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Cripa Marion Juv Detention Ctr in Investigation Findings 8-6-07

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U.S. Department of Justice
Civil Rights Division

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

August 6, 2007
The Honorable Robert R. Altice, Jr.
The Honorable Gary L. Miller
The Honorable Tanya Walton Pratt
The Honorable Gerald S. Zore
Executive Committee
Marion County Superior Court
T-1221 City-County Building
200 E. Washington Street
Indianapolis, Indiana 46204
The Honorable Monroe Gray
Marion County Council
241 City-County Building
200 E. Washington Street
Indianapolis, Indiana 46204
Re: 	 Marion County Juvenile Detention Center,

Indianapolis, Indiana 

Dear Executive Committee Members and County Council President:
I write to report the findings of the Civil Rights
Division’s investigation of conditions at the Marion County
Juvenile Detention Center (“Marion”). On July 18, 2006, we
notified County officials of our intent to conduct an
investigation of Marion pursuant to the Civil Rights of
Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997, and
the Violent Crime Control and Law Enforcement Act of 1994,
42 U.S.C. § 14141 (“Section 14141”).
As we noted, both CRIPA and Section 14141 give the
Department of Justice authority to seek a remedy for a pattern or
practice of conduct that violates the constitutional or federal
statutory rights of youth in juvenile justice institutions.
On December 13-15, 2006 and February 20-22, 2007, we
conducted on-site inspections at Marion with expert consultants
in juvenile justice, special education, custodial sexual
misconduct, and environmental health and sanitation. We

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interviewed direct-care and administrative staff, youth, and
school personnel. Before, during, and after our visits, we
reviewed an extensive number of documents, including policies and
procedures, incident reports, investigative reports, grievances
from youth, staff personnel files, unit logs, orientation
materials, staff training materials, and school records. In
keeping with our pledge of transparency and to provide technical
assistance where appropriate, we conveyed our preliminary
findings to Marion and Marion County officials at the close of
our on-site visits.
We commend the staff at Marion for their helpful and
professional conduct throughout the course of the investigation.
We received full cooperation with our investigation and
appreciate the County and Court’s receptiveness to our
consultants’ on-site recommendations.1 We would also like to
recognize the recent addition of Mr. Richard Curry as the
Superintendent of the Marion County Juvenile Detention Center.
During his brief tenure, Mr. Curry had already begun to identify
areas of improvement and had identified target dates to address
various concerns. We anticipate that Mr. Curry will continue
these efforts to improve conditions at Marion.
In addition, we note that Marion is planning to implement a
Radio Frequency Identification Device (RFID), an innovative
program to monitor staff movement. The facility is also planning
to install internal video cameras to supplement the existing
external cameras. These changes have the potential to be
positive steps toward meaningful change at Marion. Based on
reports we received during our investigation, these programs
should be underway in the near future.
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 Marion violate the constitutional
rights of the youth. In particular, we find that youth confined
at Marion are not adequately protected from harm. We also find
that deficiencies in the areas of fire safety, general
sanitation, and general safety pose a significant risk of disease


The facility is owned and funded by Marion County,
Indiana, and operated by the Marion County Superior Court under
the direction of its Executive Committee and Chief Probation

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and injury to youth and staff. In addition, the facility fails
to provide required education services pursuant to the
Individuals with Disabilities Education Act (“IDEA”), 20 U.S.C.A.
§§ 1400-1482 (West, Westlaw through July 3, 2006).
In the course of our investigation, we also reviewed
allegations of custodial sexual misconduct. We find no current
systemic constitutional deficiencies in this area, and commend
the County for its commitment to safeguarding youth at the
facility from staff sexual misconduct in the wake of the multiple
sexual misconduct charges filed against staff members in 2006.
County and Court officials responded vigorously after learning of
those criminal charges, and exhibited strong leadership in
working to alleviate the threat of continued sexual misconduct.
We applaud the efforts that County and Court officials have
already taken in this regard.


Marion is a secure juvenile justice facility built in 1989
and located in Indianapolis, Indiana. Marion is primarily a
detention center, receiving youth between the ages of seven and
17 who are awaiting adjudication, or who have been adjudicated
delinquent and are awaiting placement at a State facility. The
facility has a capacity to hold 144 youth, including a population
of approximately 30 females. The youth population at Marion
fluctuates daily. On December 14, 2006, 116 youth were confined
at the facility. During our tour on February 20, 2007, the
facility confined 124 youth.
Our investigation of systemic conditions at Marion began
following the criminal indictment of ten former employees of the
facility, including Marion’s former superintendent. Those
employees had been charged with a total of 52 criminal counts,
including child molestation, sexual misconduct with a minor,
child solicitation, and official misconduct including concealing
evidence and failing to report sexual child abuse.2 We
subsequently received information regarding an independent
investigative report authored by the National Partnership for
Juvenile Services3 regarding conditions at the facility. That


As of this writing, charges have been dismissed against
six employees, one employee was convicted, one employee was
acquitted, and the two remaining employees are awaiting trial.

The National Partnership for Juvenile Services is a
coalition of four former juvenile advocacy organizations

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report, based on a February 14-16, 2006 facility assessment,
concluded, among other things, that “residents at the facility
are not safe.”


