An unbiased look at the Justice Department's investigation of a County Jail

C. Protection from Harm
We evaluated the Jail’s detainee supervision procedures, security classification process, housing practices, grievance procedures, disciplinary process, and training program. We found that many Jail policies and practices are consistent with minimum correctional standards. Yet, at the same time, we also found some significant and often glaring operational deficiencies. For security matters in particular,
the Jail lacks:
(1) a minimally adequate system for deterring excessive use of force, and
(2) an adequate plan for managing a large and sometimes violent detainee population.

1. Excessive Use of Force
We have serious concerns about the use of force at the Jail.
The Jail’s use of force policy is flawed in several regards.
First, neither written policy nor training provide staff with clear guidance on prohibited use of force practices. For example, Harris County Jail does not train staff that hogtying and choke holds are dangerous, prohibited practices. Indeed, we found a significant number of incidents where staff used inappropriate force techniques, often without subsequent documented investigation or correction by supervisors.
Second, use of force policies fail to distinguish between planned use of force (e.g., for extracting an detainee from a cell) and unplanned use of force (e.g., when responding to a fight). In many planned use of force situations, staff should be consulting with supervisors, and possibly medical staff, before using force.
Third, Jail policies do not provide for routine videotaping of use of force. Fourth, the Jail does not have an appropriate administrative process for reviewing use of force. Jail policy does not clearly require the individual using force to file a use of force report; nor does Jail policy provide for routine, systematic collection of witness statements. When supervisors review use of force incidents, they do not have ready access to important evidence. Instead, they appear to rely excessively on officer statements to determine what happened during an incident.
While Jail staff were helpful and willing to assemble use of force documents requested by our review team, we found it troubling that the Jail did not collect such documents as a matter of course.
In other words, use of force occurs at the Jail without adequate review, and Jail data regarding use of force levels cannot be considered reliable.
We believe that the incidents noted during our review may only reflect part of what is really occurring within the facility.
As a result of systemic deficiencies including a lack of appropriate policies and training, the Jail exposes detainees to harm or risk of harm from excessive use of force.
In a particularly troubling January 2008 case, staff applied a choke hold to a detainee, who subsequently died.
The autopsy report identified the manner of death as homicide. Our review of the Jail’s records suggests that such improper force technique is being used with troubling frequency.
For instance, our consultant found a pattern of such incidents when reviewing use of force reports dated from January through June 2008. ...
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These and other similar incidents suggest that staff use hazardous restraint and force techniques without appropriate guidance or sanction.
In some cases, medical records confirm that detainees may have suffered notable injuries, such as lacerations to the scalp or eye. Notably, when force was investigated by supervisors, it appears that the supervisors often determined that staff’s use of force was appropriate without obtaining independent medical review or multiple witness statements.
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A. Medical Care
The Jail has functional systems in place to provide medical care and treatment to a large population of detainees. These systems include an initial screening process, a more comprehensive health assessment for longer-term detainees, a sick call process, a modern clinic, qualified medical staff, a professional management structure, and mechanisms to obtain outside specialty care. Despite the general quality of such systems, the Jail fails to provide consistent and adequate care for detainees with serious chronic medical conditions. We found specific deficiencies in the Jail’s provision of chronic care and follow-up treatment. These deficiencies, in themselves and when combined with the problems in medical record-keeping and quality assurance discussed below, are serious enough to place detainees at an unacceptable risk of death or injury.
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Examples of the Jail’s failure to provide appropriate follow-up treatment and continuity of care include the following examples from 2007-2008:

• DD was a 74-year-old detainee with a history of open heart surgery. When DD visited the clinic presenting complaints of incontinence, medical staff failed to give DD a physical exam or take his vital signs. Staff sent DD back to DD’s unit. The following day, DD returned to the clinic with incontinence and elevated blood pressure.
Clinic staff sent DD to the hospital, where he died shortly thereafter.

• EE had a documented history of diabetes that received inadequate medical attention. When EE complained of symptoms, staff merely prescribed pain medication. Initially, EE complained of leg pain and knee swelling. In response, staff provided EE with pain medication. EE complained again 5 days later about her symptoms. The medical notes were essentially illegible, but apparently staff again just provided pain medication. The detainee complained of her symptoms once more that same day.
While waiting to be seen in the clinic, EE collapsed and died shortly afterwards.
The documentation suggests that after EE collapsed, staff failed to provide an appropriate emergency response. For instance, the records show that EE had a low blood sugar level at the time of her collapse, but staff failed to respond to the symptoms. Medical records also suggest that the staff did not try to use an automatic emergency defibrillator during the incident.

• FF had a history of cirrhosis. Over several weeks, FF’s liver condition worsened, but staff repeatedly failed to respond in a manner consistent with generally accepted correctional medical standards.
FF initially presented to the clinic with a complaint of swelling to his legs. Jail staff prescribed blood pressure medication, even though FF’s blood pressure was normal. FF complained of chest pain and other conditions over the next several weeks. Jail staff repeatedly sent FF to the hospital but repeatedly failed to change his medications, treatment plan, or conduct other appropriate follow-up. For instance, on one of these occasions, a deputy reported that FF was having trouble walking. The staff sent FF to the hospital, and an undated medical note indicates that FF needed fluid removed from his stomach. Again, however, staff did not alter FF’s treatment plan; nor was there any apparent documentation of vital signs.
Approximately one month after his initial complaint, FF died during his last hospital stay.
One troubling additional note about this case is that during the period in question, FF apparently spent much of his time at the Jail in a housing unit instead of the infirmary. Given the seriousness of FF’s medical condition, he needed to be in an infirmary in order to receive the level of care required by generally accepted correctional medical standards. The discontinuity of care and a lack of follow-up by staff are of serious concern in this case​

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Housing practices for detainees with mental illness are problematic. For example, even though the ratio of male to female mental health patients is about 2:1, the number of male single cells to female single cells appears to be 32:1. Thus, female detainees with mental illness are much more likely to be left in inappropriate housing conditions while awaiting care. As with medical care generally, the clinic in the 1200 Baker building serves as the primary mental health resource. As noted previously, the 1200 Baker clinic is overwhelmed.

