Adele:
A Detainee at the Missoula County Detention Facility

An Investigative Report
by:
DISABILITY RIGHTS MONTANA

November 2008

Adele:
A Detainee at the Missoula County Detention Facility
An Investigative Report

November 2008

DISABILITY RIGHTS MONTANA

1022 Chestnut
Helena, MT 59601
1-406-449-2344
1-800-245-4743

PREFACE
As the designated protection and advocacy system for people with disabilities in
Montana, one of Disability Rights Montana's (DRM) functions is to advocate for people
with disabilities who are held in facilities, which includes detention centers, and to
investigate allegations of abuse and neglect. In July 2006, DRM staff learned that Adele
(called Adele in this Report to protect her identity) a woman with mental illness and
developmental delays arrived at Montana State Hospital with seven deep and distinctive
bruises on her arms and body. DRM started an investigation to determine how Adele
received the bruises. We learned that Adele was brought to St. Patrick Hospital for help
with her medication. A dispute took place with the hospital security. Missoula City
Police were called and they transported Adele to the Missoula County Detention Center.
This Report details the events that took place between the time Adele was received at the
Missoula County Detention Center until she was released less than 18 hours later with a
misdemeanor charge and on a $10.00 bond. During the time she was held in custody,
Adele was shackled, placed in a restraint chair for two and a half hours, later placed in a
locked cell, shot seven times with a pepperball gun, again placed in a restraint chair
where she sat for 44 minutes without the opportunity to be decontaminated. DRM
confirmed that the detention center staff were familiar with Adele and aware she was a
person with a mental illness and developmental delays. We learned and confirmed that
Adele was crying and confused while in their custody but did not refuse or resist the
detention officers' directions. We conclude that the detention center staff violated their
policies, mistreated and abused Adele, lacked appropriate oversight, and is in need of
training to respond appropriately to people with mental illness and developmental
delays.
The purpose of this Report is to document and highlight the events experienced by
Adele, a person with a disability in the detention center, and to make recommendations
for improvements. We have made every attempt to be accurate in this Report.
Sheriff Mike McMeekin, who is responsible for the Missoula County Detention Center,
was provided a draft copy of this Report on October 8, 2008, with the opportunity to
respond. He responded on October 13,2008, asking for clarification, which we
provided. Sheriff McMeekin asked for two extensions of time to respond. Both times
we agreed. On November 9th we received a letter from the Sheriff stating that "we are
preparing a comprehensive response and will independently disseminate it to anyone
asking us about the Report. You will be provided with a copy as soon as it is completed
and approved by counsel." We have not received Sheriff McMeekin's response.
Attached to this Report is all the correspondence between DRM and Sheriff McMeekin.
All the documents have been redacted to preserve Adele's privacy.

On May 22, 2008, through private counsel, Heather M. Latino, of Paoli, Latino &
Kutzman, P.C., Adele filed lawsuit against Sheriff McMeekin and the officers who
mistreated and abused her.
Disability Rights Montana wants to acknowledge Michael Burch, the detention officer
whose moral conscience guided him to do the right thing and report the abuse to the
authorities. We are outraged that the authorities chose to fire Officer Burch and
exonerated the officers who assaulted and abused Adele.
This Report is published in Michael Burch's honor. Michael died of a heart attack
several months after he was fired. May his doing the right thing bring the much needed
training and appropriate oversight to the Missoula County Detention Center.
Finally, a special thank you to Alexandra Volkerts, attorney and the investigator in this
case, and the DRM staff who are responsible for the content of this RepOli.
Sincerely,
DISABILITY RIGHTS MONTANA

emadette Franks-Ongoy
Executive Director

Table of Contents
Introduction

1

Summary of Conclusions

2

The Investigation

3

Legal Fralnework

4

1.

Constitutional Issues

4

2.

Statutory Enactments

4

a.

Screening and Diversion of Persons with
Mental Illness from Detention

4

Montana Elder and Persons With Disabilities
Abuse Prevention Act

5

c.

Jail Policies and Procedures

5

d.

Missoula County Detention Facility (MCDF)
Policies and Procedures
1.
Use of Force
2.
Use ofPepperspray/OC
3.
Use of Restraint Chair
4.
Mistreatment of and Assault upon Inmates .. . . . . . . . . . . . . .

6
6
7
7
7

b.

Facts

8

Analysis .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
1.

Statutory Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11
a.

Screening and Diversion of Persons
with Mental Illness from Detention . . . . . . . . . . . . . . . . . . . . . . . .. 11

2.

b.

Montana Elder and Persons With Disabilities
Abuse Prevention Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12

c.

Mistreatment of and Assault upon Irunates

12

Jail Policies and Procedures .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 13

Conclusions .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16
Recommendations
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
1.
Screening, Booking and Information Sharing
2.
Medical Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
3.
Training
4.
Psychiatric and Other Resources
5.
Citizens Oversight Committee

16
16
19
21
22
22

INTRODUCTION
On July 7, 2006, Montana Advocacy
Program (MAP), now known as Disability
Rights Montana (DRM), received a call that
a woman with mental illness and
developmental delays had arrived at the
Montana State Hospital (MSH) with seven
deep and distinctive bruises on her arms and
body. DRM began an investigation which
found that on July 1, 2006, the woman
(called Adele in this report to protect her
identity) was brought to St. Patrick Hospital
emergency room (ER) for help with her
medications. Although known to the
hospital as a woman with mental illness and
developmental delays, she was refused
services at the ER. She ended up in a
dispute with hospital security staff who
called the Missoula Police Department to
remove her. The police took her to the
Missoula County Detention Facility (Jail).
Although she was no longer obviously
agitated when she arrived, she was met by
overwhelming force, patted down without
incident, and immediately put into a
restraint chair for more than two and a half
hours. The Jail perfonned no psychiatric or
mental health evaluation for her and no
medical staff was called to evaluate her
before, while, or after she was in restraint.
At least one medical staff was on duty at the
time.
After two and a half hours, Adele was
released from restraint after she fell asleep
in the chair. She was then put in a cell. She
awoke around 2:30 a.m., frightened,
confused, and calling or screaming for her

father. No medical staff or mental health
professionals (MHPs) were called to
evaluate her, talk to her, or provide calming
medication. Although confused and crying,
but responding to commands, she was shot
more than six times with a pepperball gun
while standing on the floor against a wall in
a locked cell. Both she and her cell were
covered with Oleocapicain powder (OC),
the primary ingredient in pepperball guns
and pepperspray. She compliantly exited
the cell only to be strapped again into a
restraint chair without the opportunity to
decontaminate herself. A nurse briefly
checked her for injuries, but did not insist
she be decontaminated nor asked critical
medical questions. She was released from
restraint after forty-four minutes. At some
unknown time, she was taken to the showers
in another part of the Jail to decontaminate.
Adele was released from Jail July 2, 2006,
after paying a nominal fine for disorderly
conduct. Fearful, confused, and highly
emotional, as well as in considerable pain,
Adele went to the Community Hospital
emergency room the next day seeking help.
She was evaluated and released with pain
medication. Several days later she returned
to the St. Patrick Hospital emergency room,
where she was recognized as
decompensating from mental illness,
evaluated by a MHP, and taken to MSH on
emergency detention, pending commitment.
That is when Disability Rights Montana
received a call reporting Adele's injuries.
Montana has several systems that should
have helped Adele. Those systems identify
people with mental illness, provide humane
treatment at the hospital and, divert people

Adele Report - November 2008

with mental illness from incarceration. All
systems failed Adele. This incident raises
difficult issues regarding the community's
response to vulnerable people in a mental
health crisis, the use of jails as a default
holding system when community crisis
services fail to respond appropriately, and
the inadequate training, standards,
information access, and safeguards in the
Jail to appropriately, safely and humanely
respond to people with mental illness and
developmental disabilities. It also points
out the deficiencies in the statutorily
mandated procedures for evaluation and
diversion ofpeople with mental illness who
are charged with minor crimes.

to the Jail in violation of Montana
Code Annotated § 53-21-138. 1
2.

The Jail violated both the substantive
requirements and reporting
responsibilities of the Montana Elder
and Persons with Developmental
Disabilities Abuse Prevention Act,
Montana Code Annotated § 53-2-801
et seq.

3.

The Jail violated many of its own
policies, including 7.24, which limits
and defines the circumstances under
which force, restraint, and non-lethal
weapons, including the pepperball
gun, may be used, and mandates
safeguards and follow-up procedures;
12.02, which prohibits personal
abuse,
punishment,
and
discrimination based on disability;
and 11.54 which provides a protocol
for the treatment of inmates at risk for
suicide.

4.

The Jail violated Montana Code
Annotated § 45-5-204, which defines
"assault on an inmate" as a crime; and
§ 7-32-2248, a Montana statute

This report is bifurcated: This report will
address what happened at the Jail, the
second report will address what happened at
81. Patrick Hospital Emergency Room.

SUMMARY OF CONCLUSIONS
The decisions to release Adele from the 81.
Patrick Hospital ER without evaluation or
treatment by a doctor and to send her to Jail
where she was detained without screening
her for mental illness led to a cascade of
events which violated Adele's rights under
Montana's Constitution, statutes, and
multiple jail policies and procedures.

1.

