychotic
medications for three weeks after intake.

c.

Julius T. was prescribed antipsychotic, antianxiety,
and antidepressant medications. The rationale for
prescribing these medications could not be determined.
In fact, the psychiatric portion of his medical record
concerning substance abuse, depression, anxiety, and
withdrawal could not be located.

d.

Jones C. was prescribed three varying doses of an
antipsychotic medication without clarification as to
which dosage was appropriate (40mg, 60 mg, or 80 mg) or
clarifying changes in dosage, if that was the case. It
appeared that CCJ clinicians were engaging in
polypharmacy, the inappropriate practice of prescribing
multiple medications within the same class, without
justification, for the same illness. He was also being
prescribed two additional antipsychotic medications
with no justification in the record for the multiple
medication orders. It is likely that the lack of
available records contributed to the disorganization of
the care of this inmate.

e.

Arnold R. was being prescribed an antipsychotic
medication and an antidepressant without any
documentation in his medical record as to the rationale
for the prescription or any follow-up on his
psychiatric medications.

- 66 

f.	

Diego F. was receiving two antipsychotic medications
and an antidepressant medication. His record contained
no rationale for the medications and identified him as
having no psychiatric problems.

4.	

Inadequate Suicide Prevention

Suicide prevention practices at CCJ are grossly inadequate.
Constitutional requirements mandate the development of suicide
prevention standards. These standards require (1) an appropriate
policy and procedure; (2) education and training for all staff
members; (3) appropriate screening to assess suicide risk;
(4) appropriate housing for those identified as at risk;
(5) appropriate supervision, observation, and monitoring of those
inmates so identified; (6) appropriate referrals to mental health
providers and facilities; (7) appropriate communication between
correctional health care and correctional personnel;
(8) appropriate intervention addressing procedures of how to
handle a suicide in progress; and (9) appropriate notification,
reporting, and review if a suicide does occur.
CCJ’s current practice of suicide prevention does not
comport with generally accepted professional standards of
correctional mental health care. CCJ’s written policy on suicide
prevention fails to ensure appropriate management of suicidal
inmates and lacks major components of an adequate suicide
prevention program. For example, CCJ’s policy states that “if a
patient is determined to be an imminent risk of harm to self,
they will be placed in restraints following protocol.” This
practice of manually restraining suicidal individuals is contrary
to generally accepted professional standards and, as affirmed in
conversations with CCJ staff, being utilized solely due to lack
of staff for continuous observation of the suicidal inmate. The
result of this inappropriate policy is the unnecessary and
excessive use of restraints.
An illustrative example is inmate Dallas W. who was placed
in four-point leather restraints (all limbs) after expressing
thoughts of committing suicide, despite the fact that he
exhibited no aggressive or suicidal behavior. The review of
restraint logs from July 2006 to June 2007 showed that in over 50
percent of the episodes, inmates were shackled with full leather
restraints because of suicidal ideation and the fact that
continuous observation was unavailable. This is grossly
inappropriate.
In addition, the appropriate observation of suicidal inmate
patients is hindered by physical limitations of the rooms in

- 67 

which they are being placed. Observation rooms have blind spots
and windows that are set too high for routine viewing. Moreover,
many of the rooms contain numerous environmental risk factors
including exposed plumbing and electrical hazards.
Contrary to generally accepted correctional practices, CCJ
correctional officers and other staff have no access to cut-down
tools for quick response in the event of a suicide attempt by
hanging. In each of the three CCJ suicides completed in 2008,
there was a delay between discovery of the inmate hanging and
removal of the noose. For example, on January 1, 2008, the first
correctional officer to discover inmate Grant N. hanging from his
bunk attempted to lift Grant to remove the sheet from his neck,
but was unable to do so. Approximately six additional minutes
elapsed before paramedics were able to cut Grant down, using a
key to sever the noose.
As a result of the administrative division between
corrections and health care at CCJ, communication between mental
health staff and correctional staff is informal and often
strained. Significant communication problems between custody and
mental health staff result in a fragmented, uncoordinated system.
This problem is exacerbated because suicide prevention is not
under the direction and supervision of mental health staff.
Inmates placed on suicide watch are being observed by
correctional officers who have a myriad of other responsibilities
in addition to the observation task and have limited or no
familiarity with the on-going assessment of suicidal individuals.
The current suicide prevention program fails to contain different
levels of supervision of the inmate based on the presenting risk
factors for suicide. Staff are not appropriately trained in
suicide prevention. Annual training for correctional officers
regarding suicide prevention is not required. Correctional
officers assigned to the mental health units do not receive any
additional specialized training on working with individuals with
mental illness. Finally, contrary to generally accepted
practice, there is no adequate clinical administrative review by
mental health staff following a suicide or a suicide attempt to
identify what could have been done to prevent the act. Our

- 68 

review of the records of two recent inmate suicides51 illustrates
the significant problems:
a.	

On July 27, 2006, inmate Manuel M. hanged himself to
death in a maximum security wing of CCJ. A
correctional officer reportedly found Manuel hanging
from a bed sheet at 3:20 a.m. He had been in CCJ
approximately one week on a charge of failing to
register as a sex offender. His records reveal that at
intake he provided a history of suicide attempts in the
past, but denied current suicidal ideation. No
secondary mental health evaluation was conducted.
Manuel received no additional mental health assessment
prior to his death in the facility.

b.	

On July 25, 2006, inmate Andrew K. committed suicide by
hanging himself in his cell, two days after arriving at
CCJ. Andrew was discovered by another inmate. His
record reveals that at the time of intake, Andrew
denied suicidal ideation and no secondary mental health
evaluation was conducted. Andrew’s documented past
history included three prior psychiatric
hospitalizations, including a suicide attempt by
overdose. Nevertheless, Andrew received no additional
mental health assessment prior to his death. No
recommendations or findings were made in the mortality
review, except for the comment “May consider a two
person accommodation to watch over each other.”

5.	

