U.S. Department of Justice
Civil Rights Division

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

April 29, 2008
The Honorable Deval Patrick
Massachusetts State House
Office of the Governor
Room 360
Boston, MA 02133
Re: 	 Investigation of the Worcester County Jail and House of
Correction, West Boylston, Massachusetts
Dear Governor Patrick:
On November 17, 2006, we notified then-Governor Mitt Romney
of our intent to investigate conditions at the Worcester County
Jail and House of Correction (the “Jail”), pursuant to the Civil
Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C.
§ 1997. In accordance with statutory requirements, we write to
report the findings of our investigation and to recommend
remedial measures that will ensure the Jail’s compliance with
federal constitutional requirements. See 42 U.S.C. § 1997b.
On February 13-15 and May 9-11, 2007, we conducted on-site
inspections at the Jail with consultants in the fields of
protection from harm and mental health care. While on-site, we
interviewed administrative staff, corrections staff, mental
health care providers, nursing staff, pre-trial detainees, and
sentenced inmates. Additionally, before, during, and after our
on-site inspections, we reviewed a large number of documents,
including policies and procedures, incident reports, and mental
health records. Consistent with our commitment to provide
technical assistance and conduct a transparent investigation, we
concluded our tours with extensive debriefings at which our
consultants expressed their initial impressions and concerns.
We appreciate the full cooperation we received from the
Commonwealth of Massachusetts and the Worcester County Sheriff’s
Office. We especially wish to thank Sheriff Guy Glodis, Deputy
Sheriff Jeffrey Turco and the administration and staff at the
Jail for their professional conduct, their timely responses to
our information requests, and the extensive assistance they
provided during our tours. Additionally, we value the immediate

- 2 

attention given to address some of our concerns and appreciate
that the Sheriff continues to update us on changes to policy and
procedures in response to our on-site observations. While we
have not had the opportunity to assess the implementation of
these measures, we commend such leadership and commitment to
reform.
Having completed the fact-finding stage of our
investigation, we conclude that certain conditions at the Jail
violate the constitutional rights of persons confined there. As
detailed below, we find that the Jail fails to: (1) protect
pre-trial detainees and sentenced inmates (collectively,
“inmates”) from harm; (2) protect inmates from exposure to
unsanitary and unsafe environmental conditions; and (3) provide
inmates with adequate mental health care to address their serious
mental health needs.
I.
A.

BACKGROUND

Facility Description

The Jail is located in West Boylston, Massachusetts,
approximately 50 miles west of Boston, and is operated by the
Worcester County Sheriff’s Office.1 The Jail houses adult males
who are pre-trial detainees or have been sentenced to a maximum
of two and a half years. Although the Jail was designed to house
approximately 800 inmates, it is significantly overcrowded; the
average census in 2006 was 1,400. When we first visited the Jail
in February 2007, the inmate population was approximately 1,427.
During our second tour in May, it was approximately 1,380.
The Jail is comprised of several buildings that provide
housing for inmates with various security classifications.
Opened in 1973, the Main Jail houses maximum and medium security
inmates. It has five housing units -– A-1, A-2, Maximum B,
Maximum C, and Medium C. Inmates are also housed in the
gymnasium when there are not enough cells in the regular housing
units. The upper tier of A-1 has 16 single-bunked cells that are
used for inmates on suicide watch.

1

In 1998, the Worcester County government was abolished
and the Sheriff’s Office became an independent agency of the
State. Auditor of the Commonwealth, Independent State Auditor’s
Report on Certain Activities of the Worcester County Sheriff’s
Office, at 1 (June 9, 2005).

- 3 

The lower tier of A-1 and both tiers of A-2 have 16 cells that
can be single-bunked or double-bunked and are used for
disciplinary and administrative segregation.
The Modular Complex houses medium security inmates in five
housing units with double-bunked cells. The Minimum Security
Facility houses minimum security inmates in a dormitory style
setting. The Annex provides dormitory-style housing for inmates
who are on work release. Clinic health service areas are located
in the Main Jail and the Modular Complex.2
B.

General Legal Framework

CRIPA authorizes the Attorney General to investigate and
take appropriate action to enforce the constitutional rights of
pre-trial detainees and sentenced inmates. 42 U.S.C. § 1997. In
defining the scope of inmates’ Eighth and Fourteenth Amendment
rights, the Supreme Court has held that corrections officials
must take reasonable steps to guarantee inmates’ safety and
provide “humane conditions” of confinement. Farmer v. Brennan,
511 U.S. 825, 832 (1994); Bell v. Wolfish, 441 U.S. 520 (1979)
(pre-trial detainees are protected by the Fourteenth Amendment).
The “humane conditions” standard is satisfied when a corrections
system provides for inmates’ basic needs for safety, medical
care, food, clothing, and shelter. Id.; Giroux v. Somerset
County, 178 F.3d 28, 31 (1st Cir. 1999). As discussed below, the
conditions at the Jail do not comport with these legal standards.
II.
A.

FINDINGS

Failure to Protect Inmates from Harm

The Eighth Amendment requires that inmates be protected from
the unnecessary and wanton infliction of pain by corrections
officers. Whitley v. Albers, 475 U.S. 312, 319 (1986).
Corrections officers may use reasonable force in a good faith
effort to maintain or restore discipline, but force is not to be
used maliciously and sadistically to cause harm. Hudson v.
McMillan, 503 U.S. 1, 6 (1992). The Eighth Amendment also
imposes a duty on prison officials “to protect prisoners from
violence at the hands of other prisoners.” Farmer, 511 U.S. at
833; see also Calderon-Ortiz v. Laboy-Alvarado, 300 F.3d 60, 63

2

Health services office space also is available in the
Minimum Security Facility and the Annex. The Jail contracts with
an outside provider, Advocates, Inc., to provide mental health
care at the facility.

- 4 

64 (1st Cir. 2002). Being violently assaulted while incarcerated
simply is not “part of the penalty that criminal offenders pay
for their offenses against society.” Rhodes v. Chapman, 452 U.S.
337, 347 (1981). Punitive treatment amounting to gratuitous
infliction of "wanton and unnecessary" pain is prohibited under
the Eighth Amendment. Hope v. Pelzer, 536 U.S. 730, 738 (2002).
Moreover, when applied to pre-trial detainees, a sanction that is
disproportionate to the infraction may constitute punishment in
violation of the Fourteenth Amendment. Suprenant v. Rivas, 424
F.3d 5, 13 (1st Cir. 2005).
Notwithstanding these legal requirements, inmates at the
Jail are subjected to serious harm and the risk of harm from:
(1) the excessive use of restraint; (2) inmate-on-inmate
violence; (3) inadequate supervision; (4) inadequate
classification; (5) deficient internal investigations; and (6) an
inadequate system for filing grievances.
1.

Excessive Use of Restraint
a.

Physical Restraint

Although there is no constitutional prohibition regarding
the use of physical restraints, courts review their use with
great care to ensure it does not amount to punishment or inflict
wanton and unnecessary pain in violation of the Eighth Amendment.
Ferola v. Moran, 622 F.Supp. 814, 820-21 (D.R.I. 1985); see also
Bell v. Wolfish, 441 U.S. at 535-36 (restrictions on conditions
of confinement for pre-trial detainees should not amount to
punishment).
Our investigation revealed that, in a significant number of
instances, Jail staff inappropriately restrain inmates,
specifically via four, five, and six-point restraints.3 Between
April 2006 and March 2007, Jail staff performed 155 cell
extractions and used the restraint chair/restraint bed 161 times.
In many of these instances, Jail staff used restraints after the
need for restraint had passed and/or used restraints for
excessive periods of time.4 On December 13, 2007, however, the

3

The use of restraints in this context is the
simultaneous restraint of all four limbs, usually at the ankles
and wrists, and around the chest.
4

At the conclusion of our May 2007 on-site tour, we
notified officials of our immediate concerns regarding the
restraint usage practices. We then memorialized our concerns in

- 5 

County sent us a letter providing that it has revised its
policies and conducted a self-audit regarding the Jail’s use of
restraints. The County has noted a decrease in the use of
restraints particularly between the period of May 1 and January
31, 2008.5 They also noted a significant drop in the time
inmates were held in restraints. We commend the County for
promptly reviewing and changing its practices, policies, and
procedures, and we look forward to assessing whether the changes
made are consistent with constitutional and generally accepted
professional standards.
Notwithstanding these positive developments, we found
restraint practices during our tours that substantially departed
from generally accepted practices and that inmates were not
adequately protected from serious harm. Jail staff routinely use
restraints after a Special Operations Group (“SOG”) performs a
cell extraction -- a procedure in which an allegedly noncompliant
inmate is forcibly removed from his cell.6 Because these
incidents generally are videotaped, we were able to observe the
inmate’s behavior as he was extracted, escorted to a restraint
area, and placed in restraints.7
During our May 2007 tour, we reviewed nine randomly-selected
videotapes of SOG teams extracting inmates from their cells and

writing. Letter from Shanetta Y. Cutlar, Chief of the Special
Litigation Section to Deputy Superintendent Jeffrey Turco,
Esquire (May 18, 2007).
5

Letters from Deputy Superintendent Jeffrey Turco,
Esquire to Shanetta Y. Cutlar, Chief of the Special Litigation
Section (December 13, 2007 and March 7, 2008).
6

The SOG is a specialized unit that is responsible for,
among other things, conducting cell extractions. They routinely
videotape these extractions. In the videotaped cell extractions
we reviewed, SOG teams were comprised of at least five officers
wearing dark uniforms, riot helmets, body gear, combat coots, and
elbow and knee pads. SOG officers carry handcuffs, leg irons,
flex cuffs, oleoresin capsicum (“OC”) spray, and non-lethal
weapons known as FN 303s, which look like rifles and shoot
pellets of OC.
7

SOG team members are not the only corrections officers
who place inmates in restraints. It is our understanding,
however, that SOG team members are the only officers who
videotape the application of restraints.

