December 8, 2006

The Honorable Margaret Keliher
Presiding Officer
Dallas County Commissioners Court
411 Elm Street, 2nd Floor
Dallas, TX 75202
Re:

Investigation of the Dallas County Jail, Dallas, Texas

Dear Judge Keliher:
On November 28, 2005, we notified you of our intent to
investigate conditions at the Dallas County Jail (“DCJ” or
“the Jail”), in Dallas, Texas, pursuant to the Civil Rights of
Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997.
Consistent with our statutory requirements, we write to report
the findings of our investigation and to recommend remedial
measures to ensure that DCJ meets federal constitutional
requirements. See 42 U.S.C. § 1997b.
From February 20-24, 2006, and from March 20-23, 2006, we
conducted on-site inspections of DCJ with consultants in the
fields of correctional medical care, correctional mental health
care, and environmental health and safety. While on-site, we
interviewed administrative and security staff, medical and mental
health care providers, and inmates. Before, during, and after
our on-site inspections, we received and reviewed a large number
of documents, including policies and procedures, incident
reports, grievances, medical and mental health records, and other
records. Consistent with our commitment to provide technical
assistance and conduct a transparent investigation, we provided
extensive debriefings at the conclusion of our inspections,
during which our consultants expressed their initial impressions
and concerns.
In July 2006, we received updated information regarding the
efforts the Jail is undertaking to address many of the problems
cited by our consultants during the two exit interviews and that
are discussed herein. We are encouraged by the County’s prompt
efforts to address deficient conditions at DCJ.

- 2 We appreciate the full cooperation we received from County
and DCJ officials throughout our investigation. We also wish to
extend our appreciation to the Sheriff and the staff and
administration at the Jail for their professional conduct and
timely responses to our requests.
Having completed the fact-finding portion of our
investigation of the Jail, we conclude that certain conditions at
DCJ violate the constitutional rights of inmates confined there.
As detailed below, we find that DCJ fails to provide inmates
with: (1) adequate medical care; (2) adequate mental health
care;1 and (3) safe and sanitary environmental conditions.
I.

BACKGROUND
A.

DESCRIPTION OF DCJ

The Dallas County Jail is operated by the Dallas County
Sheriff’s Office (“Sheriff’s Office”) and is the seventh largest
detention facility complex in the country. DCJ receives 90,000100,000 admissions per year, 57% of which are released within
three days, and 68% within seven days. As of February 20, 2006,
the Jail housed approximately 7,770 inmates, both pre-trial and
sentenced, in five separate adult facilities: the Suzanne Kays
Detention Facility; the Decker Detention Facility; the George
Allen Courts Building; and the adjoining Lew Sterrett Center
Tower Facilities (“Lew Sterrett”).
Most of the inmate population is housed in Lew Sterrett
which includes: an intake area for all of DCJ; a medical
infirmary; the majority of the Jail’s behavior observation cells
for inmates with mental illnesses; housing for female inmates,
including female observation cells; a male geriatric unit; a unit
for juveniles; and a large general population. The George Allen
facility has a female infirmary and houses both men and women of
all classification levels. The Decker Detention facility is a
minimum-security facility which houses both male and female
inmates. Lastly, the Suzanne Kays facility is a minimum-security
facility that houses both male and female inmates.
The Sheriff’s Office is responsible for all operations of
the Jail, including classification, physical plant and services,

1

We note that in late 2004, the Dallas County
Commissioner’s Court commissioned a study of medical and mental
health care, the results of which became public in February 2005,
and are consistent with the findings contained herein.

- 3 security, escort, and transportation for inmates. From
October 2002 through February 2006, medical and mental health
care services at the Jail were provided by the University of
Texas Medical Branch at Galveston (“UTMB”) through a contract
monitored by Parkland Health and Hospital System (“Parkland”).
Parkland began providing medical and mental health care effective
March 1, 2006.
II.

LEGAL FRAMEWORK

CRIPA authorizes the Attorney General to investigate and
take appropriate action to enforce the constitutional rights of
jail detainees and inmates subject to a pattern or practice of
unconstitutional conduct or conditions. 42 U.S.C. § 1997.
Pre-trial detainees, individuals who have not been convicted of
the criminal offenses with which they have been charged, comprise
the majority of inmates at the DCJ. The rights of pre-trial
detainees are protected under the Fourteenth Amendment which
ensures that these inmates “retain at least those constitutional
rights . . . enjoyed by convicted prisoners.” Bell v. Wolfish,
441 U.S. 520, 545 (1979) (applying the Fourteenth Amendment
standard to a facility for adult pre-trial detainees);
Scott v. Moore, 85 F.3d 230, 235 (5th Cir. 1996) (finding that a
municipality assumed a Constitutional obligation under the
Fourteenth Amendment to provide pre-trial detainees with minimal
levels of safety and security); Hare v. City of Corinth,
74 F.3d 633, 639 (5th Cir. 1996) (en banc), rev’d on other
grounds, 135 F.3d 320, 326 (5th Cir. 1998) (recognizing a
“pretrial detainee’s constitutional right to be secure in his
basic human needs, such as medical care and safety...”).
In Scott v. Moore, 85 F.3d 230, 235 (5th Cir. 1996), the
Fifth Circuit has held that the protection of pre-trial
detainees’ rights under the due process clause of the Fourteenth
Amendment is “at least as great as the Eighth Amendment
protections available to a convicted prisoner.” Id. (quoting
City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983)).
Under the Eighth Amendment, prison officials have an affirmative
duty to ensure that inmates receive adequate food, clothing,
shelter, and medical care. Farmer v. Brennan, 511 U.S. 825, 832
(1994); Bell, 441 U.S. at 535-36, 537 n.16; Scott,
85 F.3d at 235; Hare, 74 F.3d at 639. The Eighth Amendment
protects prisoners not only from present and continuing harm, but
also from future harm. Helling v. McKinney, 509 U.S. 25,
33 (1993).
Detainees have a constitutional right to adequate medical
and mental health care, including psychological and psychiatric

- 4 services. Farmer, 511 U.S. at 832; Gates v. Cook, 376 F.3d 323,
332 (5th Cir. 2004). Inmates’ Eighth Amendment rights are
violated when prison officials exhibit deliberate indifference to
their serious medical needs. See Estelle v. Gamble, 429 U.S. 97,
102 (1976). The standard for adequate medical and mental health
care requires a showing of both the subjective and objective
components of “deliberate indifference.” Gates, 376 F.3d at 333.
Deliberate indifference may be inferred when a prison official
“knows of and disregards an excessive risk of inmate health.”
Farmer, 511 U.S. at 837. Prison personnel exhibit “deliberate
indifference” to an inmate’s health when they refuse to treat
him, ignore his complaints, intentionally treat him incorrectly
or “engage in any similar conduct that would clearly evince a
wanton disregard for any serious medical needs.” Domino v. Texas
Dep’t Of Criminal Justice, 239 F.3d 752, 756 (5th Cir. 2001).
III. FINDINGS
A.

MEDICAL CARE

DCJ fails to provide inmates with adequate medical care that
complies with constitutional requirements. We found the
following serious deficiencies: (1) inadequate intake screening;
(2) inadequate acute care; (3) inadequate chronic care;
(4) inadequate treatment and management of communicable disease;
(5) inadequate access to health care; (6) inadequate follow-up
care; (7) inadequate record keeping; (8) inadequate medication
administration; (9) inadequate medical facilities;
(10) inadequate speciality care; (11) inadequate staffing,
training, and supervision; (12) inadequate quality assurance; and
(13) inadequate dental care.
1.

Inadequate Intake Screening

DCJ fails to adequately identify inmates’ health needs
through appropriate intake screening, thereby preventing inmates
from receiving adequate care for acute or chronic needs.
Generally accepted correctional medical standards require that
incoming inmates be screened by staff trained to identify and
triage serious inmate medical needs, including drug and alcohol
withdrawal, communicable diseases, acute or chronic needs, mental
illness, and potential suicide risks. DCJ’s intake screening
process fails to identify such needs and places inmates at risk
of serious harm.
Prior to March 1, 2006, detention officers, who lacked
adequate training and medical supervision, were responsible for
conducting intake screenings. On March 1, 2006, DCJ began using

- 5 paramedics to perform intake screenings. While this staffing
change is an improvement, the intake screening process remains
deficient because there are no medical policies governing the
intake process and signs and symptoms of serious illness or
contagious disease go unrecorded. Further, the screening form
used by DCJ lacks sufficiently specific questions regarding acute
and chronic illness, including drug and alcohol withdrawal.
Moreover, screening interviews are conducted with a total lack of
privacy, further compromising the quality of information
received. These practices contravene generally accepted
correctional medical standards and place inmates at significant
risk of harm. The following examples illustrate the intake
screening deficiencies.
!

Inmate P.C.2 was booked into DCJ on February 21, 2006.
Although he was diagnosed with alcohol withdrawal, the
screening process failed to identify that he was
suffering from delirium tremens, a potentially lifethreatening complication of alcohol withdrawal. As a
result, P.C. did not receive appropriate medical care.
Two days after intake, our medical consultant examined
P.C. and found that he was acutely psychotic with
tremors, delusions, and hallucinations. It was only
after we brought his conditions to DCJ’s attention that
P.C. was transferred to the hospital for necessary
care.

!

Inmate A.L. died in October 2005, two days after being
booked into DCJ, of diabetic ketoacidosis, a lifethreatening complication of diabetes. At intake,
A.L.’s blood sugar level was recorded at a dangerously
high level yet he received no physician care while at
DCJ. We note that while this incident occurred prior
to the March 1, 2006 change, this type of deficiency
can recur given that DCJ lacks policies and procedures
to govern its intake process.

!

Inmate A.N. suffered from HIV and died on
October 5, 2005 of pneumocystis pneumonia, an
opportunistic infection, which could have been
prevented if he had continued to receive the antibiotic
he was prescribed at the time he was admitted to DCJ.

2

Throughout this letter, when referring to a specific
inmate, we use pseudonymous initials to protect the identity of
the inmate. We are providing to the County a key to the identity
of inmates referenced in this letter under separate cover.

- 6 The Jail failed to provide A.N. with this prescription
for 11 days following intake.
!