2

The Jail failed to screen Adele for
mental illness when she was brought

IThe statute, captioned "Diversion of
certain persons suffering from mental
disorders from detention center" mandates that
all inmates be screened for mental illness to
identify those persons accused of minor
misdemeanor offenses, including disorderly
conduct, who appear to be suffering from mental
disorders and who may require commitment. The
Jail intake and booking procedures include no
effective screening tools to determine whether a
person may be suffering from a mental illness.

Adele Report - November 2008

prohibiting the mistreatment
inmates at detention centers. 2
5.

of

The Jail's training program appears
inadequate in respect of teaching
officers to screen, identify, recognize,
and treat detainees with mental illness
and/or developmental disabilities,
including appropriate use of force
and restraint, and their reporting
requirements in instances of alleged
abuse and neglect.

process of investigation, the Jail did make
some positive steps which may serve to
mitigate some of the problems highlighted
herein. 4
access to detention officers who
participated in the pepperball shooting.
The Sheriffs office initially obstructed
access to irunate witnesses of the shooting
and removed the investigator from the
facility.
•

THE INVESTIGATION
This investigation was complex, and was
hindered and slowed by certain
complicating factors. 3 However, in the

The Sheriff allegedly ordered his staff and
medical staff not to speak with the
investigator except with his permission.
•

2The list of prohibited actions also
provides for criminal penalties.
3Complicating Factors: this investigation
was complicated by a number of factors.

•

•

•

The Sheriff s office consistently delayed
or refused to provide information for over
eighteen months to the extent that at the
time of this report essential evidence
including video tapes of Adele's arrival at
the Jail, audio tapes confirming when she
was actually taken to the shower, and other
essential documentary evidence, including
the FBI investigative report, has never
been provided.
The Sheriff s office appears to have
provided erroneous information when it
provided a list of inmates in the cell pod at
the time of the pepperball shooting.
The Sheriffs office obstructed DRM

The medical clinic contracted to provide
medical services to the Jail has failed to
provide access to the nurse who examined
Adele immediately after the pepperball
shooting.

The Sheriff initially supported and was
actively involved with developing a
screening and diversion program for
people with mental illness in conjunction
with 4 th Judicial District Court and other
stakeholders as required by statute.
Currently the Sheriff s representatives
have withdrawn their participation in and
support of the Diversion Committee.

4Mitigating Factors. The investigation
and its results have been mitigated by:

•

The Sheriff sent three detention officers
and up to 5-6 beat officers to Crisis
Intervention Training (CIT) to train
officers how to work with people with
mental illness. CIT training was held in
Helena in April 2007.

•

The Sheriff has become occasionally
involved with and is a member of the
Board of Directors for the Western Service
Area Authority which is made up of

Adele Report - November 2008

3

LEGAL FRAMEWORK
1.

Constitutional Issues

2.

Both the U.S. and Montana Constitutions
require that an inmate receive adequate
medical and mental health treatment while
in custody. To deny adequate medical care
while a person is in custody and unable to
obtain their own medical care constitutes
cruel and unusual punishment. s
Respect for the dignity of each individual is
a fundamental right protected by Article II,
Section 4 of the Montana Constitution
which provides that "the dignity of the
human being is inviolable."6 Montanans
with mental illness are entitled to the same
civil rights as are other citizens ofMontana.
In addition, people with mental illness have
a statutory right to treatment suited to their
needs that is administered skillfully and
humanely with full respect for the person's

consumers and other stakeholders
working to develop an integrated
mental health services system in
Western Montana.

5u.S. Constitution, Article 8; see Estelle v.
Gamble, 429 U.S. 97 (1976) (denial of adequate
medical treatment constitutes cruel and unusual
punishment); Hoptowit v. Ray, 682 F.2d 1237 (9th Cir.
1982) (the right to adequate medical care includes the
right to adequate mental healthcare); Morelli v. Lake
County, 255 Mont. 23 (1992) (county has a duty to
give medical aid and treat prisoners humanely).
6Montana Constitution, Article II, Section 4;
Armstrong v. State, 1999 MT 261, ~ 72, 296 Mont.
361, ~ 72,989 P.2d 364, ~ 72.
4

dignity and personal integrity. 7 This right to
be treated humanely, with dignity and
respect has been consistently recognized by
the Montana Supreme Court. 8

Statutory Enactments
a.

Screening and Diversion of
Persons with Mental Illness
from Detention

It is the policy ofthis State that people with
mental illness be identified and diverted
away from jails and back into the mental
health treatment system, when appropriate.
Montana Code Annotated § 53-21-120 and
124 prohibit holding a person facing
cOlmnitment proceedings in jail while they
await their hearings. 9 Since 2003,jails have
been mandated to screen all inmates to
identify people with mental disorders
accused of minor misdemeanors to
determine ifthey may require commitment. 10
"Minor misdemeanor offense" means nonserious misdemeanors such as criminal
trespass to property, loitering, disorderly
conduct, and disturbing the peace. It covers
a broad range of minor crimes which entail

7

Mont. Code Ann. § 53-21-101(1).

8See In the Matter ofthe Mental Health of
KGF, 2001 MT 140, ~ 45,306 Mont. 1, ~ 45, 29 P.3d
485, ~ 45 (citing Armstrong in the context of right to
dignity while under civil legal proceedings).
Forty percent ofjails acknowledge that in
spite of the law, they use minor or no charges to hold
people with mental illness until they can release them
or obtain community mental health treatment. MAP
Jail Survey July 2000, published by Montana
Advocacy Program, page 24.
9

laMont. Code Ann. § 53-21-13 8.

Adele Report - November 2008

no significant injury to other people or
property.
If a person does require
commitment, she or he may not be held in
jail pending evaluation and hearing.]]

b.

Montana Elder and Persons
With Disabilities Abuse
Prevention Act

As a group, people with developmental
disabilities are more vulnerable to abuse,
neglect, and exploitation and require
additional protections.
Consequently,
statutes impose an obligation on
professionals and public employees,
including law enforcement officers, to
watch for and report incidences of abuse,
neglect, or exploitation of people with
developmental disabilities to the
Department of Health and Human Services,
Child Protective Services or Adult
Protective Services, as appropriate.]2

c.

codes, there are no statewide standard
policies and procedures applicable to jails or
detention facilities.]4
Currently, each
detention center administrator is allowed
discretion to develop and adopt his or her
own policies and procedures regarding the
operation of local jails or detention
facilities, at least with regard to city/county
inmates subject only to constitutional,
statutory, and common-Iaw.]5 Missoula
city-county detainees and Jail staff are
subject to the policies and procedures
adopted by the Jail facility administrators,
under the supervision and oversight of the
County Board ofCommissioners. ]6 The Jail
has chosen to adopt some MSPOA and
American Correctional Association (ACA)
policies but created many of its own. Many
jail policies have remained in draft form for
years, and some were adopted in final fonn
after this incident or during the
investigation.

Jail Policies and Procedures

To distinguish between assault on an inmate
or inmate endangerment and necessary use
of force, the Montana Sheriff and Police
Officers' Association (MSPOA) has
developed and recommended policies to
clarify this grey area. However, it is entirely
voluntary whether a county adopts in part or
in whole the MSPOA policies. 13 Other than
sanitation, safety, and fire and building
l1Mont. Code Ann. § 53-21-120, 124.
12Mont. Code Ann. § 52-3-801, et seq.
13See Mont. Code Ann. § 7-32-2201,2204,
2234. County commissioners have jurisdiction and
power ... to cause a detention center to be ...
operated.

14Mont. Code Ann. § 7-32-2222. Detention
center shall comply with state and local fire codes for
correctional occupancy and with sanitation, safety and
health codes.
15Mont. Code Ann. § 7-32-2234. When a
detention facility accepts State or Federal prisoners, it
agrees to abide by the policies and procedures set
forth by the State or Federal contract for the care and
custody of such prisoners. State policies are only
mandatory for state prisoners while Federal policies
are only mandatory for Federal prisoners.
16Pursuant to interview with Missoula County
Sheriff, September 19, 2006.

Adele Report - November 2008

5

d.

Missoula County Detention
Facility (MCDF) Policies and
Procedures

A number ofcurrent policies and procedures
adopted by the Sheriff or his predecessors
provide some guidance on the use of force,
pepperspray or powder (OC) and restraint
chairs. These policies expressly recognize
the civil rights of inmates to humane
treatment and to be free from discrimination
based on disability.
An employee is
required to abide by the Jail's policies and
procedures or face sanctions up to and
including dismissal. MCDF Policy 3.10.

1.

Use of Force

Policy 7.24 provides guidance regarding if
and when it is appropriate to use force
against inmates. The policy identifies a use
of force continuum to clarify increasingly
forceful steps to be worked through in a
roughly sequential manner when an officer
faces a challenging situation. The policy
further provides that force will only be used
to the degree necessary to prevent serious
bodily injury or death to staff or inmates.
The policy later clarifies that an escalating
use of force may only occur when a person
presents an imminent danger of serious
bodily harm or death to staff or third parties.
The use of force continuum starts with lowlevel passive intervention, such as talking to
the person, video taping the person and
bringing more officers to the scene in a
show of force. If these do not work, the
officer may move to active measures,
including control holds, self-defense
techniques, and restraint which would
6

include hands on or handcuff restraints as
well as the use of a restraint chair. The use
of pepperspray and batons is restricted to
the more severe incidents, requiring either
an immediate response or a planned
response under supervision of the shift
supervisor or trained tactical team. Finally,
in extreme situations, deadly force may be
used ifthere are no other means ofresolving
the imminently dangerous situation.
To assist officers in the decision to use
increasing levels of force, the policy
mandates four factors which must be
considered to detennine whether the
inmate's actions constitute a threat of
imminent danger of death or serious bodily
InJury:
1)

The ability or apparent ability
of the inmate to cause serious
injury (disparity in size, age,
strength, numbers and level of
aggressiveness are important
enumerated factors);

2)

Opportunity to cause senous
bodily injury or death;

3)

Imminent jeopardy (i.e. is it
reasonable to believe that right
now the person's acts could
cause serious injury or death);
and,

4)

Has the officer exhausted all
reasonable options.