Both CRIPA and Section 14141 authorize the Department of
Justice to seek a remedy for a pattern or practice of conduct
that violates the constitutional or federal statutory rights of
youth in juvenile justice institutions. 42 U.S.C. §§ 1997,
14141. States and their political subdivisions must provide
persons confined in a non-penal context – like the youth confined
in Marion who are either awaiting adjudication or have been
adjudicated delinquent and not convicted of a crime – with
reasonably safe conditions of confinement. See Youngberg v.
Romeo, 457 U.S. 307, 315-16 (1982) (recognizing that a person
with mental retardation in State custody has substantive due
process rights under the Fourteenth Amendment); Bell v. Wolfish,
441 U.S. 520, 535-36 & n.16 (1979) (applying the Fourteenth
Amendment standard to facility for adult pre-trial detainees);
K.H. v. Morgan, 914 F.2d 846, 851 (7th Cir. 1990) (stating
“Youngberg v. Romeo made clear . . . that the Constitution
requires the responsible state officials to take steps to prevent
[youth] in state institutions from deteriorating physically or
psychologically.”); Nelson v. Heyne, 491 F.2d 352, 360 (7th Cir.
1974) (recognizing that juvenile detainees have a right under the
Fourteenth Amendment due process clause to rehabilitative
treatment, and that “[t]he ‘right to treatment’ includes the
right to minimum acceptable standards of care and treatment for
juveniles and the right to individualized care and treatment.”).4
Such constitutionally mandated conditions include the right to be

including the National Association for Juvenile Corrections
Agencies, the National Juvenile Detention Association, the
Juvenile Justice Trainers Association, and the Council for
Educators of At-Risk and Delinquent Youth.

See also, Doe v. Strauss, No. 84C2315, 1986 WL 4108, at
*4 (N.D. Ill. Mar. 28, 1986) (unreported) (“[Concluding] that
what we have here is a long elevated Fifth, Eighth and Fourteenth
Amendment right decisionally recognized in this state and many
others. It protects juveniles when they are placed by state
action in special custody, management and control because of
their homeless, their delinquent conduct, and their unmonitored
living. It is a right to care, management and therapy reasonably
designed and calculated to effect rehabilitation, moral
restoration and proper development.”

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free from undue restraint and the use of excessive force by
staff. Youngberg, 457 U.S. at 315-16; Nelson, 491 F.2d at 356.
Youth who are placed in disciplinary isolation are entitled to
certain procedural safeguards. Mary and Crystal v. Ramsden, 635
F.2d 590, 599 (7th Cir. 1980). Youth in state or local custody
also have a constitutional right to be reasonably protected from
harm inflicted by third parties. K.H. v. Morgan, 914 F.2d at
Youth in state custody also have a constitutional right to
adequate fire and occupational safety. French v. Owens, 777 F.2d
1250, 1257 (7th Cir. 1985); Duckworth v. Franzen, 780 F.2d 645,
655 (7th Cir. 1985) (stating “[p]rison fires . . . are common and
both their hazards and the necessary precautions well known.”)
(abrogated on other grounds as noted in Haley v. Gross, 86 F.3d
630 (7th Cir. 1996)). In addition, youth in State or County
custody are constitutionally entitled to “life’s necessities,”
including adequate shelter, sanitation, clothing, and hygienic
materials. Gillis v. Litscher, 468 F.3d 488, 493 (7th Cir.
The State and County are also obliged to provide special
education services to youth with certain disabilities pursuant to
the IDEA. 20 U.S.C.A. §§ 1400-1482 (West, Westlaw through July
3, 2006). As described below, the County has fallen short of
these constitutional and federal statutory obligations.


We find that Marion fails to adequately protect youth in its
care from harm and serious threat of harm, fails to provide
adequate fire safety and environmental health conditions, and
fails to provide youth with required special education services.


Youth at Marion are not adequately protected from harm
because youth are subjected to excessive levels of youth
violence, excessive and improper seclusion practices, inadequate
suicide prevention measures, a dysfunctional youth grievance
process, and an unreliable child abuse reporting and
investigations system.

Youth Violence

Youth in institutions have a constitutional right to be
reasonably safe from harm inflicted by other youth. Facilities
must maintain sufficient structures, safeguards, and staffing to

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ensure reasonable safety. Our investigation revealed an
unacceptably high rate of youth violence, and a serious danger of
continuing and intensifying physical harm at the facility.
Nearly all of the youth interviewed by our consultants
reported that they do not feel safe at Marion. We found
unacceptably high levels of youth-on-youth assaults, and grossly
inadequate safeguards to prevent and mitigate such violence.
Indeed, DOJ staff and consultants witnessed, first hand, three
youth assaults during our investigatory tours. Disturbingly,
youth are routinely involved in incidents requiring emergency
room treatment. Violent incidents at the facility requiring
“code blue” or emergency response team intervention occur daily.
For example:

On February 11, 2007, two youth [SX]5 and [JN] were involved
in a fight in the gym, resulting in lacerations requiring
treatment in a local emergency room. The incident report
suggests that a lack of staff support may have exacerbated
the severity of the injuries.


On January 3, 2007, two youth were involved in a fight.
One of the youth, [BN], required medical attention for a
bloody nose. After repeated attempts to summon medical
staff to the unit, a staff person went to the clinic to find
the nurse. Both nurses had their coats on and were
preparing to depart, without any intention to deliver the
requested medical care. Ultimately, the nurses assessed the
youths’ injuries, and ordered treatment for [BN] at the
local emergency room.

A variety of factors contribute to the violent conditions at
Marion, including inadequate staffing levels, inadequate staff
training, inadequate youth programming, an inadequate behavior
management program, and an inadequate housing classification

Inadequate Staffing Levels

A significant factor contributing to the high levels of
youth-on-youth violence at Marion is the absence of sufficient
numbers of staff to adequately supervise youth. Without adequate
levels of trained staff on duty, it is not possible to respond in

To protect the youths’ identities, we use fictitious
initials throughout this letter. We will separately transmit to
counsel for Marion County a schedule cross-referencing the
fictitious initials with youths’ names.