- 6 

placing them in restraints. Although the Jail’s policies state
that restraints should only be used as a last resort to control
inmates who exhibit violent behavior, threaten staff, or are out
of control, none of the inmates in the tapes we reviewed appeared
to be appropriate candidates for this highly restrictive
measure.8 The following examples are illustrative.
•	

In a videotaped incident from March 28, 2007, a SOG
team removed four inmates from their cells because they
reportedly had broken the glass from their television
sets, were in possession of bleach, and were
threatening staff. After deploying a distraction
device (a device that creates billows of smoke making
it difficult to see), two of the inmates were taken to
the rear isolation cells in the Maximum B housing unit
and placed in four-point restraints on metal beds.9
The other two inmates were sent to the A-2 housing unit
where they were placed in four- or six-point
restraints.10 At the time the inmates were restrained,
none appeared to be a threat to themselves or staff.
Indeed, the videotape and accompanying written
documentation we reviewed indicated that the inmates
were immediately compliant once they were removed from
their cells. Notably, only one of the four inmates
received a disciplinary write-up.11

8

In each case, we had ample opportunity to observe the
inmate’s behavior because the videotapes lasted between 15 and 30
minutes. Again, we commend the Jail for its policies and
procedures to videotape. It provides managerial accountability
and is consistent with generally accepted professional standards.
9

It is worth noting that the isolation cells in the
Maximum B and Maximum C housing units are inappropriate places to
restrain inmates. Dungeon-like in appearance, because these
cells are dank and dark, officers have no direct line of sight
through which to observe restrained inmates. After we expressed
our concern about conditions in these units, the Jail revised its
policy to prohibit the use of restraints in these locations. We
commend Jail officials for their swift action to address this
concern.
10

The documentation provided to us was inconsistent
regarding the types of restraints used.
11

We do not dispute the very serious actions taken by the
inmates and disciplinary action was likely in order.

- 7 

•	

Another videotaped incident from February 2, 2007
showed the SOG team removing inmate S.C.12 from his
cell, taking him to the A-2 housing unit, and placing
him in six-point restraints. According to the
videotaped explanation provided by a SOG team member,
S.C. was removed from his cell because he was
threatening staff, kicking his cell door, and refusing
to be placed in handcuffs. From the moment the SOG
team opened S.C.’s cell door, however, the inmate
complied with the team’s instructions. He did not
resist handcuffs or leg irons, did not resist being
escorted to the restraint bed in the A-2 housing unit,
and actually assisted the SOG team as they applied the
restraints.

•	

On February 2, 2007, the SOG team was called after
inmate J.R. refused to move to a different cell in his
housing unit. J.R. allowed the SOG team to handcuff
him and place him in leg irons, but refused to be strip
searched. Following this refusal, the SOG team
escorted J.R. to the restraint area in the A-2 housing
unit. Upon arrival in the restraint area, J.R. can be
heard on the videotape agreeing to be searched. The
SOG officer responded by saying “Now you’re going to
strip? It’s too late now; you had an opportunity.”
Despite the inmate’s express statement that he would
comply with the search, the SOG team placed him in sixpoint restraints. Once the restraints were applied,
the SOG team cut off J.R.’s clothing, leaving him to
lie exposed in his boxer shorts in the middle of
winter.13
Almost immediately after being restrained, J.R. started
convulsing. In the videotape, J.R. can be heard
telling a nurse in the restraint area that he thought
he was having an anxiety attack. The nurse responded,
“I think you are too,” but left without intervening.
J.R. continued to convulse for a period of time without

12

To protect inmates' privacy, throughout the document we
identify inmates by initials other than their own. We will
separately transmit to the County a list that cross references
the initials with inmate names.
13

We found a number of instances where, while being
restrained, inmates were stripped to their underwear for no
apparent reason.

- 8
receiving any assistance from mental health, medical,
or custody personnel. There is no record of how long
J.R. was restrained.
•	

On January 16, 2007, the SOG team was called because
inmate P.Q. flooded his cell, was allegedly throwing
items at officers, and refused to be placed in
handcuffs. The SOG team asked P.Q. to lie down in his
cell and place his hands behind his back. At that
point, P.Q. began to cut his wrist with a sharp
instrument. P.Q. was then taken to the medical unit
and, thereafter, transported to the emergency room
where he received stitches. The videotape showed that
upon P.Q.’s return to the Jail several hours later, he
appeared in control of his behavior and informed the
officers that he was in pain. He also told the
officers that he understood that he had broken the
rules and stated that he would comply with their
instructions. Nevertheless, the officers placed P.Q.
in six-point restraints. When P.Q. asked why he was
restrained, staff responded that he had attempted
suicide and was in an agitated state.14

Given that the inmates described above exhibited no loss of
control or threatening behavior during these lengthy incidents,
the use of restraints cannot be justified.15 Absent a sound
penological or therapeutic rationale for using restraints, we are
left to conclude that staff at the Jail used restraints in these
cases for punitive purposes -– in violation of constitutional
standards, Jail policy and generally accepted professional
standards. When inmates violate Jail rules, the Jail should
appropriately address the infractions through a fair and
objective disciplinary process, but not by placing inmates on a
bed or chair that restrains their arms, legs and torsos.

14

The propriety of using restraints for mental health
purposes is addressed in Section III(C)(3) of this letter.
15

We recognize the deterrent effect that the very
presence of the SOG has on inmates -- they likely will comply
once the SOG is dispatched (which is a good thing) –- but the
policy/practice should provide for next steps when there is
compliance, as well as when there is not. Otherwise, the Jail is
not fully utilizing this team and, inadvertently, failing to
encourage compliance from the inmates, and arguably inflicting
restraints as a form of punishment rather than a compliance tool.

- 9 

In addition to finding that inmates are inappropriately
restrained, our investigation also revealed that even when the
initial use of restraints is justified, in many cases the length
of time inmates are restrained makes the practice punitive. We
reviewed reports documenting 12 instances of restraint use
between April 1 and 30, 2007. Nine of the inmates were
restrained for four or more hours; one was restrained for 23
hours. We also found that inmates oftentimes are restrained
without consultation with medical or mental health staff. In
fact, as discussed in Section III(C)(3) below, mental health
staff rarely are involved in the decision to restrain inmates on
the mental health caseload (who may be suicidal or mentally ill).
In a departure from generally accepted professional standards,
this decision is made by solely security staff.
According to Jail policy, a supervisor or administrator must
review the use of restraints. We discovered, however, that this
review, if it occurs at all, often takes days, weeks, or even
months. In light of these extensive delays, it is impossible for
an inmate who is inappropriately restrained to receive timely
relief. We note that the Jail reportedly has made some changes
in this regard. At the end of our May 2007 tour, the Jail issued
a directive requiring that an Assistant Deputy Superintendent or
Operations Captain personally interview and observe an inmate who
is subject to restraint longer than two hours. Because this
practice was scheduled to be implemented after our departure, we
were not able to assess its efficacy.
b.

Chemical Agents

In addition to the unlawful use of restraints, we found that
the Jail does not comply with generally accepted professional
standards or its own policy regarding the use of the chemical
agent oleoresin capsicum (“OC”). Specifically, we found only one
instance in the videotapes we reviewed where the Jail
decontaminated an inmate who was sprayed with OC. Moreover,
despite a policy requiring staff to review inmates’ medical
records for contraindications before using OC, we found no
evidence that such a review actually occurs.
For example, on January 10, 2007, a SOG team was called to
remove inmates D.W. and T.G. from their cell because they
reportedly were threatening to assault officers, disrupting the
cellblock, and destroying their cell. The SOG team fired OC
projectiles into the cell, striking both inmates. Thereafter,
both D.W. and T.G. were handcuffed, placed in leg irons, escorted

- 10 

to A-2, and placed on adjacent restraint beds.16 No one
attempted to ascertain whether the use of OC was contraindicated,
and neither inmate was allowed to shower after being exposed to
this chemical.
2.

