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Cripa King County Wa Investigation Findings 11-13-07

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U.S. Department of Justice
Civil Rights Division

Assistant Attorney General
950 Pennsylvania Avenue, NW - RFK
Washington, DC 20530

November 13, 2007

The Honorable Ron Sims
King County Executive
701 Fifth Ave. Suite 3210
Seattle, WA 98104
Re: 	 King County Correctional Facility,

Seattle, Washington 

Dear Executive Sims:
I write to report the findings of the Civil Rights
Division’s investigation of conditions at the King County
Correctional Facility (“KCCF”).1 On October 30, 2006, we
notified you of our intent to conduct an investigation of KCCF
pursuant to the Civil Rights of Institutionalized Persons Act
(“CRIPA”), 42 U.S.C. § 1997. As we noted, CRIPA gives the
Department of Justice authority to seek a remedy for a pattern or
practice of conduct that violates the constitutional rights of
inmates in adult detention and correctional facilities.
On March 6-8, 2007 and August 1-2, 2007, we conducted onsite inspections at KCCF with expert consultants in corrections
and custodial sexual misconduct, medical care and contagious
disease prevention and treatment, and suicide prevention. We
interviewed security staff, medical staff, administrative staff,
and inmates. Before, during, and after our visits, we reviewed
an extensive number of documents, including policies and
procedures, incident reports, investigative reports, grievances
from inmates, staff personnel files, unit logs, orientation
materials, and staff training materials. In keeping with our
pledge of transparency and to provide technical assistance where
appropriate, we conveyed our preliminary findings to King County
officials at the close of each of our on-site visits.


The King County Correctional Facility, also referred to
as the King County Jail, is located at 500 5th Avenue, Seattle,

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During our August 2, 2007 exit meeting, and by letter on
August 8, 2007, we notified King County officials of lifethreatening deficiencies in medical care for certain inmates at
KCCF. In particular, we indicated that certain inmates were
being deprived of urgent medical attention. On August 10, 2007,
the County responded by indicating that a number of corrective
measures were being implemented to address our concerns.
We commend the staff at KCCF for their helpful and
professional conduct throughout the course of the investigation.
We received complete cooperation with our investigation and
appreciate the County’s receptiveness to our consultants’ on-site
recommendations. It is particularly noteworthy that King County
provided us with unfettered access to records and personnel, and
responded to all of our requests in a transparent and forthcoming
manner. We have every reason to believe that the County is
committed to remedying all known deficiencies at KCCF.
Consistent with the statutory requirements of CRIPA, we now
write to advise you of the findings of our investigation, the
facts supporting them, and the minimum remedial steps that are
necessary to address the deficiencies we have identified.
42 § U.S.C. 1997b. As described more fully below, we conclude
that certain conditions at KCCF violate the constitutional rights
of inmates. In particular, we find that inmates confined at KCCF
are not adequately protected from harm, including physical harm
and custodial sexual misconduct. In addition, we find that
inmates are not adequately protected from self harm. Finally, we
find that inmates do not receive adequate medical care.


KCCF serves King County, including inmates from the City of
Seattle. The facility houses both pre-trial inmates and inmates
serving sentences of up to one year. The facility opened in 1986
and has a capacity of 1,700. The average daily population for
January 2007 was 1,368, with a high count of 1,443 and a low
count of 1,298. KCCF is currently undergoing rolling
renovations, with one floor closed at a time. Security functions
at KCCF are administered by the King County Department of Adult
and Juvenile Detention (“DAJD”). Health care services at KCCF
are provided by Jail Health Services (“JHS”), a division of
Public Health Seattle-King County, the County’s public health

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CRIPA gives the Attorney General authority to seek
injunctive relief when a jurisdiction violates the constitutional
rights of inmates. See 42 U.S.C. § 1997; U.S. Const. amend.
VIII, XIV. In defining the scope of jail inmates’ Eighth and
Fourteenth Amendment rights, the Supreme Court has held that
corrections officials must take reasonable steps to guarantee
inmates’ safety and provide “humane conditions” of confinement.
Farmer v. Brennan, 511 U.S. 825, 832 (1994); Bell v. Wolfish, 441
U.S. 520 (1979) (holding pre-trial detainees protected by
Fourteenth Amendment); Hydrick v. Hunter, — F.3d —, 2007 WL
2445998 (9th Cir. 2007) (stating right to reasonably safe
conditions clearly established for prisoners and civilly
committed persons); Hoptowit v. Ray, 682 F.2d 1237, 1250 (9th
Cir. 1982). Providing “humane conditions” requires that a
corrections system must satisfy inmates’ basic needs, such as
their need for safety, medical care, food, clothing, and shelter.
Id. Additionally, jail officials have a duty to take reasonable
steps to protect inmates from physical abuse and the use of
excessive force. See Hydrick, 2007 WL 2445998, at *15; Hoptowit,
682 F.2d at 1250.
The duty to protect inmates from physical abuse includes
protecting inmates from custodial sexual abuse. Schwenk v.
Hartford, 204 F.3d 1187, 1197-98 (9th Cir. 2000) (the Eighth
Amendment right of prisoners to be free from sexual abuse has
been unquestionably and clearly established.). “‘Rape, coerced
sodomy, unsolicited touching of women prisoners’ vaginas, breasts
and buttocks by prison employees are simply not part of the
penalty that criminal offenders pay for their offenses against
society.’” Schwenk, 204 F.3d, at 1197, quoting Women Prisoners
of the Dist. of Columbia Dept. of Corrections, 877 F. Supp. 634,
665 (D.D.C. 1994).
The federal courts have also held that the right to “humane
conditions” includes a right to adequate medical care. Hoptowit
at 1255 (citing Estelle v. Gamble, 429 U.S. 97, 104 (1976)
(quoting Gregg v. Georgia, 428 U.S. 153, 182-83 (1976)). Under
the Supreme Court’s standard for relief, a jurisdiction fails to
meet constitutional requirements if local officials exhibit
“deliberate indifference” to inmates’ serious medical needs. The
standard for relief has three components: (1) subjective
knowledge of the risk of serious harm; (2) disregard of that
risk; and (3) conduct that is more than mere negligence. Farmer,
511 U.S. at 834. The Supreme Court has said that “prison
officials show deliberate indifference to serious medical needs
if prisoners are unable to make their medical problems known to

