The Honorable Parris N. Glendening
Governor of Maryland
Annapolis, Maryland 21401
Re: Baltimore City Detention Center
Dear Governor Glendening:
We write to report the findings of our investigation of
conditions at the Baltimore City Detention Center ("BCDC"). On
October 16, 2000, we notified you of our intent to investigate
BCDC pursuant to the Civil Rights of Institutionalized Persons
Act ("CRIPA"), 42 U.S.C. § 1997. In addition, 42 U.S.C. § 14141
provides us jurisdiction to investigate the conditions of
confinement for juveniles at the facility.
On December 12-15, 2000, January 3-5, 9-12 and April 25-27,
2001, we conducted on-site inspections of the facility with
expert consultants in corrections, medical care, mental health
care, sanitation, fire safety, juvenile detention and education.
While at BCDC, we interviewed correctional and administrative
staff, inmates, medical and mental health care providers, fire
safety, food service and sanitation personnel, and school staff.
Before, during and after our visit we reviewed an extensive
number of documents, including policies and procedures, incident
reports, medical and mental health records, inmate grievances,
use of force records, investigative reports and school documents.
Consistent with the statutory requirements of CRIPA, we write to
advise you of the results of this investigation.
We commend the staff of the facility for their helpful and
professional conduct throughout the course of the investigation.
The staff have cooperated fully with our investigation and have
provided us with substantial assistance.
As described more fully below, we conclude that certain
conditions at BCDC violate the constitutional rights of inmates.
We find that persons confined suffer harm or the risk of serious
harm from deficiencies in the facility's fire safety protections,
medical care, mental health care, sanitation, opportunity to
exercise and protection of juveniles. In addition, the facility
fails to provide education to eligible inmates as required by the
Individuals with Disabilities Education Act (IDEA), 20 U.S.C.
1401, et seq., and Section 504 of the Rehabilitation Act of 1973,
29 U.S.C. § 794, and violates some inmates' rights to equal
protection in the provision of educational services.
A. FACILITY DESCRIPTION
With portions of the facility dating to 1803, BCDC is
Maryland's oldest pretrial detention facility. (1)During fiscal
year 2000, there were 43,456 persons admitted to BCDC. During
our April 2002 visit to the facility, there were approximately
2500 inmates housed at BCDC, of whom about 2000 were awaiting
trial. Of these 2500 inmates, there were approximately 125
juveniles ranging in age from 15 to 17 (including a handful of
female juveniles) who were charged as adults, and approximately
500 women. These inmates are housed in 5 separate buildings:
the Men's Detention Center, the Wyatt Building, the Annex
Building, the Jail Industries Building, and the Women's Detention
Center. Inmate housing includes single cells, double cells and
dormitories. The facility also has modular educational
facilities and space for drug treatment programs.
Male inmates with chronic mental illnesses are housed in the
Special Needs Unit (SNU). Other inmates with mental illness,
both male and female, are housed in Inpatient Mental Health Units
(IMHU). Those with serious medical illnesses are temporarily
housed at the infirmary, which for the women is inside the
Women's Detention Center. The men's infirmary is located within
the Metropolitan Transition Center (MTC), which is a regional
facility located nearby, serving four other Maryland state
correctional facilities as well as BCDC. Our investigation
examined the medical care provided at the infirmary, but did not
examine the overall conditions of confinement at that facility.
Alongside BCDC is the Baltimore City Booking and Intake
Center (BCBIC). All inmates pass through BCBIC upon intake, but
some remain housed there. This facility is operated as a
separate institution from BCDC, with its own administrative staff
hierarchy. Our investigation examined those functions at BCBIC
that impact the services provided to BCDC detainees, such as
intake medical screening and processing. This investigation did
not examine the overall conditions of confinement for inmates
housed at BCBIC.
B. LEGAL BACKGROUND
CRIPA gives the Department of Justice authority to
investigate and take appropriate action to enforce the
constitutional rights of inmates in jails, prisons and juvenile
detention facilities (and the federal statutory rights of
juveniles in juvenile facilities). 42 U.S.C. § 1997.
Section 14141 of the Violent Crime Control and Law Enforcement
Act of 1994, 42 U.S.C. § 14141, makes it unlawful for any
governmental authority to engage in a pattern or practice of
conduct by officials with responsibility for the incarceration of
juveniles that deprives them of constitutional or federal
statutory rights. Section 14141 grants the Attorney General
authority to enter a civil action to eliminate the pattern or
With regard to sentenced inmates, the Eighth Amendment's ban
on cruel and unusual punishment "imposes duties on [prison]
officials, who must provide humane conditions of confinement;
prison officials must ensure that inmates receive adequate food,
clothing, shelter, and medical care." Farmer v. Brennan,
511 U.S. 825, 832 (1994). Prison officials have a further duty
"to protect prisoners from violence at the hands of other prisoners." Id. at 833. The Eighth Amendment protects prisoners
not only from present and continuing harm, but from the
possibility of future harm as well. Helling v. McKinney, 509
U.S. 25, 33 (1993). It also forbids excessive physical force
against prisoners. Hudson v. McMillian, 503 U.S. 1 (1992).
Medical needs which must be met include not only physical health
needs, but mental health needs as well. Bowring v. Godwin, 551
F.2d 44, 47 (4th Cir. 1977); Young v. City of Augusta ex rel
Devaney, 59 F.3d 1160 (11th Cir. 1995).
With regard to pre-trial detainees, the Fourteenth Amendment
prohibits imposing conditions or practices on detainees not
reasonably related to the legitimate governmental objectives of
safety, order, and security. Bell v. Wolfish, 441 U.S. 520
Juvenile detainees at BCDC, at a minimum, have the same
constitutional rights as adult detainees. See also Gary H. v.
Hegstrom, 831 F.2d 1430 (9th Cir. 1987); Youngberg v. Romeo,
457 U.S. 307 (1982). In addition, as applicable to this
investigation, juvenile detainees also possess federal statutory
rights under the Individuals with Disabilities Education Act
("IDEA"), 20 U.S.C. § 1400 et seq., Section 504 of the
Rehabilitation Act of 1973, 29 U.S.C. § 794 ("Section 504"), and
the Americans with Disabilities Act, 42 U.S.C. §12101 et seq.
A. FIRE SAFETY
Inadequate fire safety measures at BCDC compromise
residents' safety. These deficiencies include inoperable fire
alarm and smoke detection systems, improper maintenance of the
sprinkler system, insufficient protection from smoke exposure,
excessive combustible materials, and substandard evacuation
routes and procedures.
1. Alarm, detection and sprinkler systems
At the time of our visit, BCDC's fire alarm and smoke
detection systems were inoperable, and we have not received word
of any changes, despite our invitation to the facility to update
us on changes since the time of our tours. Some staff members we
interviewed were unaware that these systems were not working;
thus they had a false sense of security that a mechanical system
would detect smoke or fire, when in fact staff and inmate
awareness was the only detection system in place.
In addition, BCDC's sprinkler system, which is required to
cover all areas from which fire can spread to resident living
areas, suffers from serious deficiencies. Many of the sprinkler
heads have been painted over or have clothing or other materials
hanging from them. In other cases, they are too close to debris,
walls or ceilings. These conditions may not only prevent the
sprinkler heads from activating promptly during a fire, but also
may interfere with the sprinkler head's fire suppressing spray of
water after activation. Moreover, there are several locations
within the facility in which there is no sprinkler coverage, or
sprinkler heads were missing from the fixtures. Finally, the
sprinkler main shutoff valves, at the time of our fire safety
tour, were neither secured nor electronically monitored. Without
proper security, someone could tamper with or deactivate the
sprinkler system undetected.
2. Smoke exposure
The facility does not protect residents from dangerous
exposure to smoke. For example, the exhaust system in the Men's
Detention Center circulates air in such a manner that every cell
within a particular cellblock is subject to smoke contamination
from the generation of smoke in any cell. Moreover, stairwells
in the Men's Detention Center, the Women's Detention Center, the
Annex Building, and the Jail Industries Building are not fully
enclosed to prevent them from becoming avenues by which heat,
smoke, toxic fumes and other products of combustion can spread
throughout those buildings. The stairwells in their present
condition are also unreliable means of escape, as they provide no
protection from heat, smoke, toxic fumes and other products of
combustion. In the Annex building, an office space had been
constructed on the landing of a stairwell, eliminating its use as
an area of refuge protected from smoke or fire.