In December 2004, DCJ transferred inmate Q.S. to the
hospital where he died of alcohol withdrawal. Q.S. had
been admitted to DCJ a week prior with a history of
alcoholism and seizures during alcohol withdrawal.
Within four days of intake, he became disoriented,
developed a fever, and had an elevated blood pressure.
Q.S. was kept in the facility with no physician or
nursing care, and no monitoring of his vital signs.
Q.S. soon became lethargic and was later discovered
lying in his feces. After finding him in this state,
it took an additional five hours before Q.S. was
transferred to the hospital where he subsequently died.

DCJ’s intake screening process also fails to identify the
health needs of juveniles, notwithstanding this population’s
particular vulnerabilities to mental illness and suicide. On
February 20, 2006, DCJ had 11 juveniles in custody. Only six had
a medical screening, and none had been screened for suicide risk.
On March 21, 2006, there were also 11 juveniles in custody, but
only two had a medical screening. There were no medical
evaluations for those juveniles with asthma or for a youth with a
history of being on pyschotropic medications.
Finally, DCJ inmates do not receive a full health assessment
within a reasonable period after admission. The generally
accepted correctional medical standard is to conduct health
assessments within two weeks of admission. Appropriate and
timely health assessments reduce the risk of harm should
screening procedures fail to identify an inmate’s serious health
needs and improves the facility’s ability to provide efficient,
adequate care. Typically, this assessment includes a review of
the intake information, a complete medical and mental health
history, a physical examination, and screening for TB and
sexually transmitted diseases. Approximately one in four inmates
are still at DCJ two weeks after intake and many do not receive a
health assessment. At DCJ, the need for a prompt assessment is
compounded by the inadequacies in the intake screening process
described above.
2.

Inadequate Acute Care

DCJ fails to provide inmates adequate acute care, that is
care for urgent and/or emergent medical conditions. Jail staff
frequently mismanage inmates’ acute medical needs, thereby
significantly delaying appropriate medical care. Most seriously,

- 7 we found numerous instances where DCJ’s mismanagement contributed
to preventable deaths, hospitalizations, and unnecessary harm.
Correctional facilities should provide adequate nursing and
physician care for the treatment of serious and emergent
conditions. Jail staff should be adequately trained and prepared
to manage emergent situations in accordance with generally
accepted correctional medical care standards. DCJ’s failure to
provide such care has subjected inmates to serious harm. The
following examples highlight DCJ’s deficiencies in providing
acute care:
!

On February 23, 2006, during our initial tour, we
witnessed an emergent situation unfold involving inmate
E.C. who had experienced a seizure. When medical staff
evaluated him, E.C. was found to have a severely low
blood sugar level. Contrary to generally accepted
correctional medical standards which dictate that the
inmate receive glucogon or an intravenous injection of
glucose, the nurse failed to consult with a nearby
physicians’ assistant, and inappropriately gave C.C.
orange juice and peanut butter.

!

In early 2006, inmate E.E. suffered a severe leg
infection as a result of DCJ’s failure to provide
adequate acute care both prior and subsequent to his
hospitalization for a severe leg wound. Notably, even
after E.E. was discharged from the hospital, DCJ failed
to treat him in accordance with the directions provided
in his hospital discharge instructions. E.E. received
inadequate care for an additional five months. In
fact, his care was so deficient that he was released by
court order so that he could obtain medical care
outside of DCJ.

!

On April 28, 2004, inmate C.D. sustained trauma to his
left eye. Although Jail staff were aware of the
injury, C.D. was not seen by a physician for seven
days, until he was hospitalized. By this time, C.D.’s
injury was inoperable and he is now blind in that eye.

!

Inmate A.F. died on February 1, 2004 after not
receiving adequate care for an emergent and life
threatening condition. A.F., who suffered from HIV,
was admitted to DCJ in October 2003. In late December,
Jail staff ordered an x-ray after A.F. complained of
chest pain. Over two weeks passed before his x-ray was
taken. During the interim, he developed pneumocystis

- 8 pneumonia, a life-threatening condition. The results
of A.F.’s x-ray were not reviewed until late
January 2004. On January 31, 2004, a physician who had
reviewed A.F.’s chart ordered that A.F. be brought to
him the next day. A.F. died prior to seeing the
physician.
3.

Inadequate Chronic Care

DCJ fails to provide constitutionally adequate care to meet
the serious medical needs of inmates with chronic medical
conditions. See, e.g., Lawson v. Dallas County,
112 F. Supp. 2d 616, 637 (D. Tex. 2000) aff’d 286 F.3d 257
(5th Cir. 2002) (finding deliberate indifference where prison
officials, aware of an inmate’s deteriorating medical condition,
failed to administer required medication and treatment). See
also Domino v. Texas Dep’t of Criminal Justice, 239 F.3d 752, 756
(5th Cir. 2001) (finding deliberate indifference where jail staff
had refused to treat, ignored complaints of, or intentionally
mis-treated an inmate despite serious medical need). Jail staff
may not effectively deny, substantially delay, or refuse care for
an inmates’ serious medical needs. See Stewart v. Murphy,
174 F.3d 530, 537 (5th Cir. 1999) citing cf. Hudson v. McHugh,
148 F.3d 859, 863-64 (7th Cir. 1998) (noting deliberate
indifference where jail officers and nurse refused to address an
inmate’s repeated requests for epilepsy medicine despite knowing
of his serious medical need).
Inmates who suffer from chronic medical conditions require
ongoing coordinated care and treatment to prevent the progression
of their illnesses. DCJ has no clinical practice guidelines for
chronic and communicable diseases, such as diabetes, asthma,
hypertension, HIV and sexually transmitted diseases. In
particular, DCJ’s care for inmates with chronic medical
conditions fails in two areas: (a) assessment of chronic
conditions; and (b) timely and adequate follow-up medical
treatment, including proper medication administration.
a.

Failure to Assess for Chronic Conditions

Generally accepted standards of correctional medical care
require that medical staff be able to identify inmates in need of
chronic care and provide timely treatment or referrals for
inmates’ chronic conditions. DCJ fails to ensure that inmates
receive thorough assessments and monitoring of their chronic
illnesses. The Jail has no established policies and procedures
for identifying and caring for inmates with chronic illnesses or
diseases. DCJ inmates with chronic conditions are not routinely

- 9 identified and assessed at intake or shortly thereafter. As a
result, no plan is made for their ongoing assessment and
monitoring. Moreover, inmates with chronic conditions are not
routinely seen by a physician to evaluate the status of their
health and the effectiveness of the medication they are taking
for their chronic conditions.
Additionally, DCJ intake nurses are not adequately trained
to identify inmates with chronic conditions, and commonly fail to
administer standard tests for treatment and prevention of medical
complications, including blood tests for diabetics and peak air
flow measurements for asthmatics. Without such routine tests, it
is not possible to identify those who require urgent medical care
and for medical staff to appropriately monitor inmates with these
chronic illnesses.
b.

Inadequate Follow Up Treatment and
Medication Administration

Care for inmates with chronic conditions is plagued by
delays in the treatment and administration of medication. Delays
begin during the Jail’s intake routing process and are
exacerbated by overall inadequacies in the medical care system.
Our review of inmate medical records revealed consistent
significant delays for inmates receiving care for chronic
conditions. Such delays increase the risk of harm to inmates and
the likelihood that their chronic conditions may worsen. This
deficiency was acknowledged by DCJ’s medical director, who
reported to us that inmates commonly wait two to three weeks
before receiving medications following intake.
Inmates who are identified with chronic health conditions
are often not scheduled for follow-up medical assessment.
Rather, they are transferred to their housing unit, where they
must avail themselves of the deficient processes described below,
to seek further medical care. Consequently, inmates with chronic
medical needs are routinely not seen timely by clinicians.
During our investigation, we reviewed the medical charts of
18 inmates admitted to DCJ on February 13, 2006. Five of these
inmates had a history of chronic disease yet, according to their
medical records, one week later none had been seen by DCJ medical
staff. Such delays are contrary to generally accepted standards
of correctional medical care and expose inmates with chronic
conditions3 to significant and unnecessary risk of harm. For

3

Inmates with chronic conditions require earlier
assessment and treatment sooner than the two week health

- 10 example, Inmate Y.G. died of heart failure within 20 days of
arriving at the Jail in October 2004, because he was unable to
get care for his multiple chronic conditions and abdominal
swelling (a symptom of heart failure). Despite efforts by both
Y.G. and his sister to get the Jail to treat his diabetic and
heart conditions, DCJ failed to administer Y.G.’s medication.
The lack of coordinated care for chronic conditions is
particularly dangerous for diabetic inmates. As part of our
review, we randomly selected 12 inmates from those designated as
diabetics by DCJ. In a gross departure from generally accepted
medical standards, none of the 12 inmates had been tested for two
standard indicators of their diabetic condition and potential
complications. Additionally, only nine of the 12 inmates had
blood sugar measurements taken during intake; six did not receive
their first dose of medication for a period ranging from six days
to two months after intake; and two never received medication.
These failings were typified by our interactions with inmate A.R.
who had been in medical housing at the facility for three weeks
as of our February 21, 2006 tour. A.R. had received no insulin
and Jail staff had failed to measure his blood sugar level. At
our request, DCJ checked A.R.’s blood sugar and discovered that
it was extremely high. A.R. was unnecessarily exposed to
potentially life-threatening harm due to DCJ’s failure to monitor
his condition.
We found numerous additional instances of deficient chronic
care that put inmates’ health and lives at serious risk:
!

Inmate B.P. has HIV, asthma, and a drug-resistant skin
infection. Although B.P. reported during our
February 2006 tour that he has prescriptions for three
HIV medications, his medical record reveals that Jail
staff were administering only one of these medications.
The failure to administer all three of the prescribed
medications may cause B.P. to develop resistance to HIV
medication. Moreover, without his HIV medications,
B.P. becomes more susceptible to potentially fatal skin
infections.

!

Inmate N.T. has a seizure disorder. Although she
suffered seizures on both October 10, and
November 28, 2005, DCJ staff failed to order her

assessment, which is the generally accepted correctional medical
standard for all inmates.

- 11 seizure medication for several weeks, until
February 16, 2006.
!

Inmate B.Q. was admitted to the Jail in July 2005 but
in February 2006 he reported to us that he was not
receiving his HIV medication. A review of his medical
record reveals that B.Q. had neither received his
medication nor been evaluated by a physician during his
seven months in custody.

!

Inmate I.S. had five seizures at DCJ over a period of
12 days in December 2005. As of February 2006, she had
not been seen by a physician for her condition. Our
medical consultant reviewed her chart and found that
I.S. had been prescribed a sub-therapeutic dosage of
medication for her seizure disorders. I.S. remains at
risk for repeated seizures.