Inadequate Staffing, Training, and Supervision

CCJ’s fragmented system of providing mental health care has
contributed to many of the problems above. In addition, many of
the shortcomings in mental health care are exacerbated by the
lack of adequate staffing, support, training, and supervision.52

51

In addition to the suicides discussed above, on
March 14, 2008, an inmate was found hanging in his Division I
cell. He was hospitalized in critical condition and died when he
was taken off life support on March 18, 2008. On April 14, 2008,
another CCJ inmate hanged himself with a bed sheet in a
Division I cell, and was pronounced dead at the hospital.
52

Concerns were raised by the Chief Executive Officer of
the IRC regarding the decreased budget for mental health services
and the resulting mental health staff cuts, particularly the
decrease in the number of MHSs and the replacement of existing

- 69 

CCJ maintains an insufficient number of appropriately trained
mental health and custody staff to provide adequate mental health
services.53 Moreover, delays in access to mental health care are
exacerbated by an insufficient number of staff trained to
identify, respond, and provide the necessary mental health
treatment. Generally accepted correctional standards of care
require that facilities maintain adequate staffing to provide
inmates with necessary mental health care.
Shortages in key staff areas (MHS, correctional staff,
nursing, medical records, and social workers) interfere with
adequate access to mental services.54 As indicated, there is an
inadequate number of MHSs to provide screening and supportive
mental health care. This problem is compounded by the fact that
recently hired MHSs lack the necessary training and experience.
As indicated, correctional staff are inadequately trained to work
with mental health inmates. In addition, officers are being
rotated too frequently to develop familiarity with the

MHSs with less qualified individuals. The severe budget
cutbacks, as reflected in decreased staffing, resulted in a
“breakdown in translation and execution of mental health care.”
53

We observed very limited programming on the units. An
interview with the Chief Psychologist verified that within the
last six months due to budget cuts and the resulting staff
reduction, programming on the units had been severely reduced.
54

These staffing shortages were noted by the Court

Monitor for Mental Health responsible for monitoring compliance

with the CCJ consent decree in Harrington v. DeVito, No.

74-C-3290 (N.D. Ill. Oct. 19, 1978). In his 1998 and 2002

reports, the Court Monitor for Mental Health found that a

shortage of adequately trained nurses, activity therapists,

mental health specialists, psychiatrists and psychologists

resulted in inmates “facing significant access barriers to care

and adequate therapeutic programming resources.” He further

found that the lack of adequate numbers of medical record

technicians resulted in incomplete records, included filing not

being completed in a timely fashion or misfiling, and lack of

availability of records during clinical assessments. Our

independent evaluation identified that inadequate staffing

currently results in unconstitutional mental health care

deficiencies. These same staffing deficiencies were identified

by the Harrington lawsuit and referenced in the 1998 and 2002

Court Monitor for Mental Health’s reports.


- 70 

population.55 There are an insufficient number of nurses to
provide mental health services for the designated mental health
units and to run a medication administration program that
comports with generally accepted professional standards.56 In
addition, there are insufficient numbers of social workers to
provide for discharge planning, continuity of care, and
reintegration into the community. Finally, there are an
inadequate number of trained health record technicians to operate
an effective health record system.
D.

INADEQUATE FIRE SAFETY

The level of fire safety at CCJ is poor. Inadequate fire
safety at any correctional institute presents a grave risk of
harm from smoke, fire, and the serious security concerns that
arise during an emergency. These serious risks are present
throughout CCJ. There are no smoke detectors in most inmate
housing areas, which means staff have no way to receive warning
of fire or smoke other than from the inmates who may have set the
fire. Keys are not marked for rapid identification in an
emergency. Staff was often not prepared to quickly unlock the
doors for rapid evacuation, not knowledgeable of how the fire
alarm system works, and poorly prepared for an emergency. Weekly
Divisional Reports, from February 26, 2007 through June 17, 2007,
show an average of 1.8 fires per week at CCJ. During our site
visits, we saw evidence in numerous cells that inmates are
setting fires beneath their beds in order to utilize the metal
bunk as a hot plate to heat food. Multiple inmates reported that
they resort to lighting fires in their cells in order to get
correctional officers’ attention. Considerable improvement in
built-in protection and staff preparedness is necessary to meet
generally accepted standards for fire safety in a correctional
setting.57

55

The Court Monitor for Mental Health also noted the lack
of compliance with the Harrington Consent Decree with regard to
security staffing. He found that the failure to utilize
appropriately trained correctional officers on a regular basis in
mental health areas was noted to have significantly impacted the
treatment offered to inmates with serious mental illness.
56

This was acknowledged by the Acting Director of Nursing
who indicated it is difficult to maintain adequate psychiatric
nurse coverage on the psychiatric units.
57

In addition to generally accepted correctional
standards, the Illinois Office of the State Fire Marshal requires

- 71 

One CCJ correctional officer is assigned to make monthly
fire safety “inspections” for the entire facility. These are
cursory inspections to confirm that items on a standard checklist
are done. The designated officer has not had training in fire
safety and apparently just fills out the inspection check list
with little in-depth evaluation of safety issues. Reportedly,
there is a fire safety officer for each division, but these
officers’ only responsibility regarding fire safety is the
monthly inspection of fire extinguishers. Fire safety
inspections should be done by persons trained in fire safety.
They should have knowledge in basic housekeeping, emergency
preparedness, basic applicable codes, fire extinguishers, and
sprinklers.
Key control is a major problem. On several occasions during
our on-site visits, when officers were asked to unlock doors,
there was confusion as to which key unlocked a specific door or
if the correct key was on the ring the officer carried. In many
cases, several keys were tried without success, and then a key on
the same ring was found that would unlock the door. The keys
were not identified by touch and the visual markings were
difficult to read in low light situations. In a correctional
setting, generally accepted correctional standards require that
all emergency keys be identified by sight and touch.58 On October
5, 2007, the Sheriff’s Office reported that CCJ had made
improvements in key control, but we have not yet verified this
information.
Divisional emergency procedures and fire plans are different
between divisions with no standard format or standard procedures.
For example, the Division IV instructions require that emergency
keys to be color-coded red, but other divisions do not. Some
instructions include floor plans, while others do not. While it
is understandable that both the physical plants and levels of
security differ by division and require some variation, the
general format and information should be similar. This will help
employees to more easily familiarize themselves with the
procedures as they move positions.
Fire drills are not being done on a regular basis on each
shift. Many officers reported that they had not participated in
any recent fire drills and had not had training on fire safety

that all jails must comply with the National Fire Protection
Association’s Life Safety Code (“LSC”) (200).
58

See also LSC § 23.7.5.

