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Bradley v. Hightower, Expert Report, Al, Mental Health Care, 2000

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Expert Report
Mental Health Care in the Alabama Department of Corrections
Bradley v. Hightower
Kathryn Burns, M.D., M.P.H. & Jane Haddad, Psy.D.
Introduction and Overview
Kathryn Burns, M.D., M.P.H. and Jane Haddad, Psy.D. were retained as experts by
plaintiffs’ counsel in the above captioned matter. Although complete resumes are provided
in Appendix A, brief overviews of our experience with correctional mental health follow.
Dr. Kathryn Burns is a Medical Doctor licensed to practice medicine in the state of

She is Board Certified in the practice of general psychiatry and has added

qualifications in Forensic Psychiatry. Dr. Burns was the Chief Psychiatrist for the Ohio
Department of Rehabilitation and Correction from May 1995 until August, 1999, and as
such, provided clinical direction to correctional mental health staff by developing a
comprehensive mental health care system within Ohio’s prisons and implementing policies
and procedures. She served as a member of the Task Force appointed by the President of
the American Psychiatric Association to revise the national guidelines for the delivery of
psychiatric services in jails and prisons. She has served or been retained as an expert in the
field of correctional mental health care in Illinois, New Mexico and Ohio.
Dr. Jane Haddad is a clinical psychologist with extensive experience in correctional
and forensic mental health. Prior to assuming administrative and program development
responsibilities for correctional mental health systems, she provided clinical services for
both jails and state prisons. As Director of Mental Health Services for the Kansas
Department of Corrections, Dr. Haddad developed a day treatment program for inmates with
serious mental illness that achieved national recognition. She also developed a statewide
mental health system achieving 100% compliance with the standards of the National
Commission on Correctional Health Care. In the private sector, Dr. Haddad was responsible
for mental health program development, implementation and the monitoring of services
provided by Correctional Medical Systems throughout the country. She also served as the

Director of the Forensic Unit and Adolescent Unit for the Commonwealth of Virginia. Dr.
Haddad currently provides consultation to state and county agencies regarding adult and
juvenile correctional mental health programs. She provides legal and clinical consultation
in system issues and in individual inmate cases. She recently completed a five-year
involvement in the monitoring of the Ohio Department of Rehabilitation and Correction’s
compliance with the Dunn Consent Decree.
In forming our opinions in this case, we studied the documents listed in Appendix B
and conducted site visits of the following seven Alabama prisons:

March 13, 2000 – Kilby Correctional Facility
March 14, 2000 – St. Clair Correctional Facility
March 15, 2000 – Donaldson Correctional Facility
March 16, 2000 – Holman Correctional Facility
March 17, 2000 and June 21, 2000 – Bullock Correctional Facility
(Dr. Burns not present for second visit)
June 21, 2000 – Easterling Correctional Facility (Dr. Burns not present)
June 22, 2000 – Limestone Correctional Facility

During the site reviews, we were accompanied by class counsel, two or three lawyers
representing the defendants, and Fred Cohen, an expert in the area of Correctional Mental
Health who was serving at the time as an expert for the plaintiffs. Counsel for the
defendants remained in close proximity throughout the visits, providing auditory privacy
when requested. We were unable to engage in lengthy discussions with staff of the
Alabama Department of Corrections (ADOC) or staff of the medical and mental health
contract provider, Correctional Medical Services (CMS), some because they had been
advised by their counsel not to speak with us. We were able to ask specific questions
through defendants’ counsel.
Three fundamental factors must be analyzed when assessing the quality of a
correctional mental health care system:

Bed and treatment space


Quantity and quality of mental health care staff


Inmate access to these physical and human resources


To some extent the first two factors may be assessed by a “paper” review, although
simply listing and characterizing something as a “mental health bed” or providing the formal
credentials of a doctor is not the end of the inquiry. Site visits are essential for determining
the inmates’ awareness of how to obtain mental health assistance as well as for ascertaining
whether adequate treatment is provided.
During the site visits, we reviewed the ADOC mental health units and the areas
designated at each institution for mental health treatment. We met with numerous inmates
in small groups or individually to gain an understanding of current practices and to gauge
the level of inmate satisfaction with mental health treatment. We visited the segregation
units of each institution we toured and conducted cell-front interviews with inmates housed
there. We observed medication administration practices and also reviewed the medical
records of selected inmates.
As a very general introduction to our detailed findings, summary statements of our
overall findings are provided. In our judgment, the ADOC fails to provide even minimally
adequate mental health care for its inmates with serious mental illness, and the record
provides evidence that ADOC administration either knew or ignored the serious
shortcomings of the system.
We uncovered no evidence of meaningful oversight of mental health treatment either
by ADOC officials or by CMS. Indeed, high-ranking ADOC officials appeared to have little
information about mental health services and either had not actually visited these facilities
or could not recall their last visit. Since Merle Freisen’s departure about two years ago,
there has been no replacement for the position of Director of Treatment. This has seriously
compromised ADOC’s ability to monitor mental health care. Further, the deposition of Dr.
Feldman indicated that the oversight of mental health services by Alabama’s Medical
Advisory Committee (MAC) is limited to review of deaths related to suicide; acceptance of
information provided by Dr. Gail Williams, the chief psychiatrist for CMS; and very brief
tours of mental health areas by Dr. Feldman during quarterly MAC meetings held at various


prisons. This is totally inadequate oversight of a large mental health system.
The ADOC mental health system is deficient as to staff; including numbers and
quality; as to bed/treatment space; and as to access to the limited care that is available. As
stated previously, these three factors are essential for any correctional system. We believe
current practices result in the prolonged and needless suffering of many inmates with serious
mental illness.
To be somewhat more specific, it is our opinion that:
1. There is no practical access to needed hospital-level treatment, and the care that
is given this designation at Kilby Mental Health Unit does not approximate
hospital care.
2. Inmates with serious mental illness report that they frequently must violate rules,
hurt themselves or cause property damage to gain the attention of staff. Often
even this destructive behavior does not eventuate in treatment; only further
disciplinary action and segregation result.
3. The medical records do not reflect adequate treatment planning or interventions
and there is simply no way to determine continuity of care.
4. Acutely psychotic inmates are locked-down for long periods of time with little
or no treatment. For example, in the case of the Donaldson inmate (125433)
who committed suicide on January 11, 2000, the medical records document
diagnostic swings from “psychosis” to “never saw evidence of psychosis”; from
“clearly paranoid ideation” to “doing fine”; and from pleas for help that go
unanswered to a response which is unduly delayed to his completed suicide.
5. Medications are administered in a dangerous and unprofessional manner.
6. Therapeutic programs and counseling are wholly inadequate. Some claims as to
providing psychotherapy, both in terms of frequency and what this clinical
activity entails, are transparently false.
7. Conditions of confinement in some areas housing inmates experiencing serious


mental illness are totally unfit for these very vulnerable inmates.
8. Based on inmate reports and medical record documentation, some mental health
staff have demonstrated a general distrust of and contempt for individual inmatepatients.
9. The only treatment consistently available is psychotropic medication, but the
medication is administered improperly; required monitoring often is not done;
and medication is sometimes prescribed without the physician ever seeing the
inmate. Medication is not supplemented anywhere we visited by adequate
therapy or therapeutic programming. We believe that a prison system which, in
practical effect, provides only medication to inmates with mental illness, is
grossly inadequate.

Treatment for inmates with serious mental illnesses

encompasses more than medication.
10. There is little or no evidence of effective training of staff on the rudiments of
mental illness and medication.
The section entitled “Individual Prisons”, which immediately follows, provides our
findings and opinions as to each of the prisons we visited. General conclusions as to certain
aspects of each prison also are included. The final section, “Conclusion”, summarizes our
Individual Prisons
The site review of Kilby Correctional Facility was conducted on Monday, March 13,
2000. Kilby is the ADOC male reception center and houses approximately 1200 inmates.
Kilby has been designated as the primary site within ADOC for the treatment of inmates
with acute serious mental illness. These services are provided on P-I, the Mental Health
Unit (MHU) and South Ward. Kilby is the only ADOC facility in which non-emergency
involuntary medication orders may be initiated.


Kilby mental health staff are responsible for the completion of reception mental
health evaluations, the treatment of inmates on P-I, the MHU and South Ward, as well as the
treatment of inmates on the outpatient caseload who are housed either in segregation or in
general population.
Documentation provided by ADOC reported the Kilby mental health staffing as of
May 15, 2000 follows. (Note: The May 15th staffing report reflects an increase in
psychiatric coverage from twenty-four hours per week in February 2000 to forty hours per
week in May 2000.)
Psychiatrists (CMS)

Sanders - 16 hours per week
Williams – Approx. 8 hours per week
Bell – 16 hours per week

Licensed Pschologists (CMS)

Woodley – 40 hours per week
Campbell – 8 hours per week
Van Wyck – 8 hours per week

Social Workrs (CMS)

Moody – 40 hours per week
Wilson – 40 hours per week

Psychiatric Nurse (CMS)

Schofield – 40 hours per week

Mental Health Technicians (ADOC) Crenshaw – 40 hours per week
Barnett – 40 hours per week
Cannon – 40 hours per week
The ADOC psychological associates, listed below, perform the reception mental
health evaluations and conduct what are termed rounds of segregation:
Psychologist Associates (ADOC)

Smith – 40 hours per week
Brantley – 40 hours per week
Goltry – 40 hours per week
Johnson – 40 hours per week

The CMS psychiatrists provide all psychiatric services, including the psychiatric
evaluation of inmates referred at reception.


According to Dr. Woodley’s deposition, the mental health technicians provide a
supportive function for inmates on P-I, the MHU and South Ward, as well as conduct
rounds of the segregation units. The responsibilities of a mental health technician, as
outlined in the Kilby Standard Operating Procedure: Mental Health Unit, effective July 10,
1998, are as follows:

The cleanliness of the unit; which entails light duty housekeeping


The inmate’s personal hygiene. Unit inmates will be allowed to shower/shave every


Insuring that clean clothing (pressed whites) are issued Monday through Friday or as


Coordinate/supervise recreational activities of the Mental Health inmates


Coordinating and participating in the treatment programs by monitoring behavior of
Mental Health inmates.


Recording daily activities of the Mental Health inmates on DOC forms and logs.
The deposition of Roberta Crenshaw, a Kilby mental health technician, indicated

that she spends the majority of her time on correctional tasks (providing inmate clothing,
coordinating commissary orders, serving meal trays, completing forms related to inmate
movement) and not in clinical treatment.
Only one correctional officer, Officer Woodard, is consistently assigned to the
mental health areas. Additional coverage is provided by officers on a rotating basis, a
practice found to be disruptive to staff and inmates as well as general operations in other
correctional mental health units with which we are familiar.
The site review of Kilby began with a visit to P-I, the six-cell unit designated for the
treatment of inmates who are unable to be safely managed within the MHU due to clinical
or security concerns. Although P-I remains a dark, dreary isolation unit, it was evident that
ADOC had attempted to improve the conditions. All cells, except one, have been enlarged


to provide the inmate with additional space, and the cell-fronts have been covered with
plexiglass to reduce the risk of suicide attempts by hanging.
Even with these modest modifications, P-I is not an acceptable place to provide
mental health interventions for more than a few days. It is dark and inmates are isolated
from adequate mental health contact. Reportedly, rounds of P-I are completed weekly by
the psychiatrist, psychologist and nurse and daily by the psychologist and mental health
technicians. There are also five to twenty minute evaluations completed by the psychiatrist
on an irregular basis. Other than these minimal contacts, the inmates in crisis see nurses
only during medication administration and correctional officers when rounds are conducted.
P-I inmates are permitted out-of-cell time in shackles forty-five minutes per day.
ADOC has acknowledged the restrictive and insular conditions in P-I by requiring
mental health review of any inmate’s placement on this unit for more than seven days. The
most recent data available (Third Quarter 1999) indicated that the average length of stay of
the forty-five inmates placed on P-I was 8.14 days. The longest length of stay was fortyfour days.
During the site visit, five of the six P-I cells were occupied. All the inmates were
termed “psych hold” inmates, although P-I rosters from other dates indicate that ADOC
sometimes places segregation overflow and other Kilby inmates in P-I. An institutional
procedure, issued on July 10, 1998, indicated that the Psychological Isolation (P-I) Ward is “
a series of six cells located in the hospital, designated to house mental health, medical
and/or high-risk security inmates.” Thus, the P-I cells are not dedicated solely for mental
health interventions.
Dr. Woodley stated in his deposition that P-I is the initial placement for many
inmates referred to Kilby for acute care. An inmate is placed on the MHU directly only if
there is a single cell available or the inmate is sufficiently stable. According to the Woodley


deposition, death row inmates with mental illness are confined to P-I throughout their
treatment at Kilby.
Brief interviews during the site review with all of the five P-I inmates suggested that
their placements were related primarily to security concerns. None appeared obviously
psychotic, and none was on a precautionary watch related to suicide prevention.
Placement on P-I for longer than a few days is not therapeutic. If an inmate is on PI, rather than the MHU, he receives less out-of-cell time, less staff involvement, no
programming, and is maintained in an environment without even a television for sensory
stimulation. The institutional procedure for the P-I security officer, issued July 10, 1998,
indicates that department-provided radios could be tuned to an “easy listening” station and
played at the lowest volume level upon inmate request, but for no longer than one hour on
each shift. This is not currently done.
Dr. Bell stated in his deposition that P-I is also used as a time-out area for MHU
inmates who request such placement and also is used when an MHU inmate acts out. Since
the majority of the MHU cells are single cells, it is not clear why placement on P-I (also
single cells) is used as a response to hostile or assaultive behavior. That some inmates may
request P-I placement does not justify its utilization, since the inmate’s rationale for
requesting this isolation may be indicative of his mental status. There is also evidence from
inmates, supported in mental health records, that P-I is used for inmate placement as a more
restrictive setting when an inmate refuses psychotropic medication, regardless of his clinical
condition. Confinement to this highly restrictive setting, then, may serve several purposes,
including use as a mechanism to coerce medication compliance.
P-I could be marginally adequate for the provision of brief psychiatric stabilization
of acutely psychotic inmates, but only if adequate staff interaction were provided daily. The
medical records confirmed very limited mental health interaction other than the previously
discussed brief evaluations of continued need for placement.


The MHU is a nineteen-bed unit composed of eleven single cells, one two-man cell
and two three-man cells. Although there is a room serving as a nursing station on the unit,
there were no other enclosed areas for individual interviews and programming. Inmates
reported that while they may be permitted to go to mental health staff offices off the unit for
individual interactions, this is rare and typically only for appointments with a psychiatrist.
Individual interventions by mental health staff are routinely conducted at cell-fronts or on
the dayhall.
The little group programming that exists is provided on the unit’s dayhall and
outdoor patio. Dr. Woodley’s deposition suggests that ADOC has recently agreed to
soundproof a holding cell to provide a small group room for mental health programming.
This is indicative of the staff’s knowledge of inadequacies as well as a possible affirmative
While the lack of office and programming space severely compromises the ability of
the MHU to provide services, the unit seemed otherwise nominally acceptable for the
treatment of inmates with serious mental illness. Whether it is an acceptable substitute for
hospital care, however, is an entirely different issue that will be discussed later in this report.
The placement of a restraint chair on the dayhall certainly does not contribute to a
therapeutic environment. Since we were advised by security staff that the restraint chair is
used infrequently, the placement of the chair on the dayhall is questionable.
During the site review, six of the nineteen beds of the MHU were unoccupied. This
appeared to be related to the utilization of the three cells able to accommodate more than
one inmate being used to house only a single inmate. Dr. Woodley’s deposition indicated
that this occurs when an inmate is unable to handle placement with others based on clinical
presentation. Given this completely justifiable practice, the capacity for the MHU is more


often fourteen beds than the nineteen beds regularly reported as being available for
“inpatient” care.
Out-of-cell time for the MHU inmates varies based on their security and clinical
status. Inmates who are maximum or close security, or who are medium security with
pending disciplinaries, are considered to be on “walk alone” status. When on “walk alone”
status, an inmate is permitted only forty-five minutes daily out-of-cell time daily with their
hands cuffed behind their backs and their feet shackled. Mental health staff may designate
other inmates on “walk alone” status based on clinical status and potential for disruptive
During the site review, most MHU inmates were on “walk alone” status. The MHU
roster from the previous week indicated that ten of the sixteen inmates at that time were on
“walk alone” status. Dr. Woodley stated in his deposition that the number of MHU inmates
on “walk alone” status had been increasing, presumably due to increased number of inmates
on close security. The Warden’s approval is required to remove these restrictions from a
close security or segregation inmate to facilitate treatment while on the MHU.
When we entered the MHU, there were numerous shackled inmates walking through
the unit and on the outside patio. Three of the inmates on the patio were actually attempting
to play horseshoes while shackled. Brief interviews with the “walk alone” inmates did not
reveal acute psychosis. Review of their records confirmed higher security levels and
histories of disruptive behavior.
While the “walk alone” inmates confirmed receipt of at least forty-five minutes of
out-of-cell time daily, they reported only limited treatment. They stated that “treatment” is
primarily restricted to cell-front contacts during mental health rounds. Consistent with the
deposition of Officer Woodard, the “walk alone” inmates reported that the mental health
technicians will at times conduct limited group activities with these cuffed inmates.