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the medical staff.” Estelle, 429 U.S. at 103-04. The Ninth
Circuit has stated that deliberate indifference may appear “when
prison officials deny, delay, or intentionally interfere with
medical treatment, or it may be shown by the way in which prison
physicians provide medical care. Jett v. Penner, 439 F.3d 1091,
1096 (9th Cir. 2006). Moreover, the Ninth Circuit has explained
that the “medical staff must be competent to deal with prisoners’
problems.” Gibson v. County of Washoe, 290 F.3d 1175, 1187 (9th
Cir. 2002), (quoting Hoptowit, 682 F.2d at 1252-55) (internal
quotation marks omitted). The prison must provide “adequate
facilities and staff to handle emergencies within the prison.”
Corrections officials may be constitutionally liable when
they “know or should know of a particular vulnerability [of an
inmate],” such as an inmate in severe emotional distress, and
fail to protect the inmate from that vulnerability. Redman v.
County of San Diego, 942 F.2d 1435, 1443 (9th Cir. 1991) (citing
Colburn v. Upper Darby Township, 838 F.2d 663, 669 (9th Cir.
1988). The prison must provide “adequate facilities and staff to
handle emergencies within the prison.” Hoptowit, 682 F.2d at
1252-55. Further, these requirements apply to mental health
care. Id. Delay in providing hospitalization to a prisoner in
need of immediate psychiatric care constitutes deliberate
indifference. Gibson v. County of Washoe, Nev., 290 F.3d 1175,
1190-91 (9th Cir. 2002), cert. denied, 537 U.S. 1106. Finally,
prison officials have an obligation to act when there is a strong
likelihood that an inmate will engage in self-injurious behavior,
including suicide. See Funtanilla v. Rubles, 5 Fed. Appx. 590
(9th Cir. 2001).


We find that KCCF fails to adequately protect inmates from
harm and serious risk of harm by staff, fails to adequately
protect inmates from self harm, and fails to provide inmates with
adequate medical care.


Corrections officials must take reasonable steps to
guarantee inmates’ safety and provide “humane conditions” of
confinement. Providing “humane conditions” requires that a
corrections system must satisfy inmates’ basic needs, such as
their need for safety. Additionally, jail officials have a duty
to take reasonable steps to protect inmates from physical abuse.

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To ensure reasonably safe conditions, officials must take
measures to prevent the use of unnecessary and inappropriate
force by staff. In addition, officials must provide adequate
systems to investigate staff misconduct, including alleged
physical and sexual abuse of inmates. For the reasons set forth
below, KCCF fails in both these regards.

Unnecessary and Inappropriate Uses of Force

A determination of whether force is used appropriately
requires an evaluation of the need for the use of force, the
relationship between that need and the amount of forced used, the
seriousness of the threat reasonably believed to exist, and
efforts made to temper the severity of a forceful response.
Hudson v. McMillian, 503 U.S. 1, 7 (1992). Generally accepted
corrections practices provide that appropriate uses of force in a
given circumstance should include a continuum of interventions,
and the amount of force used should not be disproportionate to
the threat posed by the inmate. Lesser forms of intervention,
such as issuing disciplinary infractions or passive escorts,
should be used or considered prior to more serious and forceful
Inmates at KCCF are routinely subjected to unnecessary uses
of serious force. Staff at KCCF are quick to resort to serious
physical force or pepper spray, even when the inmate is passive
or poses no immediate security threat. In addition, inmates are
pepper sprayed often, despite being confined in mechanical
restraints, making the use of pepper spray unnecessary. Also,
staff use pepper spray on inmates even when several staff are
present and could gain control of the inmate using far less
severe methods. Further, there is little evidence that staff
employ a continuum of interventions when faced with a resistant
We also found the frequent and routine use of a technique
known as the “hair-hold technique.” Specifically, the hair-hold
technique, involves grabbing and pulling the inmate’s hair in
order to direct the inmate’s movement, or otherwise obtain
compliance. According to our corrections consultant, the hairhold technique is a highly painful and degrading technique that
carries a high risk of injury when compared to equally effective
control techniques commonly taught in self-defense training
courses at correctional academies. It is an especially dangerous
tactic when utilized as a takedown technique on a

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The following examples of unnecessary and inappropriate uses
of force are taken from KCCF’s incident reports:

On January 23, 2007, a restrained female inmate in the
Intake Release Unit (“ITR”) was “angry and uncooperative as
soon as she arrived at the facility.” Staff used hair-hold
and counter joint techniques “to restrain her against the
counter” although nothing in the use of force report
provided justification for use of the hair-hold technique.
Thereafter, staff applied pepper spray on the inmate while
she was in a fetal position and posing no threat to the
staff. Accordingly, the use of force in this incident was
both excessive and unnecessary.


On January 10, 2007, a female inmate in the ITR was being
“verbally abusive,” threw her clothes on the floor, and then
picked them up and threw them at staff. Staff grabbed her
by the hair and “spun” her to the floor, at which time the
inmate sustained a head injury (bleeding ear). The hairhold technique was excessive and disproportionate to the
nature of the threat posed by the inmate.


On October 16, 2006, a female inmate in the ITR who was to
be housed on the psychiatric floor for suicidal statements
refused to “pick up her underwear and put them in a bag.”
Security staff applied a hair-hold on the inmate in order to
gain compliance. The hair-hold technique was an extreme and
unnecessary use of force given the nature of the inmate


On September 11, 2006, a female inmate showing signs of
mental distress was being escorted to the mental health unit
on the seventh floor. She was placed in a wheelchair with
both waist and leg restraints. As she was wheeled from the
elevator to seven North, she “continued to yell, scream, and
tried to stand up out of the wheelchair.” Staff used hairholds “to keep her in her wheelchair until [they] got to
seven North.” The use of the hair-hold technique against an
inmate in arm and leg mechanical restraints is inexplicable.