!

In July 2005, inmate L.E., who is bipolar and is
HIV-positive, suffered repeated delays in receiving his
medication each time he was transferred to a new cell.
An examination of his medical record reveals that, with
each of his four transfers, the Jail failed to
administer his medication for periods ranging from
four days to seven weeks.
4.

Inadequate Treatment and Management of
Communicable Disease

DCJ fails to adequately treat and manage communicable
diseases. DCJ’s management of tuberculosis (“TB”), Methicillin
Resistant Staphylococcus aureus (“MRSA”),4 and other infectious
diseases deviates significantly from generally accepted
correctional medical practices. Inmates with communicable
diseases are not appropriately screened, treated, or isolated.
Further, the crowded conditions at DCJ exacerbate the serious

4

MRSA (“methicillin-resistant staphylococcus aureus”) is
a bacteria resistant to certain antibiotics, including
methicillin, oxacillin, penicillin, and amoxicillin. Centers for
Disease Control and Prevention, at
http://www.cdc.gov/ncidod/hip/Aresist/ca_mrsa_public.htm. MRSA
manifests itself as a boil or sore on the skin and is spread
through contact with an infected person or a surface the person
has touched. Id. In some cases, MRSA can have serious medical
consequences, for example, by causing surgical wound infections,
bloodstream infections, and pneumonia. Id.

- 12 risk of spreading communicable disease among inmates and staff.
We note that DCJ’s inadequate practices pose a serious risk to
DCJ inmates, staff, and even the Dallas community at large when
the facility’s high turnover is taken into account. Similar to
the deficiencies in chronic care, DCJ lacks practice guidelines,
based on generally accepted correctional medical standards, for
managing and treating communicable diseases in a correctional
setting.
a.

Tuberculosis

Pulmonary Tuberculosis (“TB”) is a potentially lifethreatening disease commonly found in correctional facilities.
The transmittal of TB can be prevented or controlled with an
appropriate TB control plan. A TB control plan provides
guidelines for identification, treatment, and prevention of
transmission of TB to staff and other inmates. The Jail has
acknowledged the necessity of developing and implementing a TB
control plan that is consistent with generally accepted
correctional medical standards, however, such a plan is not
currently in place.5 Consequently, we found deficiencies in:
(1) screening; (2) containing; and (3) treating inmates for TB.
(1)

Insufficient Screening

DCJ fails to adequately identify potential TB cases during
intake screening, and fails to conduct timely and consistent
clinical evaluations and diagnostic x-rays. These deficiencies
expose inmates, staff, and the Dallas County community to an
unnecessarily high risk of transmission.
Inmates
screened for
provision of
testing (for
programs are

5

who display symptoms of TB should be assessed and
exposure in a timely manner to facilitate the
any needed care. Screening tools include skinexposure) and chest x-rays, as needed. TB screening
intended to identify inmates who require treatment

On April 3, 2006, we notified the County of specific
instances of emergent medical concerns that required immediate
attention, including the creation and implementation of an
effective TB control plan. The County responded on
April 10, 2006, and stated that there was a TB screening team and
program in place at the Jail. However, our review of the
documents indicated a continued lack of appropriate planning to
screen and treat inmates, and to contain TB transmission in
accordance with general standards of care.

- 13 as well as to determine if certain inmates require isolation to
limit the risk of transmission.
TB-suspect inmates at DCJ must contend also with the
deficiencies in care noted previously. There is a lack of
necessary policies and procedures; inadequate follow-up care and
assessment; and significant lags in inmates’ receiving
appropriate diagnosis and medication. Tests are not consistently
performed on inmates who display symptoms of TB, contrary to
generally accepted correctional medical care standards. For
example, on January 15, 2006, inmate J.M. was coughing up blood,
a symptom of possible TB. Yet, by late March 2006, over two
months later, J.M. had not received a chest x-ray to identify or
rule out TB.
Overall, our review of DCJ’s screening program yielded
disconcerting results. Nationwide, 15 to 25% of inmates have
latent tuberculosis. Yet, at DCJ, only 2% of the 11,668 TB skin
tests read between December 1, 2005 - February 28, 2006 were read
as positive. Such a low percentage identified, compared to the
national average, suggests that Jail staff are either not
conducting or interpreting tests properly.
Additionally, we found a several week backlog for x-rays of
inmates suspected of having TB. Our review of the Jail’s
computer system revealed that on March 21, 2006 the unanswered
backlog for x-rays reached 891. As a result, inmates who are TBsuspect are inappropriately housed with the general inmate
population, while they wait weeks for chest x-rays.
(2)

Insufficient Containment

DCJ fails to ensure the adequate containment of TB. Inmates
with suspected TB should be placed in specialized respiratory
isolation (“negative pressure”) rooms to reduce the risk of
transmission through airborne particles. When properly used,
these rooms are effective in preventing contagion. In addition,
staff who are potentially exposed to the risk should wear and be
trained in the use of specialized respirators. However, DCJ does
not comply with these generally accepted standards of care.
The risk of TB transmission is heightened by DCJ’s practices
and inattention to precautionary measures. DCJ’s negative
pressure isolation cells in the Jail are sufficient and capable
of creating negative pressure when properly utilized and
maintained. However, we observed both inmate and staff conduct
that defeat the negative pressure systems by leaving open cell
doors and feeding ports (slots in cell doors through which inmate

- 14 meals can be delivered). We also observed an inmate diagnosed
with active tuberculosis defeating the system by covering the
HVAC return vent with newspaper without effective staff
intervention. Additionally, DCJ staff fail to take appropriate
precautions in isolating inmates with active TB because such
inmates are not consistently identified. DCJ uses its
respiratory isolation cells to house inmates with active TB and
also for overflow housing of general population inmates.
Nonetheless, DCJ does not consistently identify those inmates who
are placed in respiratory isolation cells for medical reasons.
(3)

Inadequate Treatment

DCJ fails to ensure that inmates with TB receive complete
treatments to decrease the risk for the emergence and
transmission of multidrug-resistant TB.6 Treatment for TB
requires at least a six-month course of antibiotics.
Interruptions in an inmate’s antibiotic treatment can lead to the
development of multidrug-resistant TB.
DCJ’s failures to adequately treat and manage communicable
diseases has potentially resulted in inmates and staff being
exposed to active TB. The following examples are illustrative:
!

Inmate C.C. waited over two months to have an x-ray for
suspected TB. Despite a medical order on
January 9, 2006, the x-ray was not taken until two
months later, on March 18, 2006. As a result of the
x-ray, C.C. was then put into medical isolation.

!

Inmate C.T. complained of coughing up blood and night
sweats (both symptoms of active TB) seven days after
admission to DCJ on March 14, 2006. Our review of his
medical chart revealed that C.T. had not had an intake
examination, chest x-ray, or evaluation by medical
staff.

!

Inmate C.V. was admitted to DCJ on January 6, 2006,
with a history of treatment for active TB during the
preceding two months. His diagnosis was confirmed to

6

Multidrug-resistant tuberculosis is a variant of the
tuberculosis bacteria that resists treatment with several antituberculosis drugs. If the wrong medications are used, this
condition is fatal in 25% of cases and can be transmitted to
others who come into close contact with the patient in a confined
space.

- 15 be multidrug-resistant TB on January 13, 2006, yet C.V.
was not seen by a physician for 11 days, nor did he
receive any treatment in the interim.
!

Inmate C.X. had been on TB medication for five weeks
prior to admission to DCJ on February 14, 2006. C.X.,
however, was not put on medication necessary to
complete his treatment and was thus exposed to
developing multi-drug resistant TB.
b.

Skin Infection

DCJ fails to adequately manage contagious skin infection.
Generally accepted correctional medical care standards dictate
that a jail adopt a skin infection control plan to guide the
prevention of transmission of skin infections, including drugresistant infections such as MRSA. An effective control plan
would delineate a course of care to prevent the spread of
infection. DCJ lacks such a plan.
Although DCJ reports approximately 250 newly-identified skin
infections each month, it has not developed or implemented a plan
to address this serious issue. Without an adequate control plan,
inmates are not properly treated and the risk of transmitting
skin infection among the inmate population increases
significantly. DCJ staff do not have specific training in
treating skin infections or managing related wounds. As a
result, inmates receive inappropriate wound care and, thus, are
more likely to develop complications such as deep tissue
infections, which may lead to hospitalization or death. For
example, in October 2005, both inmate L.B. and inmate R.O. had to
be hospitalized to treat deep tissue infections after Jail
nursing staff failed to treat them with the proper antibiotics
for their respective wounds. Despite his hospitalization, R.O.
still had not been evaluated by a DCJ physician by February 2006.
DCJ’s inadequate care for skin infections is compounded by
inadequacies in other areas of care, including the failure to
respond to inmate requests for care; properly assess and treat
inmates to identify and contain the spread of infections; and
maintain adequate medical documentation. Indeed, we noted
numerous instances where multiple requests for care for skin
infections had gone unanswered.
5.

Inadequate Access to Health Care

The process by which inmates at DCJ are permitted to request
medical care is inadequate and presents a significant barrier to

- 16 receiving adequate medical care. Specifically, there are no
protocols for collecting, processing, distributing, logging, and
triaging medical requests. Additionally, the current process
deprives inmates of any professional medical privacy.
Generally accepted correctional medical care standards
dictate that facilities like DCJ have a logging system to track
requests for care, to evaluate whether inmates are seen in
response to their requests, and to identify those still in need
of care. Moreover, facilities must provide appropriate policies
and procedures to guide nursing staff on how to conduct sick
calls, and when to refer requests to higher levels of care. The
failure of DCJ’s medical requests system to meet these essential
standards hinders the ability for inmates to seek, and for
clinicians to provide, appropriate medical care.
At DCJ, medical and mental health requests are initiated by
the submission of a sick call slip. Inmates complete a slip
stating their reason for requesting care. While there are locked
boxes for the slips to be placed, these boxes are located outside
of inmate housing units. Thus, inmates must give the slips to
detention officers, who then are expected to put them in the
locked box. In many units, inmates utilize cardboard cookie and
cracker boxes to collect completed slips within their unit for
pick-up by an officer. In others, detention officers sort the
slips and deliver them to either nursing or mental health staff.
This process offers inmates no confidentiality and, as discussed
below, can create a barrier to needed care.
Our investigation revealed several instances where inmate
medical requests were either lost or unanswered, resulting in the
denial of care for serious medical conditions. For example,
inmate A.H. was admitted to DCJ on December 15, 2005, with an
ulcerating vascular tumor on his leg. Although A.H. requested
care, he did not receive treatment for his tumor for over a
month, even after our consultant directed Jail staff to his
condition. With this kind of ulceration, A.H. is at risk of
serious deep tissue and possible blood infection. Similarly,
inmate A.A. was admitted to DCJ on December 18, 2005, three weeks
pregnant and bleeding, as reflected on her intake form. On
January 13, 2006, she submitted a sick call complaining of
continued bleeding. At the time of our February 2006 tour, she
had not been evaluated by the Jail’s medical staff, despite her
requests.
Even when DCJ does respond to medical requests, inmates are
often not directed to the appropriate level of care:

- 17 !