In addition, in the Men's and Women's Detention Centers,
piping and chases (spaces between walls in which pipes are
located) create vertical openings through floors which could
allow the spread of smoke, debris and fumes during a fire. The
Men's and Women's Detention Centers also have walls intended to
be smoke barriers that do not effectively keep out smoke, and
therefore fail to serve their intended purpose of providing a
refuge in the case of fire.
Many of the cells and other locations throughout the
facility contain excessive amounts of combustible materials
including clothing, books, paper, bedding material, and other
personal property. These combustibles will help fuel any fire
that is ignited in the facility. Similarly, paper bags are used
as waste receptacles, which can contribute to the ignition or
spreading of fire.
4. Fire and evacuation preparedness
In parts of the Men's Detention Center, the mechanism that
allows the staff to release all of the cell doors without a key
is inoperable. Furthermore, throughout the facility, staff were
unable to identify the keys that open cells or exit doors without
looking at the keys. Conditions may arise during a fire which
make visual identification impossible, and therefore the
inability to identify keys by touch may prevent resident
evacuation in cases of emergency.
In other places in the facility, correctional staff
responsible for those areas did not carry keys to unlock doors
blocking routes for resident evacuation, and there was
considerable delay during our fire safety tour in locating the
keys. Such delay could be fatal in a fire emergency.
Furthermore, officers asked to open other non-occupied spaces
such as storage rooms and cleaning supply closets were unable to
do so, despite the possibility that staff might need to open such
spaces in an emergency.
There are additional problems with the fire evacuation
routes in several of the buildings. For example, in the Men's
Detention Center, in several sections, residents do not have
sufficient alternative methods of exit. Such alternate exits are
required to keep occupants from being trapped if the primary exit
is blocked by a fire. In the Jail Industries Building, for
example, one exit stair discharges into the garage in which a
large amount of combustible material is stored, making it an
unsafe route of escape from a fire.
During our fire safety tour, officers in at least some
buildings seemed unaware of evacuation procedures. This appears
to be the result of the failure to conduct frequent fire drills.
Many officers could not remember when the last fire drill had
occurred. A mock fire drill conducted at our request confirmed
that staff are unprepared to evacuate inmates safely in the event
of a fire. During the drill, officers did not respond in
sufficient number and took too long to arrive on the scene.
Officers asked to demonstrate the use of the self-contained
breathing apparatus were unable to use the equipment properly
with sufficient speed.
The facility relies on the local fire department to respond
to any emergency related to fire. However, jail officials have
not conducted any emergency planning with the fire department to
improve the likelihood of effective emergency response.
5. Problems with particular buildings
The educational and drug treatment buildings have particular
fire safety problems. The men's drug treatment building is
located close to the Wyatt Building, does not have sprinklers,
and contains a high level of combustible material. Thus, there
is danger that a fire started in the drug treatment building
would spread to the Wyatt Building. Similarly, the women's drug
treatment building is located close to the Women's Detention
Center and lacks sprinklers. This creates the danger that a
large fire, unsuppressed by any sprinkler system, will spread
from the drug treatment building to the Women's Detention Center.
Finally, part of the drug treatment building blocks access to
water that the fire department would use to pump water into the
sprinkler and/or standpipe system to fight any fire.
In the Jail Industries Building, newer acoustical ceiling
tiles appear to have been installed below older fiber tiles. The
older tiles, which should have been removed when new ceilings
were installed, are out of reach of the sprinkler system, and are
The education building, a wood frame modular structure, has
no sprinkler system. Some of the classrooms have no emergency
escapes or have escapes that are blocked by metal security
screens. Moreover, this building only has battery operated smoke
detectors. Because the alarms are not part of a building-wide
system, only an alarm in the immediate area of smoke or fire
would sound. The individual alarms are not loud enough to warn
all occupants of the building in the event of a fire, so an alarm
might go undetected if rooms near the fire were not occupied.
6. Fire Extinguishers
On our initial safety tour, we noted that fire extinguishers
were not inspected or repaired at appropriate intervals. By the
end of our on-site investigation work, the extinguisher
inspections and repairs had been brought up to date.
B. Medical Care
The provision of medical services to inmates at BCDC is
seriously deficient and puts inmates at risk of serious harm.
1. Intake Screening and Assessment
The screening and assessment process is insufficient to
ensure that inmates receive necessary medical care in the first
few days of their stay at the facility. Inmates arrive at the
facility through the Booking and Intake Center. There, an
Emergency Medical Technician (EMT) meets arrestees at the
entrance and refuses to admit anyone in obvious need of medical
attention. An EMT is not there at all hours, however. If there
is no EMT, or if the EMT allows admission, the arrestee is
brought to an officer for booking and asked a series of personal
data and medical screening questions. The booking screen is
intended to determine whether the inmate needs prompt medical
attention, but the system fails to provide timely treatment to
those who need it, and fails to collect accurate information to
guide future care.
The officer booking screen process is crucial to the success
of the medical intake system, because it is the only formal
opportunity an inmate has to signal to the jail that he or she
has medical needs and to have those needs addressed for the first
24 hours or more of confinement at the facility. The policy is
that arrestees who answer "yes" to any of the questions about
medical needs are seen by a triage nurse immediately on site,
rather than waiting for the nursing health screen, which is
supposed to occur within 24 hours of bail review. In practice,
the officer booking screen does not produce accurate information,
and the nursing screen is not occurring quickly enough.
Our observations revealed that some officers do not conduct
the screen properly. We observed officers filling in the answers
on the computer screen before the inmate had given the answer,
skipping asking some questions altogether, and putting in answers
contrary to what the inmate had responded. Furthermore, the
physical setup for the officer booking screen is such that
arrestees are asked to respond to questions about confidential
medical information in an open space. Sometimes another arrestee
is handcuffed at the same booking window. The lack of
confidentiality minimizes the likelihood that inmates will
respond truthfully to questions about whether they have serious
medical or mental illness. This puts the booked inmate and other
inmates at risk because inmates may not be provided with timely
medical care, and inmates with communicable diseases may be mixed
with the general population. Finally, it was unclear from the
medical record review whether each inmate even had a booking
screen completed. In 65% of the records, no booking screen was
to be found in the file, or it was completed improperly.
One inmate died of hypertension and cardiovascular disease
on May 19, 2000, after one and a half days at the facility. His
file indicated an officer booking screen (with all "no" answers)
and no medical screening or other attention during his time at
the facility. Investigation revealed that he had needle tracks
on his arms and cocaine and other drugs in his system. While
there is insufficient information in his record to determine if
medical intervention could have saved his life, it is possible
that appropriate screening would have identified potential
withdrawal problems that the booking officer did not.
Another inmate died at the facility on July 18, 2000, after
being in custody for only 24 hours. His pretrial services
information printout indicates that he had a ten-year daily
heroin addiction and high blood pressure, and his officer
screening indicated that he was on medication for high blood
pressure. Despite this information available to the detention
center, this inmate's medical record has no indication of contact
with a health professional during his stay at the facility. He
died of cardiovascular disease, complicated by vomiting and
diarrhea, which may have been the result of detoxification from
drugs. These and other records reveal that the booking screen
process does not sufficiently identify those who need medical
attention or observation, nor sufficiently trigger medical care
Inmates should be seen for screening by a health care
practitioner promptly upon entering a detention facility. While
we were told that those who answered "yes" to any of the
questions would be seen by a triage nurse within an hour (BCDC's
policy says "immediately"), in reality it took up to seven hours
for those individuals to be seen. This delay is problematic for
inmates who may need to receive the next dose of a medication,
who are experiencing detoxification from drugs or alcohol, or who
suffer from mental illness. Those inmates whose answers were
recorded incorrectly, who did not feel comfortable telling the
truth about their medical conditions to a non-medical
practitioner in this non-confidential setting, or whose booking
officers failed to ask the questions might have to wait until the
scheduled nursing screen, often three to seven days later, to see
a medical practitioner.
