Independent
Review
Commission
on
Hillsborough
County
Jails

Final Report

September 10, 2008

Prepared by the
Independent
Review
Commission
on
Hillsborough
County
Jails

Final Report

September 10, 2008

Independent Review Commission on Hillsborough County Jails
Final Report
Table of Contents
Topic

Page

Introduction

1

Commission Membership

1

Commission Charge

2

Commission Activities

2

Commission Acknowledgements

4

Commission Findings

5

Charge 1: Patterns, customs, and practices of conduct in the jail

6

Commentary

6

Recommendations

16

Charge 2: Policies and procedures that are or should be in place

19

Commentary

19

Recommendations

24

Charge 3: Management and supervisory oversight

25

Commentary

25

Recommendations

29

Charge 4: Training and employee development

30

Commentary

30

Recommendations

33

Appendix A
Independent Review Commission on Jails - Meeting Agendas
March 10
March 21
April 4
April 15
April 25
May 5
June 2
June 20
July 11
August 1
August 15
August 22
Appendix B
Preliminary Report of the Independent Review Commission on Jails
Appendix C
Tasks to be Completed Following the Preliminary Report
Appendix D
Grievance Work Group Report
Appendix E
Internal Affairs Work Group Report
Appendix F
Use of Force Work Group Report

Final Repor t

Report of the Independent Review Commission
On Hillsborough County Jails
Introduction
On February 28, 2008, Hillsborough County Sheriff David Gee announced the
creation of an Independent Review Commission to examine the policies,
practices and procedures in the Orient Road and Falkenburg Road jails. The
development of this Commission followed several publicized incidents in the jail,
including one involving Brian Sterner, an inmate in a wheelchair. As the news
release announcing this body indicated:
Recent reports about alleged abuse of inmates have cast a critical light on
the Department of Detention Services. Sheriff Gee is keenly aware of the
public reaction and questions about what occurred in the jail, and
understands that public confidence in the county jail system is an essential
element in protecting the citizens.
Internal investigations into the
allegations are currently under way; however Sheriff Gee believes an
independent commission needs to further examine the inmate booking
and incarceration procedures, and afford the public a legitimate, unbiased
report on the jails.
As established by Sheriff Gee, the Commission includes a diverse group of
professional and community leaders and lay citizens who have been given
unrestricted access to facilities, staff, inmates and documents in carrying out its
assessment of the Hillsborough County jails.
Commission Membership
The Commission is composed of eleven members:
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Dr. James D. Sewell, Assistant Commissioner (Retired), Florida
Department of Law Enforcement, Chair
Dr. Lorie Fridell, Associate Professor, University of South Florida, and
Board Member, American Civil Liberties Union of Florida
Ned Hafner, Director of Corrections (Retired), St. Johns County, FL,
Sheriff’s Office, and Director of Corrections and Jail Services, Florida
Sheriffs Association
Honorable Al Higginbotham, Hillsborough County Commissioner
Brian Kensel, Special Agent (Retired), Federal Bureau of Investigation
Reverend Beverly Lane, Pastor, Bethel African Methodist Episcopal
Church
Clarence McKee, Chief Executive Officer, McKee Communications
Linda McKinnon, Chief Executive Officer, Central Florida Behavioral
Health Network, and President, Florida National Alliance on Mental Illness

Report of the Independent Review Commission On Hillsborough County Jails

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Dr. Delia Aguirre Palermo, Professor, St. Petersburg College
General Peter J. Schoomaker, U.S. Army (Retired)
Chief Raymond E. Velboom, Dade City Police Department

Personnel from the Hillsborough County Sheriff’s Office have provided staff
support for the Commission throughout its tenure.
Commission Charge
As indicated, the Independent Review Commission on Jails was established by
Sheriff David Gee to examine the inmate booking and incarceration policies,
conditions, and procedures in Hillsborough County jails and to provide the
citizens of Hillsborough County a legitimate, unbiased, and public report.
Specifically, the Commission has been charged with examining:
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Patterns, customs, and practices of conduct and discipline in the
jails;
Policies and procedures that are or should be in place;
Management and supervisory oversight;
Training and employee development.

The Commission was further charged with conducting public workshops as
necessary and with providing two reports: a preliminary report by May 9, 2008,
and a final report by September 1, 2008. This Final Report is being submitted to
Sheriff Gee on September 10, 2008.
Commission Activities
During the course of its work, the Commission held twelve public meetings, all of
which provided time for public comment:
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On March 10, 2008, at Orient Road Jail
On March 21, 2008, at Jefferson High School
On April 4, 2008, at University Area Community Center
On April 15, 2008, at Hillsborough County Sheriff’s Office Training
Division, Pinebrooke Building Auditorium
On April 25, 2008, at Tampa Port Authority
On May 5, 2008, at Tampa Port Authority
On June 2, 2008, at the Falkenburg Jail and at the Hillsborough
County Sheriff’s Office Training Division, Pinebrooke Building
Auditorium
On June 20, 2008, at the Florida Department of Law Enforcement,
Tampa Bay Regional Operations Center
On July 11, 2008, at the 13th Judicial Circuit Main Courthouse,
Judicial Conference Room

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Report of the Independent Review Commission On Hillsborough County Jails

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On August 1, 2008, at the Hillsborough County Planning
Commission Board Room
On August 15, 2008, at the Hillsborough County Sheriff’s Office
Training Division, Pinebrooke Building Auditorium
On August 22, 2008, in the Hillsborough County Center 26th Floor
Conference Room

During the course of its 180 day work period, the Commission heard
presentations and testimony from 30 individuals who were invited to speak, a
number of whom, because of their responsibilities and expertise, appeared at
several meetings. Among those invited were representatives from a number of
groups, including the National Association for the Advancement of Colored
People, American Civil Liberties Union, Equality Florida, Florida’s Children First,
Hillsborough County Criminal Defense Lawyers Association, and the Advocacy
Center for Persons with Disabilities. Fourteen (14) other individuals offered
comments during the Public Comments section of the meeting agendas.
Appendix A reflects the formal agenda and invited speakers for each of the
Commission sessions. Additionally, as part of the Commission’s efforts to
ensure the transparency of its actions, transcriptions of each meeting and copies
of all handout material provided to the Commission are available on the
Hillsborough County Sheriff’s Office website (www.hcso.tampa.fl.us).
All
Commission meetings have been videotaped, and copies of these are
maintained by the Hillsborough County Sheriff’s Office.
Individual members of the Commission have conducted on-site visits of booking,
confinement, housing, and other functions at the Orient Road and Falkenburg
Road Jails, and, for comparison purposes, at the Pinellas, Polk, Broward, and
Citrus County jails. Commission members conducted numerous staff and inmate
interviews during these on-site visits. Several members observed detention
trainees participating in the Final Practical Exercises for new Detention personnel
on March 26 and on June 8. Members of the Commission also attended several
of the monthly inmate representative meetings and other sessions involving
Detention personnel. Commission members had, and took advantage of,
unhindered 24/7 access to jail facilities and employees.
As part of its formal information gathering process, Commission members
conducted 12 focus group interviews with Detention personnel, broken into the
following groups: captains and lieutenants (one session); sergeants and
corporals (one session of day shift personnel; one of night shift); Detention
deputies assigned to Central Booking (one session of day shift personnel; one of
night shift); Detention deputies assigned to confinement units (one session of day
shift personnel; one of night shift); Detention deputies assigned to housing units
(one session of day shift personnel; one of night shift); Detention deputies
assigned to transportation duties (one session); and medical personnel (two
sessions). A total of 148 individuals participated in these focus group sessions.