Inmate F.A. filled out a request for care on
February 9, 2006, noting chest pain with left arm
numbness (both symptoms of a possible heart attack).
Although DCJ nursing staff reviewed the slip, F.A. was
not referred to a physician for evaluation.

!

Prior to our first tour in February 2006, inmate L.E.
submitted a slip complaining of a swollen testicle. At
the time of our March 2006 tour one month later, L.E.
had still not been evaluated by the appropriate medical
staff.

!

Inmate A.G. had seven nurse visits before he was sent
to see a physician in response to his complaint of a
skin infection. As a result of this delay, A.G. had to
be hospitalized in November 2005 for dehydration and an
abscess (an infected collection of pus which may
require surgical removal).

DCJ lacks an effective system for triaging medical requests.
Contrary to generally accepted professional standards of medical
care, all requests are given equal treatment regardless of the
seriousness of the medical issue because there are no nursing
protocols for triaging medical requests. This results in a
significant backlog of potentially urgent requests.
We found that nursing staff respond to sick call requests on
the housing unit rather than in the medical clinic. Cell-side
responses provide inmates with no privacy or opportunity for
appropriate examination. At the Decker facility, for example,
the nurse conducting sick call does not carry the basic medical
equipment essential for appropriate clinical evaluation such as a
stethoscope.
The deficiencies in the medical requests system are also
aggravated by the failures in DCJ’s grievance system. Inmates
consistently reported that the grievance system at the Jail is
not effective when inmates seek relief for inadequacies in
medical care. In this respect, both systems fail to address
inmates’ medical needs. For example, inmate A.K. was
hospitalized with bacterial endocarditis, a potentially lethal
infection of a heart valve. On December 14, 2005, he had his
aortic valve replaced with the insertion of a pacemaker at
Parkland. However, when he returned to the Jail, DCJ health care
staff did not follow up on A.K.’s medical needs, including a
failure to administer his prescribed medication. A.K. attempted
to use the grievance process to address this significant lack of
care and, perhaps most importantly, to receive the needed

- 18 medication. However, despite sick calls, hospitalization, and
filing a grievance, A.K. never received his prescribed
medication.
6.

Inadequate Follow-up Care

DCJ fails to provide appropriate follow-up care for inmates
after discharge from the hospital. See, e.g., Lawson,
112 F. Supp. 2d at 634-637 (finding conscious disregard where
jail staff observed the progression of an inmate’s medical
condition, failed to comply with hospital discharge orders, and
failed to render appropriate follow-up care and administer
regular medications). Inmates who receive specialty care or
return from hospitalization should be evaluated upon their return
to the facility to ensure, at a minimum, that discharge
instructions are noted and appropriate care is provided.
The Jail fails to provide timely follow-up care after
inmates have received hospital care, including the failure to
adequately document and execute relevant medical and discharge
orders. For example:
!

On March 10, 2006, inmate C.Z. was admitted to Parkland
and was treated for severe bowel obstruction, a lifethreatening condition associated with the use of her
prescribed pyschotropic medication, Seroquel. The
hospital discharge instructions recommended decreasing
her dose of Seroquel. This note was never acknowledged
by DCJ staff. When C.Z. returned to the facility on
March 14, 2006, her Seroquel dose was actually
increased by 300% further putting C.Z. at increased
risk of developing additional bowel obstructions.

!

Inmate A.Q. suffers from rhabdomyolysis, a serious
medical condition which, if left untreated, can result
in kidney failure. He was hospitalized for this
condition on October 13, 2005, but was not seen for
follow-up by DCJ medical staff when he returned to the
facility. There were also no hospital notes in A.Q.’s
chart when we reviewed it in February 2006.

!

Inmate A.P. was hospitalized for an overdose of antiseizure medication on October 11, 2005. DCJ never
checked A.P.’s blood levels for this medication either
before or after his hospitalization. Thus, A.P. may
still be receiving a dangerous dosage and could suffer
additional harm.

- 19 !

Inmate D.A. has not received his prescribed asthma
medication following his discharge from the hospital on
February 24, 2006. His medical record includes a
discharge summary that clearly indicates that he was to
be given asthma medication. D.A. is at risk of an
exacerbation of his condition and another
hospitalization.

!

Inmate A.M. was admitted to DCJ with a wound on
September 6, 2005 but did not receive medical care
until October 4, 2005. Moreover, the treatment he
received was inadequate; as a consequence, A.M.
developed cellulitis (an infection of the skin and
underlying tissues that can affect any area of the
body), and had to be hospitalized ten days later.
Following A.M.’s hospitalization, he was not seen by
DCJ medical staff and by February 2006 still had not
received his prescribed medication.

!

Inmate A.O. was hospitalized with cellulitis on
October 25, 2005 after having complained of a wound
over a three-month period beginning July 7, 2005. A.O.
was never seen by medical staff at the Jail and
received no follow-up care following his
hospitalization.

!

Inmate C.F. was hospitalized on April 5, 2005 for
pneumonia. C.F. returned to the Jail a month later
with a prescription for an antibiotic. Our review of
his medical records indicated that C.F. received
neither his prescribed medication nor a follow-up
clinical examination.

!

On November 7, 2005, inmate A.I. was hospitalized for
cellulitis. On returning from his four-day
hospitalization, he was neither seen by medical staff
at DCJ nor received his prescribed medication.

!

Inmate A.J. was hospitalized for infected orthopedic
hardware on November 11, 2005. There are no clinical
notes documented in his medical record. Moreover,
there is no indication that A.J. received any follow-up
care after his hospitalization.

!

Inmate O.H., a juvenile, was sent to the emergency room
at Parkland on June 5, 2005, to receive sutures. Upon
his return to DCJ, no one evaluated his wound or
provided the appropriate follow-up care. As a result,

- 20 O.H. had to cut his own sutures and later remove them
himself.
7.

Inadequate Record Keeping

DCJ fails to keep complete, accurate, readily accessible,
and systematically organized medical records. A complete and
adequate medical records system for a facility like DCJ is
critical to ensure that medical staff is able to provide adequate
care.
DCJ’s electronic medical record system (“EMR”) maintains
records for some inmates. However, there is no central data
repository to manage critical functions such as scheduling,
locating patients, performance measurements, and registries of
inmates with chronic or specialty needs. As a result, DCJ
continues to lose track of such inmates and fails to provide
adequate treatment for their conditions.
Our investigation revealed innumerable gaps and
inconsistencies in DCJ’s medical documentation. For example,
when an intake screening is recorded on paper it is rarely
entered into the EMR. Due to a limited number of computer work
stations, health care staff must record notes by hand and, if
they have time, later enter such into the EMR. This duplicative
system greatly increases the risk of omission or error.
Furthermore, most EMR entries consist of scanned images of
handwritten pages, which often are illegible. Without accurate
medical records, DCJ cannot meet constitutional standards to
provide adequate medical care.
Finally, DCJ’s EMR lacks any sort of backup system to
protect against computer system downtime. For example, the EMR
system was down for two weeks in early February 2006 and again
for part of the day on February 24, 2006. During this time,
staff could not access medical records or enter pertinent
clinical information. The result was a serious lapse in
continuity and coordination of care.
8.

Inadequate Medication Administration

Medication administration at DCJ suffers significant delays,
errors, and lapses, all of which are typically caused by
inaccurate or inadequate documentation. We found that DCJ
frequently fails to do the following: (1) administer medication
in accordance with prescriptions; (2) maintain inmate medication
administration records (“MAR”) concurrently with distribution;

- 21 and (3) follow general standards of care to monitor and adjust
inmates’ prescribed medication regimens.
Generally accepted correctional medical standards require
that facilities administer medication and maintain adequate
medication records to meet the medical needs of the inmates and
to prevent medication errors and other risks of harm. Regular
and systematic reviews of medication usage is also required to
ensure that each inmate’s prescribed medication regimen continues
to be appropriate and effective for his or her condition.
At DCJ, inmates routinely miss doses of life-sustaining
medications, such as Coumadin, a blood thinner used to prevent
blood clots in the deep veins of the legs, heart, and brain.
According to the MARs we reviewed, inmates D.D. and D.E. each
missed two successive days of their Coumadin in March 2006.
Additionally, medication is often not distributed as appropriate.
For example, a significant portion of the Jail failed to receive
their medication on the morning of February 20, 2006, the first
day of our tour. DCJ medical personnel acknowledged this failure
in medication administration.
In one particularly egregious example of missed medication,
Jail staff failed to provide inmate D.G. with prescribed
medication that may have prevented his death. D.G. was admitted
to DCJ on April 3, 2004 and had congestive heart failure, with
symptoms that included swelling of his face and of his scrotum.
The Jail transferred him to the hospital on April 10, 2004, but
when he returned, DCJ failed to administer his prescribed
medication. Two weeks later, on April 24, 2004, D.G died of
congestive heart failure.
DCJ also fails to maintain MARs contemporaneously with
medication administration. Contemporaneous documentation is a
generally accepted standard of care necessary to ensure that
errors do not occur. DCJ medical staff often leave records blank
or fail to log critical clinical information contemporaneously
with the distribution of medication to inmates. During our tour,
we observed a medication technician serially initial a log of
medication records after she had delivered medication to housing
units. Such retrospective documentation is inconsistent with
generally accepted professional standards of medical care and
greatly increases the risk for error.
Our review of DCJ medication records revealed numerous
instances of blank MARs. For example, on two floors of
Lew Sterrett, approximately 15-20% of the boxes on the MARs were
blank; on another floor in Lew Sterrett, more than 10% of the