Records indicated in some cases that a nursing screen had
been performed, and that the nurse determined that the inmate
needed to be seen by another medical or mental health
practitioner, but the inmate did not receive the care
recommended. In other cases, the nurse should have referred the
inmate for immediate care, but did not. For instance, in
numerous files, the inmate's substance abuse practices indicated
the potential need for detoxification or withdrawal treatment yet
there was no referral to an appropriate practitioner for such
One 15-year-old inmate showed clear signs of suicidality
during his receiving screen, stating that he thought he would
harm himself. Instead of referring him immediately for
appropriate mental health care, medical staff placed him in
protective custody and made no attempt to restart the medication
he reported to have been prescribed for his attention
deficit/hyperactivity disorder prior to incarceration. He was
not seen by a mental health professional until 25 days later,
after his attorney called to seek attention for him, at which
time the psychiatrist evaluated him and ordered medication.
Records do not show the patient ever receiving those medications.
Many of the medical records we reviewed did not include
record of a nursing screen. If the nursing screen did not occur,
this means that inmates whose booking officers completed the
booking screen improperly could go for two weeks or longer
without medical evaluation, until the history and physical
examinations are performed. While the jail's policy requires the
history and physical to be done within 14 days of admission,
which is the standard of care in the industry, the records we
reviewed showed some delays as long as 28 days before this exam
In addition to delay, the history and physical procedures
are also flawed in ways that can be dangerous for inmates. For
example, we observed one nurse asking an inmate's history
questions too fast for an inmate to respond with needed detail
and accuracy. Our chart review indicated that many records had
histories with insufficient information recorded in the file.
Interviews with medical staff revealed that in the Women's
Detention Center, medical staffing is insufficient to perform
complete histories and physicals with the care and time necessary
for them to be completed properly. Only one staff member is
responsible for all histories and physicals for women entering
the facility. One former staff member who had been in that role
reported that her job was overwhelming, that she was pressured to
complete more exams than she believed she could conduct
competently, and that she eventually quit as a result of these
We were also concerned about the lack of sensitivity to
mental health needs. For example, an inmate indicated that he
had thought about suicide in the past and might be feeling
suicidal currently. The nurse told the inmate, "If you say that,
they will strip you naked, put you into a room and send you to
mental health." He then said he was not suicidal. Such an
approach could allow a suicidal inmate to be placed in the
general population without proper mental health attention and
precautions to protect him from self-harm.
Our review also revealed that inmates experiencing or with
the potential to experience detoxification often do not receive
the treatment or supervision necessary for safe withdrawal from
drugs or alcohol. We observed one inmate who had arrived at the
facility at 5 a.m. and reported experiencing opiate withdrawal.
At noon she was just seeing a triage nurse for the first time,
and had not been provided any medical attention or treatment for
withdrawal. A large number of inmates reported to us that they
experienced withdrawal from drugs or alcohol at the facility
without any supportive measures, despite reporting symptoms to
health care staff and requesting treatment. Our conversations
with health staff confirmed that while they have stock
medications available for treating drug withdrawal, they rarely
File review revealed many cases in which inmates who were
likely candidates for withdrawal did not receive sufficient
supervision. For example, an inmate who was eight months
pregnant reported a history of daily heroin use. While she
received a history and physical one day after arrival at the
facility, it took three more days for her to see an OB/GYN.
Heroin withdrawal in a pregnant woman can have quite harmful
results for a fetus, and it appeared that insufficient attention
was paid to this risk.
When health care staff does place male inmates under medical
supervision for alcohol withdrawal, the treatment appears
adequate. However, the female inmates appear to receive
inadequate observation. Only one nurse is available in the
Women's Detention Center medical unit to monitor both the
infirmary and the mental health unit, which are separated by
security doors. Given the potential lethality of alcohol
withdrawal, this level of supervision is inadequate.
Finally, inmates who come in to the facility on medications
experience serious delays in restarting those medications,
including medications needed to control asthma, seizures, mental
illness, HIV and blood clotting. In the meantime, they may
experience withdrawal symptoms and/or re-experience the symptoms
of their illnesses. The failure to provide medications in a
timely manner is a serious deficiency in care at this facility.
2. Acute and Emergent Care
BCDC fails to provide adequate medical care for inmates with
acute and emergent care needs. Our review indicated that nurses
sometimes practice outside the scope of their training and
licensure, by failing to refer patients with serious symptoms for
appropriate evaluation by a medical practitioner. Some inmates'
files revealed that they had requested attention through sick
call on several occasions for the same problem without having
been referred to a physician assistant, nurse practitioner or
For example, an inmate came to the infirmary after being
kicked in the face. He was not referred to a medical
practitioner for evaluation. Another inmate had systemic lupus.
She went to sick call on several occasions complaining of cough,
chest pain and other symptoms which would be consistent with a
possible recurrence of her condition, but the nurse never sent
her to a higher level practitioner. Another inmate came to sick
call complaining of chest pain and headache on at least four
occasions without a referral to a higher level provider. Still
another inmate with a history of cocaine addiction complained of
chest pain and had an elevated blood pressure, a profile putting
her at high risk for cardiac disease. She was treated with
Tylenol and sent away, when she should have been referred to a
higher level practitioner immediately. The medical staff places
inmates at risk of serious harm by failing to evaluate serious
symptoms at an appropriate level.
Men's Detention Center sick call is conducted in a large
room with a desk and numerous chairs. Because it is only one
room, without a separate waiting area or sight and sound
separation, there is no opportunity to maintain appropriate
confidentiality. This both limits the information that an inmate
may feel comfortable sharing with the nurse and limits the scope
of the examination the nurse can conduct, compromising the
quality of care.
Sick call completion is also a large problem. While triage
logs reflected that those inmates seen in sick call were
generally seen within 48 to 72 hours of their complaint, we also
understood from both inmates and staff that many inmates with
complaints were never seen in sick call, or that they waited
excessively long periods of time. Health care staff reported
that some inmates on their scheduled sick call list were never
brought to sick call, and that when they tried to contact
correctional staff they were told that due to insufficient staff
or other reasons the inmate would not be brought to sick call.
Inmates reported having to put in more than one request to be
seen, or to wait periods up to one month to be seen by medical
staff. Correctional staff reported that inmates sometimes had to
wait up to 10 days to be seen. Thus, it appears that not all
inmates with medical complaints are actually getting to sick call
for treatment, and others must wait too long to be seen.
In some instances, practitioners ordered additional care for
inmates, but the care was delayed or the inmate never received
such care. For example, a 16-year-old with a stab wound was
ordered by a doctor during his history and physical to return for
removal of stitches four days later. Three days after he should
have been seen, the inmate had to file a sick call slip to
request that the stitches be removed, and then waited another
three days to be seen. The history and physical had noted signs
of potential infection, and when he finally saw a nurse, the
nurse referred him to be seen by a nurse practitioner or
physician for evaluation of pus pockets in the wound. The record
has no indication that he was ever seen by the higher level
practitioner. These delays and omissions in the course of his
treatment put this youth at unnecessary risk of infection. Other
examples of failure to complete ordered treatment include orders
to monitor elevated blood pressure, laboratory work, dental care
and follow-up physician visits.
Because inmates in segregation are isolated, special care
must be taken to ensure that their health and mental health are
not deteriorating. Inmates at BCDC have insufficient opportunity
to communicate confidentially with health care professionals
about their needs.
Correctional staff in the Women's Detention Center reported
that when they had an immediate need to refer an inmate for care,
they were frequently told by medical staff that the health unit
was too busy and they could not send someone to the unit,
regardless of the inmate's discomfort. In one striking example
of lack of responsiveness by the health unit, an inmate had
painful lesions on her face, which our expert recognized as
Herpes zoster. Many inmates had called her to our attention,
because they were concerned for her health as her condition
seemed to be worsening. The correctional officer on duty
reported that she had to try several times for that inmate to be
seen for medical care, and regularly had to "fight" with the
nurses to have inmates seen right away when she was concerned
that it might be necessary.
Upon review of the inmate's medical records we discovered
that the inmate had been mis-diagnosed in our medical
consultant's opinion, and that her condition was deteriorating.
