U.S. Department of Justice
Civil Rights Division

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

January 15, 2009


Mr. Stephen Nodine

President

Mobile County Commission

205 Government Street

Mobile, AL 36644

Sam Cochran

Sheriff

Mobile County

510 South Royal Street

Mobile, AL 36601

Re:

Mobile County Metro Jail


Dear Mr. Nodine and Sheriff Cochran: 

We write to report the findings of the investigation of the

Civil Rights Division into conditions at the Mobile County Metro

Jail (“MCMJ”). On March 12, 2003, we notified officials of

Mobile County (“County”) and the Mobile County Sheriff’s Office

(“Sheriff”) of our intent to conduct an investigation of MCMJ

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 May 27-30, 2003, and July 6-7, 2003, and again on

September 22-25, 2003, we conducted on-site inspection tours with

expert consultants in the fields of corrections, custodial

medical and mental health care, and safety and sanitation. We

interviewed administrative and security staff, medical and mental

health care providers, and inmates. We reviewed an extensive

number of documents, including policies and procedures, incident

reports, grievances, medical records, and use of force records. 


- 2 ­
In keeping with our pledge of transparency and to provide

technical assistance where appropriate, our expert consultants

conveyed their preliminary impressions and concerns to the County

and the Sheriff. 

As you are aware, at the conclusion of our tours, the County

and the Sheriff approached us to begin negotiating a means to

correct the deficiencies present at MCMJ as identified by our

expert consultants. Although we would not normally engage in

negotiations prior to the issuance of our statutorily-required

written findings, we found the desire of the County and the

Sheriff to correct the deficiencies at MCMJ sincere enough to

warrant our accommodation, and we immediately began negotiations

while continuing our investigation and preparing our written

findings. During these negotiations, we contacted the County and

the Sheriff in 2006 to request cooperation in conducting a fourth

tour of MCMJ to update and inform our factual findings. In

continuing our pledge of transparency and to provide technical

assistance, we also provided, at that time, copies of the written

reports prepared by our consultants that identified deficiencies

at MCMJ and recommendations on how to correct the identified

deficiencies. 

It was while negotiating mutually agreeable terms and

conditions of our tour that the County and the Sheriff took the

extraordinary and unexpected step of ceasing all communications

with the Department of Justice regarding this investigation.

Accordingly, and as we advised you after each of our attempts to

reinitiate communications throughout 2007, we were forced to

continue our investigation absent your cooperation.

Specifically, since that time, we have examined state and federal

survey information, media reports, and other publicly available

data, as well as conducted interviews of former inmates, family

and friends of inmates, attorneys, advocates, and other persons

familiar with present conditions at MCMJ. In addition, as

warned, we considered the failure of the County and the Sheriff

to cooperate with our investigation as an adverse factor when

preparing our written findings. 

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. We conclude that certain conditions at MCMJ

violate the constitutional rights of the inmates confined there.

As detailed below, we find that MCMJ engages in a pattern or

practice of subjecting inmates to egregious or flagrant

conditions, specifically in regard to: (1) the medical care of


- 3 ­
inmates; (2) the mental health care of inmates; (3) the use of

restraints; (4) the right of inmates to be protected from

physical harm from other inmates; and (5) the right of inmates to

be confined in sanitary and safe conditions.

I.

BACKGROUND


The MCMJ is operated by the Sheriff of Mobile County. The

Sheriff has appointed a Warden to be responsible for the day-to­
day operations of MCMJ. The Sheriff employs approximately 230

corrections officers and a civilian support staff at MCMJ, as

well as a medical staff which includes several nurses, a

physician, and a part-time psychiatrist. 

The MCMJ houses a mix of pretrial detainees and convicted

prisoners (“inmates”) and houses both male and female inmates.

The MCMJ is comprised of two facilities – the main facility,

known simply as “the Jail,” and a minimum security annex,

referred to as “the Barracks.” The main facility (“Jail”) at

MCMJ was built in sections, with the first portion completed in

the mid-1980s and the final sections completed in 1991. The Jail

has a design capacity of 816 inmates. The Jail is constructed as

a remote supervision facility, in which staff work in control

areas observing inmates housed in ten semi-circular “pods.”

Eight pods house male inmates, and two pods house female inmates.

The eight pods housing male inmates are subdivided into six

eight-cell “wedges,” designed to house 16 inmates in each wedge.

The two pods housing female inmates are subdivided into two

twelve-cell wedges. For male inmates, two wedges are designated

for administrative segregation; two wedges are designated for

protective custody; one wedge is designated for medical housing;

and one wedge is designated for potentially suicidal inmates.

The Jail also has a medical clinic and a booking area with

holding cells for recent arrestees. 

The MCMJ’s minimum security annex (“the Barracks”), is

located across the street from the Jail. The Barracks opened in

September 2002, with a design capacity of 325 inmates. The

Barracks contains eight dormitory-style housing units that

resemble military barracks. 

The population of the Jail steadily remained at

approximately 1,000 inmates during 2007, while the Barracks

averaged close to 300 inmates. Prior to 2007, the population in

the Barracks had been significantly below design capacity. For

example, at the time of our first tour in May 2003, there were

only 113 inmates in the Barracks. By contrast, the Jail has

frequently exceeded design capacity. For example, in the six


- 4 ­
months prior to our first tour in May 2003, the average daily

population for each month was over 1300 inmates for the Jail and

Barracks combined.

II.

LEGAL STANDARDS


CRIPA authorizes the Attorney General to investigate and,

when necessary, initiate civil action to obtain appropriate

relief from egregious jail conditions that subject inmates to a

pattern or practice of deprivation of their constitutionally

protected rights. 42 U.S.C. § 1997. The Eighth Amendment

affords convicted prisoners protection from cruel and unusual

punishment. U.S. Const. amend. VIII. This protection is

incorporated into the Due Process Clause of the Fourteenth

Amendment and binding upon the states. Robinson v. California,

370 U.S. 660, 667 (1962). Moreover, the Due Process Clause of

the Fourteenth Amendment affords at least the same Eighth

Amendment protection from cruel and unusual punishment to an

inmate of a jail incarcerated prior to trial, as it would to a

convicted prisoner. City of Revere v. Massachusetts Gen. Hosp.,

463 U.S. 239, 244 (1983). As defined by the Supreme Court, this

constitutional protection from cruel and unusual punishment

requires corrections officials to provide “humane conditions” of

confinement to jail inmates. Farmer v. Brennan, 511 U.S. 825,

832 (1994).

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

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.


- 5 -

Helling v. McKinney, 509 U.S. 25, 33 (1993) (internal citations

and quotations omitted).

A.

Medical Care


A corrections official’s “deliberate indifference” to an

inmate’s serious medical needs is a violation of the Eighth

Amendment. Estelle v. Gamble, 429 U.S. 97, 104 (1976); Farrow v.

West, 320 F.3d 1235, 1243-46 (11th Cir. 2003); Steele v. Shah, 87

F.3d 1266, 1269 (11th Cir. 1996). Corrections officials act with

deliberate indifference when an inmate needs serious medical care

and the officials fail to, or refuse to, obtain or provide that

care. Farrow, 320 F.3d at 1246. Said another way, a corrections

official will violate the protections of the Eighth Amendment

when the official “knows of and disregards an excessive risk of

inmate health.” Farmer, 511 U.S. at 837. The corrections

official must “both be aware of facts from which the inference

could be drawn that a substantial risk of serious harm exists,

and he must also draw the inference.” Id. Providing only

cursory care is insufficient when the need for more serious

treatment is obvious. McElligott v. Foley, 182 F.3d 1248, 1255

(11th Cir. 1999). 

B.

Mental Health Care


The constitutional requirement imposed on corrections

officials to provide adequate medical care includes a duty to

provide adequate mental health care. Farmer, 511 U.S. at 832;

see also Campbell v. Sikes, 169 F.3d 1353, 1362 (11th Cir. 1999)

(“proper medical care” in question consisted of mental health

care provided by defendant corrections psychiatrist); Steele, 87

F.3d at 1269 (same). Delay in providing hospitalization to a

prisoner in need of immediate psychiatric care may constitute

deliberate indifference. See e.g., Gibson v. County of Washoe,

Nev., 290 F.3d 1175, 1190-91 (9th Cir. 2002). 

Furthermore, corrections officials have a constitutional

obligation to act when there is a strong likelihood that an

inmate will engage in self-injurious behavior, including suicide.

Snow ex rel. Snow v. City of Citronelle, AL, 420 F.3d 1262, 1268­
69 (11th Cir. 2005). In corrections suicide cases alleging

constitutional violations, “the plaintiff must show that the jail

official displayed ‘deliberate indifference’ to the prisoner’s

taking of his own life.” Cook ex. rel. Tessier v. Sheriff of

Monroe County, 402 F.3d 1092, 1115 (11th Cir. 2005) (quoting

Cagle v. Sutherland, 334 F.3d 980, 986 (11th Cir. 2003)). In

order to establish ‘deliberate indifference’ in a corrections

suicide case, the plaintiff must demonstrate: “(1)subjective


- 6 ­
knowledge of a risk of serious harm; (2) disregard for that risk;

(3) by conduct that is more than mere negligence.” Cook, 402

F.3d at 1115 (quoting Cagle at 986). 

C.

Use of Restraints


The Eighth Amendment protection from cruel and unusual

punishment forbids the use of excessive physical force against

inmates. Hudson v. McMillian, 503 U.S. 1, 5 (1992); Skrtich v.

Thornton, 280 F.3d 1295, 1301 (11th Cir. 2002). The use of

mechanical restraints is a type of physical force, and the

initial decision to employ such restraints is evaluated under

Eighth Amendment standards. See Williams v. Burton, 943 F.2d

1572, 1575 (11th Cir. 1991) (initial decision to place inmate

into four-point restraints evaluated under Eighth Amendment use­
of-excessive-force standards). The use of force by a corrections

officer will violate the Constitution when it is not applied “in

a good-faith effort to maintain or restore discipline,” but

instead is administered “maliciously and sadistically to cause

harm.” Hudson, 503 U.S. at 6-7; Campbell, 169 F.3d 1353, 1374

(11th Cir. 1999); Harris v. Chapman, 97 F.3d 499, 505 (11th Cir.