- 22 medication administration record boxes were blank; and on
February 17 and 18, 2006, most of the afternoon shifts’ boxes
were blank. Blank MARs are indicative of inadequate training,
supervision, and staffing.
Additionally, blank MARs and otherwise poor record keeping
greatly limit DCJ’s ability to manage and account for items such
as narcotics and syringes. Generally accepted professional
standards of medical care require correctional facilities to
maintain regular counts on the inventories of items such as
narcotics and syringes. DCJ has no system in place for reliable,
periodic counts for these items. Together, the failure to
maintain adequate MARs and maintain counts on inventories makes
it almost impossible for DCJ to control and account for these
items in a correctional jail setting.
MARs at the Jail do not adequately contain standard
prescription information for each medication, including start
date, stop date, prescribing practitioner, and nurses/technicians
signatures to match to their initials. General standards dictate
that each DCJ inmate on chronic medications should have a
medication review, as part of a face-to-face encounter with the
prescriber every three months, or sooner if medically
appropriate. This allows for timely follow-up on the inmate’s
condition and ensures the appropriateness of the continued
medication, a practice which is lacking at DCJ. For instance,
while reviewing data on the use of appropriate antibiotics, we
found that seven of the 12 records reviewed had no documentation
of any examination or diagnosis despite the receipt of
medication.
DCJ also fails to ensure that medication distribution is
hygienic. Medication rooms we inspected were cluttered, with
medication on the floor, and with no soap or towels for hand
washing. In the main infirmary area, we observed insulin being
drawn in advance for more than 20 inmates. This is a dangerous
practice that can cause serious medication errors. Giving a
person with diabetes the incorrect dose of insulin can result in
serious illness or death.

- 23 9.

Inadequate Medical Facilities

Medical facilities at DCJ lack adequate space, privacy,
lighting, and sanitation to provide inmates with medical care
consistent with generally accepted standards. In a facility the
size of DCJ, approximately 700 inmates per day require face-toface medical care. Inadequate space is an especially significant
problem because it limits DCJ’s ability to provide medical
services such as intake screenings, sick calls, and health
assessments as well as care for inmates with specialty, chronic,
and acute needs.
Generally accepted professional standards of medical care
require that for a proper clinical evaluation inmates be examined
in a clean and private setting with sufficient lighting and
access to necessary diagnostic tools. Medical examination rooms
at DCJ do not have sufficient lighting and are not adequately
clean. Likewise, some of these rooms lack accessible handwashing sinks, towels to dry hands, and contain unsecured
syringes and dental tools. Notably, hazardous waste was observed
on the floors of several medication areas.
10.

Inadequate Specialty Care

Specialty care generally refers to care provided in various
medical specialties, including orthopedics, gynecology,
cardiology, and geriatric medicine. Access to speciality care at
DCJ is severely lacking. For instance, between January 1 and
February 20, 2006, Jail staff made 316 referrals for specialty
care. However, by late March 2006, the Jail had not scheduled
appointments for any of these referrals. Such a large backlog
for specialty care is grossly inconsistent with generally
accepted standards of care.
Additionally, geriatric care and facilities at DCJ are
inadequate. Given DCJ’s large population, dozens of older
inmates will require nursing care on a daily basis for their
specialized needs. However, DCJ is not providing such care. For
example, in February 2006, we observed inmate E.A. who has severe
multiple sclerosis, Parkinson’s, atrial fibrillation, and
dementia. Although he was incontinent of urine and feces, he was
housed in the general population without nursing care. If not
for the care volunteered and provided by another inmate, E.A.
would likely have died.
The geriatric housing area located in George Allen is illequipped, overcrowded, and generally inadequate. The area is
equipped with double bunk beds. Because falls and injuries often

- 24 result from the use of such beds, elevated bunks pose a
significant risk to elderly inmates. Also, due to overcrowding,
many bunks are placed very close together, resulting in these
medically vulnerable inmates sleeping face-to-face. This greatly
increases the risk that respiratory infections may spread among
this more susceptible population.
Prenatal care at DCJ is also inadequate. DCJ does not
maintain a registry of pregnant inmates. Without such, it is
very difficult for DCJ to provide and monitor the necessary
specialized care, such as vaccinations. This is especially
troubling in light of the preventable illnesses that can occur in
correctional facilities. For example, if a pregnant inmate is
found to be susceptible to viral hepatitis B and contracts it
while at DCJ, this infection can be transmitted to the baby. DCJ
fails to screen or immunize pregnant inmates against hepatitis B.
11.

Inadequate Staffing, Training, and Supervision

DCJ maintains an insufficient number of medical and custody
staff to provide adequate medical services. Delays in access to
medical care are exacerbated by an insufficient number of staff
trained to identify, respond, and provide the necessary medical
treatment. Generally accepted standards of care require that
facilities maintain adequate staffing to provide inmates with
necessary medical care.
An example of the type of harm that arises from these
failures is the death of inmate W.T. on November 13, 2005. W.T.
had a history of schizophrenia and was receiving daily doses of
Lithium (an anti-depressant) and Zyprexa (an anti-psychotic). On
November 13, she fell from her top bunk as the result of an
apparent seizure. Officers responded, but did not send W.T. for
a medical evaluation. Instead, the officers reported to the
nurses on duty that W.T. was dizzy. Based on the information
provided by the officers, the nurses decided not to assess W.T.’s
condition. Within three hours, W.T. was found dead. This death
may have been prevented had the officers recognized that W.T.’s
condition was critical and communicated this to the nursing
staff.
Our investigation also revealed substantial nursing
vacancies, including vacancies for five registered nurses and ten
vocational nurses in February 2006. Some of these vacancies are
being temporarily filled with agency nurses who are unfamiliar
with jail policies and procedures. This staffing shortage has
been acknowledged by representatives of Parkland.

- 25 Moreover, DCJ is currently operating with an interim medical
director and an outside health services administrator to provide
leadership for medical care at the Jail. Full-time, on-site
administrators are needed to ensure appropriate medical treatment
is provided. In addition, there is insufficient staff to support
and provide the required medical care. A facility the size of
DCJ should have staff dedicated to training, infection control,
quality management, nursing direction, and utilization management
to monitor under and over-utilization of on-site and outside
services.
Finally, currently deficient medical services are hindered
further by DCJ’s shortage of correctional officers to escort
inmates to medical units.
12.

Inadequate Quality Assurance Review

DCJ fails to engage in consistent, effective quality
assurance review in order to track and trend medical-related
incidents at the facility. Investigative review, tracking, and
trending of such incidents is a critical component to implement
and monitor corrective action in order to avoid future incidents
and to keep inmates safe of medical-related harm.
For example, DCJ failed to conduct a mortality review
following the questionable death of C.G. who died five days after
entering the Jail. Although he reported a history of congestive
heart failure at intake in July 2004, C.G. received no clinical
evaluation and no medication while at DCJ. This inmate’s death
may have been related to a lack of medical care at DCJ, however
no autopsy or mortality review was conducted to ensure that
proper policies and procedures are in place to correct any
failures and ensure adequate care, prospectively.
13.

Inadequate Dental Care

DCJ fails to provide adequate dental care to its inmates.
Failure to treat inmates for dental-related conditions will
expose them to risk of infection and significant pain. During
our initial tour in February 2006, we found that no dental care
was provided to inmates. DCJ’s dentist started work on
February 21, 2006, but lacked an adequate examination room to
provide dental care – the dental chair had no water, no suction,
no light, no clean instruments, and no dental x-ray equipment.
These equipment deficiencies were still evident during our
subsequent on-site tour.

- 26 Notably, at the time of our March tour, there was a backlog
of 1,200 requests for dental care and inmates with serious dental
needs, such as tooth abscesses, which can cause bone infection if
not appropriately treated.
B.

MENTAL HEALTH CARE

Jail officials violate the Eighth Amendment when they
exhibit deliberate indifference to inmates’ serious mental health
needs. Gates, 376 F.3d at 333. Deliberate indifference may
include intentionally denying or delaying access to medical care,
or intentionally interfering with treatment or medication that
has been prescribed. Id. See also Woodall v. Foti,
648 F.2d 268, 272 (5th Cir. 1981) (finding that an inmate stated
a claim of “deliberate indifference” where prison officials knew
of his diagnoses as a pedophile and a manic depressive with
suicidal tendencies, but refused to treat him). Consequently, a
prison’s failure to take any steps to protect a suicidal detainee
from self harm may constitute a constitutional violation.
Partridge v. Two Unknown Police Officers of the City of Houston,
791 F.2d 1182, 1188 (5th Cir. 1986).
We find that DCJ fails to provide inmates with mental health
care that complies with these constitutional standards. DCJ
fails to address the specific needs of inmates with mental
illness, including: (1) failure to timely and appropriately
evaluate inmates for treatment; (2) inadequate assessment and
treatment; (3) inadequate psychotherapeutic medication
administration; and (4) inadequate suicide prevention.
1.

Failure to Timely and Appropriately Evaluate
Inmates for Treatment

DCJ fails to properly identify inmates with mental illness
through adequate screening. Adequate screening of incoming
detainees for mental health care needs is instrumental to a
facility’s ability to provide adequate mental health care to
inmates, and to reduce potential harm to those whose conditions
would otherwise go unrecognized at intake and throughout the
initial medical screening. Mental health screening should
comport with constitutional requirements and generally accepted
standards of care to aid in classification, identification of
emergent mental health care needs, provision of continuous care,
and management of medication.
Follow-up of known or newly identified mental health
problems is a key focus of intake screening. Mental health
screening information should be incorporated into an inmate’s

- 27 medical record. This ensures the prompt continuation of
necessary medication for all inmates with chronic mental health
conditions. Persons with potentially serious chronic mental
health illness (i.e., active psychosis, suicidal) should be
referred from screening for prompt mental health evaluations and
examinations by a psychiatrist.
As discussed above, DCJ’s medical screening and follow-up
practices deny care to inmates. DCJ does not have policies and
procedures to govern screening, including screening for mental
health needs. Additionally, intake screening officers and intake
nurses receive no training in detecting or querying inmates with
mental illness. Screening is currently done by paramedics
without policies or training on appropriate standards of care.
For mental health screening, DCJ staff utilize a self-report
form entitled “Mental Disability/Suicide Intake Screening Form”
that is not then incorporated into the medical record.
Consequently, we found that less than 20 per cent of inmates
referred for a mental health assessment were evaluated within
seven days after intake. In addition, these mental health
assessments are typically done by mental health liaisons who have
no specialized training in mental health care and are
inadequately supervised. We found that even for those inmates
affirmatively identified with serious mental illness, the
subsequent referral process to mental health is flawed.
2.

