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Cripa Cleveland Oh Investigation Holding Cells 6-4-03

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U.S. Department of Justice
Civil Rights Division

Special Litigation Section - PHB
950 Pennsylvania Avenue, N.W.
Washington, DC 20530

June 4, 2003
Subodh Chandra, Esq.
Law Director
Cleveland City Hall
601 Lakeside Avenue
Room 106
Cleveland, Ohio 44114
Re: 	 Investigation of Cleveland Division of Police
Central Prison Unit and Holding Cell Facilities
Dear Mr. Chandra:
As you know, the Civil Rights Division is conducting an
investigation of the Cleveland Division of Police (CDP) pursuant
to the Violent Crime Control and Law Enforcement Act of 1994,
42 U.S.C. § 14141, as well as the Safe Streets Act, 42 U.S.C.
§ 3789d. On July 23, 2002, we notified you that the Division had
expanded the scope of this investigation to include conditions of
confinement at the Central Prison Unit (CPU) and district police
station holding facilities. We greatly appreciate the continuing
cooperation of the City and the CDP in our investigation.
The CDP has a total of 150 holding cells currently in use
located in six separate facilities. The CPU is a 50-cell, secure
facility located within the police headquarters building in the
Third District. The five separate holding cell facilities in the
First, Second, Fourth, Fifth, and Sixth Districts have
approximately 20 cells in each district. We understand that each
of these facilities is considered to be a “five day facility” as
defined by Ohio Revised Code § 5120:1-7-02(A)(2). Accordingly,
these facilities are subject to the standards set forth in the
Minimum Standards for Jails In Ohio, promulgated by the Ohio
Director of the Department of Rehabilitation and Correction.
Although we are ultimately guided by constitutional and federal
statutory standards, we have considered these standards as well,


along with other relevant materials, in making the observations
and formulating the recommendations described below.
In 2001, over 50,000 detainees were held in CDP holding
cells. The holding cells are intended for short-term, prearraignment detention. Our preliminary review indicates that
detainees are typically held for 24-48 hours, but that a number
of detainees were held for as long as five days. The Deputy
Chief for administrative operations has responsibility for all
holding cell operations. The CPU and holding cell facilities are
supervised by the CDP Commander for Administrative Services,
assisted by a CDP captain, lieutenant and a sworn officer-incharge (OIC). At the CPU, the OIC’s sole responsibility is to
supervise the day to day operation of the jail. By contrast,
each district’s OIC, often a sergeant, is responsible for
overseeing the general operation of the district, as well as the
holding cell facilities. The district OICs report directly to
the district commanders. The CPU and district OICs each
supervise a staff of Institutional Guards (IGs), civilian CDP
employees who perform the day-to-day functions within the
facilities. Although the CPU OIC exercises significant
supervision over the IGs under his/her command, in the districts
the IGs generally operate the district facilities with limited
involvement by the OIC. District holding cell facility
operations also are supervised by the Commander for
Administrative Services.
Over the course of three trips, September 5-6,
October 15-16, and October 22-23, 2002, we toured the CPU and
each of the five police district holding facilities three
separate times with consultants in medical care, suicide
prevention, correctional practices, and environmental health and
safety. We have interviewed the command staff charged with
administration of these facilities, medical personnel, the food
service contractor, numerous institutional guards and detainees,
and the officers in charge of each facility. Following each of
our visits, we conducted informal exit conferences with CDP
command staff and holding cell supervisors in which we related
our preliminary concerns about conditions in the holding cells
and highlighted particular areas including suicide prevention,
fire safety, and security practices. This letter provides a more
comprehensive discussion of our concerns and recommendations in
the following areas: suicide prevention, medical care, fire
safety, security and administration practices, and environmental
health and safety. This letter is limited to conditions in the


holding cell facilities and does not include further discussion
of the issues raised about other CDP policies and practices in
our letter dated July 23, 2002.
Some of the concerns addressed in this letter relate to
physical and environmental conditions in the CDP holding cells,
while others relate to detention policies and procedures, e.g.
detainee intake. The City and the CDP could address many of the
concerns regarding medical care, physical conditions and
environmental conditions by implementing our recommendations in
the CDP holding cells or by housing detainees in an expanded or
alternative facility. With respect to other concerns raised in
this letter, we suggest that the CDP revise and expand upon its
detention polices and procedures in order to implement our
recommendations, regardless of whether the CDP decides to house
detainees in an alternate location.
This letter discusses the results of our tours and
investigation of the CPU and holding cell facilities to date. We
continue to review documents that were recently provided to us by
the CDP relating to the use of the restraint chair at the CPU.
We will notify you of any additional concerns.