1996); Williams, 943 F.2d at 1575. Courts may examine a variety

of factors in determining whether the force used was excessive,

most commonly including: (1) the need for the application of

force; (2) the relationship between the need for force and the

amount of force applied; (3) the threat, if any, reasonably

perceived by responsible corrections officers; and, (4) any

efforts made to temper the severity of a forceful response.

Hudson, 503 U.S. at 7-8; Campbell, 169 F.3d at 1375; Harris, 97

F.3d at 505; Williams, 943 F.2d at 1575. Additionally, courts

will also factor into the analysis the extent of the inmate’s

injury at the hands of the corrections officers. Id. 

Further, “once the necessity for the application of force

ceases, any continued use of harmful force can be a violation of

the Eighth and Fourteenth Amendments, and any abuse directed at

the prisoner after he terminates his resistance to authority is

an Eighth Amendment violation.” Williams, 943 F.2d at 1576

(citing Ort v. White, 813 F.2d 318, 324 (11th Cir. 1987)). In

addition to the Eighth Amendment standards applicable to the use

of restraints, Fourteenth Amendment procedural due process

considerations must be accounted for when the restraint is

employed as punishment, defined as “a penalty administered after

reflection and evaluation and intended to deter similar conduct

in the future,” distinct from restraints employed as immediately

necessary “to bring an end to an ongoing violation.” Id.


- 7 ­
D.

Security, Supervision, and Protection From Harm


The Supreme Court in Farmer made clear that inmates have a

constitutional right to be protected from harm. Farmer, 511 U.S.

at 832. Accordingly, corrections officials have a duty “to

protect prisoners from violence at the hands of other prisoners.”

Farmer, 511 U.S. at 833 (internal quotation marks and citations

omitted). Not every injury suffered by an inmate at the hands of

another inmate, however, will constitute an Eighth Amendment

violation. The inmate invoking the right must demonstrate that

(1) he or she was “incarcerated under conditions posing a

substantial risk of serious harm,” and (2) that corrections

officials were “deliberately indifferent” to the risk. Farmer,

511 U.S. at 834. A corrections official’s failure to supervise

inmates, particularly inmates known to be violent, may result in

unconstitutional conditions of confinement where assaults between

inmates occur due to the lack of supervision. Cottone v. Jenne,

326 F.3d 1352, 1360 (11th Cir. 2003).

E.

Safety and Sanitation


The Eighth Amendment guarantees that prisoners will not be

“deprive[d] . . . of the minimal civilized measure of life’s

necessities.” Rhodes v. Chapman, 452 U.S. 337, 347 (1981).

Accordingly, corrections officials are required to provide

“reasonably adequate ventilation, sanitation, bedding, hygienic

materials, and utilities (e.g., hot and cold water, light, heat,

plumbing).” Chandler v. Baird, 926 F.2d 1057, 1065 (11th Cir.

1991) (citations omitted). Conditions will violate the

Constitution when they pose an unreasonable risk of serious

damage to an inmate’s current or future health, and the risk is

so grave that it offends contemporary standards of decency to

expose anyone unwillingly to that risk. Helling v. McKinney, 509

U.S. 25, 33-35 (1993); Chandler v. Crosby, 379 F.3d 1278, 1289

(11th Cir. 2004).

III.
A.

FINDINGS


Medical Care


Our investigation revealed constitutional inadequacies in

the level of care provided by MCMJ in responding to inmates’

serious medical needs. In 2007, we shared with the County and

the Sheriff the written findings and concerns of our expert

medical consultant regarding the inadequate medical care at MCMJ.

Information we have obtained since that time, however, strongly

suggests that MCMJ has done little to correct the identified

deficiencies. 


- 8 ­
Specifically, we found that MCMJ failed to provide adequate

acute care, chronic care, treatment of infectious diseases,

intake screening, and general access to medical care. As

explained below, such deficiencies primarily result from

inadequate staffing, lack of proper supervision, and the lack of

adequate written medical policies and protocols.

1. 	 Acute Care

At the time of our tour in September 2003, MCMJ had failed

to provide timely and appropriate responses to the acute medical

needs of inmates. Three inmate deaths that occurred near that

time exemplify these failures. Our expert medical consultant

reviewed the medical circumstances surrounding the three inmate

deaths and concluded that the lack of timely and appropriate

response to the inmates’ acute medical needs may have contributed

to their deaths. For instance: 

•	

In June 2002, an inmate complained of fever, shakes,

and acute pain in her leg and foot. This inmate was

not evaluated by a MCMJ physician. A licensed

practical nurse examined her and found swelling,

bruising, and sores. Generally accepted corrections

medical practices call for a physician to evaluate any

acute onset of leg pain to evaluate for blood clots or

deep infection, which can pose a serious risk of harm.

Instead, this inmate received an antibiotic and Motrin1

by telephone order from the physician. Although MCMJ

reports that this inmate was transported to the

hospital at this time and then returned to MCMJ, there

were no records of the hospital visit in the inmate’s

medical record. The next day, her leg was tender and

warm, and she was so sick that she was incontinent of

feces. She then went into cardiac arrest, MCMJ staff

performed CPR, and she was transported to the hospital,

where she died soon thereafter. This inmate’s deep

vein thrombosis was not timely recognized or treated. 


•	

Another inmate upon arrival at MCMJ in December 2002

reported a history of high blood pressure and

hepatitis C. The inmate was not evaluated or treated

by a physician. Six days later, corrections staff took

him to see the nurse because he was disoriented,

shaking, and incoherent, which are signs of a


1


“Motrin” is a brand name for the anti-inflammatory

medication ibuprofen.


- 9 ­
life-threatening emergency requiring immediate care.

He did not receive immediate care, but instead the

licensed practical nurse placed his name on the list to

see a psychiatrist and sent him back to his unit. The

next day corrections staff again took the inmate to the

nurse after he was observed vomiting blood. He

remained disoriented and had substantially elevated

blood pressure. The nurse placed his name on the list

to see the physician during regular sick call, six

hours later. She left him alone for 90 minutes, and

when she returned to the clinic she sent him to the

hospital emergency room. The inmate died in the

hospital. Timely medical treatment may have prevented

this death.

•	

In August 2003, an inmate arrived at MCMJ with an acute

trauma to his left eye and a paralysis of the right

side of his face. He reportedly refused to see the

physician, although his chart contained no signed

refusal and no documentation of any attempt to convince

him to agree to medical care. Even if the inmate

refused medical care at intake, he should have been

housed in the infirmary and observed. Instead, this

inmate was placed in the general population. Five days

later, when he requested medical care, his left eye was

dilated, his speech slurred, and he was unable to walk.

His condition had deteriorated to such an extent that

he was sent to the hospital, where he was diagnosed

with a heart valve infection — which could have caused

his facial paralysis — congestive heart failure, and

sepsis (infection of the blood). He died before he

could receive surgery to replace his heart valve. If

this inmate had received treatment several days

earlier, his chance of survival would have been much

higher.


Since our September 2003 tour, we have learned of at least

six more in-custody deaths at MCMJ. In three of those cases, it

is alleged that MCMJ’s poor response to the inmates’ serious

acute medical needs contributed to the inmates’ deaths.2 We have

requested the opportunity to examine the medical circumstances

surrounding those deaths, but the County and the Sheriff have

denied our request. 


2


We are equally concerned about the other three cases

which are reportedly suicides, and discussed in section III.B.4

of this letter. 


- 10 ­
Furthermore, since our 2003 tour, we have learned of

allegations regarding the MCMJ’s inadequate treatment of serious

injuries suffered by inmates while incarcerated at MCMJ. For

example, in July 2005, an MCMJ inmate reportedly suffered serious

spine and neck injuries after a fall during a work-shift. It is

alleged that after waiting an hour to receive emergency medical

treatment, the inmate was given aspirin to relieve his pain.

Reportedly, no other treatment was provided, and no further

medical appointments were scheduled, despite the inmate’s request

to see a physician. Allegedly, after several weeks, the inmate’s

condition worsened as he began to lose weight, become frail and

non-ambulatory. By the time the inmate eventually saw a

physician in a hospital, it is reported that his injuries had

already begun to heal improperly and the inmate suffered

permanent damage to his spine and neck. 

We found that MCMJ’s problems in providing acute medical

care were caused or exacerbated by inadequate protocols,

supervision, and training. The protocols for nurses did not

provide adequate guidance regarding treatment of inmates who

exhibited common acute symptoms. In addition, nurses did not

receive training in taking medical history or in conducting

physical assessments. Thus, the nurses had no guidance on when

it was appropriate to seek a higher level of care from a

physician.

2.

Chronic Care


Generally accepted corrections medical practices require

inmates with chronic conditions to receive ongoing, coordinated

care and monitoring to prevent or minimize the progression of

their diseases. After completing our 2003 tour, we concluded

that MCMJ failed to identify and treat adequately inmates with

chronic conditions such as asthma, diabetes, hypertension and

HIV. The MCMJ did not separately track inmates with chronic

diseases as required by generally accepted corrections medical

practices. We therefore had to review medication administration

records to attempt to identify inmates with chronic conditions.

We found the number of inmates being treated for diabetes,

hypertension, and asthma to be one-third of what is expected for

jails in the United States.3 This finding indicates that MCMJ

was likely failing to identify inmates with chronic diseases,


3


National Commission on Correctional Health Care, Health

Status of Soon-to-Be-Released Inmates,

http://www.ncchc.org/pubs/pubs_stbr.html (last visited September

2, 2008). 


- 11 ­
which probably stemmed from an inadequate screening and

assessment process discussed in further detail in section III.A.4

of this letter.

