December 29, 2006

The Honorable Ruth Ann Minner
Governor of Delaware
Tatnall Building
William Penn Street, 2nd Fl.
Dover, DE 19901
RE:

Investigation of Delaware Correctional Center, Symrna,
Delaware; Howard R. Young Correctional Institution,
Wilmington, Delaware; Sussex Correctional Institution,
Georgetown, Delaware; John L. Webb Correctional
Facility, Wilmington, Delaware; and Delores J. Baylor
Women's Correctional Institution, New Castle, Delaware

Dear Governor Minner:
I am writing to report the findings of the Civil Rights
Division's investigation of conditions and practices at the
following five Delaware Department of Correction ("DOC")
facilities: the Delaware Correctional Center ("DCC"), the
Howard R. Young Correctional Institution ("HRYCI"), the Sussex
Correctional Institution ("SCI"), the John L. Webb Correctional
Facility ("Webb"), and the Delores J. Baylor Women's Correctional
Institution ("BWCI").
On March 7, 2006, we notified you of our intent to conduct
an investigation of these facilities pursuant to the Civil Rights
of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997,
which gives the Department of Justice authority to seek remedies
for any pattern and practice of conduct that violates the
constitutional or federal rights of incarcerated persons. We
informed you that our investigation would focus on medical and
mental health care.
We note that the State has cooperated thoroughly with our
investigation and, under the leadership of DOC Commissioner
Stanley W. Taylor, Jr., has unequivocally indicated its clear
desire to improve medical and mental health care services at the
facilities. From the outset of our investigation, the State has
been proactive in evaluating the conditions at the facilities.

- 2 Indeed, the State retained its own expert consultants, Dr. Ronald
Shansky and Dr. Roberta Stellman, to evaluate medical and mental
health care services, respectively, at DCC, HRYCI, SCI, Webb, and
BWCI in July and September 2006. Following these evaluations,
the State shared the results of its internal evaluations with us.
The State's experts identified systemic deficiencies in
medical and mental health care at four of the five facilities:
DCC, HRYCI, SCI, and BWCI (hereinafter, "the facilities"). These
findings were presented to the Department of Justice in oral and
written presentations by Fried, Frank, Harris, Shriver &
Jacobson, outside counsel for the State. To facilitate our
investigation, the State agreed to stipulate to the accuracy of
these factual findings. Given the State's complete cooperation
with our investigation, the unsolicited disclosure of its
comprehensive internal audit of medical and mental health care
services, and the State's stipulation, we elected to limit our
expert tours to a representative subset of the facilities.
Department of Justice staff toured the five facilities on
June 22, 2006, July 17-19, 2006 and August 14-16, 2006. We
conducted additional tours of HRYCI, Webb and BWCI, accompanied
by expert consultants in the fields of medicine, mental health
care, and suicide prevention on October 4-6, 2006, October 23-25,
2006, and November 15-17, 2006. During these tours, we reviewed
a wide variety of State and facility documents, including
policies, procedures, and medical and mental health records
relating to the care and treatment of inmates. We interviewed
prison administrators, professionals, staff and inmates at each
facility. In keeping with our pledge of transparency and to
provide technical assistance where appropriate regarding our
investigatory findings, we conveyed our preliminary findings to
certain State and facility administrators and staff during verbal
exit presentations at the close of each of our on-site visits.
As detailed below, our investigative findings mirrored those of
the State's experts.
We commend the administrators and staff of the five
facilities we toured for their helpful and professional conduct
throughout the course of the investigation. In particular,
facility personnel cooperated fully and expeditiously with our
document requests.
We are confident that our work with the State will continue
in the same cooperative manner we have enjoyed throughout our
investigation. However, consistent with our statutory obligation
under CRIPA, we set forth below the findings of our
investigation, the facts supporting them, including those facts

- 3 stipulated to by the State, and the minimum remedial steps that
are necessary to address the deficiencies we have identified. As
described below, we conclude that inmates confined at the
facilities suffer harm or are placed at the risk of harm from
constitutional deficiencies in certain aspects of the medical and
mental health care services, including suicide prevention.
Notwithstanding the foregoing, we are pleased to report that we
find no constitutional deficiencies at Webb.
I.