Suicide Prevention

Within the past three years there have been a number of near
fatal suicide attempts, by hanging, by CDP detainees. Our review
of suicide prevention measures throughout the CDP holding cells
revealed that the CDP lacks adequate measures for suicide risk
assessment and suicide prevention. We recommend that the CDP
immediately address this potentially life-threatening issue.
While further specific recommendations are provided below, in
general, we recommend that the CDP develop and implement written
policies and procedures in the following areas of suicide
prevention: intake screening focusing on suicide risk; staff
training; communication and intervention; safe housing of
suicidal detainees; follow-up; and mortality review.

Identification and Screening

Effective identification and screening procedures are
critical to any jail’s suicide prevention efforts. The CDP’s
initial identification and screening process is insufficient to
identify a detainee’s suicide risk for several reasons. When a
detainee is initially processed into a holding cell, a Booking


Information Form is completed. This form has only two areas of
suicide risk inquiry, and we understand that the arresting
officer fills out the form without necessarily consulting the
detainee. This process is problematic because the arresting
officer may not have or be able to solicit accurate information
regarding the detainee’s level of suicide risk. In addition,
there is an increased likelihood that suicidal indicators will be
overlooked to the extent that an officer relies on observations
of any suicidal behavior instead of direct questioning of the
detainee. The likelihood that suicidal indicators will be
overlooked is further increased by the fact that the arresting
officers have not received adequate training to identify
potentially suicidal behavior and the lack of involvement by
medical personnel in screening detainees.
The Booking Information Form is also an inadequate screening
tool because it does not sufficiently inquire into a detainee’s
potential suicide risk. For example, the form fails to inquire
about a detainee’s current thoughts of self-harm, history of
suicidal behavior and current or prior mental health treatment.
In addition, the Booking Information Form fails to include a
“Disposition” section indicating actions which are to be taken
once a detainee is determined as a potential suicide risk.
Further, the CDP does not have an automatic mechanism for staff
to determine whether the detainee was deemed to be a suicide risk
during a prior CDP confinement.
We recommend that the Booking Information Form be revised to
include all areas of inquiry into potentially suicidal behavior
identified below. The revised booking procedures should include
inquiry by the booking officer as to any information known to the
arresting officer and/or the detainee which indicates that the
detainee is a medical, mental health or suicide risk. Further,
inquiries should be directed to the detainee regarding his/her
current thoughts of self-harm, recent significant loss (death of
a family member/close friend, break-up of a significant
relationship, job loss); history of suicidal behavior by the
detainee or a family member; expression of hopelessness/
helplessness; and current or prior mental health treatment.
In addition, we recommend that the CDP review and revise its
Record Management System (RMS)to provide for easier access to
information regarding a detainee’s prior suicide risk while in
the jail system. When a new detainee is booked, CDP personnel
should verify through RMS whether the detainee was a medical,


mental health, or suicide risk during any prior CDP confinement.

Staff Training

The CDP lacks written policies to guide staff regarding the
appropriate levels of supervision of suicidal detainees. The
CDP’s training curriculum for both IGs and sworn officers fails
to convey current standards of care. In addition, the CDP does
not provide any annual suicide prevention training to its
facility staff. This overall lack of suicide prevention training
and guidance significantly hampers the IGs, who have the most
contact with the detainees, in their ability to prevent a
suicide. Moreover, OICs and other sworn officers who may come
into contact with potentially suicidal arrestees are not provided
appropriate training to help identify and assist such
individuals. For example, the CDP training does not provide
adequate training on the specific indicators of an increased risk
of suicide.
We strongly recommend that the CDP develop pre-service and
annual in-service training programs for both IGs and sworn
officers in the area of suicide prevention. Training for IGs
should also include specific instruction regarding the role of
jail and medical staff in responding to suicide attempts and
providing first aid and CPR. Annual suicide prevention inservice training should be provided for holding cell and medical
We would be pleased to provide further technical assistance
in the development of appropriate policies and a training

Communication and Intervention

The CDP also lacks formal policies governing the
communication of information regarding suicidal detainees. We
observed a general absence of the communication among staff in
the holding cell facilities that is necessary to prevent detainee
suicide attempts. Because detainees can pose a suicide risk at
any point during their detention, staff must constantly maintain
awareness, share information and make appropriate referrals to
mental health and medical staff. However, as discussed below,
there is insufficient medical staff involvement in the initial
screening and intake of detainees. This inadequacy is compounded
by the lack of verbal and written communication between and among


