Prisons watchdog again calls for an end to ‘double housing’ of certain prisoners after deaths by 2022

Nebraska State Penitentiary in Lincoln. (Rebecca S. Gratz for the Nebraska Examiner)

LINCOLN – A state prison watchdog is again urging the Nebraska Department of Correctional Services to stop double-housing inmates in restrictive housing, at least by the time the new state prison opens.

In one 38 page report Released Thursday, the Office of the Inspector General of Corrections outlined findings into the 2022 death of an inmate, “John Doe,” who died two days after another inmate, “John Smith,” was taken to his cell transferred. About three months earlier, staff recommended Doe’s removal from long-term, restrictive housing, and a review of his housing was scheduled.

However, that revision never came as he died three days before the scheduled date.

The inspector general did that expressed similar concerns in the past about double bunking, especially after the Murder in 2017 of one 22 year old inmate with double bunk beds at the Tecumseh State Correctional Institution, when the agency recommended suspending “double bunks” in restrictive housing until after further investigation. The department rejected that advice.

The inspector general later encouraged the state in at least two more reports to end the practice completely. It only continues at the Nebraska State Penitentiary in Lincoln.

“Restrictive housing is a volatile situation, even for a correctional facility, and staff cannot be expected to determine in these circumstances which cellmates are safe and which are not,” the report said.

The Office of the Inspector General for Corrections is a statutory agency created in 2015 to increase accountability and oversight of the Department of Corrections. It investigates all deaths in department facilities.

The Death of ‘John Doe’

In this case, Doe was placed in the restrictive housing unit about five months before his death after staff found a homemade 6-inch gun in his pocket, even though Doe was making progress in completing all nine Courage to Change booklets and three different non-clinical booklets. programming books available on the device.

Doe wrote in an “inmate responsibility statement” the week of his death that he had been dealing with depression, family issues and “other things beyond my control,” but that when he returned to the yard, he could gain better control over his life. live, program more and finish school.

“I really want to make a change and I’m not just saying that to get out,” he wrote. “I really want to change my life and educate myself more and become a better person for myself and my son on the street.”

Smith, Doe’s later cellmate, was moved to a single cell after speaking to a mental health doctor three days before Doe’s death, and when Smith had to be moved back to a double bunk, he specifically requested to To be allowed to live.

Staff completed the required documentation and checked with Doe to ensure he was comfortable with the change. After the two were placed in a double bed, a case manager spoke to both men separately, and neither expressed concerns at the time, the report said.

The next day, staff found Doe unconscious on his cell floor shortly after 4 p.m. After approximately 25 minutes of emergency response, Doe was pronounced dead.

An autopsy two days after said Doe died of “ligature asphyxia,” or lack of oxygen.

Corrections staff notified the Office of Inspector General within a few hours of the incident with an email with his name and the subject line “NSP suicide.”

Inspector General Doug Koebernick said in an email Friday that it is unknown whether Doe died by suicide or homicide. The report indicates that some details about the scene were omitted due to an ongoing criminal case related to Doe’s death.

The report does not identify Doe or Smith by their real names, but the case is similar October 2022 death of 26-year-old Philip Garcia. A Lancaster County The grand jury indicted Garcia’s cellmateTyler Stanford, 38, charged with first-degree murder in May 2024.

Policy of double-bunking prisoners

The Inspector General’s report indicates that there are some benefits to double-bunking in these environments, such as increasing capacity in congested systems (such as Nebraska’s), less isolation, the ability to share items and the potential reduction of self-harm or suicide.

However, there are also disadvantages, such as lack of physical space, lack of privacy, difficulty searching cells or identifying the owner of found contraband, a sense of increased risk for staff when having to open cells in an incident, possible sexual victimization without witnesses and possible assault or murder.

The inspector general could not find a comprehensive study on whether the combined risk of death, either by suicide or homicide, is greater in restrictive residential cells with one or two bunk beds.

“Some studies have shown that people are more likely to die by suicide in single-cell disciplinary housing; However, the recommended solution was more attention from staff, and no double bunk beds,” the report continues.

In the past four years, three people have committed suicide in a single bunk bed in a Nebraska prison. Meanwhile, there are in the same time frame three suspected murdersand in each case, the person’s cellmate was the suspected murderer.

It is unclear whether the Doe case is included in the cases counted for those years.

One staff member told investigators that double bunking had become the ‘expectation’ and was treated as ‘business as usual’ among senior management.

The report states that a month before Doe’s death, unit staff were told that decisions about double bunk beds were in accordance with department policy and that they should pair as many people as possible “to free up as many cells as possible” in the restrictive housing unit. .

The inspector general said the department’s policy allows people in restricted housing to be dually housed “as long as the cell assignment provides each cellmate reasonable protection from mistreatment.”

The report says staff followed policy.

“It has been a goal of the agency to reduce the behavior that results in restrictive housing,” Dayne Urbanovsky, a department spokesperson, said in a Friday email, “and through multiple improvements that the NDCS implemented over the past two years, the use of double bunk beds in restrictive housing at NSP has largely been reduced.”

Policy recommendations

Currently, the Corrections Department does not meet the requirements of the American Correctional Association, through which the department is accredited, for double-housing inmates in restricted housing because the cells are too small.

The report states that the Corrections Department’s “action plan” is new construction. The new replacement facility is not expected to be completed until 2028.

The report offers several recommendations if double bunking continues:

• Requires approval at the administrator level or higher for double bunk placements in restricted housing, which must be cellmate specific and granted in advance, or within 24 hours in an emergency.

• Clarify whether double bunk beds are allowed in limited, longer-term housing.

• Prohibit co-defendants in double bunk beds while in restricted housing.

• Review the violence risk score used for cell assignments and determine if they can be updated periodically, or removed altogether if not.

• Prohibit the placement of cellmates with people in restricted housing who are considered to pose a high risk of violence toward other incarcerated persons.

Investigate roadblock

The Office of the Inspector General completed its initial investigative work into Doe’s death almost immediately and suspended the investigation pending further law enforcement investigation.

In August 2023, an opinion from Nebraska Attorney General Mike Hilgers questioned the question constitutionality of the Inspectors General of Corrections and Child Welfare. That prompted the Corrections Department to suspend officials’ access to facilities, files and personnel.

No state officials filed a lawsuit against the laws, and no courts blocked the laws.

Access was partially restored to the Office of Inspectors General in February via a memorandum of understanding between the legislature and the executive. The legislature has set up a committee for this purpose to fully investigate its supervisory authoritywhich the office of Sen. John Arch of La Vista, the chairman of the Legislature, said Friday is underway.

After consulting with law enforcement, the inspector general resumed its investigation into Doe’s death in April.

“The AG advisory did impact our investigation because much of our access to information and facilities was limited due to actions taken after the advisory,” Koebernick said Friday.

The investigation concluded six months later with the full report and an Oct. 22 letter to corrections director Rob Jeffreys. The department’s chief inspector responded on behalf of Jeffreys on Nov. 4, saying he would consider the recommendations.

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