- 7 

a safe and timely manner when violence and other crises occur.
Moreover, without adequate numbers of qualified staff, detention
officers do not have the time to build the relationships with
youth that are necessary to identify and preempt potential
Of the staffing sampling reviewed by our consultants for
2006 and 2007, we determined that during waking hours,
approximately 80% of the units were staffed substantially below
generally accepted professional standards.6 Specifically, the
16-bed units were typically staffed with a single dedicated staff
person, or a 1:16 staff-to-youth ratio. Such staffing levels
during waking hours are dangerously inadequate, and make it
difficult for staff to prevent and quickly intervene in youth
Indeed, incident reports were full of examples in which a
single staff person was tasked with separating multiple youth
involved in assaultive behavior. In one example from January
2007, a lone staff person was required to separate multiple youth
involved in a fight. In an example from February 2007, a lone
staff person required the assistance of three youth in order to
restrain two fighting youth until additional staff assistance
arrived. As one staff person so aptly reported to us during an
interview, “there are 16 of them, and I only have one set of

Inadequate Staff Training

In addition to adequate numbers of staff, generally accepted
professional standards require that facilities provide staff with
adequate training in behavior management, de-escalation
techniques, assault intervention, and use of force. That
curriculum should be included in both staff pre-service training,
and in the required annual in-service training. A lack of
training in these areas hampers the staff’s ability to diffuse
tensions, discourage and prevent violent incidents, and safely
and appropriately intervene once an assault has occurred. Staff
at Marion do not receive adequate levels of training, and, in
fact, receive no pre-service instruction in the use of force

Generally accepted professional standards typically
require one direct care staff to every eight to ten youth during
waking hours, and one direct care staff to every 16 to 20 youth
during sleeping hours. At certain facilities, additional
factors, such as poor facility layout, may require additional

- 8 

continuum. This lack of training contributes significantly to
the violent conditions at the facility.
In November 2006, Marion contracted with a private company
to provide eight hours of in-service training with all staff on
“Critical Movement Intervention.” This program included training
on verbal de-escalation, positive interactions, and physical
restraint techniques. The program lacked any formal assessment
of whether staff had learned the material or techniques, and
generally appeared to be inadequate to provide staff with
essential skills.
The gross inadequacy of training at Marion is highlighted by
our interview with several staff who were unable to articulate
what they had learned or how they would apply their training in a
real-world setting. In addition, a review of incident reports
revealed that staff were unable to specify types of
interventions, and appeared unfamiliar with basic use of force
The amount and effectiveness of staff training at the
facility is a substantial departure from generally accepted
professional standards. Indeed, the paucity of training
opportunities means that staff are not adequately equipped to
prevent or intervene in physical altercations and to protect
youth from harm by others.

Inadequate Youth Programming

The amount and quality of structured daily programming in
juvenile facilities has a significant impact on the rate of
violent and antisocial incidents. Simply stated, youth who do
not have adequate opportunities to engage in programmed
activities become bored, and are more likely to become involved
in mischief or assaultive behavior. Generally accepted
professional standards mandate that youth in juvenile justice
facilities receive a minimum of one hour of large muscle activity
per weekday, two hours of large muscle activity per weekend day,
educational programming during weekdays, and other structured
developmental and rehabilitative activities. Inadequate youth
programming at Marion contributes to the high levels of youth
violence, and departs substantially from generally accepted
professional standards.
Youth at Marion generally receive only 40 minutes of largemuscle activity per day. Some youth in isolation or in various
other disciplinary categories do not receive educational services

- 9 

of any kind. Other types of programming are scarce, and youth
spend a significant portion of their day watching television.
Youth reported that they are bored, particularly on the weekends.
Detention officers reported that low staffing levels prevent
meaningful programming at the facility.

Inadequate Behavior Management Program

Generally accepted professional standards require that
facilities confining youth provide effective behavior management
systems in order to encourage appropriate behavior and discourage
violent or disruptive behavior. Effective behavior management
systems generally involve incentive-based programs for promoting
appropriate behavior throughout the day, and clearly defined
guidelines that are consistently applied within the facility.
For youth identified as having behavioral problems, behavior
management programs should be coordinated with a treatment plan.
The behavior management program should be based on proven
techniques and focused on achieving lasting change through the
integration of evidence-based (or scientifically measurable)
outcomes. Facilities must continuously track behaviors of their
youth with behavior problems and adjust their behavior management
programs, when necessary, to achieve desired results.
The behavior management program at Marion is poorly
structured and inadequately implemented. The range of rewards
and sanctions under the program are not adequate to deter
aggressive youth behavior, and therefore contribute significantly
to the high levels of violence at the facility. In addition,
staff are not fully aware of the features of the program, and
staff and youth interviews indicate that the program is
inconsistently applied. For example, when asked what the maximum
number of points they could award a youth on a given day, staff
reported vastly different answers. The policy regarding reward
points is not clear and comprehensive. In addition, the
penalties available under the system for misbehavior are limited
and ineffective.

Inadequate Housing Classification

The absence of an adequate classification system guiding
youth housing assignments contributes to the high frequency of
youth-on-youth assaults at Marion. Generally accepted
professional standards require that youth be housed and
supervised in accordance with their housing classification
status. Reliable classification systems take into consideration
such information as a youth’s age, committing offense, physical

- 10 

size, maturity, history of
attempts, known enemies or
affiliation. In addition,
validated using historical

institutional violence and escape
rivals, and gang membership or
reliable systems are objective, and
facility data.

Marion does not use any type of objective classification
instrument. Housing at the facility is based primarily on age.
Youth of all different sizes, levels of maturity, histories of
aggression and violence or other predatory behavior are all
housed together, with no distinction between those who are
potentially vulnerable and those who are demonstratively
predatory. The current subjective housing assignment system at
Marion is a substantial departure from generally accepted
professional standards.