staff, especially medical staff. For example, an in-custody
death at the CPU occurred shortly before our October 2002 tour,
however, medical staff we spoke with were unable to provide us
with information regarding the surrounding circumstances.
Although apparently not a suicide, this incident demonstrates the
medical staff’s lack of involvement in or knowledge of
significant events in the holding cell facilities. In addition,
during our second tour of the CPU, we noticed that a detainee was
dressed in a paper gown and was housed in a cell reserved for
suicidal detainees. Despite the fact that the detainee was on
“suicide watch,” the IG we spoke with was unable to provide us
with any documentation indicating that the detainee was
potentially suicidal. Instead, the CPU “jail log” only indicated
that this detainee had hepatitis B.
We recommend that the CDP develop and implement written
policies for communicating the medical and mental health needs of
detainees, including potential suicide risk, to relevant
personnel. These policies should establish a procedure for
communicating information from one shift to another, as well as
from one district holding facility to another following
transportation. In addition, we recommend that medical staff,
who currently have very limited holding cell facility duties,
meet on a regular basis to assess suicidal detainees.
The CDP’s practices regarding intervention measures
following the discovery of a suicide attempt are adequate in
general, although these practices were not formalized in a
written policy and we noted inconsistent implementation of these
practices. For instance, all IG and police personnel were
reported to be certified in first aid and CPR (although one
sergeant admitted that he had not received any CPR training since
1993). In addition, each facility had a first aid kit (although
several kits were not fully stocked) and appropriate cutting
tools in the event of a suicide attempt by hanging. Finally,
each facility had an Automated External Defibrillator (AED) and
the IGs were trained in its use. The placement of AEDs exceeds
both state and national standards and is commendable.
We recommend that the CDP develop and implement written
policies and procedures for intervention following a suicide
attempt. These policies should include specific instruction
regarding the role of all jail and medical staff in responding to
suicide attempts and providing first aid and CPR. In addition,
with respect to the proposed annual in-service suicide prevention


training, the CDP should also review its intervention procedures
and schedule “mock drills.”

Housing and Level of Supervision

All of the CDP’s holding cells pose significant problems for
housing suicidal detainees. All of the facilities have cells
containing dangerous protrusions that can serve as anchoring
devices in hanging attempts. For instance, all facilities have
cells with horizontal and vertical bars, with large-gauge mesh
wiring on the upper bars that obstructs visibility, and air vents
located on the walls, also with large-gauge mesh wiring. Other
dangers evident in all facilities were large-gauge cages over
smoke alarms and large-gauge mesh wiring over ceiling vents. At
the First, Fourth and Fifth Districts, we observed holes in the
mattress platforms through which a sheet or other item could be
anchored. Exposed electrical conduits were observed at the CPU,
the First, Fourth and Fifth Districts. The Fourth and Fifth
Districts also have blind spots that prevent staff from
monitoring potentially suicidal detainees.
We recommend that the CDP ensure that specific cells are
designated to house suicidal detainees and that these cells be
made as suicide resistant as possible, i.e., remove obvious
protrusions, such as those described above. As our consultants
emphasized during our exit interviews, we also recommend that due
to the numerous protrusions, distance from staff, and obstructed
visibility in the present isolation holding cells, suicidal
detainees should not be housed in these cells, until the
designated cells are made as suicide resistant as possible. We
recommend that these cells not be used until they can be
modified. As an interim measure, suicidal detainees should be
housed in cells where they may be continuously observed by staff.
In addition to the physical deficiencies of the cells, we
also found that the supervision provided to suicidal detainees is
inadequate. It appears that the CDP’s practice is to isolate
suicidal detainees in a cell that is in reasonably close
proximity to staff. However, the cells utilized in some
districts were too far away from the IG’s station to allow for
close supervision or obstructed from view because of the physical
design of the facility. For example, in the Fifth District, the
cells used for isolating detainees were located in a separate
area behind a cement wall; an area reportedly designated for



Follow-Up and Mortality Review

The CDP does not currently have a formalized “follow-up
review process” for suicide attempts or “mortality review
process” for all detainee deaths, and the current process appears
to be inadequate. The purpose of follow-up or mortality reviews
is to investigate the underlying events and to learn how to
prevent future incidents. This does not appear to be the focus
of the CDP’s follow-up or mortality reviews, however. For
instance, regarding an attempted hanging in the First District,
the CDP review failed to raise any issues concerning basic
suicide prevention practices. In fact, the two reviewing
sergeants concluded only that no actual policies were violated in
that case. The review did not address that fact that the
detainee had made multiple suicide attempts in the same holding
facility, indicating that the second and third attempts could
have been prevented.
We recommend that the CDP institute a formalized follow-up
and mortality review process following a detainee death or
suicide attempt. Furthermore, we recommend that the review be
conducted by a multi-disciplinary committee comprised of jail
personnel and medical and mental health professionals.