Inadequate Incident Review and Investigation

Management’s failure to adequately review and investigate
incidents contributes to the high number of excessive restraint
incidents at the Jail. The principal purposes of management
incident review are to ensure that no criminal conduct has
occurred, that facility procedures have been followed, that no
remedial training is necessary, and that no review or change in
policies is required. Because the Jail’s policies fail to set
forth a time frame for supervisory review, the process varies in
length from days to weeks to, in some instances, months. In
addition, because supervisors are not required to sign the
incident reports they review, it is impossible to determine
whether a supervisory review has taken place. This gap in the
system allows for improper uses of force to go unaddressed.
Compounding this problem is the fact that the computer
system used to track use of force incidents lacks reliability. A
functional system should allow supervisors to easily review all
reports relating to a particular use of force incident and should
include documentation of witness statements from staff and
inmates. At the Jail, however, corrections officers and
supervisors enter incident information into the computer located
at their posts or work areas. Each entry generates a number in
sequential order. Thus, if one incident results in multiple
incident reports from multiple participants and witnesses, each
individual report will have a different number. This makes it
difficult for supervisors to track all of the reports related to
a particular incident to ensure that all relevant information is
considered. A further complication is that the system includes
entries about routine daily activities on the unit such as the
distribution of meals and sick call. The fact that staff can
make entries using each others’ passwords further undermines the
integrity of the system. The officers we interviewed were
uniformly frustrated with the system’s cumbersome nature. Given
the deficiencies outlined above, the computer system cannot be
relied upon to generate accurate statistics, patterns, or trends.

16

As discussed in Section III(C)(3), below, after we
expressed our concern about restraining more than one person in
the same area, the Jail changed its policy to forbid this
practice.

- 11 

3.

Inmate-On-Inmate Violence

The lack of adequate inmate supervision has contributed to a
number of inmates being assaulted by other inmates at the Jail.
The Jail’s “Significant Incident Summary” reports that 233
inmate-on-inmate assaults occurred between April 2006 and March
2007. For jails of similar size (with inmate populations 1,000
to 1,999), a reliably reported average is 108 inmate-on-inmate
assaults,17 less than half the number of assaults reported at the
Jail.
Further, many of the Jail’s inmates suffered serious
injuries. During this same time period (April 2006 and March
2007), there were 155 medical referrals for inmate injuries
sustained during such assaults. The injuries included head
wounds, bleeding, lacerations, and bruises. In 2005, a pre-trial
detainee at the Jail died from injuries he sustained after
allegedly being beaten by his cell mate who was a sentenced
inmate. A high incidence of inmate-on-inmate assaults is
compelling evidence of the Jail’s inability to keep its inmates
safe.
4.

Inadequate Investigations

A functional investigation process should be governed by
policies and procedures that address file management, tracking
procedures, authorization protocols for initiating
investigations, training requirements for investigators, time
frames for conducting investigations, interview processes of
staff and inmates, polygraph requirements (if applicable),
reporting requirements regarding allegations of staff misconduct,
and final disposition procedures. The Jail conducted 39
investigations in 2006, and 21 investigations during the first
five months of 2007. We reviewed a random sample of these
investigations which revealed that the Jail’s policies and
procedures do not provide investigators with adequate guidance to
conduct appropriate investigations.
For example, there is no requirement that investigations
involving allegations of excessive force include medical evidence
(or an affirmative statement that medical evidence was not
available). Information regarding the extent of an inmate’s
injuries following a use of force incident is important to the
investigation. Such information allows the investigator to

17

The Criminal Justice Institute, Inc., The 2000
Corrections Yearbook: Jails, at 85 (2000) .

- 12 

determine whether the injury is consistent with what has been
reported or alleged. The investigations we reviewed did not
consistently include medical evidence.
The Jail’s policies and procedures also do not adequately
address when staff are required to report allegations and
incidents, nor do they provide guidance as to who should be
interviewed as part of an investigation. The policies and
procedures also fail to require that investigation reports
include the final disposition of staff sanctions when staff
misconduct is sustained or there was a recommendation for
disciplinary action. The effect of the deficiencies in the
Jail’s policies and procedures is reflected in the following
examples:
•	

18

In October 2006, inmate A.C. informed a sergeant that
two officers had used excessive force on him. The
sergeant contacted Internal Affairs who sent two
officers to speak with A.C. When A.C. stated that he
did not wish to make a formal complaint, the matter was
dropped. The investigation was reopened after inmate
A.C. filed a formal grievance. According to A.C., an
officer shook him, choked him, and slammed him into a
wall, after A.C. asked the officer to stop banging on
the P.A. system microphone. Another officer reportedly
was involved as well. The investigators interviewed
both officers, but their investigative report did not
outline the discrepancies between the officers’
versions of events and A.C.’s version. Moreover, some
of the officers who witnessed the incident failed to
write up a report and others did so weeks after the
incident took place. There were also allegations that
one of the officers involved in the incident prepared
two conflicting incident reports. In the first, he
wrote that a “jugular clamp”18 was used on the inmate.
In the second, he used different terminology to
describe the incident. Although A.C. identified
several inmates who witnessed the event, investigators
did not speak to any of these individuals. Ultimately,
the Assistant Deputy of Special Services found both
officers to have violated the Jail’s codes of conduct,
and recommended that the case be referred to the local

A jugular clamp is similar to a chokehold; the
technique involves restricting blood flow and oxygen to the
brain. Generally accepted professional standards prohibit such
holds unless the use of deadly force is justified.

- 13 

district attorney for possible criminal prosecution.
Although the Assistant Deputy appears to have taken
appropriate action, this incident would not have been
pursued, even though a third party initially tried to
report it, if the inmate victim had not filed a
grievance.
•	

Another inmate, who has two prosthetic legs and uses a
wheelchair, complained that on March 21, 2007, he was
transported to court in a van that was not wheelchair
accessible. The inmate alleged that during the drive,
he was bounced around for four hours and ended the ride
bruised and ill. He also claimed that he was not
allowed to use the bathroom during trip. In addition
to these allegations, the inmate stated that his legs
were chafing and cracking because of the “freezing”
cold air in his cell. The investigator who reviewed
these allegations never interviewed the inmate or
looked into whether any of the claims were true.
Instead, he simply concluded that the allegations were
unfounded.

•	

Internal Affairs reviewed allegations that on August
24, 2006, an officer had grabbed an inmate in the neck
and chest area. Based on information received from
another sheriff’s department, the assigned investigator
reported that the inmate is “animated and sort of a
pain in the neck.” Although the investigative report
states that the inmate had no visible injuries, the
investigator did not interview the inmate or search for
injuries until a month after the incident. The
investigator did not interview the officer involved in
the incident nor did he interview any witnesses who
could corroborate or repudiate inmate’s story.
Finally, the investigative report made no mention of
the fact that there was no incident report regarding
the alleged use of force.

•	

Another investigation was opened after an inmate’s
mother complained that her son had been abused while in
four-point restraints. The investigative report notes
that the investigator spoke with the inmate and his
mother, but it does not reference or include the
incident report associated with the incident.19 It

19

Because the incident resulted in a disciplinary report,
an incident report should have been generated.

- 14
also is not clear from the report whether the inmate
was, in fact, ever placed in restraints.
In addition to the flawed investigatory process and the
reports it generates, we are concerned that the Assistant Deputy
of Special Services, who supervises the internal affairs
officers, also supervises communications/dispatch, perimeter
security, inmate grievances, K-9 operations, the range
supervisor, the armorer, inmate rules and regulations, the SOG,
fleet maintenance, transportation, and serves as the criminal
justice liaison. In order to avoid impropriety or the appearance
of impropriety, the special services deputy should not oversee
both tactical operations and inmate grievances.
As currently structured, the special services deputy is
responsible for reviewing incident reports and videotapes from a
tactical operation, such as a cell extraction, that he authorizes
or supervises. Moreover, if the tactical operation results in a
grievance, the deputy is responsible for supervising the
grievance officer who reviews the incident, and he would hear any
appeal of the grievance officer’s finding. Accordingly, the very
person who authorized the underlying activity is charged with
reviewing it for any impropriety. It is highly inappropriate for
one person to have responsibilities that create such a clear
conflict of interest.
5.

Inadequate Staffing and Inmate Supervision

Staffing levels at the Jail are inadequate to protect
inmates from harm. As of December 15, 2006, the Jail had 710
employees. Only about 438 (60% percent) of these employees had
custody-related duties. Although the serious overcrowding at the
Jail makes staffing an issue throughout the facility, we are
particularly concerned with the staffing in the A-1 and A-2
housing units, which provide disciplinary and administrative
segregation housing as well as housing for inmates on suicide
watch. Because these inmates present unique risks to themselves
and others, they require more monitoring and supervision than
inmates in the general population.
Notwithstanding the risks of leaving the inmates on A-1 and
A-2 unattended, the Daily Roll Call Assignment rosters document
that the security posts in A-1 and A-2 often are unmanned.20

20

It is worth noting that the Daily Roll Call Assignment
roster also shows unmanned security posts in the Main Jail’s
Maximum B and C housing units.

- 15 

Furthermore, although Jail policies and procedures require that
corrections officers make frequent and regular security checks on
these units, many of the security checks we observed involved
little more than quick walks up and down the unit. Although the
purpose of a security check is to ensure that inmates are safe,
the officers we observed failed to stop at each cell door to view
and/or interact with the inmates. This failure places inmates at
serious risk of harm. The Jail plans to install video
surveillance equipment in inmate living areas, importantly,
however, such surveillance is not an adequate substitute for
frequent, in-person visual checks of each inmate.
The lack of staffing also makes it difficult for inmates on
suicide watch to receive sufficient out-of-cell time. For
example, some A-1 inmates are only allowed out of their cells for
one hour, three days per week. This is also their only
opportunity to shower and use the telephone. As discussed in
Section III(C), below, inadequate staffing results in inmates on
suicide watch being locked down at least 23 hours each day.
Additionally, the lack of adequate assessments and interventions
available to these inmates from the mental health staff may
contribute to their length of stay on A-1 and exacerbate their
mental illness.
Overcrowded conditions at the Jail magnify the staffing
deficiencies in A-1 and A-2. Many, if not most, of the inmates
housed in these units should be placed in single-bunked cells for
security reasons. Instead, a number of them are required to
share their cell with other special management inmates -- a
management practice that is extremely unsafe.
Finally, we also are concerned about the Jail’s practice of
housing inmates in the gymnasium. Inmates housed in this
location are at particular risk of harm because officers do not
have a direct line of sight into the shower areas and bathrooms.
Accordingly, inmates can harm each other in these locations
without fear of detection.
6.