The policy further clarifies that use of force,
security equipment, and restraint equipment
are intended only as control measures and

Adele Report - November 2008

are to be used only when absolutely
necessary. Only the minimum amount of
force necessary may be used. Force cannot
be used for punishment, harassment,
coercion, or abuse.

2.

Use of Pepperspray/OC

Policy 7.24 provides that OC, the active
ingredient in the pepperball gun
ammunition, "should only be used in an
amount necessary to gain control and cause
an inmate to cease [his or her] aggression."
OC is defined as an inflammatory agent
derived from habanero pepper plants that
effects the mucous membranes and upper
respiratory system. "[I]t is the policy of the
Jail that when use of force has been used,
and particularly when OC has been used, the
irunate will be examined by medical staff
and receive any necessary treatment as soon
as possible . . . ." Necessary treatment
specifically includes the opportunity to
shower as soon as possible.

3.

Use of Restraint Chair

Policy 7.24. Restraint chairs are molded of
fibreglass and use "soft wrist restraints
made of webbed nylon and soft ankle
restraints of the same material" to hold a
person in the chair. The policy recognizes
that use the restraint chair may be necessary
to prevent security threats, escape, assault,
suicide, to protect staff or inmates, for
mental health reasons, or for certain
necessary circumstances within the
discretion of the Sheriff or designee. Like
all uses of force, it should be employed only
to the degree necessary to control the inmate
and further, it should "only be used as a last

resort." It is "not to be used to punish,
harass, coerce, or abuse inmates." During
restraint, the inmate must be closely
monitored and removed from the restraint
chair as soon as possible. At a minimum,
inmates must be checked every 10 minutes
and the checks must be logged and an
incident report completed. Once removed
from the chair, "the inmate must be seen by
medical staff." (Emphasis added.) State
policy prohibits the use of restraint chairs
for State prisoners.

4.

Mistreatment of and Assault
upon Inmates

Detention officers also have specific
obligations to perform their duties in a
manner which does not mistreat prisoners.
Under Montana Code Annotated § 45-5204, it is a felony for detention staff
responsible for the care or custody of
prisoners to purposely or knowingly assault
or otherwise injure a prisoner; intimidate,
threaten, endanger or withhold reasonable
necessities from a prisoner for any purpose,
or violate the civil rights ofthe prisoner. An
officer committing such an offense may be
fined and must be removed from office or
employment. "Knowingly" means that the
officer was aware ofhis own conduct, while
"purposely" means that the officer acted
deliberately to achieve the result or
conduct.]7
A detention center administrator or staff
member commits the offense of inmate
endangerment if she or he knowingly uses
corporal punishment against an inmate or

17Mont. Code Ann. § 45 -2-101 (35), (65).
Adele Report - November 2008

7

uses physical force against an inmate
Legal
without legal justification. I8
justifications for the use of force by
detention officers is authorized in very
limited circumstances for necessary selfdefense, control of inmates, for the
protection of another person from imminent
physical attack or to prevent a riot or escape.

FACTS

Adele, a young adult, has lived in Missoula
for several years and is well known to the
various mental health emergency services as
well as to the police and Sheriff s
departments. She had been committed to
MSH two times and to a community
inpatient hospital at least twice before this
incident. Personable and sunny natured
most of the time, Adele has multiple
disabilities including psychotic disorder,
major depression, mild mental retardation,
fetal alcohol syndrome, and PTSD from
childhood trauma. Her medical conditions
include asthma. She has experienced many
losses in her life, including both her natural
parents, her home, her language, and more
recently, her foster father. She receives
supported living and employment services
as well as case management services for her
disabilities.
Even with community supports, Adele had
made 28 visits to the ER over the five years
prior to this incident for treatment of her
mental illness and had been hospitalized

four times before this incident. Transport to
and from MSH for emergency detention,
returns for judicial hearings and final
commitment to MHS is provided by the
Missoula County Sheriff s Department. In
addition, Adele had been detained at the Jail
on at least four previous occasions and has
had numerous contacts with the city police.
At least two Jail employees or former
employees noted that they were well aware
Adele has limited cognitive ability and
mental illness.
On the weekend ofJuly 4 th , Adele had either
failed to take her medications as prescribed
or they were no longer working. Her case
manager had been trying to locate Adele for
two days. On Saturday, July 1st, Adele
called her foster sister who brought her to
the ER around 7:20 p.m. She became
agitated, demanded medication and threw
other medication on the floor. Failing to
consider her mental health issues, the ER
nurse determined that Adele had no
"medical" issues, and called security
officers, who eventually wrestled Adele to
the floor. No one else was injured, but
Adele suffered a bloody nose.
The
Missoula City Police were called to arrest
her on misdemeanor disorderly conduct
charges. 9-1-1 dispatch alerted the Jail that
the city police were bringing in a combative
woman but apparently gave no other
infonnation.
According to video evidence, most of the
team on duty that night, one of whom was
carrying a tazer, met a crying Adele in the
Jail garage or "sally port." Six large officers
accompanied Adele into the remand area to
be frisked with her hands cuffed behind her

18Mont. Code Ann. § 7-32-2248.
8

Adele Report - November 2008

back, although only two officers actually
touched her to lead her into the remand area.
She was crying but not otherwise obviously
struggling. Two officers shoved her facefirst into a long pad on the wall of the
remand area, one officer clamping his hand
to the back of her head while the other
patted her down.
As soon as she was released from the pat
down, non-resisting but crying, she was
shoved backwards into a restraint chair by
two officers, taking her full weight on her
handcuffed arms, while the other officers
stood around watching.
(The official
written report states that she became so
combative, all the officers present were
needed to gain control of her, which is
contradicted by video evidence.) Adele, a
city/county detainee, could be put in a
restraint chair, but only in conformance with
Jail Policy 7.24, and only as a last resort.
The video evidence provided failed to
justify the use of the restraint chair
There is no evidence that Adele was
evaluated medically while in the restraint
chair for two and a half hours or after
release as required by policy. One female
officer apparently observed Adele and
agreed she was compliant and could be
released, but noted that only the senior
detention officer (SDO) could release her.
Finally, a sleepy Adele was released from
the chair and taken to a cell where she slept
for several hours.
Around 2:30 a.m., Adele woke and began
screaming and allegedly threatening suicide.
The SDO heard the report over the intercom
in his office.
Before evaluating the

situation, he armed himself with a
pepperball gun and ammunition. He failed
to call for medical assistance to calm her or
mental health support to address her alleged
suicidality. Contrary to policy, no videotape
was made of the incident from inside her
cell which would have provided a more
complete recording of Adele's alleged
suicide threats.
The SDO stated the
mounted VCR cell unit was not working.
By official report, Adele apparently said, "I
know how to kill myself," and climbed on a
concrete desk 30 inches high.
Other
witnesses state she woke crying, screaming
and calling for her "daddy" but that they
heard no threats of suicide. A female officer
on duty allegedly talked her off the bunk or
desk before the SDO arrived. There is no
independent evidence corroborating that she
was actually threatening suicide.
The only video tape ofthe shooting incident
was two or three minutes recorded by a
hand-held video camera through the glass in
the cell door. The official report alleges she
was threatening to throw herself head first
offthe desk onto the concrete floor, creating
a dangerous situation which could only be
deterred by shooting Adele with OC. Adele
was yelling and crying when the video
begins. Adele was standing directly across
from the cell door, next to or on the I8-inch
high bunk. She is not standing on a desk.
There is no evidence of threats to herself.
Nor is there any evidence the SDO
attempted any other less forceful
interventions, to talk to her, try to calm her
or call a mental health professional or nurse.
The SDO stated he did not try any of these
lesser interventions.