Use of Isolation

Marion’s isolation practices substantially depart from
generally accepted professional standards. Marion’s use of
isolation is excessive and lacks essential procedural safeguards.

Inappropriate Use of Isolation

Isolation at a juvenile detention facility should be used
only to the extent necessary to protect youth from harm to
themselves or others, or to maintain institutional discipline.
Generally accepted professional standards prohibit the use of
excessive isolation. Punitive isolation,7 if used at all, should
be used in conjunction with a continuum of interventions,
beginning with techniques such as verbal re-direction and loss of
certain privileges. Facilities are required to provide isolated
youth with certain services and programming, such as medical
care, mental health care, daily exercise, and to the extent
reasonably possible, educational services. The length of


Juvenile justice institutions typically place youth in
isolation for two different reasons. Punitive or “disciplinary”
isolation involves placing a youth alone in a locked room as a
sanction or punishment for negative behavior for a pre-determined
period of time. A separate form of isolation involves placing
youth who pose an immediate and continuing threat to themselves
or others alone in a locked room in order to prevent immediate
self harm or harm to others. Sometimes this latter form of
isolation is called a “cool down” and should only last as long as
the youth continues to pose an immediate threat, and is therefore
necessarily indeterminate in duration.

- 11 

punitive isolation should be proportional to the offense
Prior to February 15, 2007, Marion used three forms of
isolation: “DOE” (an orientation phase requiring an initial
three days in isolation upon admission to the facility), “Re-DOE”
(essentially a return to the orientation phase), and “2H”
(punitive isolation lasting from four to seven days). On
February 15, 2007, the new superintendent issued a memo
abolishing DOE, Re-DOE, and 2H, replacing them simply with
punitive isolation lasting from two to 24 hours and requiring
different levels of approval at each increment.8 Regardless of
the name used to describe it, the facility excessively relies on
isolation as a means of attempting to control youth behavior.
Based on the review of housing assignments in January and
February 2007, on any given day, approximately 15 to 20 percent
of the youth population was in some form of isolation.
In addition, staff at Marion have historically failed to
distinguish violent and dangerous rule infractions from less
serious disruptive or annoying behaviors. For example, our
review of incident reports revealed that the vast majority of
staff recommended isolation as the sanction for rule violations,
together with a reduction in the youths’ behavior management
level. These recommended sanctions were generally the same
whether the alleged misbehavior included failing to follow
instructions, refusing to take a shower, or stealing food, as
well as more serious misbehavior such as threatening staff,
assaulting another youth, or destroying property. Punitive
isolation should never be the sole response to misbehavior in a
juvenile detention facility.9

At the time of our most recent tour in February 2007,
the new isolation policy had been in effect for only three days.
Therefore, there was an insufficient sampling to fully evaluate
the program’s effectiveness or implementation. However, the new
policy appeared to be severely flawed, suffering from illogical,
redundant, and overlapping guidelines, a lack of procedural
safeguards, lack of staff training in the new policy, and unclear
and disproportionate durations of isolation. In addition, the
new policy failed to provide meaningful alternatives to the use
of isolation.

Examples of other generally accepted disciplinary
sanctions short of isolation include letters of apology, essay
writing, community service, probated sanctions, and loss of
certain privileges.

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The facility also fails to provide isolated youth with
certain required services. For example, youth in isolation do
not regularly receive mental health care services, special
education services, regular access to medical care, or daily
large muscle exercise. Failure to provide youth in isolation
with essential services creates an additional impermissible form
of punishment.

Lack of Procedural Protections

Generally accepted professional standards require that youth
placed in punitive isolation receive notice of the charges, a
hearing before an independent decision-maker, and an opportunity
to present evidence in their defense. Marion fails to provide
these important procedural safeguards in imposing punitive
isolation. At the facility, a supervisor is required to review
and approve the use of isolation. However, there is no formal
process for the youth to be notified of the charges and their
rights, to dispute the charges, to present exculpatory evidence,
or to receive consideration from a neutral decision-maker. One
predictable consequence of this failure is that Marion youth
perceive the disciplinary process to be unfair and arbitrary.

Suicide Prevention Measures

Juvenile justice facilities must protect youth from selfharm. Youth in detention settings, like the youth at Marion, are
at a much higher risk of suicide than their counterparts in the
community. For reasons set forth below, Marion fails to provide
adequate protections for potentially suicidal youth.
Generally accepted professional standards require facilities
to screen youth upon intake for suicidality using a validated and
developmentally-appropriate suicide risk instrument. In
addition, staff must be trained to identify warning signs in
youth after intake, and to make appropriate referrals to a
qualified mental health professional (“QMHP”). Youth identified
as potentially suicidal must be subject to a number of
precautions, including heightened staff supervision, recurring
contact with QMHPs, suicide resistant housing, and frequent staff
searches for any restricted or dangerous items.
Generally accepted professional standards also require that,
depending on the severity of the risk, QMHPs may order heightened
supervision from a continuum of close observation, generally four
randomly-timed (unpredictable) checks per hour, to one-on-one
constant supervision. After a youth has initially been

- 13 

identified as potentially suicidal, only a QMHP may remove that
youth from precautions, or lower the level of precautions for
that youth. Youth on a high level of suicide precautions should
be gradually “stepped-down” to lower levels, rather than being
abruptly removed.
Marion’s policies and practices regarding suicide prevention
are inadequate to protect youth from self-harm. Staff conduct
periodic welfare checks in predictable intervals. Moreover, the
existing policy fails to provide for welfare checks during waking
hours. Additionally, the facility fails to adequately document
or preserve evidence that welfare checks are performed. For
example, Marion was unable to produce youth observation forms for
any of the 15 youth on suicide precautions we requested.10 Youth
Counselors at Marion routinely make decisions regarding
precautions and treatment of suicidal youth, rather than QMHPs.
In addition, youth on a high level of precautions are sometimes
abruptly removed, without any step-down.
Staff at Marion receive only minimal training in suicide
prevention and intervention, and staff routinely ignore warning
signs and act inappropriately in response to suicidal ideations,
gestures, and attempts. Most staff were unable to articulate how
they would respond if they observed a youth hanging, and were
unaware if the facility had a cut down tool.11 One recent
example demonstrates numerous failures to implement an adequate
suicide prevention system over a period of several months:

On June 25, 2006, a youth [EL] tied a sheet to the sprinkler
head in his room and was attempting to tie it around his
neck when staff intervened. [EL] was not assessed by the
Youth Counselor until five days later, on June 30th, when he
was placed on pink card status,12 but was then removed from
suicide precautions on July 5th. On July 7th, [EL] again
tried to hang himself using a sheet, and in response he was

Although some staff and youth reported that
observations were being recorded on observation forms, we were
unable to corroborate this with any documentary evidence.

Cut down tools are specialty blades used in
correctional settings to quickly cut down hanging inmates. These
tools are specially designed to minimize the danger that the
blade will be used as an improvised weapon.

Pink card status requires staff at Marion to record
observations of the youth every 15 minutes during sleeping hours.

- 14
placed back on pink card status. Despite being on a
supposedly enhanced level of supervision, the next day he
attempted to tie a sheet around his neck twice, and
attempted to place his head in a sink full of water.
Finally, he was transferred to a psychiatric hospital on
July 8th.
Later in the month, [EL] returned to Marion from the
hospital. On July 22nd, staff observed him banging his head
against the wall on two separate occasions. On July 24th,
the youth verbalized a plan to jump off the second tier of
the unit. On July 28th, the youth actually jumped off the
tier. The Shift Manager “advised [EL] of the negative
consequences of his behavior.” On July 29th, the youth
jumped from the second tier again, this time with a sheet
tied around his neck, and “was informed he would receive
additional discipline.” On July 31st, [EL] tied a shirt
around his neck and, in a separate incident, placed his head
in a sink full of water. Another round of similar incidents
occurred in November 2006. For the July 31st and November
2006 incidents, there was no record that [EL] was seen by a
QMHP or that a safety plan was created to prevent him from
hurting himself. Further, observation forms could not be
produced for any of these time periods, and thus the
facility cannot demonstrate that the youth received any
enhanced supervision in response to these repeated serious
Marion also fails to protect suicidal youth from
environmental hazards or contraband. The facility fails to
reasonably ensure that the youths’ environment and person are
free of items that could be used in self-harm attempts. Staff do
not receive clear instructions on what items a suicidal youth may
possess. For example, in February 2007, a youth [UK] was on
cautionary status after stating his intent to kill himself. On
two different occasions, he was found with a length of string in
the padded room in which he had been placed. For a second
example, in January 2007, a nurse determined that all of another
youth’s [TU] belongings and clothing should be removed to protect
the youth’s safety. The nurse returned to the unit two hours
later to find that staff had given [TU] all of her belongings


The dysfunctional grievance system at Marion contributes to
the facility’s failure to ensure a reasonably safe environment.

- 15 

An adequately functioning grievance system ensures that youth
have an avenue for bringing serious allegations of abuse and
other complaints to the attention of the administration. It also
provides an important tool in evaluating the culture at the
facility, and alerting the administration about dangers and other
problems in the facility’s operations.
Youth should have timely access to the grievance system, and
grievances should be reasonably confidential. Grievances should
be tracked, audited, and periodically reviewed by senior
management in order to identify patterns and problems.
Grievances should be responded to in a timely manner, and youth
should be informed about how their grievance was resolved.
Although Marion has invested in technology to improve the
grievance process at the facility, the system remains a
substantial departure from generally accepted professional
First, the Marion grievance system relies heavily on five
“Student Concern Phones” located outside of the youth housing
units in certain common areas of the facility. Several youth,
particularly those in isolation or restricted housing, complained
that the Student Concern Phones were not accessible to them, or
that limited staffing in their units inhibited their ability to
access the phones.
Second, although the Student Concern Phone is an important
tool in Marion’s grievance system, youth should also have
additional avenues for reporting concerns or allegations. For
example, youth witness statements in incident reports should
provide an additional avenue for reporting staff misconduct or
abuse. Youth at Marion do not have the opportunity to provide
written statements in connection with an incident. Currently,
staff interview youth involved in an incident, and then write a
summary of the youth’s statement on the incident report. This
practice creates the possibility that staff may, purposefully or
inadvertently, misrepresent or misinterpret the youth’s
statements. While the current practice may be appropriate in
certain situations where youth lack the ability to write, youth
should first be offered the opportunity to complete their own
Third, the Marion grievance system also violates generally
accepted professional standards because youth are often not
informed of how their particular grievance was resolved. For
example, when a grievance is determined by a Marion administrator
to be unfounded or not grievable, the administrator fails to

- 16 

inform the youth. One obvious consequence of the lack of followthrough is that youth lose confidence that their grievance has
been reviewed or given serious consideration.

Child Abuse Reporting and Investigations

Mandated Reporting

Generally accepted professional standards and State law13
require personnel at Marion to report all allegations of child
abuse to appropriate external social services and law enforcement
agencies. Personnel must report all allegations, and may not
filter reporting of the allegations based on the perceived
credibility of the youth, or merit of the allegations.14
Professional standards also mandate that once an allegation
of child abuse has been received, management must restrict the
accused staff member from contact with youth, pending the outcome
of the referral and investigation.
Marion practices substantially depart from professional
standards. Supervisory personnel at the facility routinely fail
to report allegations that they subjectively determine not
credible.15 In addition, because the allegations are often not
determined to be credible, the accused staff are not subsequently
placed on non-contact status pending the investigation. For
example, the following incidents did not result in any external

See Ind. Code §31-33-5-1 (“an individual who has reason
to believe that a child is a victim of child abuse or neglect
shall make a report as required by this article.”).