Chronic conditions are progressive, and require proper

monitoring and treatment to prevent conditions associated with

end-stage organ failure, such as blindness, heart disease, kidney

failure, and lung disease. For example, generally accepted

corrections medical practices require that asthmatic inmates

receive peak flow monitoring to measure the volume of air flowing

out of the lungs, which can reveal narrowing of the airways well

in advance of an asthma attack. This monitoring should be done

on a quarterly basis, or more frequently if the inmate is short

of breath. However, at the time our tour, MCMJ did not conduct

peak flow monitoring unless inmates provided their own peak flow

meters. 

Similarly, diabetic inmates did not receive simple

laboratory tests of their insulin levels to monitor their status.

As the example below illustrates, we found the monitoring of

inmates with chronic conditions at MCMJ to be deficient. 

•	

In August 2003, an inmate with diabetes reported a

sudden onset of blurry vision, which indicates

potential acute retinal disease that can lead to

blindness without prompt evaluation and treatment.

This inmate did not receive an adequate eye examination

and had not been referred to an ophthalmologist at the

time of our third tour, over one month later. 


Several recent allegations regarding diabetic inmates

suggest that the chronic care deficiencies present at MCMJ at the

time our tour remain. For example, in 2005, an inmate who was

Type I diabetic alleged that she made repeated requests for

insulin and glucose tests. Corrections officers reportedly

assumed that the inmate was “detoxing” from a drug addiction and

denied all of the inmate’s requests for medical attention,

despite the inmate’s insistence that she was not a drug-addict.

After several days without insulin, the inmate’s condition

allegedly worsened to a life-threatening level. Reportedly, the

medical staff at MCMJ transferred her to a local hospital and the

inmate spent the next six days in the hospital, the first four

days of which she remained in the intensive care unit. 

Moreover, at the time our tour, MCMJ did not stock the basic

medications necessary to treat chronic diseases such as asthma,

diabetes, hypertension, major depression, and schizophrenia. As

a result, inmates with chronic diseases routinely waited three to


- 12 ­
five days from prescription to the administration of the first

dose of medication. Such a period of time is unacceptably long

in light of the severity of the issues. Other inmates with

chronic diseases waited longer to receive their medications, and

some never received prescribed medications at all. For example:

•	

During one of our tours in 2003, an inmate was

exhibiting severe respiratory compromise from acute and

chronic asthma. Although she had been prescribed

prednisone, a steroid that would reduce the inflamation

in her lungs and allow her to breathe, she had not

received the medication. Without prednisone, she was

at risk of developing respiratory failure.


3. 	 Infectious Diseases

We found that MCMJ did not adequately identify or treat

infectious disease. Failure to adequately identify and treat

infectious disease places inmates, staff, and the community at

unnecessary risk of serious health problems. Our review of MCMJ

records indicated MCMJ ordered purified protein derivative

(“PPD”) skin tests, which test for tuberculosis, for only about

half of the inmates, and documented test results for less than 10

percent of inmates. Similarly, we found syphilis screening

results in less than 10 percent of inmate records. Both PPD

tests and syphilis screening are required by MCMJ policy and by

generally accepted corrections medical practices. Furthermore,

MCMJ has inadequate policies in place to recognize and prevent

the transmission of blood-borne (e.g., HIV and viral hepatitis)

and air-borne (e.g., tuberculosis) pathogens. For example, the

policies failed to address post-exposure protocols for blood

exposures, maintenance of respiratory isolation, and vaccination

against Hepatitis B. 

During our September 2003 tour, we concluded that MCMJ

failed to treat properly inmates with tuberculosis. For example:

•	

We identified at least three inmates who were receiving

a particular antitubercular medication – Rifampin –

alone, a medication that should never be used without

other antitubercular medications. Using Rifampin alone

can result in the development of drug resistance, which

not only threatens the health of the inmate, but also

poses a serious public health danger. 


- 13 ­
•	

An inmate who had HIV was clearly receiving Rifampin in

error. His prescription was written for Rifabutin, a

medication used in late stage HIV; instead, he received

Rifampin. 


•	

The MCMJ also apparently failed properly to isolate

inmates with potentially contagious tuberculosis. An

inmate with suspected tuberculosis was housed in a

reported negative pressure room, which is designed to

contain contagious tuberculosis. Consistent with

generally accepted corrections medical practices, such

rooms must be tested monthly to ensure proper

functioning. However, the room did not appear to be in

operation and the health services administrator was not

aware if the room had ever been tested. Such a failure

places staff and other inmates in the infirmary at risk

of tuberculosis infection. 


Furthermore, our expert corrections medical consultant

identified a widespread skin infection, which had not been

identified by MCMJ medical staff. Numerous inmates exhibited

large boils on various parts of their bodies that they contracted

well after reception into MCMJ, and these inmates faced long

delays in treatment. The MCMJ had not conducted cultures which

likely would have assisted in identifying the outbreak, and MCMJ

had not contacted local health officials to provide notice of the

contagious infection or to receive assistance or guidance. The

skin infection was likely Staphylococcus aureus, a bacteria that

can cause septicemia (blood infection), myocarditis (heart valve

infection), infections of the tissues surrounding the brain, and

death.4

4. 	 Intake and Initial Assessment

When we evaluated MCMJ’s intake process and initial medical

assessments in 2003, we found that MCMJ failed to identify

inmates with serious medical needs and thus put inmates at an

unreasonable risk of harm. At MCMJ, corrections officers


4


We note that at the Sheriff’s request, we have provided

technical assistance to MCMJ regarding the skin infections. We

understand that MCMJ was working with the Mobile County

Department of Health to address this outbreak. The MCMJ reports

taking several measures to address this outbreak, including

purchasing new laundry machines and cleaning inmate-occupied

areas. The MCMJ did not, however, provide the Department of

Justice information regarding the final status of the outbreak. 


- 14 ­
conducted intake screening as each inmate was received. However,

the officers received no training concerning health screening,

and many serious medical issues were ignored at intake. For

example, the Jail Receiving Screening Form utilized by

corrections officers failed to collect the following basic

information: all current illnesses, past serious infectious

disease, recent symptoms of infectious diseases, past mental

illness, legal or illegal drug use, and specific drug withdrawal

symptoms.

The MCMJ policy required a nurse to perform a supplemental

medical history within 72 hours of each inmate’s intake. For

more than half of the current and recently-released inmates whose

files we reviewed, MCMJ failed to comply with this policy, even

for inmates with very serious medical needs. The health services

coordinator confirmed that the medical clinic was not adequately

staffed to review each inmate within 72 hours, and estimated that

30 to 35 percent of inmates are not seen within 72 hours of

admission. Even if MCMJ complied with its own policy, 72 hours

is too long a delay for an assessment of inmates with acute or

chronic medical needs, continuity of medication requirements, or

infectious diseases. Generally accepted corrections medical

practices require that inmates with acute or chronic medical

conditions be seen by a nurse within four hours of intake for

evaluation and referral to a physician, if necessary.

Moreover, the 72-hour supplemental nursing assessment at

MCMJ was inadequate to identify inmates’ serious medical needs,

as the assessment consisted of nothing more than recording basic

vital signs. For example: 

•	

An inmate incarcerated in August 2003 with diabetes did

not have a documented blood sugar test on intake, which

placed this inmate at risk of ketoacidosis, a

potentially fatal complication of diabetes. 


Although MCMJ policy was consistent with generally accepted

corrections medical practices by requiring a complete health

assessment to be conducted within 14 days of an inmate’s arrival,

we noted unreasonable delays in conducting these assessments and

a lack of appropriate referrals. For example, during our

September 2003 tour, an inmate reported that he was incontinent

of urine, but was not referred to a physician for diagnosis and

treatment. 

In addition, MMCJ did not properly identify and treat

serious drug and alcohol intoxication and withdrawal symptoms,


- 15 ­
placing inmates at risk of potentially life-threatening symptoms

such as seizures and delirium. For example: 

•	

In May 2003, MCMJ did not identify, evaluate, or treat

an inmate at intake who was at risk of experiencing

benzodiazepine withdrawal.5 The inmate subsequently

made at least seven requests for medical evaluation due

to her withdrawal symptoms, but received no treatment

for her potentially serious drug withdrawal. 


•	

Another inmate, who was in restraints, apparently was

suffering from alcohol withdrawal and had purple

extremities, was sweating profusely, and was “jerking

badly.” A note in the inmate’s medical file quotes the

nurse as responding, “That’s part of DTs and there

isn’t nothing we can do.” Delirium tremens, a physical

and mental disturbance caused by withdrawal from

alcohol use after prolonged drinking – sometimes called

the “DTs” – can cause serious hallucinations and

potentially life-threatening seizures. By generally

accepted corrections medical practices, this inmate

should have received Librium, a medication helps

prevent the symptoms of delirium tremens from

worsening, as well as fluids, and close monitoring of

his vital signs. 


We have since learned that in February 2008, a MCMJ inmate

died of an apparent drug overdose. The inmate was reportedly

found unconscious in his cell on the same day he was arrested on

drug possession charges. The MCMJ allegedly transported the

inmate to the hospital where he was pronounced dead, and

preliminary tests reportedly indicated the presence of drugs in

his system. This recent death suggests that the problems we

identified in 2003 have not been resolved, despite the fact that

we provided the County and the Sheriff our expert medical

consultant’s written report in 2007. 

5. 	 General Access to Medical Care

At the time of our tour, MCMJ’s sick call process failed to

provide adequate access to medical care. The MCMJ inmates


5


Benzodiazepine is a medication that depresses the

central nervous system and is used, for example, to treat certain

seizure disorders and anxiety. Withdrawal from benzodiazepine

can result in potentially life-threatening symptoms such as

seizures and delirium if not appropriately treated. 


- 16 ­
accessed medical services by completing sick call requests.6

Inmates reported making multiple requests before receiving

medical care. Our review of medical files confirmed that many

inmates made between two and six requests for treatment of

serious medical needs before receiving care, such as the inmate

in benzodiazepine withdrawal discussed above in section III.A.4.

Other examples include:

•	

Medical staff failed to respond to three requests for

care from an inmate with vaginal discharge. Failing to

evaluate this inmate put her at risk of serious

infection, and created a potential public health risk,

as such symptoms are consistent with a venereal

disease.