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Report of the Independent Review Commission On Hillsborough County Jails

Informally, members of the Commission have been approached by and received
information from citizens, former inmates and their families, and current and
former Detention staff about issues pertaining to the operation of the
Hillsborough County Jail.
Working groups of Commission members conducted in-depth reviews of three
critical areas: (1) use of force, (2) formal investigations of misconduct, and (3)
inmate grievances. The results of these reviews are included as appendices to
this report, and key findings and recommendations are contained in the body of
this report.
Commission members have also reviewed a variety of documents pertaining to
jail and prison practices, including numerous Hillsborough County Sheriff’s Office
policies and procedures and selected policies from Armor Health Services.
Individually, members have interviewed a number of subject matter experts,
including personnel from the National Institute of Corrections, the Jail Operations
Section of the National Sheriffs Association, the Florida Justice Institute, and the
Los Angeles County Jail, to add to their knowledge and understanding of jail
operations.
Commission members were provided with the full investigative and disciplinary
files for the incident involving Brian Sterner. Sergeant Danny Tewmey, the
Sheriff’s Office Internal Affairs supervisor, provided the Commission with a
detailed case briefing on the incident at its August 15 meeting.
Finally, the Commission’s Preliminary Report, submitted on May 9, laid the
foundation for our direction and activities over the past four months. It provided a
preliminary assessment within each of our areas of examination, identified
specific action steps that should be taken during our comprehensive review, and
made a number of initial recommendations. The Preliminary Report is included
as Appendix B of this Final Report. One component of that Report was a list of
tasks identified as necessary for the purposes of completing the Final Report;
Appendix C reflects those tasks that were identified and completed.
Commission Acknowledgements
The Commission acknowledges and commends Sheriff David Gee for his
decisive action in establishing this body. It is difficult to open up one’s agency to
an outside, independent group for the review of internal actions and procedures.
His leadership in aggressively responding to the situation is outstanding, and his
willingness to allow the Commission to operate freely and without constraint for
these 180 days is commendable.
Second, the Command Staff and a number of other personnel of the Hillsborough
County Sheriff’s Office have provided the Commission with a significant amount

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Report of the Independent Review Commission On Hillsborough County Jails

of testimony, written material, and personal assistance to facilitate our efforts to
understand the operations of the Hillsborough County Jail system. The
Commission appreciates their availability, openness, and willingness to work with
us. The candor of all the detention personnel who were either individually
interviewed or involved in the focus groups was refreshing, and we appreciate
their professionalism, concern, and commitment to the Hillsborough County
Sheriff’s Office and the clientele it serves.
Third, the Commission wishes to recognize and commend the great degree of
cooperation between the Sheriff’s Office, Public Defender, State Attorney, and
Chief Judge which is so essential to the smooth and professional functioning of
the criminal justice system in Hillsborough County. As we learned, such
cooperation is long-standing and on-going, and the Commission believes that it is
a model for the components of the criminal justice system in each of Florida’s
counties.
Fourth, aside from those invited to appear or those who requested to present to
the Commission, few citizens and little media regularly attended these publicly
announced Commission meetings. The Commission would like to thank
Suzanne Guillet, Shirley Johnson, and Al McCray for their interest and regular
attendance at these sessions.
Finally, the Commission commends the performance of the Hillsborough County
Sheriff’s Office staff assigned to assist throughout our tenure: Corporal Theresa
Sweat and Detective Clint Gomes. Their professional approach to this difficult
assignment, their positive attitude, and their responsiveness to the many
requests by Commission members were an outstanding reflection on the Sheriff’s
Office. Without their support and assistance, the Commission would not have
been able to discharge its tasks completely or in a timely fashion. We sincerely
appreciate their hard work and dedication.
Findings of the Independent Review Commission
Introduction
The members of the Commission—like the residents of Hillsborough County and
the personnel of the Hillsborough County Sheriff’s Office—were shocked and
dismayed by the incident on January 29, 2008, that gave rise to this body. We
were greatly disturbed by the actions of the deputy as well as by the inaction of
supervisory and other Detention personnel at the scene. This incident resulted in
the independent and thorough review by this Commission that is documented in
this report.
This specific incident notwithstanding, the Commission has documented many
more strengths than weaknesses in the Hillsborough County jails. This finding is
confirmed by local groups who represent various “constituencies” of the jail and

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Report of the Independent Review Commission On Hillsborough County Jails

by officials representing the other components of the criminal justice system in
the jurisdiction. It is confirmed by a number of national experts who report to us
that the Hillsborough County jails enjoy a stellar reputation nationwide. This
reputation is further confirmed by the extent to which Colonel David Parrish is
called upon to advise his peers nationwide and his longstanding leadership in
national organizations.
We recognize that bad incidents occur in even the best-run institutions. The key
is how an institution responds to such events. The response of the Hillsborough
County Sheriff’s Office has been very strong—conveying clearly and publicly its
accountability to its constituency and its commitment to preventing future
incidents. The Sheriff’s Office thoroughly investigated the incident that occurred
on January 29 and provided appropriate consequences to personnel who were
involved. Following the incident, the Sheriff’s Office immediately initiated
changes in its policies, practices, and training that were directly linked to the
deficiencies producing it. These include enhancements to supervisory practices
in booking, expanded use of video review as an accountability/review
mechanism, and more hands-on attention by upper level managers. The
Sheriff’s Office initiated work on a training program for staff on how to effectively
deal with people with disabilities and enhanced their scenario-based training,
focusing on what was expected of personnel in the detention setting. Finally, the
Sheriff created this Commission to help the Sheriff’s Office identify other areas of
its important work that could be strengthened.
Charge 1: Patterns, customs, and practices of conduct in the jail
Commission Commentary
As we discuss the policies, procedures, and practices of the Hillsborough County
Jail System, the Commission first recognizes that Hillsborough County jails have
been voluntarily accredited by three professional bodies for a significant period of
time: the Commission on Accreditation for Corrections (since 1989), the National
Commission on Correctional Health Care (since 1983), and the Florida
Corrections Accreditation Commission (since 1999). The requirements of these
accreditations and their on-going compliance reviews indicate that the formal
policies, procedures, and basic operations meet national and state standards,
and the Hillsborough County Jail fully complies with Florida’s Model Jail
Standards. National accreditation has been achieved by only approximately 120
of the country’s 3300 jails, and the staff of the Sheriff’s Office is to be
commended for its proactive efforts to attain and subsequently maintain these
professional recognitions.
This Commission also finds that, complementing these professional standards,
Colonel David Parrish is considered accessible to and responsive to the
concerns of other major actors in the criminal justice system. Chief Judge
Manuel Menendez, Jr., State Attorney Mark Ober, Public Defender Julianne Holt,