BACKGROUND

Delaware is one of six states that house both pre-trial
detainees and sentenced prisoners in a single unified system,
although detainees and prisoners are not housed together.
Medical and mental health care services at the facilities are
provided through a contract with a private vendor. DCC is
located in Smyrna, Delaware, and houses approximately 2,500 male
inmates, including both pre-trial detainees and sentenced
prisoners. DCC also contains the Security Housing Unit ("SHU"),
which houses inmates with disciplinary problems or who otherwise
require the maximum level of security. DCC also contains the
State's death row. HRYCI is located in Wilmington, Delaware.
The facility houses approximately 1800 males, both pre-trial
detainees and sentenced inmates. SCI is located in Georgetown,
Delaware, and houses approximately 1200 male inmates, including a
100-bed boot camp. BWCI is located in New Castle, Delaware, and
houses approximately 400 female pre-trial detainees and sentenced
inmates at all security levels. Webb is located in Wilmington,
Delaware, and houses approximately 80 minimum security male
inmates.
II.
A.

FINDINGS

MEDICAL CARE

Under CRIPA, the Department of Justice has authority to
investigate violations of the constitutional rights of inmates in
prisons, and pre-trial detainees in jails. The rights of
sentenced inmates fall under the Eighth Amendment, which
prohibits the imposition of cruel and unusual punishment. Under
the Eighth Amendment, jails must provide humane conditions of
confinement, which include adequate medical care. Farmer v.
Brennan, 511 U.S. 825, 832 (1994). Failure to provide adequate
care to address the serious medical needs of inmates can
constitute deliberate indifference, a violation of the Eighth
Amendment prohibition against cruel and unusual punishment.
Estelle v. Gamble, 429 U.S. 27 (1976). The responsibility to
provide adequate medical care includes mental health care.

- 4 Tillery v. Owens, 907 F.2d 418 (3d Cir. 1990). Failure to
protect a suicidal prisoner from self-harm can also amount to a
constitutional violation. Inmates of Allegheny County v. Pierce,
612 F.2d 754, 763 (3d Cir. 1979); Colburn v. Upper Darby
Township, 838 F.2d 663 (3d Cir. 1988). The responsibility to
protect inmates from harm includes the possibility of future harm
as well as present harm. Helling v. McKinney, 509 U.S. 25, 33
(1993); Tillery, 907 F.2d at 426.
With regard to pre-trial detainees, the Fourteenth Amendment
prohibits imposing conditions or practices on detainees not
reasonably related to the legitimate governmental objectives of
safety, order, and security. Bell v. Wolfish, 441 U.S. 420
(1979). The Third Circuit has opined that the protections
afforded to pre-trial detainees are at least as great as those
afforded to sentenced prisoners. Hubbard v. Taylor, 399 F.3d
150, 166-167 (3d Cir. 2005) (pre-trial detainees claims of
constitutional violations to be analyzed under Fourteenth
Amendment).
Our investigation revealed that the medical care provided at
the facilities falls below the standard of care constitutionally
required in the following areas, all of which were also
identified by the State as deficient: intake; medication
administration and management; nursing sick call; provider sick
call; scheduling, tracking, and follow-up on outside consults;
monitoring and treatment of communicable diseases; monitoring and
treatment of chronic diseases; medical records documentation;
scheduling; infirmary care; continuity of care following
hospitalizations; grievances; and patient confidentiality. In
addition, we found that care for patients with acute medical
urgencies was also constitutionally inadequate.
1.

Sick Call

The State's expert found that sick call is not being
regularly conducted at the facilities and that sick call
"no-shows" (inmates who do not appear for their scheduled medical
appointments) are not tracked. Our investigation confirmed that
there are inadequate sick call systems in place which directly
interferes with inmates' access to care for their serious medical
needs. Specifically, the systems are deficient in scheduling
appointments, and tracking no-shows. For example, the inadequate
scheduling system at HRYCI resulted in only seven of the
representative sample of 14 patients scheduled for sick call on
one day being seen. In addition, we found that inmates who
missed sick call were not tracked and, as a consequence, often
not rescheduled. The sick call process for inmates' requiring

- 5 mental health care suffers from similar inadequacies in
scheduling and follow-up. During our tours of BWCI and HRYCI, we
found that the sick call process is not functioning properly and
that there were significant delays for inmates who had requested
to see the psychiatrist. Overall, these conditions place inmates
at serious risk of harm.
2.

Acute Care

Our investigation revealed that patients with lifethreatening conditions are not receiving timely care. We
reviewed the records of ten patients sent to the local emergency
room; six of these patients were admitted. One patient, known to
be infected with HIV, was admitted from HRYCI with pneumocystis
carinii pneumonia (“PCP”), a potentially fatal infection in
people with AIDS. We determined that this inmate's care had been
mismanaged at HRYCI for one month before the inmate was finally
sent to the hospital. In addition, this inmate was never tested
for active tuberculosis, a likely diagnosis for patients with HIV
and pneumonia. The failure to properly diagnose and treat this
inmate could have put other inmates and staff at risk of
contracting tuberculosis.
3.