Inadequate Classification System

Generally accepted professional standards require that
correctional facilities classify inmates in a timely fashion and
in a manner that maximizes security and safety. An effective
system classifies inmates based on, among other things, their
medical and mental health needs, their gang affiliation (if any),
their past behavior, the nature of their offense, and/or their
need for protective or administrative segregation. The system
also should track inmates throughout their incarceration and

- 16
provide quality control information so that inmates can be
reclassified, if necessary.
At the Jail, however, the location of available cell space
seems to be a primary factor in the classification process. For
instance, because there are not enough segregation cells, inmates
who commit disciplinary infractions often are put on a waiting
list to serve their disciplinary time, or may simply serve that
time locked in their general population cells with a cell mate.
Our understanding is that the cell mate is not locked down with
the inmate on disciplinary confinement. During our tour, the
classification supervisor estimated that as many as 45 inmates
were restricted to their cells in general population housing
awaiting a segregation cell or serving their disciplinary
sentence.
We understand that the Jail’s population is well over its
capacity and that the severe overcrowding complicates the
classification process. This situation does not, however,
obviate the need for the Jail to comply with generally accepted
professional standards regarding the classification of inmates.
The Jail’s poor classification system can be linked to the murder
of at least one pre-trial detainee. In February 2005, a pre
trial detainee, housed in the same cell as a sentenced inmate,
was allegedly violently kicked and beaten to death by his cell
mate. The Jail must immediately implement a system that is built
on appropriate penological principles and that, to the extent
possible, ensures the safety and security of the inmates.
7.

Inadequate Grievance Process

An adequate grievance process is an integral part of
generally accepted professional standards and should be designed
to ensure that there is an administrative means for the
expression and resolution of inmate concerns. The process can
also help management identify problems inside the facility
thereby increasing safety and security for inmates and staff. To
comply with generally accepted professional standards, a
grievance system should include a written form that is completed
by the inmate, provide an opportunity for staff to investigate
and resolve the inmate complaint, and set forth an appeal process
that must be completed within a specific time frame. The Jail’s
grievance system does not comply with these requirements.
The Jail attempts to circumvent the formal grievance system
by encouraging inmates to “informally communicate” their problems
to the senior corrections staff in their housing areas. Until
recently, these informal communications were not entered into the

- 17 

Jail’s management system and thus could not be tracked. Perhaps
more significantly, this informal process breaks down if an
inmate’s grievance concerns the senior corrections staff.
The Jail’s grievance process is difficult for inmates to
access. As an initial matter, inmates do not have direct access
to grievance forms and must obtain them from the housing unit
captain. Once a form is completed, inmates must “complete and
forward the form in an envelope, with postage, addressed to the
(‘Facility Inmate Grievance Coordinator’) by way of the outgoing
facility mail.” Pursuant to the Jail’s policy, inmates must file
a grievance form within ten days of the incident at issue,
although the grievance officer told us that he does not enforce
this rule. Inmates are subject to these same rigorous
requirements if they wish to appeal the grievance officer’s
decision.
The inaccessibility of this system is reflected in the low
number of grievances that are filed. For instance, when we asked
about grievances filed during a three-month period in late 2006,
we discovered that only 18 grievances were processed during that
time frame. Given the Jail’s population and the volume of
grievances filed in other correctional facilities, our expert
consultant found this number to be extremely low. Moreover, many
of the inmates we interviewed expressed frustration with the
Jail’s grievance system. Those inmates found it particularly
difficult to obtain grievance forms and/or postage for mailing
the forms to the grievance officer.
Upon the completion of our initial tour in February 2007,
the Jail made some changes in its grievance system. At present,
unit lieutenants (as well as captains) are permitted to provide
inmates with grievance forms. The Jail also issued a memorandum
to inmates indicating that they could use the in-house mail
system to file grievance forms. However, during our second tour,
the grievance officer stated that he was not aware of either
change. Additionally, the inmate handbook had not been revised
to reflect the reported changes. Most importantly, the changes
the Jail has made are insufficient. Inmates still complain about
the difficulty of obtaining forms and the overall process is
extremely prohibitive to inmates who need to be able to express
serious concerns regarding jail operations.21

21

In the December 13, 2007 letter referenced previously,
the County reports an increase in the number of grievances since
the changes in practice and we agree that this may be a positive
indicator that inmates find the grievance process more accessible

- 18 

B.

Environmental Health Deficiencies

Prison officials must ensure that inmates are protected from
harm and receive adequate food, clothing, and shelter, Farmer,
511 U.S. at 832. Officials must also ensure that prisoners are
not "deprive[d] . . . of the minimal civilized measure of life's
necessities." Rhodes, 452 U.S. at 347. The conditions at the
Jail fall short of these constitutional requirements.
1.

Physical Plant, Sanitation, and Hygiene

The Jail has severe problems with its physical plant that
directly affect the health and safety of inmates housed there.
In a February 2007 report, the Massachusetts Department of Health
and Human Services identified many of these deficiencies,
including the poor structural condition of the physical plant,
overcrowding, unsanitary showers, too few showers, low hot water
temperatures throughout the facility, and inmate exposure to
extensive dust in areas that were being renovated.
During our tour, many of the showers we saw were covered
with soap scum and mold, suggesting that the showers are not
routinely cleaned. When combined with water temperatures that
are not hot enough to kill bacteria, these unsanitary conditions
can create serious health hazards and encourage the spread of
disease. These risks are magnified in a correctional setting
where numerous people share toilet and shower facilities in
small, confined spaces.
Additionally, during the February 2007 tour, inmates
complained that several of the housing units in the Main Jail
were extremely cold. At the direction of our expert consultant,
the Jail took random temperature readings in the A-2 housing unit
and the temperatures confirmed the inmates’ complaints. We also
observed cells where inmates covered their vents and windows with
plastic bags in an effort to keep cold air out.
We also are concerned about unsanitary conditions that may
arise during lockdowns, which occur frequently at the Jail.
Inmates reported that they do not receive clothing or linen
changes while their housing units are locked down for days at a
time, or even a few weeks. The failure to provide clean clothing

and fair. We look forward to evaluating the County’s changes to
its grievance process. See Letter from Deputy Superintendent
Jeffrey Turco, Esquire to Shanetta Y. Cutlar, Chief of the
Special Litigation Section (December 13, 2007).

- 19 

and linens can lead to the development and spread of infectious
diseases.
2.

Emergency Preparedness and Key Control

In the event of a fire or other emergency, inmates at the
Jail are at serious risk of harm, including death, because of
deficiencies in emergency preparedness and key control which
prevent staff from quickly unlocking cell doors. During our
February 2007 tour, we also found that emergency keys and locks
could not be identified by sight and touch, which is essential in
the event that smoke from a fire obscures officers’ ability to
visually distinguish keys.22
At the time of our February 2007 tour, we also found that
Jail staff did not have the means to manually release cell doors
in the A-1 and A-2 housing units on an individual basis.
Because these units house special management inmates, including
those placed on suicide watch, it is critical that staff be able
to open a particular door quickly in the event of an emergency
such as a suicide attempt. During our second visit in May 2007,
we were pleased to find that the maintenance staff created a
special tool that was capable of opening individual cell doors.
However, because this tool is kept in the maintenance department,
it is not readily available to security staff on the A-1 and A-2
housing units. We were told that more tools were being
manufactured and would be kept in the units themselves. Once
this occurs, the Jail should implement a testing program in which
staff practice opening cells doors with the tool.
3.

Risk of Food-Borne Illness

The kitchen at the Jail is unsanitary and the food service
practices are deficient, which places inmates (and staff who also
eat meals prepared at the Jail) at risk of food-borne illness.
The Massachusetts Department of Health and Human Services
reported in February 2007 that the Jail’s “food service is in the
worst condition that [we have] seen in over 30 years of
inspecting the facility.”
Approximately 5,000 meals are prepared daily in the Jail’s
kitchen. During our February 2007 tour, we observed remarkable
health code violations that place inmates and staff at risk such
as no soap or paper towels in the inmate bathroom or kitchen

22

We note that some progress had been made by the time of
our second tour in May 2007.

- 20 

serving area hand washing sink.23 We also observed, among other
things, debris and dirt build up in the floor drains and grease
build-up on the overhead vents. More examples of lack of
sanitation of the food service area are found in our expert
consultant’s report.
Additionally, the staff and inmates who work in the kitchen
do not handle food properly. The inmate kitchen workers we
interviewed had not been trained on how to properly sanitize
pots, pans, and utensils. Further, we observed unsafe food
handling practices, such as thawing frozen chicken in hot water
and storing undated leftover food in the refrigerator.
We also observed serious physical plant problems in the
kitchen area such as: (1) exposed electrical wiring on food
service equipment and walls; (2) holes in walls;24 (3) floor
surfaces that were peeling, porous and dirty and thus could not
be effectively cleaned; and (4) paint that was peeling off walls
and the ceiling.
C.