On September 9, 2006, an inmate who is developmentally
disabled was observed having a seizure on the seventh floor.
When staff arrived, the inmate appeared “disoriented.” He
was moved to a cell for psychiatric care. The inmate was in
an “agitated” state when he was subjected to pepper foam,
which had “little or no effect.” He was then re-handcuffed

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with a hobble cord. There is no explanation for why pepper
spray was justified against a disabled inmate who was in
medical and mental distress.
Effective measures to prevent excessive and inappropriate
uses of force include adequate staff training, and adequate use
of force policies and procedures. KCCF fails to provide adequate
use of force training for staff and relies upon inadequate and
outdated policies and procedures.

Inadequate Staff Training

Comprehensive annual staff training in appropriate use of
force techniques is an essential element of a jail’s required
in-service training. However, training personnel at KCCF
conceded that there is currently no in-service training of staff
in use of defensive tactics. In addition, as described below,
the remainder of the use of force curriculum is inadequate. This
lack of training contributes to the prevalence of inappropriate
uses of force at KCCF, and creates a significant danger of
inmates being unnecessarily subjected to serious bodily harm and
even death.

Inadequate Policies and Procedures

Adequate policies and procedures regarding proper use of
force are essential to ensuring that inmates are not
unnecessarily injured by security staff. The policies should be
comprehensive and clear, and should reflect currently accepted
practices. KCCF’s policies and procedures are lacking on all
three counts.
As of the time of our March 2007 corrections tour, KCCF was
operating with outdated use of force policies and procedures.
The basic policy is undated and contains numerous handwritten
interlineations. Moreover, it includes unauthorized control
tactics such as the choke hold and carotid sleeper hold; however,
both of these control holds have handwritten annotations
prohibiting their use. The policy is devoid of guidance on the
use of chemical agents such as pepper spray, which is routinely
used by security staff at the facility. The policy contains no
guidance on the use of non-lethal weaponry on restrained inmates.
Further, the policy contains no guidance or reference to a
continuum of force or interventions.
We were provided with a copy of a single-page chart entitled
“Use of Force Continuum” that simply lists response tactics
equated with resistance levels. The continuum contains responses

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that are either no longer authorized or may be unlawful. In a
stark departure from generally accepted corrections practice, the
continuum authorizes “lethal force” as a response to “active
aggravated aggressive” but fails to define “active aggravated
aggressive.” This lack of definition causes a serious danger
that lethal force may be used without adequate justification.
Moreover, we reviewed a document that classified two incidents as
an “aggravated aggressive,” where neither of the presented
circumstances would have justified the use of lethal force.

Inadequate Systems to Investigate Staff Misconduct
(Physical and Sexual Abuse)

The number and nature of allegations involving custodial
sexual misconduct at KCCF are generating an abnormally high
number of Internal Investigations Unit (“IIU”) investigations. A
review of IIU’s report on “Internal Investigations 2006-Current”
indicates in excess of twenty-five investigations related to
allegations of staff misconduct of a sexual nature. A number of
these investigations remain open, while others have been closed
with “undetermined” or “non-sustained” findings and “no
discipline due to timeliness.” However, sustained investigations
or incidents resulting in suspensions, terminations, and criminal
charges since at least 2002 reflect a pattern of sex-related
staff misconduct by an alarming number of security staff.2
To ensure reasonably safe conditions for inmates,
correctional facilities must develop and maintain adequate
systems to investigate staff misconduct, including alleged
physical and sexual abuse by staff. Essential elements of an
internal investigation system includes a comprehensive
investigation procedures manual, and adequately trained
investigators to implement the investigations process. KCCF is
lacking in both of these essential elements.

Lack of Investigative Policies and Procedures

Generally accepted correctional practices require clear and
comprehensive policies and procedures governing the investigation
of staff use of force and misconduct. Adequate policies and
procedures include, at a minimum, screening of all use of force

Three former KCCF staff have recently been convicted of
crimes relating to custodial sexual misconduct, including Harland
Richmond (second-degree sexual misconduct), Cedric McGrew
(second-degree custodial sexual misconduct and third-degree
assault), and Louis G. Laurencio (custodial sexual misconduct).

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incident reports, specific criteria for initiating investigations
based upon the incident report screening, specific criteria for
initiating investigations based upon allegations from any source,
timelines for the completion of internal investigations, and an
organized structure and format for recording and maintaining
information in the investigatory file.
As of the time of our March 2007 corrections tour, KCCF had
no policy for conducting investigations. The IIU is guided by a
regulation of the General Policy Manual, Section 3.01.000. This
regulation provides only that the IIU “establish methods and
procedures to investigate complaints.” However, there was no
formal investigatory methods and procedures manual.

Lack of Training in Investigatory Techniques
and Procedures

Adequate internal investigation systems require
investigators to receive appropriate training in investigatory
processes, techniques, and procedures. While we found the IIU
staff to be committed and professional, we determined that the
IIU leadership and staff lacked any formalized training
requirement or process. For example, the IIU commander has
substantial experience as a correctional administrator, but lacks
any prior experience, expertise, or training in managing and
conducting internal correctional investigations. Similarly, the
IIU sergeants are not required to complete formal investigative
training prior to or during their assignment to the unit.



As a result of these failures, there are serious operational
deficiencies in KCCF’s internal investigations. Investigations
are inadequate, poorly documented, and often disorganized. For

Case Number 0605-018 - Reported Sexual Assault
The IIU case file indicates that a female inmate purportedly
submitted a four-page grievance to staff alleging that she
was sexually assaulted on October 26, 2005. The inmate also
supplemented the grievance the following day. IIU staff
could not locate either the grievance or the supplement, and
closed the case as non-sustained. There is no evidence that
staff conducted appropriate follow-up or contacted the
inmate to discuss her complaint.

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Case Number 0612-008 - Sexually Explicit Behavior
A KCCF captain was accused of engaging in sexually explicit
behavior while on the job in the presence of another captain
and a female sergeant. The captain has acknowledged that he
did indeed simulate a sexual gesture in the presence of the
two staff. This same captain, on three prior occasions,
between January 2005 and October 2006, has been counseled
for inappropriate workplace behavior. He was promoted to
captain in June 2006 after having been assigned as an IIU
investigator from approximately 2003 through January 2006.
It is noteworthy that this commander/supervisor, who himself
was recently in charge of conducting investigations of staff
sexual misconduct, has been allowed to develop a chronic
record of workplace misconduct while being promoted to
positions of greater authority at KCCF.