Social service and investigative agencies routinely
“screen-out” child abuse allegations based on lack of credibility
or evidence. Staff at these agencies provide an objective and
non-involved perspective on the merit of the allegations, and are
specifically trained in investigating allegations of abuse.
Conversely, investigations by Marion personnel do not share these

It is noteworthy that the former facility director has
been criminally charged for failing to report allegations that a
female youth in his charge was raped by a staff person. The
former director has publicly indicated that he did not report the
allegations because he did not perceive the allegations to be
credible. As of this writing, the former superintendent is
awaiting trial.

- 17
reporting, and did not result in any attempt to remove the
accused staff from direct youth supervision:

During our second tour, a youth reported to us that a Youth
Manager had sprayed him in the face with bleach in response
to his misbehavior the day before. The youth indicated that
one of the facility supervisors talked to him about what had
happened and that he [the youth] reported the incident as he
reported it to us. The youth also stated that he was not
seen by medical staff following the incident. We located
the incident report, and indeed, the supervisor recorded the
youth’s allegation that he was sprayed in the face with
bleach. We were told that the incident was not forwarded to
Child Protective Services because staff did not believe the
allegation was true, indicating that because the youth
“could open his eyes” after the incident, the episode could
not have happened.


An incident report from mid-February 2007 indicated that a
staff person observed a youth with a bloody nose say to
another youth, “staff hit me and you are going to be my
witness.” The reporting staff felt that the instruction to
the other youth was evidence of collusion and that the youth
with the bloody nose was lying about what occurred. The
youth was disciplined “for trying to get staff in trouble.”
There was no record of the youth receiving any type of
medical treatment.


Two different youth called the Student Concern Phone
alleging that a particular staff person threatened to harm
them in separate incidents. While a single allegation
should have been sufficient to trigger a report to Child
Protective Services, the fact that the reported threats were
so similar (“I’m going to slap the shit out of you!”) is
additional cause for concern. These threats were not
reported to Child Protective Services, and disciplinary
action amounted to telling the staff person that “she should
not play this way with any student as she makes herself an
easy target.”

Facility Internal Investigations

Certain allegations of staff misconduct, including
allegations of child abuse screened-out or found unsubstantiated
by external agencies, should nevertheless be investigated
internally for misconduct that does not rise to a criminal level.
Marion recently implemented an internal facility-based

- 18 

investigatory process to gather evidence and review employee
conduct. At the time of our tour in February 2007, the facility
had conducted one such investigation.
The resulting investigative report revealed a number of
significant inadequacies in the internal investigations process.

Factual errors (e.g., the report indicates that a single
medical staff person received the allegation from the youth,
but the various attachments reveal that the youth reported
the incident to at least three other staff).


Failures to interview key witnesses (e.g., the accused staff
person provided a written statement but was never
interviewed; the youth reported that two other girls, since
released from the facility, were also mistreated by the
accused staff person, but they were never interviewed; the
staff members who received the allegations provided written
statements but were never interviewed).


Poorly written narrative (e.g., several unclear references,
poor grammar, spelling and punctuation errors, not well
organized so the flow of information is difficult to

A properly functioning internal investigation system is
essential to ensure that staff are held accountable for any
policy violations or provided with any additional necessary
training or re-training, and that youth are treated


The environmental health and safety conditions at Marion
pose a significant risk of disease and injury to youth and staff.
We identified deficiencies in the areas of fire safety, general
sanitation, and general safety.

Fire Safety

We identified several deficiencies in Marion’s fire
suppression and evacuation systems and procedures. For example,
Marion does not adequately conduct or document fire drills. Fire
alarm boxes are key activated, as opposed to manually pulled, but
not all employees have keys to the alarm boxes to activate the
fire alarm system. Delays in fire notification can have deadly

- 19 

consequences. We found very heavy lint and dust accumulation on
all surfaces in the main laundry room. High concentrations of
lint and dust can create explosive fire hazards around electrical
equipment, such as washer and dryer motors. Additional fire
safety hazards include a blocked emergency exit door; fire
extinguishers not properly secured to the wall; an overloaded
electrical receptacle holding nine devices; missing sprinkler
heads; and surge protectors connected in a series. These
conditions present numerous scenarios for harm to youth and

General Sanitation

The laundry facilities do not adequately clean and sanitize
youths’ clothing, which increases the risk of transmitting
infectious diseases, such as methicillin-resistant Staphylococcus
aureus (“MRSA”)16 and scabies, a pruritic rash caused by the skin
mite Sarcoptes scabiei. Youths’ laundered clothing often is
returned to them wet, which indicates that dryer temperature
settings and/or time cycles are insufficient to ensure the
destruction of pathogens, including MRSA, and results in an
increased risk of disease transmission through the sharing of
contaminated clothing. Youths’ laundered clothing is also
transported in the same laundry carts that are used for soiled
clothing, which further exacerbates the risk of disease
Numerous mattresses, pillows, and safety mats were worn or
torn and could not be adequately cleaned and sanitized.
Mattresses and pillows in this condition can easily aid in the
transmission of bacteria and diseases such as scabies and MRSA.
Youth are further at risk of disease transmission through
Marion’s practice of requiring youth on most housing units to
share a single bottle of roll-on deodorant on the unit. This
practice may be contributing to the spread of scabies in the
facility. The Sarcoptes scabiei mite can be transferred personto-person by sharing the same deodorant bottle.