Chronic Care

The State's expert found that there are consistent backlogs
with respect to the treatment of chronic care inmates as
evidenced by infrequent scheduled appointments. When
appointments are scheduled, they are subject to cancellation
without explanation or follow-up. The State's expert also found
that the chronic care rosters are not adequately maintained.
Our investigation confirmed that there is no functioning
chronic disease registry at HRYCI. The absence of a chronic
disease registry means that patients with chronic diseases, such
as diabetes, hypertension, asthma, HIV, and Hepatitis C are not
being followed and treated according to generally accepted
medical standards for chronic care. As a result, inmates with
chronic disease are at risk for deterioration in function,
including blindness, kidney disease, heart disease, liver
failure, and death.
We found that care was especially poor for inmates with
diabetes, asthma, and HIV. Of nine inmates with diabetes whose
charts we reviewed, only four had received tests deemed necessary
pursuant to generally accepted professional standards for care of
persons with these serious, chronic diseases. In addition, only
two inmates had been immunized against pneumococcus, a bacterium

- 6 that is the leading cause of bacterial pneumonia. The failure to
immunize chronically ill inmates against pneumococcus places them
at serious risk of harm, including death from pneumococcal
pneumonia, and constitutes a substantial departure from generally
accepted standards of care. Another diabetic inmate whose chart
we reviewed went without insulin for three days, despite severely
elevated blood sugar levels that were known to staff, placing him
at risk of death.
Similarly, for inmates with asthma, the chronic care
practices also fall below a minimally acceptable standard of
care. For example, of nine asthmatic inmates who should have
been seen in the chronic care clinic over a three month period,
only three were seen. Only two had documented measurement of
peak expiratory flow, which is a departure from the generally
accepted standard of care for asthmatic patients.
Finally, with respect to HIV-infected inmates, we found that
chronic care practices also fall below a minimally acceptable
standard of care. Only two of five patients whose records our
medical consultant reviewed had documented laboratory
measurements of their CD4 cells1 and their viral load, both of
which are necessary to gauge response to medication.
4.

Specialty Care

The State's expert found that outside consultations are
delayed by days or even weeks in non-emergency situations because
of bureaucratic obstacles within the private vendor's system for
obtaining authorization. The State's expert also found that
shortages of security staff available to transport inmates to
outside medical appointments contributes to the inadequacy of
care. In addition, the State's expert determined that, even when
outside consults are scheduled, post-consult follow-up does not
consistently occur.
Similarly, our investigation found that access to specialty
care is untimely, and that tracking of outside care is deficient,
creating an unacceptable barrier to adequate medical care ordered
by physicians. For example, of 10 patients who were referred by
facility doctors for outside care, three received no care at all.
All three patients had serious medical issues: two had upper
gastrointestinal symptoms, including one patient who had

1

CD4 cells are white blood cells that identify, attack
and destroy infections. A normal CD4 cell count measures the
strength of a person’s immune system.

- 7 documented possibly cancerous polyps with a biopsy ordered and
performed, but no results in his file. A third patient had no
documented follow-up with an orthopedist following serious trauma
to his finger.
And, in the most extreme example, specialty care may have
been denied altogether: in March, 2002, an SCI inmate died from
a malignant brain tumor that had grown so large that it distorted
his facial features, and was so noticeable that other inmates
referred to him as “the brother with two heads.” Fourteen months
before he died, SCI medical staff allegedly misdiagnosed the
cancerous growth as a cyst or an ingrown hair, and allegedly made
no specialty care referral nor provided any specialty care to the
inmate before he died.
5.

Skin Infections

It is well-documented that, across the country, the
incidence of skin infections among inmates is rising. These skin
infections can include methicillin-resistant staphylococcus
aureus ("MRSA"), a potentially dangerous drug-resistant bacteria
that can cause serious systemic illness, permanent disfigurement,
and death. MRSA transmission can be prevented by environmental
controls, scrupulous laundry practices, early identification,
effective treatment, wound care, and follow-up.
The State's expert found that, until recently, the medical
staff were generally unfamiliar with the diagnosis and treatment
of MRSA, and that the medical staff did not culture potential
MRSA infections or educate inmates on proper precautions against
the spread of MRSA until Fall 2005.
Our investigation revealed that proper diagnosis of and care
for skin infections falls below the minimally acceptable level of
care. We also found that medical staff routinely failed to
culture skin infections; in addition, we found that wound care
and follow-up were inadequate. For example, we reviewed the
charts of eight inmates with skin infections at HRYCI; only two
of these inmates received adequate care. One had a deep skin
infection of the neck, but had no follow-up to see if his
infection was spreading. Another inmate had inappropriate
treatment for an infection that was accompanied by fever and
chills, indicative of a systemic infection that could have led to
pneumonia, brain infection, and death. Both of these patients
were treated with the antibiotics that are ineffective in
treating MRSA. With respect to wound care, we found another
inmate at BWCI who was inappropriately treated with a topical
cream for an infection on her face, but who did not see the