Adele Report - November 2008

9

The SDO ordered Adele to tum around and
kneel. Her response was unintelligible
except for "No, ... come on." In a raised
voice he ordered, "On the bunk now,"
although she was standing on or in front of
the bunk at the time. She moved away from
the bunk to lean, crying, on the wall, and
had now eliminated any possible danger to
herself. He then yelled, "On the bunk or
force will be used against you." She
continued crying against the wall and he
fired at least six shots into her body. She
cowered, crying harder. He screamed,
"Face down on the bunk!" and fired at least
three or more shots into the cell. Adele
cried that it hurt, moved to the bunk and lay
down crying, coughing, and holding her
body. He ordered her to lie on her stomach,
arms at her side. Crying and squealing, she
complied. The officers entered her cell,
cuffed her hands behind her back and pulled
her up, coughing, and she said she couldn't
breathe.
Adele, compliant and non-resistant, was
immediately placed in a restraint chair. No
effort was made to decontaminate her, wash
her face or bare skin. She was not asked
about asthma or high blood pressure, either
of which can cause death with the use of
OC. The facility nurse was called to check
Adele at approximately 3:00 a.m. while she
was in the restraint chair. The nurse said
she was unable to obtain vital signs due to
the restraint chair and Adele's alleged
aggressive behavior. She told Adele "to try
and relax and rest," but made no effort to
decontaminate her, and took no medical
history although she noted two bruises on
Adele's left side and abdomen. According
to witnesses, the nurse stated it was obvious
10

Adele had mental retardation. Adele was
released from the restraint chair and taken to
shower more than 45 minutes later, and
returned to her cell.
The next shift finally completed booking
Adele into the Jail more than 12 hours after
she was atTested, and had her examined by
the medical clinic. The nurse practitioner
documented that Adele received services
from a community provider ofmental health
and developmental disability services. She
also noted that "a friend had called to say
Adele was off her medications." Her notes
indicate Adele had two noticeable bruises
and complained of back pain, had a mental
health diagnosis, was prescribed
psychotropic medications, and had a
developmental disability.
Adele's case manager posted $10.00 bail
and took Adele home. She had been
without medications for at least four days,
and was confused, disoriented, and
traumatized. She sought help on July 3rd at
the Community Medical Center ER for pain
caused by the shooting and then again on
July 4 th at St. Patrick Hospital ER for pain
and confusion. The St. Patrick Hospital ER
doctor gave her a 6-day supply of
psychotropic medications, but stated she did
not need commitment. She was brought by
the city police to the ER early on July 6 th •
When she became loud and disruptive, she
finally received a mental health evaluation
and was sent on emergency detention to
Montana State Hospital.
The Jail has three resources available for an
inmate exhibiting a mental health crisis. A
psychologist provides court ordered mental

Adele Report - November 2008

health evaluations; a state-employed social
worker is also available as a resource for
non-state inmates during nonnal working
hours; and a licensed clinical professional
counselor is on-call for after-hours
emergenCIes.
Adele was originally brought in during the
medical clinic registered nurses' nonnal
shift. The nurses are available to go to
booking if asked, and may offer Ativan to
an inmate to calm down. If staff detennines
it is not safe to open a cell door, they may
also call a nurse to offer the inmate Ativan.
Nurses are available on-call to see any
person agitated enough to restrain.
According to clinic personnel, during
nonnal working hours the Jail staff
generally call the medical staff "right away"
for someone "acting out." None of these
resources were called to assist with Adele.

ANALYSIS

1.

Statutory Violations
a.

Screening and Diversion of
Persons with Mental Illness
from Detention

The provisions ofMontana Code Annotated
§§ 53-21-120, 124 and 138, which reflect
the policy of this state that people with
mental illness be identified and diverted
away from jails and back into the mental
health treatment system, were clearly not
followed. These statutes prohibit holding a
person facing commitment proceedings in

jail while they await their hearings l9 , and
require that persons with mental illness be
detained in the least restrictive possible
environment. Since 2003, jails have been
mandated to screen all inmates to identify
people with mental disorders accused of
minor misdemeanors to determine if they
may require commitment,20 and to divert
them into mental health treatment facilities.
"Minor misdemeanor offense" means nonserious misdemeanors such as criminal
trespass to property, loitering, disorderly
conduct and disturbing the peace. It covers
a broad range of minor crimes which entail
no significant injury to other people or
If a person does require
property.
commitment, she or he may not be held in
jail pending evaluation and hearing. 21
The facts show that Adele was already
broadly known to the medical, mental health
and law enforcement communities of
Missoula to be an individual with mental
illness - which in the broadest tenns means
that the nurse at the St. Patrick ER, very
probably the security officers at the hospital,
the arresting Missoula Police Department
officers and the staff on duty at the Jail
knew that her behavior was the result of
mental illness and that she belonged in a
hospital bed. Legally, as medical and law
enforcement professionals, they had an

19Forty percent ofjails acknowledge that in
spite of the law, they use minor or no charges to hold
people with mental illness until they can release them
or obtain community mental health treatment. DRM
Jail Survey July 2000, published by Montana
Advocacy Program, page 24.
20Mont. Code Ann. § 53-2]-138.
21Mont. Code Ann. § 53-2]-]20, ]24.

Adele Report - November 2008

11

affinnative duty to get her into that hospital
bed. Instead, this frightened, disoriented,
and very vulnerable woman was subjected
to hours of abusive and illegal behavior
which exacerbated her already fragile
condition.
It is DRM's view that there is no excuse for
what happened to Adele the night of July 1,
2006. The medical and law enforcement
professionals not only should have known
but undoubtedly did know that they were
mistreating a sick and vulnerable woman,
and in spite of that knowledge and with
callous indifference to their professional
duties, went right ahead and did the wrong
thing.

b.

Montana Elder and Persons
With Disabilities Abuse
Prevention Act

The Jail violated Montana Reporting Statute
Montana Elder and Persons with
Developmental Disabilities Abuse
Prevention Act. Mont. Code Ann. § 53-2801, et seq. The legislature has recognized
that there is a need for law enforcement
agencies, among others, to prevent "abuse,
sexual abuse, neglect and exploitation of
Montana's ... persons with developmental
disabilities through the identification,
reporting and prosecution of acts of abuse,
neglect and exploitation." Abuse means the
infliction of physical or mental injury. Law
enforcement officers are specifically listed
as required to report incidents of abuse to
the DPHHS, child or adult protective
services, as appropriate. At least seven
employees directly participated in or
witnessed Adele's unjustified pepperball
12

shooting, the supervising officer's failure to
allow her to be decontaminated as soon as
possible and her unnecessary restraint after
she was compliant.
Numerous other
employees, including the Jail commander
and the Sheriff, were aware of the incident
and viewed the video tape of the shooting.
Nonetheless, only one officer reported it to
the press, to the FBI, and to the ACLU. No
officer DRM spoke with was aware ofhis or
her statutory obligation to report abuse.
Most unfortunate, the officer who publically
reported the incident was fired for making
public "confidential infonnation" because
he did not know to whom he should report,
although he believed that her treatment was
abuse. The Sheriff s department failed to
adequately train its staff and lacks
procedures in the requirements of law
enforcement officers to report incidents of
abuse or neglect of people with
developmental disabilities.

c.

Mistreatment of and Assault
upon Inmates

Jail inmates are vulnerable to mistreatment
and abuse by guards. For that reason, the
Montana legislature has both defined what
constitutes endangerment of prisoners, and
prohibited the practice. 22

22Inmate endangerment -- penalty. (1) A
detention center administrator or staff member
commits the offense of inmate endangerment if the
administrator or staff member knowingly...
(b) uses corporal punishment against an inmate; or
(c) uses physical force against an inmate, except as
necessary for:
(i) self-defense;
(ii) control of inmates;
(iii) protection of another person from imminent
physical attack; or

Adele Report - November 2008

If the common run of inmates in detention
centers are vulnerable to endangerment, by
virtue of being outnumbered, unanned and
frequently restrained, then an inmate who is
a person with mental illness or a
developmental disability has increased
vulnerability. Adele, frightened, short,
disoriented, shackled, and outnumbered by
male officers with weapons, was helpless
against what the few videotapes the Jail has
released show as overwhelming aggressive
behavior. It is perfectly clear that the Jail
staff used the pepper ball gun as well as
wrist and ankle shackles and the restraint
chair unnecessarily. It is also clear that they
used physical force against a helpless and
disoriented woman without the justification
of a need for self defense, control,
protection of others from an imminent
physical attack, or possible escape or riot.
The statute makes endangennent a crime,
and sets a criminal penalty associated with
misdemeanors for a "person who commits
the offense of inmate endangerment."
Elsewhere, the criminal code makes it a
felony to mistreat prisoners 23
(iv) prevention of riot or escape.
(2) A person who commits the offense of inmate
endangerment shall be fined an amount not to exceed
$500.
Mont. Code Ann. § 7-32-2248.

23Mistreating prisoners. (1) A person
commits the offense of mistreating prisoners if, being
responsible for the care or custody of a prisoner, he
purposely or knowingly:
(a) assaults or otherwise injures a prisoner;
(b) intimidates, threatens, endangers, or withholds
reasonable necessities from the prisoner with the
purpose to obtain a confession from him or for any
other purpose; or
(c) violates any civil right of a prisoner.

It is a fair interpretation of the videotapes

and the records of the Jail that the SDO
knowingly armed himself with a weapon
with the intention of committing an assault
on and otherwise injuring Adele, and in fact
accomplished that purpose. It is also a
reasonable inference that by keeping Adele
confined in a restraint chair while she was
coated with OC powder for three quarters of
an hour, they knowingly and purposely
withheld reasonable necessities from Adele
for no lawful reason. It is clear that the
actions of the officers and their leadership
purposely and knowingly violated Adele's
civil rights.

2.

Jail Policies and Procedures

The extreme use of a pepperball gun on a
confused, crying, and clearly disoriented
woman who was not presenting a danger to
herself or others was in direct violation of
jail policies. The SDO violated Jail Policy
7.24 regarding use of force, which requires
that escalating the use of force in the Jail
may occur only when a person presents an
imminent danger of serious bodily hann or
death to staff or third parties, and sets forth
criteria to be considered before
implementing use of force. There are four
factors to be considered before using
increasing force: (1) ability to harm self or
others, (2) opportunity to cause serious

(2) A person convicted of the offense of mistreating
prisoners shall be removed from office or employment
and shall be imprisoned in the state prison for a term
not to exceed 10 years or be fined an amount not to
exceed $50,000, or both.
Mont. Code Ann. § 45-5-204.