- 72 

since the academy. According to generally accepted correctional
standards, monthly fire drills are required in institutional
occupancies.59 Monthly drills should rotate so that they are
conducted quarterly on each shift. Drills should be conducted at
differing times and under differing conditions, such as using
different egress routes to confirm that officers have the
necessary keys and know how to use them. Records of each drill
should be maintained for at least one year.
CCJ does not have sufficient smoke detection and sprinkler
systems. Smoke detection should be installed in all housing
units in accordance with generally accepted correctional
standards.60 Basement storage areas should have sprinkler
protection or be enclosed in fire resistive construction.61
Stairs should be enclosed so that smoke will not travel
throughout the buildings. Most of the CCJ Divisions do not
comply with these generally accepted correctional standards. For
example, Division I, which was built in 1929, has no sprinklers
and no smoke detection. A manual fire alarm system is installed.
The cells are open-barred in the front and back and the doors to
the stairs are open bars from the basement to the fourth floor,
which could allow smoke to spread quickly throughout the building
in the event of a fire. Only Division XI, Dorm 4 of Division II,
and Cermak are fully protected with automatic sprinklers. Some
of the buildings have partial sprinkler protection in selected
areas of the basements, while others do not. Several fire/smoke
barrier doors were not working properly. Many of the stairwell
and fire doors throughout CCJ were wedged open, which would allow
smoke and heat to travel quickly throughout the building. In
addition, in many divisions no one is consistently checking
emergency doors and locks to ensure that they are operational.
We found that the locking mechanisms on multiple emergency exits
in housing units had been sabotaged by inmates inserting debris
into the lock, unbeknownst to staff, which prevented the doors
from opening from inside the housing unit. This is a major
safety hazard.
In many divisions, we found extra mattresses stored
inappropriately in rooms without adequate fire protection.

59

For

The Municipal Code of Chicago, Fire Prevention Code

(“FPC”), also requires monthly fire drills. FPC, Article XVI,

§ 1 (15-4-920) (Jan. 1999).

60

See also LSC § 23.3.4.4.

61

See also FPC § 9 (15-16-030)(b); LSC § 23.3.2.

- 73 

example, in Dormitory Two of Division II, we found several
mattresses stored in the multi-purpose room on the first floor,
which is not designed or protected as a storage room. A fire in
these mattresses could quickly spread smoke throughout the
building and unnecessarily expose inmates to danger. Mattresses
should only be stored in designated areas that are protected
against fire risks. The potential risk from CCJ’s flammable
mattresses is clear. On January 4, 2007, two officers were
injured after an inmate in Division IX set his mattress on fire.
One officer suffered smoke inhalation and was admitted to the
hospital. Another officer was cut on his arm during an
evacuation of the housing unit.
Finally, as discussed above, the RCDC becomes very crowded
in the late afternoons and evenings. There are two doors out of
this area. Assuming each door has a clear width of 34 inches,
generally accepted correctional practices indicate that each door
is a sufficient exit for a crowd of 135 to 170 persons.62 That
means the RCDC can safely provide emergency exits for 270-340
people. The number of RCDC occupants, including newly admitted
inmates, inmates returning from court, correctional officers, and
medical and mental health care staff, often swells well beyond
400 persons, clearly exceeding the available egress capacity.
E.

INADEQUATE SANITATION AND ENVIRONMENTAL CONDITIONS

CCJ has severe environmental health and safety problems at
every level of operation.63 Most CCJ staff appeared well meaning
with regard to environmental conditions, even when, in some
instances, the staff person had never received adequate training
to sufficiently understand the task at hand. However, inadequate
staffing, inadequate training, insufficient oversight, and a lack
of uniformity of policies and procedures across divisional lines
are detrimental to staff who want to perform at a professional
level.
1.

Facility Maintenance

In a facility the size and age of CCJ, it is normal and
expected that maintenance and repair work would be an on-going
62

63

See, e.g., LSC § 7.3; FPC § 10 (13-160-210).

Although the John Howard Association found “reasonably
successful” sanitation efforts in 2007 (Court Monitoring Report
at 64), conditions at CCJ were far below compliance with
constitutional requirements during our on-site visits.

- 74 

challenge. In a correctional setting where inmates and staff are
dependent on maintenance staff for their water, heat, lighting,
and ventilation, it is also expected that these issues would be
addressed in a timely manner in order to reduce risks of illness
and injury to inmates and staff alike. That is not the case at
CCJ. Work orders generated by correctional staff are transmitted
to the Cook County Facilities Management Department. During our
site visits, we observed hundreds of maintenance and repair
needs, many of which had not been addressed for months. Upon
review of work orders generated between February and July 2007,
we found 2715 were uncompleted, including many that were more
than four months old. With the exception of Division XI, staff
uniformly complained about the lack of timely responses to work
order requests. The failure to timely process work orders
exacerbates the overcrowding issues at CCJ. In Division V alone,
more than 100 cells (approximately ten percent of the division’s
capacity) were closed because of maintenance issues during our
July 2007 visit.
Part of the backlog regarding work orders is a result of the
division between CCJ’s correctional staff and the County
Facilities Management Department. Correctional staff are not
permitted to undertake any facility repair work. Even a burned
out lightbulb in an inmate’s cell requires a Facilities
Management work order and an electrician to change the bulb.
This results in inmates having no lighting in their cells for
multiple days in a row, which is especially dangerous when the
inmates are locked inside their cells for extended periods.
Electrical hazards were prominent throughout the housing
areas and neither correctional officers nor maintenance staff
seemed to be concerned about them. During our July 2007 on-site
visit, 34 uncompleted work orders for exposed wiring in Division
XI dated as far back as February 23, 2007. We frequently
observed broken switch plate and receptacle covers with exposed
live wires throughout the housing units, including shower and
toilet areas where floors were wet, creating a severe shock
hazard. In Division VIII, a receptacle in a recreation room was
pulled completely away from the wall, with no cover plate. The
outlet tested live, which is a major safety hazard to inmates and
staff.
Plumbing deficiencies were also abundant. It was common to
find that multiple sinks, toilets, and showers were inoperable in
a single tier. It was rare to find hot water availability in a
cell, and we observed many inmates locked in cells for as long as
26 hours with no access to drinking water. We saw multiple in

- 75 

cell plumbing leaks that resulted in constant cell flooding.
Many of these conditions had existed for more than a month.
Serious ventilation issues were observed in some areas. In
Division VI, Unit 2-C, 21 out of 22 cells had no ventilation
because metal plates had been installed behind the grate on the
supply ducts, prohibiting the movement of air into the cells.64
Although the unit was designed to house 44 inmates, it was
overpopulated at the time of our visit and housed more than 60
inmates, with many inmates housed three to a cell and locked in
for 26-hour periods every other day. These cells are not big
enough to meet generally accepted correctional standards for
three inmates.65 Air quality measurements indicated excessive
temperature and relative humidity within the tier. The
combination of high temperature and humidity, overcrowding, and
lack of air movement creates an unhealthy environment that
increases the risk of disease transmission. This particular tier
also had exposed wiring in the dayroom; all three of the sinks in
the toilet area were out of order; two of the three showers were
inoperable; a water leak under the tile on both sides of the
bathroom door created a falling hazard; and six burned out lights
in the dayroom resulted in unacceptably low light levels.
Finally, as discussed above, conditions in the RCDC intake
area are grossly inadequate for the purpose it serves and the
number of inmates who are processed through the area each day.
Consistent with generally accepted correctional standards, the
limited toilets available should serve a dormitory of a maximum
of 36 inmates, not the several hundred inmates processed through
the RCDC each day. Given the lack of timely responses to
plumbing problems at CCJ, it is easy to imagine the filthy

64

This condition violated Illinois County Jail Standards
701.120(a)(4).
65

None of the cells at CCJ are sized to accommodate more
than two inmates per cell. In fact, the American Correctional
Association waived their sizing standards for portions of the
facility to allow accreditation because many of the cells do not
meet current standards for housing two inmates. A third inmate
in these cells has to place his mattress on the floor of the
cell, further reducing the unencumbered space in the cell and
making it difficult for the inmates to move around in the cell.
The third inmate on the floor is forced to sleep with his face at
floor level where he inhales dust particles and airborne
allergens that settle to the floor, increasing the risk to the
inmate of contracting respiratory infections.