Failure to Provide Adequate Mental Health Care

Corrections officials have an obligation under the Eighth
Amendment to provide medical and mental health care to
incarcerated individuals. Estelle, 429 U.S. at 104-05. The
"deliberate indifference" to [inmates'] serious medical needs
constitutes "unnecessary and wanton infliction of pain." Id.
Serious medical needs include the mental health needs of suicidal
inmates. A suicidal inmate can demonstrate a jail’s "deliberate
indifference" to his/her serious medical needs by showing: "(1)
an unusually serious risk of harm (self-inflicted harm, in a
suicide case), (2) defendant's actual knowledge of (or, at least,
willful blindness to) that elevated risk, and (3) defendant's
failure to take obvious steps to address that known, serious
risk." Manarite v. City of Springfield, 957 F.2d 953, 956 (1st
Cir. 1992); see also Pelletier v. Magnusson, 201 F. Supp.2d 148,
164 (D. Me. 2002); Stewart v. Robinson, 115 F. Supp.2d 188, 193
(D.N.H. 2000); Elliott v. Cheshire County, New Hampshire, 940
F.2d 7, 10-11 (1st Cir. 1991) (deliberate indifference is

23

Like many other correctional facilities, the Jail
relies heavily on inmates for its food preparation.
24

The holes were immediately sealed once we brought them
to the Jail’s attention.

- 21 

determined by whether the corrections officials, "knew, or
reasonably should have known, of the detainee's suicidal
tendencies.").
The deliberate indifference on the part of corrections
officials to the “serious medical needs” of inmates constitutes
“unnecessary and wanton infliction of pain.” Estelle v. Gamble,
429 U.S. 97, 104-05 (1976). The Eighth Amendment also protects
against deliberate indifference to an inmate’s serious mental
health and safety needs. Torraco v. Maloney, 923 F.2d 231, 234
(1st Cir. 1991); Cortes-Quinones v. Jimenez-Nettleship, 842 F.2d
556, 559-60 (1st Cir. 1988) (finding sufficient evidence that a
jury could conclude corrections officials were deliberately
indifferent to the health and safety needs of a psychiatrically
disturbed inmate held in an overcrowded jail). “Deliberate
indifference may be found where the attention received is so
clearly inadequate as to amount to a refusal to provide essential
care.” Torraco, 923 F.2d at 234 (internal citation and
quotations omitted).
We find that the Jail violates inmates' constitutional
rights by failing to provide for their serious mental health
needs. Specifically, the Jail: (1) fails to provide an adequate
array of mental health services; (2) fails to respond
appropriately to the needs of suicidal inmates; (3) fails to use
restraints in a manner consistent with generally accepted
professional standards; (4) fails to ensure proper management of
psychotropic medications; (5) fails to keep complete and accurate
medical records; and (6) fails to ensure that an adequate quality
assurance/quality improvement system is in place.
1.	

Failure to Provide an Appropriate Array of Mental
Health Services

At the time of our May 2007 visit, 21% of the total inmate
population and 31% of the inmates on lockdown were part of the
mental health caseload. The mental health staff we interviewed
indicated that these percentages are typical for the Jail.
Mental health staffing at the Jail is insufficient to assess,
treat, and monitor this population. The only psychiatrist
serving the facility is on-site for just 13 hours each week, and
only one person on the day shift is a licensed mental health
clinician.25 Additionally, a lack of escort officers has made it

25

The Jail informs us that the hours for mental health
clinicians has increased. However, the psychiatrist’s hours
remains unchanged. Letter from Deputy Superintendent Jeffrey

- 22 

difficult for mental health staff to interview inmates in a
setting that allows for adequate sound privacy. As a result of
these staffing issues, inmates with serious mental illness suffer
from delays in, or lack of, adequate treatment, and are
continually placed at risk of becoming a danger to themselves and
others.
Generally accepted professional standards require
correctional mental health systems to provide the following types
of treatment programs: (1) crisis intervention, including access
to beds in a healthcare setting for short-term treatment (usually
less than ten days); (2) acute care (an inpatient level of
psychiatric care); (3) chronic care and/or special needs unit
(housing for inmates with chronic mental illness who cannot
function in the general population); (4) outpatient treatment
(provided to inmates in the general population); and
(5) discharge/transfer planning (including services for inmates
in need of further treatment at the time of transfer to another
institution or discharge to the community). The Jail falls far
short of providing these required services.
a.	

Crisis Intervention Provided under Non-Therapeutic
Conditions

The Jail attempts to provide crisis intervention by moving
suicidal inmates to the upper tier of Unit A-1, or, when those
cells are full, placing suicidal inmates in the “restraint areas”
located in the A-1 and A-2 dayrooms.26 Both of these settings
are grossly inadequate locations in which to house and treat
inmates in need of crisis intervention. Both closely resemble a
segregation unit because inmates remain in their cells for at
least 23 hours each day. Although Medical Services Policy
#932.05 requires that certain inmates on suicide watch be offered
one hour of tier time each day, the Jail follows the more
restrictive Custody Policy #926, which has no such requirement.
Indeed, consistent with Custody Policy #926, inmates on suicide
watch are allowed out of their cells just three times each week
for the purpose of taking a shower, and receive no therapeutic
treatment. For all practical purposes, suicidal inmates are
treated as if they were high security inmates, not inmates in

Turco, Esquire to Shanetta Y. Cutlar, Chief of the Special
Litigation Section (March 7, 2008).
26

These restraint areas are larger than regular cells,
but resemble cages because the walls, doors, and ceilings are
made out of open, expanded metal.

- 23 

need of mental health treatment. The current policy and
procedures governing suicide watch are equivalent to the use of
seclusion for mental health purposes. The infrequent clinical
contacts with mental health staff, combined with the conditions
on the upper tier of A-1, violate generally accepted standards of
care and are likely to exacerbate the inmates' mental health
problems.
The harsh conditions on the upper tier of A-1 are likely to
exacerbate the mental health symptoms of inmates housed on this
unit. Yet, as discussed in Section III(C)(3), below, these
inmates rarely are assessed or treated by the psychiatrist.
Moreover, because of staffing issues, inmates housed on the upper
tier of A-1 do not receive daily visits from mental health staff.
Many of the general population inmates we interviewed had
previously been housed on the upper tier of A-1. Several of
these inmates indicated that they had been placed on suicide
watch because of a past history of suicide attempts as opposed to
current suicidal thinking. They were fairly unanimous in their
descriptions that the property restrictions and lockdown nature
of A-1 were draconian.
b.

Acute Care

The Jail does not provide acute mental health care on-site.
Instead, inmates who require such services are transferred to
either a state hospital or the Emergency Services Unit at the
Hamden County Jail. We find this practice to be an adequate
solution; it is worth noting, however, that during 2006, only 35
inmates were transferred out of the Jail to one of these
facilities. This number seems surprisingly small given the large
inmate population and suggests that inmates with serious mental
illness do not have appropriate access to acute mental health
services.
c.

Chronic Care

Inmates whose chronic mental illnesses prevent them from
functioning in the general population should be housed in a
special needs unit ("SNU"). Consistent with generally accepted
professional standards, SNU inmates should receive at least ten
hours of out-of-cell, structured, therapeutic activity and at
least ten hours of unstructured recreational time each week.
The Jail does not purport to have anything approximating an
SNU to assist inmates who require this level of care.
Consequently, treatment for inmates with chronic mental illnesses

- 24 

primarily consists of medication and includes little or no
counseling. Because there is no chronic care program and
seemingly limited access to an acute care program, inmates who
are the most symptomatic and impaired from their mental illnesses
often are labeled "suicidal" and sent to the upper tier of A-1 or
are placed in segregation housing. Indeed, inmates with mental
illness are over represented in both units. As noted above, 21%
of the total inmate population is on the mental health caseload.
In segregation housing, 31% of the inmates are mental health
patients. When the upper tier of A-1 is included with
segregation housing, the percentage of mental health patients on
these units jumps to 38%.
At the time of our second tour, inmate C.T. had been on the
upper tier of A-1 for approximately 22 days. This was the third
time C.T. had been placed on suicide watch during the 77 days he
had spent at the Jail. When we spoke with C.T., he stated that
he was not suicidal and did not understand why he had been placed
on suicide watch. A review of his mental health record indicated
that he has a serious mental disorder associated with psychotic
features. Although there was little in the record to justify
suicide precautions, it is clear that C.T. needed specialized
housing and treatment for his serious mental illness. The Jail,
however, offered only medications, infrequent clinical contacts
and segregated housing. This care was inadequate.
When we spoke with M.B., another inmate housed on the upper
tier of A-1, he had been on the unit for five days. He was
placed on suicide watch because he had been hearing voices
telling him to harm himself. During the three weeks before his
transfer to the upper tier of A-1, M.B. had refused to take his
medications. Nursing staff was aware of these refusals, yet the
psychiatrist had not met with M.B. during this time period. Like
C.T., M.B. had been placed on suicide watch a number of times
during his stay at the Jail. His serious mental illness,
however, required intensive treatment, not seclusion. By placing
M.B. on the upper tier of A-1 for prolonged periods of time,
giving him little access to the psychiatrist, and offering
nothing in the way of out-of-cell structured activities, the Jail
neglected to address this inmate's serious mental illness.
Another inmate in need of treatment for his chronic mental
illness is C.P. He preferred the upper tier of A-1 to general
population housing, notwithstanding the restrictions on the A-1
unit. C.P.'s mental health assessment noted that he presented a
chronic risk of self-harm and harm to others. A review of C.P.'s
mental health record suggests that he needed more structured
housing than what is available in the general population.