After the “walk alone” inmates were returned to their cells, two inmates were
released from their cells unshackled. These inmates reported that they are permitted to be
out-of-cell for a maximum of four hours a day (starting about 9:45 AM and ending at 1:45
PM) but this time is reduced when the number of “walk alone” inmates requires their
recreation in two groups. These inmate reports were confirmed by the depositions of Dr.
Woodley and Officer Woodard.
Officer Woodard, the only correctional officer regularly assigned to the MHU, stated
that the inmates are allowed out-of-cell time only when two officers are present and two
officers are assigned to the MHU only during the dayshift which ends at 2:00 PM. Dr.
Woodley’s deposition suggested that the regular presence of a second correctional officer on
the second shift would permit additional inmate treatment. The inmates reported that there
are times on the second and third shift when there is not even one officer present on the
MHU because the assigned officer must cover multiple posts.
Although there were nursing staff present in the nursing office during our visit, and
Dr. Woodley’s deposition indicated that there are nursing staff assigned to mental health
each shift, the inmates reported that nurses are not consistently present on the MHU. While
nursing staff, comprised primarily of licensed practical nurses -- not qualified psychiatric
nurses -- may be present periodically on the unit to administer medication, these nurses also
have medical responsibilities. The ADOC-CMS contract does not require the provision of
twenty-four hour nursing coverage for mental health services, and Dr. Woodley’s deposition
indicated that the available nurses have other duties outside the MHU, P-I and South Ward.
Thus, the required twenty-four hour, seven day a week coverage essential to an acute
psychiatric treatment setting is neither contractually required nor consistently provided.
The MHU inmates who were not on “walk alone” status reported that they typically
participate in one or two groups a week conducted by the social workers or mental health
technicians. These groups are however, unstructured and not clinically driven. Other
mental health staff interaction is limited to staff rounds or brief interactions at the inmate’s


cell-front. The staff rounds include those completed daily by Dr. Woodley that, according to
the deposition of Officer Woodard, take from ten to thirty minutes for Dr. Woodley to
complete for the entire month. The weekly “grand rounds” conducted by Dr. Woodley, the
psychiatrists, and a registered nurse, according to the inmates, is sometimes the only time
that an inmate regularly sees a psychiatrist. If the inmate reports are accurate, treatment
planning and discharge decisions are primarily based on the “grand rounds.”
Brief clinical interviews with the inmates who were permitted access to the dayhall,
whether shackled or unshackled, confirmed their serious mental illness but at least marginal
stability. Four inmates (185110, 209212, 181582 and 174212) who remained in their cells
demonstrated obvious symptoms of acute psychosis. One of these inmates (181582) may
have been transferred to P-I during our visit.
A cursory review was conducted of the current treatment documentation for the
MHU inmates. The review of the MHU records uncovered virtually no documentation
evidencing continuity of care:

no admission or discharge orders for placement in the MHU;


no admission summary of condition or rationale for admission;


no multidisciplinary assessments;


inadequate treatment plans;


no evidence of informed consent for medication treatment;


no evidence of coordination with the “main” medical record;


no notes reflecting the treatment efforts of mental health technicians; and


nursing notes that did not address mental health issues at all, but rather spoke to
inmate vital signs and overall medical condition or activity.
While many of the inmates on the MHU were able to name the medication they were

taking, only a few were able to provide the dosage they were receiving or the anticipated
benefits of the specific medication.


In his deposition, Dr. Bell, the psychiatrist now providing weekly psychiatric
monitoring for the MHU inmates, indicated that he believed each inmate had a treatment
plan but that he was not routinely involved in the plan’s development. His report was
consistent with those of the mental health technician, Ms. Crenshaw, who stated that while
she may or may not be provided a treatment plan for a specific inmate, those that she
receives are completed by the social workers or Dr. Woodley. Thus, there is no coordinated
multidisciplinary approach to treatment.
Dr. Bell acknowledged that inmates for whom he has been providing weekly
psychiatric services may be discharged from the MHU or transferred to P-I without his
knowledge or consultation. Dr. Bell’s deposition indicates that he does not consider himself
to be the primary psychiatrist for these patients, even though his notes are the only
documentation of psychiatric care in the medical record.
Review of the medical records of inmates who had previously received treatment on
the MHU confirmed that a Release Summary is provided at discharge. These summaries
provide a minimally adequate description of the treatment provided, the inmate’s response
to treatment, and a plan for follow-up that is typically limited simply to a recommended
placement and continued medication. The release summary diagnosis frequently differs
from the diagnosis the inmate carried at the time of admission, yet there is no supporting
rationale to explain the discrepancy (behavioral observations, longitudinal course, review of
outside records, psychological testing, etc.) This lack of congruity provides no guidance to
mental health staff subsequently responsible for coordinating and providing follow-up
mental health care upon the inmate’s discharge from the MHU.
Although the MHU plainly does not provide treatment or a treatment milieu
consistent with inpatient psychiatric treatment standards, there are inmates who appear to
have benefited from the placement. The unit is now providing some acute stabilization and
maintenance but, to repeat the point, it does not approximate a hospital level of care.


Psychotropic medication is the primary treatment modality. Based on the inmate
reports and documentation in the medical records, efforts to improve the inmates’
understanding of their mental illness and the need for treatment compliance, as well as
efforts to improve inmate coping skills, are seriously limited. The most recent information
available to us (April 1999) indicated an average length of stay on the MHU of thirty-two
days; which is adequate time to provide this type of basic psychoeducational treatment.
South Ward is a twenty-two bed dormitory described as providing transitional
mental health care for inmates whose clinical condition or security status no longer requires
the single cell placement of the MHU. This dormitory was clean, well lit and physically
appropriate for the extended care of inmates with serious mental illness. However, there
was severely limited space for any active treatment. The inmates reported that any
individual and group treatment is usually provided at the picnic table on the outside patio.
During the site review, five of the twenty-two South Ward beds were unoccupied.
While Dr. Woodley’s deposition indicated that South Ward typically has two or fewer
unoccupied beds, the South Ward roster for March 9, 2000, reported nine unassigned beds.
It is a curiosity that in a system so desperate for mental health space, the limited space there
is not fully used.
When we entered South Ward, the inmates were sitting or lying in their beds,
walking through the dormitory or sitting at the picnic tables on the outdoor patio. These
inmates have access only to a few games and a television at specified times. Several
inmates reported that they do nothing but watch TV all day.
No overt symptoms of acute psychosis were detected among the South Ward
inmates, although the majority appeared seriously compromised by chronic serious mental
illness. Several inmates reported that they would be able to manage placement in general
population if accompanied with ongoing outpatient services. Brief clinical interviews and


review of the records of the inmates supported their views. These inmates were awaiting
transfer to another institution or were being maintained on South Ward until their release
from ADOC at the end of their sentence. Dr. Woodley’s deposition confirmed that inmates
may be retained on South Ward simply because there are no available beds at the designated
parent institution. A printout dated October 28, 1999, indicated twenty-five inmates from
South Ward and the MHU were awaiting transfer. Analysis of the list indicated that fifteen
of the twenty-five inmates had been waiting a transfer for more than thirty days. It is
perplexing that transfers out of South Ward and the MHU would be so delayed given the
scarcity of mental health resources within the system and the pervasiveness of the unmet
mental health needs of the inmates.
Consistent with the MHU, the South Ward inmates reported extremely limited active
treatment and programming. The inmates did not confirm the consistent provision of one
weekly group by each of the two social workers and three mental health technicians, as
reported in Dr. Woodley’s deposition. Officer Williams’ deposition indicated that the
mental health technicians conduct groups as security and time permits. Ms. Crenshaw’s
deposition also suggested that the conduct of group activities is determined by the
availability of sufficient security and time. Ms. Crenshaw’s description of the activities
provided indicated that the groups are unstructured and not clinically-driven.


commented that arts and crafts activities had ceased after January of 2000 because supplies
were no longer available.
The effectiveness of the South Ward program would begin to move toward minimal
acceptability with additional attention to individual and group treatment focused on skill
building for these dysfunctional inmates. The provision of psychotropic medication alone
does not qualify as acceptable treatment. While Alabama is free to elect individual or group
counseling, therapeutic communities, behavior modification, therapeutically driven
programming (and more), Alabama does have to make such an election and then provide
access to that aspect of treatment. If that election has been made, we found little or no
operational evidence to support any such election.


One of the major complaints of the South Ward inmates was their inability to smoke
cigarettes, even while outside, when placed on South Ward or the MHU. Because inmates
on the MHU's at Bullock and Donaldson have access to cigarettes, it is unclear why those at
Kilby would be so denied. The inmates reported that the restriction causes them distress and
frequently results in disciplinary infractions since general population inmates are able to
pass cigarettes to the South Ward inmates through the outside fencing. Informal discussion
with the ADOC lawyers during the site review suggested that Kilby might reconsider the
current practice.
There are no clear admission or discharge criteria for each of these purported levels
of care. Inmate placement in P-I, the MHU and South Ward appears driven primarily by
security or bed availability rather than mental health clinical condition. Further, as
indicated, if an inmate refuses medication, he may be moved from one setting to a more
restrictive setting to coerce medication compliance.
Four of five inmates confined to P-I were prescribed antipsychotic psychotropic
medication, with two of the four receiving the long-acting injectable antipsychotic
medication, Prolixin Decanoate, all with no evidence of informed consent. Treatment of
acute mental health problems with a long-acting medication is contraindicated because
medication adjustments can be made only infrequently. In the MHU, ten inmates were
prescribed antipsychotic medication, with eight of the ten prescribed the long-acting
injectable. Four of the ten were also receiving Risperdal – a newer atypical antipsychotic
medication – but none were prescribed the other newer medications: Clozaril, Zyprexa or

In South Ward, eleven of the thirteen inmates prescribed antipsychotic

medication were receiving Prolixin Decanoate injections.
None of the medical records reviewed had evidence that the forced, involuntary
medication procedure had been invoked or that the inmate had given informed consent to


treatment with the prescribed medication. These factors, coupled with an over-reliance on
long-acting injectable antipsychotic medication in an acute care setting where nurses are
available to administer oral medications, are indicative that the forced medication policy is
being circumvented in the only institution where the policy may be implemented.
Review of the ninety-six Kilby administrative segregation cells found seven inmates
(151575, 181185, 203277, 175612, 207710, 177547, 116878) who were least as, or even
more, acutely mentally ill as any of those inmates located on P-I and the majority of inmates
on the MHU. These inmates were being provided seriously deficient mental health attention
and treatment. While the inmates were readily identified even by their peers as requiring
more intensive treatment, they remained on the segregation units with only cursory mental
health rounds and nominal psychiatric follow-up. Since only brief clinical interviews could
be conducted at the cell-fronts, it is highly likely that there are other inmates with less
obvious mental illness who were not identified.
The records indicated that several of the seven inmates identified with acute
psychosis had received treatment on the MHU or at Taylor Hardin and were discharged after
reaching “maximum benefit” from treatment (151575, 177547). While at least three of the
inmates identified as psychotic were prescribed medication, either the inmate was not taking
the medication or the medication was ineffective. In either case, the inmates required a
clinical intervention and a period of stabilization. Continued placement on a segregation
unit is clinically unacceptable for these inmates, disruptive for the other inmates housed on
the unit and, in many instances, will contribute to the suffering and mental deterioration of
the inmates with mental illness.
The inmates with serious mental illnesses who appeared currently stabilized on
medication (208080, 136634, 132708) reported delays in access to care and inadequate
answers to questions regarding their mental health treatment


The presence of inmates demonstrating acute psychosis on the segregation units
during the site visit suggests that the mental health staff may consider segregation to be an
acceptable placement for such inmates, since staff routinely review the segregation units.
Dr. Bell, in his deposition, reported that he goes cell-to-cell in each of the four Kilby
segregation units monthly to assess all inmates and determine the need for psychiatric
assistance. Dr. Bell added that when he conducts these rounds, he has the medical charts of
the inmates and notes the contact. Ms. Crenshaw reported that the mental health technicians
rotate providing rounds of mental health inmates in segregation twice a week.
Observation of medication administration in segregation indicated the following:
medications are pre-poured by one nurse into small envelopes labeled with the inmate’s
name and the names of the medications prescribed to him. A different nurse, accompanied
by correctional officers, walks along the segregation range, stops at cell-fronts, and pours
the envelope contents into the out-stretched hand of the inmate. The inmate is told to get
some water with which to swallow his medication(s). The ingestion of medication is not
observed, and their mouths are not checked to ascertain whether or not the inmate actually
swallowed his medications. Documentation that the medication was delivered to the inmate
occurs after the fact, a practice that likely jeopardizes the nurses’ licenses.
We were not permitted by ADOC counsel to move freely among the general
population inmates to assess the possible presence of inmates whose serious mental illness
was unidentified. We were permitted to interview approximately fifteen general population
inmates whom we selected from the medication administration records. Four of these
inmates reported problems with mental health services. Two of these inmates (209119,
209078) reported that the medications they had been prescribed and taken when in the
community, Risperdal and Wellbutrin, had been summarily changed to Thorazine and
Sinequan upon their arrival at Kilby. Another inmate (209078) reported the non-renewal of
Sinequan and Artane, and the non-renewal may well have clinical justification. However, in
such a case the inmate must be monitored to assess the impact of such change. This inmate


stated he had not been scheduled for follow-up and there was no evidence in the record of
monitoring. The most troublesome report was from an inmate (154941) who stated he had
been prescribed Haldol while at Taylor Hardin but he had not received the medication for
the three weeks he had been at Kilby.
It is disturbing that four of fifteen of the inmates receiving psychotropic medication
in general population credibly reported problems with mental health services. If we had
been permitted access during the visit to speak with mental health staff, it is possible that
these reported problems would have been explained by staff.
Two of the fifteen general population inmates interviewed also reported there were
inmates in their dormitories who appeared to have serious mental illness. The inmates
described the inmate bed locations but were unable to provide the inmate names. Thus, we
were unable to interview these inmates.
Kilby has twelve single cell infirmary cells located in the South, East and West
Ward Isolation areas. These cells are not dedicated for mental health treatment and plainly
should not be part of any count of mental health beds. While there are also forty-one
infirmary dormitory beds, dormitory beds are inappropriate for the treatment of inmates
requiring mental health crisis stabilization.
Our site visit of St. Clair Correctional Facility was conducted on Tuesday, March 14,
2000. St. Clair is a male, maximum-security institution with an inmate census of
approximately 1330. General population inmates are housed in dormitories. There are 216
segregation cells used interchangeably for administrative and disciplinary placements.
There are three cells in the infirmary designated for mental health crises. One additional
single cell and a sixteen-bed dormitory are reportedly available for some mental health care
as well as medical treatment.