- 76 

environmental conditions that exist in the RCDC when the toilets
become clogged.
Maintenance and sanitation are categorically inadequate
throughout the facility, exposing inmates and staff to unhealthy
and unsafe environments as a result.
2.

Pest Control

The three major pest problems observed during our site
visits involved mice, cockroaches and drain flies. Although mice
and cockroaches are nocturnal by nature and are not generally
seen in daylight hours, we did observe a few of these during our
visits and found evidence of their presence. Staff and inmates
alike commented on the presence of mice in the facility and many
inmates had towels or other types of barriers across the bottom
of their celldoors to keep the mice out of their cells at night.
Drain flies are small flies that are found in shower and toilet
areas where they lay their eggs in gelatinous organic matter that
builds up under the rim of toilets and in floor drains. These
flies were noted in several of the divisions including the Cermak
medical area where fly traps were being used to capture adult
flies. Outbreaks of adult flies have been associated with
bronchial asthma in susceptible individuals. Their presence is
also a sign of inadequate housekeeping and sanitation.
Except for the food service and Cermak hospital areas, pest
control is managed by CCJ staff. CCJ has only one person
assigned to conduct pest control for the entire 96-acre facility.
While this person is a licensed and certified pest control
operator (“PCO”), one person cannot perform adequate pest control
for a facility of this size and nature. Staff indicated that the
PCO works on an on-call basis to resolve acute problems. Pest
control at CCJ is totally a reactive effort. The size of the
facility does not allow the PCO to do much follow up or
preventive work. We found numerous mousetraps that had heavy
layers of dust on them, indicating that little follow up work was
done to check the traps and to replace bait as needed.
3.

Sanitation Oversight

We were informed that CCJ has a single registered sanitarian
on staff. However, upon interviewing the facility’s sanitarian,
we learned that she was not registered by any state or national
professional organization and had no formal education as a
sanitarian. She has been in her current position for six years,
but has never had an opportunity for any in-service training
outside of the department. She also had not had any

- 77 

opportunities for training on the few pieces of sanitation
equipment provided to her. This lack of training severely limits
her ability for professional growth to learn about current
environmental health practice as well as emerging environmental
issues in correctional facilities such as MRSA. The CCJ
sanitarian is not being supported through training and education.
CCJ’s sanitarian functions as an inspector who also provides
some training to staff on chemical usage. Her inspections duties
cover areas such as housekeeping, lighting, plumbing, chemicals,
pest control, fire extinguishers, hot water temperatures, and the
like. Housekeeping inspections are done by visiting one tier per
division per month. Given the facility’s size, it could be six
months to a year before she is able to make a return visit to a
particular tier. She checks hot water temperatures by asking the
inmates because she has no tools to measure the temperature. She
checks fire drill logs and the inspection tags on the fire
extinguishers to make sure documentation is completed, but she
has no involvement in the actual fire drills themselves. She
checks lighting by looking for burned out fixtures because she
has had no training on how to use a light meter. She inspects
the kitchen but has no equipment to test or measure anything with
to insure that safe food conditions exist in the kitchen. Her
last ServSafe© and Illinois Department of Public Health Food
Service Certification training occurred in 2001 and expired in
2006. Despite all of the inspection work she does, she has no
authority to effect changes in housekeeping practices, food
service operations, housing conditions, pest problems, or fire
safety issues. In effect, she is an inspector of documentation
more than a verifier of actual conditions at CCJ.
Organizational oversight appears to be weak throughout the
divisions. We constantly observed conditions that should not
have existed if staff were being held accountable for conditions
in the housing areas. Staff must be aware of and take action
when policies are violated by inmates and unsafe conditions are
seen. Staff frequently seemed to turn their back on issues such
as obvious safety hazards caused by inmates tampering with
electrical outlets, hanging clothes lines from damaged light
fixtures in cells or in shower areas, the accumulation of large
amounts of commissary items and/or food items in their cells,
etc. Apparently no one is held accountable for the poor levels
of housekeeping that we observed throughout the jail.
Oversight must also extend to the inmates themselves. They
must be held accountable for their actions when they do not
adequately clean their cells and dayrooms, when they damage CCJ
property, and when they openly violate CCJ policies. Failure to

- 78 

enforce inmate accountability greatly increases the maintenance
load on staff and creates a higher risk for staff and inmate
injuries.
4.

Housekeeping

The level of cleanliness at CCJ is very poor. In the
housing and medical areas we observed accumulations of dirt,
trash, mold, and mildew that had been allowed to exist for long
periods of time. Cells frequently had heavy layers of dirt and
dust under the bunks and around the toilet areas. Shower areas
frequently had dirt, mold, and mildew on walls and ceilings.
Toilet areas were extremely unsanitary.
Mattresses are not cleaned and sanitized between uses.
Hundreds of mattresses were seen in use that were worn to the
point that they were incapable of being cleaned and many covers
were missing entirely. Torn and damaged mattresses allow the
transfer of harmful pathogens, such as MRSA, from person to
person and also serve as convenient hiding places for shanks and
other contraband.
5.