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Report of the Independent Review Commission On Hillsborough County Jails

and Judge James Dominguez, Chairperson of the Public Safety Coordinating
Council, emphasized this relationship during their appearance before the
Commission on July 11, 2008. In a follow-up appearance, Public Defender
Julianne Holt testified that, during her 16 years in this elected office and 11
previous years as a defense attorney, only an estimated 10 incidents of “jail
abuse” have been reported to her. In each instance, she contacted Colonel
Parrish, who, she reported to the Commission, acted upon the information
immediately. Ms. Holt reports that many of her peers in other jurisdictions do not
enjoy such cooperative relationships with detention leadership.
In any organization, it is the corporate culture—the patterns, customs, and
practices of accepted conduct—that defines the parameters of accepted
behavior. Especially in a law enforcement agency, it is imperative that such
patterns of behavior, customs, and accepted practices meet the highest
professional standards. The Commission’s review indicates that the written
policies and stated practices of the Hillsborough County Sheriff’s Office set a
high bar for professional conduct. In addition, in individual meetings and during a
number of the Cell Representative meetings attended by Commission members,
even inmates made favorable comments about the Detention personnel
supervising them in facility housing.
Hiring Practices
It is significant that just one in 10 applicants for positions within the Hillsborough
County Jail is hired. The minimum requirements, background assessment and
psychological screening components appear to reflect industry standards and
would seem to facilitate and ensure the hiring of quality personnel. During his
testimony, Dr. Vincent Skotko recommended that the battery of pre-employment
psychological tests be expanded to include the Wonderlic Personnel Test, a
cognitive ability test with standardized norms for numerous occupations,
including correctional and law enforcement officers.
Staffing
While inmate overcrowding is not an issue in the Hillsborough County jails,
Detention personnel are concerned about understaffing. During several focus
group sessions, a number of Detention personnel emphasized that the on-going
staffing shortage negatively impacts their safety by reducing the number of
deputies available to respond when a violent incident does occur. Because of
the extended distances between some housing units, Falkenburg Road Jail
personnel most commonly voiced this concern; however, Central Booking
personnel also expressed their concern that, when the number of Booking staff
fell below a certain level, it was difficult for them to effectively perform their
functions. The Commission also acknowledges the further impact of stress on
detention personnel who must work with such staffing shortages, particularly
when excessive overtime results; such stress can lead to inappropriate behavior
on the part of those personnel.

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Report of the Independent Review Commission On Hillsborough County Jails

The Commission heard from Detention leadership about the difficulty of
maintaining a full complement of Detention personnel. While the number of
vacancies have remained around 88 for the last year, the addition of 36
personnel recently released from the Pinellas County Sheriff’s Office during a
budget cutback, will have a meaningful effect once they complete their initial and
Field training programs. This will not, however, completely solve the problem of
understaffing.
Because of these personnel vacancies, Detention management has established
a minimum number of detention personnel necessary to staff each shift and
authorized the use of overtime to meet these minimum staffing levels. Personnel
are authorized to work up to 48 overtime hours a month (24 hours per pay
period); until recently, that maximum level had been set at 72 hours per month.
Line staff mentioned a number of issues pertaining to these overtime
requirements/policies. Some deputies do not want to work overtime and yet are
required to do so; others want to work more than the allotted 48 hours and
believe they can do so without an adverse impact on their performance. Several
deputies expressed concern that they have been called in to work required
overtime on their days off and then sent home after only two hours; the disruption
for two hours of pay, they report, is not worthwhile.
Inmate Services/Treatment
Direct Supervision appears to be a strong model for jail operations that promotes
the dignity of the inmate while ensuring the safety of staff and inmates.
According to the philosophy underlying the model, the inmate is expected to
exhibit appropriate behavior and is treated based on that assumption until
inappropriate behavior is exhibited.
The Sheriff’s Office uses various media to inform inmates about the jails. A video
describing the booking process plays non-stop in the intake area. Upon
transition to housing, each inmate receives an Inmate Handbook that is available
in English, Spanish and Braille.
Topics include arraignment, canteen,
contraband/searches, grievances, per diem fee, inmate disciplinary hearings, law
library, mail, money, outside recreation, educational and vocational services,
smoking, telephones, visitation, and frequently asked questions. Another video,
shown to inmates that are new to housing areas, apparently reviews key
information in the handbook; however, Commission members were not able to
view this video.
Hillsborough County Jails offer a number of educational, vocational and selfimprovement programs for inmates, including Adult Basic Education classes and
General Education Diploma (GED) preparatory classes. Vocational training
classes include computer skills, carpentry/building trades, hotel and tourism,
culinary arts, sewing and alterations, and horticulture/nursery operation. Through
the Horticulture Department, inmates make and bottle the Jail House Fire Hot
Sauce. Life skills classes address a number of topics, including employment
searches, anger management, decision-making, budgeting, food and nutrition,
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Report of the Independent Review Commission On Hillsborough County Jails

and parenting. Domestic Violence and Substance Abuse programs and meetings
are held on site for members of Alcoholics Anonymous and Narcotics
Anonymous. “Seeking Safety” is a model program to help female inmates deal
with some of their traumatic life experiences. While available spots within the
programs do not match level of interest/need, the Commission notes that the
level and quality of available programs (and spots) at the Hillsborough County
Jails seem to significantly exceed national norms. The substance abuse course
is reportedly one of the best in the country. In 2007, the Sheriff’s Office received
the American Correctional Association Program of the Year Award for their
Discharge Planning Program. It should be noted, however, that, of the inmates
interviewed, a number were unaware of the programs (e.g., drug treatment)
available to them while in confinement or expressed their concern that they were
not readily available for their attendance.
The Commission examined the disciplinary process for inmates. Attention was
paid to the quality of the investigation and the due process associated with this
function. The Commission learned about the nature of the punishments imposed
on inmates who were adjudicated as guilty. The maximum punishment for a
particular incident is 30 days in confinement, a loss of privileges, or both loss of
privileges and confinement. In 2007, 5400 disciplinary hearings were held.
For a number of years, the jail system has been holding monthly Cell
Representative Meetings in each jail facility (Falkenburg and Orient). At these
meetings, one inmate represents each of the housing units (pods) and can report
concerns/issues to jail staff. Certain staff members, representing the major areas
about which there may be questions, are required to attend. Concerns raised by
inmates at the forums that were observed pertained to many topics including
canteen items, medical response, laundry services, food, program availability,
temperature of the housing units, phone service, and visitation; the priority
concerns seem to center around issues relating to medical treatment and to the
quality of food services, as well as the consistent quantity of food provided.
Inmates who were interviewed at these forums had mixed reviews of the
process. While a number indicated that they volunteered for this assignment,
others reported that a pod deputy may, instead, select the individual who will
attend; such a staff-selected group may not provide the most representative input
at these meetings.
Inmate Grievances
The Inmate Grievance process is a key method by which inmates can
communicate concerns to jail staff. It is a critical accountability mechanism and
management tool that can promote quality behavior in all detention operations;
its counterpart is the citizen complaint system associated with the law
enforcement (versus detention) side of the Sheriff’s Office. A Work Group of the
Commission conducted a review necessary of this system. Its full report is
included as Appendix D; key observations and the recommendations resulting
from their review are provided herein.