St Clair mental health staffing as of May 2000 was as follows:
Psychiatrist (CMS)
Sanders/Williams (rotated) - 8 hours per week
Licensed Psychologist (CMS) Leonard – 8 hours per week
Licensed Practical Nurse (CMS)
Noell – 16 hours per week
Psychologist (ADOC)
Sandefer – 40 hours per week
St. Clair inmates who receive psychotropic medication participated in a group
discussion with us and reported that they have no interaction with the licensed practical
nurse except during medication administration and when she assists the psychiatrist during
his inmate reviews.
The ADOC psychologist, Dr. Sandefer, provides services to general population
inmates and conducts rounds of segregation inmates. When an inmate reports a psychiatric
problem, Dr. Sandefer reportedly refers the inmate to CMS staff. In his deposition, Dr.
Sandefer agreed that he spends about 40% of his time providing clinical services to inmates,
with the remaining 60% of his time spent on such administrative functions as participating
on the Institutional Segregation Board and Progress Review Committees or completing
evaluations for the Parole Board and individuals seeking employment at the institution.
It was in this facility that we became aware of Alabama’s use of what we would
estimate to be one-half inch thick rubber or plastic mats used for sleeping in lieu of a regular
mattress. While it appeared that at most ADOC institutions these mats were used only in the
mental health cells, they were used in many of the St. Clair segregation cells. In three of the
St. Clair segregation cells, a white foam was escaping from the pad and oozing onto the
concrete block, which serves as the firm portion of the bed. When lifted, the surface in each
case was blackened, resembling some type of fungus or mildew. Inmates could actually
scoop-up the white foam and display it in their hands. When asked, the inmates said they
had no access to any cleaning materials and claimed that they were being medically affected
by the foam and fungus. One inmate displayed a rash over much of his body and said it
came from the pad and the fresh mortar used to construct his new bed.


The generally terrible condition of the St. Clair segregation cells suggests that for the
five inmates who told us they asked to be placed there, it was better than living in the vast
dormitories. Two of these five inmates described themselves as paranoid and, in accord
with the other inmates who spoke to us, they indicated that mental health treatment was
virtually nonexistent.
Review of the list of inmates on psychotropic medication indicated that twenty-six of
the segregation inmates were prescribed such medication. Brief cell-front interviews with
the inmates on the segregation units identified at least fifteen inmates with serious mental
illness. Dr. Sandefer’s deposition confirmed our observation of the presence of acutely
psychotic inmates on the St. Clair segregation units.
One severely regressed inmate (100116) reported that he had been on SSDI (Social
Security Disability Income) and prescribed Prolixin (an antipsychotic medication) while in
the community, but had been prescribed only Benadryl (an antihistamine with some sedative
effect) in the prison.
The segregation inmates reported that since the psychiatrist sees them only very
briefly, they have very limited opportunity to ask questions or discuss their problems. The
inmates who are prescribed injectable medications reported that at times the psychiatrist
sees them only when they are lined up to receive their injections. This cannot reasonably be
considered “treatment” or “therapy” by any standard. The St. Clair inmates also reported
that if a psychotropic medication injection is refused, it may be forced, apparently without a
The segregation inmates reported little follow-up by the CMS or ADOC
psychologist. While the inmates acknowledged that Dr. Sandefer does conduct weekly
rounds, they claimed that his rounds of the twenty-four cells in one of the segregation units
can take less than ten minutes. In his deposition, Dr. Sandefer stated that he spends from one


to three hours completing the segregation rounds of 216 segregation cells. The inmates
described the rounds as more like a “drive through.” This theme -- rounds as a “drive
through” -- was repeated in most of the facilities visited, giving rise to our overall
conclusion that rounds exist primarily in name only.
The segregation inmates reported that there is little staff observation of medication
ingestion. Indeed, several inmates volunteered that they routinely “cheek” their medication
to save it for when they feel they need it or to pass the medication on to other inmates.
We were not permitted to move freely among the general population dormitories
because of security concerns expressed by ADOC counsel. As a consequence, we
conducted two groups with general population inmates. The inmates provided a description
of mental health services that was consistent with that of the segregation inmates,
emphasizing the lack of contact with mental health staff and inattention to their medication
Medication administration for general population inmates is scheduled for 4 AM, 11
AM and 4 PM. Observation of 11 AM medication administration disclosed that the
administering nurse made no attempt to verify that an inmate had in fact ingested the
medication. The inmates also reported that their medications are not always available and
they may appear for their medication only to be told to return the following day because the
medications had not yet arrived.
With regard to accessing care, inmates consistently reported that for immediate
mental health attention, it was necessary to beat on your cell door or bed, flood the cell, start
a fire, or “to act out - like mutilate yourself.” (In fact, inmates at several institutions gave
the same report.) Written requests for care took several days for any response or, more
likely, were never answered.


Review of the mental health records of St. Clair inmates indicated consistently
inadequate documentation by the psychiatrist, with no recorded evidence of treatment efforts
other than medication. There were no treatment plans found in the records. There was no
evidence of an informed consent process; no documentation of whether or not the inmate
had ever undergone the involuntary medication procedure; and there was inappropriate, or
simply no, monitoring of laboratory work.
There was evidence that inmates had been started on medications without ever
having been seen by the prescribing psychiatrist and then continued on medication without
appropriate follow-up to determine the medication’s effectiveness or side effects.
Again, overutilization of long-acting injectable antipsychotic medication was
apparent with no supporting rationale in the medical records. Medications commonly
prescribed in other correctional systems with which we are familiar, and in the free world,
for the treatment of bipolar disorder, impulse control problems and aggression (e.g., lithium,
Tegretol and Depakote) were rarely being utilized. This is very surprising given a
maximum security setting where inmates are routinely described as having problems with
impulsivity and aggression.
Although Dr. Sandefer reported that he was able to review an inmate’s medical
record, he has not been permitted to document in the medical record since some time in
1999. Dr. Sandefer retains his own inmate files and also documents certain information in
the inmate’s Institutional File but never in the medical file. Since Dr. Sandefer provides
monitoring and counseling to inmates also receiving psychiatric care, the omission of Dr.
Sandefer’s notes from the medical record precludes the sharing of important information.
Confidential mental health information maintained by Dr. Sandefer in a file separate from
the medical record also poses serious problems relating to continuity of care whenever an
inmate is transferred.


The paucity of documentation in the mental health record makes it impossible to
ascertain whether there is any continuity of care and whether even the most basic of medical
requirements (informed consent for psychotropic medication) are being observed. Inmates
are at-risk because of these omissions since medications appear to be prescribed absent
personal contact with a psychiatrist and because medications which are routine in other
correctional systems are not utilized here.
During the site review, one of the three mental health cells was occupied by an
inmate on suicide watch; another was occupied by a medical patient; and the third was
unoccupied. Although the inmate on watch had been provided a suicide blanket and tunic,
the St. Clair inmates in the outpatient group chuckled at this news. They unanimously
reported that inmates on watch consistently are left nude with only the thin rubber mat to
sleep on.
The small windows of the mental health cell doors do not permit the total
observation of the cell required for the regular monitoring of the inmate without staff
opening the door. One window actually was painted over and the paint then attempted to be
scratched out, further reducing visibility. The inmates unanimously reported that the cell
door is not opened except for meals and when nursing staff checks vital signs.
An inmate may be placed in a mental health cell by security staff but is discharged
by a psychiatrist. Since a psychiatrist is on-site only one day a week, the inmate may remain
nude in the Spartan cell for six days without a psychiatric evaluation. There is no
documentation of active treatment of the inmate during the interim. Although CMS staff are
present only two days a week, Dr. Sandefer, the ADOC psychologist who is present 5 days a
week, reported that he no longer has the authority to admit or discharge an inmate from a
mental health cell, nor is he expected to provide monitoring of inmates placed in these cells.
Indeed, Dr. Sandefer stated that Dr. Williams told him “to stay the hell away from his


The delay in the treatment of inmates experiencing a crisis is totally unacceptable by
any professional standard of which we are aware for an inmate whose behavior or
verbalizations resulted in placement in this restrictive setting. Indeed, if it is a mental health
crisis that precipitates the move (vis a vis overt punishment), then the inmate suffers
needlessly in this cell and there is a strong likelihood of preventable deterioration in the
inmate’s mental health.
In his deposition, Dr. Woodley noted one inmate who had been transferred to Kilby
after spending three weeks in the St. Clair infirmary for having voiced suicidal ideation.
This report contradicts any claims to using these mental health cells only for short periods of
Because St. Clair staff reported that they do not maintain logs for the use of
restraints, it was not possible to determine the frequency or duration of such use. The
security staff indicated that restraints were used infrequently and that they do not use a
restraint chair.
The site visit of Donaldson Correctional Facility was conducted on Wednesday,
March 15, 2000. Donaldson is a male maximum-security institution with a census of
approximately 1450 inmates. The institution has eight segregation blocks with a total of 212
segregation cells. One of the segregation blocks of twenty-four cells is known as the
Donaldson Mental Health Unit (MHU). The remaining general population inmates are
housed in dormitories and cell blocks containing two-man cells that are open during the day.
There are two cells in the infirmary designated for mental health treatment.
Donaldson mental health staffing as of May, 2000 was as follows:
Psychiatrist (CMS)
Licensed Psychologist (CMS)

Murbach - 24 hours per week

Licensed Practical Nurse (CMS)
Psychologist (ADOC)

Hendrix – 40 hours per week

(Dr. Rankart, the CMS psychologist who had provided 16 hours per week at
Donaldson, resigned prior to our visit and CMS was said to be recruiting for a replacement.)
Warden Mitchem stated in his deposition that Donaldson had approval to recruit for
the vacant ADOC psychological associate position and was seeking approval to hire an
additional psychological associate. The duties of the ADOC psychological associate
include: services for general population inmates; crisis intervention; rounds of the
administrative segregation units including the MHU; and referrals to CMS for psychiatric
Warden Mitchem also indicated that CMS had recruited for a mental health
technician on numerous occasions without success.
The Donaldson MHU is characterized in CMS/ADOC documents as a transitional
unit for inmates with serious mental health problems who would have difficulty managing
in the large maximum-security dormitories. Dr. Woodley’s deposition indicated that
maximum-security inmates who received mental health treatment at Kilby may be
transferred from the South Ward dormitory to the Donaldson MHU as a “step-down” from
Kilby. There is no indication in the CMS/ADOC documentation that the Donaldson MHU
would maintain inmates with serious mental illness who do not respond to treatment.
The MHU is located on the 3 Side of Seg 5 Block and has twenty-four single cells in
a two-story cell-block. There is no protective covering on the second-floor railing or on the
stairwell as a suicide, self-injury protective measure. A central dayhall with tables and
chairs for inmate dining included a plexiglass shower that permitted total observation of the
inmates during bathing. The showers leak water onto the concrete floor, forming puddles


that constantly need to be mopped, adding humidity to an already physically uncomfortable
While some acoustical dampening material has been installed to reduce the noise
within the unit and some wall murals were added in an attempt to provide a therapeutic
milieu, the environment remains dark, dreary and stark. The inmates reported that the unit
may become very warm or very cold depending on the weather. Several inmates reported
that the unit is infested with rodents and insects. The unit has an outside recreation area, but
there are no staff offices or group areas for confidential treatment or group activity. Thus,
the environment is physically unacceptable as a therapeutic setting.
While some documents suggest that the Donaldson MHU began functioning in 1995,
Warden Mitchem’s deposition indicated that the full time correctional officer presence on
the MHU on the dayshift required for treatment activities may not have been effectuated
until early in 1997. At that same time, a CMS licensed practical nurse was assigned to the
unit on the day shift.
The MHU is fortunate that the correctional officer assigned to the unit, Officer
Evans, received some mental health training while in the military. Officer Evans’
deposition reflected his appreciation for providing the “eyes and ears” for mental health
staff. On the other hand, the licensed practical nurse, Mr. Hendrix, reported that his only
preparation for mental health responsibilities were two weeks of mental health training
while in nursing (LPN) school in 1990 and the on-the-job training provided by CMS staff.
Depositions indicated that the MHU inmates are permitted to be out-of-cell
approximately three hours a day as a group unless contraindicated by security or clinical
concerns. The depositions of Officer Evans and Mr. Hendrix indicated that they jointly
make the decision of whether or not an inmate receives out-of-cell time. Inmates who are
not permitted group out-of-cell time are given the forty-five minutes of shackled out-of-cell
time consistent with “walk alone” status.


The inmates reported receiving less out-of-cell time than three hours a day,
particularly when the need to exercise inmates on “walk alone” status decreases the time
available for groups of inmates. No inmate is permitted out-of-cell after the day shift ends at
4 PM.
A typical day on the MHU was described by the inmates as follows:
3 AM


8 AM until 9:30 AM






9:30 AM until 12:30 PM

One group of approximately 10 inmates is
permitted out-of-cell for lunch and then activities
and outdoor recreation.

12:30 PM until 3:30 PM

A second group of inmates is permitted out-ofcell for activities and outdoor recreation and then

3:30 PM

A few inmates remain out-of-cell to complete
cleaning chores.

4 PM

All inmates locked down.

The inmate reports of a typical day were consistent with the depositions of Officer
Evans and Mr. Hendrix, as were the reports of the treatment that is provided.
Dr. Rankart, the CMS psychologist who recently resigned his position and has not
yet been replaced, reportedly spent from two to three hours on the MHU two days a week.
On Mondays, he would arrive about 11 AM and the inmates would be returned to their cells
so that Dr. Rankart might complete cell-to-cell rounds. During the rounds, he reportedly
entered the cell of most inmates, had a five to ten minute interaction, and assessed the
cleanliness of the cell. His assessment was conducted through the cell-front for unstable or
hostile inmates. After completing the rounds, Dr. Rankart participated in watching the


weekly movie provided as a reward for inmates who demonstrated acceptable hygiene. He
then left the unit at the end of the movie. While the inmates reported no discussion of the
movie, depositions suggest that at times the content of the movie may have been discussed.
On Tuesdays, Dr. Rankart arrived at the unit at about 11 AM and conducted a
“community meeting” for inmates electing to participate. Dr. Rankart was then available to
speak with inmates and in some fashion engage in outdoor sports with them until
approximately 2 PM.
The activities available to inmates when out-of-cell on Wednesday, Thursday and
Friday mornings, and during all weekday afternoons, are primarily limited to simple board
games and outdoor recreation. Inexplicably, there is no television available to the inmates.
A local religious leader may come to the unit on Wednesday mornings for about an hour to
conduct religious programming for interested inmates.
In his deposition, Mr. Hendrix reported that while he conducts some group
programming he has had no formal training in psychoeducational or supportive groups. He
indicated that he has no lesson plans for the groups but will present such topics as anger
management and personal hygiene based on some unspecified material he has read.
Dr. Murbach began providing three days of psychiatric coverage at Donaldson
shortly before our visit. He is the only psychiatrist available at Donaldson. (Previously, he
provided only two days per week.) According to his recent deposition, his time may soon
increase to four days per week.
According to Officer Evans’ deposition, Dr. Murbach arrives about 3 PM and spends
approximately ninety minutes on the unit. Mr. Hendrix reported that Dr. Murbach may
remain on the unit from two to two and half hours. Dr. Murbach has a list of ten to fifteen
inmates that he interviews. The individual inmate interviews reportedly last from five to ten