Food Service

The food service program at CCJ is contracted to the Aramark
Corporation, which operates two kitchens, one located in the
basement of Division XI and a larger, central kitchen. The
kitchens operate under a Health Analysis Critical Control Point
process that is approved by the Chicago Department of Health.
The food service supervisors currently have ServSafe© and
Illinois Department of Public Health Food Service Manager
Certifications. They receive outside inspections once or twice a
year from the Cook County Department of Public Health and are
inspected on a weekly and monthly basis by jail personnel.
The Division XI kitchen prepares approximately 4500 meals
per day and operates three shifts per day seven days per week.
While sanitation was problematic during our June 2007 visit, the
Division XI Superintendent took immediate action and conditions
were vastly improved during our July 2007 visit. However, as
both of the dishwashing machines in this kitchen had been out of
order since March 2007, so all pots, pans, and preparatory
utensils are washed by hand without adequate sanitization
procedures.
The central kitchen prepares approximately 30,000 meals per
day and works 200 inmates per day in four crews. Although the
County selects the inmates who work in the food service area,

- 79 -

Aramark is responsible for their training and supervision.
Inmate workers reported that they receive no training prior to
working in the kitchen. Aramark staff confirmed that no formal
training takes place. The correctional officers who work in the
kitchen are responsible only for security.
In March 2007, CCJ found that inmate workers were not
utilizing gloves or hairnets, numerous sinks had clogged drains,
and excessive garbage was piled on the floor. During our on-site
visits, the dishwashing machines had a very heavy scale buildup
from hard water deposits that tend to clog spray nozzles and
limit the effectiveness and proper washing of food contact
surfaces. The floor in the dishwashing area is in poor repair,
causing standing water, and is not easily cleanable as required
by food codes. The Cook County Department of Public Health cited
CCJ on March 13, 2007 for this violation.
The delivery of food to the housing areas is accomplished
with non-insulated carts that are loaded from the plating line
and held until they are picked up by the staff who are
responsible for the delivery. The kitchen supervisor estimated
that some carts are held two to three hours between plating and
delivery. Because these carts are not insulated or heated, food
is allowed to cool to a point at which bacterial growth can
occur. Additionally, food was observed being plated at
unacceptable temperatures. Food codes require that hot food be
held and served at 140 degrees, but we observed food being plated
for delivery at 26 to 44 degrees below the required temperatures.
The low plating temperatures and significant delays in food
delivery greatly increase the risk of food borne disease.
IV.

REMEDIAL MEASURES

In order to rectify the identified deficiencies and protect
the constitutional rights of inmates confined at CCJ, this
facility should implement, at a minimum, the following remedial
measures:
A.	

Protection from Harm
1.	

Use of Force
a.	

Develop and maintain comprehensive and
contemporary policies and procedures regarding
permissible use of force.
(1)

Prohibit the use of force as a response to
verbal insults or inmate threats.

- 80 


b.

(2)

Prohibit the use of force as a response to
inmates’ failure to follow instructions where
there is no immediate threat to the safety of
the institution, inmates, or staff, unless
CCJ has attempted a hierarchy of nonphysical
alternatives which are documented.

(3)

Prohibit the use of force as punishment.

Establish effective oversight of the use of force.
(1)

Develop and implement a policy to ensure that
staff adequately and promptly reports all
uses of force.

(2)

Ensure that management review of incident
reports, use of force reports, and inmate
grievances alleging excessive or
inappropriate uses of force includes a timely
review of medical records of inmate injuries
as reported by medical professionals.

(3)

Ensure that incident reports, use of force
reports and inmate grievances are screened
for allegations of staff misconduct and, if
the incident or allegation meets established
criteria, that it is referred for
investigation.

(4)

Develop and maintain comprehensive policies,
procedures, and practices for the timely and
thorough investigation of alleged staff
misconduct.

(5)

Develop and implement policies and procedures
for the effective and accurate maintenance,
inventory and assignment of chemical and
other security equipment.

(6)

Develop and implement a process to track all
incidents of use of force that at a minimum
includes the following information: the
inmate(s) name, housing assignment, date and
type of incident, injuries (if applicable),
if medical care is provided, primary and
secondary staff directly involved, reviewing
supervisor, external reviews and results (if

- 81
applicable), remedy taken (if appropriate),
and administrative sign-off.
c.	

2.	

Develop an effective and comprehensive training
program in the appropriate use of force.
(1)

Ensure that staff receive adequate
competency-based training in CCJ’s use of
force policies and procedures.

(2)

Ensure that staff receive adequate
competency-based training in use of force and
defensive tactics.

(3)

Ensure that IAD management and staff receive
adequate competency-based training in
conducting investigations of use of force
allegations.

Safety and Supervision
a.	

Ensure that correctional officer staffing and
supervision levels are appropriate to adequately
supervise inmates. Discontinue the practice of
cross-watching.

b.	

Ensure that inmate work areas are adequately
supervised whenever inmates are present.

c.	

Ensure frequent, irregularly timed, and documented
security rounds by correctional officers inside
each housing unit.

d.	

Develop and implement policies and procedures
requiring all tools, utensils, equipment,
flammable materials, etc. are inventoried and
locked down at all times.

e.	

Ensure that staff adequately and promptly report
incidents.

f.	

Develop a process to track all serious incidents
that captures all relevant information, including:
location, any injuries, if medical care is
provided, primary and secondary staff involved,
reviewing supervisor, external reviews and results
(if applicable), remedy taken (if appropriate),
and administrative sign-off.

- 82
g.	

Establish a procedure to ensure that inmates do
not possess or have access to contraband. Conduct
regular inspections of cells and common areas of
the housing units for contraband.

h.	

Ensure that inmates placed in lock down status are
provided with appropriate due process that has
been developed and implemented in policies and
procedures.

i.	

Increase use of overhead recording security
cameras throughout the common areas of the
facility.

j.	

Conduct regular inspections of cells and common
areas of the housing units to identify and prevent
rule violations by inmates.

k.	

Review, and revise as applicable, all security
policies and Standard Operating Procedures
(“SOPs”) on an annual basis.

l.	

Review, and revise as applicable, all security
post orders regularly.

m.	

Revise policies, SOPs, and post orders for all
armed posts to include instruction on use of
deadly force and when and under what circumstances
the weapon should be used.

n.	

To the extent possible, taking in account the
different security levels and different physical
layouts in the various divisions, standardize
security policies, procedures, staffing reports,
and post analysis reports across the divisions.

o.	

Provide formal training on division-specific post
orders each time a correctional officer is
transferred from one division to another.

p.	

Implement specialized training for officers
assigned to special management units, which
include the Special Incarceration Units,
disciplinary segregation, and protective custody
units. Officers assigned to these units should
possess a higher level of experience and be

- 83
regularly assigned to these units for stability
purposes.
3.	

4.	

5.	

Disciplinary Process
a.	

Ensure that inmates are afforded due process for
any disciplinary actions against them, including
promptly receiving a disciplinary ticket and a
fair hearing.

b.	

Ensure that disciplinary hearings are conducted in
a private setting.

Classification
a.	

Develop and implement policies and procedures for
an objective classification system that separates
inmates in housing units by classification levels.

b.	

Update facility communication practices to provide
officers involved in the classification process
with current information as to cell availability
on each division.

c.	

Update the classification system to include
information on each inmate’s history with the
Special Incarceration Unit “level system” at CCJ.

d.	