- 8 doctor for six days, by which time she had developed cellulitis,
a deep skin infection that ultimately required hospitalization.
Our investigative findings and the State’s stipulation are also
consistent with reports that DCC staff failed to properly
diagnose and treat an MRSA infection in an inmate for four months
in 2005. This failure to recognize and treat MRSA allegedly
caused the inmate to be hospitalized for five weeks, lose the
skin on his scrotum, and undergo painful skin grafts, resulting
in permanent deformity.
Our investigation confirmed that the existence of the above
inadequacies place inmates and staff at risk of acquiring the
infection and passing it to others in the community beyond the
prison walls. We also found that identification and treatment of
skin infections at the facilities is inadequate, including
failure to culture and treat wounds. We found that facility
staff does not keep adequate logs of skin infections, which
prevents staff from being able to analyze data and identify
potential sources of transmission. Notably, in many cases
physicians were prescribing the antibiotic Keflex, which not only
is rarely effective for skin infections, including MRSA, but
actually leads to prolonged infection and increased opportunities
for the infection to spread. Finally, we found that laundry
practices at the Facilities are inadequate to prevent the spread
of skin infections, including MRSA.
6.

Medication Administration and Management

The State's expert found that prescribed medications are
routinely discontinued or delayed and that the current vendor has
no systems in place for ensuring that medications do not run out,
for notifying inmates when their medications have arrived, or for
verifying that the vendor is providing inmates with the correct
medications.
Our investigation confirmed these deficiencies which put
inmates at risk of harm, particularly those with chronic
conditions such as HIV. We observed significant lapses in
medication, due either to lack of availability of medications or
the failure to administer medications consistently. For example,
one inmate had missed 20 consecutive days of his anti-viral
medication used to treat the HIV, a potentially life-threatening
situation; another inmate with HIV had a one month lag in
receiving his HIV medications.
We also found that serial refusals to take medications were
not monitored. Numerous inmates missed three or more doses of
medications on three consecutive days, without any evidence of

- 9 follow-up by the prescribing practitioner, or evidence that the
inmate was sought out or counseled.
The State's expert found that numerous systemic problems
with medication administration and management exist at the
facilities, including: failure to distribute medications at the
proper time intervals, leading to over- or under-prescribing
medications; failure to provide necessary food at night to
diabetic inmates; failure to properly monitor whether inmates are
actually swallowing their medications; and pre-pouring
medications.
Our investigation found similar deficiencies. Our review of
medication administration records at HRYCI revealed that
approximately ten percent of the entries were left blank,
indicating that inmates had not received their medication, or
that the medication administration was undocumented. We also
found that the State routinely prescribes Keflex, an antibiotic,
for skin infections, despite the fact that Keflex is rarely
effective when used to treat skin infections. We also learned
that the State plans to administer each dose of medication from
stock bottles, instead of filling prescriptions for each patient,
a practice which we believe will lead to poor inventory control,
diversion, error, and lack of accountability.
B.

MENTAL HEALTH CARE

The responsibility to provide adequate medical care includes
mental health care. Inmates of Allegheny County Jail v. Pierce,
612 F.2d 754, 763 (3d Cir. 1979); Tillery v. Owens, 907 F.2d 418
(3d Cir. 1990). The State is constitutionally required to
provide adequate mental health care to inmates with serious
mental or emotional disturbances. The failure to provide
necessary psychological or psychiatric treatment to such
individuals will result in the "infliction of pain and suffering
just as real as would result from the failure to treat serious
physical ailments." Inmates of Allegheny County Jail, 612 F.2d
at 763. The key to determining whether the State has provided
constitutionally adequate mental health care depends on whether
inmates have reasonable access to "medical personnel qualified to
diagnose and treat such illnesses or disturbances." Id.
The State's mental health expert found substantial
deficiencies with the mental health care provided at the
facilities. The State's expert conducted a number of on-site
visits and determined that there is a "continuing need for
substantial remedial efforts, training and auditing of mental
health services provided by [the State's medical care provider]."