Medical Care

The CDP has no systematic method of providing medical care
to detainees. There are no policies or procedures specifically
directed to guide medical treatment for detainees. The only
existing policies that touch on medical care are general police
orders that provide guidance for accepting detainees into the
jail and relate to transporting detainees to the hospital or
emergency room. The CDP has very limited medical staffing, who
only treat detainees housed at the CPU, consisting of: a
registered nurse from Employee Health Care, which is located in
the police headquarters building, who conducts limited review of
screening and medications on week days; and a physician, who
conducts rounds five days per week for approximately one-half
hour per day. Because there is no medical supervision of health
care in the district facilities, the IGs of the different
districts, under the supervision of the OICs, have developed
their own ad hoc practices for dispensing medication and
identifying persons with medical conditions. These practices put
detainees at risk.

-9Our consultant’s review of four in-custody deaths which
occurred between 1999 and 2002 exemplify the problems with the ad
hoc system. In these cases, the detainees described being on
medication for a chronic disease, but there was no medical
follow-up and they did not receive their medication in the
holding cells. For example, on April 6, 2000, a detainee was ill
at the time of her arrest and transported directly to a local
hospital and admitted for asthma. Two days later, she was
released from the hospital and taken to the First District, but
her asthma became worse and she was readmitted to the hospital on
April 9. She was returned to the First District the same day
with a prescription for prednisone and an inhaler. The following
day she was brought to the CPU for a court appearance where she
complained of shortness of breath and died. Despite two trips to
the hospital, there was no evidence that the detainee received
her medications as ordered or that there was any medical followup following her return to CDP custody.
While further specific recommendations are provided below,
in general we recommend that the CDP develop and implement a
program to provide medical care to detainees. Further, we
recommend that the CDP utilize qualified medical personnel to
help develop appropriate policies and procedures.

Detainee Intake/Screening

Effective intake and screening procedures are crucial to the
early identification of medical and mental health issues among
detainees and, thereby, the prevention of injury, illness and
death among detainees. There is insufficient involvement of
medical professionals in the CDP intake/screening process.
Instead, IGs who have not received sufficient medical training
are tasked with conducting an initial medical screening of
detainees by asking a series of questions on the booking form.
In the district holding facilities, there are no trained
medical staff.1 We were informed that any detainee with an
apparent medical condition or who reports that he/she requires
medication is taken to the hospital for treatment. This practice
was not reflected in our review, particularly with regard to
medication. For example, during our first tour, a detainee with
The First District had an EMS team located in the
police station, but they were not involved in detainee screening.

-10epilepsy had a seizure while we were on site at the Second
District. Although he had indicated earlier, during intake
screening, that he took prescription medication for epilepsy and
did not have that medication with him, he was not sent to the
hospital until after he suffered a seizure.
While there is more involvement of medical professionals at
the CPU than in the district facilities, the practices at CPU are
also insufficient. A registered nurse from Employee Health Care
may review selected intake forms at the CPU; however, there is no
systemic process, governed by policy, to review each of these
intake forms relating to medical conditions. Effectively, the
only medical screening that occurs on a routine basis throughout
all holding cell facilities is that done by the IGs.
CDP’s procedures to screen for contagious diseases also are
inadequate. There is no routine tuberculosis or other contagious
disease screening at the CPU or in the districts. Isolation of
detainees is based on the judgment of IGs who rely on detainees’
self-identification through responses to the medical
questionnaire, which does not include routine symptom screening
for tuberculosis.
The CDP’s isolation procedures for contagious diseases have
been developed without medical oversight, resulting in inadequate
precautions in some cases and needless precautions in others.
Both in the CPU and the districts, detainees who report that they
had or have tuberculosis are put in single cells which have open
bars, do not have negative pressure ventilation and are in close
proximity to the other holding cells. These cells do not
sufficiently isolate such individuals from other detainees and
are therefore inappropriate for housing persons with active
tuberculosis. The Employee Health nurse does visit the CPU and
contact the Cuyahoga County Health Department to determine the
current medication for a detainee with tuberculosis; however, the
nurse is on-site only Monday through Friday, so detainees with
tuberculosis who enter on a Friday night may not be seen for
three days. Detainees who report a history of HIV or hepatitis
are deemed to be contagious and are also housed in single cells.
These practices are not generally necessary for individuals with
HIV or hepatitis.
We recommend that either 1) intake, contagious disease and
isolation screening be conducted by a medical professional, or 2)
IGs receive additional training on conducting intake, contagious

-11disease and isolation screening and that such screening is
reviewed by a medical professional. All detainees with symptoms
of, or who report having, a chronic illness should be examined on
the day of intake by a nurse and appropriate follow-up by the
physician should occur. Contagious disease screening and
isolation practices should be modified to be consistent with
generally accepted medical practices.