Case Number 0610-015 - Excessive Use of Force
On September 23, 2006 a nurse in the ITR believed she had
witnessed excessive force when she observed staff “slamming
[an] inmate’s head on the counter, holding the inmate on the
floor with his knee/foot, and yelling at the inmate.” She
further alleged that the staff’s supervisor took no action
to intervene in the incident. The nurse contacted the ITR
shift commander to report the incident. The commander
advised her to report the matter to the ITR sergeant, who
was the very supervisor the nurse had claimed failed to
intervene in the incident. The shift commander, in a memo
entitled “Preliminary Investigation,” in effect exonerated
both the sergeant and staff based on his general discussion,
rife with his personal opinions, of the difficulty in
dealing with inmates during the intake process. The memo
did not in any fashion address the actual substantive
evidence related to the incident notwithstanding that the
staff acknowledged in his report, among other things, that
during the use of force incident, he held the inmate by the
ear and told him he was going to “rip his ear off.” The IIU
investigator entered a finding of “non-sustained,”
notwithstanding the nurse’s initial detailed observations of
the incident. The investigator did note that a letter of
corrective counseling “may be in order” for the staff’s
threatening remark. However, there was no record of the
staff having received any form of disciplinary action.

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Case Number 0612-005 - Unnecessary Use of Force
An inmate, handcuffed behind his back, was under escort by
two staff when a verbal exchange occurred regarding escort
procedures. The inmate was returned to his cell and was
asked to get on his knees for the handcuffs to be removed.
He refused and was taken to the floor. While the inmate was
handcuffed and on the floor, staff administered two
applications of pepper spray because he was “refusing to
cooperate.” According to a grievance filed by the inmate,
he was “slammed” to the ground while handcuffed, hitting his
head on the “metal side of [his] bed.” He was then
subjected to pepper spray while another staff member held
him by the neck. The investigation concluded that the
allegation of unnecessary force was “unfounded.” Nothing in
the case file indicated an assessment of why it was
necessary to utilize the chemical agent on a handcuffed
inmate who had been taken to the ground with no fewer than
four staff present. In addition, there is no indication
that the involved staff were recommended for remedial or
corrective training in escort procedures and available

In addition, some incidents that merit an investigation are
never investigated. Our review of a sample of incident reports
revealed that none of the following incidents were investigated
by IIU or even questioned by supervisors:

On January 22, 2007, a handcuffed inmate was not cooperative
during an escort. The inmate was “placed” against the wall
and then taken to the floor, at which time security staff
applied pepper spray. Staff then placed his head under the
bunk, ostensibly “to facilitate a safer way to take the
handcuffs off.” The inmate sustained a nose injury, a
swollen cheek, and an eye laceration that required
hospitalization for sutures. The number and nature of the
injuries sustained by a handcuffed inmate clearly merited
some level of investigative inquiry.


On January 1, 2007, an intoxicated inmate was being moved
from a holding cell in the ITR when he “raised a sandal in
the direction of staff.” He was restrained and “pinned”
against the cell wall. Pepper spray was utilized with
“little effect.” The inmate was then handcuffed by
utilizing “wrist locks and hair-holds.” While on the floor
in handcuffs, another burst of pepper spray was
administered. The inmate sustained multiple head
contusions, including an injury to his eye. In reviewing

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the matter, a supervisor commented that staff were unaware
of how the injuries occurred because they “were focused on
getting him processed into clean clothing and did not notice
the facial contusions.” Unexplained multiple head injuries
and the use of a chemical agent on a fully restrained inmate
in the control and presence of a supervisor with no less
than five staff present, merits some level of investigative

An inmate alleged that, on November 7, 2006 in the ITR,
security staff placed his boot on the head and neck of the
inmate. Nursing staff “noted some swelling to the left side
of the face and contusions to the back of the head.” The
incident report failed to explain the injuries. This
incident came to the attention of a supervisor only when
nursing staff notified a sergeant of the allegations and
injuries. Indeed, contrary to generally accepted practices,
the security staff did not promptly report the use of force,
but instead provided a report two days after nursing staff
notified the supervisor.



Corrections officials have the obligation to protect
vulnerable inmates from harm, such as those who are at risk of
suicide. [Number redacted] inmates committed suicide in the past
three years under circumstances that indicate that KCCF fails to
take reasonable measures to prevent and manage these risks. An
adequate suicide prevention program requires that all staff be
adequately trained and be active participants in executing a
comprehensive plan.

Lack of Training in Suicide Prevention Measures

Correctional facilities must provide adequate suicide
prevention training to staff to ensure the safety of all inmates.
Pre-service and annual in-service training requirements should be
clearly set forth in the relevant policy and should include an
array of topics to ensure that staff are able to recognize the
verbal and behavioral signs that indicate a suicide risk, what to
do when such a risk is suspected, and how to respond when there
is a suicide attempt. Successful suicide prevention is a
collaborative process among all staff; however, training is
particularly critical for security staff because they are often
the only staff available 24 hours per day and have regular
contact with inmates. Because KCCF policy fails to specify

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adequate suicide prevention training requirements, and the
facility fails to provide adequate hours of training, suicide
prevention training at KCCF falls far below generally accepted
correctional practices.
First, pre-service and in-service training requirements are
not clearly set forth in DAJD or JHS policies. For example,
during our March 2007 suicide prevention tour, DAJD Policy
7.02.006 (Suicide Prevention and Psychiatric Procedures) required
only that “all staff that have regular contact with inmates shall
be trained in the identification and management of suicidal
inmates . . . officers receive on-line training each year related
to suicide prevention.” JHS Policy (Suicide Prevention Program)
requires “training for staff members who work with inmates.”
These statements are too general to be useful. For example, they
do not state how many hours of pre-service and in-service
training staff are required to complete.
Second, KCCF does not provide significant training hours,
and the training that is provided is cursory at best.
Specifically, training for new staff is limited to three hours
during a four-week training program provided at the Washington
State Training Academy, and only one hour completed during the
11-day New Employee Training Program provided by KCCF. As for
existing staff, training on suicide prevention is even more
limited, consisting of a one-hour computer course of 25
PowerPoint slides and a rudimentary true/false test of ten
questions. The course refers to DAJD’s suicide prevention
policy, but merely advises employees to review it. Monthly
workshops offered by JHS have included topics concerning suicide;
however the workshops are only offered to security staff assigned
to the mental health housing units and participation is not
required by policy.
Four hours of suicide prevention training for new staff and
one hour of annual training for existing staff are grossly
inadequate. Moreover, the one-hour computer course observed by
our consultant does not ensure that staff are adequately trained
on this critical topic. Suicide prevention is a collaborative
process. If all staff are not adequately trained on how to
prevent and manage suicides, they will be unable to identify the
risks and respond appropriately.