Adele Report - November 2008

13

bodily injury, (3) imminent jeopardy, and
(4) exhaustion of all reasonable options.
Adele did not have the ability to harm
herself or anyone else when six shots were
fired into her cell. It is undisputed that
Adele was the sole occupant of a locked
cell, therefore unable to present a danger to
staff or other inmates. The conflicting
evidence as to whether Adele actually meant
to hurt herself or even had the means to do
so is irrelevant. The truncated video of the
incident clearly shows that before Adele
was shot she had complied with the
commands to step down from the bunk removing any danger of injury to herself.
When Adele was shot, she was standing on
the floor next to a wall crying and lacked all
ability to hurt herself.
Adele did not have the opportunity to inflict
serious bodily injury when she stood crying
next to the wall. Staff must reasonably
believe the inmate is within effective range
and in a position to cause serious bodily
injury or death to a staff or third party
before escalating force. However, Adele
was not in range of any item to inflict injury
or in a position to cause serious bodily
injury. Rather, she was trying to obey the
officers' orders.
When the first and
subsequent shots were fired, Adele stood
against the wall on the floor.
Without the ability or opportunity to inflict
serious bodily injury, it is obvious from the
tape no reasonable person would conclude
Adele was in imminent jeopardy of serious
bodily injury or death. She tried to comply
with every order the officers shouted at her.
She stepped off or away from the bunk and
14

moved away. She was scared and crying,
but even if she had earlier been threatening
to jump off the bunk on her head, when the
officer shot her she was no longer capable
of injuring herself or others. In fact she had
eliminated any possibility of injury to
herself when she left the bunk area.
Officers neither tried, nor exhausted all
reasonable options to de-escalate the
situation before more than six shots were
fired into her cell. The decision to pick up
and bring the pepperball gun was made
without an evaluation of Adele's actual
behavior, medical status, or psychological
state. The SDO arrived at the scene armed.
Anecdotal evidence indicated that Adele
had already been talked down from the desk.
Incomplete video evidence fails to capture
any previous efforts or results before the
officer arrived with the pepperball gun. But
the video does show he only used orders and
commands, escalating in volume and clear
anger, with little time to comply before
further escalation and threats. At no time on
the video does it appear that the officer
simply tried to talk to her himself, have
another team member talk to her, call a
nurse to assist her, or seek guidance from
any of the three professional mental health
resources available to him.
The SDO violated Jail Policy 7.24 which
states: "Force should be employed only to
the degree necessary to control the inmate
and to the level that will be effective with
minimum harm to both staff and inmate,"
and is "not to be used to punish, harass,
coerce or abuse inmates." When the SDO
fired the pepperball gun Adele was
complying with his commands to the best of

Adele Report - November 2008

her understanding. Multiple shots were
fired without pause between them,
indicative more of an intention to punish or
cause harm than to bring order to a situation
which was not out of control.
The officer also violated Jail Policy 7.24 by
using the pepperball gun excessively, rather
than as the policy states: "only [] in [the]
amount necessary to gain control and cause
an inmate to cease [his or her] aggression."
Therefore, use ofthe pepperball gun at all to
cause Adele to cease aggression as she was
attempting to comply with orders was
unjustified: firing multiple shots on rapid
fire - the sound on the videotape is that the
shots were continuous, rather than spaced,
was completely unjustified.
The officers violated Jail Policy 7.24 by
failing to both immediately decontaminate
Adele or consider any medical effects ofthe
OC. Recognizing the danger of "unduly
injur[ing]" an inmate with pepperspray, the
Policy states: "[W]hen use of force has been
used, and particularly when OC has been
used, the inmate will be examined by
medical staff and receive any necessary
treatment as soon as possible, including the
opportunity to shower." Prior to using OC,
"the person's medical information shall be
considered."
No one asked or even
considered whether Adele had a medical
condition - which in fact she does - which
can cause injury or death should she be
exposed to pepper spray. Adele was
complying with orders when she exited the
cell. There is a shower within 60 feet of
where Adele was restrained which offered
the opportunity for her to wash her face and
exposed skin, or for an immediate shower.

The officers had water and materials
available to wash her face, hands, anTIS and
exposed skin - none of which they did.
Instead, she was left nearly ilnmobilized for
at least 44 minutes in the chair, coughing,
gasping, crying, and calling out that she was
dying. Although a nurse came to visit her,
the nurse apparently was completely
unfamiliar with the effects of OC, noting
that Adele's thrashing in pain and to escape
the effects of the OC powder seemed
"aggressive."
The officers violated Jail Policy 7.24
regarding appropriate use of restraint chairs
and soft restraints on wrists and ankles by
using metal restraints. The chair is "molded
fibreglass and [uses] soft wrist restraints
made of webbed nylon and soft ankle
restraints of the same material." Soft
restraints are necessary to prevent nerve and
muscle damage caused by metal cuffs
compressing vulnerable nerves against
bones of the wrists and ankles. DRM
investigators examined the restraint chair
used, viewed the special leg restraints and
questioned the SDO about the restraints
used on Adele. Metal handcuffs were used
as Adele came out of the police car and left
on her when she was shoved backwards into
the restraint chair with her arms captured
behind her, risking both wrist damage and
shoulder damage. Metal cuffs were also
used on her ankles to restrain her legs,
contrary to Jail Policy.
The Policy makes clear that use of the
restraint chair is justifiable for self defense,
protection of others, protection of property,
and to prevent escapes. None of these
circumstances existed, either when Adele

Adele Report - November 2008

15

arrived or after she was shot with OC
powder. Moreover, the policy directs that,
"[f]orce should be employed only to the
degree necessary to control the inmate and
to the level that will be effective with
minimum hann to both staff and inmate." It
is "not to be used to punish, harass, coerce
or abuse inmates." When the SDO ordered
Adele into the restraint chair the second
time, she was compliant according to the
official report. The video also showed she
was led by her hand out of the cell, crying
and stating she was dying. No resistance or
aggression is shown on the video tape. The
report admits she was compliant with
commands and had finished resisting.
Nonetheless, she was ordered restrained in
the chair and not allowed to decontaminate
before such restraint, exposing her to cruelty
and abuse, all contrary to Jail Policies.

CONCLUSIONS

From testimony and evidence obtained to
date, with minimal cooperation from the Jail
and the Sheriffs office, it appears this was
an unjustified assault. The SDO did not
take the time or correctly interpret the
infonnation available to realize that Adele
was a person with mental illness and
developmental delays. Certainly the Jail
administration has violated the Montana
statute requiring jails to screen inmates
charged with minor crimes for diversion
since the Jail had adopted no policies or
adequate screening tools to do so, nor has it
trained its staffto do adequate mental health
screening. The officers on duty and its SDO
violated numerous Jail policies and
16

procedures including use of force, use of
restraint chairs, and use of OC. There is
also serious concern whether the SDO
violated Montana statutes prohibiting
assault against inmates.
These problems are symptomatic of the
issues that currently face the Sheriff s
Department. Inadequate training and lack of
appropriate oversight leads to erroneous
decisions that hann inmates. Ifthe State can
serve its prisoners without use of restraint
chairs and prohibits their use in local
detention facilities, viable alternatives exist
for safely controlling and maintaining
potentially violent inmates or inmates with
mental illness without their use. As this
case illustrates, having the restraint chair
and pepperball gun available, may lead
some staff to rely on equipment before
utilizing less intrusive and less forceful
methods of calming disruptive, agitated, or
mentally ill inmates.

RECOMMENDATIONS

There are five areas where the Sheriff s
Department can improve its ability to
identify, divert and humanely treat people
with mental illness and developmental
disabilities who are brought to the Jail as
detainees.

1.

Screening, Booking
Information Sharing

a.

The Jail must develop procedures and
tools to comply with the statutory
mandate to screen all inmates for

Adele Report - November 2008

and

mental illness. The Jail will require
validated diversion screening tools to
identify people with mental illness
and develop agreements with mental
health providers to accept inmates so
identified who are charged with
mInor misdemeanors.
This
evaluation must occur immediately
upon detention or as soon thereafter
as practical.
b.

Ifa detainee is brought into the Jail in
an agitated state that makes it
unfeasible to book the person
immediately, the detainee must still
be asked a series of questions to
determine whether the detainee is a
person with mental illness or
developmental delay, is suicidal, or
under the effects of drugs or alcohol.
The detainee will also be asked about
any medical conditions including
asthma, heart conditions or high
blood pressure, which would affect
decisions regarding use of force.

c.

If a detainee IS too combative,
struggling too much, or refuses to
respond, as a first choice the detainee
will be placed in a cell until calmer.

d.

If a detainee IS restrained In a
restraint chair after all reasonable
alternatives have been tried, at every
check the SDO will ask the series of
questions regarding mental illness,
suicidality, etc., until the person is
able to answer the questions or is
calm enough to be released and
booked.

e.

The Jail will find or develop, in
conjunction with the Diversion
Committee, a validated diversion tool
which will be used at every booking
to screen and evaluate all inmates for
mental illness, suicidality,
developmental delays and other
disabilities.

f.

The booking or receiving officers will
obtain information from the transport
officers to determine whether the
detainee has exhibited any abnormal
behavior during transport, or whether
the detainee IS known to the
transporting officers as a person with
mental illness, developmental delays
or other disabilities and include this
information on the booking fonn.

g.