Medication Administration

Medication administration practices at the CPU and district
holding facilities are inadequate and put detainees at
substantial risk. At all facilities, we observed lax practices
regarding the storage, dispensing and provision of prescription
medications. At the CPU, if detainees have medication with them
at intake, IGs place those medications in a cardboard box in a
locked cabinet and write instructions in the logbooks for the IGs
to dispense the medication. There is insufficient medical
supervision over this process. During the week, the nurse visits
the CPU daily and checks the medication box to see what it
contains. The nurse may inspect the medication containers to
verify the contents, but there is no other supervision by a
health professional over medication distribution. During the
weekends, IGs inspect medication containers and make judgments as
to whether the containers are appropriately labeled with the
detainee’s name and whether the detainee will be permitted to
take the medication. If the container is not marked, the
detainee must wait until Monday for the nurse to review the
container, which results in detainees being without medication
for two or three days. For detainees on insulin the nurse will
draw the insulin in a syringe and place the syringe in a
refrigerator with instructions in the logbook for IGs to deliver
the medication. This is not a medically acceptable practice.
There is no standardized control or storage of medication in
the districts. For example, in the Fifth District medications
are kept in open drawers and in the Fourth and Sixth Districts
detainees are permitted to keep some medications, like asthma
inhalers, in their cells. In several districts expired
medication was stored in cabinets with medication currently used
by detainees. Moreover, narcotics and other scheduled drugs were
not handled differently than other medications and not stored in
double locked cabinets, as required by standard pharmacy
protocols. In several districts, expired narcotic medications
remained in medication drawers or cabinets and were not


destroyed. No process for inventory or disposal of drugs is
maintained. At the Fifth District, medications which must be
refrigerated are kept in refrigerators that also hold food.
Practices for dispensing medication in the district
facilities are also inadequate and vary from district to
district. For example, in some districts, detainees who are
admitted with asthma inhalers are permitted to keep these on
their persons, in other districts, detainees are prohibited from
keeping inhalers. These decisions are not made by medical
personnel, but apparently by IGs. If detainees have medication
with them at intake, the IGs will also examine the label and
determine whether the detainee will be permitted to take the
medication. If the detainee is permitted to take the medication,
the IG will store the medication and note the administration of
the medication in the general log book. There is no medical
personnel supervision of this practice for dispensing medication,
resulting in inconsistent administration of medication. For
example, at the Second District where the detainee suffered a
seizure during our tour, another detainee was taking medication
for epilepsy and had only received one dose of his medication at
5:00 p.m. although he was prescribed to take it three times per
In both the CPU and the districts, the treatment of
detainees who state that they are on medication but do not have
it on their person varies with the IG on duty. In some cases,
IGs will attempt to verify with a pharmacy or physician what
medication is currently prescribed. In other cases, the detainee
is sent to a local emergency room to see a physician. The
general, unwritten policy appears to be that detainees who come
in without medications should be taken to the local emergency
room, but this is not consistently followed, as noted above. One
factor leading to such departures from generally accepted
practices is that, at all the holding facilities, medical
information regarding detainees is communicated by word of mouth
between shifts.
We recommend that medication, prescription, storage and
distribution systems be improved and made uniform. Further,
written policies and procedures should be developed to be
compliant with current correctional medical standards and
pharmacy regulations.

Clinical Treatment

-13Although the CPU and district holding facilities are
intended for short term detention, chronically ill detainees need
to receive appropriate medical care to prevent relapse or
exacerbation of their conditions. At the CPU, based on the
history obtained at intake, the IG will refer to the nurse any
detainee who is ill or who may have a chronic disease that the IG
believes requires medical attention. These referrals are
judgments made by untrained IGs and can result in untimely
medical referrals. The physician makes rounds in the CPU four
days a week for approximately one half-hour each day. There is
no sick call process other than requesting the attention of the
physician at the time he makes his rounds. Moreover, most
physician encounters are done cell-side and evaluations are
generally without examination. Medical encounters with the
physician are documented by single line entries in a book that
includes only the name, age, race and complaint of the detainee
and the medication that is being taken or was prescribed.
Detainees we spoke with apparently did not know how to access
medical services. No separate medical records on detainees are
kept and records that are maintained are not confidential. The
CDP provides even less medical treatment to detainees at the
districts, where there is no medical staff. Any treatment is
obtained by conveying detainees to the hospital and, as noted
above, the CDP does not transport detainees in need of medical
evaluation or treatment to the hospital consistently.
The problems with screening, medication administration and
treatment are exacerbated by the lack of adequate medical
staffing at the CPU and district holding facilities. There is no
single position specifically assigned to manage health care for
detainees in the holding cell facilities. As a result, practices
relating to medical treatment for detainees have apparently been
developed and instituted by CDP sworn and civilian staff. At the
CPU, a registered nurse from the Employee Health Services,
provides a brief period of time from Monday through Friday to
assess detainees brought to her attention by CPU staff. In
addition, an Employee Health Services physician spends
approximately one half-hour, 5 days per week at the CPU. Neither
the nurse nor the physician evaluate or treat detainees in the
districts. IGs, who reportedly receive no medical training,
apparently perform medical evaluations, distribute medication and
perform medical triage at all facilities.
We recommend that a physician be responsible for directing
clinical medical care at the facilities. Clinic space should be