MRSA is a virulent staph infection that thrives in
close populations such as juvenile justice facilities, prisons,
and medical facilities. MRSA is resistant to traditional
antibiotics, and can cause severe reactions, usually after a
strain of bacteria enters the body through an opening or break in
the skin. An untreated infection of MRSA can cause swelling,
boils, blisters, fever, pneumonia, bloodstream infections, and
eventually loss of limbs and even death.

- 20 

Marion’s shower areas in the housing units are not
adequately clean. Some housing units had fly infestations in the
shower drains, which may exacerbate bronchial asthma in
susceptible populations and indicate inadequate sanitation. Some
shower areas had peeling paint and mold and mildew growths on the
walls. Peeling paint increases the risk of bacteria and mold
growth. Building dampness or moldiness has been linked with
respiratory health problems such as cough, wheeze, and asthma
exacerbation. Respiratory health risks may become particularly
high when such fungal growth occurs inside a building.

General Safety

Chemical safety was also inadequate at Marion. For example,
we observed numerous instances of unsecured, unsupervised
chemicals, including bleach, in housing and education areas.
This poses a significant risk of harm to youth and staff through
accidental or intentional spills. Additionally, chemicals were
not accompanied by accurate Material Safety Data Sheets (“MSDS”),
and some chemicals had no MSDS sheets. In one instance, an
unidentified chemical in a five-gallon container was being used
to prop open a door. Without MSDS sheets, personnel may not be
able to adequately respond in case of chemical exposure or other
chemical-related injury.
Marion also places youth at risk of accidents by creating
unacceptable safety hazards. For example, the seats on the
small, four-seat fixed-metal tables in five housing units were
broken, exposing the sharp metal seat mounts. This poses a very
serious risk of accidental or intentional harm to youth. A trip
or fall in the area of the table could produce a fatal injury if
someone’s head struck the seat mount. The seat mounts could also
be used as weapons to inflict youth-on-youth injury.


Youth with certain disabilities have federal statutory
rights to special education services under the Individuals with
Disabilities Education Act. In states that accept federal funds
for the education of youth with disabilities, such as Indiana,
the requirements of the IDEA apply to juvenile justice
facilities. See 20 U.S.C. 1412(a)(1); 34 C.F.R.
§ 300.2(b)(1)(iv). Marion violates the IDEA by failing to
adequately deliver required special education services and by
denying access to any educational services to certain youth.

Special Education Program

Even when youth have access to the education program, the
special education program is inadequate.

- 21 



The facility appears to be under-identifying the number of
youth who are eligible for special education services. Of the
124 youth in custody during our February 2007 visit, only 30 were
identified as eligible for special education services.17 This is
24 percent of the youth population, which is significantly lower
than the 40 to 60 percent which, in our consultant’s experience,
are commonly identified in juvenile detention and correctional

Education Staffing

Marion has one special education teacher. Even with the
relatively low number of identified eligible youth, it is
unlikely that a single special education teacher could provide
the services required by their Individualized Education Programs
(“IEPs”). Special education youth at Marion are served in
Regular Class settings (served in a special education setting for
0-20% of the school day), in a Resource setting (served in a
special education setting for 21-60% of the school day), or in a
Separate Class setting (served in a special education setting for
more than 60% of the school day). A single teacher is simply not
able to provide for the diversity of needs among the youth
population at a relatively large detention facility like Marion.
Even with the currently small number of identified eligible
youth, at some point, the single teacher’s class size would
exceed generally accepted professional standards.18

Individualized Education Plans

The IDEA requires that each youth qualified for special
education services have an Individualized Education Plan, and
describes the IEP components required to ensure that each youth
receives adequate special education services. 34 C.F.R.
§§ 300.346, 300.347. The 30 youth identified as eligible for
special education services at Marion had IEPs that were prepared
before their detention at the facility. However, Marion fails to
ensure that these IEPs are updated and appropriate for each
youth. Neither the Director of Alternative Education for
Indianapolis Public Schools nor the school principal could
remember a single situation in which a youth’s IEP was outdated


Nineteen of these youth were enrolled in school; an
additional 11 youth were eligible for special education services,
but had not been enrolled.

The acceptable class size will vary based on the needs
of the youth, but generally ranges from ten to twenty students
per class.

- 22 

and required a case conference to make it current. However, a
review of just five randomly selected IEPs revealed several in
which the IEP appeared to be expired at the time of admission,
yet MDJDC had taken no action to review or update the document.

One youth [UK] was in custody from January 11 through March
8, 2007, or 40 school days. The youth’s previous IEP had
expired approximately nine months prior to the youth’s
admission. No current IEP was located among the documents
provided by the MDJDC.


Another youth [UX] was in custody from January 22 to
February 26, 2007, or 26 school days. Her most recent case
conference revising her IEP was held on March 23, 2005, and
thus had expired well over a year prior to her admission to
Marion. Again, no documentation was provided to indicate
any action had been taken to update the youth’s IEP.


Another youth [CT] was in custody from January 28 to
February 27, 2007, or 22 school days. The most recent case
conference to update her IEP was held on January 17, 2006.
This IEP expired just prior to the youth’s admission to
MDJDC, and yet no documentation was provided to indicate
that any action had been taken to update the youth’s IEP.
All actions taken on behalf of a youth need to be clearly
documented in the youth’s file. Even when another school is
responsible for the action itself, the school that is
presently serving the youth should receive frequent progress
reports to ensure the documents needed to certify
eligibility and to direct service provision are in
compliance with State and federal law.

School administrators also indicated that they were unable
to provide speech, language, and other types of related services,
and could not accommodate youth who required assistive devices or
technology. Administrators stated that the facility did not have
access to qualified consultants or assistive equipment. Services
prescribed by a youth’s IEP cannot be denied by the facility.