Inmates are seen approximately once a month by the psychiatrist for the individual
five or ten minute sessions noted above. Inmates are handcuffed when brought to see Dr.
Murbach at the desk in the dayhall, even when inmates are not required to wear cuffs at any
other time when out of their cells. This practice obviously further inhibits the development
of a positive or trusting relationship with the psychiatrist. Curiously, we were permitted to
assemble an inmate group outside and there were no cuffs used. The inmates said they had
never before been in a group where they could sit outside, talk, and be treated like people.
The type and level of individual and group treatment available to the MHU inmates
is seriously deficient. The psychiatrist and psychologist provide only cursory individual
reviews of the inmates. Individual treatment plans are developed but they are generic and
provide very limited information about the inmate. A typical treatment plan, for example,
lists the following goals: optimize psychopharmacotherapy (medication); participate in
group therapy (156007).
As noted previously, everything denominated as treatment must be provided on the
dayhall of the unit or at the inmate’s cell, without apparent attention to confidentiality.
The only group programming that the psychologist offered was to provide a weekly
movie and a “community” meeting; each a potentially valid activity but totally inadequate
and certainly not requiring the skill of a psychologist. The licensed practical nurse, although
plainly well intentioned, is not trained to conduct psychoeducational groups. An essential
component of treatment with this population is medication education designed to foster an
informal basis for treatment compliance. Mr. Hendrix continues to learn the basics about
psychotropic medications, but his deposition indicates that he does not yet know what
constitutes an atypical antipsychotic medication.
It is perplexing why MHU inmates capable of group interaction are not given the
opportunity to be out-of-cell routinely both in the morning and afternoon. Mr. Hendrix’s


deposition indicated that there was no limit on the number of inmates permitted to attend the
Monday movie or Wednesday religious programming.
While we were not present for the “morning” (12:30 AM) or “mid-day” medication
administration times (8:00 AM), Mr. Hendrix’s deposition indicated that he and Officer
Evans go cell-to-cell and request the inmate to step out of his cell so that medication
ingestion may be observed. Observation of the “evening,” that is, last medication pass of
the day at 3:00 PM, revealed unacceptable medication administration practices. Mr.
Hendrix provided the inmates with medications from small envelopes that he took from his
pocket as the inmates sat around the dayhall tables. Documentation of the administration is
not completed at the time of administration. Although the process supported the seeming
rapport the nurse has with the inmates, it is inconsistent with nurse practice standards.
While treatment practices on the MHU fall well below acceptable standards of care,
the majority of the inmates observed on the dayhall appeared to have somehow achieved at
least marginal functioning. However, several of these inmates demonstrated the tremors
often associated as a side effect from psychotropic medication.
The major complaints voiced by the inmates concerned delays in pending transfers
and the monotony and total boredom of the unit.
The medical records suggest that while mental health staff may request a reduction
in an inmate’s security to permit treatment in a less restrictive environment, the institution’s
approval of the modification is often denied or delayed (156007).
Cell-front interviews with MHU inmates who either were restricted to their cells or
refused to participate in unit activities revealed the inmates with the most serious problems.
Brief interactions quickly identified eight inmates (109970, 124298, 135129, 108809,
113878, 111156, 137113, 150579) suffering with acute psychosis. The inmates evidenced
delusional and tangential thinking and in our presence appeared to be responding to


hallucinations. Their personal hygiene and cell cleanliness were generally poor. The body
odor emanating from three of the cells was overwhelming. Several of the inmates confined
to their cells also appeared to experience profound side effects from prescribed
antipsychotic medications in the form of severe tremors of the musculature of the arms and
neck. Record reviews indicated that these inmates had not recently become psychotic but
had been experiencing symptoms of serious mental illness over extended periods of time.
One record, for example, (124298) indicated that the inmate had been deteriorating for
months and that for weeks the psychiatrist had contemplated a transfer to the acute care
supposedly available at Kilby.
What we saw and read contradicted Dr. Woodley’s deposition testimony that when
Donaldson MHU inmates exhibit symptomatology of acute mental illness, stabilization
through psychiatric evaluation and medication on-site are the first interventions. According
to Dr. Woodley, if an inmate did not respond within twenty four to forty eight hours, he was
to be transferred for more intensive treatment at Kilby. Our visit simply did not confirm this
Warden Mitchem’s deposition indicated that Dr. Williams and Dr. Woodley
coordinate with the Donaldson classification staff in arranging transfers in and out of the
MHU. He gave testimony that mental health staff assigns priority for placement of inmates
on the MHU and that inmates may be retained in administrative segregation while awaiting
transfer to the Unit. While there is no doubt that there is a waiting list of inmates awaiting
transfer in or out of the MHU, we were unable to determine how many inmates were on the
list or the duration of time spent waiting for transfer.
Our review of the Donaldson MHU found a physical environment and treatment
practices that seriously contradict Dr. Feldman’s description in the MAC minutes of March
12, 1998 of the unit as “one of the most therapeutic mental health units one could get.” In
our opinion the absence of regular clinically-driven activities combined with the bleak


environment and restricted movement results in grossly inadequate care and leads to
needless suffering.
Review of medication administration records during the site visit indicated that
thirty-two of the inmates in the 192 administrative segregation cells (approximately 17%)
had psychotropic medication ordered on their behalf. Mental health follow-up of these
inmates was provided by Dr. Murbach and by Dr. Rankart previous to his departure. In his
deposition, Dr. Rankart indicated he maintained a caseload of approximately twenty
segregation inmates and, in addition, he reviewed inmates referred to him.


interventions were usually conducted at the inmate’s cell-front.
Brief cell-front interviews conducted with inmates on the administrative segregation
unit quickly identified four inmates with serious mental illness (including inmates 108804,
135129, 109315). Inmates who may be just as sick but with less overt symptoms would
likely be identified with a more intensive review. One inmate (109315) reported that he
chose to be on the administrative segregation unit for his “paranoia.” He reported that he
has received Prolixin at times but often refuses the medication because the psychiatrist will
not order medications for his side effects.

Another inmate reported that while he was

treated for “hearing voices” in the free world and in the county jail, he receives no treatment
at Donaldson in spite of experiencing the same symptoms. A review of his record
demonstrated that he earlier had in fact been prescribed both Haldol and Prolixin but that his
diagnosis had been amended while in ADOC custody to “personality disorder and
malingered psychosis.” His medications were discontinued.
While we did not observe medication distribution on the segregation units,
discussion with the nurse completing the process (with the approval of ADOC lawyers)
indicated a process inconsistent with nursing practice standards. The nurse provided the
medication from envelopes labeled with the inmate’s name and medication. These
envelopes were prepared by a different nurse. The distributing nurse stated that she would


document the inmates’ acceptance or refusal of medication on the medication administration
records while preparing the envelopes for the next shift of nurses. This process violates the
chain of responsibility required by nursing practice, which requires the same nurse to
prepare, administer and document the medications.
Although the nurse confirmed that she observed the inmates’ ingestion of
medication, the quality of the observation is questionable. When one inmate was asked
about his medication shortly after the administration process, the inmate replied that he did
not know the name of his medication but could show us the pills and he did.
Review of medication administration records during the site visit indicated that
thirty-two of the general population inmates were prescribed psychotropic medication.
Since there were security concerns expressed about our moving freely among the
general population dormitories, our review of these inmates was restricted to individual
meetings with six selected inmates. The individual inmates were selected either because
they were receiving psychotropic medication or because they were identified by other
inmates as experiencing serious mental health problems.
Mental health follow-up of general population inmates is completed by Dr. Murbach
and Dr. Rankart. In his deposition, Dr. Rankart indicated that he saw from six to seven
inmates in his office on Mondays and Tuesdays from 8:30 AM until approximately 11 AM.
He reported that the individual interviews with general population inmates might last from
ten minutes to an hour.
Interviews with the general population inmates uncovered no signs of acute mental

The inmates identified by other inmates as behaving in unusual ways did

demonstrate some idiosyncratic and paranoid thinking, but there was no obvious evidence of
acute psychosis.


Review of one of the mental health crisis cells revealed a bare room with a rubber
pad on the floor. While nurses and correctional officers are to maintain “watches” in these
cells, there were areas of the room that could not be seen through the small door window.
Inmates consistently reported that staff do not open the doors to conduct the required
observations, and we have no contradictory evidence.
Inmate reports that they are typically placed in the mental health cells nude and for
extended periods of time were confirmed by the medical records. The records indicate that
an inmate may be placed in a mental health cell by security staff for risk of self-harm or
disruptive behavior possibly related to mental illness. The on-call psychiatrist is contacted
for “watch orders” to govern the placement and possibly also for medication orders. The
inmate is then maintained in the cell until the CMS psychiatrist or psychologist is next on
site. Thus, there can be a period of several days before an inmate receives a face-to-face
mental health evaluation. While the inmates reported that nursing staff check vital signs
each shift, many found this disturbing since they had no clothing or even a sheet with which
to cover themselves in the presence of female staff.
The inmates reported, and one correctional officer confirmed, that when inmates are
restrained at Donaldson, they are restrained on their stomachs; a dangerous, unprofessional
practice which may have serious medical implications, including positional asphyxia and
death. Constant observation by staff with the inmate in the supine position is the acceptable
The site visit of Holman Correctional Facility was conducted on Thursday, March
16, 2000. Holman is a male, maximum-security institution with an inmate census of
approximately 750. The facility has 160 cells for death row inmates and eighty-nine
segregation cells. General population inmates live in large dormitories. There are no


infirmary mental health beds at Holman. Holman inmates experiencing a mental health
crisis are transferred to mental health cells at nearby Fountain Correctional Facility.
Holman’s mental health staffing as of May 2000 was as follows:
Psychiatrist (CMS)
Passman - 4 hours per week
Licensed Psychologist (CMS) Crum – 8 hours per week
Psychiatric Technician (CMS)
Pearson – 40 hours per week
Psychological Associate (ADOC)
Holbrook - 40 hours per week
(At the time of the site review Dr. Williams, rather than Dr. Passman, was providing
the four hours per week of psychiatric service at Holman.)
Ms. Pearson’s deposition indicated that her duties as the mental health technician
include reviewing referrals to schedule inmates for the CMS psychologist and psychiatrist;
interviewing inmates for possible inclusion in groups; counseling inmates “who need to talk
to someone;” and evaluating inmates who threaten or inflict self-injury.
Dr. Crum’s deposition indicated that the ADOC psychologist provides general
follow-up and group treatment for general population inmates as well as conducts rounds of
the segregation areas. Inmates presenting with psychiatric problems are referred to CMS
The site review began with a visit to the Holman Receiving Unit. While we are
unable to determine exactly why an inmate is held in this medieval five cell unit, the
placement must be related to security or discipline since it is the most restrictive, isolated
placement in the institution, perhaps the entire state. The double-door cells were dungeonlike and filthy. Even with both doors open, there was little illumination within a cell.
Opportunities for inmate interaction are limited to yelling between cells and infrequent
correctional officer’s rounds. While these inmates are provided forty-five minutes of out-of-


cell time daily, many refuse because the out-of-cell time reportedly is offered extremely
early in the morning.
At the time of the site review, two of the five Receiving Unit inmates were receiving
psychiatric follow-up. One (186652) appeared stable on his medication and the other
(181334) reported that he had discontinued his medication. Review of the records of the
inmate refusing medication indicated that the inmate had numerous placements on the Kilby
MHU and had been maintained in the Fountain mental health cell (“the padded cell”) for
more than a month in July of 1999. His receiving unit cell was filthy, which is a sign of
acute mental illness.
In his deposition, Dr. Crum reported that he visits the inmates in the Receiving Unit
to “keep an eye on them.” We agree with his evaluation that no inmate with mental health
problems should be placed on this unit. Placing such inmates in this type of environment
enhances the chances for suicide, reduces the opportunity to prevent or even react to it, and
is likely to exacerbate serious mental illness. It is our further opinion that no person whether mentally ill or not - should be required to live in the conditions of the receiving
Brief interviews were conducted with those segregation unit inmates who were not
sleeping. Those interviews were very difficult to conduct because of the high noise level
and limited meshed cell window areas. However, even under these conditions, at least four
inmates with overt signs of acute psychosis were identified (116798, 129721, 121152,
143399). Others appeared to be regressed and functioning at a marginal level. Several of
the segregation inmates expressed concern with the limited attention paid to a segregation
unit inmate who is deaf and unable to speak. We were unable to communicate with this
inmate who appeared to be utterly frustrated by our unavailing efforts.


Review of the medication administration records indicated that twenty-one
segregation inmates were prescribed psychotropic medication. Three other inmates reported
at one time that they had received medication at one time but that the psychiatrist had
discontinued the medication reportedly because the inmate did not need medication.
One inmate (129721), who we believe was psychotic, reported that he had received
medication but it had been discontinued in 1998 because he was non-compliant. Although
the inmate said that he had requested to see the psychiatrist three weeks earlier, his records
revealed no documentation of the request. The records did contain a psychiatric order on
12/3/99 indicating “May give Haldol 10 mgm IM q. 4 hours as needed PRN agitation. May
use 4-point restraints PRN indicated for uncontrolled behavior.” PRN orders to use
injectable antipsychotic medications for agitation, rather than psychotic thought processes,
is a highly suspect practice. PRN orders for four-point restraint are a violation of accepted
psychiatric practice and specifically prohibited by health care regulatory bodies of which we
are aware.
Dr. Crum’s deposition indicated that he spends about one hour, twice a week,
monitoring inmates of the segregation units who are on his caseload or have been referred to
him. He stated that he sees from six to seven inmates in an hour and characterized his
interactions as “bam-bam.” It is doubtful that the psychiatrist could do any more since he is
only at the institution four hours per week.
The records provide limited information and provide no evidence of meaningful
treatment other than medication.
Segregation pill call is conducted in as unacceptable a manner at Holman as the
other facilities described thus far. Medications are prepared by one person and placed in
small envelopes labeled with the inmate’s name, cell location and medication. Medication
envelopes are then distributed by a different nurse by placing them into the inmate’s
outstretched hand. Ingestion is not observed. Documentation that the medication was


delivered does not occur until after the entire process has been completed. Once again, this
violates acceptable nursing practices.
Review of the medication administration records indicated that twenty-six general
population inmates were prescribed psychotropic medication. A group meeting with nine
inmates selected from the medication roster revealed general dissatisfaction with the
services but no evidence of acute psychosis. The inmates identified other inmates they
believed had serious mental health problems. Individual interviews with these identified
inmates confirmed marginal functioning and idiosyncratic thinking but no acute psychosis.
Dr. Crum’s deposition indicates that he has limited time to follow-up on the general
population inmates. His report suggests that he spends less than two hours each week
monitoring the general population inmates, which is consistent with his reports that he
spends from five to ten minutes with twelve to thirteen inmates. Dr. Crum stated that he
conducts a weekly group for fifteen to twenty inmates. Since only three or four of these
inmates receive psychotropic medication, it appears that most of the inmates receiving group
psychotherapy do not have a serious mental illness.
As noted previously, Holman inmates requiring precautionary mental health
placements are transferred to nearby Fountain Correctional Facility. The inmates report, and
the records confirm, that the inmates are placed in the cells nude with only the rubber mat
favored by the ADOC. They spend extended periods under these restrictive measures
because discharge requires a psychiatric order and a psychiatrist is in the area only one day
per week. This must challenge Holman operations because Dr. Crum reported that if an
inmate is a death row or life without parole inmate, Holman must provide the correctional
officer observation while the inmate is at Fountain.


Documentation that Holman inmates have been maintained in the Fountain mental
health cells for weeks at a time demonstrates an unacceptable and grossly deficient practice.
An inmate requiring more than a few days to stabilize clinically requires a transfer for more
intensive treatment. In his deposition, Dr. Crum stated that when a transfer to Kilby is
approved by Dr. Woodley, the transfer typically occurs within three or four days.
The presence of a CMS psychologist and psychiatrist only 12 hours per week
compromises the ability to provide timely crisis intervention. Ms. Pearson’s deposition
indicated that she may provide the initial assessment of an inmate potentially at risk for self
harm and then shares her assessment with the on-call psychiatrist. Ms. Pearson defined
decompensation as “to lose – their muscles and stuff start deteriorating. Start looking a lot
older than what they are, just totally.” She also stated that decompensation is related to lack
of exercise or sunlight. Given her obviously complete lack of knowledge about acute
psychosis, her ability to effectively evaluate inmates in crisis is dubious at best.
The initial site visit of Bullock Correctional Facility was conducted on Friday,
March 17, 2000 with a follow-up visit conducted the morning of June 21, 2000, by Dr.