- 10 The State identified the following deficiencies: poor responses
to sick call requests, particularly in cases involving
potentially suicidal inmates; inadequate group and individualized
therapy; staffing inadequacies, lack of privacy for inmate mental
health counseling, insufficient discharge planning, inadequate
administration and management of psychotropic medications,
failure to properly develop treatment plans that are regularly
updated, failure to develop site-specific policies and procedures
for mental health care, failure to properly document
medical/mental health records, and failure to obtain consent
forms. Our investigation confirmed the serious systemic
deficiencies in psychiatric staffing, treatment and counseling,
medication administration and management, and intake and
screening identified by the State's mental health expert. We
conclude that these deficiencies violate inmates' constitutional
right to adequate care for serious mental illness.
1.

Psychiatric Staffing Deficiencies

The State's expert found that low psychiatric staffing at
the facilities have caused a backlog of inmates requiring
psychiatric care. Although the facilities do have psychiatrists
who are available to provide care on-site, their hours at the
various facilities are limited.
Our investigation confirmed that psychiatric staffing is
inadequate to provide for inmates' serious mental health needs.
For example, during our tour of HRYCI, the State informed us that
there are two part-time psychiatrists who provide care at HRYCI,
but our investigation revealed that their combined time on-site
totals less than twenty hours, and there is no on-site
psychiatric coverage provided for two days out of the week.
Psychiatric coverage at BWCI is even more limited. Our
investigation revealed that a psychiatrist is on site only four
hours per week, and the "on-call psychiatrist" generally provides
guidance only via telephone. Further, we understand that
included in the four hours is time that the psychiatrist spends
at the Violation of Probation Center attached to BWCI for two
hours every other week. Such limited psychiatric staffing is not
constitutionally adequate care because inmates do not have
reasonable access to psychiatrists. See Inmates of Allegheny
County Jail v. Pierce, 487 F. Supp. 638, 643 (W.D. Pa. 1980).
As a result of inadequate psychiatric staffing, we found
numerous instances in which the mental health clinical staff are
providing care that they are not licensed to provide (e.g.,
diagnosis of mental health disorders, treatment development
without proper psychiatric consultation, decisions regarding

- 11 suicide watch step-downs, etc.). We found that psychiatrists are
routinely unavailable for treatment team and staff meetings, and
often are not involved in crucial decision-making, and are not
adequately involved in monitoring and supervision of staff. In
addition, we found that the psychiatrist who provides most of the
care at HRYCI was not familiar with the procedures utilized for
making decisions about which medications to prescribe for
patients with psychotic disorders. Generally accepted standards
of care dictate that a psychiatrist be responsible for providing
mental health treatment to seriously mentally ill patients should
lead treatment teams, direct medication procedures, and be
meaningfully involved in treatment decisions.
2.

Treatment Planning and Counseling Deficiencies

The State's expert found that treatment plans for inmates
need to be developed more regularly so that psychologists do not
unnecessarily change diagnoses and so that patients are put on
the appropriate problem list. Treatment plan development is an
integral part of mental health care. One aspect of treatment
planning consists of psychiatric and clinical staff providing
consistent notations in medical records to ensure that important
information regarding an inmate's care is documented. The
State's expert, Dr. Stellman, concluded that there is a continued
need for remedial efforts and training in the area of medical
records documentation at DOC facilities. Dr. Stellman also found
that many medical records do not contain consent forms, and
contain improperly completed mental health forms.
Likewise, we found that the poor documentation impacts
treatment because it is virtually impossible for a qualified
mental health professional to review patient medical records and
determine how basic clinical decisions are being made (e.g., why
an inmate was admitted to the infirmary; why medications are
prescribed; why and how psychiatric close observation levels are
changed; what are the bases for diagnostic conclusions). During
our tour of BWCI, we reviewed the medical record of an inmate who
had recently attempted suicide and found the psychiatric notes
were deficient and difficult to interpret. Both the on-site and
"on-call" psychiatrists made adjustments to this inmate's
medication without any explanation. Also, despite the fact that
this inmate had been on suicide watch on three occasions within a
four-month period and was obviously in distress, there were
sparse psychiatric notes in her file.
Generally accepted standards of care dictate that discharge
treatment planning be provided for inmates who have serious
mental illness to ensure continuity of care. The State's expert