•	

In August 2003, an inmate complained he was incontinent

of urine, which may be caused by an infection or a

serious, but treatable, neurologic problem. There was

no indication in his file that he was referred to a

physician for treatment. 


Additionally, at the time of our tour, MCMJ charged a $10.00

co-payment for each visit to a licensed practical nurse. The

MCMJ policy also required that indigent inmates be provided free

medical care and MCMJ appeared to be implementing this policy.

Nevertheless, while this policy does not violate inmates’

constitutional rights, we are concerned that numerous inmates

told us that requests for medical care by indigent inmates are

ignored. Apparently this alleged practice of ignoring the

medical requests of indigent inmates is so pervasive as to result

in indigent inmates not requesting medical care for serious

medical needs. We flag this finding because, although not a

constitutional violation, the perception that indigent inmates

will not be provided medical care is a barrier to accessing such

care.


6


Inmates submitted sick call requests to corrections

staff, who delivered them to the medical unit. Allowing

corrections staff to serve as gatekeepers for medical services

potentially compromises timely access to medical care. We

understand that the MCMJ has recently installed lock boxes for

inmates to file grievances and we encourage a similar system for

sick call requests.


- 17 ­
6.

Staffing


The above-noted deficiencies in acute care, chronic care,

intake services, and identification and treatment of infectious

diseases were likely caused or aggravated by inadequate medical

staffing. At the time of our tour, MCMJ provided its 1,000 to

1,300 inmates with only 20 hours per week of physician staffing

for their primary medical care needs. This is grossly

insufficient to meet the acute and chronic needs of this large

population, and health care provided to inmates was compromised

by this significant shortage.7 In addition, the nursing staff

was inadequately supervised, which led to the deficiencies noted

above in acute care, intake assessment, sick call, and medication

errors.

B.

Mental Health Care


Our investigation revealed that mental health services at

MCMJ were grossly inadequate to meet the serious mental health

needs of inmates. At the conclusion of our tours in 2003, our

expert corrections mental health consultant identified specific

concerns in MCMJ’s delivery of mental health care. In 2007, we

provided the County and the Sheriff with a written report

prepared by our expert corrections mental health consultant

outlining the mental health care deficiencies at MCMJ. Despite

our several requests to revisit the facility and evaluate MCMJ’s

progress on improving the mental health care provided to its

inmates, neither the County nor the Sheriff have provided us with

access or any documentation to suggest that the deficiencies we

identified in 2003 and 2007 have been addressed or corrected. In

fact, three MCMJ inmate suicides that have occurred since 2003

strongly suggest the problems present at the time of our tour

remain unresolved. 

Specifically, we identified problems and deficiencies in

intake screening; access to mental health care; assessment,

management and treatment of mental illnesses; and suicide

prevention. As explained below, such deficiencies result in part

from inadequate mental health care staffing and the lack of a

mental health care program, as well as inadequate policies and

procedures.


7


In the opinion of our expert corrections medical

consultant, a facility of MCMJ’s size requires a minimum of 60

hours per week of physician staffing to provide adequate medical

care.


- 18 ­
1.	

Intake and Initial Assessment


Failure to identify and respond appropriately to inmates’

serious mental health needs can lead to significant medical

deterioration, and in some cases can even lead to death by

suicide. We found that MCMJ’s intake process failed to identify

adequately inmates with serious mental health needs. 

Intake screening should be used to identify inmates with

histories of mental health treatment, major mental illness, and

suicide potential, as well as inmates who need psychiatric

medications. As discussed above in section III.A.4 of this

letter, corrections officers conducted initial intake screening

on incoming inmates by filling out Jail Receiving Screening

Forms. The officers received no training on mental health

screening. In addition, the screening forms themselves did not

require officers to gather adequate mental health information;

for example, the forms lack screening questions regarding major

mental illness or developmental disability. 

The MCMJ also failed to record consistently or respond

adequately to the mental health information in the screening

form. The forms were often incomplete, completely blank, lacking

pertinent information such as current medications, or contained

no information about an inmate’s mental health status or history.

Other forms contained pertinent mental health information, but

medical records indicated there was no, or significantly delayed,

follow-up by MCMJ staff. For instance: 

•	

The intake screening of one inmate in May 2003 revealed

that he had possible suicidal ideation, yet some four

months after his intake, there was no documentation

that he was ever referred for, or received, an

evaluation by MCMJ mental health care staff. 


•	

Although an inmate in August 2003 was identified as

potentially suicidal at intake, the inmate did not see

the psychiatrist until 10 days later. 


•	

One inmate’s custody screening in July 2003 revealed a

history of past mental problems, including a history of

treatment with Zyprexa, an antipsychotic.

Nevertheless, she was not seen by the psychiatrist for

two months, by which time her condition had worsened to

the point that she had become psychotic. 


- 19 ­
As will be discussed further below, we noted similar

failures to identify or respond to inmates taking psychotropic

medications. Such failures delay the continuity of medications

and create a serious risk of harm for inmates with psychosis and

mood disorders. Left untreated due to interrupted or

discontinued medications, such inmates may harm themselves or

others.

The first step in providing inmates with proper mental

health care is identifying and diagnosing inmates with serious

mental health needs. At the time of our tour, however, MCMJ

significantly under-diagnosed serious mental illnesses. Without

proper diagnoses, mentally ill inmates risk receiving inadequate

or inappropriate medication and treatment, or no medication or

treatment at all. This can lead to psychiatric decompensation,

that is, the inmate’s psychiatric symptoms can worsen and lead to

depression, psychosis, or other acute problems. Such inmates are

often subject to heightened victimization or to violent outbursts

which can impact jail staff and other inmates. 

As with inmates with chronic illnesses, MCMJ should, but did

not, keep lists of inmates with mental health needs.

Accordingly, we had to examine medication administration records

to attempt to identify inmates with psychiatric needs. At the

time of our tour, national studies indicated that approximately

16 percent of male inmates and 23 percent of female inmates can

be expected to have a mental illness.8 At MCMJ, however, only

six percent of male inmates were being treated with psychotropic

medications, which is about one-third of the number of male


8

Paul M. Ditton, Bureau of Justice Statistics, Mental

Health Treatment of Inmates and Probationers (1999),

http://www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf (last visited

September 2, 2008) (This study defined a “mentally ill” inmate as

any inmate that “reported a current mental or emotional

condition, or . . . reported an overnight stay in a mental

hospital or treatment program.”). We note that recent national

studies illustrate a dramatic increase in population of jail

inmates with mental health care needs. For example, Doris J.

James and Lauren E. Glaze, Bureau of Justice Statistics, Mental

Health Problems of Prison and Jail Inmates (2006),

http://www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf (last visited

September 2, 2008) reports that 75 percent of female jail

inmates, and 63 percent of male jail inmates, have a mental

health problem. This study defined an inmate with a “mental

health problem” as any inmate that had “a recent history or

symptoms of a mental health problem” within the prior 12 months. 


- 20 ­
inmates with mental illness typically found in jails in the

United States. Seventeen percent of female inmates were on such

medications, about two-thirds of the number of female inmates

with mental illness typically found in jails in the United

States. These findings indicate that many inmates in need of

mental health care, particularly male inmates, likely were not

identified and as a consequence did not receive necessary mental

health treatment. Indeed, the problem of under-diagnosing

mentally ill inmates at MCMJ is likely worse than we estimate, as

our examination of the medication administration records to

identify mentally ill inmates consequently excludes those

mentally ill inmates who are not being treated with psychotropic

medications. 

This observation was corroborated by reviewing individual

inmate records, which indicated widespread under-diagnosis of

mental illness. For example: 

•

One inmate’s intake screening in June 2003 did not
indicate any mental illness. Although he was placed in
administrative segregation for suicidal ideation the
day after being taken into custody, his 72-hour nursing
assessment also did not indicate any mental illnesses
and he did not see the psychiatrist until after he
submitted a request over two weeks later. The
psychiatrist concluded the inmate had a bipolar
disorder and prescribed the antipsychotic medication
Zyprexia.

•

Another inmate’s intake assessment in June 2003 did not
note any mental health care concerns, but a nursing
assessment twenty days later revealed that the inmate
had a history of treatment with the psychotropic
medications Prozac and Ritalin. The intake assessment
failed to identify this inmate’s mental health care
needs, and thus delayed any mental health treatment the
inmate may have required.

2.

Access to Mental Health Care

In September 2003, we found that MCMJ did not provide

adequate access to mental health care. Inmates typically made

numerous requests to see the psychiatrist, and were faced with

significant delays in response to their requests. Our review of

records indicated that the delays ranged from weeks to many

months, even for inmates with very serious mental health needs.

We also noted many instances where follow-up care ordered by MCMJ

mental health staff did not occur. For example: 


- 21 ­
•	

An inmate with a documented diagnosis of

Schizoaffective Disorder9
 and a history of treatment

with four antipsychotic medications made five written

requests in July 2003, to see the psychiatrist before

she was seen, five weeks after her arrival at MCMJ. 


•	

In July 2003, a nurse made a referral for an inmate to

see the psychiatrist due to depression. Almost two

months later, he still had not seen the psychiatrist

and had become suicidal. It still took an additional

three weeks for the inmate to receive an initial

psychiatric evaluation. 


•	

In April 2003, a nurse referred an inmate for a

psychiatric consult as a result of the inmate’s

fearfulness, hyperactivity, and sleeplessness, but this

inmate was not seen by the psychiatrist until three

weeks after the nurse’s referral. These delays are far

too long, and are a substantial departure from

generally accepted corrections mental health practices,

especially when inmates are experiencing acute mental

health symptoms. Without adequate access to mental

health care, serious mental health needs may go

undiagnosed and mentally ill inmates who present a risk

of harm to themselves and others may be left untreated.


All of the information we have collected since our review of the

records strongly suggests that this problem continues.

Appropriate, timely mental health treatment is critical to

regulate the symptoms of mental illness and to minimize

psychiatric decompensation. 

3.	