Provide competency-based training and access to
all supervisors on the full capabilities of the
CCJ classification and inmate tracking system (or
any replacement system).

Inmate Grievance Procedure
a.	

Develop and implement policies and procedures to
ensure inmates have access to an adequate
grievance process that ensures that grievances are
processed and legitimate grievances addressed and
remedied in a timely manner, responses are
documented and communicated to inmates, inmates
need not confront staff prior to filing grievances
about them, and inmates may file grievances
confidentially.

b.	

Ensure that grievance forms are available on all
units and are available in Spanish.

- 84 

c.	

6.	

B.	

Ensure that inmate grievances are screened for
allegations of staff misconduct and, if the
incident or allegation meets established criteria,
referred for investigation.

Access to Information
a.	

Ensure that newly admitted inmates receive
information they need to comply with facility
rules and regulations, be protected from harm,
report misconduct, access medical and mental
health care, and seek redress of grievances.

b.	

Ensure that inmates who are not literate are
afforded the opportunity to have information on
facility rules and services explained to them
orally.

c.	

Ensure that information on facility rules and
services is available in Spanish.

Medical Care
1.	

Intake Screening
a.	

Ensure that adequate intake screening and health
assessments are provided. Develop and implement
an appropriate medical intake screening instrument
that identifies observable and non-observable
medical needs, including infectious diseases, and
ensure timely access to a physician when
presenting symptoms require such care.

b.	

Ensure that acute and chronic health needs of
inmates are identified in order to provide
adequate medical care.

c.	

Ensure that medical screening information is
reviewed in a timely manner by trained medical
care providers.

d.	

Provide adequate screening and health assessments
for inmates in accordance with generally accepted
correctional standards of care and ensure adequate
evaluation for mental illness and suicide risk.

e.	

Ensure that tuberculosis (“TB”) screening is
conducted in a timely manner.

- 85 

2.	

3.	

Acute care
a.	

Provide timely medical appointments and follow-up
medical treatment. Ensure that inmates receive
treatment that adequately address their serious
medical needs. Ensure that inmates receive acute
care in a timely and appropriate manner.

b.	

Provide adequate acute care for inmates with
serious and life-threatening conditions.

c.	

Ensure that staff are adequately trained and
prepared to handle emergent situations in
accordance generally accepted professional
standards.

Chronic care
a.	

Ensure that inmates receive thorough assessments
for, and monitoring of, their chronic illness.
Develop clinical practice guidelines for inmates
with chronic and communicable diseases. Ensure
that standard diagnostic tools are employed to
administer the appropriate preventative care in a
timely manner.

b.	

Adopt and implement appropriate clinical
guidelines for chronic diseases such as HIV,
hypertension, diabetes, asthma, and elevated blood
lipids, and policies and procedures on, inter
alia, timeliness of access to medical care,
continuity of medication, infection control,
medicine dispensing, intoxication/detoxification,
record-keeping, disease prevention, and special
needs.

c.	

Ensure that medical staff are adequately trained
to identify inmates in need of immediate or
chronic care, and provide timely treatment or
referrals for such inmates.

d.	

Ensure that inmates with chronic conditions are
routinely seen by a physician to evaluate the
status of their health and the effectiveness of
the medication administered for their chronic
conditions.

- 86
e.	

4.	

5.	

Ensure adequate follow-up treatment and medication
administration concerning all inmates with chronic
conditions.

Treatment and Management of Communicable Disease
a.	

Provide adequate treatment and management of
communicable diseases, including TB and
Methicillin-resistant Staphylococcus aureus
(“MRSA”).

b.	

Ensure that inmates with communicable diseases are
appropriately screened, isolated, and treated.

c.	

Ensure that inmate and staff do not interfere with
HVAC and negative pressure systems.

d.	

Develop and implement an adequate TB control plan
in accordance with generally accepted correctional
standards of care. Such should provide guidelines
for identification, treatment, and containment to
prevent transmission of TB to staff or inmates.

e.	

Develop and implement policies that adequately
manage contagious skin infections. Develop a skin
infection control plan to set expectations and
provide a work plan for the prevention of
transmission of skin infections, including
drug-resistant infections to staff and other
inmates.

f.	

Conduct a sufficient initial health assessment,
including screening for TB and STDs, of all
inmates in a timely fashion.

g.	

Develop and implement adequate guidelines to
ensure that inmates receive appropriate wound
care.

Access to Health Care
a.	

Ensure inmates have adequate access to health
care.

b.	

Ensure that the medical request process for
inmates is adequate and provides inmates with
adequate access to medical care. This process

- 87
should include logging, tracking, and timely
responses by medical staff.
c.	

6.	

Follow-Up Care
a.	

7.	

8.	

Develop and implement an effective system for
triaging medical requests. Ensure that sick call
requests are appropriately triaged based up the
seriousness of the medical issue.

Provide adequate care and maintain appropriate
records for inmates following hospitalization.
Ensure that inmates who receive specialty or
hospital care are evaluated upon their return to
the facility and that, at a minimum, discharge
instructions are noted and appropriately provided.

Record Keeping
a.	

Ensure that medical records are adequate to assist
in providing and managing the medical care needs
of inmates at CCJ.

b.	

Ensure that medical records are complete,
accurate, readily accessible, and systematically
organized. All clinical encounters and reviews of
inmates should be documented in the inmates’
records.

Medication Administration
a.	

Ensure that treatment and administration of
medication to inmates is implemented in accordance
with generally accepted professional standards of
care.

b.	

Ensure that administration of medication is
accurate and adequately documented. Develop
policies and procedures for the accurate
administration of medication and maintenance of
medication records. Provide a systematic review
of the use of medication to ensure that each
inmate’s prescribed regimen continues to be
appropriate and effective for his condition.

c.	

Ensure that medicine distribution is hygienic and
appropriate for the needs of inmates.

- 88 

9.

Medical Facilities
a.	

Ensure that sufficient space is available to
provide inmates with adequate medical care
services including: intake screening, sick call,
physical assessment, and acute, chronic,
emergency, and speciality medical care (such as
geriatric and pregnant inmates).

b.	

Ensure that medical areas are adequately clean and
maintained, including installation of adequate
lighting in medical exam rooms. Ensure that hand
washing stations in medical areas are fully
equipped, operational, and accessible.

10.	 Specialty Care
a.	

Ensure that specialty consultations are timely and
that any resulting reports are forwarded to CCJ
staff. Specialist recommendations should be
implemented in a timely manner or, where deemed
inappropriate, a CCJ physician should properly
document why such recommendations were
implemented. Provide adequate long-term care
planning for inmates with chronic illnesses.

b.	