Lack of Adequate Supervision of Suicidal Inmates

Correctional facilities must protect inmates from suicide by
providing adequate supervision. When an inmate attempts suicide,
his or her life depends on the time it takes for staff to learn

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of the event and respond to it. The promptness of staff’s
response to a suicide attempt is often driven by the level of
KCCF inmates who have been identified as suicidal and who
are placed on suicide precautions are purportedly observed every
fifteen minutes. However, in addition to the 15-minute
observation usually performed by security staff, suicidal inmates
must also be assessed daily by a mental health professional.
Currently, KCCF mental health staff only assess inmates once per
week, which falls far short of generally accepted correctional
practices. Moreover, each assessment is only five to ten minutes
in length. This is not adequate time to evaluate the inmate’s
status to properly determine whether he or she should remain on
suicide precautions. Thus, mental health staff may overlook an
inmate whose status is in rapid decline. On the other hand, it
is also critical for mental health staff to identify those
inmates who are no longer in need of being on suicide precautions
because the restrictive environment can quickly become antitherapeutic. Five to ten minutes, once per week, is not adequate
to make this determination.


Jail officials are responsible for providing adequate
medical care to inmates. Moreover, a jail may not deny or
intentionally interfere with medical treatment. A delay in
providing medical treatment may be so significant that it amounts
to a denial of treatment. Our investigation revealed that
medical care provided at KCCF falls below the constitutionally
required standards of care. We found the following serious
deficiencies: (1) inadequate assessment of acute conditions;
(2) inadequate treatment of chronic conditions; (3) inadequate
emergency care; (4) inadequate medication management; (5)
inadequate prevention and treatment of communicable diseases,
particularly skin infections and MRSA; and (6) inadequate intake

Inadequate Assessment of Acute Conditions

Jail officials are required to adequately assess inmates so
that jail officials can provide appropriate and timely treatment.
KCCF fails to provide adequate assessments, which has resulted
in serious delays in treatment for inmates who require urgent
medical attention. Delays, and outright denials, can cause
unnecessary pain, suffering, and morbidity in inmates, and can
contribute to the unnecessary transmission of illness.

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The most egregious example of KCCF’s systematic failure to
adequately assess and treat inmates –- and the grave harm that
can result –- is a recent inmate death, which we found was likely
preventable. The inmate had a history of alcohol withdrawal
seizures and active skin infection on his legs and buttocks. The
day he was admitted to the jail, he was sent to the emergency
room at Harborview Medical Center. There, he was diagnosed with
multiple abscesses, profound anemia and either cellulitis (a
potentially serious bacterial infection) or deep vein thrombosis.
Although the hospital arguably should have admitted him, it did
not do so. Upon his return to KCCF, the inmate was not seen by a
physician, even though he should have been. Instead, he was
forced to wait more than 30 hours to receive his first dose of
the antibiotic that had been prescribed for his skin infection.
When the inmate requested care and was finally examined by a KCCF
physician, he had a tender abdomen with questionable bowel
sounds, highly abnormal and unstable vital signs, and a very low
oxygen saturation. Even after observing this, the KCCF physician
failed to send the inmate back to the hospital. Early in the
morning on his third day back at KCCF, the inmate developed
severe abdominal pain, was sweating and doubled over, and had a
tender abdomen. Nonetheless, he was forced to wait for seven
hours before he was examined by a physician, who ultimately sent
him to the hospital. The inmate died at the hospital, apparently
of a perforated gastric ulcer. KCCF’s inadequate diagnosis and
inordinate delays in providing treatment likely contributed to
this inmate’s death.
Under KCCF’s current health care system, inmates who request
or present for medical attention are prioritized by using the
designations P1 through P4. These priority designations are
designed to represent a need for follow-up care within one day,
three days, one week, and four weeks, respectively. Due to
perceived staffing and resource shortages, however, KCCF’s
current practice is to deny follow-up scheduling and treatment to
any inmate classified as P3 or P4. Instead, inmates classified
as P3 or P4 are expected to re-request medical care if their
conditions do not improve in one or three weeks, respectively.3
As we explained in our August 8, 2007 emergency letter regarding
an inmate whom we encountered during our August tour, we found
that misclassification of inmates as a P3 or P4 has had


Medical staff routinely do not record P3 or P4
designations because inmates classified as such are not being
seen. Accordingly, an unknown and undocumented number of
additional inmates have informally been determined to fall under
this category.

- 16 

life-threatening consequences. Specifically, one day prior to
our tour, the inmate presented to a KCCF physician with shortness
of breath and a lump in his neck. The physician classified him
as P3 and sent him back to general population without orders for
referral or any follow-up. However, a physical exam by our
consultants revealed that the inmate required urgent evaluation
at an acute care hospital to rule out the risk of sudden death
from obstruction of his trachea. The physician’s failure to
adequately assess the inmate falls far below generally accepted
standards of correctional health care and placed the inmate’s
life in jeopardy.4
In reviewing the medical records of seven inmates who had
been classified as P3 or P4, we found that six had been
misclassified. The following inmates required prompt medical
attention and should have been designated as P1 or P2 so that
they would receive follow-up care accordingly:

An inmate with a skin infection had been treated with three
failed courses of antibiotics and never received a wound


An inmate on medications for a pituitary tumor had no
evaluation, medication, or lab tests.