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Report of the Independent Review Commission On Hillsborough County Jails

First, it is important to note that one expert with whom we conferred reported that
many jails in this country have no inmate grievance process whatsoever. The
Hillsborough County Sheriff’s Office changed its methods for processing
grievances on November 21, 2006. Pursuant to the new policy and consistent
with the philosophy of direct supervision, pod deputies are directed to try to
resolve issues raised by inmates immediately without filing any paperwork. If the
deputy cannot resolve the inmate’s concern, the inmate will next meet with a
supervisor. If the issue is not resolved during that meeting, an Inmate Grievance
Form (IGF) is completed. The inmate’s grievance is investigated and a
disposition produced and reported back to the inmate. The inmate can appeal.
Both Public Defender Julianne Holt and Colonel Parrish highlighted the
importance of inmates understanding how the grievance process works. This
topic in the Inmate Handbook, however, is addressed with just two sentences:
“Inmates are afforded the opportunity to register complaints about the conditions
of confinement, policy, or incidents. Grievance forms are available upon request
from the pod deputy.” This very brief description does not convey sufficient
information or fully reflect the new procedures that were adopted by the Sheriff’s
Office in 2006. Both Holt and Parrish similarly highlighted the importance of the
inmate Orientation Video for purposes of transmitting this information to illiterate
inmates. As previously noted, Commission Members were not able to view the
Orientation Video.
Staff who were interviewed or participated in focus groups, for the most part,
reported that the grievance system is sufficiently “accessible” to inmates. Other
staff members and some inmates, however, expressed concerns about the ability
of inmates to utilize/access the grievance system. Some inmates were reticent
to approach a pod deputy with their concerns, particularly if that deputy was the
source/object of the concerns (e.g., the inmate’s concern was with force used by
that deputy). Some inmates expressed frustration that they did not understand
what types of concerns were officially “grievable” and “not grievable.”
Some interviewed inmates reported successful and fair processing of their
concerns and, in this context, reported that certain staff members were
particularly approachable and otherwise quite clearly dedicated to serving
inmates in a respectful manner. Some supervisors, they noted, went “above and
beyond” what was required to listen and respond to inmate concerns. Other pod
deputies and supervisors were not similarly regarded.
Commission members reviewed all grievances filed in 2007 and requested and
received disposition information for grievances filed in both 2006 and 2007. One
phenomenon identified through these processes was that not one inmate
followed up on his/her stated intention to appeal the disposition of the grievance.
While we might expect a low level of inmate follow up, the 100% failure rate
raises the question of whether the inmates understand what they must do—
beyond checking the box on the form–to proceed. The grievance form indicates

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Report of the Independent Review Commission On Hillsborough County Jails

that, “Appeals must be submitted within 15 days and must include a copy of this
grievance.” It does not indicate how the appeal is initiated (using the Inmate
Request Form).
In the context of discussing the relatively new procedures, Colonel Parrish told
the Commission that he wants to “get it automated so I can track it like we do all
the other things.” Subsequent interviews with command staff indicated that a
new tracking system is, in fact, forthcoming. This will include computerized
tracking of requests for and dispositions resulting from supervisor meetings with
inmates.
Much of the information about strengths and weaknesses of the system came
from interviews with inmates and staff. The committee members understand fully
that some individuals in either of these groups might be motivated to put the
system in the “best” or “worst” light. These interviews were important for
highlighting aspects of the system that one might expect would need
strengthening if it were implemented in any jail, if only because human beings
are being asked to implement it. Because we have come to believe that most of
the staff in the Hillsborough County Sheriff’s Office detention system are highly
professional and well intentioned, we do not recommend a return to the earlier
system nor a switch to some of the other systems we identified through our
research on other jails. Instead, we have produced some recommendations to
strengthen the current system.
Formal Investigations of Misconduct
During the course of its deliberations, the Commission, through another of its
work groups, reviewed the formal investigation of misconduct function, which is in
place to conduct administrative and criminal investigations into alleged
misconduct on the part of Sheriff’s Office employees. The report of the Work
Group on Formal Investigations of Misconduct is included as Appendix E.
Under current policies of the Hillsborough County Sheriff’s Office, formal
investigations of misconduct are concluded in one of the following categories of
findings:
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Sustained: finding or conclusion that an allegation is supported by
a preponderance of evidence.
Unfounded: A finding or conclusion that an allegation is
demonstrably false.
Unsubstantiated: A finding or conclusion that sufficient credible
evidence was lacking to prove or disprove the allegation.
Exonerated: A finding or conclusion that the incident occurred but
the individual's actions were lawful and proper.
Exonerated Due to Policy Failure: A finding or conclusion that a
present policy, procedure, rule or regulation covering the situation
was nonexistent or inadequate. In all cases involving a finding of

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Report of the Independent Review Commission On Hillsborough County Jails

Exonerated Due to Policy Failure, the person making the finding
must initiate a review of the policy in question and draft a
recommendation to resolve the failure.
As part of its review, the Work Group examined all incidents requiring formal
investigations of misconduct between January 2005 and December 2007.
During 2005, 71 incidents required a formal investigation of misconduct. These
incidents, which involved 90 detention personnel, included 148 different criminal
or administrative charges (findings). As a result of these investigations, 114
charges were sustained and disciplinary or criminal action initiated; 14 were
unfounded; and 20 were found to be unsubstantiated.
During 2006, 71 incidents required a formal investigation of misconduct. These
incidents, which involved 82 detention personnel, included 161 different criminal
or administrative charges. As a result of these investigations, 121 charges were
sustained and disciplinary or criminal action initiated; 9 were unfounded; 23 were
found to be unsubstantiated; and 8 were exonerated.
During 2007, 56 incidents required a formal investigation of misconduct. These
incidents, which involved 62 detention deputies, included 150 different criminal or
administrative charges. As a result of these investigations, 132 charges were
sustained and disciplinary or criminal action initiated; 9 were unfounded; 7 were
found to be unsubstantiated; 1 was exonerated; and 1 was exonerated due to
policy failure.
As part of its analysis, the Work Group reviewed 25 randomly selected formal
investigations of misconduct from this 3-year period and found them to be
substantive and quality investigations. This review confirmed that allegations of
excessive use of force were in fact being followed up as internal investigations.
During the course of its assessment, this Work Group identified a number of
issues that were later reinforced by staff interviews:
� There is some confusion about what constitutes a Use of Force and
what must be reported. The atmosphere within Detention following the
Sterner incident has resulted in uncertainty and lack of consistency in
definition and reporting across shifts and personnel. Even the Sterner
case itself presented some confusion over “where to put it and whether
to report it” within current parameters of incident reporting.
Supervisors appear to be divided about what to report and what form
to use, and this uncertainty for deputies may lead to over or
underreporting.
� Formal investigations of misconduct rely on the use of Assailant
Control Reports and Assailant Control Investigator Reports generated
by deputies and supervisors at the jails. The Work Group identified
several cases in which the use of force was not documented through
the filing of an Assailant Control Report form, and no consistent