The Jail will compile and make
available on its computer system a list
of all persons transported by the
Sheriff's Department to Montana
State Hospital,
Montana
Developmental Center,
or
Providence Center on emergency
detention or for commitment and all
transports to the local emergency
rooms for mental health evaluations
or treatment.
This list will be
updated daily and made available to
the booking officers so all new
detainees can be checked against the
list to determine whether he or she
has a history of mental illness or
developmental disability.

h.

The booking officer must make a
visual inspection of the detainee to
determine whether he or she has any

Adele Report - November 2008

17

obvious physical
disabilities.
1.

or

mental

Any infonnation obtained from the
visual inspection, booking, interview
or screening responses given to the
fonn questions that indicates the
detainee may have a mental
disability, will be (a) recorded on the
fonn, and (b) a supervisor notified.
This infonnation will be immediately
available to any booking officer when
booking the person into the Jail. The
booking officer will always check to
detennine whether the Jail has
previous contacts with the detainee
which would alert the Jail staff that
the person has a mental illness,
developmental disability or other
disability, and what, if any,
accommodations are required to
maintain the person's health and
safety while in the Jail.
If the detainee is charged with a
minor crime involving little or no
injury to persons or property, the shift
supervIsor will call a MHP to
evaluate the detainee for mental
illness or developmental disabilities
to detennine whether the person
requires commitment and to divert
the detainee from the criminal justice
system.

k.

18

Every inmate will be screened,
booked, and evaluated within two
hours of arrival unless exceptional
circumstances exist.
Such
exceptional circumstances shall be
documented in the inmate's file in

Exceptional
lieu of booking.
circumstances include ifthe inmate is
intoxicated to the point of being
unable to cooperate or so agitated that
the inmate is unable or unwilling to
communicate about the booking and
screemng process. If an inmate is
unable to be screened, evaluated, and
booked within 24 hours, the inmate
shall be seen by a MHP within that
time unless the inmate IS too
intoxicated to communicate
effectively.

1.

If after a detainee is booked, Jail
personnel suspect that a detainee may
have a mental disability, he or she
will immediately notify the shift
supervisor and the nurses who shall
perform the steps set forth in these
recommendations. Other than for a
psychiatric emergency, only a
qualified physician or psychiatrist
shall detennine the treatment needs of
a mentally disabled detainee.

m.

If the questions reveal or the
detention staff are otherwise aware
that a detainee receives support and
therapeutic services from the Western
Montana Mental Health Center,
Winds of Change, AWARE, OR!, or
other community providers ofmental
health or developmental disability
serVIces, the Jail staff will
immediately notify the provider that
the detainee is at the Jail.

n.

If it is detennined that the person has
a mental disability and has committed
a crime ineligible for diversion, the

Adele Report - November 2008

liaison, as designated by the Sheriff,
between the Jail and the designated
court will notify the mental health
court coordinator.

2.

Medical Clinic

a.

The shift supervisor must direct the
detainee with mental illness to the
medical clinic for further screening in
the following circumstances:

nurse will direct the detainee to a
psychiatrist, doctor, or nurse
practitioner with special training in
working with people with mental
illness and developmental disabilities
retained by the Jail for the purposes
of providing mental health
consultations, examinations and
treatment decisions.
d.

If a detainee is transferred from a
psychiatric hospital to Jail, medical
staff will make reasonable efforts,
including exercise of the right of
jailers to obtain mental health
information, to get the necessary
records to continue the detainee's
treatment at the time the detainee
arrives at the Jail. The existing
treatment plan will be followed by the
Jail until another treatment plan is
prescribed by an appropriate
physician or psychiatrist.

e.

The ratio of medical staff to
inmate/detainee ratio shall not be
reduced, and all practical efforts will
be made to replace medical staff and
consultants who stop working for the
facility.

f.

Nurses and MHPs will be scheduled
between the hours of 7:00 a.m. and
10:00 p.m. In addition, MHPs and a
nurse will be on-call for the
remainder of the day. There will be
nurse and MHP coverage every
Saturday, Sunday and holiday to
distribute psychotropic medications
and do mental health evaluations,
medical evaluations, and other

(a) if the person if charged
with something other than a
.
.
mIllor cnme; or
(b) the MHP determines
(i) the person has a mental
illness or developmental
disability but does not need
commitment, or
(ii) the person's disability
involves something besides
mental
illness
or
developmental disabilities.
b.

c.

The medical clinic must complete a
secondary questionnaire to elicit
additional information as to the
patient's disability status and whether
necessary accommodations are
required to meet the person's needs in
the Jail. The medical clinic shall
maintain at least one nurse per shift
with special training in working with
people with mental and
developmental disabilities.
If, upon further evaluation, the nurse
determines the person may have a
mental or developmental disability
unnoticed by the detention staff, the

Adele Report - November 2008

19

services recommended herein. There
will be at least one physician or
psychiatrist with additional training
and experience in psychiatric and
developmental disabilities available
24 hours a day for the detention staff
to call to discuss necessary responses
to psychiatric or medical emergencies
and who may come to the Jail as
needed for evaluation of emergency
medication, restraint or seclusion.
g.

20

Only nurses will distribute
psychotropic medications and only
appropriately licensed clinicians will
proscribe psychotropic medications.
Nurses will maintain the medical
records, note each time medication is
given, note any significant physical
or behavioral observations in the
detainee's medical records, and will
report any problems to a treating
physician, nurse practitioner, or
psychiatrist. If a detainee refuses
medication, it will be documented in
the file. The detainee will continue to
be offered psychotropic medications
after his or her refusal and the
detainee will be referred to his or her
treating psychiatrist as soon as
possible, but no later than 24 hours or
upon the next business day,
whichever occurs first. If a detainee
cheeks or otherwise accumulates
medication or inappropriately uses
medication, such activity will be
noted in his or her file, additional
precautions shall be observed when
offering medication and medication
will continue to be offered as
prescribed.

h.

A psychiatrist will regularly evaluate
the detainees who are on
psychotropic medications to
recommend whether or not the
medication needs are being
adequately met or if changes are
necessary.

l.

If a detainee is detennined through
the screening process to be mentally
disabled, the detainee will be
classified for housing pursuant to
instructions given by the doctor who
is prescribing the treatment plan. If
the doctor determines the individual
needs to be isolated from the general
population for protection of the
detainee or other inmates, that person
will be detained in a segregated unit
but will be provided ample
opportunity to leave his or her cell for
the number ofhours recommended by
his or her treating clinician. Isolation
aggravates the symptoms of mental
illness and causes skills to deteriorate
in people with developmental delays,
therefore, these conditions will not be
used to curtail opportunities for
recreation, socialization or physical
and mental exercise.

J.

All detainee requests for treatment
will be documented and included in
the medical files and referral of such
requests will be made to medical
staff.

k.

If a detainee is transferred from the
Jail to a psychiatric hospital, prison,
prerelease center, or other facility,
medical staff will make reasonable

Adele Report - November 2008

efforts to transmit, with the detainee,
cun-ent treatment plans, and relevant
medical records to the new facility.
In any event, medical records shall be
transmitted within three working
days.

3.

Training

a.

Jail staff will be trained in how to
effectively use the screening tools
identified or developed by the
Diversion Committee.

b.

Jail staff will be trained in how to
recognize and effectively respond to
a psychiatric emergency.
In a
psychiatric emergency, the Jail
personnel will notify the shift
supervisor who will contact the oncall MHP to determine what type of
intervention is most appropriate. If
the on-call MHP is not immediately
available or there is a realistic
possibility of immediate harm to the
person or others, the staffmay use the
minimal amount offorce and restraint
necessary to defuse or control the
situation, starting with calmly talking
to the person, calling a nurse to offer
calming medication, then moving up
the scale of use of force considering
the criteria set forth in the Jail
policies and procedures manual. As
soon as the detainee desists from
aggression or threatening self-harm,
the amount of force used will
decrease.

c.

call the MHP and the nurse on call to
evaluate the detainee's mental status
and to evaluate whether the detainee
has suffered any injury. The MHP
will detennine whether a physician or
psychiatrist should be called to
provide medical support.
The
specific behaviors that predicated
intervention, the specific procedures
considered, and why they were used
will be recorded in the detainee's
medical file. The nurse will offer
calming medication.
d.

All Jail staff will undergo training in
the procedures described above
before they begin working. Training
will address the use of force
continuum as it applies to people with
disabilities emphasizing de-escalation
techniques when a person is
responding, as well as the criteria for
increasing or decreasing use of force
as established in the Jail policies and
procedures manual. Retraining in use
of force policies will occur no less
than every 12 months.

e.

Training will address proper restraint
of detainees with mental illness and
alternatives to restraint. All staffwill
receive at least 8 hours initial training
and thereafter 4 hours of training per
year in screening, suicide prevention,
side effects of psychotropic
medications, and identification of
mental disability in classes conducted
by an appropriate psychiatric training
facility.

Once the immediacy ofharm is under
control, the Jail staffwill immediately
Adele Report - November 2008

21

f.

Specific training, policies, and
protocols regarding the use of the
pepperball gun and OC will be
developed in conjunction with the
Diversion Committee. This training,
policies and protocols will be
maintained in written format and will
emphasize the necessity to learn
whether a detainee has health
conditions which may make the use
of these types of force lethal. Such
protocols shall include a requirement
that the situation must be evaluated
before the pepperball gun or other
similar devices are brought into use.

g.

