An audit of the Milwaukee County Jail found “unsafe” suicide watch practices

Deeply disturbing. Dangerous. Ill-equipped.

The long-awaited independent audit details the Milwaukee County Jail’s suicide prevention practices and training – one of many concerns that have sparked public outrage in recent years and sparked a months-long investigation.

The audit highlighted systemic problems, ranging from “unsafe” suicide watch practices and challenges to the management of mental health care, as well as poor management oversight, continuing critical staffing shortages and prisoner overcrowding.

Calls for a prison audit come after six deaths in prisons in 2022-23, including two confirmed suicides.

In June 2022 Brieon Green, 21 He choked to death with a telephone cord in the reservation area.

In December, 20-year-old Cilivea Thyrion choked on an adult diaper while staying in a special needs pod.

The case was initially reported by the Milwaukee County Sheriff’s Office Octaviano Juarez-CorroThe cause of death was unknown and there were no signs of injury or trauma at this time. However, documents later revealed evidence suggesting he had suffocated.

Shortly thereafter, the County Board turned to: internal review from the Milwaukee County Sheriff’s Office, which oversees jail operations.

Because board members and local advocates were not satisfied with the information presented, a vote was taken on an external audit, which was approved to resolve concerns about the circumstances surrounding the death and conditions at the facility. The board later selected Texas-based Creative Corrections to conduct the audit.

This is not the first time a prison has been inspected. Shortly after the prison opened in 1992, it faced a class-action lawsuit over concerns about overcrowding and its impact on safety and conditions at the facility.

The lawsuit resulted in a consent decree in 2001. To address concerns about crowding, the jail had to limit the number of pretrial inmates, limit the time spent in the booking process to 30 hours, and face mandatory judicial oversight of the health care services provided.

In 2022 A Journal Sentinel investigation revealed significant staffing shortages at the jail during former Sheriff Earnell Lucas’s tenure. Lucas violated the consent decree. During this period, there were reports of hunger strikes, lockdowns lasting over 21 hours, lack of mental health care, and delays in the delivery of medicines.

A year later, under the leadership of current Sheriff Denita Ball, the prison remained in crisis continued to struggle with unprecedented labor shortages and long lockdowns.

‘Deeply alarming’ suicide surveillance and prevention practices

Although the audit found that the prison’s mental health department “stands out as a significant force” and that the facility and its health care provider, Welladhere to mental health and suicide prevention policies, suicide prevention practices were found to be of great concern.

During the on-site portion of the audit, investigators reported the unsafe practice of chaining suicidal inmates to benches while booked and, in some cases, for extended periods exceeding eight hours.

Investigators also reported witnessing a suicide attempt in which an inmate, handcuffed to a bench in the booking area, attempted to suffocate himself using a leg restraint device attached to the floor.

The audit described the practice as “deeply disturbing” and said it must be stopped.

“Reliance on this method reveals a critical lack of training and understanding of appropriate suicide surveillance protocols,” the report said.

The audit also found concerns about current continuous surveillance practices posing “significant safety risks.” In one case, an inmate was placed in a cell with the lights off and a dirty, scratched window. The officer responsible for monitoring the person was seated at a table 5 meters away and that “the monitor could not see into the cell, making ‘continuous’ surveillance ineffective.”

Many suicide cells were reported to have broken lights, internal switches that could be tampered with and pose a security risk, and windows that were scratched or obstructed visibility due to items stuck to the glass.

Auditors recommended wearing ankle monitors to ensure constant vital signs to monitor inmates and notify staff of changes to improve individual observation practices.

Auditors found that management failed to review critical incidents, particularly those involving self-harm, during weekly meetings to discuss operational issues. The report called the oversight a “significant missed opportunity” to identify systemic problems, improve staff responses to critical incidents and safety conditions, and prevent future incidents of self-harm.

The audit found that probation staff were not sufficiently trained in the management of inmates with mental health conditions, suicide awareness and prevention and de-escalation techniques, leaving them “unprepared to deal with the complex and demanding realities of the correctional environment, which may pose a threat to safety.” and safety of both staff and residents.”

Training records reviewed during the audit found that Wellpath contractors did not complete required annual suicide prevention training and that prison staff had limited knowledge of suicide risk factors as well as procedures and protocols for dealing with at-risk inmates.

The sheriff’s office has not yet commented on the inspection.

Contact Vanessa Swales at 414-308-5881 or [email protected]. Follow her on X @Vanessa_Swales.