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Report of the Independent Review Commission On Hillsborough County Jails

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discipline was imposed on those who failed to submit these required
reports. Holding detention personnel accountable for the completion
and submission of these forms is critical to an effective program of
behavioral control. Further training of supervisors on the Use of Force
reports should improve their understanding of reporting requirements.
Supervisor training should also improve the usefulness and value of
investigations before they reach the level of a formal investigation of
misconduct and should improve the consistency across shifts and
personnel of Use of Force reporting.
Taser use is limited and rare. However, some Detention personnel are
requesting that these instruments be made more readily available to
supervisors. If Tasers are made more accessible than is currently the
case, their use, and the necessary investigative follow-up, may
increase. The Sheriff’s Office reports that its personnel review the data
recorded by the Taser itself to assess proper use and to corroborate
investigative reports. That this information was used as part of the
investigation was not indicated in any of the reports reviewed by the
Commission.
One of most useful investigative tools is the review of images captured
from multiple cameras at the jails. The camera system used in the
jails, particularly at Orient Road Jail, has been updated since its
installation. These cameras do not, however, capture sound as part of
the monitoring capability. The existence of an audio record to enhance
the existing video would protect both inmates and deputies and allow
for a more complete understanding and review of any incident.
Detention deputies are not regularly assigned to Internal Affairs as part
of their professional development or to ensure this critical function is
undertaken by personnel who fully understand the unique
circumstances of detention operations. Similarly, Detention personnel
should be encouraged to take advantage of existing Sheriff’s Office
career development policy which allows rotation into other elements of
the agency.

Medical Issues
Medical services are contractually provided by Armor Health Services. Interviews
with Detention and medical personnel indicated similar issues raised by the
Department of Detention Services and its medical services provider:
� High turnover in clinical and administrative personnel
� Lack of on-going opportunities for professional development and
training
� Lack of adequate medical supplies
� Lack of communication within and between the entities
� Need for management and supervisory development training
� Lack of flexibility in scheduling personnel
� Limited scheduling options which reduce available PRN and
regular staff and result in increased need for agency personnel.
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Report of the Independent Review Commission On Hillsborough County Jails

�
�
�
�

High use of agency personnel to supplement Armor staff
Inability of evening and night shift to access medical supplies
The inability of PRN and agency medical staff to access
computers impedes their ability to do the job
Lack of documented oversight

Interviews with medical staff generally reflected a good working relationship and
communication with Detention staff. Detention personnel and some medical staff
raised concerns about patient care, citing instances when, particularly at the pod
level, bandages had not been changed in a timely fashion or prescribed
medications were not available. Personnel in Central Booking expressed
concerns about the accurate and prompt assessment of inmates. Interviews
suggested that supervisory medical personnel do not routinely review medical
activities at the pod level. Additionally, limitations attributed to the Health
Insurance Portability and Accountability Act (HIPAA) appear to act as a barrier to
effective communication between Detention and medical personnel.
The Department of Detention Services provides one on-site fulltime equivalent
(FTE) position devoted to contract management and oversight, including the
review of a number of monthly and daily reports. This Contract Manager also
completes an informal review of medical charts and medical operations on a daily
basis and is responsible for identifying and addressing specific issues for
resolution between Armor and the Sheriff’s Office. In addition to this oversight,
Medical Services are reviewed by the National Commission on Correctional
Health Care (onsite every three years), Florida Model Jail Standards (annually),
Commission on Accreditation for Corrections (every three years), and Florida
Corrections Accreditation Commission (every three years). The contract does
not identify specific requirements regarding incident reporting, although Armor
Health Services completes incident reports within the Sheriff’s Office system and
through its own company reporting system. There appears to be no formal
annual contract monitoring document or benchmarking of performance currently
in place. Additionally, while the contract requires a written summary of
deficiencies and performance, the contract manager does not currently document
this.
Armor has a clear process for inmates to request medical services as well as for
handling medical grievances.
The latter process, which exceeds the
requirements of the contract, requires that the Grievance Coordinator investigate
the complaint, ensure actions are taken if the complaint is valid, and inform the
inmate in writing of those actions. It further includes reviews up to the Health
Services Administrator and Medical Director. Armor maintains individual data on
requests for medical review and on medical grievances and addresses major
issues through their Continuous Quality Improvement (CQI) process; trends on
grievances are reported monthly to Department of Detention Services
management.

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This CQI program included monthly auditing activities and process studies. This
program meets the requirements of the National Commission on Correctional
Health Care (NCCHC) and is subject to annual review by that body. The contract
also requires an annual per review, which is to be completed each year by
outside consultants who review medical care, psychiatric care, and dental care in
three separate reviews.
Mental Health Issues
The Hillsborough County Jail system has long recognized the impact of mental
health issues on those who are incarcerated there. In 2001, for instance,
following a year in which three suicides occurred (after a ten-year period with
only one suicide), the Sheriff’s Office brought in an expert to review its
processes/facilities for dealing with suicidal inmates. The Hillsborough County
Jail has subsequently adopted new practices of suicide prevention, including
providing a suicide information/risk factors card to each member of the
Department of Detention Services staff.
At its August 1 meeting, the Commission heard from Judge Steven Leifman, who
currently serves as a Special Advisor on Criminal Justice and Mental Health to
the Florida Supreme Court. As he noted, on any given day, there are
approximately 15,000 people with mental illnesses in Florida’s local jails, and our
jails and prisons have become warehouses for inmates with mental illnesses.
While the correctional and mental health communities in Hillsborough County
have been recognized for their innovative ways of dealing with such populations,
this continues to be a statewide issue affecting the entire criminal justice system.
Legislation being introduced in the 2009 session of the Florida Legislature would
promote the diversion of such persons to appropriate services prior to and
instead of processing them through the criminal justice system.
Language Capabilities
The Commission heard testimony from Public Defender Julie Holt at its August
22 meeting about the significant increase in inmates for whom English is, at best,
a second language; her information was reaffirmed by Colonel Parrish. By the
nature of the Hillsborough County community, the majority of such individuals are
Spanish-speakers. While the Hillsborough County Jails have made great strides
in assuring that all publications, including inmate handbooks and legal forms, and
signage are produced in English and Spanish, the administration must continue
this effort and identify any areas where gaps exist. The Sheriff’s Office is to be
commended for providing a monetary incentive for its personnel to become
fluent, and maintain their fluency, in Spanish; this effort, supplemented by the
use of “street survival Spanish” courses for law enforcement and detention
deputies, should also be continued. Similarly, programs offered through the
Department of Detention Services, particularly General Education Diploma
preparation, substance abuse, and anger management, should also be offered in
Spanish as resources permit and are available. As the population and diversity