Our medical consultant recommended to appropriate medical
personnel that she be re-evaluated quickly, as the condition
appeared to be spreading closer to her eyes, which had the
potential to cause blindness. Even our requests for attention
for this woman were not heeded; when we checked back 24 hours
later this inmate had not received care. At that point BCDC's
lawyer arranged for her immediate attention and she was
In addition, correctional staff confirmed that access to
emergency care can vary depending on which correctional officer
an inmate asks or which unit the inmate is on. Staff explained
that some staff will not call the medical unit to seek attention
for an inmate complaining of emergent symptoms, even though they
are trained to do so. This problem may in part be due to the
lack of responsiveness the officers receive from the medical
department, and in part due to the lean security staffing which
allows little time for officers to advocate for inmates or
transport them for care.
Staff also reported that there is some delay in getting
inmates emergency care from the more remote locations of the jail
such as the Jail Industries building. For example, an inmate was
stabbed in the Jail Industries building and was first transported
through many security gates and doors to the Medical Unit before
being brought to a hospital, even though an ambulance could have
pulled directly up to the street entrance to the Jail Industries
building. Such delay in an emergency such as a stabbing could be
fatal. One inmate died at BCDC on December 2, 2000, unable to
breathe due to his asthma. Once the correctional officer became
aware of the emergency, it took 15 minutes to contact the medical
unit. There was no answer when the officer first called.
Our review of inmate deaths revealed several instances in
which correctional officers failed to perform CPR, and waited for
health care or emergency personnel to arrive instead. In an
interview with a nurse by an investigator of a death that
occurred at Central Booking on October 29, 2000, the nurse
complained that she noted a pattern of correctional officers
failing to initiate or assist in CPR.
Especially troubling was a death at BCBIC on November 22,
2000, in which an inmate collapsed and his roommate tried for
several minutes to get the attention of corrections personnel
before someone responded. Even after that, correctional
personnel were on the scene for several minutes before medical
staff arrived and began CPR. Brain death occurs within four to
five minutes after blood flow to the brain ceases. If CPR is not
initiated during this time, then it is likely that the individual
will not be revived, or if revived will have serious brain
injury. Correctional officers, who are likely the first
responders to an inmate emergency, need to be prepared to perform
this crucial life-saving skill, and should be trained and
3. Chronic Care
In order to properly treat inmates with chronic illnesses, a
correctional facility health clinic must see inmates on a regular
schedule appropriate to the disease, so that their illnesses may
be monitored, the symptoms controlled and documented, and
medications delivered and adjusted in a timely manner. BCDC has
established lists for chronic care treatment of patients with a
variety of chronic illnesses. However, a review of charts
illustrates that treatment is not provided on a regularly
occurring schedule, medications are frequently not ordered or
delivered, recordkeeping is poor, and records do not show timely
lab work or physician response to lab reports in some cases.
Treatment of patients with asthma at the facility is
especially problematic. Our medical consultant deems that two
deaths at the facility attributed to asthma (one in August 1999
and one in December 2000) were preventable if the inmates'
conditions had been properly treated. In both cases, the inmates
experienced wheezing and required medical intervention in the
days prior to their deaths, but relief of their bronchospasms was
never achieved. Health care providers failed to bring the
inmates back into the clinic for prompt re-evaluation after
intervention, to see if treatment had been successful, even
though peak flow measures indicated that the patient was in
serious jeopardy. The inmate who died December 2, 2000 was last
seen in the medical unit on November 17, 2000, at which time he
had a severely limited peak air flow and was experiencing severe
enough problems to require IV fluids and other treatments. The
treating physician ordered that he be re-evaluated in one week,
which was insufficient monitoring of his condition as it
presented itself. Furthermore, there is no record that the
re-evaluation occurred. He died from uncontrolled asthma,
struggling to use an inhaler to relieve his bronchospasms. By
that point, the inhaler failed to work because he had overused
it, due to lack of appropriate treatment and follow-up.
Both medical records and reports from inmates indicated that
some inmates had trouble accessing their prescribed inhalers. In
several medical records it appeared that inhalers had been
prescribed but not provided to the inmates. Records indicate
that some inmates' asthma was not stabilized and when they began
having problems breathing, the response was not as swift or
aggressive as it should have been. Some inmates also reported
that they were not allowed to keep their inhalers themselves and
that corrections staff sometimes did not allow access when they
requested their inhalers. In a building such as BCDC, which is
old and poorly ventilated, health care staff should be especially
vigilant in its monitoring and treatment of asthma.
The treatment of HIV-positive individuals is also of
concern. We noted records in which patients' medication was
halted while the facility awaited medical records or awaited
approval of nonformulary medications. Because of the risk that
patients may develop resistance to HIV drugs, lengthy
interruption of medications is especially problematic. One HIV
positive individual experienced seizures for the first time, but
a nurse never referred her to a higher level practitioner.
It appears that the medical grievance system is failing to
provide the safety net that it should for inmates in need of
care. The grievance system should respond in a timely manner to
remedy failures in the system of care. While BCDC has a
responsive grievance system for other matters, the system for
medical grievances breaks down due to the need for communication
between jail administration and the medical contractor. Despite
a facility policy that requires medical grievances to be
forwarded to the contractor for response within two days of
receipt, and written response from medical within five days
thereafter, it took 25 days on average for inmates to receive
responses, if they received them at all.
One inmate had asthma and complained that she was not able
to get her inhaler and was having attacks. It took almost one
month for a response to her grievance, and the response was that
the grievance coordinator could not assist until she filled out
the section of the form indicating what action she wanted taken.
Another inmate was seven and a half months pregnant and wished to
be housed in the maternity dorm. She also complained that she
had not yet received any medical attention at the facility.
Although the grievance was marked received three days after it
was written, there was no response for another month. A third
inmate complained of chest pains and chills. It was over one
month before the grievance reached the grievance coordinator and
almost seven weeks before he was seen by a physician.
C. MENTAL HEALTH
BCDC fails to deliver adequate mental health care to its
residents who need such services. Specifically, BCDC does not
provide adequate access to medication, access to care, and
suicide prevention. Certain conditions in the men's inpatient
mental health unit (IMHU) present particular problems.
1. Access to medication
A significant number of newly admitted residents to BCDC do
not receive needed psychotropic medications in a timely fashion.
During our investigation, we learned of residents who did not
receive their medications until a week or even two weeks after
their arrival at the facility. Treatment records reveal cases of
residents decompensating and requiring admission to BCDC's IMHU
because of this delay in receiving medication. One staff member
estimated that 25% of the inmates admitted to the men's IMHU had
problems due to discontinuation of medications at the time
inmates were incarcerated. Sudden withdrawal of some
psychotropic medications may have physiological effects in
addition to contributing to mental decompensation.
For example, one inmate was incarcerated on December 5,
2000. During a mental health status examination he reported that
prior to his incarceration he had been taking Risperdal and
Thorazine, which are antipsychotic medicines. At the time of the
examination he reported experiencing auditory hallucinations.
Two days later he cut himself on his left forearm and was sent to
the IMHU. It took five more days before a psychiatrist visited
him or prescribed any psychotropic medications.
Another inmate arrived at the facility October 10, 2000, and
only began receiving his psychotropic medications on October 20.
He attempted suicide on October 26 and required admission to the
IMHU. It is likely that his need for an IMHU admission was
related to the delay in starting his psychotropic medications
BCDC also fails to ensure that residents in the general
population have their psychotropic medications renewed in a
timely fashion once prescriptions run out. Again, this failure
leads to residents decompensating and having to be admitted to
BCDC's inpatient facility. Significant staff shortages
contribute to the problems achieving timely delivery of
medications to both new and continuing inmates.
Finally, stimulant medications are not available to juvenile
residents with diagnosed attention deficit hyperactivity
disorder. Failure to provide these medications can cause youth
to re-experience symptoms. They may act out in inappropriate
ways because they cannot control their behavior, thus leading to
increased punishment. In addition, failure to provide
medications which youth have been taking for several months may
cause physiological effects. Elavil, a anti-depressant which has
side effects such as drowsiness, constipation, dry mouth,
sedation and slowed mental status is used to treat juveniles at
this facility, when other medications with fewer side effects are
available and would be more appropriate.
2. Access to care
When residents need mental health services, such services
are not provided in a timely fashion. This has led to residents
decompensating and requiring admissions, and sometimes multiple
admissions to the inpatient mental health units. Inmates do not
receive timely follow-up once they have been seen by a mental
health provider either. These deficiencies are tied, at least in
part, to significant staff shortages.