Assessment, Diagnosis, and Treatment


Our investigation revealed that when MCMJ identified and

responded to inmates with serious mental health needs, it failed

to provide adequate treatment. All aspects of the mental health

care delivery system were inadequate, including assessment and

diagnosis, treatment planning, and pharmacological interventions.

These problems, as will be discussed below, were exacerbated by


9


Schizoaffective Disorder is a condition in which a

person meets the criteria for both schizophrenia and a mood

disorder. Such a person may experience psychosis such as

hallucinations or delusions commonly associated with

schizophrenia, while concurrently experiencing symptoms of

depression. 


- 22 ­
inadequate psychiatric staffing. In addition, MCMJ did not

provide non-psychiatric mental health care services, such as

group therapy or other services provided by social workers,

counselors, or other mental health care workers.10 Providing

these types of services are in accordance with generally accepted

corrections mental health practices. 

Additionally, many psychiatric progress notes lacked

diagnoses, which are essential to determining the appropriate

treatment for an inmate’s mental health needs. For example: 

•	

In May 2003, one inmate was treated with several

psychotropic medications but did not have a specific

psychiatric diagnosis. 


•	

Another inmate who entered MCMJ in April 2003, had

significant periods of self-injurious behavior,

including head-banging and swallowing glass, but never

received any psychiatric diagnosis. Nonetheless, he

was treated with increasing doses of antipsychotic

medications. 


•	

Still another inmate was treated with antipsychotic

medications, although he had no history of treatment

for mental illness or other clear indications of the

need for antipsychotic medication. Antipsycotic

medications have a number of potentially serious side-

effects, including tardive dyskinesia.11 Failing to

appropriately diagnose inmates with mental health

needs, but treating them with psychotropic medications,

is grossly inappropriate and unnecessarily places

inmates at risk of harm. 


Moreover, MCMJ frequently prescribed Elavil, an

antidepressant medication, to address inmates’ sleeping

difficulties. Elavil has significant and potentially serious

side effects, and can be lethal in overdose. Elavil therefore

should not be used for sleep disturbances without appropriate

evaluation or medical assessment. 


10


Reportedly, MCMJ has hired a psychiatric nurse who

accompanies the psychiatrist to MCMJ for six hours a week.

11


“Tardive dyskinesia” is a potentially irreversible

movement disorder characterized by repetitive involuntary

movements. 


- 23 ­
Inmates also experienced serious delays in receiving

psychiatric medication. For example: 

•	

One inmate in June 2003 waited 23 days after intake,

including five days after seeing the psychiatrist,

before receiving two psychotherapeutic drugs, Remeron

and Buspar. 


•	

Another inmate went at least three weeks without

treatment with the psychotropic medications that she

had been taking when she arrived at MCMJ, and had no

documented psychiatric evaluation. 


Delays in the continuity of psychiatric medications pose a

serious risk for mentally ill inmates, and may cause the inmate

to experience psychotic decompensation or cause the inmate to

harm himself or others.

We further identified inmates who received no treatment for

their psychiatric needs. For instance:

•	

One inmate’s initial assessment, which occurred three

weeks after his arrival in March 2003, revealed a

history of treatment with the antipsychotic medications

Zyprexa and Thorazine during a recent prior

incarceration at the MCMJ. Despite this recent

history, five months later, when we examined his

medical chart, he had not been evaluated by the

psychiatrist or received psychotropic medication. 


•	

Another inmate in July 2003 requested a psychiatric

evaluation to continue his treatment for depression.

At the time of our examination of this inmate’s medical

chart, almost three months later, the inmate had not

been seen by a psychiatrist and had received no

psychiatric treatment. 


4.	

Suicide Prevention


At the time of our tour, MCMJ failed to provide adequate

assessment, monitoring, and housing of suicidal inmates. Suicide

is a form of mental illness constituting a serious medical need

for which MCMJ must provide adequate treatment. We have learned

that at least three MCMJ inmates committed suicide since our

September 2003 tour. According to a recent public statement by

the MCMJ Warden in the Mobile-Register, “about six inmates a year


- 24 ­
attempt suicide, and about one a year
suicide a year is approximately twice
facility the size of MCMJ.13 Thus, it
not resolved its very serious suicide

is successful.”12 One

the national average for

would appear that MCMJ has

prevention problem.


All three of the recent suicides were reportedly hangings,

two of which allegedly occurred with bedsheets. Two of the three

suicides occurred within three months of each other. The most

recent suicide was committed by a male inmate who at the time of

his arrest at his home, according to police, doused himself with

gasoline and threatened to set himself afire in front of his wife

and children. Despite this conduct at the time of his arrest, it

does not appear that the inmate was put on suicide watch at MCMJ

until four days after intake. More troubling still, the inmate

was reportedly removed from suicide watch by medical staff prior

to his death. 

As noted above, we observed unreasonable delays in providing

mental health care to suicidal inmates in MCMJ. In addition,

MCMJ did not assess properly the severity of an inmate’s suicide

risk and did not provide treatment specific to the inmate’s risk

of suicide. Instead, suicidal inmates were frequently asked to

sign behavioral contracts promising not to harm themselves.

These contracts were simply forms that state that the inmate

“promise[s] not to harm myself while incarcerated at the Mobile

County Jail.” After an inmate signed a contract, the inmate was

usually placed in the general population without any suicide

precautions. These contracts are not an adequate method of

preventing suicide or self-harm and appear to provide a false

sense of security for staff, and an excuse not to monitor

regularly inmates who sign the contracts.

Additionally, we found that MCMJ improperly monitored

suicidal inmates. We specifically brought this urgent matter to

the attention of MCMJ during our tour. Suicidal inmates who

refuse to sign behavior contracts are housed in the medical unit

or in the “suicide wedge.” Although we note that corrections

staff performed adequate 15-minute checks of inmates in the


12


Dan Murtaugh, Jail to Revamp Suicide Cells, Mobile-

Register, May 30, 2007, at B1.

13


Bureau of Justice Statistics, Deaths in Custody

Statistical Tables: Local Jail Deaths 2000-2005,

http://www.ojp.usdoj.gov/bjs/dcrp/tables/jailstab3.htm (last

visited September 8, 2008) (average annual suicide rate for 2000

- 2005 is 45 per 100,000 local jail inmates).


- 25 ­
suicide wedge, the physical attributes of the cells in the

suicide wedge presented dangers to inmates. The cells had solid

metal doors and thus their interiors, as well as inmates in the

cells, were not directly visible to corrections staff. The cells

had not been modified to remove sharp edges or other items that

could be used for self-harm. Many cells had writing on the

walls, indicating that suicidal inmates had access to writing

utensils that could be used for self-harm. In addition, inmates

in the suicide wedge did not receive regular and periodic

evaluations by mental health staff. Some inmates who had been

placed on suicide watch were never seen by a psychiatrist. 

The MCMJ relied on an inmate “buddy system” to monitor

suicidal inmates housed in both the medical area and in the

suicide wedge as a supplement to the monitoring by corrections

staff. These inmates sat with and monitored suicidal inmates. 

While this is an acceptable procedure, MCMJ must provide adequate

monitoring, training, and select inmates who can be relied upon

to perform this service. We found that MCMJ provided little or

no training to these inmate workers and some showed little

motivation or interest in performing their duties. 

5.

Policies and Procedures


The failures of MCMJ’s mental health services were caused in

part by MCMJ’s lack of adequate policies and procedures, as well

as its failure to implement some policies and procedures that

appear to be adequate. A number of MCMJ policies and procedures

did not address fundamental components of the topic they cover.

For example, the policy regarding suicide prevention did not

include instructions on how to assess suicide risk. Similarly,

the policy on the use of forced psychotropic medications was

silent on basic tenets of the use of forced psychotropics, such

as duration of use and monitoring of the inmate. Other MCMJ

policies on mental health appear adequate, yet in practice the

policies were ignored. For example, the policy on chemically

dependent inmates required MCMJ to refer these inmates to an

outside treatment center. The actual practice revealed that

numerous chemically dependent inmates were not referred for

treatment; in fact, chemically dependent inmates were not

properly identified, and many received no treatment from MCMJ,

which is a substantial departure from generally accepted

corrections mental health practices.


- 26 ­
6.

Staffing


The absence of sufficiently qualified mental health staff at

MCMJ contributed significantly to the inadequacy of mental health

care. At the time of our tour in September 2003, the MCMJ

psychiatrist was required by contract to provide on-site services

six hours per week. Six hours a week is grossly inadequate and

insufficient to address the mental health care needs of MCMJ’s

inmate population, which ranges from 1,000 to 1,300 inmates. As

stated above in section III.B.1, national studies suggest that

approximately 16 percent of male inmates and 23 percent of female

inmates can be expected to have a mental illness.14 Further,

despite having a psychiatrist under contract, our review

indicated that there were weeks, and sometimes months, with no

psychiatric coverage at all. The inadequate psychiatry schedule

also directly contributed to the failure to provide inmates with

timely psychiatric medications.

The lack of adequate psychiatric staff caused MCMJ to rely

on improperly trained staff to identify and address inmates’

psychiatric needs. For example, MCMJ used untrained corrections

officers to conduct intake screening, which contributed to the

failure to identify initially inmates with psychiatric problems.

This problem was compounded by MCMJ’s reliance on licensed

practical nurses who lacked psychiatric training, which

contributed to the failure to identify inmates in need of

immediate psychiatric care. Such care is crucial in preventing

psychiatric decompensation and potential harm to self or others.


14

Paul M. Ditton, Bureau of Justice Statistics, Mental

Health Treatment of Inmates and Probationers (1999),

http://www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf (last visited

September 2, 2008). This study defined a “mentally ill” inmate

as any inmate that “reported a current mental or emotional

condition, or . . . reported an overnight stay in a mental

hospital or treatment program.”). Again, we note that recent

national studies illustrate a dramatic increase in population of

jail inmates with mental health care needs. For example, Doris

J. James and Lauren E. Glaze, Bureau of Justice Statistics,

Mental Health Problems of Prison and Jail Inmates (2006),

http://www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf (last visited

September 2, 2008) reports that 75 percent of female jail

inmates, and 63 percent of male jail inmates, have a mental

health problem. This study defined an inmate with a “mental

health problem” as any inmate that had “a recent history or

symptoms of a mental health problem” within the prior 12 months. 