An inmate had bladder symptoms related either to a sexually
transmitted infection or acute prostate disease who should
have had an evaluation and treatment but did not receive


An inmate had a sustained tachycardia (elevated heart rate)
for four days. Notably, this inmate had seen nursing staff,
who did not provide for immediate access to a physician. By
the time a physician finally examined the inmate, the
inmate’s medical problems had exacerbated significantly, and
he was complaining of serious urinary symptoms. Rather than
working him up to finding a diagnosis, the physician coded
the inmate for no further follow-up. These symptoms could
indicate a potentially life-threatening condition, such as
alcohol withdrawal or shock, and should not have been


By letter dated August 10, 2007, the County responded
to our emergency letter and stated that it was “taking immediate
steps” to address the deficiencies we identified.

- 17 

2. 	 Inadequate Treatment of Chronic Conditions
KCCF fails to provide adequate treatment to inmates with
chronic conditions or diseases that require monitoring and
follow-up medical care. This failure places inmates who are
already physically and/or mentally ill at risk of even greater
suffering and harm.
Specifically, in examining a sampling of medical records of
inmates who have chronic conditions and/or are on certain
medications, we found the following serious deficiencies:

We reviewed the records of 20 inmates who were on lithium,
Dilantin, or valproic acid. (The first is commonly used in
the treatment of bipolar disorder and the latter two are
anti-seizure medications.) These three medications have
very narrow therapeutic indexes; if an inmate is given too
little, the medication will be ineffective, but if the
inmate is given too much, he or she will experience
substantial detrimental effects. It is absolutely critical
that patients’ blood levels are monitored to ensure that
there are appropriate levels of the medication.
Accordingly, laboratory measurement of the levels of these
medications in a patient’s blood is a nationally accepted
standard of care. Only six of the twenty inmates whose
records we reviewed had their levels checked and documented
in the record. Some of the records contained no orders for
such checks, and others contained orders that nurses had
failed to pick up.


Similarly, we reviewed the records of the six inmates at the
facility who are on coumadin, a blood-thinner prescribed for
those at high risk for a blood clot and for some heart
conditions. Like the medications discussed above, coumadin
has a very narrow therapeutic index. Accordingly, frequent
measurement of the blood-clotting ability of inmates taking
it is critical. We found that one of the inmates on
coumadin was not being monitored appropriately, putting him
at risk for a potentially life-threatening blood clot or a


We reviewed the records of nine inmates on antipsychotic
medications. Inmates on antipsychotic medications should
have documented screening for abnormal involuntary movements
and for metabolic syndrome, a forerunner to diabetes. Not
one of the files contained documentation indicating that the
inmates had been screened for either of these potentially
dangerous side effects.

- 18 


In reviewing the records of nine diabetic inmates who had
been at KCCF for more than a month, we looked for seven
nationally accepted interventions.5 There is substantial
evidence that selective interventions with diabetics will
prevent organ failure such as blindness, stroke, heart
disease, kidney disease, and peripheral vascular disease.
Review of the inmates’ files revealed that KCCF does not
adequately monitor these inmates through chronic care visits
or consistently screen them for the conditions that they are
at risk of developing.6


We reviewed the treatment of 14 inmates with moderate or
severe asthma, as determined by their medications. Chronic
follow-up care and regular monitoring of peak expiratory
flow (a test that measures how well the airways are working)
are critical in the proper care of asthmatics. Only five
had been seen for chronic care within the past three months
and only three had any measurement of their peak expiratory
3. 	 Inadequate Emergency Care

KCCF fails to provide adequate emergency care to inmates,
putting them at risk of grave harm. We observed a lifethreatening example of this during our first tour, when we
encountered a female inmate who was known by KCCF staff to be
depressed and suicidal. While we were on her housing unit, the
inmate swallowed multiple medications. Disturbingly, despite the
unfolding emergency, security staff did not call for medical help
for a crucial eight minutes after the inmate had swallowed the
medications. A nurse did not arrive at the housing unit with the
crash cart for a total of 15 minutes after the incident. And, it
took a total of 25 minutes for EMS to arrive. Further
compounding this situation, this suicidal inmate did not speak


These interventions are: measurement of sugar levels
upon intake, measurement of urinary microalbumin, dilated
examination of the retina, cholesterol measurement, measurement
of A1c hemoglobin, chronic care visit with physician, and aspirin

For example, not one of the inmates had had a
measurement of his or her urinary microalbumin or a dilated
examination of the retina. Only one had had a cholesterol
measurement, only two had had their A1c hemoglobin measured, only
three had had a chronic care visit at all, and only four were on

- 19 

English. The mental health staff who prescribed medication for
her had done so without the use of a translator, even though one
was reportedly available by telephone.7
In observing this incident, we learned of some unwritten
“policies” that, according to security staff, must be followed
before a medical nurse may respond to an emergency call. First,
a psychiatric nurse must evaluate the inmate, even if the inmate
is experiencing clearly life-threatening physical symptoms, like
crushing chest pain or hemorrhaging. Second, the page system
must be used, even if it would be much faster to summon the nurse
from an adjacent medical office or housing unit. These
“policies” favor process over provision of critical care of
inmates whose lives are at risk.
Moreover, although correctional facilities typically keep
logs of inmates they send to hospital emergency rooms, KCCF lacks
such logs, making it difficult to ascertain the full extent of
the KCCF’s deficiencies in this area. We were able to review
care for 11 inmates who were sent to the emergency room, however,
and found that one of them was forced to wait two days to see
KCCF’s in-house physician for an infection before finally
receiving treatment in the emergency room. This inmate’s trip to
the emergency room may have been prevented altogether if KCCF had
provided the inmate with timely care.

Inadequate Medication Administration and Management

We found numerous systematic problems with medication
administration and management. KCCF places inmates at risk of
grave harm through significant delays and lapses in providing
critical medications to inmates and the practice of giving nurses
“standing orders” to administer antibiotics for skin infections.
First, orders for diagnostic tests and medications are
picked up by nursing staff on an inconsistent basis. The failure
to perform this important task regularly results in significant
delays and lapses in providing critical medications to inmates.
For example:

An HIV-positive inmate who had an abscess was forced to wait
26 days for his first dose of antibiotics and medications
for HIV.


Since our first tour, DAJD and JHS staff have made
increasing use of telephonic translation services.

- 20 


An inmate was admitted to the
medication for drug-resistant
at KCCF, he received only one
putting him at risk of a more
drug resistance.

jail on linezolid, a
staph skin infections. Once
of his six prescribed doses,
serious infection and further


An inmate had a persistent skin infection because of a
ten-day lag between the day he was prescribed an antibiotic
and the day he received his first dose.