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1. Inadequate Access to Mental Health Treatment

The Jail’s written policies include a process for screening and prioritizing detainees with serious mental illness, but in practice, the Jail does not adequately treat detainees based on the seriousness of their condition.
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The Jail does not provide access to mental health care for many inmates with serious needs.
Examples from 2007-2008 include:
(six examples given)

• JJ served time in the Jail on multiple occasions.
Staff medicated JJ without following generally accepted correctional medication standards. Without an initial screening, the Jail staff involuntarily medicated JJ and housed him in the mental health department’s acute treatment cellblock.
Staff then repeatedly treated JJ with both anti-psychotic and mood-stabilizing medications without adequate laboratory studies or proper monitoring, placing the detainee at risk of sudden death.​

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2. Inadequate Treatment and Psychotropic Medication Practices
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In our document review, some of the treatment orders appeared to depart significantly from generally accepted professional mental health standards. Some of these orders suggest that staff may be utilizing medications in a clinically inappropriate or unsafe manner. Examples of improper chemical restraints and unsafe medication practices during the period from 2006-2008 include the following:
(five examples given)

• MM was in an acute psychotic state for nearly two weeks before he died.
At intake, staff prescribed medications but they were never dispensed.
As MM became increasingly uncooperative, staff injected MM with an intramuscular drug. Medical records suggest significant problems with basic medication documentation and staff approaches to medication non* compliance.
Soon after MM was injected, MM’s breathing grew shallow, and he became unresponsive.
MM died shortly afterwards.

• NN spent the better part of a year in a State Hospital.
NN was found not competent and not restorable. For some reason, he was sent back to the Jail. Despite his competency status, Jail staff nevertheless placed the detainee in general housing and allowed him to keep various medications on his person. NN was not a good candidate for self-medication. NN appeared to suffer a seizure and he was sent to the clinic.
The clinic staff suspected the detainee was “sleepy” due to his psychotropic medications.
They released the detainee from the clinic, and he died shortly afterwards.​

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While crowded conditions may not, in and of themselves, violate the Constitution, we are compelled to raise our concerns here because
(1) the Jail’s crowded conditions currently exacerbate many of the constitutional deficiencies identified in this letter; and
(2) the Jail needs a more comprehensive, systemic approach to dealing with a large and growing Jail population.
Jail crowding affects multiple Jail systems. For instance, it impedes detainee access to medical care, indirectly affects detainee hygiene, and reduces the staff’s ability to supervise detainees in a safe manner. How the Jail handles inmate supervision and violence illustrates some of the complexities associated with overcrowding.
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D. Sanitation and Life Safety
The Jail buildings are generally modern and adequately maintained. Staff receive training on a variety of emergency procedures. The Jail lacks, however, certain necessary structured maintenance, sanitation, and fire safety programs.
Given stresses upon Jail infrastructure crowding, the lack of such programs raises concerns about sanitation and fire safety in the Jail.
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1. Sanitation and Hygiene
While the Jail generally appeared to be clean and many systems seemed to be well-maintained, certain deficiencies in the Jail’s hygiene practices and maintenance programs expose detainees to an unacceptable risk of injury, disease, or other harm.
Jail crowding contributes to these deficiencies.
First, the Jail does not have systems in place to ensure adequate detainee personal hygiene. For example, the facility’s laundry facilities and procedures are currently inadequate given the size of the Jail population. As a general matter, the Jail does not even have a “par level” of clothing or linen available for detainees. In other words, the Jail does not maintain enough accessible clothing or linen on-hand for the number of detainees housed at the facility.
Moreover, the laundry operation does not
meet minimum sanitary standards. The laundry operation does not properly wash and sanitize clothing. The laundry has only a few machines, and a number of those were inoperative during our tour.
The staff also use a variety of inconsistent, and often inadequate, schedules and procedures for handling and cleaning laundry. As a result, we found a significant amount of unsanitary bedding, clothing, and mattresses throughout the facility. Such unsanitary conditions can expose detainees to a serious risk from infectious disease.
Another example of poor hygiene practices involves detainee grooming and shaving equipment. The Jail’s barbers practice their trade in an unhygienic manner. Clipper blades, guards, and supply boxes appeared to be dirty and had not been cleaned between uses. Detainee barbers did not keep their equipment in disinfectant solutions.
As discussed previously in this letter’s section on protection from harm, razor blades are not well controlled in the facility.
The availability and use of dirty, shared razors and blades is a serious risk, both in terms of disease transmission and as a security matter.
Finally, the Jail’s plumbing and mechanical systems require improved maintenance in order to ensure hygienic conditions in certain housing units. While most of the Jail is properly maintained, the Jail’s population size and gaps in the Jail’s maintenance program result in unsanitary conditions in the intake and mental health units, where the Jail utilizes archaic flush-able floor drains, essentially holes in the floor, instead of toilets.
Using such grossly inadequate facilities for long periods of time is itself problematic because they are unhygienic.
Moreover, when we tested some of the drains, they back-flushed into the cells.
Elsewhere throughout the Jail, we found drains clogged with significant accumulations of debris.
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