For example, an inmate submitted a sick call request on
December 13, 2000, requesting emergency mental health services.
He was not seen until December 30, at which time he was
experiencing auditory hallucinations and having trouble sleeping.
Another inmate was admitted to the IMHU on November 7, 2000,
after attempting to swallow a razor blade. He was not seen by a
psychiatrist until November 13, and received no medications until
November 20, 2000.
A third inmate we interviewed reported experiencing panic
attacks following his start on a medication prescribed for him in
BCDC that was different from the one he had received before his
incarceration. Despite initiating several sick call requests, he
had not yet seen a psychiatrist for this problem.
These deficiencies in care continue through the resident's
discharge from the facility. Residents do not receive needed
psychotropic medications at the time of their discharge from
BCDC, nor do staff attempt to connect mentally ill inmates to the
community resources they will need upon release.
3. Suicide prevention
There were at least five completed suicides during the six
months prior to our on-site investigation of BCDC. For example,
on December 18, 2000, a 41-year-old inmate committed suicide.
The mentally ill inmate, who appeared to be intoxicated when
admitted, was never referred to a mental health professional for
evaluation. Moreover, although staff put the inmate on a suicide
watch, a nurse discontinued the watch, even though there is no
evidence that the nurse performed any assessment. A doctor at
BCDC found that the case demonstrated deficiencies in the intake
screening and evaluation process. He noted that there was no
policy or practice that required a mental health provider to even
look at an inmate who during admission admits to a history of
mental health problems, but then refuses further evaluation. To
date, we have not received any revised policy that would require
an inmate who refuses a mental health referral to have a face-to-face mental health evaluation, which would be appropriate
On August 15, 2000, a 29-year-old inmate attempted to hang
herself with her paper gown. A physician ordered that she
continue in a single cell with suicide precautions and without a
paper gown. Despite this order, the next day she committed
suicide by tying a paper gown around her neck. Investigators
found no explanation as to why she did not receive a suicide
smock, and was instead given a paper gown in violation of
physician's orders. These and other completed suicides
illustrate lapses in the suicide prevention system and also
reflect the systemic mental health service delivery problems such
as inadequate access to care outlined in this findings letter.
There are also deficiencies in the care provided at BCDC's
inpatient mental health units. As in other parts of the
facility, psychiatrists often do not see inmates in a timely
fashion, and do not prepare treatment plans. Staff providing
care in a setting such as an IMHU should coordinate care to
ensure proper follow-through of treatment goals and to solve
treatment problems, but this does not occur at BCDC.
Provision of mental health care to women is especially
limited. During the time that a psychologist position for women
remained unfilled, mental health treatment of female inmates
declined due to lack of staff. During the same time, there was
an increase in the number of female inmates experiencing severe
enough mental health problems that they needed to be admitted to
the women's IMHU.
In addition, inmates in the men's IMHU do not have
reasonable access to bathrooms. In some parts of that unit,
inmates are expected to urinate into bottles instead of having
access to toilets. This practice does not meet standards of
The men's IMHU contains two crisis management cells, in
which inmates sometimes stay for one to three days. Staff often
fail to provide timely mental health assessments or interventions
other than medication management, which may result in stays in
isolation longer than necessary. Until shortly before our visit
to the facility, there was no policy nor procedure governing the
use of restraints in the mental health setting. The new policy,
not yet implemented, fails to guide staff in the appropriate use
1. Food service and pests
The food service operation at BCDC does not meet sanitation
requirements and puts residents at risk of developing food borne
Food service staff are storing food improperly. For
example, trays of food were observed on top of garbage containers
prior to service. We also observed food trays being placed on
the floor. Major pieces of food storage and service equipment
were broken, including refrigerators, ice machines and baking
equipment. In addition, we found numerous examples where foods
were kept at unsafe temperatures, which could allow for growth of
food borne bacteria.
The floors and walls in the kitchen in the Men's Detention
Center are not properly sealed, which exposes food to insects and
rodents. In fact, insects are a major problem in the facility.
Dead roaches and droppings were prevalent in the commissary area
of the Jail Industries Building. We found evidence of roaches
and rodents throughout the kitchen in the Men's Detention Center,
including live roaches in the dishwashing equipment. We also
found roach droppings, spiders, and gnats in residence areas
throughout the facility. Many parts of the facility are not
treated for rodents, especially the utility chases. The improper
storage of food service equipment and materials contributes to
this rodent problem.
Finally, food utensils, trays, preparation equipment and
pots are not always sanitized as required. Some dishwashers do
not reach sufficient temperatures to achieve sanitization.
Moreover, chemical test strips were not available in many
locations, making it difficult for facility staff to test whether
sanitization requirements are being met. The hand washing sink
in the Women's Detention Center was broken, making it unlikely
that food workers were washing their hands when necessary.
2. Plumbing, ventilation, light, electricity
The facility also has serious problems with plumbing,
ventilation and lighting. With regard to plumbing, vacuum
breakers are missing in various places throughout the facility.
Vacuum breakers are crucial to proper sanitation because they
prevent introduction of contaminated water into the potable water
supply. Moreover, we observed broken toilets throughout the
facility, water in showers that was either too hot or too cold
for safety and hygiene purposes, and broken lavatory sinks and
drains. There were also insufficient shower and lavatory
facilities in some places. Showers throughout were dirty and
The facility lacks proper ventilation to prevent disease
transmission and control odors. For example, a block of rooms in
the Women's Detention Center where medically fragile inmates
reside was too cold because of windows that allow wind in, and an
inadequately balanced heating system. Other parts of the
facility were far too hot. Some areas lacked any ventilation at
all, or were recirculating stale air. The facility's school
trailer was not circulating air properly. When inmates lack
adequate personal space in an environment in which ventilation is
poor, disease transmission is more likely. Numerous locations in
the facility house inmates too closely together for their health
and safety, given the other sanitation problems in existence in
Lighting at the facility must be a least 20 foot candles to
provide for reading, sanitation and personal hygiene. Some
showers had no functioning light source, and some dorms had
lighting as low as two to seven foot candles. In addition, we
found instances of exposed wires, frayed power cords and other
electrical shock hazards.
3. Medical examination areas
The medical examination areas present special sanitation
concerns. These areas are dirty, equipment is in bad repair, hot
water for hand washing is not consistently maintained and some
lighting is below acceptable standards. Some examination table
covers are torn and cannot be properly cleaned or sanitized.
Moreover, medicine refrigerators do not have thermometers to
check that proper temperatures are maintained. We observed
medication being improperly disposed of in trash cans (which
inmates empty and may therefore access the medications) and drugs
and food being stored in the same refrigerator as medications,
which can lead to contamination.
We also found expired medical equipment. For example, in
the Men's Detention Center first floor medical screening area,
there were expired Occult Blood Specimen kits. The use of this
equipment could lead to errors in diagnosis.
Our inspection revealed torn and cracked mattresses
throughout the facility. Such mattresses cannot be cleaned or
sanitized properly. Furthermore, they present an increased fire
risk, as torn and cracked mattresses lose their fire-resistive
We observed many inmates washing their clothes in the
toilets in their cells. While facility staff claim that inmates
have access to utility sinks or can send their wash to the
laundry, inmates reported that they do not have time to wash
their clothes in the sink and also shower and take care of other
needs during their very limited out-of-cell time. They reported
that they did not always get their clothes back if they sent them
to the laundry.