improved and minimal medical supplies should be available where
detainees are examined. Medical documentation should be improved
so that it is confidential and accurately reflects the care
provided. Further, we recommend that the CDP designate an
appropriate number of holding cell facilities to house those
detainees with medical issues, to avoid the need to replicate a
medical program in every facility.
III. Fire Safety
Our tours revealed an absence of certain fire safety
precautions that cause significant concern. While we noted that
all of the facilities had operable smoke detectors, there was no
apparent system for regularly checking emergency doors, grills
and locking mechanisms for operation. During our second tour, we
observed two doors at the CPU to have inoperable locks and an
emergency door at the Second District that was extremely
difficult to open. Staff attempting to open and lock some of the
metal gates at the CPU reported that there was no system for
regularly inspecting doors and gates for operability. Further,
there was no indication that a safety program was in place for
conducting emergency fire drills or evacuations. Although all
the facilities reported having evacuation plans, when queried,
staff members from all facilities, including some who had worked
for the CDP for up to eight years, stated that they had never
participated in a fire drill. The CPU and most of the districts
lacked sufficient handcuffs or flex cuffs in the event a mass
evacuation was necessary.
We recommend that the CPU develop appropriate fire safety
policies and procedures, including plans to regularly inspect the
operability of all exits, locked doorways, smoke detectors and
fire extinguishers. The CDP should also regularly conduct fire
drills. Further, we recommend that the CDP acquire a sufficient
supply of handcuffs or flexcuffs in the event of a mass

Detainee Safety and Security

The CPU and district facilities are often overcrowded and
understaffed. These conditions, coupled with deficiencies in the
practices used to house and supervise detainees in facilities
which lack adequate communication equipment, present substantial
risks of harm to detainees. We set forth below how, in our
consultant’s opinion, these particular deficiencies contributed

-15to the death of one detainee.

Security Screening and Classification

Detainee Population and Housing

We observed a number of deficiencies in CDP policies and
practices regarding safety and security screening and detainee
monitoring. The CPU and district holding cells lack an objective
method to screen detainees for potential security risks.
Although the security screening necessary in a holding facility
is not as extensive as the classifications systems required at a
long term facility such as a prison, a system of screening and
housing detainees based on objective, behavior-based criteria is
an important component of providing a reasonably safe
environment. However, the CDP lacks such a system and fails to
determine systematically whether detainees are suspected crime
partners, combative or assaultive, or may be likely victims of
inmate-on-inmate violence while in the holding cells. Booking
staff reported that cell assignments are made on the basis of
available cell space and unguided judgments by line staff as to
the appropriate placement of detainees. These practices pose
safety and security risks to both detainees and staff. We
recommend that the CDP develop an objective detainee security
screening system and would be happy to provide technical
assistance in this regard.
The concerns presented by the lack of an objective security
screening system are exacerbated by mild overcrowding in the
holding cell facilities. The CPU is designed to house 60
detainees in single cells which are approximately 48 square feet
in size with one bunk. On the date of our second tour, there
were 65 detainees at the CPU, which we were told was a typical
daily census. However, a review of recent population counts
revealed that the population at the CPU can climb as high as 103.
We observed that the majority of detainees in the CPU and in the
district holding cells were double celled due to the population
and, in some cases, because cells were out of service due to
inoperable toilets and sinks. We were also told that triple
celling occurs at times, depending on the population and number
of cells in service.
While capacity is apparently regularly exceeded at the CPU
and often at the districts, there is no procedure to increase
staffing levels during these periods. At the CPU, staffing


consists of six to eight IGs, supervised by an OIC. Staffing at
the districts consists of an OIC, who is generally not involved
in direct supervision of detainees, and one or two IGs. When the
district facilities become overcrowded, the discretionary
administrative response is to close these facilities for new
bookings. This occurs most frequently when there is only one IG
on duty who, along with the OIC, bears the responsibility for all
holding cell operations including detainee supervision. We
recommend that the CDP review staffing and detainee population
patterns to ensure that appropriate supervision is provided to
detainees at all times.