Bullock is a male, medium security institution with an inmate census of

approximately 1125. The institution was opened in 1987 to specifically treat inmates with
intermediate mental health problems. The inmates are housed in dormitories ranging in size
from eight to forty-four beds. Two 44-bed dormitories are managed by CMS staff and
named the Transitional Mental Health Unit. Five 38-bed and three 8-bed dormitories are
managed by ADOC staff as the Intermediate Mental Health Unit. Recently, a four-bed
dormitory was designated as a “time out” room. We observed four single cells of the
infirmary available for mental health treatment. Bullock has twenty cells that are used
interchangeably for disciplinary and administrative segregation.
The CMS mental health staffing at Bullock as of May 2000 was:


Psychiatrists (CMS)

Sanders - 16 hours per week
Downs – 40 hours per week

Licensed Psychologists (CMS)

Gilbert – 16 hours per week
Van Wyck – 8 hours per week

Licensed Practical Nurse (CMS)

Penn – 40 hours per week

Mental Health Technician (CMS)

Goodwin – 40 hours per week

(Note: Psychiatric coverage at Bullock increased from forty to fifty-six hours per
week from the time of our initial visit in March.)

The two dormitories of the Transitional Mental Health Unit provide a total of eightyeight beds. During the initial site review, only a few beds were unoccupied, but at least
seven of the forty-four beds of one dormitory were filled with “overflow” inmates without
any mental health needs. These did not appear to be temporary placements since two of the
inmates (including 194108) had been maintained on the unit for more than thirty days. Dr.
Gilbert’s deposition confirmed that ADOC uses mental health beds for other inmates when

Again, this is an odd use of specialized beds in a system where decent

bed/treatment space is so limited.
The environment of these units generally was acceptable for the long-term housing
of inmates with non-acute mental illness. The dormitories were well lit, clean, orderly and
provided access to outdoors. However, the space available for staff office and group
treatment was limited to dayhall space and one office. The inmates have limited space to sit
other than their bunk beds. They are permitted to have meals in the institutional dining
Brief interviews with the inmates identified only two inmates who were
experiencing symptoms of acute psychosis. In fact, some of the inmates demonstrated


functioning that might permit general population placement with adequate outpatient
support. Four of the inmates were functioning well enough to have jobs off of the unit. The
major complaint of the inmates in this unit was the non-stop boredom.
Interviews of the two inmates identified by their peers as having difficulty
functioning (141037, 143814) confirmed auditory hallucinations and sleep disturbance. It is
troublesome that while the inmates noticed the signs of decompensation, staff apparently
had not brought the situation to the psychiatrist’s attention. An interview with one of these
inmates (141037) during the second Bullock visit found the inmate remained psychotic.
The inmate demonstrated poverty of speech and appeared to be attending to auditory
hallucinations. In his deposition on May 10, 2000, the mental health technician Charles
Goodwin identified this inmate as talking to himself and displaying shifting eye movements.
Mr. Goodwin also stated that the psychiatrist knew that the inmate had been talking to
himself. Review of the inmate’s medical record revealed the most recent psychiatric review
on March 20, 2000 indicated “no change” in treatment. There were no progress notes
reflecting staff assessment or intervention with an inmate who had been demonstrating overt
signs of psychosis for several months.
The inmates reported adequate, if brief, monitoring by the psychiatrists and
acknowledged that Dr. Sanders spends a couple of hours in the dorm office twice a week
and is available for inmates who wish to speak with him. The inmates on medications
requiring periodic laboratory testing reported, and records confirmed, that laboratory testing
had been sporadic in the past but, presently, Dr. Downs routinely orders such testing for
inmates on his caseload. The inmates suggested that the nurses do not always follow
through on Dr. Downs’ orders but continue to follow old orders. We could not confirm or
disprove this report. In his deposition, Dr. Downs acknowledged that he had also received
such inmate reports.
Programming seems limited to three thirty minute psychoeducational sessions
conducted weekly by the mental health technicians. All forty-four inmates of each


dormitory are required to sit on their beds while the technician conducts the group.
Although the most recent topics of the sessions, problem solving and the pursuit of
happiness, may have value, smaller groups with increased inmate involvement would likely
have more benefit.
A few inmates stated that they leave the unit to attend programming by the ADOC
psychologist associate held in the general population. Inmates reported that while a staff
person may initiate these group sessions, it also was routine for an untrained fellow inmate
to actually conduct the groups.
Review of the records found limited, if any, treatment planning and did not provide
any evidence of continuity of care. In many cases, the only treatment modality referenced
was psychotropic medication. For many of the inmates, the medication was a decanoate (the
long-acting injectable antipsychotic medication) with no evidence of informed consent.
Inmates of the Transitional Mental Health Unit receive medication at the medical
infirmary. Observation of the process revealed that the inmates were not required to supply
verification of their identification prior to be given the medication. Two inmates advised
the nurse that they were given the wrong medication, suggesting that nursing practices to
minimize such occurrences are not consistently followed. A correctional officer was present
to monitor the inmates’ ingestion of medication. The routine manner with which the
inmates responded to the process suggested that monitoring of ingestion is an established
practice at this institution.
A problematic, humiliating practice which appears unique to Bullock was observed
during medication administration. Inmates prescribed Artane (a medication to control side
effects of older antipsychotic medication with some abuse potential in correctional settings)
is administered in crushed form onto the inmate’s outstretched palm. Inmates are told to
swallow the medication crumbs with water. However, if any residue remains on their hand,
the officer instructs them to lick it off. If the inmate refuses, the Artane will be summarily


discontinued whether or not the inmate has side effects. This development is very curious
given that 1) there are many alternatives to the prescription of Artane for side effects with
much lower abuse potential; 2) the utilization of the newer, readily available antipsychotic
medications would likely permit the discontinuation of side effect medication altogether as
the newer medications do not have the same side effect profile; and 3) Artane is available in
a liquid preparation.
Inspection of several large thirty-eight-bed Intermediate Mental Health Unit
dormitories confirmed an environment similar to the Transitional Mental Health Unit. Brief
interviews and group discussion revealed that while many of these inmates had mental
health problems, not all experienced serious mental illness. While these inmates were
among the most functional interviewed during all four prior site reviews, they were also
among the most vocal in expressing their dissatisfaction with mental health services. Some
of the inmate allegations appear related to their personality disorders, but it is clear that
treatment other than medication is severely limited. Mr. Jones, an ADOC social worker,
was said to conduct groups related to anger management, life skills, parenting and the Bible.
Indeed, Mr. Jones was consistently praised for his work and attitude toward the inmates.
During both site reviews, we never saw a single therapeutic activity. The inmates were on
their beds or milling around, and we saw nothing that would suggest a treatment milieu.
When the inmates of the large dormitories were asked where the inmates with
serious mental illness were housed, they directed us to the smaller eight-bed dormitories.
The inmates were accurate.

Most of the inmates in the smaller dormitories were

significantly compromised by serious mental illness and were receiving inadequate
treatment. The personal hygiene and sanitation of these dormitories was dramatically lower
than the other dormitories and reflected the level of the inmates’ dysfunction. Several of
these inmates reported that they had “chosen” the smaller dormitories to minimize their
contact with others.

However, these inmates were existing in a non-therapeutic

environment that does not offer the opportunity for improved functioning. In our opinion,


several of these inmates (156422, 133328, 104205) required acute mental health treatment,
if not psychiatric hospitalization.
The second site visit of Bullock, conducted by Dr. Haddad, focused on the inmates
within the smaller eight-man dormitories. While these areas continue to house the inmates
most seriously impaired by mental illness, the areas and inmates were cleaner than during
the first visit. Over 75% of the inmates in the smaller dorms were prescribed Prolixin
Decanoate (long-acting medication). The number of inmates demonstrating negative side
effects that were ineffectively managed by a side effect medication was significantly higher
that that typically seen in current mental health settings. The inmates reported that
psychiatric appointments continue to last no more than ten minutes.
One inmate (133328) in the smaller dormitories identified in April as potentially in
need of inpatient treatment appeared improved by the change in medication to Zyprexa.
There was no noticeable change in the mental health of the other inmates except that one
(156422) demonstrated increased agitation and nervousness. This inmate reported that his
requests for medication had been denied.
The inmates’ identification of the most ill inmate in the smaller dorms confirmed
their ability to assess level of functioning. This inmate (107711) was very regressed and
likely in need of more intensive treatment. The inmate’s medical records indicated no
treatment other than infrequent psychiatric reviews.
The Intermediate MHU inmates continued to report programming limited to that
which is provided to all Bullock inmates. Some of these groups are conducted by inmates.
Others are conducted by Mr. Jones. Inmate participation in these groups apparently depends
upon the inmate signing up for the group. Thus, participation is not clinically-driven by the
specific needs of the inmate but likely related to the inmate’s desire to gain a certificate for
the Parole Board.


The inmates were appreciative of the one hour on the recreation yard offered twice
weekly for mental health inmates only. The inmates reported that the mental health
technicians conduct multiple sports activities during these times. These activities are
important but are inadequate programming for inmates with serious mental illness.
Three of the inmates in the smaller dormitories reported that they had third shift
custodial work assignments. They were pleased to have meaningful work but reported that
it was difficult to complete the nighttime work when receiving psychotropic medication,
which is sedating, at evening pill call rather than in the morning when these inmates would
be trying to sleep after having worked the nightshift.
The inmates uniformly complained about the institutional requirement that all
inmates leave the housing areas from approximately 7 AM until 9 AM every day (assuming
that it is not raining, snowing or extremely cold) to permit the mopping of the housing areas.
They recommended that we return one morning to see the number of inmates on
psychotropic medication sleeping on the ground during these periods.
During the second review of Bullock, the inmates continued to report that they are
forced to accept their Prolixin Decanoate shots. In some cases, the “force” is reportedly the
summoning of correctional officers to demonstrate that force will be used if the inmate does
not comply. This does not constitute voluntary acceptance of medication. In other cases,
inmates reported they were locked down in segregation cells if they refused the shot. The
inmates identified one inmate (191537) who they stated was placed in segregation because
he refused his shot. Indeed, the inmate was on a “mental health hold” in segregation. A
cell-front interview with the inmate confirmed the prior reports. The inmate was upset that
he had not yet been released from segregation even though he had accepted the shot three
days ago. During a brief interview, Dr. Sanders denied that the inmate had been placed in
segregation for non-compliance but reported that the inmate had made threats requiring him
to be locked-up. The limited and poorly legible documentation in the inmate’s medical
record made it difficult to substantiate either the inmate’s allegation or Dr. Sanders’ report.


The implementation of a four-bed time-out dormitory appeared to be a recent
development at Bullock. There were two inmates in the unit during our initial review. One
(154285) was covered with a blanket and would not respond to us. His medical record
indicated that he had been seen by Dr. Sanders on March 13, 2000, and he was described as
being in “stable remission” from “chronic schizophrenia.” There were no subsequent chart
entries to explain his placement in the time-out dorm or describing the condition or behavior
which led to the placement. The other inmate (140675) stated that he had been placed there
because his Dilantin had “made his heart pound.”
Since there were no staff in the time-out unit, the purpose of the inmates’ placement
in the room could not be determined. Apparently, the area is used for inmate stabilization
without a staff observation requirement. Oddly enough, this “time-out” unit was one of the
most brightly lit units used for inmates with serious mental illness that we encountered.
Where a darkened area would have been helpful, there was light; at Donaldson, where light
would help, it was dark.
During the second review of Bullock, the inmates reported that they could request
placement in the time-out area when they were feeling stressed. The inmates said that
generally they are permitted to stay in the small unit until they request to leave. It is
possible that the time-out unit reduces the practice of transferring an inmate who is unable
to handle the large dormitories to an infirmary or segregation cell.
An interview of the one inmate (136966) in the time-out area during the June review
suggested agitation but no acute psychosis. The inmate was thankful for the environment,
claiming he was afraid he was going to be hurt in the dormitories.


Of the eighteen inmates in the segregation unit during the site review, only two were
receiving psychotropic medication and they appeared stable. One inmate reported that he
received weekly therapy from the psychologist. He was pleased with the psychologist but
dissatisfied with the psychiatrists who allegedly refuse him medication for his mood swings.
The inmate added that he had signed a release while at Kilby for records of his prior
psychiatric treatment but no one had acknowledged their receipt or discussed his treatment
history with him.
Review of the records of inmates on the Bullock mental health units suggests that
mental health staff may place an inmate in segregation, apparently as a step-down to the
dormitories, after an inmate has required a crisis placement due to decompensation or
suicidal ideation. The records of one inmate (183213) indicated that after he decompensated
he spent a month in either an infirmary mental health cell or segregation cell before he was
considered appropriate for return to the Transitional MHU. This is grossly inadequate
treatment. Transfer to the Kilby Mental Health Unit would have been a clinically
appropriate option.
In his deposition, Dr. Downs reported that an inmate may be placed under mental
health observation in a segregation cell when the infirmary mental health cells are not
available and the inmate is not considered at risk for suicide or self harm. Dr. Downs stated
that inmates appropriate for mental health observation in the segregation cells would be
“Someone who is psychotic, agitated, potentially violent, having auditory hallucinations
telling them to hurt others.” While these inmates would appear to qualify for Kilby transfer,
Dr. Downs stated that such transfer is considered when “ They would have gotten to the
point that I simply could not control them here or, I suppose, that they were requiring single
cell placement for some unusually long period of time.” Dr. Downs could remember only
one inmate that had been transferred to Kilby since he began providing services at Bullock
in December of 1999.


The four single rooms designated for mental health crisis intervention at Bullock
were superior to those observed at the other institutions reviewed in terms of cell visibility
and lighting. The one cell that was being utilized for placement of a “suicidal” inmate
during our visit, however, did contain exposed electrical wires in an easily accessible
portion of the wall. It appeared that a plate of some sort which would ordinarily cover the
wiring was missing. One of the four cells was not available for mental health crises since it
was occupied by a very elderly infirm inmate (141464). A memo on the wall dated 1998
that provided staff information on the management of this elderly inmate’s meals and
incontinence suggested that this inmate was a long-term resident, limiting the number of
cells available for mental health care to a maximum of three. (Dr. Downs identifies only
two mental health cells in the Bullock infirmary, contradicting earlier reports of four cells
dedicated to mental health care.)
The inmates reported, and the records confirmed, that inmates are routinely placed in
the mental health cells nude with only a rubber mat.
Inmates are provided with various colored plastic bracelets that we initially assumed
had some housing or clinical significance. The inmates we talked with during our initial
Bullock review professed not to know their meaning, saying you get whatever bracelet is
available. During the second review, the inmates confirmed the statements in the deposition
of Charles Goodwin that the bracelets are based on an inmate’s housing assignment.
Orange bracelets indicate placement on the Transitional MHU; green bracelets indicate
placement on the Intermediate MHU; and red bracelets indicate general population
placement. However, the inmates suggested that at times bracelets are not assigned as
intended. For example, one general population inmate who was housed in the Intermediate
MHU due to bed space issues was give a green bracelet to permit his attendance at meals
and recreation periods with the other inmates of his dormitory.


It is unclear why a given inmate is placed on Transitional MHU rather than the
Intermediate MHU. Indeed, even Dr. Downs could not distinguish the differences in
programming or inmate illness severity between the two. Bed availability may well be the
determinant as to unit placement rather than the exercise of any sort of clinical judgment.