- 27 ­
C.

Use of Restraints


We found that MCMJ’s use of four- and five-point

restraints,15 raised significant concerns. In appropriate

circumstances, the proper use of such restraints is an effective

tool to prevent inmates from harming themselves or others.

However, we concluded that MCMJ’s monitoring of restrained

individuals to be constitutionally deficient, and found serious

concerns regarding MCMJ’s decisions to apply such restraints. We

shared these concerns with the County and the Sheriff in 2003 and

in 2007. 

1.

Monitoring of Restrained Individuals


Restraining inmates, although necessary at times, is a

dangerous activity for both inmates and staff because of the

force that may be necessary to restrain the inmate. Restrained

inmates must be monitored appropriately. The dangers of

inadequate monitoring were evidenced by the July 2000 death of a

restrained MCMJ inmate from complications caused by necrotizing

fasciitis, commonly referred to as “flesh-eating bacteria.”

According to the Mobile County Special Grand Jury Report

regarding this incident, during the 14 days this inmate was at

MCMJ, he was stripped naked, handcuffed, and shackled almost

continuously. The inmate was reportedly restrained because he

clogged the toilet with his clothes, causing it to overflow, and

also spread excrement on himself and the cell. Typically, the

limbs of a person infected with necrotizing fasciitis will swell

and may develop a purplish rash within three to four days of

infection. Within four to five days, an infected person will

experience critical symptoms, during which the body will go into

toxic shock and the person may lose consciousness. Thus it

appears that either checks were not performed or, if they were

performed, no action was taken. Although this incident occurred

several years ago, it informs our review of the MCMJ’s current

policies and practices regarding the use of restraints. Indeed,

the Special Grand Jury Report concluded that “a massive systemic

failure in the administration of the Mobile County Metro Jail

resulted in” this inmate’s death. 

Although MCMJ revised its policies following this incident,

at the time of our tour, MCMJ policies regarding checks of


15


Using four-point restraints means the inmate is placed

in a prone position and his or her arms and legs are secured.

Five-point restraints also includes restraining the inmate’s

head.


- 28 ­
restrained inmates’ welfare (“welfare checks”) were inadequate.

The revised policies required welfare checks every 15 to 30

minutes, but only required a check of the restrained inmate’s

extremities for visible injuries. Although some inmates were

restrained in the medical clinic, MCMJ did not require checks of

vital signs, range of motion, neurological condition, or other

physiological checks of the restrained inmate’s condition, which

are required by generally accepted corrections practices. The

limited evaluation required by MCMJ is a substantial deviation

from generally accepted corrections practices and unreasonably

places inmates at risk of harm. For example, an inmate in

restraints who appeared to have delirium tremens – a physical and

mental disturbance caused by withdrawal from alcohol use after

prolonged drinking – apparently received no treatment for this

condition and did not have his vital signs monitored. In

addition, restrained inmates may go into respiratory distress,

which may be interpreted as agitation or resistance and would not

be revealed by a simple check of the inmate’s extremities for

visible injuries. 

The paucity of documentation regarding welfare checks of

restrained inmates at MCMJ raised serious concerns that these

checks were not performed or were not performed with sufficient

frequency to protect inmates from harm. Documenting the basis

and duration of the use of restraints and the condition of the

restrained inmate is generally accepted corrections practice.

However, the only documentation of the basis for, and duration

of, the use of restraints by MCMJ were brief notations on the

Inmate Restraint Log. The MCMJ policy does not require

documentation of welfare checks or the health condition of the

restrained person, although we noted a few checks on the Inmate

Restraint Log. For example, a welfare check for one restrained

inmate was noted at 3:56 p.m., and there was a notation that the

inmate was briefly released from restraints to eat at 5:10 p.m.,

then restrained again at 5:25 p.m. The log does not indicate any

other welfare checks were performed, although generally accepted

corrections practices require range of motion, neurological and

vital signs checks every 15 minutes. In addition, in a number of

instances the first notation that an inmate had been placed in

restraints occurred when staff noted a welfare check. 

The limited content of the welfare checks that were

documented reinforces our concerns regarding the scope of the

welfare checks performed by MCMJ. For example, most such

notations simply indicated “checked,” without further

elaboration. This does not reflect an adequate evaluation of the

physical condition of the restrained inmate and places inmates at

risk of harm. 


- 29 ­
2.

Application of Restraints


At the time of our 2003 tour, MCMJ policy provided that

officers may use restraints as a “preventative measure” if the

officer believed the inmate was a threat to himself or herself or

to others. The MCMJ policy did not require supervisory approval

for the use of restraints, although the Inmate Restraint Log did

have a column to record the name of the supervisor who was

notified of the use of restraints. There were numerous examples

of the use of restraints for medical purposes, such as for

potentially suicidal inmates. Although MCMJ policy required

physician approval for the use of restraints for medical reasons,

it did not require documentation of the physician’s basis for

approving the restraints. Thus, we were not able to evaluate

whether physician approval was obtained or if the use of

restraints was appropriate. 

The notations on the Inmate Restraint Log provided only

cursory descriptions of the basis for the use of restraints, such

as “breaking sprinkler” or “suicidal.” In addition, the log was

frequently incomplete, and commonly failed to note the date and

time that restraints were applied or were removed. In fact, upon

our request for completed restraint logs for a one-year period,

MCMJ could only provide completed Inmate Restraint Logs for ten

non-consecutive days.

Even based on this extremely limited documentation, it was

clear that MCMJ utilized restraints successively on the same

individuals for extended periods of time, raising concerns

regarding the need for the use of restraints. Indeed, our expert

corrections consultants noted that the frequency of the use of

restraints at MCMJ was atypically high for a jail of its size.

Inappropriate use of restraints can be dangerous for both inmates

and staff, and MCMJ’s failure to document and review the use of

restraints was inconsistent with generally accepted correctional

practices and put inmates at risk of harm. 

The prolonged and successive use of restraints is an

improper practice and indicative of a failure to manage

disruptive or mentally ill inmates. For example, a particular

inmate at MCMJ was placed in five-point restraints in May 2003

for “breaking sprinkler head” at 11:30 p.m. and remained in

restraints until 8:30 a.m. the following morning. The inmate was

again placed in five-point restraints for “breaking sprinkler

head” at 9:15 a.m. and was not released until 6:00 p.m. This

inmate was placed in five-point restraints a third time for

“breaking sprinkler head” at 6:39 p.m. and the date and time of

his release from restraints was not noted. This cyclical use of


- 30 ­
five-point restraints indicates that MCMJ failed to either

identify and treat an inmate who possibly had serious mental

health needs or, if he was not mentally ill, to manage

appropriately this inmate’s behavioral issues.16

D.

Security, Supervision, and Protection From Harm


During our tours, we found that MCMJ failed to protect

inmates from harm adequately. We noted a high, and increasing,

level of inmate-on-inmate violence at MCMJ. For example, in

2003, MCMJ reported 89 fights in four months, an increase of 36

percent over the same period in the prior year. While this

statistic alone does not evidence a pattern or practice of

deliberate indifference to inmate-on-inmate violence, it is an

example of the deficient security practices that subject MCMJ

inmates to an unreasonable risk of harm. Our expert corrections

consultant concluded that the increasing inmate-on-inmate

assaults stem from a variety of deficient MCMJ practices. 

Specifically, our review revealed that MCMJ failed to: take

adequate measures to limit the introduction of contraband into

the facilities; classify inmates appropriately based on their

anticipated in-custody behavior; and supervise inmates

adequately. Such failures significantly increases the risk of

violence, placing both inmates and staff at risk of serious harm.

The security, supervision, and protection from harm deficiencies

at MCMJ were exacerbated by a lack of adequate policies,

procedures, training, and staffing.

1.

Control of Contraband


Inmates reported a significant problem with contraband,

including illegal drugs, at MCMJ. Our review of MCMJ documents,

such as Shakedown Forms, confirmed these reports. The shakedowns

revealed inmates possessed various shanks, razors, bleach, and

other contraband. For example: 


16


Furthermore, our review of MCMJ records did not

indicate that this inmate’s limbs were exercised during this

period of time. Failure to attend to a restrained inmate’s

physical needs during such extensive periods of restraint, such

as the range of motion of the inmate’s arms and legs, can cause

serious medical harm. 


- 31 ­
•	

A shakedown conducted in one wedge17
 in February 2002,

revealed six razors/shanks, a maintenance screw tip,

two metal ceiling pieces, and an ink pen for tattooing,

along with other contraband items. 


•	

Similarly, a shakedown of a pod18
 in April 2003,

uncovered 13 containers of bleach, which could be used

as a weapon. 


We also noted some inadequate responses to the discovery of

contraband. For example, in April 2002, when staff found an

inmate smoking marijuana, the only action indicated in the file

was the suspension of the inmate’s commissary privileges for one

week. 

Despite the apparent presence of significant amounts of

contraband, MCMJ conducted too few shakedowns. Indeed, although

the Cell Condition Check List, last modified in 1999 at the time

of our 2003 tour, contained a directive from the MCMJ Warden that

shakedowns should be performed once per week, our review

indicated they were performed significantly less frequently. One

potential source of this problem is a lack of sufficient

staffing. According to MCMJ policy, inmates are to be taken to

the recreation yard during shakedowns of entire housing wedges, a

procedure that requires intensive staffing. However, both MCMJ

staff and records indicated that staffing shortages have largely

prevented MCMJ from allowing inmates to use the recreation yard,

and consequently resulted in fewer shakedowns. 

2.