- 12 found that its inmate treatment plans fail to address how the
patient's care will continue once he or she is released from the
DOC facility.2
The State's expert also found deficiencies in the
individual and group counseling services provided at DOC
correctional facilities. There appears to be a limited ability
to provide individual counseling sessions to inmates because of a
lack of privacy. The State's expert found that when inmates are
housed in the infirmary, psychiatrists and mental health staff do
their interviews through the cell door and that, because cells
typically have at least one other occupant when these interviews
are being conducted, the encounters are not confidential. This
is a wholly inadequate practice evidencing a denial of reasonable
access to psychiatric diagnosis and care. See Inmates of
Allegheny County Jail, 612 F.2d at 763.
Group counseling services at the facilities fall below
accepted standards, as well. The State's expert found that there
was a need for remedial measures and training with respect to the
provision of group and individualized therapy.
Similarly, we found the counseling services to be
constitutionally inadequate. Because the facilities are
substantially understaffed with respect to psychiatrists,
physicians generally do not participate in the treatment team or
staff meetings. For example, during our tour of BWCI we found
that the master's level clinicians who run the group
psychotherapy program (e.g., depression group, anger management
group, and addiction group) in the Harbor House Unit do not
receive any oversight from a psychiatrist. Generally accepted
professional standards dictate that the psychiatrist be the
treatment team leader and be meaningfully involved in key
treatment decisions. However, clinicians are making important
treatment decisions that should be left to the professional
judgment of a psychiatrist, or at least made with the
consultation of a psychiatrist. Our review of the medical
records at BWCI and HRYCI revealed that clinicians are recording

2

NCCHC standards J-E-13 and P-E-13 require jurisdictions
to develop discharge planning for inmates with serious mental
illness (e.g., medication for a short period of time following
release and referrals to community health providers). Also see,
Foster v. Fulton County, 223 F. Supp 2d 1301, 1310 (N.D. Ga.
2002) (holding that a jurisdiction was required to develop
meaningful discharge planning for physically and mentally ill
prisoners).

- 13 psychiatric diagnoses and making observation status decisions
about patients in the infirmary, including which inmates should
be removed from suicide watch, and at what pace. Psychiatrists
should be performing these tasks because psychiatric diagnoses
drive treatment decisions.
The State’s practice of allowing clinicians to make
important decisions regarding the care and treatment of inmates
with serious mental illness puts patients at risk. There were
three suicides at HRYCI in 2006. A clinician’s decision, in May
2006, to downgrade an inmate’s observation status may have aided
the inmate’s ability to commit suicide a few days after he
entered the facility. The State took custody of this inmate
after his release from a local hospital for treatment related to
a suicide attempt. Apparently he was initially placed on one-toone observation status, but he was later downgraded to a lessrestrictive suicide watch despite warnings from a mental health
advocate about his vulnerable mental state and need for a mental
health evaluation.
3.

Psychotropic Medication Administration and Management

The State's expert found that there is a continuing need for
substantial remedial efforts, training, and auditing with respect
to the management of psychotropic medications.
Our investigation revealed that the medication
administration and management of psychotropics at DOC facilities
is constitutionally inadequate. We observed during our tours at
BWCI and HRYCI that there are systemic problems with initiating
drug therapy for newly admitted inmates. It appears that this
problem may be partially the result of a deficient intake and
screening process. Because the intake process is deficient there
is rarely an attempt to obtain psychiatric records from community
providers which would identify any psychotropic medications that
were previously prescribed. If outside records were routinely
obtained the delay that we observed with regard to initiating
drug therapy for newly admitted inmates might be eradicated or at
least greatly diminished.
We also found that the psychotropic medications that newly
admitted inmates are often prescribed by community providers were
substituted with other medications which may not be as
therapeutically effective. We encountered inmates at HRYCI who
appeared to have diminished symptom control and decreased
functional ability as a result of the substitution of
psychotropic medications. Another deficiency that we found with
psychotropic medication administration is a lack of consistent

- 14 and timely distribution of medications. Because the medication
inventory does not appear to be properly controlled, medication
shortages have resulted in interrupted drug therapy.
Finally, we found that monitoring of medication is deficient
at the facilities. The use of certain psychotropic medications
may cause metabolic effects, such as weight gain, hyperlipidemia,
and type II diabetes mellitus. As such, generally accepted
standards of care require prescribing physicians to monitor
weight, body mass index, and abdominal girth on a regular basis.
Our review of medical records at BWCI and HRYCI indicate that the
State is not following this practice. Another side effect of
certain psychotropic drugs is tardive dyskinesia (involuntary
movement disorder). Psychiatrists generally monitor this side
effect by performing the Abnormal Involuntary Movement Scale
("AIMS") on a regular bases. The State's expert found that AIMS
tests are not being done once every six months as required.
4.