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of Hillsborough County continue to grow, so should the Sheriff’s Office program
and information capabilities in other languages.
Other Detention Staff Issues
Detention staff was extremely forthcoming during their presentations before the
Commission and during our focus group sessions, and their input is reflected
throughout this Report. Several other issues were raised during the focus group
sessions and are worthy of consideration by the administration of the Sheriff’s
Office.
First, Detention staff throughout the various ranks spoke with pride about their
membership in the Hillsborough County Sheriff’s Office and offered that they feel
part of a family, especially within the Department of Detention Services. They did
note, however, that they felt as “second class citizens” in the hierarchy of the
organization and expressed concerns about their mobility within the agency,
particularly their ability to move into law enforcement positions, and their
opportunities for professional development. They acknowledged the significant
gains in salary that have occurred under Sheriff Gee’s administration, but
recognize that true pay parity with law enforcement does not yet exist.
Second, all shifts expressed a desire to see and hear from ranking officers aside
from those who directly supervise them. Personnel in the housing units,
especially on night shift, would like to be visited for more than just a walkthrough
by the Sheriff, Chief Deputy, Detention Services Colonel, and other agency
command officers. As is done in many law enforcement departments, Detention
personnel would like to have their own command occasionally work a full shift in
Booking or in the housing units to retain their proficiency and awareness of
current issues in detention.
Third, Detention personnel expressed a need for greater communication with and
information from agency command staff. They were frustrated about the lack of
communication about the issues, investigation, and discipline which arose as a
direct result of the incident involving Brian Sterner.
Recommendations
The Commission recommends that:
o The Sheriff’s Office should consider the inclusion of the
Wonderlic Personnel Test among the battery of tests given to
applicants being screened for hiring.
o The administration of the Department of Detention Services
should ensure that inmates selected to attend Inmate
Representative meetings do so voluntarily and are
representative of their housing unit.

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o The administration of the Department of Detention Services
should ensure that inmates understand how to initiate a
grievance and what to expect from the system once it has been
filed. This should include accurate and expanded coverage in
the Inmate Handbook that reflects the procedures adopted in
2006 and corresponding coverage in the “Orientation Video.”
o The administration of the Department of Detention Services
should make it clear to both inmates and staff that a grievance
can be filed on a shift other the one during which the grieved
about incident/behavior occurred. This information should be
included in the written and video material provided to inmates
and, if necessary, Department policy.
o The administration of the Department of Detention Services
should ensure that Detention staff members understand the
importance of both the grievance system and their own role in it.
o The administration of the Department of Detention Services
should incorporate into policy (e.g., DTN 914.06) a provision
indicating that a jail staff member is subject to discipline if he or
she intentionally or due to ignorance of policy thwarts an
inmate’s efforts to use the grievance procedures for what
appears to be a viable grievance.
o The administration of the Department of Detention should
ensure through policy and/or training that supervisors who are
charged with investigating/resolving grievances conduct
sufficiently comprehensive reviews and document them in their
reports.
o The Department of Detention Services should supplement
procedures and forms, as necessary, to ensure that inmates
who check “I would like to request an appeal,” are uniformly
provided with information regarding the tasks they must
complete.
o To ensure grievances are used as both a monitoring and a
management tool, reports on the number, nature and disposition
of grievances should be reviewed by supervisory staff up to and
including, at regular intervals, Facility Commanders.
o Grievance disposition statistics should be compared on a
regular basis across similarly situated supervisors who are
conducting the investigations. A finding that a particular
supervisor has disposition statistics that are very different from

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his/her peers should result in a further review of his/her
processes.
o The definition of Use of Force should be clarified and
disseminated to ensure that all deputies understand what Use of
Force is and what must be reported.
o Once this above noted consistency has been accomplished, the
discipline for failing to document use of force through an
Assailant Control Report should be clearly defined and
consistently applied.
o Training of supervisory personnel in the documentation and
investigation of use of force incidents, including the Early
Warning System, should be continued and enhanced.
o The Sheriff’s Office should ensure its Use of Force investigative
reports reflect the review of any data recorded by the Taser data
port.
o The Sheriff’s Office should explore the addition of sound
recording devices at designated areas of the jail, particularly in
certain areas of Central Booking, to supplement the existing
video recording equipment.
o The Sheriff’s Office Legal Counsel should work with appropriate
staff from Armor Health Services to explore better information
sharing between Detention and medical personnel within the
constraints of the Health Insurance Portability and
Accountability Act.
o Department of Detention Services management should ensure
that medical requirements not met through the various
credentialing bodies are regularly reviewed and documented
according to a clearly defined process understood by both the
Sheriff’s Office and Armor Health Services.
o Detention management should ensure that, per contract, an
annual external peer review of medical services is conducted
and that the results are made available to appropriate
management within the Sheriff’s Office.
o The Department of Detention Services Medical Services
Contract Manager should ensure the creation of appropriate
medical trend reports, including requests for interviews and on
grievances, deficiencies, and performance, for review by
Detention management.

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o Sheriff Gee should assume a leadership position within the
Florida Sheriff’s Association in supporting the passage of the
Supreme Court’s mental health/criminal justice legislation.
o The Department of Detention Services should identify needs
and gaps in the translation of all forms, publications, and signs
into Spanish and make appropriate translations.
o The Sheriff’s Office should institute an aggressive program of
recruitment of interpreters in a variety of languages in addition
to Spanish and assure their access by Detention personnel.
Charge 2: Policies and procedures that are or should be in place
Commission Commentary
Especially in a detention setting, it is critical that policies, procedures, and
practices achieve their desired result. It is equally important that the reasons
behind a particular practice not be misconstrued or, particularly during this time
at the Hillsborough County Jail, generate an appearance of impropriety.
Consequently, all policies and procedures must be scrutinized to assure
compliance with these two goals.
A particular example of a practice that can be misunderstood is the use of wellbeing checklists in the booking area. Detention deputies tape these checklists to
the glass walls of the Orient Road Jail holding cells to document the 15- and 30minute checks of inmates. In one instance, the paper was placed in such a
manner that the view of the inmate by the surveillance camera was impeded; we
note, however, the view by detention personnel was not restricted. The inmate
involved later claimed that he had been mistreated and that the paper was
intentionally placed to prevent surveillance filming of the incident. It is the
Commission’s understanding that this practice has been eliminated; additionally,
we understand that the Detention administration is reviewing other electronic or
computerized means of documenting such checks.
Development and Dissemination of Policies
Participants in the focus groups recognize the importance of effective policies in
the governance of the Hillsborough County Jail system. Many, however, felt the
need for increased involvement of line Detention personnel in the development of
these policies and procedures.
New or revised policies are frequently first disseminated as a Departmental
order. Subsequently, such orders produce new or revised policies that are
electronically provided to employees. Although an asterisk in the margin
indicates provisions of policy that have been changed, staff in focus groups