- 25 

Continuing him on suicide precautions with lockdown restrictions,
however, likely exacerbated his clinical condition.
Suicide watch in this context appears to have been a “ticket
of admission” to this unit or was used as a rationale for
continuing to stay on this unit because the inmates have
difficulty functioning in the general population due to their
mental health problems. These inmates have either a serious
mental illness and/or a personality disorder associated with
significant functional impairments that require mental health
intervention. Such inmates are in need of an intermediate level
of care that is not being provided by the Jail.
As discussed above, the upper tier of A-1 is far from a
therapeutic milieu. Inmates housed on this unit receive few
visits from mental health professionals and are locked down in
single cells for more than 23 hours each day. Segregation
housing has similar conditions of confinement. Neither area
provides appropriate care for inmates with chronic mental
illness. Instead, many of the mentally ill inmates housed on
these units exhibit increased symptoms of their underlying
psychiatric disorder or fail to show any improvement in their
current symptoms. The lack of adequate treatment actually
increases the risk that these inmates will harm themselves or
others.
d.

Outpatient Treatment

The Jail attempts to provide outpatient treatment services,
but staffing shortages, vacancies, absences and allocation issues
make timely, effective treatment difficult to achieve. There are
insufficient mental health staff to provide regular, consistent
therapy and counseling for general population inmates who are on
the mental health caseload. Instead, the treatment of choice at
the Jail appears to be medication. The only psychiatrist for the
facility is on-site just three mornings and spends a total of 13
hours each week at the Jail. In general, the psychiatrist sees
patients on a "block schedule," meaning that, for the most part,
he only sees inmates when he is scheduled to be in their
building. The psychiatrist's schedule allows him to visit each
building once every two to three weeks. Only about 10-15 percent
of the psychiatrist's appointments are based on the immediate
clinical needs of the inmates. Although inmates can "self-refer"
to mental health, it usually takes between two and four weeks to
see the psychiatrist. Our document review revealed that the
number of inmates on the mental health waiting list ranged from
31 to 69 patients.

- 26 

During our May 2007 tour, we interviewed 12 mental health
caseload inmates in a group setting at the Annex. About half of
these inmates had been in the Jail for over six months. All but
one of them took psychotropic medications. The inmates generally
met with a mental health counselor about once every two months.
Only one inmate reported meeting with a mental health counselor
on a regular basis. Several inmates reported meeting with
different counselors in response to self-referrals. All others
reported that they only met with the psychiatrist and did not
have access to a mental health counselor. This information was
confirmed by mental health staff who reported that the mental
health clinician assigned to the Annex had been on sick leave for
the first three months of 2007. The Jail does not offer any
group psychotherapy.
Inmates often were not interviewed in a setting that allowed
for adequate sound privacy, consistent with generally accepted
professional standards, because there were insufficient escort
officers to move them to a sound-proof location. The mental
health team has recognized and documented this problem since at
least June 2006, yet the problem has not been addressed and it is
unclear what steps, if any, have been taken to rectify the
problem.
e.

Discharge/transfer Planning

Generally accepted professional standards require that case
management services be a part of discharge/transfer planning.
These services include (1) arranging an appointment with mental
health agencies for all mentally ill inmates; (2) providing
referrals for inmates with a variety of mental health problems;
(3) notifying reception centers at state prisons when mentally
ill inmates are going to arrive; and (4) arranging with hometown
pharmacies to have inmates' prescriptions renewed. The Jail
falls short of providing these services.
Staffing allocation issues and logistical problems such as
not being able to adequately identify discharge dates have
prevented the Jail from developing a formal discharge planning
process. For the very small percentage of inmates who are
Department of Mental Health ("DMH") clients, the Jail contacts
the appropriate DMH clinician when the inmate leaves the
facility. Other inmates receive informal discharge planning in
the context of receiving information about community mental
health resources. Although mental health staff told us that
inmates can receive a 30-day supply of discharge medications,
none of the inmates we met with who had been discharged from the
Jail in the year before their current incarceration had received

- 27 

discharge planning or prescriptions for discharge medications.
These inmates seemed surprised that prescriptions for discharge
medications were available to them.
2.

Failure to Provide Adequate Suicide Prevention

The Jail’s process for identifying, housing, and treating
suicidal inmates does not comply with generally accepted
professional standards.27
a.

Screening and Assessment

As an initial matter, the Jail needs to improve the
screening and assessment tools it uses to identify potentially
suicidal inmates when they arrive at the facility. At present,
the initial screening and assessment process consists of: (1) a
"suicide potential screening form" which has 17 questions and is
completed by an intake officer; (2) a "Q-5 form" which is filled
out by records personnel after they consult the statewide
Criminal Justice Information System to determine whether the
inmate has a prior history of suicidal behavior while
incarcerated in the state system; and (3) a "medical entrance
exam form" which contains a limited inquiry regarding suicide
risk and is completed by medical staff.
In addition to these three screening tools, mental health
staff are required to assess all inmates within 14 days of
confinement. About 88% of these assessments were completed
within the two-week time frame specified in policies and
procedures. Also, each inmate is assessed by the classification
department and assigned to a housing unit based upon this
classification. Although it would not be difficult to do so,
classification personnel do not consult the Sheriff’s Information
and Reporting System (“SIRS”) to determine whether the inmate was
identified and housed as a suicide risk during a previous
confinement at the facility.

27

We note that, following an alarming number of suicides
in the first six months of 2005, the Jail retained Lindsay Hayes,
a nationally-recognized expert on suicide prevention in jails and
prisons who is also a consultant to DOJ in other matters, to
provide short-term technical assistance in the area of suicide
prevention. Mr. Hayes’ services were of limited duration and he
did not oversee the Jail’s implementation of his recommendations.

- 28 

One problem with the Q-5 form is that there was confusion in
the records department as to what types of information should be
included. Although the form should report suicide attempts and
threats, many records department personnel were only including
actual attempts on the Q-5 form. Another problem is that the
various departments do not review the forms filled out by other
departments at the Jail. For example, the suicide potential
screening form and the Q-5 form are placed in the inmate's jail
file. The medical staff never see this form because they only
review the inmate's healthcare file. Additionally, the medical
staff does not attempt to find out whether an inmate exhibited
any suicidal behavior or mental illness during previous
confinement in the facility.
Another problem with the Jail's screening and assessment
process is that it often is untimely and incomplete. For
instance, inmate G.J. had been admitted to the upper tier of A-1
one day before our May visit. He had attempted suicide 18 months
earlier and was on Prozac (an anti-depressant) before his
incarceration. G.J. told us he was a single father of four
children, and he described significant distress about his current
incarceration. The disposition section on both the medical
entrance exam form and the suicide potential screening form was
blank, when there should have been some indication in that
section of both forms that a referral to mental health was
recommended. Staff decided to renew G.J.’s suicide watch status
and have him evaluated by the treatment team. The initial mental
health evaluation, however, provided little information relevant
to the dynamics and/or precipitating factors related to this
inmate's apparent depression. In addition, despite G.J. having
been assessed as having an illness severe enough to place him on
suicide precautions, he had not been seen by a psychiatrist or
the treatment team.
b.

Rationale for Placing Inmates on Suicide Watch

Related to the issue of poor screening and assessments is
the lack of adequate documentation of the rationale for placing
an inmate on suicide precautions. Indeed, it appears that some
of the inmates housed on the upper tier of A-1 did not need to be
on suicide watch. The practice of placing a person on suicide
precautions when such precautions are not clinically indicated is
problematic. Suicide precautions often include close or constant
observation, denial of all or nearly all personal effects, and
entail a near total denial of privacy. While appropriate to
safeguard persons who are at risk of suicide, this level of
precaution may adversely effect the mental health of persons not
at risk.

- 29 

For example, at the time of our May 2007 visit, T.S. had
been on the upper tier of A-1 for a few days. The medical
entrance examination report was completed from a mental health
perspective, but the disposition section on the form was not
completed. The initial mental health evaluation indicated the
presence of memory loss, a past history of hallucinations, and
fleeting suicidal thinking. The clinical impression was alcohol
abuse, depression, and that he exhibited symptoms of substance
induced mood disorder. Although the rationale for placing T.S.
on suicide watch appeared to be his past history of suicide
attempts, the rationale was poorly documented, and without proper
documentation it is impossible to determine whether the placement
was clinically indicated.
The rationale for placing L.S. on suicide precautions was
equally unclear. At the time of our May 2007 visit, L.S. had
been on the upper tier of A-1 for four days. He told us that he
was feeling depressed and wanted to talk to a psychiatrist, but
claimed that he was not suicidal. L.S.’s initial mental health
evaluation form indicated a provisional diagnosis of symptoms of
bipolar disorder, psychotic disorder, and personality disorder.
L.S.’s answers relevant to presence or absence of suicidal
thinking were somewhat evasive, and the plan was to refer him to
the mental health director for case review and treatment plan.
Thus, the documented rationale for placing L.S. on suicide watch
was very weak. There also was no clear treatment plan.
c.