Ensure that inmates are provided adequate access
to specialty care in accordance with generally
accepted professional standards of care.

c.	

Ensure that pregnant inmates are provided adequate
care in accordance with generally accepted
professional standards of care.

11.	 Staffing, Training, and Supervision
a.	

Provide adequate staffing, training, and
supervision of medical and correctional staff
necessary to ensure adequate medical care is
provided.

b.	

Ensure that medical staffing is adequate for
inmates’ serious medical needs and that physicians
adequately monitor their patients.

c.	

Provide adequate physician oversight and
supervision of medical staff.

- 89 

d.	

Ensure that there is an adequate number of
correctional officers to escort inmates to medical
units.

12.	 Dental Care
a.	

Ensure that inmates receive adequate dental care
in accordance with generally accepted professional
standards of care. Such care should be provided
in a timely manner.

13.	 Quality Assurance Review

B.	

a.	

Ensure that CCJ’s quality assurance system is
adequate to identify and correct serious
deficiencies with the medical system.

b.	

Ensure that CCJ’s quality assurance system is
capable of assisting in managing and treating
inmate medical needs. At a minimum, such a system
should be reliable and capable of tracking medical
related incidents.

Mental Health Care:
1.	

Timely and Appropriately Evaluate Inmates
a.	

Ensure CCJ properly identifies inmates with mental
illness through adequate screening.

b.	

Ensure that inmates with potentially serious
chronic mental health illness are referred for
prompt mental health evaluations and examinations
by a psychiatrist.

c.	

Provide adequate mental health assessment and
treatment in accordance with generally accepted
professional standards of mental health care.

d.	

Ensure that adequate crisis services are available
to address the psychiatric emergencies of inmates.

e.	

Provide staffing adequate for inmates’ serious
mental health needs. Provide adequate on-site
psychiatry coverage. Ensure that psychiatrists
see inmates in a timely manner. Ensure that
psychotropic medication prescriptions are reviewed
by a psychiatrist on a regular, timely basis.

- 90
f.	

Provide adequate screening to properly identify
inmates with mental illness. Ensure that CCJ's
intake evaluation process includes a mental health
screening that is incorporated into an inmate's
medical record.

g.	

Develop and implement an appropriate intake
screening instrument that identifies mental health
needs, and ensure timely access to a mental health
professional when presenting symptoms require such
care.

2. 	 Assessment and Treatment
a.	

Ensure that treatment plans adequately address
inmates’ serious mental health needs and that the
plans contain interventions specifically tailored
to the inmates’ diagnoses and problems. Provide
therapy services where necessary for inmates with
serious mental health needs. Provide adequate
opportunities for inmates and staff to have
confidential communications related to mental
health treatment, while maintaining appropriate
security precautions.

b.	

Ensure that mental health evaluations done as part
of the disciplinary process include
recommendations based on the inmate's mental
health status.

c.	

Provide adequate on-site psychiatry coverage for
inmates’ serious mental health needs. Ensure that
psychiatrists see inmates in a timely manner and
that psychotropic medication orders are reviewed
by a psychiatrist on a regular, timely basis.

d.	

Ensure that medications are provided to inmates in
a timely manner and that they are properly
monitored.

e.	

Provide staffing adequate for inmates with serious
mental health needs. Ensure that services, such
as distribution of medications, are performed by
nurses or other properly trained staff.

f.	

Provide policies and procedures that appropriately
assess inmates with mental illness.

- 91 

g.	

Provide adequate medical documentation and general
procedures as part of the mental health
assessments that accounts for inmates’ psychiatric
histories.

h.	

Develop and implement an appropriate intake
screening instrument that identifies mental health
needs, and ensure timely access to the mental
health professional when presenting symptoms
require such care.

3. 	 Psychotherapeutic Medication Administration

4.	

a.	

Ensure timely responses to orders for medication
and laboratory tests, and prompt documentation
thereof in inmates’ charts.

b.	

Ensure that adequate psychotherapeutic medication
administration is provided in accordance with
generally accepted professional mental health care
standards.

c.	

Ensure that changes to inmates’ psychotropic
medications are clinically justified. Screen
inmates on psychotropic medications for movement
disorders and provide treatment where appropriate.

d.	

Ensure that inmates receive adequate screening and
evaluation for the administration of psychotropic
medications in a timely manner.

Other Mental Health Issues
a.	

Ensure that administrative segregation and
observation status are not used to punish inmates
for symptoms of mental illness and behaviors that
are, because of mental illness, beyond their
control.

b.	

Ensure that CCJ mental health records are
centralized, complete, and accurate.

c.	

Ensure that CCJ quality assurance system is
adequate to identify and correct serious
deficiencies with the mental health system.

- 92 


D.	

d.	

Ensure that a psychiatrist or physician conducts
an in-person evaluation of an inmate prior to a
seclusion or restraint order, or as soon
thereafter as possible. Seclusion or restraint
orders should include sufficient criteria for
release.

e.	

Ensure that all staff who directly interact with
inmates (including Correctional Officers) receive
competency-based training on basic mental health
information (e.g., diagnosis, specific problematic
behaviors, psychiatric medication, additional
areas of concern); recognition of signs and
symptoms evidencing a response to trauma; and the
appropriate use of force for inmates who suffer
from mental illness.

Suicide Prevention Measures
1.	

Provide adequate treatment for inmates with selfinjurious behavior.

2.	

Develop policies and procedures to ensure appropriate
management of suicidal inmates and the establishment of
a suicide prevention program.

3.	

Ensure that all staff are educated and adequately
trained on suicide recognition and intervention,
including pre-service and annual in-service suicide
prevention training.

4.	

Provide a curriculum for pre-service and annual inservice competency-based suicide prevention training
that includes an array of topics so that staff are
adequately trained to identify and manage suicide.

5.	

Ensure that, prior to assuming their duties and on a
regular basis thereafter, all staff who work directly
with inmates have demonstrated competence in
identifying and managing suicide.

6.	

Ensure that CCJ suicide prevention policies include an
operational description of the requirements for both
pre-service and annual in-service training.

7.	

Ensure that any staff who are exempt from suicide
prevention training have limited inmate contact.

- 93
8.	

Screen all inmates upon intake, including questioning
to assess current and past suicide risk.

9.	

Document inmate suicide attempts at CCJ in the inmate’s
correctional record in the classification system, in
order to ensure that intake staff will be aware of past
suicide attempts if an inmate with a history of suicide
attempts is admitted to CCJ again in the future.