E. EXERCISE AND OUT-OF-CELL TIME
Residents receive insufficient opportunities for exercise
and out-of-cell time. A majority of residents housed in the
Men's Detention Center, notwithstanding that they are classified
as general population residents, are confined in small cells in
excess of twenty-two hours per day. During the winter months,
the outdoor recreation yard is closed. As a result, the limited
out-of-cell time for Men's Detention Center residents is confined
to small indoor day-spaces that do not have room for large muscle
exercise, with use of the gymnasium perhaps once per week. The
limited out of cell time and opportunity for outdoor exercise
provided to inmates can exacerbate the conditions of residents
with mental illnesses, and can put inmates, especially the
juveniles, at risk of developing anxiety and symptoms of
In 1998, BCDC implemented a violence reduction program which
has effectively reduced assaults on staff and other residents,
and acts of malicious destruction. However, this has been
achieved in large part by increasing the time during which
residents are confined to their cells. If residents are allowed
out of their cells to remedy exercise deprivation, security
deficiencies that currently exist caused by lack of sufficient
correctional staff could be exacerbated and could well lead to
increase violence and acts of destruction. In other words, to
achieve needed remedies, additional staff will be necessary to
avoid security problems. For example, at times only a single
officer provides security for each of several units in the Men's
Detention Center. When fully double celled these cellblocks each
have populations of 120 residents. In double-celling situations,
having only one staff member is dangerous because an officer can
be overtaken when opening a cell door. Furthermore, no one is
available to handle emergencies such as transporting an ill
inmate to receive emergency care, when only one officer is on a
The current mixing of security classifications could also
threaten resident safety once residents are given more freedom of
movement. Residents are assigned to a bed primarily based on
space availability, not security classification. Consequently,
most housing units contain mixed security levels. Even inmates
who commit institutional infractions and are reclassified often
are not moved to more secure housing. Current housing
arrangements may need to be altered with increased movement of
inmates, in order to protect staff and inmate safety.
F. JUVENILE DETENTION
1. Sight and Sound Separation From Adults -
Protection from Harm
Boys under age 18 detained at BCDC are housed in four
locations, two of which do not provide sight and sound separation
between youth and adult inmates. The majority of boys reside in
cells in the L Unit, the general population juvenile boys'
housing unit. Boys in protective custody reside in the R Unit.
In these units, youth are sight and sound separated from adults,
as no adult males reside in those units. This is not the case,
however, in either the male maximum segregation or medical units,
where juveniles and adults are housed side-by-side. None of the
girls at BCDC are sight and sound separated from adult women
except for girls in the area reserved for protective custody,
administrative segregation, and medical quarantine.
Finally, youth are transported to court with adult inmates.
Boys are kept in holding cells with groups of men prior to
transportation. Only boys on protective custody status are
transported separately. Approximately 250 to 300 inmates are
transported daily from the holding cell area for male
transportation. Inmates await transportation in large holding
cells where 25 or more inmates may wait together at one time.
While there are many correctional officers present in this area
processing people for their trips to court, the holding cells are
not closely supervised, nor are there clear sight lines to all
inmates in a holding cell. The risk for youth to be victimized
in this environment is high.
Failing to sight and sound separate youth from adults in
their living areas places them at serious risk of harm, by
subjecting them to the undue influence and harassing behavior of
adult inmates. For example, girls must pass the women's
dormitories on the way to their own, and reported feeling
disturbed when adults would frequently yell sexually harassing
and frightening comments at them, both in passing and during the
night. Such exposure can be psychologically harmful to minors.
In addition, in the transportation holding areas and during
transportation, where youth and adults are not physically
separated, youth are at a risk of physical victimization as well.
2. Excessive Isolation
Some youth are kept isolated in segregation cells for
lengthy periods of time that may be psychologically damaging to
young people. Juveniles housed at BCDC may be placed in
disciplinary segregation for institutional infractions or
"supermax" status due to the seriousness of their charges,
sometimes resulting in stays of several months in segregation.
These youths are confined 22 to 23 hours per day in single cells,
and receive showers approximately twice per week.
Youth generally experience time and confinement more
severely than adults. Youth may experience symptoms such as
paranoia, anxiety and depression after very short periods of
isolation, and thus the lengthy stays in segregation at BCDC are
Youth first admitted to the facility remain on medical
quarantine until they are cleared for release into the
population. During this time they are single celled on a
separate tier of the juvenile unit. While intended to last only
two to three days, staff reported that youth sometimes remain
under medical quarantine for up to three weeks. During this
time, youth are allowed out of their single cells only for an
occasional shower or dayroom recreation time, medical appointment
or to see the social worker. They are not enrolled in school
until after clearing medical quarantine. This extent of
isolation is excessive and potentially harmful to youth.
The Baltimore City Public School System operates a school
within the walls of BCDC for the minors incarcerated there. The
school operates during hours comparable to those of other public
schools during the school year, and a partial day during the
summer. It has six classrooms at the main school (a collection
of trailers on the grounds of the jail), plus one self-contained
classroom inside the protective custody unit. Students are
assigned to classes based on the last grade in which they were
enrolled, with the girls grouped all together with the boys who
are working toward their General Educational Development degrees
We commend the jail, the State Department of Education and
the Baltimore City Public School System for having an organized
school program which most minors at the facility attend.
However, the education program at BCDC violates the rights of
disabled students to a free and appropriate education as defined
in the IDEA and Section 504 of the Rehabilitation Act. The
school fails to identify and evaluate adequately those suspected
of needing special education services. Furthermore, the school
does not develop, update or follow Individualized Education
Programs for students identified as disabled, and fails to
provide most related and transitional services as required by the
In addition, BCDC violates girls' rights to equal protection
under the law; girls are not provided with educational
opportunities and programs comparable to those of their male
counterparts, and there is no penological justification for this
difference. Youth housed in maximum custody are not receiving
adequate education comparable to their general population
counterparts (they receive packets of written worksheets with no
feedback or instruction) and there is no penological interest
served by this deprivation; therefore their equal protection
rights are violated as well as their rights to a free and
appropriate education if disabled. Finally, youth ages 18 to 21
receive no opportunity for education at this facility. (2)
1. Special Education
a. Screening and Identification
The IDEA requires that all children with disabilities who
are in need of special education and related services be
identified, located and evaluated. Youth who enter the BCDC
school are not screened sufficiently for identification of
special education needs. The school system fails to transfer
records in a timely manner, so the BCDC school generally gathers
only a narrow amount of information available by computer. The
school relies on SETS, the computer system from the Baltimore
City Public Schools, to determine whether a student was
identified as disabled in the Baltimore City Public School System
(BCPSS). No further attempt at screening incoming students for
This is an insufficient process for screening. Proper
screening should include systematic observation of students,
interviews and assessment of entering students to determine prior
history of special education and/or referral for evaluation for
special education eligibility. Staff should also have the
opportunity to refer students for special education evaluation
when they observe that a student may need services, but the
school has no such means for referral.
The test administered to incoming students, the Test of
Adult Basic Education (TABE) can only determine the grade level
at which someone is functioning, not assess individual skill
deficiency or skill acquisition. Thus it is an insufficient
screening or assessment tool for meeting the requirements of the
The IDEA requires that schools conduct a full and complete
assessment of students suspected of having disabilities and that
the assessment be done by an appropriate evaluation team that
includes specialists in the areas of the student's suspected
disabilities. While there is a part-time certified school
psychologist on staff at BCDC, he does not review previous
special education evaluation results, conduct initial evaluations
or conduct re-evaluations of students who have or are suspected
of having disabilities. The BCDC school staff maintains that
because it is a temporary education site and students are not
enrolled long enough to complete a three to four month evaluation
process, they are not required to identify or evaluate any
Students at BCDC, however, are detained from as little as a
few hours to as long as a year awaiting trial. The average
length of stay for students is 69 days. Thus, many students are
enrolled long enough to be evaluated and provided special
education services. Even those who leave before the evaluations
are complete are entitled to begin the evaluation process, which
could then be completed at their home schools.
c. Free Appropriate Public Education and
Individualized Education Programs
Individualized Education Programs (IEPs) must be developed
for each child determined to be entitled to special education
services. The IDEA requires that there be a written document
that: states the student's present level of performance;
specifies short term instructional objectives that are measurable
and within the student's capabilities; sets objective criteria
and a timetable for measuring achievement; defines a transition
plan and services necessary to help the student move from school
to post-school activities; outlines the special education and
related services to be provided; describes the extent to which
the student will be able to participate in the general education
program; and sets forth projected dates for the initiation and
duration of services. IEP's must be developed within 30 days of
a determination that a student needs special education and
related services, and reviewed at least annually. An IEP must be
in place each school year.