The site visit of Easterling Correctional Facility was conducted the afternoon of June
21, 2000. Easterling is a male, medium-security institution with an inmate census of
approximately 1200 inmates. The facility has two segregation units, each with twenty-six
cells. Each segregation cell can be double-bunked, creating a total of 104 segregation beds.
General population inmates live in large dormitories. There are four placements designated
for mental health crisis intervention: one room in the infirmary; another behind the Control
Center; and two cells in the segregation units.
The CMS Alabama Psychotropic Report – April 2000 indicated that seventy
Easterling inmates were prescribed psychotropic medication. Of the fifteen inmates
prescribed antipsychotic medications, five were prescribed injectable medications. No
inmate was prescribed a newer, so-called atypical antipsychotic medication.
Sixteen of the inmates prescribed psychotropic medication were selected for review
during the Easterling visit. Five of those selected were not available since they had been
transferred from Easterling or did not appear for the group meeting.
The site review of Easterling occurred after an extended period of inmate lock-down
related to an institutional disturbance at the end of May. The inmates had not had visitation
or regularly scheduled out-of-cell time for over three weeks. The Warden has reintroduced
outdoor recreation in a scheduled manner and planned to reinstate visitation the following
Easterling’s mental health staffing as of May 2000 was as follows:

Psychiatrists (CMS)

Sanders & Williams - 4 hours per week
(rotate weekly coverage)
Licensed Psychologist (CMS) Gilbert – 8 hours per week
Psychiatric LPN (CMS)
Vacant – 40 hours per week
Psychological Associate (ADOC) Croy - 40 hours per week
In his deposition, Mr. Croy explained that his duties included: assessment of inmates
as needed; inmate referral to the CMS psychologist and psychiatrists; rounds of the
segregation unit twice weekly; participation in institutional Progress Reviews; inmate
counseling; mental health updates for the Parole Board; and supervision of the substance
abuse treatment units.
The Easterling inmates were disappointed that the former LPN assigned to mental
health duties had resigned since this staff member was described as “caring.”
The institutional disturbance that occurred at the end of May resulted in the overcrowding of the segregation units. Fifteen of the twenty-six segregation cells of one unit
held three inmates. The calm and cleanliness of the segregation areas was notable in light of
the presumably temporary over-crowding. The inmates confirmed adequate access to
mental health services through the regular conduct of mental health rounds where Mr. Croy
knocks on each cell-door and asks how the inmates are doing.
Brief interviews of two selected inmates found that one (162177) was functioning
adequately with no signs of acute psychosis. This inmate reported acceptable follow-up by
the psychologist but that psychiatric follow-up consisted of only five to ten minute
The second inmate (130625) appeared to be only marginally stable and in acute
distress. This inmate had been identified by Dr. Gilbert in his deposition as one that he had
repeatedly requested transfer to Bullock due to marginal functioning. The inmate’s report
that his prescription for Navane had been discontinued by the psychiatrist the day of the site


visit was confirmed by the medical record. The inmate’s medical record indicated that a
psychiatric review on May 31st found the inmate in “remission” with a plan to continue
medications with a follow-up appointment in three months. A referral from Dr. Gilbert on
June 12th resulted in a follow-up review by a different psychiatrist on June 21st. Notes of
this review indicated: “Patient no longer psychotic but (illegible). Discontinue meds.
Discontinue Navane/Artane.” Neither the inmate’s presentation nor the medical record
provided adequate clinical justification for the change in treatment.
A group meeting was conducted with eight general population inmates who were
prescribed psychotropic medication. Although none of the inmates demonstrated symptoms
of acute psychosis, one (199151) displayed signs of significant side effects to the medication
and three denied any knowledge of why the medication was prescribed. Their only rationale
for accepting medication was that the “shots” would be forced or they would be locked-up if
they refused.
The inmate reports that they had little access to programming was confirmed in the
depositions of Mr. Croy and Dr. Gilbert. Mr. Croy reported that there were no groups
conducted since there were insufficient staff to provide them. Dr. Gilbert also reported that
additional mental health staff time was necessary to meet the needs of Easterling inmates.
While general population inmates reported several problems with medication
administration, correctional officer observation of medication ingestion reportedly was
consistent. Inmates said that medication administration times are inconsistent and that they
must wait in pill lines for over an hour. They also reported that medication administration
had been suspended at least three times in the last month, but these claims were denied by
Easterling medical staff. It was not possible at the time to reconcile the discrepancies.


The two segregation cells designated for mental health treatment were not reviewed
during the site visit. The cell behind the Control Center is acceptable for crisis care, but the
location does not facilitate clinical staff observation. The mental health cell of the infirmary
appeared to be undergoing renovation since the ceiling vents were exposed.
The inmates reported that they are placed in the mental health cells nude or wearing
only underwear. Since a CMS psychiatrist is at Easterling only four hours per week, inmate
reports that they could spend up to five days in the mental health cells without a psychiatric
assessment seemed credible. However, these reports were disputed by Dr. Sanders, who
said that when an inmate is known to him, he may change medications and/or discontinue
precautionary watches based on a telephone call from Easterling staff. This practice is not
consistent with community treatment standards.
Easterling medical staff reported an infrequent use of restraints for mental health
reasons. Staff descriptions of how restraints were applied indicated acceptable procedures.

The site visit of Limestone Correctional Facility was conducted on June 22, 2000.
Limestone is a male, medium-security institution for approximately 1900 inmates. The
facility also provides the housing for 200 male inmates of all security levels who have been
diagnosed as HIV+ (Human immunodeficiency virus infection). The HIV unit has a
capacity of 240 dormitory beds, a separate dining room, nursing station and recreational
areas. Limestone has several segregation units, one of which is designated for HIV+
inmates. Three rooms in the infirmary are designated for mental health crisis interventions.
The visit to Limestone suggested that this is a well-run institution. The facility was
clean and orderly with many landscaped outdoor areas. The inmates were calm and reacted
positively to interactions with the Assistant Warden and the Lieutenant providing our escort.


The CMS Alabama Psychotropic Report – April, 2000 indicated that sixty-nine
Limestone inmates were prescribed psychotropic medication. Of the nineteen inmates
prescribed antipsychotic medications, nine were prescribed the long-acting injectable form.
No inmate was prescribed an atypical psychotropic medication.
Limestone’s mental health staffing as of May 2000 follows:
Psychiatrist (CMS)
Murbach - 8 hours per week
Licensed Psychologist (CMS) Leonard – 16 hours per week
Psychological Associate (ADOC) Day - 40 hours per week

Brief cell-front interviews with approximately fifteen randomly selected inmates in
the Limestone administrative segregation units disclosed no inmates with acute psychosis.
One inmate (193709) who was prescribed psychotropic medication without side effect
medication displayed involuntary tongue movement. The administrative segregation
inmates confirmed that the ADOC psychologist associate, Ms. Day, conducts cell-to-cell
rounds and is available for individual sessions when requested.
Review of two inmates housed on the segregation unit for HIV+ inmates, and also
prescribed psychotropic medication (153125, 171201), found the placements were
appropriate. The inmates confirmed that their mental illnesses made functioning in the large
dormitory extremely difficult so that they had requested and been approved for placement
on the segregation unit. Since the inmates were placed on protective custody rather than
administrative segregation status, they had access to general population property and out-ofcell time. There was no programming offered for these inmates, but they had created a
garden next to the unit. Both inmates reported monthly follow-up by the psychiatrist.
Although one inmate (171201) was prescribed Cogentin, he displayed the hand tremors and
“pill-rolling” related to side effects of antipsychotic medications.


A group meeting was conducted with seven general population inmates who were
prescribed psychotropic medication. These inmates were very dissatisfied with psychiatric
services. They stated that they are summoned to the infirmary for a psychiatric appointment
and then routinely wait up to four hours for a session with the psychiatrist.
The inmates also reported that while in the past, psychiatric sessions lasted no longer
than five to ten minutes, they have been able to spend more time with a psychiatrist now that
Dr. Murbach is providing services for Limestone.
The general population inmates reported that if they refuse prescribed injectable
medications, they may be stripped and placed on watch. One inmate (164200) reported that
when he requested discontinuing lithium because he no longer wanted to attend the lengthy
pill lines, he had been placed in a mental health cell for fourteen days. This practice, which
was identified repeatedly at ADOC facilities, is coercive, punitive and unacceptable.
One inmate (139950) displayed significant akathesia, a side effect from his Prolixin
Decanoate. He said he did not want medication for the side-effects because he did not want
to wait in the pill line.
Another inmate (124198) reported that he had not seen a psychiatrist since his
transfer to Limestone on December 17, 1999, but he had continued to receive his lithium.
Review of the inmate’s medical record confirmed that lithium had been consistently
provided but there were no physician orders for the medication since December of 1999
when the inmate was transferred from Kilby. Limestone nursing staff assisted in the
medical record review to validate the presence of no notes of mental health assessment or
medication orders since the inmate’s arrival at Limestone. This gap in care is particularly
problematic since the use of lithium requires periodic laboratory testing to monitor the
effectiveness of the medication and to ensure that current dosages do not create a lifethreatening situation. The inmate had not requested an appointment with the psychiatrist to
discuss the problem because of the inmate’s perception that he would be charged a medical


co-payment fee. His belief that mental health follow-up should be scheduled automatically
when an inmate prescribed medication is transferred from one prison to another is valid.
The Limestone general population inmates reported that they have access to groups
conducted by the CMS psychologist and the ADOC psychologist associate. While these
groups may be helpful, they are not clinically-driven or related to the treatment needs of a
specific inmate. Reportedly, Dr. Leonard’s groups discuss a variety of issues ranging from
the Bible to football and DNA testing.
Observation of medication administration for general population inmates revealed a
process involving two nurses. One nurse identified the inmate and administered the
medication to the inmate after the second nurse read off the inmate’s medication from the
medication administration record. The second nurse then documented the process on the
medication administration record. The fact that the first nurse repeatedly reminded inmates
that they had to provide their identification badge before receiving medication suggests that
this requirement is not consistently followed.
Observation of the correctional officer’s monitoring of medication ingestion
indicated that this is a routine practice.

Each inmate receiving medication had to

acknowledge the receipt by signing a medication log. While not required by medical
standards, the practice may assist the institution in ensuring medication compliance.
According to a memo from the Psychology Associate, Linda Day, to Harry Lenach
dated March 26, 1999, Limestone experienced frequent lapses in medication availability.
She reported that inmates could be without prescribed psychotropic medication from one to
nine days. The fact that these lapses were reported to present the security staff with
significant problems and increased use of the infirmary single cells suggests that inmates
deteriorated while awaiting medication.


Dorm 16 housed 197 inmates at the time of the site review. We were permitted to
move freely within the Dorm 16 and interact with all interested inmates. Although the
inmates were very discouraged about the lack of programming and vocational training
provided for them, the inmates seemed proud of their dormitory and their efforts to improve
the quality of life.
The nursing station added to Dorm 16 was extremely positive and indicated the
commitment of the assigned nurse to the HIV+ inmate population. The station was painted
in pleasant pastels paid for by the nurse and completed by the inmates. The nursing station
walls include designs signed by individual inmates.
Dr. Leonard reportedly conducts a weekly group for Dorm 16 inmates. The inmates,
with ADOC approval, have also developed a peer-support group COPE (Committee on the
Prevention and Education of HIV/AIDS) to assist the inmates in “meeting their own needs
with HIV and AIDS.” Inmate leadership of the COPE program provided a program
description that confirmed the program’s benefits.
Three inmates of Dorm 16 (176000, 173858, 207018) reported that their
antidepressant medications had been discontinued because the psychiatrist judged that they
“didn’t need it” in spite of their reports that the medication was beneficial and their requests
that it be continued.
When the Dorm 16 inmates were asked to identify fellow inmates in their unit with
serious mental illness, they immediately identified one inmate (143324). An interview with
this inmate confirmed the presence of acute psychosis in an extremely vulnerable inmate.
The inmate is prescribed Prolixin but continues to experience such psychotic symptoms as
auditory hallucinations, thought blocking, and beliefs that the television/radio is speaking
directly to him. The inmate described his daily schedule of walking around, listening to
voices and doing “odd jobs” for his peers in exchange for cigarettes and coffee. Since he
cannot read, write or watch television due to his psychosis, he has limited options. The


inmate stated that he had not told the psychiatrist about his continuing “voices” because he
did not yet trust him and he was afraid that he would “spook” the doctor. He also indicated
that the “voices,” even though derogatory, were important to him. This inmate’s severe
psychological distress was evident during the interview. He acknowledged that he had been
given the option of protective custody placement but refused after trying protective custody
placement for several months. His refusal is likely related to his perception of reduced
access to bartered cigarettes and coffee. This inmate, having served only 13 years of a 99
year sentence, requires enhanced psychiatric intervention and trials of atypical medication in
an effort to address the intense suffering he experiences.
Our review of the three infirmary mental health cells found them to be acceptable
placements for crisis intervention. They were equipped with hospital beds and bedside
tables. However, the inmates reported that when placed on watch, they are nude and not
provided even a rubber mat for bedding. Limestone staff confirmed that furniture is
removed from the mental health cells when necessary.
Since a CMS psychiatrist is at Limestone only one day per week, an inmate may be
placed on watch status for many days in the mental health cells without a psychiatric
assessment. According to a memo from DOC psychologist associate Linda Day to Harry
Lensch dated March 26, 1999, a review of the use of mental health cells for the preceding
quarter indicated twelve inmates were admitted one or more times for acute mental health
problems. The average length of stay for the acute admissions was nine days with one
inmate remaining in the mental health cell for thirty-nine days. Such lengths of stay far
exceed what would be anticipated for treatment in an infirmary mental health cell.
Limestone staff reported limited use of restraints for mental health reasons, but
stated that restraints are applied by restraining the inmate’s extremities to the closest corner
of the bed, a practice which may lead to inmate shoulder joint injury and which also
inappropriately permits some upper extremity mobility which can lead to staff injury. (The


proper restraint position is to have the elbows extended and arms positioned down at the


The System as a Whole is Grossly Inadequate
In our judgment, the ADOC system for identifying, housing, and treating inmates with
serious mental illness is grossly inadequate and riddled with systemic deficiencies. This is
not to say that all aspects of the system and every facility are equally deficient. For
example, the Donaldson MHU, with some renovations, could be physically acceptable as a
mental health unit. Bullock, as another example, with the provision of far greater treatment
and programming, could be acceptable as the placement for certain inmates with mental
illness in need of transitional-type housing and care. Pockets of minimal acceptability,
however, cannot lift an entire system to the level of acceptability. As experts, we look at
physical space and the mental health tasks to which it is devoted, and we ask whether the
practice fits the label. Beyond the labels and actual practices, we also consider the services
which correctional mental health care must provide, - - for example, crisis care and hospitallike care - - and ask if it is reasonably available regardless of nomenclature.
Staffing Levels Are Seriously Deficient
ADOC mental health staffing levels do not permit the provision of timely or
minimally adequate treatment of inmates with mental illness. Without sufficient staff,
inmates identified with mental illness receive grossly inadequate care and follow-up, while
other inmates with mental illness remain unidentified. Further, those inmates who are
placed on mental health units for treatment receive little more than a protected environment.
The high number of very ill inmates found locked-down in segregation is undoubtedly a
further artifact of inadequate staffing.
Psychiatrists are essential to any treatment system for inmates with serious mental
illness. Until July 1999, CMS was authorized to provide two full-time psychiatrists for


more than 20,000 inmates. CMS subsequently was authorized to increase the psychiatric
staffing to seven full-time positions. This increase in psychiatric hours may facilitate more
frequent psychiatric intervention and medication management but it will not permit regular
psychiatric presence for multidisciplinary treatment planning, another keystone to mental
health treatment.
Outpatient services for inmates identified as experiencing serious mental illness are
provided by CMS mental health staff who may be present in a particular facility only one or
two days per week. The ADOC psychologists are not responsible for the monitoring and
treatment of inmates with serious mental illness. Inmates who experience emergencies on
days when a CMS mental health staff member is not present are routinely placed on watch
in isolation until the CMS staff member’s next scheduled day. Isolation alone, particularly
under the conditions previously described, is inadequate treatment for mental health
emergencies and exacerbates the inmate’s distress and suffering.
On days when a CMS mental health staff member is on-site, the number of
outpatient inmates requiring just routine monitoring is so great that it results in these
inmates receiving little more than a brisk, “How are you doing?” Any hope of facilitating
an inmate’s adjustment to correctional living and enhancing treatment compliance through
education is not achieved.
Mental health staff may be present on the designated mental health units, but there is
insufficient staff to provide even the most basic care necessary for inmates whose illness
requires a specialized mental health placement. Further, not all mental health staff are
qualified or trained to conduct the requisite programming. Others have their time for
clinical interventions diverted to either medical or correctional duties. The title “mental
health technician” is itself misleading given that many of the duties of these staff relate to
such correctional issues as visitor lists, commissary orders, and inmate clothing. These are
important duties but do not constitute mental health treatment.