10.	 Ensure that intake staff are sufficiently experienced
and qualified to identify inmates that pose a risk for
suicide, and conduct appropriate follow-up evaluations
by mental health professionals of new inmates within 14
days of intake.
11.	 Ensure that inmates on suicide precautions receive
adequate mental status examinations by a mental health
clinician.
12.	 Ensure that suicidal inmates are housed in an area that
is safe for them with appropriate supervision and
observation by staff.
13.	 Ensure that 15- and 30-minute checks of inmates under
observation for risk of suicide are timely performed
and appropriately documented.
14.	 Provide different levels of supervision of an inmate
based on the presenting risk factors for suicide.
15.	 Ensure that detainees placed on suicide watch are
assessed adequately, monitored appropriately to ensure
their health and safety, and released from suicide
watch as their clinical condition indicates according
to professional standards of care.
16.	 Ensure that cut-down tools are readily available to
staff in all housing units. Train staff in use of
cut-down tools.
17.	 Ensure a component of administrative review is
implemented following a suicide or a suicide attempt to
identify what could have been done to prevent the
suicide.

- 94 

E.	

F.	

Fire and Life Safety
1.	

Ensure that all facilities have adequate fire and life
safety equipment which is properly maintained and
inspected.

2.	

Implement competency based testing for staff regarding
fire/emergency procedures.

3.	

Develop and implement adequate policies and procedures
regarding fire prevention including emergency planning
and drills.

4.	

Ensure that emergency keys are appropriately marked,
available, and consistently stored in a quickly
accessible location.

5.	

Ensure that fire alarms are installed and maintained in
all housing areas.

6.	

Inventory and store all flammable, toxic, and caustic
materials in a well ventilated, but locked,
compartment.

7.	

Ensure that emergency drills are conducted on a regular
basis.

Sanitation and Environmental Conditions
1.	

Sanitation and Maintenance of Facilities
a. 	 Develop and implement policies and procedures to
ensure adequate cleaning and maintenance of the
facilities with meaningful inspection processes
and documentation. Such policies should include
oversight and supervision, as well as establish
daily cleaning requirements for toilets, showers,
and housing units.
b.	

Ensure prompt and proper maintenance of shower,
toilet, and sink units.

c.	

Ensure proper ventilation and airflow in all cells
and housing units.

d.	

Ensure adequate lighting in all housing units and
prompt replacement and repair of malfunctioning
lighting fixtures.

- 95

3.	

e.	

Ensure adequate pest control, including sufficient
staffing for routine and follow-up pest control
services.

f.	

Ensure that all inmates have access to needed
hygiene supplies.

g.	

Develop and implement policies and procedures for
cleaning, handling, storing, and disposing of
biohazardous materials.

h.	

Use cleaning chemicals that sufficiently destroy
the pathogens and organisms in biohazard spills.

i.	

Secure all sharp medical tools.

j.	

Destroy any mattress that cannot be sanitized
sufficiently to kill any possible bacteria.
Inspect and replace as often as needed all frayed
and cracked mattresses.

k.	

Develop a plan to reduce and prevent triplebunking of inmates in cells designed for two
inmates.

l.	

When triple-bunking of inmates is unavoidable,
provide a stackable bunk, moveable platform, or
cot for each triple-bunked cell, so that inmates
are not required to sleep with the mattress
directly on the cell floor.

Environmental Control
a.	

Ensure adequate control and observation of CCJ
cells, particularly with regard to razors, fire
loading materials, commissary items, and cleaning
supplies.

b.	

Repair electrical shock hazards; develop and
implement a system for maintenance and repair of
electrical outlets, devices, and exposed
electrical wires.

- 96 

4.	

5.	

Sanitary Laundry Procedures
a.	

Ensure that laundry delivery procedures protect
inmates from exposure to contagious disease,
bodily fluids, and pathogens by preventing clean
laundry from coming into contact with dirty
laundry or contaminated surfaces.

b.	

To limit the spread of MRSA and other infectious
disease, require inmates to provide all clothing
and linens for CCJ laundering and prevent inmates
from washing and drying laundry outside the formal
procedures.

c.	

To limit the spread of MRSA and other infectious
disease, ensure that clothing and linens returned
from off-site laundry facility are clean,
sanitized, and completely dry.

d.	

Provide all inmates with properly cleaned and
adequate bedding and clothing.

Food Service
a. 	 Provide training for kitchen workers in the areas
of food safety and food handling to reduce the
risk of food contamination and food-borne
illnesses.
b. 	 Ensure that dishes and utensils, food preparation
and storage areas, and vehicles and containers
used to transport food are properly cleaned and
sanitized.
c.	

Ensure that foods are served and maintained at
proper temperatures.
* * * * * * *

Please note that this findings letter is a public document.
It will be posted on the Civil Rights Division’s website. While
we will provide a copy of this letter to any individual or entity
upon request, as a matter of courtesy, we will not post this
letter on the Civil Rights Division’s website until ten calendar
days from the date of this letter.
We hope to continue working with the County in an amicable
and cooperative fashion to resolve our outstanding concerns

- 97 regarding CCJ. Assuming there is a continuing spirit of
cooperation from the County, we also would be willing to send our
consultants’ evaluations under separate cover. These reports are
not public documents. Although the consultants’ evaluations and
work do not necessarily reflect the official conclusions of the
Department of Justice, their observations, analysis, and
recommendations provide further elaboration on the issues
discussed in this letter and offer practical technical assistance
in addressing them.
We are obligated to advise you that, in the event that we
are unable to reach a resolution regarding our concerns, the
Attorney General may initiate a lawsuit pursuant to CRIPA to
correct deficiencies of the kind identified in this letter 49
days after appropriate officials have been notified of them.
42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working
cooperatively with you and are confident that we will be able to
do so in this case. The lawyers assigned to this investigation
will be contacting the facility’s attorney to discuss this matter
in further detail. If you have any questions regarding this
letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights
Division’s Special Litigation Section, at (202) 514-0195, or
Joan Laser, of the United States Attorney’s Office, at (312)
353-1857.
Sincerely,
/s/ Grace Chung Becker
Grace Chung Becker
Acting Assistant Attorney General

Patrick J. Fitzgerald
United States Attorney
Northern District of Illinois
cc:

Salvador Godinez
Executive Director
Cook County Department of Corrections

- 98
Patrick T. Driscoll, Jr.
Chief, Civil Actions Bureau
Office of the Cook County State’s Attorney
Donald J. Pechous
Assistant State’s Attorney
Office of the Cook County State’s Attorney
Peter M. Kramer, Esq.
General Counsel
Cook County Sheriff’s Office
Daniel F. Gallagher, Esq.
Querrey & Harrow
Counsel for the Sheriff’s Office
Paul A. O’Grady, Esq.
Querrey & Harrow
Counsel for the Sheriff’s Office