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report that it is sometimes difficult to discern what is “new” about a policy that is
emailed to them.
The computer-based On-Service training is used to promote knowledge of
policies and standard operating procedures by Detention personnel. Although
the tests used in the program are not difficult, many of those participating in the
focus groups found this to be an effective method of assuring that they have read
the policies.
Use of Force
The Use of Force policy, including the response-to-resistance matrix, which is
undergoing further refinement, reflects current professional standards. It is
positive that, within the Department of Detention Services, use of force reports
for all physical contact above escort are required to be reviewed up the chain of
command through Colonel Parrish.
As part of its examination of use of force within the Jail, the Commission
reviewed a frame-by-frame analysis of several use of force incidents that were
brought to its attention by the media and the American Civil Liberties Union. In
each case, we reviewed activity before and after the application of force upon an
inmate. The Commission members---several of whom are practitioner and/or
academic experts on the use of force—concluded that the Detention staff
investigations and analyses were comprehensive and that, in light of the totality
of each set of circumstances, their conclusions were reasonable.
The Commission Work Group on Use of Force examined use of force policy,
procedures, documentation, and oversight in the Hillsborough County jail system.
As part of this analysis, Work group members reviewed data on all force
incidents that occurred between January 2005 and the end of May 2008,
conducted interviews with inmates, conducted interviews and focus groups with
staff, heard presentations from staff in public meetings, and reviewed
documentation on selected use of force incidents. The Group also examined
video recordings of ten use of force incidents for compliance with standard
operating procedures. Only uses of force above Level 2 of the Use of Force
matrix were examined during this review.
Our research uncovered no systemic problems regarding the use of force in
Hillsborough County Jails. Statistically, an arrestee entering the jail system faces
less than a one percent chance of being involved in a use of force incident at any
time during his/her time in jail. In 99.8% of those incidents in which force is used,
an investigation found it necessary and appropriate to the circumstances.
The detailed report from this Work Group is included as Appendix F. Among its
key findings:
� Examination of various Sheriff’s Office data systems for the 41-month
period reflected 3078 uses of force during 1720 incidents; this reflects

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an average of 42 incidents and 75 uses of force per month. As most
incidents involve multiple deputies (on average, 1.8 deputies per
incident), each of whom is required to independently report his/her use
of force via the completion of an Assailant Control Report; the number
of Use of Force Reports will always exceed the number of incidents.
�

During this same period, 247,999 persons were booked into
Hillsborough County Jails. Force at a Level 2 or above was used 3078
times, indicating 1.2% of the population was the subject of force if each
Use of Force Report was directed at a separate person. However, as
noted above, an average of 1.8 Use of Force Reports are submitted
with each incident, thus the actual percentage of individuals booked
who are the subject of a use of force incident is .7 of 1%.

�

Since 2005, 28.6% of all incidents involving force, represented by 35%
of all Use of Force Reports, took place in Central Booking at the Orient
Road Jail. Another 2.6% of the incidents occurred in the booking area
of the Juvenile Assessment Center, which performs the same duties
for juveniles as Central Booking does for adult inmates.

�

The greatest rate of Use of Force Reports occurs as part of the
booking process, with 56% taking place during the night shift.

�

A small group of inmates was involved in an inordinately high number
of use of force incidents. A group of 230 inmates, less than one per
cent of all persons booked, was responsible for 18.2% of the reported
uses of force.

�

The annual rate of bookings and Use of Force Reports was consistent
throughout the period, showing a minor peak in 2006 with a slight
downward trend since.

�

The “average” deputy used force 3.28 times during the 41 months. A
group of 20 deputies, representing 2.1% of all deputies in the study,
were involved in 599 Use of Force Reports, or 19.5% of the total. All
but two of these 20 deputies were assigned to Central Booking.

�

HCSO defines 19 types of incident by which it classifies Use of Force
Reports. The most common incident types are “Disruptive Inmate”,
“Assaults on Staff”, and “Inmate Altercations”. During the 41-month
period under study, a total of 1629 Use of Force Reports involving a
disruptive inmate were filed, of which 1129 (67%) occurred in the
Orient Road Jail. A total of 440 Use of Force Reports involving inmate
altercations were filed, of which 271 (62%) occurred in the Falkenburg
Road Jail. There were 377 reports documenting assaults on staff, of
which 215 (57%) occurred in the Orient Road Jail.

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�

Documentation contained in the Use of Force Reports indicated that 40
inmates received injuries ranging from minor scrapes (31) to known
visible injuries (8) to hospitalization (1). During the same time,
detention personnel received injuries ranging from minor scrapes
during altercations (30) to known visible injuries (7) to hospitalization
(1).

�

There were 238 incidents, involving 383 deputies, in which Oleoresin
Capsicum (OC) foam was used. Most OC incidents (68%) occurred at
Falkenburg Road Jail; 31% took place at Orient Road Jail; the
remaining 1% occurred at the Juvenile Assessment Center, Work
Release Center, or Transportation. OC use represents 14% of the total
Use of Force incidents.

�

A Taser was used six times during the study period: five times at
Falkenburg Road Jail and once at Orient Road Jail.

�

The Pro-Straint Chair was used 1195 times during the 41 months, with
a peak of 400 in 2006 and a declining trend matching drops in booking
and Use of Force rates in subsequent years. It is noted that use of the
restraint chair is generally not reported on an Assailant Control Report,
unless Level 3 or higher force was used getting the inmate into the
chair. All chair use does, however, require submission of an Incident
Report.

�

There were no instances of Deadly Force (Level 6) used in HCSO
detention facilities during this 41-month period of study, nor were less
than lethal munitions used.

�

Under current reporting policies, the use of force at Levels 1 (presence
and dialogue) and 2 (escort, touch, restraint devices) on the
Continuum of Force does not require an Assailant Control Report and
is not considered Use of Force for the purposes of this report. For all
Jail facilities, force characterized as Level 3 was used 881 times; force
characterized as Level 4 force was used 1189 times, of which 78%
were physical takedowns, and 20% involved the use of OC foam.
Level 5 force was used 92 times, 86% of which were characterized as
“defensive strikes.”

�

Overall, there were 17 investigations into allegations of the use of
unnecessary or excessive force against Detention personnel during the
study period. Four of those allegations were sustained and disciplinary
action taken; the others were unfounded.

�

As noted in the earlier discussion concerning formal investigations of
misconduct, the Work Group’s review of files and personnel interviews
indicates that some confusion exists over what out-of-the-ordinary
circumstances must be reported on an Assailant Control Report.
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Some instances that fall outside of the standardized categories,
including the Sterner incident, are not seen as Use of Force by some
deputies, and thus are not recorded via an Assailant Control Report.
Some deputies said their supervisors now require Assailant Control
Reports for even escort force or handcuffing, because of what they
described as an environment where “everyone is walking on egg
shells.” Other supervisors apparently tell deputies to avoid using force
at all, so the supervisor will not have to “waste time entering it in Blue
Team.” Enhanced training should clarify the definition of force to
ensure more consistent reporting and thus a more accurate record of
jail activities. This would avert a sudden spike in Use of Force
statistics that is likely to occur if current practices continue.
Further Analysis of Oleoresin Capsicum (OC) Incident Reports
Most of the incidents involving OC spray in 2007 were precipitated by inmate
altercations. Deputies reported they ordered inmates to stop fighting and, when
they did not, used OC spray against one or more of the involved inmates. This
use of OC spray is consistent with the policy allowing for OC spray to defend
against physical force/resistance (against a jail employee or against other
inmates).
The Work Group found that, generally, the incident descriptions in these reports
are satisfactory and that these reports present facts as well as conclusions. The
investigators usually indicated the specific individuals whom they interviewed as
part of the investigation. Generally, this included all involved inmates and
deputies; sometimes there were specific notations indicating why a particular
inmate was not interviewed or that the inmate was uncooperative. In one
exception, a supervisor did not explain why he did not interview an inmate. Only
a few of the investigators reported interviewing inmates who had witnessed the
incident but were not involved in it, even though a number of the Use of Force
incidents (e.g., precipitated by inmate altercations in housing) were likely in view
of many. In one exception, the investigator reported that he interviewed ”the
inmates in the pod that witnessed the incident.”
In just one of the examined incidents did the investigator note reviewing the
applicable video. Focus groups with supervisory personnel indicate they now
routinely review video on Use of Force investigations. That review was
confirmed by examining recent Assailant Control Investigator Reports.
Analysis of Taser Incident Reports
It is notable and important that the Taser incident reports included detailed
narratives. Generally, these narratives provided detail on the circumstances that
led to the request to use a Taser, the preparations for its use (e.g., bringing a
video to the scene), the actual use and the follow-up (e.g., probe removal and
nurse check on subject). The reports appeared to include all information
required per policy.