Security Features

We also observed a number of security features typical of
jail operations to be absent. Facility staff do not have handheld radios or body alarms, there are few operable intercoms and
surveillance cameras, and there does not appear to be a regular
system for conducting cell searches for contraband. These
deficiencies can negatively impact staff and detainee safety and
communication. For example, our review of the in-custody death
of a detainee at the Second District on July 14, 2001, indicates
that another detainee heard the deceased’s cellmate screaming for
an IG and heard the deceased wheezing the night before he died.
A witness reported that it took 15 to 20 minutes for an officer
to respond. The deceased was later moved to an observation cell,
where he was found dead at 10:30 a.m.
We recommend that the CDP repair or replace inoperable
surveillance equipment and ensure that there are operable
surveillance cameras in strategic locations. We recommend that
staff be provided with hand held radios and/or body alarms. In
addition, we recommend that a two-way communication system be
installed for detainees to contact staff who are outside of
normal hearing distance.
Certain other security measures at the CPU appeared lax.
For example, at the CPU, cellblock grills, processing cell
grills, and control grills were observed to be open
simultaneously and were unattended. This practice contravenes
standard correctional norms. In one case, we observed one
detainee’s cell door was left unlocked along with the doors in
and out of that detainee’s cellblock. At the CPU, we also
observed an emergency key, which security staff reported would
open the cell areas and the emergency exits, that was stored in a


non-secure location - hanging on the wall by the reception desk,
available to anyone. In addition, we observed that the CPU and
holding cell facilities lacked security equipment such as metal
detectors and search wands. Further, we observed some sworn
staff enter the confinement area with their weapons. Although we
were told that the weapon was not loaded and the magazine had
been secured, this practice is contrary to standard correctional
practices and can increase the likelihood of a disturbance should
a detainee attempt to gain control of the weapon.
We recommend that the CDP review its policies and training
of security staff to develop, implement and train staff with
regard to appropriate physical security precautions. In
addition, we recommend that the CDP acquire search wands, metal
detectors and ample restraining devices for the CPU and holding
cell facilities. Further, we recommend that the CDP implement a
policy requiring that all firearms be properly secured and kept
out of the confinement areas.2

Policies, Procedures and Post Orders

The basic operational foundation for a well-managed jail is
the maintenance of current policies, procedures and post orders.
While we understand the CDP is in the process of revising these
materials, our tours revealed that the CPU and the holding cell
facilities policies, procedures and post orders are outdated or
not available. The most recent policy and procedure manual that
was available during our tour was dated 1987.
The post orders that the CDP provided to us appear to
address, in limited fashion, all security posts. These orders do
not contain, however, the duties listed in chronological order,
which would make the orders easier to follow. Moreover, the post
orders are not signed or dated. There also appears to be no
mechanism for ensuring that security staff read and understand
the orders.
We recommend that the CDP develop a system whereby policies,
procedures and post orders are regularly reviewed and updated by
the OIC. All facility policies, procedures and post orders

At the CPU, we observed firearm lockboxes installed in
the corridor leading to the reception area that apparently were
not utilized.


should be readily available to staff and consistent among the
different facilities. Further, we recommend that, as with CDP
General Police Orders, policies, procedures and post orders be
dated and signed by the appropriate CDP official. We recommend
that security staff regularly review and certify that they have
read and understood the policies, procedures and post orders.

Information for Detainees and Grievance Procedures

The holding cell facilities lack a system for providing
detainees with general information regarding: medical or mental
health services, showers, family visits, access to telephones and
attorneys, fire evacuations, food service, and any grievance
procedure. Moreover, none of the facilities we toured had a
written grievance procedure. We recommend that the CDP develop
and implement a written procedure for disseminating information
regarding obtaining services and a written detainee grievance
procedure whereby a detainee can express his or her grievance to
the OIC, with an appropriate mechanism to appeal up the chain of
command, without fear of reprisal.

Use of Force/Restraints

We understand that there is no separate use of force policy
applicable to holding cells other than the CDP’s general policy
on the Use of Force, GPO 2.1.01. While this policy addresses use
of force scenarios for police officers, it does not provide
appropriate guidance for the use of force in the holding cell
facilities staffed by non-sworn IGs. Although we understand that
authorization for the use of force by IGs is obtained from the
OIC, the policy does not contain a requirement for staff to
promptly file use of force reports and submit witness statements.
It does not contain provisions for ensuring medical treatment of
staff and detainees after a use of force incident in one of the
The only facility equipped with an emergency restraint chair
is the CPU. We understand that use of this chair must be
authorized by the OIC, or sworn personnel higher in the chain of
command, and that the CDP’s practice for use of this chair is to
place a detainee in the chair located in an office with its
windowless door shut. Security staff apparently do not maintain
monitoring or observation logs of detainees while they are
restrained and there is no record of checks by medical staff of
the restrained detainee. The CPU has no specific policies or

-19procedures governing the safe use of the restraint chair,
although we were told that detainees are not restrained for
longer than two hours.
We recommend that the CDP amend the existing use of force
policy or promulgate a specific use of force policy applicable to
staff in the holding cell facilities. Further, we recommend that
the CDP develop policies for the safe and appropriate use of its
restraint chair.
III. Environmental Health and Safety