Classification of Inmates


Adequate classification systems are a fundamental component

of providing a reasonably safe environment in a corrections

institution. The primary goal of a classification system is to

predict in-custody behavior so that appropriate security measures

can be utilized to minimize the risk of violence. Generally

accepted corrections practices for classification systems utilize

a variety of objective, behavior-based factors to determine the


17


A wedge is designed to house 16 inmates. However, MCMJ

routinely exceeds this number and therefore it is unclear the

total number of inmates housed in this wedge at the time of the

shakedown. 

18


Pods housing male inmates consist of six eight-cell

wedges. Pods housing female inmates consist of two twelve-cell

wedges.


- 32 ­
appropriate level of custody. Typically, inmates are divided

into high, medium, and low custody, and thereafter receive the

appropriate level of freedom and staff supervision for that

classification level. 

In contrast to generally accepted corrections practices,

MCMJ inmates were housed based almost exclusively on whether they

have been convicted or whether they are charged with a felony or

a misdemeanor. At the time of our tours, male inmates were

separated into six groups,19 and were still housed based

primarily on their legal status, not on whether they were

objectively dangerous. Female inmates were reportedly separated

into two groups, misdemeanents and all others, but our review

revealed that female inmates were housed according to available

space.20

Although the MCMJ classification form collected various

behavior-based information, this information was not utilized to

classify inmates. Such practice unreasonably increases the risk

of harm by failing to perform a meaningful evaluation of

anticipated behavior, particularly violent behavior. The MCMJ

failed to separate adequately predatory inmates from vulnerable

inmates. For example: 

•	

One inmate repeatedly stabbed another inmate in June

2002, with a pen while incarcerated at MCMJ causing

multiple puncture wounds to the inmate’s head, arms,

and back and requiring treatment at a hospital

emergency room. However, during a subsequent

incarceration at MCMJ in August 2003, the assailant was

housed in the protective custody wedge with MCMJ’s most

vulnerable inmates. This inmate was moved to


19

Specifically: 1) inmates charged or convicted in the

federal system; 2) inmates convicted of felonies in the state

system; 3) inmates charged with “low” and “medium” felonies;

4) inmates charged with “high” felonies; 5) inmates charged with

or convicted of misdemeanors; and 6) special management inmates

(including sex offenders and disciplinary and protective

segregation). We understand that since our tours, the U.S.

Marshal’s Service has clarified that MCMJ is not required to

separate federal inmates from other inmates. However, this does

not impact the lack of an adequate behavior-based classification

system. 

20


Since our tours, MCMJ reports that it has begun housing

some female inmates in the Barracks. 


- 33 ­
disciplinary segregation after altercations with

another inmate and staff. 

•	

In another incident in July 2003, an inmate was taken

to the disciplinary wedge because he had just been

involved in a fight with another inmate. However, he

was not isolated, but was placed in a cell with an

inmate. He assaulted this inmate almost immediately,

and the assaulted inmate required hospital treatment

for a cut above his eye. 


While the factors considered in an objective classification

system include whether the inmate has been convicted of the

current offense and the nature of that offense, numerous other

behavior-based factors also must be considered. As there are

violent misdemeanor offenses21 and misdemeanor arrestees and

offenders who have known predatory histories, as well as the fact

that there are many non-violent felonies, basing custody levels

solely on an inmate’s legal status does not adequately predict

in-custody behavior. A meaningful classification system is even

more important in crowded facilities like MCMJ. For example, our

expert corrections consultant noted that it is safer for staff

and inmates for MCMJ to increase the population density of low or

medium custody inmates, rather than high custody inmates. An

appropriate classification system would permit MCMJ to allocate

scarce space and resources appropriately to provide a reasonably

safe environment. Without such a classification system, inmates

and staff at MCMJ face an unacceptably high risk of harm.

3. 	 Supervision

We found that MCMJ failed to supervise inmates adequately.

The MCMJ is a remote-supervision jail, in which staff observe

inmates from a control area and are separated by glass walls from

the inmates in the six wedges.22 An officer assigned to the

control area cannot leave the post, except in emergencies, and

therefore floor officers are needed as additional security staff


21


Some examples of violent misdemeanors include the

following: assault in the third degree, Ala. Code § 13A-6-22

(2007); sexual abuse in the second degree, Ala. Code § 13A-6-67

(2007) (includes sexual contact with a person who is legally

incapable of consent for reasons other than age); and reckless

endangerment, Ala. Code § 13A-6-24 (2007).

22


This is in contrast to direct-supervision jails, where

staff are stationed in the housing unit. 


- 34 ­
to inspect the pods, perform shake-downs for contraband, and

ensure inmates’ safety.

The MCMJ policies required a welfare check of the inmate

population every 30 minutes. However, such checks were only

occasionally noted in the pod logs, which raised concerns that

they were not being conducted. In addition, there were no

guidelines for the conduct of such checks and no consistent

documentation of what staff observed during such checks. Such

inadequate supervision practices place both inmates and staff at

risk. For example, in April 2002, three inmates were assaulted

in their cell by two other inmates, with one of them suffering

bruising to his neck, face, and arm and a split lip. Although

the cells at MCMJ are in the line of sight of the pod officer’s

station, security staff did not notice the assault in the cell,

and the assault was only brought to light when one of the

assaulted inmates approached an officer. 

The floor officers at MCMJ were required to inspect the

condition of each pod once per shift. However, staff failed to

identify many deficiencies during these inspections. For

example, during one of our tours in 2003 we noted that several

windows to the outside of the facility were cracked or had holes

in them, and had apparently been broken for some time. This

poses a significant security risk.

The MCMJ’s security regarding escape prevention is also of

concern. We have learned that in 2007, a 19-year-old female

inmate at MCMJ allegedly attempted an escape, and reportedly was

only discovered when she was badly cut trying to climb the razor

fence surrounding the facility. It appears that MCMJ does not

know how this inmate made her way outdoors to be in a position to

charge the fence, or why she was not discovered until she had

suffered an injury on the fence. 

4.

Policies, Procedures, Training, and Staffing


The deficiencies we identified in security administration at

MCMJ stemmed in large part from a lack of adequate policies,

procedures, training, and staffing. The MCMJ policies did not

adequately address the operation of the facility. For example,

as noted above, the policies regarding facility inspections and

inmate welfare checks did not establish standards for these

evaluations and did not provide for a systematic mechanism to

address deficiencies identified by staff, thereby greatly

reducing their efficacy. Similarly, MCMJ policies did not

provide for adequate documentation of significant events, such as


- 35 ­
the use of force, the use of restraints, and facility

inspections.23

In addition, although the corrections officer who was in

charge of inmate discipline at the time of our tour in 2003 was

striving to administer discipline fairly, the disciplinary

procedures at MCMJ had significant problems. While these

problems did not violate the Constitution, our expert corrections

consultant noted that they significantly increased the tension in

the facility and fostered inmate-on-inmate violence. 

The MCMJ policy allowed for informal “sanctioning” of

inmates, including locking-down inmates for up to 72 hours with

no opportunity for the inmate to be heard or appeal the

decision.24 Our review indicated that the same type of violation

would at times be referred for formal disciplinary proceedings,

and other times the inmate would be sanctioned informally. While

not a constitutional violation, we flag these practices because

they give the perception that discipline is imposed arbitrarily,

which increases the risk of inmate-on-inmate violence. 

We observed that MCMJ staff did not receive adequate

training. At the time of one of our tours, a number of the

corrections officers hired in the last few years did not receive

pre-service training. In addition, until recently, MCMJ staff

were not receiving any in-service training.25 Thus, a number of

officers only received training through the Field Training

Officer (“FTO”) program, where officers are paired with an

experienced officer for two weeks. In addition, we identified

significant deficiencies with the FTO program. The MCMJ did not

have written procedures governing the selection of FTOs, to

ensure that FTOs are exemplary officers and demonstrate an

interest, knowledge, and ability to train new officers in MCMJ


23

The MCMJ reports that, following our tours, it

developed an unusual occurrence form and an use-of-force form,

which are centrally filed and reviewed. We have been unable to

verify this information. 

24


The MCMJ reported that, following our tours, it had

modified the sanction process. Reportedly, MCMJ no longer

conducts informal discipline unless the inmate signs a written

waiver of the hearing. We have been unable to verify this claim. 

25


We understand the MCMJ has since offered some in-

service training and plans to offer pre-service and additional

in-service training. 


- 36 ­
policies and procedures. The FTO program also did not describe

the knowledge, skills, and abilities that trainees must

demonstrate and simply listed the topics to be covered, such as

“Cell Inspections” and “Sick Call/Sick Slip.” Similarly, MCMJ

did not document the performance of the trainees in these topics

and FTOs simply noted the date the topic was covered with the

trainee. 

Other corrections officers did receive pre-service training,

but the curricula we reviewed indicated the training provided was

inadequate. The MCMJ training materials revealed that not nearly

enough training was devoted to critical jail functions. For

example, the training on the use of restraints and transporting

prisoners was last revised in 1991, and did not adequately

address the procedures for applying restraints. Moreover, the

training was apparently a lecture format, with no practical

component. 

Staff reported, and our review corroborated, that MCMJ did

not have adequate numbers of corrections staff. The MCMJ

corrections staff worked a large amount of overtime. For

example, it spent $1.5 million on overtime for corrections staff

in 2002. Yet the Jail still lacked sufficient staff to operate

the facility. The staff vacancy rate in 2003 was reportedly 28

percent. The heavy use of overtime also raised concerns about

officer fatigue, which can increase the risk of harm to inmates

and staff. 

The MCMJ also provided inadequate access to exercise, which

is a significant mechanism corrections facilities use to decrease

inmate aggression. The MCMJ had no indoor exercise facilities

and, by its own admission, made limited use of its outdoor

exercise yard. The MCMJ did provide some very limited outdoor

recreation, and so did not violate the Constitution, but the very

limited recreational opportunities raised tensions and thereby

fostered inmate-on-inmate violence. Appropriately structured and

supervised exercise provides an important outlet for inmate

aggression, and thus, is an important inmate management tool.

Futhermore, regularly scheduled exercise provides a privilege

that staff can take away from an inmate for sustained rule

violations. However, MCMJ’s outdoor yard was utilized on only 45

days in 2002. Although MCMJ apparently has improved access

somewhat since that time, it was still significantly limited at

the time of our tour. 


