Investigation into inmate's suicide faults Maryland women's prison's treatment of people with disabilities

An investigation into Maryland’s only prison for women following the 2017 suicide of an inmate found the facility violated the constitutional rights of individuals with disabilities who are placed in segregation and did not take sufficient steps to “prevent future harm.”

The investigation, released Friday by Disability Rights Maryland, reviewed the Maryland Correctional Institution for Women and its role in the death of inmate Emily Butler, who was found dead in her cell from an apparent suicide by hanging on Nov. 12, 2017. At the time of her death, Butler, who had a history of mental health issues, was serving a 14-year sentence for a charge related to arson and would have been eligible for parole this past April.


The investigative report recommends reforms for how the prison can better handle inmates with disabilities.

Disability Rights Maryland is the state’s designated authority under federal law for conducting investigations into allegations of abuse and negligence for people with disabilities. The group, along with Open Society Institute of Baltimore community fellow Munib Lohrasbi, launched a review after Butler’s death in segregation.


The report’s findings were based on interviews with women in the segregation unit at the time of Butler’s death, video security footage of the unit and a review of the prison’s records and log sheets. Investigators also made site visits, reviewed information provided by the warden, interviewed health care contractors, inmates and individuals who provide advocacy and programming for the prison.

The report found that “the restrictive conditions, applied to individuals with serious disabilities, violates the 8th Amendment of the United States Constitution, which prohibits cruel and unusual punishment, including deliberate indifference to the health care needs of incarcerated individuals.” It found the prison also violated Maryland Constitution and the Americans with Disabilities Act.

“The harm from prison segregation practices is pointedly evidenced by the death of Ms. Butler,” the report noted.

Michael Zeigler, the deputy secretary of operations for the Maryland Department of Public Safety and Correctional Services, said in an email Friday that the department, along with Warden Margaret Chippendale, “have been nationally recognized for treating inmates with dignity.”

“With her 40 years of correctional experience, Warden Chippendale is known throughout the state for implementing innovative prison programs, ranging from providing healthy inmate meals to devising a system to divert more inmates from restrictive housing,” Zeigler said in the statement. “We take our mission to protect the public, our staff and the inmates in our custody very seriously and remain confident that the warden and her staff are doing everything in their power to keep the inmates at their institution safe.”

When Butler was admitted to the Maryland Correctional Institute for Women in 2015, her extensive mental health history was documented during a psychiatric evaluation, according to the Disability Rights Maryland report. She had been receiving mental health services in the community since 2008 for depressive, bipolar and post-traumatic stress disorders, and she also had a history of multiple self-injury and suicide attempts prior to incarceration, all of which was documented in her prison medical records, the report noted.

Butler was prescribed psychiatric medications to address her anxiety and depression, but never received regular counseling, according to the report. Butler’s depression medications also were changed to address her increased depression symptoms a week prior to her death, the report said.

On Nov. 10, 2017, Butler was sent to segregation — defined as the isolation of someone for 22 hours or more per day with or without a roommate — after she threw coffee on another inmate during a dispute. She was not screened or evaluated for mental health concerns prior to being placed in segregation, the report said.


Multiple women told investigators that Butler was distraught over her argument with her friend and worried that her disciplinary charges would affect her chance for parole, the report states. She repeatedly asked to speak with her father or get mental health help over a period of more than two days, according to the report. She was not allowed out of her cell, aside from the opportunity to shower, the report states.

According to the report, prison policy requires the segregation unit staff to supervise and monitor inmates’ behavior and to make security rounds every 30 minutes. However, Butler was last accounted for during the morning count at 7:30 a.m., according to the report, and she was not found until the lunch trays were delivered around 10:15 a.m.

She was declared dead at 11 a.m., but her body lay on the floor in the middle of the segregation unit for hours until the medical examiner arrived, the report states.

Representatives of Disability Rights Maryland read aloud statements from Butler’s parents, Becky Miller and Joe Butler, during a news conference Friday. Before her death, Butler had spoken with and written to her parents about her plans for when she was released from prison. Her death came as an extreme shock, they said.

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“To isolate an individual who has problems… and abandon her is morally reprehensible,” Miller said in the statement.

Investigators also found that about six weeks prior to Butler’s death, another inmate with a disability had attempted suicide in segregation after her requests to see a mental health professional were ignored.


Following Butler’s death, Chippendale told investigators that several actions were taken, including that a chaplain was asked to visit the segregation unit and an expert on trauma-informed care was invited to speak with some staff. The warden also said she increased her participation in segregation reviews and visits to the unit.

However, investigators said they “saw no evidence that a robust review of the mental health factors that contributed to Ms. Butler’s suicide was conducted.”

The Disability Rights Maryland report makes 20 recommendations, including developing alternatives to segregation for people with serious disabilities and implementing a mandatory pre-screening evaluation before placement in segregation.

State Sen. Susan Lee and Del. Jazz Lewis announced plans at Friday’s news conference to propose legislation in the upcoming session that would require mental health examinations of inmates within 14 days of segregation.

Baltimore Sun reporter Justin Fenton contributed to this article.