Access to Education

The IDEA requires that all youth with certain disabilities
have access to free and appropriate public education (FAPE) which
meets the standard of the State education agency. 20 U.S.C.
§§ 1401(8)(b) [eff. July 1, 2005]; 20 U.S.C. §§ 1401(9)(b);
1412(a)(1)(A). See also 34 C.F.R. § 300.600(a)(2)(ii). However,
Marion routinely fails to provide certain categories of youth
with access to any educational services, including special
education. Some youth in isolation are denied any educational
services. Similarly, youth who are scheduled to be released to
the Department of Corrections (“DOC”) do not attend any school.

- 23 

Finally, Marion does not provide any special education services
to girls unless at least two girls are eligible for the services.
These practices can severely impact a youth’s education.
For example:

We identified 25 youth (20% of the total youth population at
Marion) who had been at the facility for more than three
days and who were not enrolled in school.19 Eleven of these
25 youth were eligible for special education services, but
were not receiving them.


Two youth, [OB] and [QN], had been at the facility for 19
days and 35 days, respectively, and were eligible for
special education services under the Other Health Impaired
category, but neither had been enrolled in school.


Two youth with learning disabilities, [SC] and [IT], had
been at the facility for 21 days and 29 days, respectively,
but neither had been enrolled in school.


One youth [KI] had resided at Marion for 105 days, yet had
never been enrolled in school.

Marion’s failure to provide access to any educational
services for some youth, including special education, violates
youths’ rights to access to education. Even when youth have
access to an educational program, the program is inadequate.
Marion provides a total of 260 minutes of academic instruction
daily, which is less that the 360 minutes of instruction required
by state law. Ind. Code § 20-30-2-2. Marion attempts to
rationalize this disparity by claiming that the entire school has
been designated as an Alternative School, which requires fewer
instructional hours. However, a blanket decision to enroll all
youth in an Alternative Program fails to account for the
individual needs of youth and appears to be a decision made
purely for the convenience of the facility rather than on the
needs of the youth. Indeed, some youth at MDJDC who have been on
track for high school graduation could be derailed by a stay at
MDJDC, as the facility cannot accommodate their course of study.


In order to rectify the identified deficiencies and protect
the constitutional and statutory rights of youth confined at
Marion, this facility should implement, at a minimum, the
following remedial measures:

Three days is the generally accepted standard for the
period of time in which youth must be enrolled in school
following admission to a juvenile justice facility.

- 24 




Protection from Youth Violence

Ensure that youth are adequately protected from
physical violence committed by other youth.


Ensure that the facility maintains sufficient levels of
adequately trained direct-care staff to supervise youth


Ensure that staff receive adequate pre-service and inservice training in behavior management, de-escalation
techniques, assault intervention, and suicide


Ensure that the facility provides adequate and
appropriate structured youth programming.


Ensure that there is an adequate and effective behavior
management system in place, and that the system is
regularly reviewed and modified in accordance with
evidence-based principles.


Ensure that the facility develops and implements an
adequate objective housing classification system to
ensure safe housing assignments.

Protection from Excessive and Unlawful Isolation

Ensure that youth at the facility are not isolated for
excessive periods of time or in an arbitrary or
disproportionate manner.


Ensure that youth sanctioned to punitive isolation
receive adequate procedural safeguards.


Ensure that youth sanctioned to punitive isolation
receive adequate programming and essential services.

Suicide Prevention Measures

Develop adequate suicide prevention policies and


Perform required observation checks in random
intervals. Record the checks and verify that the
checks are occurring.


Provide cut down tools in all housing units.

- 25 




Protection from General Harm

Ensure that the facility develops and maintains an
adequate youth grievance system.


Ensure that all allegations of child abuse and
mistreatment are referred to the appropriate external


Ensure that the facility adequately and timely
investigates serious incidents and allegations of staff

Fire Safety

Conduct and document adequate fire drills.


Ensure that all employees have keys to the fire alarm


Ensure that fire hazards are eliminated.

General Sanitation

Ensure that youths’ clothing is properly cleaned,
dried, and transported.


Ensure that hygiene practices minimize the risk of
disease transmission (e.g., that youth do not share


Ensure that all mattresses, pillows and gym pads are
adequately cleaned and disinfected.

4. 	 Ensure regular and periodic cleaning of all housing
areas, including toilets and showers. Ensure that
regular and periodic insect control measures are


General Safety

Develop and implement proper chemical safety measures.


Ensure that safety hazards are eliminated.

Special Education

Ensure timely and appropriate assessment and
identification of youth qualified for special education

- 26 


Provide qualified youth with adequate special education
instruction, by an adequate number of special education


Develop, revise as appropriate, and implement adequate
Individualized Education Plans and provide necessary
related services.


Provide adequate access to educational services.



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 Marion. Assuming there is a 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 of the issues discussed in this
letter and offer practical technical assistance in addressing
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
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 note
that we are also authorized, pursuant to 42 U.S.C. § 14141, to
initiate a suit to address the above described conditions.
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.

- 27
/s/ Wan J. Kim
Wan J. Kim
Assistant Attorney General
cc:	 Kobi M. Wright
Corporation Counsel
Marion County, Indiana
Robert Bingham

Chief Probation Officer

Marion County Superior Court 

Richard Curry


Marion County Juvenile Detention Center

Roberta Sabin Recker


Indianapolis Schools

The Honorable Susan W. Brooks

United States Attorney

Southern District of Indiana

The Honorable Margaret Spellings


United States Department of Education 

Mr. John H. Hager
Assistant Secretary
Office of Special Education and Rehabilitative Services
United States Department of Education
Ms. Patty Guard

Acting Director

Office of Special Education Programs

United States Department of Education