- 37 ­
E.

Safety and Sanitation


Although conditions at the Barracks were significantly

better than at the Jail at the time of our tour in 2003, safety

and sanitation conditions at both the Jail and the Barracks posed

a significant risk of disease and injury to inmates and staff.

We identified deficiencies in the areas of insect and rodent

control, physical plant, fire safety, and general sanitation and

safety. Similar to the security administration deficiencies

discussed above, the safety and sanitation failures were

exacerbated by the crowded conditions at the Jail. In 2007, we

provided the County and the Sheriff a written report prepared by

our expert corrections safety and sanitation consultant outlining

our concerns. 

1.

Insect and Rodent Infestation


We found that there was a significant insect and rodent

infestation at the Jail. We observed rodent droppings and a live

rat in the kitchen during the height of lunch preparation.

Insects and rodents in the kitchen area can spread food-borne

illnesses, such as by carrying salmonella bacteria.26 We also

saw ants and unidentified black bugs throughout the Jail.

Insects can spread disease and, given the general sanitation

problems, insect bites can become infected. As discussed in

section III.A.3, we noted an outbreak of a skin infection at

MCMJ.

2.

Physical Plant


Following our tours in 2003, MCMJ took a number of steps to

reduce the inmate population and reported that, as of December 3,

2003, the inmate census had been reduced to 1,006 inmates; 817 in

the Jail, and 189 in the Barracks. Unfortunately, this trend did

not continue, and the Jail presently remains dangerously

overcrowded. Since the start of our investigation, we have

received many allegations of inmates being forced to sleep on the

floor of their cells due to overcrowded conditions; some inmates

sleeping just inches from toilets and sinks, including an inmate

that was allegedly non-ambulatory. 

At the time of our tour, there were a number of plumbing

problems at the Jail, although we did not identify such problems


26


We understand that following our tours, MCMJ has

instituted periodic pest control visits covering the entire

facility. We have been unable to verify this assertion. 


- 38 ­
at the Barracks. We observed inoperable showers and toilets

throughout the Jail facility. For example, we observed numerous

leaking toilets, including in cells with inmates sleeping on the

floor near the leaks. In addition, we measured hot water

temperatures above 120 degrees, which create a scalding threat to

both inmates and staff. For example, the shower water

temperature in one of the female units measured 130 degrees,

which can cause burns in less than 30 seconds. These water

temperatures allow inmates to harm themselves, accidently or

intentionally, and provide a weapon for inmates who want to harm

others.

3.

Fire Safety


We identified several deficiencies in MCMJ fire suppression

and evacuation systems and procedures. For example, there were

no sprinkler heads over the ovens in the kitchen or behind the

dryers in the Jail, two places where fires are likely to

originate.27 We also identified deficiencies in evacuation

systems and practices. For example, one fire door took over two

minutes to open and another could not be opened by staff.

Additionally, MCMJ has inadequate procedures to evacuate the

facilities in the event of an emergency. We also noted several

exit lights that were not working, impeding evacuation in the

event of a fire. 

4.

General Sanitation and Safety


Many of the showers contained mildew and mold. Moreover,

the laundry facilities do not adequately sanitize the clothing,

which increases the risk of transmitting infectious diseases,

such as skin infections.28 In addition, the sink in the laundry

room did not have a vacuum breaker to prevent back-flow from

contaminating the potable water system. 

Chemical safety was also inadequate at MCMJ. For example,

we observed a container in the medical clinic marked “bleach”


27


We note that MCMJ retained a new sprinkler-maintenance

contractor shortly before our first tour, who was reportedly

working to correct these problems. The MCMJ reported that,

following our tours, it has worked with the Fire Marshal to

identify and correct fire safety problems and conducted fire

safety training.

28


We understand that since our tours, MCMJ has acquired

new washing machines. 


- 39 ­
that actually contained an ammonia-based chemical. Such

mislabeling poses a significant risk of harm to inmates and staff

because it may lead to accidental mixing of chlorine and ammonia-

based chemicals, which releases highly toxic chlorine gas. In

addition, inmate workers in the laundry were using corrosive

chemicals without protective equipment such as goggles to prevent

injury.29

IV. RECOMMENDED REMEDIAL MEASURES

In order to address the constitutional deficiencies

identified above and protect the constitutional rights of

inmates, MCMJ should implement, at a minimum, the following

measures:

A. 	 Medical Care

1.	

Revise intake procedures and the Jail Receiving Screening

form to screen incoming inmates adequately. Ensure that a

qualified medical professional reviews all screening on a

timely basis.


2.	

Develop and implement a policy to ensure that a qualified

medical professional completes a timely health appraisal of

each inmate. 


3.	

Develop and implement chronic disease policies and

procedures that adequately identify inmates with chronic

diseases and ensure adequate and timely monitoring of, and

follow-up care for, inmates with chronic diseases. 


4.	

Develop and implement adequate policies and procedures

regarding the identification and treatment of contagious

diseases such as tuberculosis and syphilis. 


5.	

Develop and implement procedures to assure timely and

appropriate access to medical care through sick call. 


6.	

Develop and implement protocols specifying the appropriate

response[s] to common acute symptoms. 


7.	

Develop and implement policies and procedures that ensure

timely and appropriate delivery of prescription medications.


29


The MCMJ reports that, following our tours, it has

taken various measures to address chemical safety issues. 


- 40 ­
8.	

Continue working with the Department of Health to prevent,

diagnose, and treat the outbreak of skin infections.

Develop and implement policies and procedures to address the

likely causes of the outbreak and to treat infections. 


9.	

Provide sufficient staffing to ensure that inmates’ serious

medical needs are met. 


B. 	 Mental Health Care

1. 	 Revise intake procedures and forms to screen adequately

incoming inmates for mental health issues. Ensure that a

qualified mental health professional reviews all screening

on a timely basis. 

2. 	 Ensure that staff conducting intake screening are trained

adequately. 

3. 	 Develop and implement procedures to ensure inmates with

mental health needs receive timely assessment by a qualified

mental health professional. 

4. 	 Develop and implement policies and procedures to ensure

timely and adequate responses to inmate requests for mental

health care. 

5. 	 Ensure adequate on-site psychiatry coverage, and ensure

adequate on-site supervision of mental health staff. 

6. 	 Develop and implement policies and procedures that ensure

adequate monitoring and follow-up treatment of inmates with

mental illness. 

7. 	 Develop and implement adequate suicide screening policies

and procedures. 

8. 	 Ensure that inmates receive psychotropic medications in a

timely manner and that inmates have proper diagnoses for

each psychotropic medication they receive. 

C. 	 Use of Restraints

1. 	 Develop and implement a policy regarding the application of

restraints that requires immediate prior written approval,

if practicable, of the use of restraints for medical

purposes by a qualified medical professional or immediate

prior written supervisory approval, if practicable, for uses

of restraints for security purposes, other than the use of


- 41 ­
routine restraints for transporting inmates, such as

handcuffing. 

2. 	 Develop and implement a policy regarding monitoring

restrained inmates that requires adequate checks of the

physical condition of restrained inmates, and adequate

documentation of the use of restraints, including the basis

for and duration of the use of restraints and the

performance and results of welfare checks on restrained

inmates. 

D.

Security, Supervision, and Protection From Harm


1. 	 Develop and implement an objective, behavior-based

classification system that separates inmates in housing

units by classification levels. 

2. 	 Develop and implement written procedures for conducting and

documenting security inspections and inmate welfare checks,

including specific criteria for such evaluations and a

systematic procedure for correcting any deficiencies

identified. 

3. 	 Provide adequate corrections officer staffing and

supervision to ensure inmate safety. 

4. 	 Develop and implement appropriate training for corrections

staff addressing security administration and providing for

proficiency testing. 

5. 	 Develop and implement policies governing the conduct of

shakedowns that increase the frequency and identify the

scope of shakedowns in order to minimize inmates’ access to

dangerous contraband. 

6. 	 Develop and implement policies requiring adequate

documentation and investigation of significant events,

including use of force by staff and instances of inmate-on­
inmate assault. 

E. 	 Safety and Sanitation

1. 	 Ensure regular and periodic cleaning and maintenance of all

housing areas, including toilets and showers. Ensure

regular and periodic insect and rodent control measures are

performed. 


- 42 ­
2. 	 Ensure proper operation of all fire detection and

suppression systems. Develop and implement adequate

evacuation procedures, including emergency door inspections. 

3. 	 Adjust the hot water in all housing areas to safe

temperatures. 

4.	

Develop and implement proper chemical safety measures. 

V.

CONCLUSION


We note again in conclusion the extraordinary and unexpected

step taken by the County and Sheriff to cease all communications

with the Department of Justice regarding this investigation, and

the negative inferences we drew regarding the present status of

the conditions at MCMJ in light of this action. Nevertheless, we

once again invite the County and Sheriff to discuss with us the

remedial recommendations we presented in this letter, with the

goal of remedying the identified constitutional violations

without resort to litigation. 

In the event we are unable to reach a resolution regarding

the above identified constitutional violations, we are obligated

to advise you that the Attorney General is authorized to initiate

a lawsuit pursuant to CRIPA, 49 days after receipt of this

letter, to correct identified deficiencies or otherwise protect

the rights of the inmates incarcerated at MCMJ.

42 U.S.C. § 1997b(a)(1). If you have any questions regarding

this letter, please contact Shanetta Y. Cutlar, Chief of the

Civil Rights Division’s Special Litigation Section, at

(202) 514-0195. 

Sincerely,

/s/ Grace Chung Becker

Grace Chung Becker

Acting Assistant Attorney General


- 43 ­
cc:	 Lawrence M. Wettermark, Esq.

Attorney for the Mobile County Commission

James B. Rossler, Esq.

Attorney for the Mobile County Sheriff’s Department

Michael W. Haley

Warden

Mobile County Metro Jail

Deborah J. Rhodes

United States Attorney

Southern District of Alabama