Contact with Mental Health Staff

Generally accepted professional standards require mental
health staff to visit inmates on suicide watch every day.
Because of staffing shortages, mental health staff at the Jail do
not comply with this standard. Indeed, two of the inmates we
interviewed had been on suicide precautions for two and six days,
respectively, but reported that they had not yet seen a mental
health clinician. Additionally, the psychiatrist told us he
rarely was involved in the assessment and/or direct treatment of
inmates on suicide watch.
Instead of complying with generally accepted professional
standards, mental health staff at the Jail evaluate the inmates
on "Suicide A Watch" -– the most restrictive suicide precaution
–- every 2-3 days; inmates on "Suicide B Watch" are seen twice
each week. The Jail justifies the lack of daily rounds by citing
the open communication that exists between mental health and
corrections staff, the implication being that if an inmate needs
more frequent visits from mental health, corrections staff will
identify that need and inform mental health personnel.

- 30 

The Jail also cites the significant cost associated with
providing for daily evaluation of every inmate on suicide watch.
It is not appropriate, however, to rely on security staff to
assess an inmate's mental health needs. These staff have neither
the training nor the expertise to evaluate whether an inmate
requires contact with mental health personnel. Moreover, daily
rounds provide much needed clinical contact for suicidal inmates
and provide continuity of care for this vulnerable population.
d.

Cut-down Tools

During our February 2007 tour, staff lacked access to
emergency cut-down tools. As we discussed in our emergency
letter of May 18, 2007, the absence of these tools placed inmates
at significant risk of harm. Although corrections staff were
allowed to carry their own knives for cut-down purposes, there
was no policy that required corrections staff to carry knives nor
was there a policy that specified an acceptable size of knife.
In any event, allowing staff to carry knives is an unsound
correctional practice because there is no accountability in terms
of how the knives will be used, their size, or their level of
sharpness. An inmate can easily remove the knife from a
corrections officer’s person without the officer’s knowledge.
Moreover, knives are not the most effective tools to assist
officers responding to an attempted hanging because many of the
materials inmates use as ligatures cannot easily be cut with a
knife.
When we raised this issue with Jail administrators, they
responded promptly to our concerns. Indeed, by the time of our
second tour, the Jail was in the process of placing cut-down
tools in all housing units and providing them to each staff
member. We recommend that the Jail develop and implement
policies and procedures relating to the availability and use of
these tools. We also recommend that staff receiving training on
how to use them.
3.

Improper Use of Restraints

A random sample of 26 inmates who were restrained suggests
that inmates with mental illness are restrained more frequently
than inmates who are not mentally ill. As a result, appropriate
care is not being provided to these inmates in accordance with
generally accepted professional standards. Although only 21% of
the total inmate population is on the mental health caseload,
over 60% of the inmates in our random sample of inmates who were

- 31
restrained were mental health patients. Although the Jail
asserts that it does not use restraints for mental health
purposes, the over-representation of inmates with mental illness
among the restraint uses indicates that restraints often are
required because the Jail provides inadequate mental health
treatment or because some of these inmates have serious mental
disorders that are not responsive to available treatment. In
either case, the Jail is, de facto, using restraints for mental
health purposes.
For example, on January 8, 2007, inmate V.N. (who was on the
mental health caseload) cut his wrist and was bleeding heavily.
The SOG team removed V.N. from his cell in A-1 and he was treated
by medical personnel in the A-1 dayroom. The videotape of this
incident shows that V.N. did not resist treatment nor did he
threaten staff or himself during this time. Right after he was
treated, the SOG team placed V.N. in six-point restraints. There
is no documentation of why he was placed in restraints nor is
there any evidence that the use of restraints was discussed with,
or approved by, mental health personnel.
As discussed above, a SOG team also restrained inmate P.Q.
after he cut himself so severely that he required treatment at
the local emergency room.
Pursuant to generally accepted professional standards,
whenever a mentally ill inmate is restrained, correctional
facilities should assume that the restraint is for mental health
purposes. This default assumption, in turn, means that custody
and mental health staff should follow policies and procedures
governing the use of restraints on the mentally ill. The Jail,
however, does not have adequate policies addressing this issue.
Contrary to generally accepted professional standards, the
current policies permit inmates to be restrained for mental
health purposes with little to no input from mental health staff.
Additionally, in a departure from generally accepted professional
standards, restraints are initiated and terminated by custody
staff. Recently, the Jail changed its policy to require that
mental health staff perform an assessment of an inmate after they
are restrained. The purpose of this assessment, however, was not
clear to staff.
In addition to having inadequate policies, the Jail does not
enforce the policies that are in place. For instance, according
to Jail policy, custody staff are tasked with performing range of
motion exercises and observing restrained inmates. However, our
document review and interviews made clear that this requirement
is not being met. This is a serious problem that could have

- 32 

life-threatening consequences such as blood clot formation.28
Consistent with generally accepted professional standards,
healthcare staff should monitor restrained inmates and perform
range of motion exercises every two hours.
Finally, we are concerned that both of the Jail’s restraint
beds and the restraint chair are located in one area in the
A-1/A-2 dayroom. One primary purpose of restraints is to help
the restrained person regain acceptable control. This process is
not facilitated by having more than one person restrained in the
same room at the same time. We note that during our second tour,
the Jail changed its policy to require that only one person could
be restrained at one time in any designated area.
4.

Poor Medication Management

The Jail's formulary is adequate with respect to
psychotropic medications. It appears, however, that inmates
routinely do not receive the medications that have been
prescribed for them. One reason for this failure is that
medications may not go with the inmates when they are transferred
between housing units. Indeed, the minutes from the March 2007
mental heath meeting state that some inmates go days without
receiving their psychotropic medications after they are
transferred from one housing unit to another.
Another difficulty arises when prescriptions expire.
Although the Jail has a system for tracking prescriptions that
need to be renewed, the system is not computerized and relies on
medication orders that are written for long periods of time –
some as long as six months. The practice of writing orders of
lengthy duration may help avoid expiration issues, but it
presents significant risks to the inmates, especially because the
psychiatrist spends so little time on-site. Inmates receiving
psychotropic medications need to be monitored carefully and seen
regularly by the psychiatrist. Standing orders that are in place
for months at a time make it easier for mental health staff to
avoid these obligations.
The Jail has no formal policy to guide staff when inmates
refuse to take their medication. Staff told us that
non-adherence practices exist, but these appear to be ad hoc.

28

As previously indicated, we reviewed documentation
reflecting that nine inmates were restrained for four or more
hours, and we found that one inmate had been restrained for 23
hours without range of motion exercises being performed.

- 33 

Some inmates reported that they have been threatened with or
actually placed on the upper tier of A-1 for failing to take
their medication. Pursuant to generally accepted professional
standards, the Jail should develop a policy and procedure that
defines medication non-compliance and tells staff how to respond.
Among other things, there should be a reporting mechanism through
which the nursing staff who administer medications can inform the
psychiatrist of the refusal in a timely manner. It is worth
noting that inmates reported that custody personnel sometimes
dispense medications in the Annex. This is a violation of
generally accepted professional standards. All medications
should be dispensed by nursing staff. The psychiatrist in turn
must meet with the inmate in a timely fashion. The psychiatrist
can educate the inmate about the medication and can, if
necessary, make adjustments in the inmate’s medication regimen
Because, as discussed in Section III(C)(6), below, the Jail
has no quality assurance/quality improvement process in place, it
was difficult to accurately assess the extent of the Jail’s
medication management issues. Both staff and inmates, however,
made it consistently clear that problems exist in this area.
Because inmates who miss doses of psychotropic medication are at
risk of serious harm, the Jail should address this issue
immediately.
5.

Failure to Keep Complete and Accurate Medical Records

The Jail fails to keep complete and accurate mental health
records. As an initial matter, there is a significant backlog -–
between one and four weeks -– of mental health records filing.
In addition, a number of the records we reviewed had documents
that were not in chronological order. Many records also were
missing medication administration records. Others had
assessments and other documentation that were incomplete.
Because the psychiatrist and other mental health staff rely
on inmates' mental health records when prescribing medication,
changing medication dosages, and determining suicide risk, the
errors and omissions described above can jeopardize inmates'
mental health treatment and lead to serious consequences.
6.