The mental health nursing staff, which is primarily licensed practical nurses -- not
trained psychiatric nurses -- provide no inmate treatment or medication education, which are
essential functions for psychiatric nurses. The primary duties of the mental health nurses are
administrative functions related to medication ordering, monitoring the medical conditions
of inmates on watch status, and assisting psychiatrists during scheduled appointments.
Since the mental health nurses also complete medical duties, their ability to provide mental
health treatment is further compromised.
Inadequate mental health staffing impacts all aspects of treatment. Therapeutic
programming is either severely limited or non-existent. As a result, individual monitoring is
brief and typically does not provide staff the opportunity to “work” with an inmate on
identified issues. Medication is an essential component of mental health treatment but
medication alone is not clinically sufficient. Finally, limited staffing contributes to limited
record documentation that does not reflect or permit continuity of care.
Treatment for inmates assigned to the mental health units is limited by the lack of
appropriately trained mental health staff and also by the lack of correctional officer presence
required for inmates to be out-of-cell in a safe manner. Inmates on the Kilby and Donaldson
units, for example, are completely locked-down except for a few hours during the day shift
due to limited security coverage. Extended periods of cramped isolation are contraindicated
for those inmates with serious mental illness who already experience significant social skill


Staff Recruitment and Retention Is Compromised
The shortage in qualified mental health staff is dramatic. In order to attract and retain
high caliber staff, especially with regard to psychiatrists, the reputation, character, and
credentials of current staff are very important. In Alabama, this situation is compromised, in
our view, and represents a significant hurdle to professional staff recruitment and retention.
Staff Training in Mental Health Issues Is Wholly Inadequate
An essential standard of the National Commission on Correctional Health Care
(NCCHC), used here as a benchmark, requires that correctional officers receive on-going
training (at least every two years) in the following mental health areas:

Recognizing acute manifestation of certain chronic illnesses (e.g., seizures, intoxication
and withdrawal, and adverse reaction to medication)


Recognizing signs and symptoms of mental illness


Suicide prevention
Correctional officers serve as gatekeepers, assisting inmates to gain access to needed

mental health care. The officers’ importance magnifies in relation to how well staffed a
prison system is with qualified mental health professionals and how often and effectively
rounds are conducted. As noted elsewhere, staffing levels in the ADOC are unacceptably
low and rounds exist primarily in name only.
According to the documentation provided by ADOC and depositions of ADOC and
CMS staff, NCCHC’s recommended training does not occur in the Alabama system. Dr.
Woodley stated that he coordinates pre-service mental health training for new correctional
officers three or four times a year. This training was reported to be a five to six hour
presentation that covers the essential NCCHC requirements. However, periodic refreshers


on these issues are not routinely provided. Officer Woodard and Officer Williams, two
correctional officers often assigned to the Kilby MHU, reported no training in suicide
prevention for at least five years.
Dr. Williams reported that he had provided staff with an “800 number” for accessing
literature about suicide prevention and Dr. Woodley stated that he had sent the major
institutions handbooks about suicide prevention prepared by the CMS corporate office. The
mental health staff also reported that they share information about mental illness with the
correctional officers during informal discussions. These efforts, while positive, do not
constitute adequate training. Without concentrated training in the identification of inmates
demonstrating signs of mental illness or suicidal risk, it is not possible for the security staff
to consistently refer inmates for clinical intervention prior to the development of a crisis.
Without training, behavior associated with serious mental illness is likely to be treated as
willful misconduct and such behavior associated with an illness becomes an occasion for a
disciplinary proceeding.
The need for additional staff training in mental health issues was identified in a 1998
study by CMS staff concerning the satisfaction of ADOC wardens and correctional officers
with the mental health services provided at their institutions. The specific training requested
by ADOC staff during the 1998 study included:

Dealing with real or secondary gain based threats of self-injury


Differentiation between symptoms of mental illness and simple behavioral problems


Basic techniques of behavior modification for mentally ill and normal inmates


Effects and side effects of psychotropic medications


Nature of treatment plans and role of the correctional officer
According to the depositions of numerous DOC officers and wardens, no system-

wide training has ever been conducted to address the above-mentioned systemic deficiencies
identified by CMS.


While all correctional officers require at least basic mental health training, systems
with effective mental health programs provide enhanced training for staff assigned to mental
health or segregation units, the areas most likely to experience mental health problems.
CMS staff reported that five-hour enhanced, voluntary mental health training sessions are
conducted each quarter for approximately fifty staff. Since half of the training participants
are mental health or supervisory staff, less than 100 correctional officers have access to one
of the training sessions each year. Further, review of the content of these training sessions
revealed the inclusion of many topics not related to the identification, treatment and
management of serious mental illness.
Correctional officers are not the only staff inadequately trained to handle the
problems that occur when persons with mental illness are incarcerated. The depositions of
the “mental health nurses” and the mental health technicians revealed their seriously limited
knowledge about basic issues concerning mental illness, medication and suicide prevention.
Bed/Treatment Space Is Grossly Deficient
ADOC has designated numerous beds as “mental health beds,” but the configuration
and utilization of these beds does not allow adequate treatment. Given that numerous
inmates with serious mental illness were found untreated in the ADOC segregation units,
the sheer number of mental health beds, to say nothing of their quality, is clearly not
adequate to meet the system’s needs. Additional bed space is particularly needed for
inmates unable to be housed in dormitories either due to security or mental health
considerations. There is a waiting list of inmates for the Donaldson MHU single cells, with
some of these inmates “waiting” in a segregation cell for months for treatment.
* Kilby MHU and P-I The MHU and P-I units at Kilby reportedly provide acute
and in-patient hospital-like psychiatric treatment. (Kilby’s inadequacy as an in-patient
hospital facility is discussed in further detail below.) While the MHU provides appropriate
bed space for inmates experiencing an acute episode of mental illness, there is no space for

programming or mental health staff interventions in a confidential manner. The dayhall and
outdoor space for recreation is also limited. The mental health beds in P-I are basically
enlarged isolation cells that do not have direct access to treatment space. P-I treatment is
typically conducted at the inmate’s cell-front.
* Kilby South Ward and Bullock Kilby’s South Ward and Bullock’s mental
health units offer dormitory housing for inmates with serious mental illness. Although the
dormitories are crowded, most offer physically adequate living areas. Again, the space
available for individual interventions or group programming is totally inadequate. Offering
“programming” to forty or more inmates while they are forced to remain seated on their
bunk beds hardly qualifies as meaningful programming. In addition, the actual content of
the programming is also inadequate.
* Donaldson MHU Donaldson’s MHU provides single cell placement for inmates
with serious mental illness whose security level does not permit placement in the Bullock
dormitories. While the physical environment of this unit is dreary, the actual physical bed
space area is adequate. As with the other units, there are no areas for confidential individual
interventions or group programming.
The utilization of the ADOC’s mental health beds is a seriously problematic. While
there were vacant beds on the Kilby MHU during our site review, there were acutely
psychotic inmates in Kilby’s segregation units, on the Donaldson MHU, and in the
segregation units at Donaldson, Holman, and St. Clair. Housing acutely psychotic inmates
in segregation cells while supposedly acute care beds on Kilby’s MHU go unoccupied is
appalling and results in needless pain and suffering. There were also inmates in the smaller
mental health dormitories at Bullock obviously in need of more intensive treatment.
ADOC reports of the number of beds available for mental health crisis care at each
of the institutions (except Holman, which has no infirmary beds), include even the infirmary


dormitory beds as back-up mental health beds. Treating inmates with a mental health crisis
in a dormitory alongside inmates experiencing medical problems is inconceivable.
Inspection of the rooms designated as the primary sites for mental health crisis care
revealed restricted visibility into the rooms unless the door was opened. This does not
facilitate the routine fifteen-minute monitoring by correctional officers required when an
inmate is placed on watch. The rooms have no beds and an inmate is typically placed in the
room naked with only a rubber mat on which to rest. While this type of placement may be
necessary for very brief periods of time to minimize the risk for self-harm (based on an
individual clinical decision), inmates report, and medical records confirm, that inmates may
be retained under these conditions for days or weeks with infrequent mental health staff
contact. This level of treatment is seriously deficient and appears humiliating and punitive
on its face.
While the use of restraints for mental health reasons may be infrequent, institutional
practices in this high risk/low frequency event are inconsistent. The Standard Operating
Procedures of St. Clair, Kilby and Donaldson defined “four point restraints” as the method
of restraining a inmate by securing each arm and leg to the nearest corner of the bed. This
suggests a spread-eagle positioning of the inmate. This position is inconsistent with CMS
policies and was reported to be the actual practice only at Limestone. Staff at Donaldson
reported that their inmates are restrained face-down. Inconsistencies in restraint application
practices present risks of serious harm to the inmate and staff.
Kilby As Inpatient/Hospital-Type Care
Clinical necessity dictates that every prison mental health system either provides its
own hospital-type care or provides reasonable access thereto. While Taylor Hardin Secure
Medical Facility is a psychiatric hospital that is theoretically available to the ADOC, in
practical effect its use for treatment of ADOC inmates with serious mental illness is
extremely limited. The prior history of objectionable delays in gaining admission to Taylor
Hardin has been “solved” in practical effect by not using it for treatment. This resource is

being denied to acutely ill inmates who would clearly benefit from such a transfer. In light
of the systemic deficiencies in the system, removing Taylor-Hardin as a treatment option is
tantamount to denying life-saving treatment.
(To the extent that Taylor Hardin might again be viewed as the appropriate hospital
placement, one would have to address the Alabama law on prison-to-hospital transfers. The
requirement of executive approval may take six to ten weeks; an unacceptable period of
delay when an inmate requires inpatient treatment and particularly so in light of the
inadequate care provided within ADOC.)
A hospital level of care requires that a comprehensive multidisciplinary assessment
occur within a short time of admission. The assessment includes the reason for psychiatric
hospitalization; a history of the mental illness and past response to treatment; a medical
assessment; personal, social, family and legal histories; a description of functioning; and a
comprehensive mental status examination which leads to a psychiatric diagnosis, and
finally, culminates in the development of a treatment plan. Inpatient psychiatric hospitals
perform psychiatric assessments at least weekly, generally more often. In addition, other
professional disciplines interact with the patient – psychology, social work, adjunctive
therapists, nursing, education and substance abuse counselors. Efforts are made to secure
past treatment records and family members are contacted to provide information about the
illness – longitudinal course, response to treatment, level of functioning possible, and so on.
Patients in psychiatric hospitals are engaged in numerous activities including
medication education, group and individual therapy and other activities aimed at symptom
reduction/symptom management while permitting trained mental health assessment of
functioning. The therapeutic milieu (hospital environment) is designed to foster positive
socialization through socially appropriate interactions with staff and other patients;
reinforcing acceptable behavior, and similar socialization arrangements. Treatment is
intense and aimed at rapid resolution or reduction of symptoms to permit a return to
previous level of functioning.


There is no evidence that any of the aspects of hospital-level care identified above
are provided by the Kilby MHU. There is no assessment (admission or otherwise) by a
multidisciplinary team, and no multidisciplinary treatment plan which defines the inmate’s
problems, the planned interventions, the staff responsible, or the goals to be achieved.
Treatment consists of brief, non-confidential interactions with the psychologist, irregular
participation in limited group sessions, and infrequent psychiatric interaction.
The primary mode of treatment is medication – for which consent is neither sought
nor granted.

Inmates are very often prescribed long-acting injectable antipsychotic

medications. These types of medications are contraindicated for management of acute
psychiatric illness due to their long duration of action. With long-lasting medications,
adjustments in dosage, increases or decreases, may be made only infrequently and one must
wait several days to determine whether the medication has any effect and several weeks to
determine whether or not the dosage is adequate.
There are no clear admission or discharge criteria for Kilby’s P-I unit and MHU.
Subsequently, mental health staff working in other institutions appear not to understand
which inmates are appropriate for transfer to the facility or when to access admission in a
timely fashion. When inmates are transferred to that level of care, they are transferred
without being provided appropriate notice or the opportunity to challenge the transfer or
The involuntary, forced medication procedure appears dramatically underutilized.
We uncovered no evidence of any inmate being on involuntary medications during the site
visit. However, inmates reported being transferred from South Ward to the MHU or from
the MHU to P-I routinely if they refused the prescribed long-acting medication. In other
words, they were transferred to a more restrictive setting if they refused medications which
they had never consented to receive. Thus, the forced medication process appears
circumvented through the utilization of long acting, involuntarily injected, coerced


medication without granting the inmate a hearing or the rights associated with it.
Nursing notes in the MHU chart are best described as medical/surgical in nature
rather than psychiatric. Notations about vital signs and notes such as “resting comfortably”
are the most common types of nursing documentation. The nursing notes do not address
mental health issues, medication compliance or education, or inmate response to
administered medications.
Programming is minimal, abysmally poor, and is not clinically-driven. It consists
primarily of ping-pong games among inmates, television, walking around outside with a
radio playing, and some group discussions with a mental health technician or a social
Inmates are granted extremely limited out-of-cell time. The vast majority of MHU
inmates are only allowed out of their cells for forty-five minutes each day in hand cuffs and
leg shackles. Even the few that are not shackled are only out-of-cell about two hours per
day. After 2:00 p.m., when the second shift begins, inmates are locked down until the
following morning. According to the depositions of Drs. Woodley and Bell, mental health
staff have very little input into these security and housing decisions. The ADOC’s failure to
consider the mental health needs of inmates in making security level and housing decisions
seriously compromises the ability of the mental health clinicians to effectively and
adequately treat their patients. This is true not only at Kilby, but at all the institutions we
Discharge summaries frequently contain diagnoses that differ substantially from
previous diagnoses and without appropriate documentation in the summary itself or in the
progress notes which describe or explain the discrepancy.
The end result is that the ADOC effectively denies access to inpatient treatment for
inmates with acute and serious mental illness.


Kilby is not staffed with twenty four-

hour/seven-day a week psychiatric nursing - - a benchmark for hospital care. There is no
multidisciplinary assessment; no comprehensive mental health evaluation; no real treatment
plan; and no intensive mental health treatment provided at Kilby. Although frequently
diagnosed, substance abuse disorders are not addressed in treatment. There is no more (and,
ironically, perhaps less) out-of-cell time in the supposed therapeutic environment than that
permitted inmates of similar security levels.
In sum, the “treatment” provided on the Kilby MHU consists of little more that
seclusion, increased correctional supervision, and coerced psychotropic medication. The
consequences of failing to provide access to inpatient treatment causes inmates with mental
illness to greatly and needlessly suffer from treatable symptoms of serious mental illness.
Persistent symptoms without relief raises the risk of suicide or attempts at self-harm.
Inmates may also be at increased risk of assaulting other inmates or staff.
Access to Care Is Grossly Deficient
Access to care is a critical component of a minimally adequate correctional mental
health system. It is our opinion that many ADOC inmates with serious mental illness have
little access to minimally acceptable mental health care. The only consistent strategy
reported by inmates to access care is to violate prison rules and cause a disturbance, damage
property, or inflict self-injury. Thus, on the most fundamental of the dynamics of prison
mental health care, Alabama does not provide reasonable ready access to required mental
health care.
Inmate Screening and Evaluation Is Deficient
Screening and evaluation for potential signs of mental illness when an inmate is
received is a critical element for ensuring access to care.

According to ADOC

documentation and staff depositions, this process at Kilby is marginal at best.


Medical nurses screen new inmates for mental health and psychotropic medication
issues. ADOC psychology associates then interview the inmates to complete a three-page
assessment questionnaire.

