The deaths of 12 inmates at the Baltimore City jail complex in a little more than two years could have been prevented, a federal court filing alleges, calling the numbers “extremely concerning and disproportionately high,” and a reflection of Maryland’s failure to protect prisoners.
The American Civil Liberties Union is asking a federal judge to enforce a 2016 settlement agreement, the latest move in a decades-old lawsuit demanding the state clean up Baltimore’s dangerous detention facilities. Gov. Larry Hogan ordered the Baltimore City Jail closed in 2015, a year before a settlement agreement that called for an overhaul of all Baltimore detention facilities.
But that overhaul never happened and won’t until a court forces the issue, the ACLU argued in a filing on behalf of plaintiff Jerome Duvall and others who first brought the case in 1994.
“Now that Defendants have spent more than four years avoiding compliance with a single medical or mental health care provision of the Settlement Agreement, it is clear that a Court order mandating that Defendants develop a plan for compliance with a specific schedule, as well as specification of the tasks that must be completed ... is necessary,” according to a Nov. 20 filing.
The filing and supporting documents refers to both the Baltimore City Booking and Intake Center and the Detention Center, which operate even after Hogan ordered one facility closed.
Mark Vernarelli, a spokesman for Maryland Department of Safety and Correctional Services, said his agency would have no comment. A spokesman for Hogan did not return several messages seeking comment.
The 23-page ACLU filing relies heavily on written reports of a monitor appointed by a federal judge as part of the settlement, along with experts in prison health systems. ACLU attorneys contend those reports show the state has “failed to achieve substantial compliance with a single substantive provision pertaining to medical or mental health services.”
The filing specifically points to a September report by Dr. Michael Puisis, the court-appointed medical services monitor, that contradicted the state’s claim that most of the 2016 agreement’s provisions had been fulfilled.
“Training resources are currently nonexistent. … Current training is ad hoc and left up to supervisory staff … to figure out which is a recipe for failure,” Puisis concluded, according to the court filing. “The scores are abysmal. Only 5% of ordered vital signs are completed.”
The case and a similar one have been in the federal court system for decades.
“Over the years, the case has resulted in numerous consent decrees, settlement agreements, and orders,” U.S. District Judge Ellen Lipton Hollander wrote in a June ruling on another matter in the case. “It has been closed and reopened on various occasions, too frequent to recount.”
“Training resources are currently nonexistent. … Current training is ad hoc and left up to supervisory staff … to figure out which is a recipe for failure.”
Dr. Michael Puisis, monitor for Baltimore jails
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Attorneys on all sides hoped that the 2016 settlement would end the matter for good, and three court-appointed monitors were tasked with monitoring compliance and reporting their findings to federal judges. The case had been closed years earlier, but was reopened because of the continuing “inhumane conditions” at the Baltimore City Detention Center and other city facilities, according to court records.
A year before the agreement, Gov. Hogan ordered the immediate closing of the Baltimore jail, calling the facility a “disgrace.”
Terms of the settlement were for four years and were supposed to expire in June, but are extended due to the court action. The ACLU filing argues that the state has not come close to meeting its obligations under the agreement.
The filing includes an analysis of the Baltimore City Detention Center by Todd Wilcox, medical director of the Salt Lake County Jail system in Salt Lake City, Utah. Wilcox concluded that the 12 deaths of inmates since 2018 were “preventable had there been appropriate systems in place to identify individuals’ medical and mental health needs.”
Wilcox’s report included the redacted names of inmates, the dates they died and each cause of death. Many deaths stemmed from drug overdoses, sickness and suicide, according to the court documents.
He outlined “systemic problems” and common themes that stood out in BCDC detainees after reviewing the medical records of the 12 inmates who died between March 2018 to September 2020.
Wilcox wrote that there needs to be written policies and procedures, qualified and adequate staff, and access to mental and health care, among many other demands, according to the documents. He added that the Baltimore facility did not take necessary measures to prevent deaths in circumstances such as suicide, which he deemed as preventable.
“The fact that a jail with an average daily population of 700 detainees experienced 12 deaths in custody in a two-and-a-half-year basis is extremely concerning and disproportionately high,” Wilcox wrote. “Many of these deaths were preventable, had there been appropriate systems in place to identify individuals’ medical and mental health needs and provide timely care.”
Three of the inmate deaths were the result of fentanyl overdoses. Another died from a methadone overdose with a combination of fentanyl ingestion. Prison staff said the most potent opiate legally allowed in the facility is Tylenol #3, an active opiate codeine.
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Those overdoses led Wilcox to conclude that there is evidence of “security lapses and smuggling of illicit drugs” inside of the jail, documents said.
In June of 2018, another inmate died of a possible drug overdose inside his cell within six hours of being booked and reporting to nursing staff that he had taken two Percocet pills shortly before his booking. Another inmate died due to a methadone overdose. He also had fentanyl in his system, according to documents.
Other inmates were cited as having health issues, including a 63-year-old man who died of acute pneumonia and a left lung abscess, Wilcox concluded.
Two other inmates died from suicide, one of them who was previously assaulted in his unit for being a “snitch.” Wilcox says the issues surrounding both men who committed suicide were not addressed, leading to his assessment that their deaths were “preventable.”
ACLU Attorney David Fathi told the Sun that the deaths are directly related to the state’s failure to comply with the settlement agreement.
“These were people who still could be alive today if the state had honored the commitments it made more than four years ago,” Fathi said. “It’s long past time for Governor Hogan to honor the promise he made more than four years ago to provide basic, life-saving medical and mental health care to this vulnerable population.”