An inmate who arrived at intake with infectious skin lesions
did not get the necessary antibiotic treatment until his
fourth day at KCCF, by which time he had developed
cellulitis. (Cellulitis is potentially serious bacterial
infection, which left untreated, may turn into a lifethreatening condition.)

Moreover, KCCF nurses have standing orders to administer
antibiotics to inmates with skin infections. Standing orders for
prescription drugs are beyond the scope of nurses’ licenses. The
only acceptable standing orders are for over-the-counter
medications, vaccines, standard treatment for
sexually-transmitted infections, and emergency medications.
KCCF’s standing orders for antibiotics puts inmates at risk of

Inadequate Prevention and Treatment of Communicable

Prevention and treatment of communicable diseases is
particularly critical in places where individuals live in
confined quarters, such as jails. Skin infections among inmates,
including methicillin-resistant staphylococcus aureus (“MRSA”), a
potentially dangerous drug-resistant bacteria that can cause
serious systemic illness, permanent disfigurement, and death, is
rising across the United States. Transmission among inmates and
staff can be prevented through attention to laundry and personal
hygiene, as well as environmental cleaning. We found serious
deficiencies in these critical areas at KCCF. Moreover, we found
that KCCF fails to provide adequate treatment for inmates with
skin infections, which places the infected inmate, other inmates,
and staff, all at risk of harm.
To prevent the transmission of infection, jails must ensure
that inmates are able to maintain proper hygiene and that
inmates’ living quarters are kept reasonably clean. Laundry is
also an important component. Inmates should have access to clean
underwear and regular changes of uniform. KCCF, however, fails

- 21 

to launder inmates’ underwear at all, thereby increasing the risk
of infection transmission. Inmates informed us that the only way
to obtain clean underwear is to purchase it from the commissary
or to wash it themselves in the cell area using their hand/shower
soap. Inmates further informed us that even when they do wash
their own underwear, they are prohibited from hanging it to dry
in the cell area.8 Moreover, the jail provides only one uniform
per week. These deficiencies greatly increase the risk of
intramural transmission of skin infections.
Surface disinfection is a also critical to the prevention of
skin infections. We learned that, while most of the cracked
mattresses we found on our first tour had been replaced, and the
mattresses used in the jail are cleaned with quaternary ammonium
disinfectant, this disinfectant is not being used properly.
Quaternary ammonium disinfectant should have ten minutes of
contact time with a mattress surface before it is wiped dry.
Currently, the disinfectant is being wiped dry nearly immediately
after it is sprayed, which likely makes it ineffective at killing
bacteria and viruses.
Moreover, KCCF fails to provide adequate treatment to
inmates with skin infections. Not only does inadequate treatment
place the inmate at risk of harm, but it also increases the risk
of transmission to other inmates and staff.9 For example, prior
to our investigation, in January 2004, a 40-year-old inmate who
had been held at the Jail for about 20 days died from a
combination of flesh-eating disease and MRSA, which was linked to
chronic injection drug abuse. The inmate’s wound purportedly had
spread to 10 inches and was leaking fluid for two days before he
received medical attention.10 Staff have expressed concern over


We certainly appreciate that this restriction is likely
intended to ensure line of sight for security and to minimize
fire risk.

According to a King 5 News investigative report, staff
have reportedly contracted MRSA at KCCF and passed the infection
on to family members. Additionally, seven staff have filed
workers compensation claims involving MRSA, and have missed an
aggregate of 530 days of work due to the illness. Investigators:
Dangerous Infection Thriving at King County Jails, King 5 News,
November 7, 2005.


Contagion in the Jail, Seattle Weekly, December 7,

- 22 

transmission of communicable diseases to the media stating that
the KCCF is understaffed, lacks an efficient medical
record-keeping system, and puts inmates at risk unnecessarily.11
During our tour, we reviewed the charts of nine inmates who
were seen in sick call in June 2007. Of those nine inmates, four
had skin infections, and all four experienced serious
deficiencies in treatment, as follows:

The most dangerous situation was that of an inmate who had
been seen for his skin infection on five separate occasions.
Each time, KCCF practitioners prescribed the same
medication, and each time, the medication was ineffective.
The inmate had developed cellulitis and an abscess, neither
of which could improve until the abscess was drained.


Another inmate with a skin infection was forced to wait
three days to get medication and five days to see a nurse


The third inmate had to wait four days before receiving a
prescription for his skin infection.


For the fourth inmate, medication was ordered, but the order
was never picked up by nursing staff. There was no
indication that the inmate ever received the medication.

Our investigation also revealed that KCCF performs very few
diagnostic cultures of skin infections. A culture, which is an
examination of a sampling of cells taken from the affected area,
may be done to identify the microorganism causing the skin
infection and to determine the antibiotic or other treatment that
will effectively treat it. KCCF reported that it performed only
13 to 21 diagnostic cultures per month for the six months prior
to our second tour. KCCF was unable to produce laboratory
records for recent months, so we were unable to quantify
bacterial cultures actually performed.
Moreover, while KCCF tracks the incidence of skin infections
in its surveillance log, this log apparently does not present the
full state of skin infections at the jail. This is because the
log is likely incomplete due to problems with intake screening,
access (appointment backlogs and inadequate physician staffing),
inadequate methods of tracking data (absence of emergency room
utilization logs), poor medical records (notably, lack of charted



- 23 

wound culture results), and inadequate laboratory testing (few
wound cultures). Thus, it was not possible for us to determine
the full extent of the jail’s problem with intramural
transmission of skin infections.

Inadequate Intake Procedures

Adequate intake procedures are essential for ensuring that
inmates are properly screened by staff who are trained to
identify and triage serious medical needs. KCCF fails to
adequately train and supervise intake staff, and exhibits serious
lapses and delays in treatment during its intake process. These
failures prevent inmates from receiving adequate treatment for
acute or chronic medical needs, placing them at risk of serious
harm. For example:

We witnessed the processing of an inmate who had been
stopped by a state trooper. The trooper told us the inmate
was staring into space and had been arrested for driving
under the influence. The inmate clearly had an altered
state of consciousness, either from drugs or psychosis.
Neither the intake officer nor the intake nurse recognized
this altered state of consciousness. Only after our expert
noted the inmate’s condition to several staff members did
the inmate receive appropriate monitoring and treatment.