The BCDC school does not conduct IEP meetings in the manner
prescribed by the IDEA nor provide services in keeping with
students' IEP's. Charts we reviewed for youth already identified
as special education students revealed IEPs as old as 1997. BCDC
alters the most recent IEP to match the services currently
available at the site, records it on an IEP Minutes Form, then
uses this (to a limited extent) to guide the student's
instruction. Without regard to student needs (which BCDC has not
evaluated), all students are reclassified as "full-inclusion" and
assigned to general education classes, with the expectation that
each teacher will provide the necessary modifications of
instruction and assignments that each child with a disability
needs. BCDC does not provide services such as resource room
instruction (prescribed in some students' existing IEP's) to any
student. The IDEA does not permit such modification of
prescribed services without a determination by the IEP team that
such a change in education and services appropriately meets the
Furthermore, to the extent that teachers were trying, within
the "full-inclusion" model assigned to every student at BCDC, to
address the goals and objectives of old IEP's, our review
revealed that students are not consistently provided with
instruction in keeping with their goals and objectives. The work
evidenced in student work files and observed in class was not
routinely crafted to fulfill the goals and objectives in
students' IEPs. While teachers could name who their students
with identified disabilities were, they were not monitoring
progress toward goals and objectives nor recording these on
students' IEPs. Some staff reported to us that they did not feel
prepared or trained to provide modifications to students with
disabilities in their classrooms. Classroom observations also
revealed that students were not receiving instruction in a manner
that kept them on-task and academically engaged. In addition to
violating the IDEA, a number of the above findings also indicate
failure to comply with the Rehabilitation Act's requirements of a
free and appropriate public education.
Finally, BCDC fails to comply with other requirements set
forth in the IDEA, such as providing surrogate parents to
represent the child in educational decision making where no
parent may be located, and providing transition services for
teenagers to help them move from school to post-school
2. Education for General Population Girls
Because of the small number of girls detained at BCDC and a
desire to keep them safe in their classrooms, staff group the
girls together in the classroom with the boys who are working
toward their GED's. This means that girls of all ages and grade
levels are grouped with boys ages 16 and older who are close to
completion of high school equivalency. While the staff's stated
goal is to provide individualized instruction to each of the
girls at her appropriate grade level, what we observed and what
the girls reported was that they were frequently expected to
complete the same assignment as the rest of the class, and that
only some of their teachers provided a consistent curriculum
sculpted to girls' individual levels. Thus, girls do not receive
an education of similar quality to that of boys similarly
3. Education for youth in segregation
Boys detained in the maximum security area (M section) of
the jail received insufficient educational instruction and
services at the time of our visit. An educational staff member
brought packets of materials once or twice per week for the boys
to complete, but neither he nor anyone else provided feedback or
instruction regarding these materials. Boys in the M section
reported that they had no idea whether they were receiving any
class credit for doing this work, and had no idea whether they
had completed it correctly. Since that time, the jail has
instituted a policy that provides for education services to
juveniles in segregation, including teachers providing assistance
with packages of work assignments as needed. We have not been
able to verify whether such assistance is being provided
Girls in administrative segregation, punitive segregation,
and protective custody receive even less instruction and services
than the boys of similar status. Girls rarely receive education
materials while in segregation. The principal of the school
reported to us that the staff member responsible for the boys was
gathering materials and providing one on one instruction for the
girls as well, but that staff member reported that he never goes
to the Women's Detention Center. The girls we interviewed
reported that they had not received educational materials while
4. Medical Quarantine
BCDC does not allow students to enroll in school until after
they have been cleared from medical quarantine upon arrival at
the jail. School staff reported that this process takes an
average of two weeks, leaving youth without education during this
period. This constitutes an unacceptable gap in educational
services for students both with and without disabilities. While
it is appropriate to ensure that newly-incarcerated youth will
not pose a health risk to themselves or others by attending
school with the rest of the population, the medical department
and the school must coordinate to find a way to avoid lengthy
delays in school enrollment and instruction.
III. REMEDIAL MEASURES
In order to rectify the identified deficiencies and to
protect the constitutional rights of the facility's inmates and
detainees and the constitutional and statutory rights of the
juveniles, the facility should implement, at a minimum, the
A. FIRE SAFETY
1) Repair the central fire alarm and smoke detection systems,
and ensure that all inmate-occupied areas are protected by
sufficiently loud, functioning fire and smoke detection
2) Replace, not just repair, any sprinkler heads that have been
painted over or otherwise damaged. Develop and implement
policies, procedures and practices to prevent the future
painting or damaging of sprinklers.
3) Develop and implement policies, procedures and practices to
ensure that sprinkler heads are kept clear of debris and
4) In those buildings currently having sprinkler systems,
install sprinkler heads to cover all areas of the building.
5) Add sprinkler capability to the educational and drug
6) Move the drug treatment trailer buildings farther away from
buildings in which residents are housed.
7) Develop a system to maintain security of the sprinkler
8) Properly enclose stairwells, piping, chases and smoke
9) Develop and implement policy, procedures and practices to
store all combustible personal property in metal containers.
10) Institute the use of non-combustible waste receptacles.
11) Use door keys that can be identified without the benefit of
sight, ensure that all keys to doors on exit routes are
readily available, and train staff in their use.
12) Ensure that there are sufficient exit route options to allow
occupants to exit safely in the event of smoke or fire, and
maintain those exit routes so that they are free of
obstacles, safe and available for use.
13) Conduct regular fire drills and increase staff training in
the use of breathing equipment.
14) Train staff in security measures necessary to compensate for
any temporary shutoff of the fire and smoke detection
15) Work with the local fire department to develop plans for
evacuation and fighting fires at the facility.
16) Ensure that all aspects of fire safety, including training
for all staff including preparing and maintaining emergency
evacuation procedures and the use of fire protection and
suppression equipment are coordinated.
17) Fix inoperable remote locking mechanisms.
18) Install an automatic smoke evacuation system in the plumbing
chase areas of the Men's Detention Center.
19) Ensure that fire fighters' access to the sprinkler/standpipe
system remains unobstructed.
20) Remove unnecessary combustible material from inside or near
B. MEDICAL CARE
1. Intake Screening and Assessment
21) Train booking officers to conduct medical and mental health
booking screens properly.
22) Provide for a more confidential environment in which to
conduct medical and mental health booking screenings.
23) Develop and implement procedures to ensure that the screen
completed by a booking officer becomes part of the inmate's
medical record immediately.
24) Train booking officers to look for signs of mental and
physical illness in the inmates they interview.
25) Revise and implement procedures to ensure that inmates
reporting or exhibiting possible signs of significant
medical or mental health problems at booking are seen
promptly by a triage nurse and receive appropriate follow-up
26) Revise and implement procedures to ensure that all inmates
receive medical screening in a timely fashion.
27) Revise and implement procedures to ensure that all histories
and physical exams are conducted within 14 days of arrival
at the facility.
28) Revise and implement procedures for addressing drug and
alcohol withdrawal to ensure that all inmates are screened
and/or treated appropriately if they report or exhibit signs
of drug or alcohol withdrawal.
29) Train health care and correctional personnel regarding the
signs and symptoms of mental illness.
30) Develop and implement procedures to ensure timely referral
for evaluation and treatment of inmates who exhibit signs
and symptoms of mental illness.
31) Train health care and correctional personnel regarding the
signs and symptoms of drug and alcohol withdrawal, and
32) Develop and implement procedures for validating and
continuing, if appropriate, current prescriptions for
medications of incoming inmates within 12 hours of arrival
at the facility.
33) Staff all medical units with sufficient medical staff to
screen and evaluate incoming inmates, and provide adequate
treatment and monitoring of inmates with serious medical
34) Provide more complete information regarding treatment
availability and options to those incoming inmates
experiencing alcohol or drug withdrawal.
35) Develop and implement procedures to ensure that inmates
exhibiting signs or known to be at risk of drug withdrawal
are questioned by a medical professional regularly during
the first three days at the facility regarding their current
symptoms and provided information and supportive measures as
36) Develop and implement policy, procedures and practice for
proper recordkeeping of detoxification treatment.
2. Acute and Emergent Care
37) Ensure that nurses provide medical care within the scope of
their training and licensure.
38) Develop and implement policy, procedures and practices to
ensure that medical staff refer inmates in need of care to
the appropriate practitioner in a timely manner.
39) Develop and implement policy, procedures and practices to
ensure that inmates receive care from the appropriate level
and specialty of practitioner in a timely manner.
40) Train correctional staff regarding their responsibilities to
deliver inmates to sick call and other medical encounters.
41) Train correctional staff regarding their role in securing
access to acute and emergent care for inmates, and provide
adequate staff to accomplish these tasks.