Intake and Screening

We found the intake and screening process with respect to
the identification of seriously mentally ill inmates to be
constitutionally inadequate. The intake and screening process
for medical and mental health is combined and performed by
nursing staff members who do not appear to have received adequate
mental health training or have a sufficient background in mental
health. Accordingly, they are unable to appropriately identify
symptoms of mental illness.
During our tour of HRYCI, we found that the staff's lack of
experience with mental health issues is exacerbated by the high
volume of newly admitted inmates that are processed per shift.
These deficiencies have resulted in the failure to identify
inmates with serious mental illness which causes delays in
treatment. Another impact of failing to identify inmates with
mental illness is that disciplinary sanctions may be
inappropriately imposed on mentally ill inmates, because of
behavior that could be more appropriately addressed by mental
health care and treatment instead of discipline. For example,
during our tour of BWCI, we observed inmates in isolation who had
not been properly identified has having mental illness, or who
had not received adequate treatment for their diagnosed mental
illness. For such inmates, care should be taken to ensure that
they are not unfairly disciplined for "acting out" when mental
health intervention is a more appropriate response.
We also found that intake and screening for juveniles was
constitutionally inadequate at HRYCI. During our tour, we

- 15 reviewed a number of juvenile medical records to determine
whether this special needs population was receiving comprehensive
mental health evaluations subsequent to their initial intake
survey. However, it appeared that such evaluations were not
being routinely performed.
C.

Suicide Prevention

Our investigation revealed that the State's practices
regarding suicide prevention substantially depart from generally
accepted professional standards and expose inmates to significant
risk of harm. Our investigation uncovered a system in which
inmates at risk for suicide are not adequately identified, housed
and supervised.
The State fails to adequately assess and identify inmates at
risk for suicide. While the form used to conduct intake
assessments is good, the personnel conducting the assessment lack
appropriate training and experience with issues related to mental
health and suicide prevention. Assessments are often performed
by contract or agency LPN's who have not been trained adequately
in suicide prevention techniques. Additionally, while the
State's medical provider conducts training of its employees on
suicide prevention, it has not implemented its training curricula
as policy or standard operating procedure. Similarly,
correctional staff receive insufficient training in the area of
suicide prevention. Training at the academy is only two or three
hours, and annual refresher training methods are not adequate.
The intake process also fails to ensure that appropriate
action is taken when an inmate reports a history of suicidal
thoughts or actions. In these instances, the inmate signs a
release, but outside confirmations of their medical and mental
health records/histories are not consistently obtained and
verified. Furthermore, post-intake follow-up of new inmates,
which should be conducted within 14 days, is not done. Instead,
follow-up is rolled into the initial intake process, increasing
the possibility that at-risk inmates will not be identified.
The State fails to ensure that inmates identified as being
at risk for suicide are housed in cells which are sufficient to
ensure their safety. Protrusions from walls and ceilings, window
frames and grates, and even the design of bunk beds in some cells
provide potential anchors strong enough to support an inmate's
weight in an attempt at hanging. For example, in August 2006, an
HRYCI inmate who hanged himself at HRYCI was housed in an
infirmary cell following his admission because he was recovering
from a gunshot wound sustained during his arrest. It is not

- 16 clear what fixture the inmate used to hang himself, but it is
apparent that the cells in the infirmary, like those in the other
areas of the facility, are not sufficient to ensure the safety of
inmates with suicidal ideations. Hanging was the means used in
the May 2006 and February 2005 suicides at HRYCI. Additionally,
unsafe light fixtures in some cells, if broken, provide a
potential source of sharp-edged pieces of plastic or glass that
could be used for self-harm.
The State fails to ensure that appropriate levels of
observation are maintained. Documentation of 15- and 30-minute
checks does not indicate that these checks are being done. Staff
at one facility reported conflicting requirements for checks at
lesser levels of observation, highlighting confusion about which
interval was the actual policy. Rounds by mental health staff
for inmates in isolation and on special units are not regularly
done. Additionally, staff at some facilities incorrectly
suggested that the various undocumented incidental contacts with
at-risk inmates throughout the day, such as dispensing medication
or picking up sick call slips, sufficed as a periodic check for
inmates' safety.
III.

MINIMUM REMEDIAL MEASURES

In order to address the constitutional deficiencies
identified above and to protect the constitutional rights of
inmates, we recommend the following measures:
1.

The State should ensure that appropriate access to medical
care, including development and implementation of a
functional sick call system that appropriately schedules
medical appointments, and properly tracks and reschedules
"no shows."

2.

The State should ensure that chronic disease registries are
implemented and maintained at DOC facilities.

3.

The State should provide appropriate continuing care for
patients with chronic diseases and ensure that backlogs are
eliminated and do not redevelop.

4.

The State should ensure that outside consultations are not
unnecessarily delayed and that appropriate post-consult
follow-up care is provided. The State should ensure that
security staffing levels do not negatively impact the
provision of outside consultations.

- 17 5.