Inadequate Assessment and Treatment

DCJ fails to appropriately assess and treat inmates with
mental illnesses. Such failure is not in keeping with generally
accepted professional standards of correctional mental health
care and causes harm to inmates. The Jail’s failure to provide
adequate mental health assessment and treatment to inmates has
resulted in inmates’ mental health deterioration and unnecessary
suffering.
In one case, despite several referrals for psychiatric care,
an inmate’s condition was allowed to deteriorate for almost two
months before Jail staff administered any care; and then, only
after he had been laying prostrate in his own excrement for
three to four days. The inmate, D.C., was not receiving his
prescribed anti-psychotic and anti-seizure medication while he
was at the Jail in February 2004. After he was discovered, D.C.
was hospitalized for dehydration and consequent kidney failure.

- 28 Our investigation revealed significant problems with mental
health treatment records, specifically, the lack of adequate
assessments. Mental health assessments frequently fail to
account for inmates’ psychiatric histories as a result of the
inadequacy of medical documentation and general procedures
detailed above. Currently, when a nurse believes that an inmate
requires a mental health evaluation, the nurse notifies an
individual mental health worker by e-mail. However, logs of
these referrals are not kept. This type of referral system lends
itself to losing track of inmates who may need urgent attention,
thereby placing such inmates at risk of serious harm. Our
consultant also found that treatment plans were infrequently done
on a timely basis and treatment team meetings do not occur.
Consequently, the Jail fails to provide the essential
components of adequate treatment programs in a correctional
mental health system. The following programs fail to comply with
generally accepted professional standards of correctional mental
health care by lacking: crisis intervention, with beds available
in a health care setting for short-term treatment; acute care
(including inpatient level psychiatric care); and chronic care to
include a special needs unit for inmates with chronic mental
illness.
The crisis level of care lacks the capacity for necessary
short-term treatment due to the lack of a licensed infirmary.
There is simply no physical space for evaluating and treating
inmates. DCJ does not have access to an acute care program that
would provide appropriate access for inpatient hospitalization.
Also, a chronic care program for inmates with serious mental
illnesses does not exist. While the Jail does provide segregated
housing units that are designated for inmates with serious mental
illnesses, these housing units lack an adequate treatment program
that is an essential component of chronic care programs.
Accordingly, DCJ fails to provide the generally accepted
necessary components of a correctional mental health system.
As a result of not having access to an acute or chronic care
program, inmates who are the most symptomatic and impaired from
their mental health illnesses are generally inappropriately
locked down in single cells for 23 hours per day. Many detainees
with serious mental illness are harmed by the lack of adequate
treatment as manifested by either increased symptoms of their
underlying psychiatric disorder or lack of improvement regarding
their current symptoms. The following examples are illustrative:

- 29 !

Inmate T.W., admitted to DCJ on February 10, 2006, was
housed on a mental health housing unit. His health
care record had a notation at intake that he had been
receiving pyschotropic medications and needed to be
evaluated. However, at the time of our second tour in
late March, more than one month later, T.W. had still
not been assessed by mental health staff.

!

Inmate D.B. was on a hunger strike as early as
January 27, 2006, and had been diagnosed as being
psychotic by a nurse practitioner on March 2, 2006.
Yet, D.B. had no medical evaluation regarding her
nutrition and state of hydration, and no psychiatric
care for her psychosis until she had to be hospitalized
for lethargy (an abnormal state of drowsiness or
dullness) on March 11, 2006, nearly three months later.

!

In September 2005, inmate J.P. was assessed at intake
with a diagnosis of bipolar disorder. Over the next
six months, J.P. suffered from a significant lack of
continuity of care. During that time, four clinicians
each made different diagnoses (from active psychosis to
lacking a psychotic illness) and prescribed various
medications to J.P. without apparent reference to notes
in his medical file. Indeed, by March 12, 2006, J.P.’s
mental health had deteriorated to the point that Jail
staff repeatedly observed him eating his own feces.
3.

Inadequate Psychotherapeutic Medication
Administration

DCJ fails to timely and appropriately evaluate inmates for
the administration of pyschotropic medications and to monitor
their continued administration. Many DCJ inmates require
pyschotropic medications to avoid the unnecessary suffering of
acute episodes of mental illness. Moreover, inmates are
prescribed pyschotropic medications during intake but do not
receive timely evaluations to determine whether such
administration is appropriate. Generally accepted correctional
mental health care standards require that a physician see an
inmate patient usually before, but clearly shortly after, a
prescription for pyschotropic medication is written in order to
evaluate whether the medication should be maintained and to
evaluate the continued administration for proper dosage and
effectiveness. Inmates who remain untreated, or who are treated
without being seen by a physician, may suffer from a worsening of

- 30 their symptoms, including suicidal and homicidal thoughts, or
from potentially lethal side effects of medication. DCJ
consistently fails to comply with these standards.
We found significant problems at the Jail with regard to
psychotherapeutic medication management, including: delays
ranging from days to weeks, for inmates to begin receiving their
pyschotropic medication; inappropriate breaks in medication
administration due to housing changes and insufficient staffing;
numerous medication errors; and medications routinely prescribed
with 11 pre-approved refills, a dangerous practice resulting in
inadequate medication monitoring.
Our review of Jail records revealed numerous inmates
suffering from mental illness who did not receive their
prescribed medications in a timely manner. This practice has
resulted in serious harm to inmates. For example, despite a
documented 20-year history of schizophrenia, inmate O.C. did not
receive his prescribed pyschotropic medication for a five week
period between December 25, 2005, and February 2, 2006. This
overall lack of care and monitoring of pyschotropic medication at
DCJ is not in keeping with constitutional requirements or
standard practices of care.
4.

Inadequate Suicide Prevention

The current suicide prevention practices at DCJ are grossly
inadequate. Constitutional requirements and generally accepted
professional standards of correctional mental health care mandate
the development of suicide prevention standards. These standards
require an appropriate policy and procedure; education and
training for all staff members; appropriate screening to assess
suicide risk; appropriate housing for those identified as at
risk; appropriate supervision, observation, and monitoring of
those inmates so identified; appropriate referrals to mental
health providers and facilities; appropriate communication
between correctional health care and correctional personnel;
appropriate intervention addressing procedures of how to handle a
suicide in progress; and appropriate notification, reporting, and
review if a suicide does occur.
DCJ’s current practice of suicide prevention does not
comport with generally accepted professional standards of
correctional mental health care. The Jail’s written policy on
suicide prevention fails to ensure appropriate management of
suicidal inmates and lacks major components of an adequate

- 31 suicide prevention program. For example, DCJ’s policy does not
require that staff be trained on suicide recognition and
intervention.
The current intake screening/assessment process fails to
assess adequately the suicide risk factors of inmates. The
process is not under the direction of trained mental health
staff. As a result, correctional staff inappropriately have the
authority to place any inmate who they deem to be suicidal into a
“suicide cell,” which is a closed observation cell in which the
inmate is under continuous lock down. There are two housing
tiers designated as suicide tiers with eight cells in each tier
that are classified as suicide cells. These cells are reportedly
visually checked by an officer at regular intervals. However,
because this check is not formally logged, monitoring is
haphazard and places inmates in potential danger.
Moreover, placement in a suicide cell appeared to be
arbitrary. The assessment is seldom performed by a mental health
staff member so placement in a suicide cell is often
inappropriate and utilized as a form of punishment. Mental
health staff repeatedly reported that it is their perception that
few of the persons placed in these cells are actually suicidal.
In addition, mental health staff reported that they disagreed
clinically with existing suicide practices, especially the
stripping of inmates of all clothing and granting them only a
paper gown.
As stated above, intake officers received no training in
suicide screening and the communication between mental health
staff and correctional staff is informal. The significant
communication problems between custody and mental health staff
result in a fragmented, uncoordinated system. It is often
unclear who initiated suicide precautions during the central
intake process. In fact, our mental health consultant found that
suicide precautions were often initiated under a DCJ clinician’s
name without his knowledge or approval.
Inmates placed on suicide watch are being observed by
correctional officers who are ill-trained and who often have a
myriad of other responsibilities in addition to the observation
task. This is especially problematic at the George Allen
facility where the physical layout does not allow for direct
observation of the inmate on suicide watch. Additionally, the
room in which inmates are placed on suicide watch contains a
myriad of suicide hazards such as exercise equipment.

- 32 The current suicide prevention program also fails to contain
different levels of supervision of the inmate based on the
presenting risk factors for suicide. Moreover, due to a lack of
training, correctional staff are ill-prepared to handle a suicide
in progress, including how to cut down a hanging victim and
employ other first-aid measures. Finally, contrary to generally
accepted practice, there is no administrative review following a
suicide or a suicide attempt to identify what could have been
done to prevent the incident.
Our review of the records of several inmate suicides
revealed significant problems. The following examples are
illustrative:
!

C.L., a 27-year-old inmate, died on October 10, 2005,
of toxic effect of an overdose of nortriptyline, an
antidepressant medication that had not been prescribed
to him. His suicide intake screening assessment had
never been completed. C.L.’s problem list in his
medical record included “mental health issues.”
A nursing clinical note, dated February 15, 2005,
indicated that his sister had called concerned that
C.L. had voiced suicidal thoughts. Yet, C.L. never
received a mental health evaluation while he was
incarcerated at DCJ.

!

While on suicide watch, inmate K.B. hung himself in
July 2003. The physician assistant subsequently
reported that he had not been able to interview the
inmate due to the lack of an available detention
officer escort. As a result, K.B.’s transfer to a
closed behavioral observation tank was delayed. This
case highlights issues related to inadequate
supervision, poor communication between custody and
mental health staff, and the lack of adequate numbers
of detention officers for escort/transfer purposes.

!

Inmate M.K. hung herself on January 5, 2003 after
having been admitted on December 4, 2002. Her record
contained the following inmate request form dated two
days before her death on January 3, 2003. The note
indicated the following:
I need to see the doctor to get my
medicine straightened out. I am
not getting my meds that my doctor
faxed prior orders for me, and I

- 33 brought in the medication myself and paid for it.
I cannot afford to be treated this way! Please
help me! I need my medicine.
There is no indication that M.K. received her
medication before her death. The case reflects
inadequate screening for mental illness, inadequate
screening for suicide prevention purposes, lack of
timely access to needed medications, and the lack of
timely response to an inmate request form.
C.