42) Ensure that all correctional officers are certified annually
in CPR. Equip all officers with pocket masks and rubber
gloves, and make clear the expectation that correctional
officers initiate CPR and continue until medical help
43) Equip units with sufficient numbers of automatic electronic
defibrillators, and train staff in their use.
44) Ensure that juveniles and adult inmates in segregation have
adequate opportunities to contact and discuss health
concerns with health care staff in a setting that affords as
much privacy as security will allow.
45) Staff health units adequately so that inmates requesting
acute and emergent care may be treated timely and
46) If the facility uses temporary health care providers, ensure
that they are trained adequately regarding the special
circumstances of correctional health care and the policies
and procedures of BCDC in particular.
47) Provide sight and sound privacy for all health care staff-inmate encounters whenever possible.
48) Provide additional training to nursing staff regarding
assessment of diseases, appropriate referrals and
3. Chronic Care
49) Establish a chronic care system which includes gathering
information and establishing medication upon intake into the
facility, establishing a system of care of inmates with
chronic diseases at established intervals, standardizing the
information gathered at treatment visits, and devoting
sufficient attention to inmates whose uncontrolled
conditions must be stabilized.
50) Develop and implement policy, procedure and practices to
ensure that inmates with chronic medications, including
inhalers, have access to those medications when appropriate.
51) Ensure that medical grievances are processed and addressed
in a timely manner.
52) Develop and implement an accurate, thorough, legible method
of medical recordkeeping.
53) Improve morbidity and mortality review process to ensure
that deaths are thoroughly and effectively evaluated and any
problems with care or access to care that are revealed
through that process are resolved.
54) Address systemic problems revealed through the grievance
55) Develop and implement a quality improvement system that
monitors and improves deficiencies identified in this
C. MENTAL HEALTH
56) Increase staffing levels of mental health professionals to
meet the serious mental health needs of the jail's
57) Develop and implement policies, procedures and practices to
ensure that staff respond to sick call mental health
requests in a timely manner.
58) Develop and implement policies, procedures and practices to
ensure that staff provide adequate ongoing care to inmates
determined to need such care.
59) Develop and implement appropriate suicide prevention
policies, procedures and practices.
60) Residents who are suicide risks should be given suicide
smocks rather than paper gowns.
61) Institute an adequate management information system and
62) Institute a more thorough quality improvement system that
covers all mental health professionals.
63) Develop and implement a system to ensure that inmates
receive all necessary mental health medications in a timely
64) Provide for inmates in the men's IMHU to have adequate
access to toileting facilities.
65) Develop and implement policies, procedures and practices
that limit uses of restraint and isolation to circumstances
necessary to protect the inmate, other individuals and
property of significant value.
66) Develop and implement policies, procedures and practices to
maintain food temperatures that avoid the growth of harmful
67) Develop and implement policies, procedures and practices to
properly maintain food preparation and storage equipment.
68) Develop and implement policies, procedures and practices to
properly wash and sanitize food preparation and service
69) Improve the training and supervision of food workers.
70) Ensure that only proper substitutions are made to dietician-approved meal plans.
71) Develop and implement policies, procedures and practices to
provide for safe food handling and storage, including proper
72) Repair kitchen sinks to prevent sewer gas backup and allow
for clean, fresh water availability.
73) Develop and implement policies, procedures and practices to
eliminate insects, rodents and their droppings from the
74) Develop and implement policies, procedures and practices to
ensure the proper functioning of vacuum breakers.
75) Develop and implement policies, procedures and practices to
ensure that water for showers is maintained at an
appropriate temperature and that showers are maintained in a
sanitary condition and sufficiently available to residents.
76) Provide proper lighting in all parts of the facility.
77) Ensure proper ventilation and maintain proper ambient
78) Develop and implement policies, procedures and practices to
ensure that toilets, sinks and drains are maintained in
sufficient quantity, clean and in proper working order.
79) Repair electrical shock hazards; develop and implement a
system for maintenance and repair of electrical outlets and
80) Develop and implement policies, procedures and practices to
adequately maintain sanitation in medical areas.
81) Develop and implement policies, procedures and practices to
properly store and dispose of medical supplies; dispose of
expired medical supplies.
82) Provide adequate opportunity for inmates to wash their
clothes by a sanitary method.
E. INMATE EXERCISE AND OUT-OF-CELL TIME
83) Develop and implement a housing and staffing scheme that
would permit increased out-of-cell and exercise time for
qualified residents in a safe environment. Retain
sufficient qualified security officers to staff this plan
and provide for safety of inmates and staff.
84) BCDC's Classification Division and the Traffic Office should
develop and implement criteria for initial classification
and reclassification of residents who should not be housed
in a mixed custody environment.
85) Implement procedures to re-examine classification following
discipline of an inmate.
86) Ensure that girls and boys under age 18 do not have harmful
contact with adult inmates.
87) Reduce use of isolation of minors to only those
circumstances necessary for safety of inmates and others.
88) Ensure that isolated minors receive ample out of cell
89) Eliminate unnecessary delay in clearing youth from medical
quarantine and enrolling them in school.
90) Ensure that youth on medical quarantine receive at least
daily visits by a mental health professional.
91) Develop and implement policies, procedures and practices for
disciplining youth that are appropriate to their ages.
92) Increase staffing on the juvenile unit to allow for
sufficient out of cell time.
93) Train staff regarding youth development, behavior and
94) Provide free, appropriate public education, including
appropriate related and transitional services, for all
qualified students with disabilities under the age of 22.
95) Develop and implement effective screening and assessment of
students' special education needs. This includes locating,
identifying and evaluating all qualified students with
96) Revise assessment materials and procedures to allow for
development of functional IEP's.
97) Develop and implement curriculum-based evaluation and
measurement procedures to monitor student improvement.
98) Create a continuum of educational placement options that
meet the needs of the BCDC student body.
99) Train general education teachers who will have special
education students in their classrooms to modify and adapt
curriculum for students with special needs.
100) Develop and implement systems for special education teachers
to monitor student progress in general education classrooms
and provide support to general education teachers.
101) Maintain adequate documentation of progress toward IEP goals
102) Provide appropriate educational opportunities for youth
housed in segregation and medical quarantine.
103) Comply with timelines and requirements for developing,
implementing, reviewing and revising IEP's.
104) Develop a functional, integrated and focused educational
105) Train all staff in the recognition and provision of
appropriate services for special needs students.
106) Provide appropriate space and resources to deliver effective
and meaningful instruction to all students.
107) Ensure that girls are provided equal access to
individualized regular and special education services.
In light of the State's cooperation in this matter, under
separate cover we will send you our experts' reports. Although
the experts' reports and work do not necessarily reflect the
official conclusions of the Department of Justice, their
observations, analyses and recommendations provide further
elaboration of the issues discussed above, and offer practical
assistance in addressing them.
Pursuant to CRIPA, the Attorney General may institute a
lawsuit to correct deficiencies of the kind identified in this
letter forty-nine days after appropriate officials have been
notified of them. 42 U.S.C. Section 1997b(a)(1). We would
prefer, however, to resolve this matter by working cooperatively
with you, and we have every confidence that we will be able to do
/s/ Ralph F. Boyd
Ralph F. Boyd, Jr.
Assistant Attorney General
cc: The Honorable J. Joseph Curran, Jr.
State of Maryland
Glenn Marrow, Esq.
Assistant Attorney General
State of Maryland
Mr. LaMont W. Flanagan
Division of Pretrial Detention and Services
Mr. Ralph Logan
Baltimore City Detention Center
The Honorable Thomas M. DiBiagio
United States Attorney for Maryland
1. The State took over operation of the facility in 1991. House
Bill No. 1059, 1991 Laws of Maryland, ch. 59.
2. With regard to the 18 to 21-year-old population, we recognize
that the Maryland State Department of Education issued a
memorandum date September 10, 2001, to all school jurisdictions
reminding them of their responsibility to provide free,
appropriate public education to inmates with disabilities under
age 22 in locally operated detention centers and correctional
facilities. This memorandum was a partial fulfillment of a
Commitment to Resolve a complaint to the Office of Civil Rights
of the United States Department of Education. We understand that
despite the acknowledgement of the responsibility, as yet no
education program for 18 to 21 year olds exists at BCDC.