The State should implement appropriate measures to identify,
track, and treat skin infections, including culturing and
treating wounds and prescribing effective antibiotics.

6.

The State should ensure the distribution of medication to
patients at proper time intervals. The State should
implement a system to ensure that proper medications are
being received and that sufficient stocks of medications are
maintained to avoid interruptions or delays in their
delivery.

7.

The State should track serial refusals of medication by
patients and ensure that prescribing physicians are notified
of such occurrences and that appropriate follow-up with
patients takes place.

8.

The State should ensure that there is adequate psychiatric
coverage provided at DOC facilities.

9.

The State should ensure that psychiatrists are actively
involved in inmate care, including: functioning as the
treatment team leader; making psychiatric diagnoses;
providing necessary monitoring and supervision of staff; and
promoting quality mental health care.

10.

The State should provide appropriate medication distribution
and management systems to ensure that psychotropic
medications are available, distributed in a timely manner,
and adequately monitored.

11.

The State should ensure that psychiatrists prescribe
therapeutically effective medications. If a decision is
made to adjust or substitute the medications that an inmate
was on prior to their detention or incarceration at a DOC
facility, the psychiatrist should provide a clear
justification for making the adjustment or substitution in
the inmate's medical record.

12.

The State should ensure that appropriately trained staff
perform a mental health screening at intake.

13.

The State should provide appropriate counseling space for
qualified mental health professionals to provide mental
health treatment to inmates with serious mental illness.

14.

The State should ensure that the mental health staff is
appropriately documenting the care provided to inmates with
serious mental illness.

- 18 15.

The State should provide appropriate treatment plans for
inmates with serious mental illness. The treatment plans
will be reviewed on a routine bases to ensure quality of
care.

16.

The State should develop site specific mental health
policies for HRYCI and DCC.

17.

The State should develop a comprehensive policy regarding
suicide prevention for DOC facilities.

18.

The State should ensure that all medical, mental health and
correctional staff are appropriately trained regarding
issues of suicide prevention, and that the content of their
training is reflective of that State's suicide prevention
policy.

19.

The State should ensure that intake staff are sufficiently
experienced and qualified to identify inmates that pose a
risk for suicide, and that follow mental health staff
conduct appropriate follow-up evaluations of new inmates
within 14 days of intake.

20.

The State should ensure that inmates identified as at risk
for suicide are housed in safe cells, free from fixtures and
design features that could facilitate a suicide attempt.

21.

The State should ensure that 15- and 30-minute checks of
inmates under observation for risk of suicide are timely
performed and appropriately documented.

* * *
Please note that this findings letter is a public document.
It will be posted on the Civil Rights Division's website and we
will provide a copy of this letter to any individual or entity
upon request.

- 19 As stated above, we appreciate the cooperation we have
received throughout this investigation from State officials and
staff at the facilities. We appreciate the State's proactive
measures to respond to its own internal audit and our feedback to
date to improve the quality of services at the facilities. We
hope to be able to continue working with the State in an amicable
and cooperative fashion to resolve the deficiencies we found at
the facilities. Provided that our cooperative relationship
continues, we will forward our expert consultants' reports under
separate cover. Although their report are their work – and do
not necessarily represent the official conclusions of the
Department of Justice – their observations, analyses and
recommendations provide further elaboration of the relevant
concerns, and offer practical assistance in addressing them. We
hope that you will give this information careful consideration
and that it will assist in your efforts at prompt remediation.
We are obligated to advise you that, in the unexpected event
that we are unable to reach a resolution regarding our concerns,
within 49 days after your receipt of this letter, the Attorney
General is authorized to initiate a lawsuit pursuant to CRIPA, to
correct deficiencies of the kind identified in this letter. See
42 U.S.C. § 1997b(a)(1). We would very much prefer, however, to
resolve this matter by working cooperatively with you.
Accordingly, we will soon contact State officials and 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/ Wan J. Kim
Wan J. Kim
Assistant Attorney General
cc:

Carl C. Danberg
Attorney General
Stanley W. Taylor, Jr.
Department of Correction Commissioner
Thomas L. Carroll, Warden
Delaware Correctional Center

- 20 Raphael Williams, Warden
Howard R. Young Correctional Institution
Rick Kearney, Warden
Sussex Correctional Institution
Robert Young, Acting Warden
John L. Webb Correctional Facility
Patrick Ryan, Warden
Delores J. Baylor Women’s Correctional Institution
Colm Connelly
United States Attorney
District of Delaware
Michael R. Bromwich, Esq.
Beth C. McClain, Esq.
Fried, Frank, Harris, Shriver & Jacobson LLP