Jail staff will be trained in how to
evaluate and report abuse or neglect
of detainees with developmental
disabilities or elders as required by
Montana statute. In addition, Jail
staff will be trained to report such
abuse or neglect to Disability Rights
Montana.

4.

Psychiatric and Other Resources

a.

The Jail will enter into a contract with
an appropriate resource for 24 hour
on-call coverage by MHPs.

b.

The Jail will enter into a contract with
an appropriate resource for 24 hour
on-call coverage by a psychiatrist.

c.

The Jail will enter into a contract with
an appropriate resource for training
by MHPs regarding the criteria for
commitment for persons with both
mental illness and developmental
disabilities.

22

d.

The Jail will enter into a contract with
an appropriate resource for training
conducted by a psychiatrist for the
training noted in Section C above.

e.

The Jail will contract with an
appropriate mental health provider to
obtain training in how to reduce the
use of seclusion and restraint when
presented with a person with a mental
illness.

5.

Citizens Oversight Committee

a.

The Sheriffs Depmiment will
collaborate with the WSAA, the
Diversion Committee, the County
Attorney and City Attorney offices
and the State Office of the Public
Defender, and other stake holders to
establish a committee made up of
interested citizens to whom inmates
and citizens may bring concerns
regarding the operation of the Jail,
the treatment of inmates and other
matters arising out of the care, health
and safety of inmates at the Jail. This
Citizens Oversight COlnmittee will be
formed following the recommended
practices established by NIC, ACA,
or other municipalities in the United
States.

Adele Report - November 2008

Attachments

civil rights protection & advocacy system for montana

disabilityrights.
m ntana

formerly Montana Advocacy Program

0

October 8, 2008

Mike McMeekin, Sheriff & Coroner
Missoula County Sheriffs Department
200 West Broadway
Missoula, MT 59802
Re:
Dear Sheriff McMeekin:
Disability Rights Montana, is a private, non-profit civil rights organization designated by the
Governor of Montana as the State's protection and advocacy system for people with disabilities,
including people with developmental disabilities and mental illness under Montana Code
Annotated § 53-2]-169, 42 U.S.c. § 1080] et seq., and 45 C.F.R. § 51. Disability Rights
Montana is legally charged to protect the rights of people with developmental disabilities and/or
mental illness through activities to ensure the enforcement of the Constitution and Federal and
State Statutes, under 42 U.S.c. § ]080](b)(2)(A). Disability Rights Montana is authorized to
pursue legal means to achieve enforcement under 42 U.S.c. § 10807.
Disability Rights Montana investigates abuse and neglect of residents at publicly-funded
institutions such as the Missoula Detention Center. As you may know,
was in
custody at the Missoula Detention Center on July 1,2006.
In the course of our investigation, Disability Rights Montana uncovered the information
contained in the draft report accompanying this letter. It is one of the functions of Disability
Rights Montana to report to governmental agencies, and to the public, conditions or
circumstances which burden or hinder the free exercise of civil rights by persons with
disabilities. The enclosed is such a report. We have forwarded it to you to give you an
opportunity to provide any information that may contradict the assertions or conclusions in the
report. We will be finalizing the report in the coming weeks and will incorporate comments we
receive from you if you provide them prior to October 20,2008. Once this report is final, it is
our intent to release it to the public.

I 1022 Chestnut Street

I

Helena, Montana 59601 VoicefTDD 406-449-2344 ToU-free 800-245-4743 Fax 406-449-2418
advocate@disabilityrightsmt.org
www.disabilityrightsmt.org

I

I

To:
Mike McMeekin, Sheriff
Re:
Date: October 8, 2008
Page: 2

In the report, we have not included M s . _ s name, but instead used the fictitious name of
Adele. If you have any comments or questions about the report or its distribution, please feel free
to contact me.

Sincerely,
DISABILITY RlGHTS MONTANA

~

Bernadette Franks-Ongoy
Executive Director

SHERIFF'S DEPARTMENT
200 W. BROADWAY ST.
MISSOULA MT 59802-4292

MISSOULA
COUNTY

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Monday, 13 October, 2008

Bernadette Franks-Ongoy, Executive Director
Disability Rights Montana
1022 Chestnut Street
Helena MT 59601

Dear Director Franks-Ongoy:
Thank you for providing me the opportunity to respond to your organization's
report concerning the July, 2006, incarceration of~t our detention facility.
Nine days (from our receipt of your letter) is clearly insufficient to research, write
and submit our response to such a lengthy and damning indictment. In order to properly
present such a response, I will need some additional information and/or clmifications of
your draft; those information needs are listed below. Once your reply has been received,
we will prepare and submit a response as promptly as possible. I would request that
completion of your report be delayed until the response process is complete.
1. Please provide documentation of any attempts by any DRM staff member to
obtain information from us relating t~or the operation of our
detention facility (report footnote #3, page 3). According to our files, the
information Ms. Volkerts requested was provided to the Missoula County
Attorney's Office in August of2006 for review, redaction if necessary, then
submittal to M.A.P. (now DRM). Did you receive those materials from Mr.
Sehestedt?
2. Please explain the facts upon which you base the statement that Ms.~s, or
was in July of2006, "well known" to the Sheriffs Department.

PAGE 1 OF 3
PHONE: (406) 523-4810 or 721-5700 or (AFTER HOURS) 829-4000

FAX: (406) 721-8575 or (24 HR. @ JAIL) 829-4080

3. Please explain the apparent contradiction between the report's detailed recounting
of sallyport and remand area "video evidence" (pages 8 and 9) and the statement
that the "Sheriffs Department has consistently delayed or refused to provide
information to the extent that at the time of this report essential
evidence ... .including video tapes of Adele's arrival at the Jail ...has never been
provided." ("Complicating Factors" footnote at page 3).
4. The report seems to use "senior detention officer (SDO)" and "shift supervisor"
synonymously (pages 9, 16, etc.)? Our senior detention officers are not
supervisors and use of that term l11<lkes it difficult to lmden;tmd your
interpretation of the decision making process in this context. Are you, in fact,
refelTing to [former] Sergeant Sorini?
5. Please explain the facts upon which you base the statement that "the staff on duty
at the Jail knew that her behavior was the result of mental illness and that she
belonged in a hospital bed." (page J2, with foundation language on preceding
page).
6. Please explain the facts upon which you base the statement that Ms._las a
medical condition "which could cause injury or death should she be exposed to
pepper spray." (page 14). Specifically, what accredited medical research did you
rely upon to reach that conclusion?
7. To who does your use of the term "potential aggressors" on page 15, column two,
refer?
8. Please describe, in detail, the "inappropriate spending on unnecessary resources"
alleged on page 16; to include expenditure descriptions, amounts of funds
expended on each, exact or approximate dates ofthe expenditures and how those
expenditures "starve[ed] the J ail ~fm0ney fOIapprcpriate trainiilg."
9. Please clarify whether the "Recommendations" section of your report (pages 1723) is, in fact, a series of recommendations that you believe we should follow or a
series of mandates that we will follow, as is implied by the language of each
recommendation. Ifthey are mandates, please identify DRM's independent legal
authority to order such actions.

PAGE20F3

10. Please describe with particularity the professional detention and/or corrections
officer training and related experience in that capacity for each of the repOli's
authors.

Since Ms.
Iwas brought to our facility from the institution that we rely on
for pre-incarceration assessments and evaluations, it would be helpful for me to have a
copy of your report on St. Patrick Hospital before I draft my response; at least the
portions that relate to July 1st, 2008.

Sincerely yours,

~

Michael R. McMeekin

cc:

Undersheriff Crego
Captain Susan Hintz, Commander, Detention Division
Charles McNeil, Counsel of Record

PAGE 3 OF 3

disabi lity

rights_
m nta na

formerly Montana Advocacy Program

0

October 27, 2008

Sheriff Michael McMeekin
Missoula County Sheriff's Department
200 West Broadway
Missoula, MT 59802-4292
Sent by U.S. Mail and via e-mail
Re: Adele Report
Dear Sheriff McMeekin
1 received your response to the Adele Report and note that none of your comments deny any
factual allegations of the report. Disability Rights Montana is not pursuing this investigation
with the intent oflitigation, therefore the interrogatory type of infannation you are requesting is
not necessary f()r you to supply a response. This report does not contain any infonnation that is
new or unexpected. You are familiar with the facts or circumstances surrounding all of these
events. IfYOLl provide verifiable substantive comments by October 31,2008, we will make every
effort to include them in the Report. The report will be released to the public on November 3.
2008.
In an effort to clarify 3:ly misconceptions, 1 note the following. For ease of comparison, I
respond to your comments/questions in the order raised.
1.

You request "documentation" of our attempts to obtain infonnation. For instance, Ms.
Volkerts orally requested copies of both the Sally Port video tapes and the audio tape
located near the shower area from Mike Sehestedt during her intenriew with SDO Sorini
on August 3] , 2006. When she did not receive the tapes, she orally requested the audio
and video tapes from you during your interview with her on September 19, 2006.
According to her notes of that interview, you indicated that the Sally Port videos were in
some way unviewable due to a sequencing or timing interface, but you assured her you
would resolve this issue and provide the missing tapes. In an e-mail dated September 20,
2008, to Mark Foss, you memOlialized the discussion and requested Mark Foss obtain the
Sally Port videos, shower audio tape, and a list of times Ms._had been at the
facility. She did not receive the requested infonnation.