An inmate who had sustained a sexual assault and was
suicidal on intake was seen by psychiatry, but KCCF made no
attempt to determine whether she had a sexually transmitted
infection or to conduct its own tests.


We encountered a seriously ill inmate on the women’s housing
unit, whom the booking officer found had “no observed
medical problems.” Her medical intake was not completed
because the nurse said the inmate was manic and could not be
interviewed. Despite the knowledge that the inmate was
mentally ill, neither the nurse nor anyone else called for
any, much less the necessary immediate, psychiatric or
medical evaluation. By the time we observed the inmate on
the housing unit, it was evident that she was seriously ill.
The inmate was shaking, vomiting, and showing signs of
serious malnourishment.


We witnessed an inmate who reported a history of bipolar
disorder. She had been screaming and pounding her fists on
the door for two hours in the intake area, yet she had not
had a medical screen and no one called for a mental health

- 24 


A sixty-year-old inmate arrived at the jail uncooperative
and lethargic, with sutured head wounds, a stiff neck, and
unequal pupils (possibly a sign of acute brain damage). He
was not seen by a physician for 24 hours.


KCCF failed to provide evaluation or treatment at intake to
a hypertensive alcoholic who had abnormal vital signs
consistent with alcohol withdrawal syndrome.


KCCF also failed to evaluate and treat a woman with a
history of suicide attempts and alcohol withdrawal seizures
who had an abscess and cellulitis upon admission.


In order to rectify the identified deficiencies and protect
the constitutional rights of inmates confined at KCCF, this
facility should implement, at a minimum, the following remedial


Protection from Harm

Develop and maintain comprehensive and contemporary
policies and procedures regarding permissible use of


Ensure that staff receive adequate competency-based
training in use of force and defensive tactics.


Develop and maintain comprehensive policies,
procedures, and practices for the investigation of
alleged staff misconduct.


Ensure that incident reports and inmate grievances are
screened for allegations of staff misconduct and, if
the incident or allegation meets established criteria,
referred for investigation.


Ensure that IIU management and staff receive
appropriate competency-based training in conducting

Suicide Prevention Measures

Ensure that the number of hours of pre-service and
annual in-service suicide prevention training are

- 25



Provide a curriculum for pre-service and annual inservice competency-based suicide prevention training
that includes an array of topics so that staff are
adequately trained to identify and manage suicide.


Ensure that, prior to assuming their duties and on a
regular basis thereafter, all staff who work directly
with inmates have demonstrated competence in
identifying and managing suicide.


Ensure that DAJD and JHS suicide prevention policies
include an operational description of the requirements
for both pre-service and annual in-service training.


Ensure that any staff who are exempt from suicide
prevention training, i.e. “contract” JHS staff, have
limited inmate contact and are prohibited from working
in the ITR area.


Ensure that inmates on suicide precautions receive
adequate mental status examinations by a mental health

Medical Care

Provide adequate and timely medical care for all


Provide adequate medical intake procedures.


Ensure that medical staff classify inmates properly and
examines and treats inmates in a timely manner.


Ensure that inmates with chronic diseases receive
adequate medical care, including appropriate monitoring
and diagnostic testing.


Develop and implement a system to review emergency room
visit and hospitalization logs to effectively monitor
the care of ambulatory-sensitive conditions (e.g.,
preventable deaths, diabetic ketoacidosis).


Provide adequate competency-based training to security
staff, medical care staff, and intake staff regarding
responding to medical emergencies.


Ensure that mattresses are frequently and effectively

- 26 


Provide adequate and sanitary laundry services to


Develop and implement adequate clinical guidelines
regarding skin infections.

10.	 Ensure that reliable data on the incidence of skin
infections are maintained, and analyze this data to
identify sources of intramural transmission.
11.	 Ensure that inmates with skin infections receive timely
and appropriate wound cultures, case identification,
treatment, wound care, and monitoring.
12.	 Ensure that inmates with persistent and recurrent skin
infections are referred to a physician.
13.	 Ensure that inmates receive adequate and timely
medication management.
14.	 Eliminate standing orders for nurses to administer
antibiotics for skin infections.



Please note that this findings letter is a public document.
It will be posted on the Civil Rights Division’s website. While
we will provide a copy of this letter to any individual or entity
upon request, as a matter of courtesy, we will not post this
letter on the Civil Rights Division’s website until ten calendar
days from the date of this letter.
We hope to continue working with the County in an amicable
and cooperative fashion to resolve our outstanding concerns
regarding KCCF. Assuming there is a continuing spirit of
cooperation from the County, we also would be willing to send our
consultants’ evaluations under separate cover. These reports are
not public documents. Although the consultants’ evaluations and
work do not necessarily reflect the official conclusions of the
Department of Justice, their observations, analysis, and
recommendations provide further elaboration on the issues
discussed in this letter and offer practical technical assistance
in addressing them.
We are obligated to advise you that, in the entirely
unexpected event that we are unable to reach a resolution
regarding our concerns, the Attorney General may initiate a

- 27
lawsuit pursuant to CRIPA to correct deficiencies of the kind
identified in this letter 49 days after appropriate officials
have been notified of them. 42 U.S.C. § 1997b(a)(1).
We would prefer, however, to resolve this matter by working
cooperatively with you and are confident that we will be able to
do so in this case. The lawyers assigned to this investigation
will be contacting the facility’s attorney to discuss this matter
in further detail. If you have any questions regarding this
letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights
Division’s Special Litigation Section, at (202) 514-0195.

/s/ Rena J. Comisac
Rena J. Comisac
Acting Assistant Attorney General
cc:	 Dan Satterberg
Interim King County Prosecuting Attorney
Reed Holtgeerts
King County Department of Adult and Juvenile Detention
Gordon Karlsson
Facility Commander
King County Correctional Facility (Seattle Division Jail)
The Honorable Jeffrey C. Sullivan
United States Attorney
Western District of Washington
Kelly L. Harris
Assistant United States Attorney
Western District of Washington