Inmates also receive an intelligence screening (BETA),

educational evaluation (WRAT) and complete a personality inventory (MMPI-II). It is not
clear if the information gained through the psychology associate’s assessment process is
utilized in later treatment planning.
If a medical nurse or psychology associate identifies an inmate as requiring
psychiatric assistance, the inmate is referred for a psychiatric evaluation. In Dr. Sanders’
deposition, he reported that evaluating new inmates who had been referred for psychiatric
evaluation was his primary responsibility during his two days per week at Kilby. However,
during that time he also is scheduled to see inmates from the MHU and P-1. Dr. Sanders
stated that he sees about five inmates an hour and may spend up to thirty minutes with an
individual inmate. While thirty minutes may be sufficient to conduct psychiatric medication
management, it is inadequate to complete an initial psychiatric assessment and develop a
treatment regimen for a previously unknown patient.
Medication Practices Are Seriously Deficient and Dangerous
* The Psychotropic Medications Administered by the ADOC The CMS
formulary (choices of psychotropic medications available to psychiatrists to prescribe for
their patients) is limited. The newer atypical antipsychotic medications (Clozaril, Zyprexa,
Seroquel and Risperdal) are available only if the prescribing psychiatrist makes a special
request for Dr. Williams’ approval.
Clozaril is the only medication demonstrated in the scientific literature to provide
symptomatic relief for patients with psychotic symptoms who have not responded to
treatment with the older antipsychotic medications. However, other atypical medications
have been demonstrated superior to the older antipsychotic medications in their side effect
profiles. That is, they are much less likely to cause problems with movement disorders,
including the development of tardive dyskinesia - a potentially irreversible, disfiguring

involuntary movement disorder. Consequently, the atypical medications do not require the
co-administration of such medications as Artane and Cogentin to prevent the development
of side effects. Both Cogentin and Artane have abuse potential in correctional settings,
while none of the antipsychotic medications have black market value. Artane may be
crushed and smoked for the “high” that may be obtained. Cogentin may also create an
altered state or “high” when ingested. In a correctional system which purports to have a
great deal of difficulty with inmates “manipulating” to obtain Artane prescriptions, it is
remarkable that the newer medications are not used to curtail this problem.
In addition, the evolving community standard of care is to utilize the atypical
medications as “first line” medications in the treatment of psychotic disorders (that is, the
first medication to try rather than a medication of last resort.) Cost containment is an issue
but it can be successfully managed through utilization of mechanisms to ensure appropriate
prescription based on diagnosis, utilization of the lowest effective dose, and monitoring of
response to treatment.
Review of the CMS Alabama Psychotropic Report - April of 2000 indicates the

1,145 male inmates were prescribed psychotropic medication.


Of the 475 male inmates prescribed neuroleptic medications, only 53 (11.2%) were
prescribed atypical psychotropic medications. Recently, the percentage of inmates on
atypical medications has dramatically increased.


Of the 475 male inmates prescribed neuroleptic medications, 252 (53%) are prescribed
injectable medications. A significant number of these inmates demonstrate side effects
from these medications not adequately controlled by side effect medication.
The analysis of the prescribing patterns prevalent throughout the Alabama system

demonstrates a profound under-utilization of the atypical antipsychotic medications and a
remarkable over-utilization of long-acting injectable decanoate preparations of the older
medications. Many inmates that we observed demonstrated serious side effects to these


medications (tremors of the extremities, tremors of the muscles involving the neck, etc.).
Inmate requests for relief from these side effects tend to be viewed as manipulative and drug
seeking with the consequence that medication side effects are not treated or are undertreated. As a result, seriously mentally ill inmates suffer needlessly with such conditions.
Of almost equal importance is the failure of the formulary to contain newer types of
antidepressant medications known as the selective serotonin reuptake inhibitors (SSRIs), so
named for their chemical mechanism of action. Older antidepressants (tricyclics) are
available on the formulary. However, the tricyclic antidepressants are potentially fatal in
overdose; the SSRIs are not. In a system which does not routinely observe or monitor
inmates for medication ingestion, utilization of medications which are potentially fatal in
overdose rather than the safer, readily available alternative medications is extremely risky
and a professionally dubious practice.
Review of the CMS Alabama Psychotropic Report (April 2000) indicated the

487 male inmates are prescribed antidepressant medications.


Of the 487 male inmates prescribed antidepressant, only 98 (20%) are prescribed SSRIs.
Many inmates with a documented history of response to treatment with an SSRI in

the free world are often immediately discontinued from that medication upon reception at an
Alabama prison. This increases the likelihood of a depressive relapse, which not only
causes needless pain and suffering, but also elevates the risk of suicide - with the
mechanism (antidepressant overdose) placed into the hands of the depressed inmate.
* Medication Administration Practices
Medication administration, or “pill call,” is not in accordance with accepted
professional standards and is dangerous to the health and safety of the inmates. Medication
administration is the act in which a single dose of an identified drug is given to the proper

inmate. It requires the same nurse to provide the right dose of the right medication to the
right inmate at the right time. A record is to be made of this transaction on the medication
administration record (MAR) by the nurse who has prepared and delivered the medication
contemporaneously with its dispensing.
The ADOC nursing practices observed by the experts violated every aspect of proper
medication administration. Medications are prepared by one nurse and placed into small
envelopes for delivery to inmates in segregation. A different nurse takes the envelopes to
segregation. He/she does not check inmate identity by requesting to see his identification

He/she cannot truly verify that the medications in the envelope are in fact the

medications that the psychiatrist prescribed.
Medications are poured from the envelope into the inmate’s outstretched hand.
Inmates are not observed to take their medication – the nurse moves on to the next
outstretched hand.

Documentation of the delivery of medication is not made

contemporaneously with pill call. In fact, it is sometimes done by yet a third nurse on a
different shift. The end result of these practices is a system in which there can be no
confirmation that a given inmate received the appropriately ordered medication at the proper
time. This could have harmful, even life threatening, consequences: a given inmate could
receive too much medication, too little medication or even the wrong medication and
something to which he is allergic or interacts negatively with another medication he is
prescribed. We heard frequent complaints from inmates about actually receiving the wrong
* Monitoring Response to Medications and Lab Testing
Anyone receiving prescription medication must be assessed by the prescribing
psychiatrist on a regular basis to determine the effectiveness or lack thereof and potential
side effects. There are numerous instances throughout the Alabama prison system in which
psychiatrists prescribe medications for periods of up to three months without any face-toface contact with the recipient. The nursing staff are medical/surgical type nurses and do not

document inmate response to prescribed psychotropic medications.
In addition, there are several psychotropic medications which require periodic blood
level monitoring and laboratory studies to check on liver, kidney and thyroid functioning to
ensure the medications are not causing damage to those organs. Blood work is not routinely
ordered on ADOC inmates. Serum levels are not checked to ensure the inmate is receiving
an appropriate dosage of medication. Subsequently, behaviors are attributed as being willful
or manipulative rather than understood as symptomatic of untreated or improperly treated
mental illness.
One example of this type of problem would be an inmate prescribed lithium to treat
bipolar or manic-depressive disorder. The therapeutic window for a serum lithium level is
well established. Lithium controls mania if prescribed in the proper manner. A level which
is too low will not treat mania.

Inmates may be loud, irritable and aggressive as

symptomatic of manic depressive illness.

These types of behavior are considered

disciplinary infractions and inmates are written up and sent to segregation rather than treated
appropriately for mental illness.
Failure to appropriately monitor serum levels of lithium can lead to toxic levels
causing coma, kidney failure and death. Failure to periodically test the blood to ensure that
other prescribed medications are not having an adverse effect on thyroid, liver, kidney and
bone marrow functioning can lead to permanent damage to those organs, and in some
instances, death.
There are numerous examples of delays of up to several weeks duration between the
time a medication is ordered for an inmate and when it is actually available for
administration. In his deposition, Dr. Murbach conceded delays but not of this extended
duration. Inmates are made to suffer untreated mental illness needlessly and are at risk for
violent behavior directed at themselves and others during these delays. The problems
associated with such delay are enhanced by the failure to medically reassess the patient’s


needs in light of the delay.
The ADOC mental health records reveal instances in which inmates experiencing
psychiatric difficulties are prescribed psychotropic medication by a psychiatrist in a remote
location who has never seen the inmate. A nurse, with no experience or training in the signs
or symptoms of mental illness, relays the information on which the psychiatrist bases his
prescription decision. There is no documentation as to the effectiveness of the prescribed
medication, and no planned follow-up.
The consequences of failing to provide medication or to monitor its effectiveness
leads to needless suffering and subsequent worsening of symptoms. For example, inmates
who attempt suicide are often given disciplinary write-ups for possession of contraband or
destruction of property if they use some object from their cell to inflict self-injury or tear a
bed sheet to construct a noose. Initially, they are stripped of all clothing and placed on a
watch status in a cell with only a rubber mat on the floor in place of a bed. They are
maintained in this setting until they deny feeling suicidal in order to earn back their
property. (It is ironic that in a system where mental health staff are quick to label behavior
and reports of symptoms as “manipulative” and malingering, there also are simultaneous
demands to “fake being good” in order to be permitted clothing and a mattress.) Finally, the
inmate may be punished by being placed in segregation for the disciplinaries they received
while the symptoms of their illness remain untreated and access to care is further
compromised by placement in segregation.
There are several additional prescribing practices that fall significantly below the
accepted standard of care that are worthy of note. The over-utilization of long-acting
injectable medications absent informed consent and without benefit of an involuntary
medication hearing has already been mentioned. There were other cases found in a
randomly studied sample of inmates wherein inmates with well-established diagnoses of
serious mental illnesses such as schizophrenia were tapered off antipsychotic medication
completely without planned follow-up. They experienced a recurrence of psychotic


symptoms including auditory hallucinations, paranoid delusions and disorganized thinking
which is then either not discovered until correctional staff refer the inmate to mental health
care, discounted by mental health staff as being false, or re-treated with a medication that
now takes weeks to have an effect. That schizophrenia is a life-long psychiatric illness
characterized by exacerbations and remissions is well established in the psychiatric
literature. Inmates with these disorders require life-long, uninterrupted treatment. Thus, the
total absence of treatment is not an option, although mental health professionals may well
have reasonable disagreements as to the precise nature of that treatment.
Medications commonly prescribed in other correctional settings and the free world
for the treatment of bipolar disorder, aggression and impulsivity are seriously under-utilized
in the Alabama system. These medications include lithium, Depakote, and Tegretol -medications that require baseline and periodic laboratory testing. As noted previously,
improperly treated mania (irritability, hyperactivity, insomnia) and impulsivity lead not only
to inmate psychological suffering, but also lead to behavior that leads to rule infractions and
subsequent placement into segregation settings -- making it even more difficult for inmates
to access mental health care.
Medications to which an inmate has had a good response in the past are often
automatically discontinued if they are not on the Alabama formulary when the inmate is
received into the system. A medication of the same general class (such as Prolixin instead
of Risperdal in the general class of antipsychotic medication) is typically prescribed. The
inmate is likely to experience an exacerbation of his illness when his medication is changed,
leading to needless suffering and deterioration. We observed instances of inmates who had
been psychiatrically stable prior to admission but relapsed when their medication was
discontinued and replaced by a medication of lower efficacy for them. They experienced
recurrent depression and had to be placed on suicide watch status to prevent the likelihood
of serious self-inflicted harm. If the inmate continues to request his previously prescribed
medication and offers his consent to have previous treatment records forwarded to mental
health staff, his actions may be viewed as manipulative. Little effort appears expended by


the Alabama system in securing outside treatment records.
In sum, the ADOC’s medication policies lead to needless pain and suffering, and
pose a substantial risk of serious harm and even death.
Inmates With Serious Mental Illnesses Confined to Segregation
In some of the prisons reviewed, we found a very high proportion of inmates with
serious mental illness confined to segregation. Some inmates in segregation appeared to be
experiencing even more acute episodes of serious mental illness than their counterparts in
the mental health treatment units. (ADOC’s Administrative Regulation #433, issued
January 10, 2000, indicates that placement of inmates with acute mental illness in
administrative segregation is authorized).
Despite the fact that the mental condition of inmates segregation were often worse than
those on the mental health units, they had even fewer contacts with mental health treatment
staff, were assessed even less frequently by the psychiatrist, and received only psychotropic
medication and intensive correctional supervision. When the psychiatrist is available to
segregation inmates, interviews are conducted at the open cell front where there is no
confidentiality from other inmates or in an open correctional office where there is no privacy
from correctional staff. Some inmates reported being confined to segregation as a result of
behavior flowing from untreated mental illness. Confinement in segregation often greatly
exacerbates an inmate’s mental illness, and tragically results in needless pain, suffering, and
The Mental Health Medical Records Are Inadequate, Inaccurate, and Unprofessional
The medical records maintained for mental health inmates are inadequate,
inaccurate, incomplete, and unprofessionally maintained. There is no standardized mental
health evaluation or assessment. Inmate diagnoses are not readily available in most records.
When the record’s “problem list” acknowledges an inmate’s mental illness, it is listed as


“MENTAL,” with no diagnosis or symptom description for other health care staff to
reference. There is no documented evidence of attempts to secure past treatment records
and many of the inmates provided confirmation that they were not asked to sign a release of
There is no attempt to incorporate historical information into inmate management. For
example, inmates who have had a previous positive response to treatment of paranoia with a
given antipsychotic medication at a particular dosage are tapered and then weaned off the
medication. When they experience an exacerbation of their paranoia, it takes weeks for them
to come to the attention of mental health staff, generally after the inmate has been returned
to segregation as a result of a rule infraction. When the inmate is finally granted a
psychiatric assessment, oftentimes a different medication is prescribed or the dosage is so
low as to be ineffective thus prolonging the course of their illnesses.
Psychiatric progress notes fall significantly below the professional standard of care. The
notes are frequently completely illegible – often to the author of the notes, much less other
mental health and health care staff. Progress notes are not reflective of the inmate’s
condition or symptoms, often stating only vague generalizations (“same,” “stable,”
“unchanged”) which essentially provide no information to other staff. Dr. Sander’s notes,
for example, often consist merely of a date and his initials, reflecting only that the inmate
had been seen. The rationale underlying psychotropic medication prescription choice is
almost never elaborated upon and frequently there is no apparent concordance between the
doctor’s conclusion: “manipulative” or “malingering” and the choice of medication; an
antipsychotic, generally prescribed for bona fide mental illness.
Some psychiatric progress notes include derogatory and negative remarks about an
inmate, rather than focusing on his illness. For example, inmates are called “losers” and
“bull shitters”. Orders for psychotropic medications are sometimes properly written on the
physician order sheet, other times in the progress notes themselves, further complicating any
medical or mental health care provider’s ability to ascertain a comprehensive knowledge of


medications prescribed, start dates, stop dates, medical and psychiatric conditions.
ADOC psychologists and psychological associates provide services to inmates with
serious mental illness but their interventions are not reflected in the medical record since
they are no longer permitted to document in the medical record. ADOC mental health staff
document their work in the inmate’s Institutional Files (which are totally separate from the
medical files) or in personally maintained files which cannot be readily accessed by other

Further, the practice of documenting mental health information in the

institutional files represents a violation of inmate confidentiality.
The consequences of inaccurate and incomplete record keeping are devastating for even
basic continuity of care. Inmates with serious mental illness who are receiving mental
health care and psychotropic medications at one institution and are then transferred to
another, fall through the cracks. Health care staff at the receiving institution cannot readily
ascertain diagnosis, current psychiatric condition, scheduled follow-up time, or even a
comprehensive listing of prescribed medications necessary to continue treatment. The end
result is that treatment is delayed or withheld altogether, causing inmates to unnecessarily
As we stated at the outset, it is our opinion that the ADOC system for providing mental
health care is grossly inadequate and riddled with systemic deficiencies. Pockets of
acceptability cannot alone lift this system to the level of minimal acceptability. In practical
effect, there is no hospital level care available to inmates with serious mental illness, given
our judgment about Kilby’s inadequacy. Even at Bullock, inmates with mental illness are
assigned bed/treatment space on the basis of bed availability and not clinical judgment. The
entire system’s clinical staff is hopelessly thin and often under-qualified. The correctional
staff assigned to mental health is also inadequate and untrained about mental illness.
Every type of what goes by the name “treatment” or “treatment unit” is seriously

deficient in some critical aspect. Rounds that are designed to assess inmates and provide
inmates with access are rapid “drive-throughs.” Brief encounters at the cell or in a “pill
line” are termed “psychotherapy.” Inmates with serious mental illness are locked-down
under primitive conditions, and, if thought suicidal, stripped and made to sleep on the floor
on a thin plastic mat. Medications are distributed in an unprofessional and dangerous
fashion. Psychotropic medications are administered without prior consent and the policy
and procedures for the forcible administration of medications are not followed.
The “treatment plans” that exist do not meet the most basic requirements for such plans and
the medical records as a whole are professionally unacceptable.
The ADOC’s system for providing care to the seriously mentally ill requires
substantial change if it is to become even minimally adequate. We have observed many
inmates with mental illness greatly suffering needless pain and offer this report in the
hopes that it can assist the court to fashion a solution that will ameliorate this suffering.