I 1022 Chestnut Street

I

Helena, Montana 59601 VoicejTDD 406-449-2344 Toll-free 800-245-4743 Fax 406-449-2418
advocate@disabilityrightsmt.org
www.disabilityrightsmt.org

I

I

To:
Re:
Date:
Page

Sheriff:v1ichael McMeekin
Adele Report
October 27,2008
2

In a letter dated October 24, 2006, to Mike Sehestedt, Ms. Volkel1s again requested the
tapes. In that letter, she also requested Ms..
s medical records and copies of her
fC)Il]ler records and bookings at the Detention Center. She did not receive them.
In her email to you dated January 19,2007, she reiterated her request for, among other
things, the audio tape from the shower area, all infonnation regarding jail staff knowledge
of Ms.
.:; disabilities including pre-Spectrum medical records, the FBI
investigative report, and copies of video training tapes for the use of pepper spray and the
pepper ball gun. Again none of this intomlation was provided.
are well aware of our interviews with SOO Sorini, Capt. Hintz, yourself, NP Judy
]\{unseJ], and several inmates who claimed to be witnesses to the pepperball shooting of
Ms. _ . You and your attorney curtailed our ability to interview the rest of the A
Team. We also interviewed Ms
land various provider staff and relatives regarding
the incidents leading up to and the events subsequent to her pepperbaJl shooting. In
addition. we interviewed both fanner and then current detention statl who kne\'I/ or knew
of Ms.
Fand voluntarily provided additional infannation. We reviewed the hand
held video recording of the incident as well as the Remand and Booking area video tapes.
SDO Sorini's report, and vmious other documents you provided.

YOll

Our legal authOlity to access this infom1ation was provided to you in Ms. Volkerts' letter
dated August 3, 2006, and her letters to Mike Sehestedt dated August 28, 2006,
September 14,2006, and October 24, 2006.

,r

2.

Please see my response to your comment 5. I believe this infonnation is contained
within the body of the repOli, e.g. the second full paragraph on Page 8.

3.

SOO Sorini's report alleges that Ms.
arrived out of control and required all the
officers present to control her. Since he stated he was not in the sally port, or even in the
remand area when she arrived, he would have only seen her entering the remand area
quietly. The evidence available refutes his report. Nonetheless, you failed to provide the
sally port videos, among other evidence, after repeated requests.
SDO Sorini's report indicates Ms._was restrained for 44 minutes. There is no
independent confinnation of how long it took for her to be decontaminated as that
infonnation is neither in written records nor on video tape. However, the audio tape at
the entrance to the shower area should have established how long she waited at or near

To:
Sheriff Michael McMeekin
Re:
Adele Report
Date: October 27, 2008
Page 3

the shower area before she could decontaminate. After repeated requests, both oral and
written, that infonnation has never been provided.
4.

We will change all references of Shift Supervisor to Senior Detention Officer in response
to your comment at ~ 4.

5.

With regard to 5 (and '12, as noted above), regarding what the detention staff knew or
didn't know about Ms.
her mental illness, your employees are imputed with
knowledge of what is in your own records. Even the briefest review of her history with
the Sheriffs Department would have revealed she had been taken by Sheriff Department
staff to Montana State Hospital at least twice for commitment. She had been incarcerated
at least four times previously at the lVlissoula Detention Center on minor charges. Other
stan- who had worked with her at the detention center stated it was obvious that she
sutfered from mental illness and/or mental retardation. All this infom1ation is set forth in
the report.

6.

Ms. _ h a s asthma. which when combined with pepper spray or OC can lead to
severe asthma attacks. Sinceivls.
.has been incarcerated at least four times
previously, one expects that competent Detention Center medical history records would
reveal her chronic illnesses. Your own Policy 7.24 rclguires inquiry into and
consiJi:ration of the person's heal th issues when OC is contemplated or used. There is no
evidence any inquiry was made: That's the point.

,r

_or

According to the notes by the RN who visited Ms]
fbrief1y after she was shot, the
nurse failed to ask any questions regarding asthma or high blood pressure, both of which
have been connected to deaths in the use of Oc. See the U.S. Dept of Justice, Research
for Practice, "The Effectiveness and Safety of Pepper Spray."
7.

The sentence to which you have objected is unclear, and we will remove it.

8.

The basis for our conclusion that Detention stafThad inadequate money for training is
based on how Ms. _ w a s treated in this situation and information by tornler staff
regarding the lack of training resources. Trained staff should have treated Ms.
•
very differently: first, by following MCDF policies regarding restraint and use of force;
second, by calling tor medical assistance to offer medication to calm her; and third, by
using the mental health staff available or on call to respond to her alleged suicidality.
The reference to inappropriate spending on unnecessary resources is not directly related
to the investigation and will be removed.

To:
Re:
Date:
Page

Sheriff Michael McMeekin
Adele Report
October 27,2008

4

9.

In response to your ~ 9, our recommendations are, as titled, recommendations. We may
rewrite this section to clearly retlect these as recommendations. The substance wi 11 not
change.

10.

Your request for the professional detention officer training of our investigators is
inelevant: the Adele Rep0l1 is not a Complaint. Disability Rights Montana is a civil
rights advocacy and protection agency, and our investigator is a trainee! civil rights
attorney who has been involved in issues relating to imnates. jails. and law enforcement
in a variety ofsenings.

The Adele Report is specific to the fllcility which you supervise. Regardless of what happened at
St. P·:vrick Hospital, your officers used excessive force against a helpless woman with
disabilities. The Adele Report stands as an independent document. As a courtesy, when the 51.
Patrick repL1rt is complete, we will provide you with a copy. Publication of the Adele Report will
not wait tor the completion of the 51. Patrick Hospital report.

J look 11)r,vard to your response.
Sincerely yours,
DTSABILlT'{ RIGHTS MONTANA

/~/".~
"-c:...
/;??
A'
.
C:.----~
// c:..
.
/ Bernadette Franks-Ongoy
Executive Director

Bernie Franks-Ongoy
From:
Sent:
To:
SUbject:

Mike McMeekin [mmcmeeki@co.missoula.mt.us]
Monday, October 27, 2008 8:49 PM
Bernie Franks-Ongoy
Re: Responses to your October 13 letter

Bernie)
I'm having e-mail problems. Did you receive my reply (either once or twice) sent a few
minutes ago indicating that I'm at an out of state school all week & can't submit the
response by Friday??
Thanks)
mike

Bernie Franks-Ongoy
From:
Sent:
To:
Subject:

Bernie Franks-Ongoy
Tuesday, October 28, 2008 9:36 AM
'Mike McMeekin'
RE: Responses to your October 13 letter

Hi Mike)
This is the only e-mail I received.
Being that you are out of state) we will extend the time for you to respond to close of
business Friday) November 7. The report will then be released to the public on Monday)
November 10.
Take care) Bernie
-----Original Message----From: Mike McMeekin [mailto:mmcmeeki@co.missoula.mt.us]
Sent: Monday) October 27) 2008 8:49 PM
To: Bernie Franks-Ongoy
Subject: Re: Responses to your October 13 letter
Bernie)
I'm having e-mail problems. Did you receive my reply (either once or twice) sent a few
minutes ago indicating that I'm at an out of state school all week & can't submit the
response by Friday??
Thanks)
mike

Bernie Franks-Ongoy
From:
Sent:

To:
Cc:
Subject:

Mike McMeekin [mmcmeeki@co.missoula.mt.us]
Friday, November 07, 2008 11 :34 AM
Bernie Franks-Ongoy
Charles E. McNeil
Response tol
report

»

Bernie,
I have not had an opportunity to work on the response this week. Will do my best to
complete it this weekend, with an e-mail copy to you by Monday followed by a signed original
in the mail.
Have a good weekend,
mike

1

SHERI FF'S DEPARTMENT
200 W. BROADWAY ST.
MISSOULA MT 59802-4292

MISSOULA
COUNTY

Sunday, 09 November, 2008

Bernadette Franks-Ongoy, Executive Director
Disability Rights Montana
l022 Chestnut Street
Helena MT 59601
Dear Director Franks-Ongoy:
Thank you for agreein~ to make the changes noted in numbered subparagraphs 4,
7,8 and 9 of your October 2i reply to my earlier request for clarifications.
The first sentence of your reply describes my October 13 th letter as a "response to
the Adele report" and the second sentence states that since you are not pursuing litigation,
the interrogatory type of my request was not necessary. I disagree. My letter was clearly
intended as a request for clarification of several points in DRM' s draft report; never as a
response. The questions were necessary in order for me to prepare our response.
Based on the language of your October 2ih letter in which you will "make every
effort" to include "verifiable substantive comments" from us in your report, it would
appear you do not intend to attach our complete response. For that reason, we are
preparing a comprehensive response and will independently disseminate it to anyone
asking us about the DRM report. You will be provided with a copy as soon as it is
completed and approved by counsel.
Please mail me a copy of your report's [mal version so that our response can be
accurate in references to points and page numbers; an e-mail with the report attached will
speed up the process. Thank you.
Sincerely yours,

71

Michael R. McMeekin

PHONE: (406) 523-4810 or 721-5700 or (AFTER HOURS) 829-4000

FAX: (406) 721-8575 or

(ff~~.1~fA~) 829-4080