SANITATION AND ENVIRONMENTAL CONDITIONS

Prison officials must ensure that inmates receive adequate
food, clothing, and shelter, Farmer, 511 U.S. at 832, and that
prisoners are not “deprive[d] . . . of the minimal civilized
measure of life’s necessities.” Rhodes v. Chapman, 452 U.S. 337,
347 (1981). Certain prison conditions are so base, inhuman and
barbaric that they violate the Eighth Amendment. Palmer v.
Johnson, 193 F.3d 346, 352 (5th Cir. 1999) (citation omitted).
One such condition is the deprivation of basic elements of
hygiene. Id. See also Gates, 376 F.3d at 338 (finding that
filthy cell conditions constituted an Eighth Amendment
violation). DCJ fails to ensure that sanitary and environmental
conditions are in accordance with these constitutionally minimal
standards.
1.

Inadequate Sanitation of Laundry

DCJ laundry procedures fail to protect inmates from the risk
of contagious diseases and/or exposure to bodily fluids and
excretions. DCJ lacks adequate procedures for distributing or
requesting replacement uniforms. Likewise, inmate uniforms and
linens are inadequately cleaned and ragged.
Equipment at the central laundry facility is outdated and
inadequate to handle the volume of laundry that the Jail
produces. Because inmate laundry is often returned from the
laundry facility still soiled, many inmates resort to washing
their laundry by hand in toilets, sinks, and mop buckets, using
detergent available from the DCJ commissary. This practice is
unhygienic and contributes to the spread of contagious diseases,
such as MRSA. Moreover, as a result of these laundering
practices, inmates hang their laundry in their cells to dry,
limiting security staff’s ability to observe inmates, creating a
security and fire risk.

- 34 2.

Inadequate Protection From Biohazards

Current Jail practices expose inmates and staff to
infectious diseases and aerosolized pathogens through improper
contact with blood and other body fluids. The Jail fails to
adequately contain, secure, store, dispose, and quarantine
biohazardous materials.
Inmates and staff do not receive adequate safety equipment,
cleaning chemicals, or supervision when cleaning and disposing of
biohazardous materials. Biohazard spill kits are not readily
accessible in the housing areas and biohazardous waste is not
properly disposed of. Biohazardous waste is stored with office
supplies, potentially exposing staff to aerosolized pathogens.
Pathogens generally include any organism such as bacteria and
viruses that cause disease in human beings. Thus, inmates and
staff may be exposed to increased risk of illness when exposed to
such pathogens. Accordingly, biohazardous waste should be marked
properly and appropriately disposed as such.
We also found that containers located in the medical areas
for the disposal of sharp biohazardous tools are improperly
installed, thereby compromising readily safe disposal. Further,
sharp medical tools, such as needles and dental utensils, are
left unsecured and in the open, creating a significant safety and
security risk for both staff and inmates.
3.

Lack of Environmental Control

The Jail lacks adequate control over razors and commissary
items distributed to inmates. Hundreds of razors were observed
throughout the Jail - virtually all with the blades missing.
These ubiquitous razor blades create two problems. First, these
blades pose a serious security hazard. There are countless razor
blades in the hands of DCJ inmates and all are potential weapons.
Second, the sharing of razors amongst inmates can lead to the
spread of diseases such as MRSA, hepatitis, and AIDS.
Because the Jail fails to control inmate commissary, inmates
stockpile commissary items, which indicates that there may be a
significant underground market among the inmates. We saw several
stockpiles of commissary items like food and razors amassed by
inmates that were too large to be for individual consumption.
This situation can lead to security and control problems such as
inmate-on-inmate violence, as well as an increase in pest
problems such as rodents.

- 35 Additionally, the Jail allows brooms and mops to remain in
cells for extended periods of time. Such a practice ignores the
fact that these items can be used as, or converted into, weapons.
4.

Inadequate Sanitation of Facilities

It is the Jail’s duty to ensure housing units and bathroom
areas are adequately cleaned. Cleaning can be performed by
inmates, but appropriate materials and supervision is required.
The Jail’s sanitation practices are grossly inadequate and vary
widely among each facility. Cleaning was not uniform throughout
the facilities, indicating that oversight by staff is better in
some areas than in others. Parts of the Jail are filthy,
subjecting inmates to increased risk of health problems.
Bacteria like MRSA can survive in a dried state on various jail
surfaces for significant lengths of time. DCJ’s failure to keep
the Jail adequately clean greatly increases the risk that inmates
will be exposed to such dangerous bacteria.
There is inadequate cleaning and maintenance of toilet and
shower areas throughout the Jail. Numerous showers and toilets
were in need of repair, rendering them inoperable or difficult to
use. Several combination sink and toilet units were seen
leaking, causing the floor area to remain wet for extended
periods of time. This situation promotes the growth of mold and
bacteria that can lead to infections as well as creates a slip
hazard, a critical risk to security if staff need to respond to
an urgent matter. Moreover, floor and shower drains are in poor
condition and need to be thoroughly cleaned. We observed drain
flies and large concentrations of fly larvae in the bathroom
areas, which is indicative of an unsanitary environment.
5.

Inadequate Fire and Life Safety Systems

DCJ fails to ensure adequate fire and life safety systems
throughout the Jail. It is critical that smoke detection systems
are provided in all sleeping areas, especially where only a
limited number of housing areas are equipped with smoke removal
systems. Fire equipment, such as air tanks and fire
extinguishers, must have up-to-date inspections and be properly
maintained. Also, safety tools must be accessible and in good
working condition. DCJ, however, does not meet these standard
system requirements.
Some areas of the Jail are not equipped with smoke detection
equipment. Also, DCJ does not ensure that all staff maintain a
working knowledge of, and the ability to execute, the Jail’s
emergency evacuation procedures. Many staff members did not know

- 36 the location of emergency keys or of the markings that enable the
keys to be identified by touch. Moreover, some emergency keys
lacked these markings. This is a significant departure from
generally accepted professional standards of care. Further,
during our February tour, we identified the fire hazard of
allowing inmates to keep excessive amounts of newspaper in their
cells. We understand that DCJ has taken measures to address the
presence of newspapers in inmate cells, however we have not had
the opportunity to fully evaluate these measures.
IV.

RECOMMENDED REMEDIAL MEASURES

In order to address the constitutional deficiencies
identified above and protect the constitutional rights of
inmates, DCJ should implement, at a minimum, the following
measures in accordance with generally accepted professional
standards of corrections care:
A.

Medical Care

1.

Intake Screening
a.

Ensure that adequate intake screening and health
assessments are provided. Develop and implement an
appropriate medical intake screening instrument that
identifies observable and non-observable medical needs,
including infectious diseases, and ensure timely access
to a physician when presenting symptoms require such
care.

b.

Ensure that acute and chronic health needs of inmates
are identified in order to provide adequate medical
care.

c.

Ensure that medical screening information is reviewed
in a timely manner by trained medical care providers.

d.

Provide adequate screening and health assessments for
juveniles in accordance with generally accepted
standards of care and ensure adequate evaluation for
mental illness and suicide risk.

e.

Ensure that tuberculosis screening is conducted in a
timely manner.

- 37 2.

3.

Acute care
a.

Provide timely medical appointments and follow-up
medical treatment. Ensure that inmates receive
treatments that adequately address their serious
medical needs. Ensure that inmates receive acute care
in a timely and appropriate manner.

b.

Provide adequate acute care for inmates with serious
and life-threatening conditions.

c.

Ensure that staff are adequately trained and prepared
to handle emergent situations in accordance generally
accepted professional standards.

Chronic care
a.

Ensure that inmates receive thorough assessments for,
and monitoring of, their chronic illness. Develop
clinical practice guidelines for inmates with chronic
and communicable diseases. Ensure that standard
diagnostic tools are employed to administer the
appropriate preventative care in a timely manner.

b.

Adopt and implement appropriate clinical guidelines for
chronic diseases such as HIV, hypertension, diabetes,
asthma, and elevated blood lipids, and policies and
procedures on, inter alia, timeliness of access to
medical care, continuity of medication, infection
control, medicine dispensing,
intoxication/detoxification, record-keeping, disease
prevention, and special needs.

c.

Ensure that medical staff are adequately trained to
identify inmates in need of immediate or chronic care,
and provide timely treatment or referrals for such
inmates.

d.

Ensure that inmates with chronic conditions are
routinely seen by a physician to evaluate the status of
their health and the effectiveness of the medication
administered for their chronic conditions.

e.

Ensure adequate follow-up treatment and medication
administration concerning all inmates with chronic
conditions.

- 38 4.

5.

Treatment and Management of Communicable Disease
a.

Provide adequate treatment and management of
communicable diseases, including TB and MRSA.

b.

Ensure that inmates with communicable diseases are
appropriately screened, isolated, and treated.

c.

Ensure that inmate and staff do not interfere with HVAC
and negative pressure systems.

d.

Develop and implement an adequate TB control plan in
accordance with generally accepted standards of care.
Such should provide guidelines for identification,
treatment, and containment to prevent transmission of
TB to staff or inmates.

e.

Develop and implement policies that adequately manage
contagious skin infections. Develop a skin infection
control plan to set expectations and provide a work
plan for the prevention of transmission of skin
infections, including drug-resistant infections to
staff and other inmates.

f.

Conduct a sufficient initial health assessment,
including screening for TB and sexually transmitted
disease, of all inmates in a timely fashion.

g.

Develop and implement adequate guidelines to ensure
that inmates receive appropriate wound care.

Access to Health Care
a.

Ensure inmates have adequate access to health care.

b.

Ensure that the medical request process for inmates is
adequate and provides inmates with adequate access to
medical care. This process should include logging,
tracking, and timely responses by medical staff.

c.

Develop and implement an effective system for triaging
medical requests. Ensure that sick call requests are
appropriately triaged based up the seriousness of the
medical issue.

- 39 6.

Follow-Up Care
a.

7.

8.

9.

Provide adequate care and maintain appropriate records
for inmates following hospitalization. Ensure that
inmates who receive specialty or hospital care are
evaluated upon their return to the facility and that,
at a minimum, discharge instructions are noted and
appropriately provided.

Record Keeping
a.

Ensure that medical records are adequate to assist in
providing and managing the medical care needs of
inmates at DCJ.

b.