Cleaning and Maintenance

In general, all holding cells except those in the Sixth
District were dirty and poorly maintained. During our
inspections, we identified problems with CDP policies and
practices regarding routine cleaning, trash removal, and physical
plant maintenance and repair. Accumulations of dirt, trash, and
debris, especially in the amounts we observed, can have a serious
and wide-ranging impact. Trash, particularly food and paper,
attracts insects and rodents, which can spread disease. It also
increases the potential for injury to inmates and staff, causes
odor problems, and provides a convenient place for detainees to
conceal contraband, thereby compromising security.
Neither the cells nor the corridors at CPU appear to be
cleaned on any regular basis. With limited exceptions, on three
separate inspections, the cells were filthy, with excessive
amounts of dirt, dust and grime. Food debris and other trash was
frequently observed in and around the cells. Trash, including
bread, breakfast cereal, spilled soup, toilet paper, and various
types of food containers, was littering the cells and corridors.
The CPU has an apparent fly infestation. Fly traps were evident
with fruit flies and house flies. Air vents were blocked with
paper waste and dirt. During our second tour of the CPU, we
observed that the plumbing chases were full of paper debris and
dead roaches. Although the chases were significantly cleaner at
the time of our third tour, the CDP does not have a system for
ensuring that these areas are cleaned routinely.
In the districts, cleaning practices varied widely. While
the Sixth District appeared to conduct routine cleaning, the
other districts had cells which were filthy and did not appear to
be cleaned on a regular basis. The Second District observation


cell had apparent blood stains on the wall during our first tour
in September which were still evident during our second tour.
Similarly, at the Fifth District, what appeared to be dried feces
on toilet paper was observed splattered on a wall outside a cell
used for observation of potentially suicidal detainees.
We also observed biohazardous waste disposal practices that
are dangerous to both staff and detainees. During our tour of
the CPU, a detainee had vomited blood and we observed a small
cardboard box being used as a container to capture and dispose of
this biohazardous waste. Staff seemed unaware of the appropriate
method for disposing of this box and it was left in the front
reception area for some time before it was removed. In the First
District, we were informed that blood spills are not cleaned up
until the following day when the maintenance crews arrive. At
the Fourth District, no biohazard bags or containers were
available for disposing of biohazardous waste and there was no
protective equipment, such as eyewear, gowns or aprons for
cleaning up such waste. At the Second District, dried blood
residue was observed on a wall in one of the observation cells,
and staff were using regular trash bags for discarding
biohazardous waste.
We recommend that the CDP develop a routine cleaning and
maintenance system for the CPU and district holding facilities.
We recommend that sweeping, mopping, toilet and sink cleaning be
done on a daily basis. Cells should be cleaned and disinfected
after each detainee’s release. Pipe shafts, closets and other
such areas should be cleaned on a routine basis.

Unsanitary Living Conditions

In addition to the inadequacies in cleaning and maintaining
the cells, our tours also revealed living conditions to be
unsanitary. Although we were told that detainees are afforded
the opportunity to shower, our interviews with staff and numerous
detainees were to the contrary. Most of the facilities either
had no towels or towels were scarce. The shower facilities in
the female wing of the CPU had a fly paper strip covered with
flies, no working light and had mold on the shower floor.
Similarly, the male shower had no light and mold all over the
floor. In numerous facilities we observed detainees in dire need
of showering. A number of detainees we spoke with had been
detained for 3 to 5 days without the opportunity for showers.

-21Further, there is no system for cleaning or sanitizing
mattresses. We observed mattresses in use that could no longer
be effectively sanitized because the mattress casing was
cracked.3 As a result, we understand that mattresses are
regularly reused by different detainees and that a single blanket
can be used by up to three different detainees in a given week.
These practices, coupled with the lack of showers, contribute to
the unsanitary conditions and foul odors in most of the holding
cell facilities, particularly at the CPU.
We recommend that the CDP establish a system whereby newly
admitted detainees are provided an opportunity to shower upon
reception and on a regular basis. Showering opportunities should
be recorded. There should also be delousing supplies available
to those who need them, and a system should be developed to
ensure that mattresses are sanitized between use and that clean
blankets are provided to detainees upon admission.



In conclusion, we appreciate the cooperation we have
received from City and CDP officials and look forward to
continued discussion about the issues raised by this letter.
/s/ Shanetta Y. Brown Cutlar

Shanetta Y. Brown Cutlar
Acting Chief
Special Litigation Section
cc: 	 Gregory A. White
United States Attorney
Northern District of Ohio

We also note that the fire retardancy of mattresses can
be significantly compromised if the casing is cracked.



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