Lack of a Quality Assurance/Quality Improvement Program

Quality assurance/quality improvement programs are critical
components of correctional mental health systems. Such programs
allow a facility to identify individual and systemic issues that
need to be addressed. Without a quality assurance program, a
facility might focus its efforts and resources on problems that

- 34 

are not critical or compelling. A quality assurance system is
especially necessary for the Jail, because its insufficient
mental health resources are stretched thin. A quality assurance
system would help the Jail distribute its limited resources in
the most efficient manner possible.
Despite the importance of a quality assurance system,
however, we found very few, if any, practices designed to address
quality assurance with respect to the delivery of mental health
services at the Jail. Indeed, we are not aware of a single
quality assurance study that has been completed. Indeed, during
a six-month period in 2005, three inmates committed suicide. In
response, the Jail hired a suicide prevention expert to review
its system management of suicidal inmates. Among other things,
the expert recommended that the Jail conduct mortality reviews.
Mortality reviews are a form of quality assurance. Their
purpose is to determine whether an inmate who dies in custody
(under any circumstances) exhibited symptoms that could have led
to earlier diagnosis and intervention. Citing attorney-client
privilege, the Jail has repeatedly refused to give our expert
consultants access to the facility’s mortality reviews.
Consequently, we are unable to determine whether the Jail is
conducting a meaningful analysis of its in-custody deaths and
detecting patterns of operational or security problems that place
inmates at risk of harm. Because we have not seen the mortality
reviews, and in light of the Jail’s woefully deficient quality
assurance, we must infer serious concerns regarding the adequacy
of its process.
We note that the Jail has developed a mental health quality
improvement process. As of the date of our last tour, however,
this process had not been implemented. In order to rectify the
mental health care deficiencies described above, the Jail must
develop and implement a quality assurance/quality improvement
program. Without such a program, the Jail will have difficulty
identifying areas that need improvement, prioritizing its efforts
and developing appropriate remedies.
III.

RECOMMENDED REMEDIAL MEASURES

To remedy the deficiencies discussed above and protect the
constitutional rights of the pre-trial detainees and sentenced
inmates at the Jail, the Worcester County Sheriff’s Office should
promptly implement the minimum remedial measures set forth below:

- 35 

A.	

Protection from Harm
1.	

Cease the use of four, five, and six-point restraints
on inmates as punishment; revise and implement the use
of restraints policy to ensure that it meets generally
accepted practice; and ensure that medical and mental
health staff are involved in the decision to use
restraints on an inmate according to generally accepted
practice.

2.	

Cease the use of the Maximum B and C isolation cells
for restraining inmates.

3.	

Ensure that all staff, and particularly the SOG, are
regularly trained regarding the facility's use of force
policy.

4.	

Ensure that all staff, and particularly the SOG, are
regularly trained regarding the restraints policy and
policy on decontamination after the use of chemical
agents.

5.	

Develop and implement policies and procedures requiring
all staff involved in a use of force to write a timely
report regarding the incident.

6.	

Develop and implement policies and procedures, and
provide training to ensure prompt supervisory and/or
management review and investigation for all uses of
force (there will be variances regarding the level of
investigation required based upon the severity of the
force), to determine whether force was appropriately
used, whether remedial training is necessary, or
whether facility policies should be revisited.

7.	

Develop and implement an incident and use of force
tracking system that ensures integrity, reliably
captures all relevant information, and is efficient.

8.	

Develop and implement policies and procedures regarding
investigations, including but not limited to, time
frame for conducting investigations, file management,
documenting medical and other physical evidence,
tracking processes, protocols for initiation, training
requirements, interview processes for staff and
inmates, allegations of staff misconduct, and final
disposition procedures.

- 36 

9.	

Develop and implement policies and procedures to ensure
that the Assistant Deputy of Special Services does not
oversee both tactical operations and inmate grievances.

10.	 Ensure that staffing levels are appropriate to
adequately supervise inmates.
11.	 Develop and implement policies and procedures for an
objective classification system that separates inmates
in housing units by classification levels.
12.	 Revise and implement policies and procedures to ensure
inmates have access to an adequate grievance process.
B.	

Environmental Health and Safety
1.	

Develop and implement an emergency key operation, by
sight and touch, that is readily available and includes
identical back-up sets of emergency keys.

2.	

Develop and implement a regular program of testing and
inspecting all cell doors and emergency doors as soon
as possible.

3.	

Ensure inmates are provided access to adequate and
sanitary showering facilities.

4.	

Adjust water temperatures in all housing areas to
appropriate levels. Monitor and adjust air
temperatures to ensure that housing area temperatures
are appropriate.

5.	

Ensure inmates receive adequate clothing and linen
changes at all times to minimize the risk of the
development of infectious diseases.

6.	

Develop and implement policies and procedures and
provide training to all kitchen staff in the areas of
food safety, proper food handling, proper sanitation,
and proper hygiene practices to reduce the risk of food
contamination and food-borne illness.

7.	

Develop and implement policies, procedures, and
practices to ensure that physical plant deficiencies in
the kitchen, including exposed electrical wiring, are
immediately rectified and repaired.

- 37 

8.	

Ensure that food preparation and storage areas, and vehicles
and containers used to transport food are properly cleaned
and sanitized.

C.	

Mental Health Care
1.	

Provide sufficient on-site psychiatrist coverage to
ensure that inmates with serious mental illness receive
care that is timely and consistent with generally
accepted professional standards.

2.	

Ensure that there are sufficient corrections staff to
escort inmates to settings that allow them to meet with
mental health staff in an appropriate, confidential
environment.

3.	

Consistent with generally accepted professional
standards, provide (or continue to provide) the
following types of mental health treatment:

4.	

a.	

Crisis intervention, including access to beds in a
healthcare setting for short-term treatment
(usually less than ten days);

b.	

An inpatient level of psychiatric care that is
available to all inmates who need it;

c.	

Outpatient treatment, including regular,
consistent therapy and counseling, to general
population inmates who are on the mental health
caseload.

Consistent with generally accepted professional
standards, provide discharge/transfer planning,
including services for inmates in need of further
treatment at the time of transfer to another
institution or discharge to the community. These
services should include the following:
a.	

Arranging an appointment with mental health
agencies for all inmates with serious mental
illness;

b.	

Providing referrals for inmates with a variety of
mental health problems;

- 38
c.	

5.	

Arranging with hometown pharmacies to have
inmates’ prescriptions for necessary mental health
medications renewed.

Provide appropriate housing and treatment for inmates
who need to be on suicide precautions. Consistent with
generally accepted professional standards, this housing
and treatment should include:
a.	

Timely and complete assessment of an inmate’s
suicide risk, that is shared between departments
and includes information about suicide threats;

b.	

Consideration of whether an inmate was identified
and housed as a suicide risk during a previous
confinement at the Jail;

c.	

Document the rationale for placing an inmate on
suicide precautions;

d.	

Provide inmates on suicide precautions with daily
visits from mental health staff;

e.	

Sufficient out-of-cell time;

f.	

Ensure that inmates on suicide precautions receive
proper supervision; and

g.	

Continue to ensure the availability of cut-down
tools that is consistent with generally accepted
professional standards.

6.	

Follow generally accepted standards when using
restraints, and ensure that staff, at a minimum,
perform range of motion exercise on all restrained
inmates on a schedule that is consistent with generally
accepted professional standards; and continue to
implement the policy requiring that no more than one
inmate be restrained in the same area at the same time.

7.	

Follow generally accepted standards in the area of
medication management, and ensure that:
a.	

Inmates receive their medication within a
reasonable time when they are moved within the
facility;

- 39
b.	

Institute an adequate medication management system
that tracks prescriptions that need to be renewed;

c.	

Psychiatrists write medication orders in
accordance with generally accepted professional
standards;

d.	

Inmates who receive psychotropic medications are
monitored carefully and seen regularly by the
psychiatrist;

e.	

Policies and procedures governing medication
refusals are developed and implemented; and

f.	

All medications are dispensed by nursing staff.

8.	

Ensure that all medical records are up-to-date,
complete, and accurate.

9.	

Develop and implement a quality assurance/quality
improvement program to assist the Jail in identifying
areas that need improvement, prioritizing its efforts
at reform, and developing appropriate remedies.
IV.

CONCLUSION

Please note that this letter is a public document and will
be posted on the Civil Rights Division's website ten calendar
days after we send it to you. The letter will be immediately
available, however, to any individual or entity upon request.
We hope to continue working with the Commonwealth and the
Worcester County Sheriff’s Office in an amicable and cooperative
fashion to resolve our outstanding concerns regarding the Jail.
Assuming there is a spirit of cooperation from the Commonwealth
and the Sheriff’s Office, we are willing to send our consultants'
written evaluations -- which are not public documents -- under
separate cover. Although the consultants' reports do not
necessarily reflect the official conclusions of the Department of
Justice, the observations, analysis, and recommendations
contained therein provide further elaboration of the issues
discussed in this letter and offer practical technical assistance
in addressing them.
We are obligated by statute to advise you that, in the
unexpected event that we are unable to reach a resolution
regarding our concerns, the Attorney General may initiate a
lawsuit pursuant to CRIPA to correct deficiencies of the kind

- 40 

identified in this letter 49 days after appropriate officials
have been notified of them. 42 U.S.C. § 1997b(a)(1). We would
prefer, however, to resolve this matter by working cooperatively
with the Commonwealth and the Sheriff’s Office and are confident
that we will be able to do so. The lawyers assigned to this
investigation will be contacting the Sheriff’s general counsel to
discuss this matter in further detail. If you have any questions
regarding this letter, please call Shanetta Y. Cutlar, Chief of
the Civil Rights Division's Special Litigation Section, at (202)
514-0195.
Sincerely,

/s/ Grace Chung Becker
Grace Chung Becker
Acting Assistant Attorney General
cc:	 The Honorable Tom Reilly
Attorney General
Commonwealth of Massachusetts
Sheriff Guy Glodis
Administrator
Worcester County Jail and House of Correction
The Honorable Michael J. Sullivan 

United States Attorney

District of Massachusetts