Ensure that medical records are complete, accurate,
readily accessible, and systematically organized. All
clinical encounters and reviews of inmates should be
documented in the inmates’ records.

Medication Administration
a.

Ensure that treatment and administration of medication
to inmates is implemented in accordance with generally
accepted professional standards of care.

b.

Ensure that administration of medication is accurate
and adequately documented. Develop policies and
procedures for the accurate administration of
medication and maintenance of medication records.
Provide a systematic review of the use of medication to
ensure that each inmate’s prescribed regimen continues
to be appropriate and effective for his or her
condition.

c.

Ensure that medicine distribution is hygienic and
appropriate for the needs of inmates.

Medical Facilities
a.

Ensure that sufficient space is available to provide
inmates with adequate medical care services including:
intake screening, sick call, physical assessment, and
acute, chronic, emergency, and speciality medical care
(such as geriatric and pregnant inmates).

- 40 b.

10.

11.

12.

Ensure that medical areas are adequately clean and
maintained, including installation of adequate lighting
in medical exam rooms. Ensure that hand washing
stations in medical areas are fully equipped,
operational, and accessible.

Specialty Care
a.

Ensure that specialty consultations are timely and that
any resulting reports are forwarded to DCJ staff.
Specialist recommendations should be implemented in a
timely manner or, where deemed inappropriate, a DCJ
physician should properly document why such
recommendations were not implemented. Provide adequate
long-term care planning for inmates with chronic
illnesses.

b.

Ensure that inmates are provided adequate access to
specialty care in accordance with generally accepted
professional standards of care.

c.

Ensure that pregnant inmates are provided adequate care
in accordance with generally accepted professional
standards of care.

Staffing, Training, and Supervision
a.

Provide adequate staffing, training, and supervision of
medical and correctional staff necessary to ensure
adequate medical care is provided.

b.

Ensure that medical staffing is adequate for inmates’
serious medical needs and that physicians adequately
monitor their patients.

c.

Provide adequate physician oversight and supervision of
medical staff.

d.

Ensure that there is an adequate number of correctional
officers to escort inmates to medical units.

Quality Assurance Review
a.

Ensure that DCJ’s quality assurance system is adequate
to identify and correct serious deficiencies with the
medical system.

- 41 b.

13.

Ensure that DCJ’s quality assurance system is capable
of assisting in managing and treating inmate medical
needs. At a minimum, such a system should be reliable
and capable of tracking medical-related incidents.

Dental Care
a.

Ensure that inmates receive adequate dental care in
accordance with generally accepted professional
standards of care. Such care should be provided in a
timely manner.

B.

Mental Health Care:

1.

Timely and Appropriately Evaluate Inmates
a.

Ensure that DCJ properly identifies inmates with mental
illness through adequate screening.

b.

Ensure that inmates with potentially serious chronic
mental health illness are referred for prompt mental
health evaluations and examinations by a psychiatrist.

c.

Provide adequate mental health assessment and treatment
in accordance with generally accepted professional
standards of mental health care.

d.

Ensure that adequate crisis services are available to
address the psychiatric emergencies of inmates.

e.

Provide staffing adequate for inmates’ serious mental
health needs. Provide adequate on-site psychiatry
coverage. Ensure that psychiatrists see inmates in a
timely manner. Ensure that pyschotropic medication
prescriptions are reviewed by a psychiatrist on a
regular, timely basis.

f.

Provide adequate screening to properly identify inmates
with mental illness. Ensure that DCJ’s intake
evaluation process includes a mental health screening
that is incorporated into an inmate’s medical record.

g.

Develop and implement an appropriate intake screening
instrument that identifies mental health needs, and
ensure timely access to a mental health professional
when presenting symptoms require such care.

- 42 2.

3.

Assessment and Treatment
a.

Ensure that treatment plans adequately address
inmates’ serious mental health needs and that the plans
contain interventions specifically tailored to the
inmates’ diagnoses and problems. Provide therapy
services where necessary for inmates’ serious mental
health needs. Provide adequate opportunities for
inmates and staff to have confidential communications
related to mental health treatment, while maintaining
appropriate security precautions.

b.

Ensure that mental health evaluations done as part of
the disciplinary process include recommendations based
on the inmate’s mental health status.

c.

Provide adequate on-site psychiatry coverage for
inmates’ serious mental health needs. Ensure that
psychiatrists see inmates in a timely manner and that
pyschotropic medication orders are reviewed by a
psychiatrist on a regular, timely basis.

d.

Ensure that medications are provided to inmates in a
timely manner and that they are properly monitored.

e.

Provide staffing adequate for inmates’ serious mental
health needs. Ensure that services, such as
distribution of medications, are performed by nurses or
other properly trained staff.

f.

Provide policies and procedures that appropriately
assess inmates with mental illness.

g.

Provide adequate medical documentation and general
procedures as part of the mental health assessments
that account for inmates’ psychiatric histories.

h.

Develop and implement an appropriate intake screening
instrument that identifies mental health needs, and
ensure timely access to the mental health professional
when presenting symptoms require such care.

Psychotherapeutic Medication Administration
a.

Ensure timely responses to orders for medication and
laboratory tests, and prompt documentation thereof in
inmates’ charts.

- 43 -

4.

5.

b.

Ensure that adequate psychotherapeutic medication
administration is provided in accordance with generally
accepted professional mental health care standards.

c.

Ensure that changes to inmates’ pyschotropic
medications are clinically justified. Screen inmates
on pyschotropic medications for movement disorders and
provide treatment where appropriate.

d.

Ensure that inmates receive adequate screening and
evaluation for the administration of pyschotropic
medications in a timely manner.

Suicide Prevention
a.

Provide adequate treatment for inmates with selfinjurious behavior.

b.

Develop policies and procedures to ensure appropriate
management of suicidal inmates and the establishment of
a suicide prevention program.

c.

Ensure that all staff are educated and trained on
suicide recognition and intervention.

d.

Screen all inmates upon intake, including questioning
to assess current and past suicide risk.

e.

Ensure that suicidal inmates are housed in an area that
is safe for them with appropriate supervision and
observation by staff.

f.

Provide different levels of supervision of an inmate
based on the presenting risk factors for suicide.

g.

Provide adequate suicide prevention training to all
staff.

h.

Ensure that a component of administrative review is
implemented following a suicide or a suicide attempt to
identify what could have been done to prevent the
suicide.

Other Issues
a.

Ensure
status
mental
mental

that administrative segregation and observation
are not used to punish inmates for symptoms of
illness and behaviors that are, because of
illness, beyond their control.

- 44 b.

Ensure that DCJ mental health records are centralized,
complete, and accurate.

c.

Ensure that DCJ’s quality assurance system is adequate
to identify and correct serious deficiencies with the
mental health system.

d.

Ensure that a psychiatrist or physician conducts an
in-person evaluation of an inmate prior to a seclusion
or restraint order, or as soon thereafter as possible.
Seclusion or restraint orders should include sufficient
criteria for release.

C.

Sanitation and Environmental Conditions:

1.

Sanitation of Laundry
a.

2.

Ensure that laundry procedures protect inmates from
exposure to contagious disease, bodily fluids, and
pathogens. Develop and implement a policy for
handling, washing, and drying of laundry. Train staff
and educate inmates regarding laundry sanitation
policies.

Protection from Biohazards
a.

Develop and implement policies and procedures for
cleaning, handling, storing, and disposing of
biohazardous materials.

b.

Ensure that any inmate or staff asked to clean up a
biohazard be properly outfitted with protective
materials and trained in universal precautions before
cleaning. Ensure proper supervision of biohazard
cleaning.

c.

Use cleaning chemicals that sufficiently destroy the
pathogens and organisms in biohazard spills.

d.

Develop and implement policies and procedures for the
control of chemicals in the facility, and supervision
of inmates who have access to these chemicals.

e.

Install biohazard disposal containers in medical areas
so that there is no unnecessary risk to staff.

f.

Secure all sharp medical tools.

- 45 g.
3.

Environmental Control
a.

4.

5.

Destroy any mattress that cannot be sanitized
sufficiently to kill any possible bacteria.

Ensure adequate control and observation of Jail cells,
particularly with regard to razors, fire loading
materials, commissary items, and cleaning supplies.

Sanitation of Facilities
a.

Develop and implement policies and procedures to ensure
adequate cleaning and maintenance of the facilities
with meaningful inspection processes and documentation.
Such policies should include oversight and supervision,
as well as establish daily cleaning requirements for
toilets, showers, and housing units.

b.

Ensure prompt and proper maintenance of shower, toilet,
and sink units.

Inadequate Fire and Life Safety
a.

Ensure that all facilities have adequate fire and life
safety equipment, which is properly maintained and
inspected.

b.

Implement competency based testing for staff regarding
fire/emergency procedures. Train staff in use of
cut-down tools.

c.

Ensure that emergency keys are appropriately marked and
consistently stored in a quickly accessible location.

d.

Ensure that fire alarms are installed and maintained in
all housing areas.
* * * * * * * * * * * * * * * * *

Please note that this findings letter is a public document.
It will be posted on the Civil Rights Division’s website. While
we will provide a copy of this letter to any individual or entity
upon request, as a matter of courtesy, we will not post this
letter on the Civil Rights Division’s website until ten calendar
days from the date of this letter.
We hope to continue working with the County in an amicable
and cooperative fashion to resolve our outstanding concerns
regarding DCJ. Assuming there is a spirit of cooperation from

- 46 the County and DCJ, we also would be willing to send our
consultants’ evaluations under separate cover. These reports are
not public documents. Although the consultants’ evaluations and
work do not necessarily reflect the official conclusions of the
Department of Justice, their observations, analysis, and
recommendations provide further elaboration of the issues
discussed in this letter and offer practical technical assistance
in addressing them.
We are obligated to advise you that, in the entirely
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
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 you and are confident that we will be able to
do so in this case. The lawyers assigned to this investigation
will be contacting the facility’s attorney 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:

Ms. Maurine Dickey
Dallas County Commissioner District 1
Mr. Mike Cantrell
Dallas County Commissioner District 2
Mr. John Wiley Price
Dallas County Commissioner District 3
Mr. Kenneth A. Mayfield
Dallas County Commissioner District 4

- 47 Bill Hill, Esquire
District Attorney
Dallas County
Ms. Lupe Valdez
Sheriff
Dallas County
The Honorable Richard B. Roper, III
United States Attorney
Northern District of Texas