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In all but one incident, the jail staff reported a single 5-second activation of the
Taser. The other incident involved one activation using the probes and two more
with direct contact. The reports of five of the six incidents mentioned that a video
was brought to the scene prior to weapon activation. Some reports mentioned
that a nurse was called to the scene prior to weapon activation; all reported that a
nurse was present at the scene after the activation to check on the subject.
Deputies are trained to apply handcuffs during the activation phase to take
greatest advantage of the inmate’s temporary incapacitation.
In several incidents the narrative did not indicate why immediate action was
necessary. There may have been reasons that were not documented. While the
Sheriff Office leadership report that information from the Taser data port and
stationary or handheld video are consistently reviewed as part of the
investigation, this generally was not documented in the investigative reports.
Currently, Lieutenants are responsible for controlling access to and use of
Tasers. Mid-level supervisors support continuing the current practice; Corporals
and Sergeants urge increasing Taser availability by extending the authority and
carriage of Tasers to their level.
Confinement
The Commission found that “confinement” (designating a more restrictive
environment with reduced contact with staff and other inmates) is used for death
row inmates, other “notorious or high profile” inmates, those in need of protective
custody, those who are a danger to self or others, and those receiving discipline.
The Commission reviewed closely (1) conditions of confinement; (2) the process
and frequency of staff review of classification to this high-security unit; (3) the
selection and training of personnel assigned to this unit; and (4) the rationale for
(and national practice regarding) the “notorious or high profile” category. We
found the policies and practices within the Hillsborough County Jail to be
reasonable and in accord with nationally accepted policies and practices.
Confinement staff in focus groups suggested that inmates who are in disciplinary
confinement should not receive all the same privileges, e.g., access to canteen,
visitation, and daily showers, that other inmates in confinement receive. They
report that there is no disincentive for being moved to Disciplinary Confinement
and that some inmates prefer disciplinary confinement over general housing
because they get “private cells” along with all the benefits they enjoy in general
housing. This issue is worth further review by the administration of the Sheriff’s
Office and the Department of Detention Services.
Recommendations
The Commission recommends that:
o Data down to the individual deputy level should be added to the
quarterly command staff reviews of the Use of Force, including
multiple Uses of Force. This should permit a comprehensive
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overview of the individuals using force, and would allow for the
consideration of contributing (and mitigating) factors such as
their location of assignment, shift, etc. that may not otherwise be
apparent.
o Additional training should be provided on definitions of the
“types of force used” in the Assailant Control Report template in
order to increase accuracy of the information and reduce use of
the category “other.”
o The Sheriff’s Office should examine the formation of dedicated
Use of Force investigation team(s) to review all Use of Force
incidents, rather than continuing the current system in which
immediate supervisors conduct the review.
o The records of those inmates involved in multiple Use of Force
incidents should be flagged so additional caution may be
exercised during future bookings and to expedite assignment to
appropriate housing during classification.
Modifications to
current classification procedures should allow at least corporals
and sergeants to determine the appropriate type of housing for
historically dangerous inmates.
o Consideration should be given to requiring law enforcement
officers from all involved jurisdictions to contact Central Booking
via a designated radio channel or by telephone when initiating
transportation to Orient Road Jail to provide at least the
name/date of birth of arrestee(s), and notification of any
resistance, medical issues, etc. which would permit booking to
appropriately prepare for the inmate’s arrival.
o Incident Reports and Assailant Control Reports in Taser
incidents should include the reason that immediate use of the
Taser was required. Investigative reports should document that
data are downloaded from the Taser data port and that the
investigator has reviewed the jail camera videos and/or shot
with handheld camera brought to the scene.
Charge 3: Management and supervisory oversight
Commission Commentary
The Use of Force Work Group examined the oversight/review system in place to
monitor Use of Force by Detention Deputies and found it to be adequate and
effective. Several policies and procedures put into effect in the last seven
months, including those noted below and the addition of new software intended
to permit supervisors to more easily identify emerging trends in Use of Force,
have strengthened that system.
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Longstanding Department of Detention Services policy has required Central
Command lieutenants to review videos of any reported incidents in Booking
involving use of force, officer needs assistance, fights, reported accidents,
disturbances, or unusual situations at the end of their shifts. It is commendable
that the Sheriff’s Office, as one component of their response to the Sterner
incident, expanded this review on March 7, requiring lieutenants in Central
Booking to spend one hour at the end of each shift reviewing random segments
of the video for that shift. After each shift, lieutenants are now required to submit
a report indicating that they have conducted this review and indicating what, if
anything, was noteworthy. As of July 7, lieutenants at Orient Road Jail are
required to conduct and document similar reviews of cameras within Housing
units.
A member of the Commission reviewed all of the reports submitted since the
policy was adopted and found them to be generally informative, including notes
of any unusual occurrences as well as descriptions of the scenes on the videos.
As time has progressed, however, some of the reports have become more brief,
reflecting, in some instances, only that the lieutenant conducted the review;
earlier reports not only reflected any incidents uncovered, but also identified the
specific camera which had been viewed.
The Booking Video Review requirement now has been incorporated into the
Department of Detention Services’ Departmental Standard Operating Procedures
Manual as has the requirement for supervisory random review of shift videos and
the daily summarization of those observations. Daily summary information is
submitted to a Detention Division Commander (Major). This Standard Operating
Procedure could be enhanced by more clearly articulating the information to be
captured in each shift report.
Also in immediate response to the Sterner incident, a new policy was adopted
requiring the on-duty booking sergeant to conduct his/her work at a location
nearer the first station at Booking. This increases the sergeant’s ability to
provide appropriate oversight of his/her staff. In focus groups, staff generally
reported increased visits to their work locations of supervisors up through and
including Captains. This increased presence enhances oversight capabilities
and also, as the staff pointed out, gives supervisory/command staff a greater
understanding of what is happening at the line level.
As previously noted in this Report, interviews indicate that there are
inconsistencies between supervisory personnel in the application of policies and
procedures and in the degree to which oversight is provided.
Promotion to Supervisory Positions
As mentioned above, lack of supervisory intervention and follow-up were key
issues in the incident that led to this Commission. It is significant that line

Page 26 of 33

Report of the Independent Review Commission On Hillsborough County Jails

personnel do not seek promotions in numbers that would allow for selectivity;
such expanded selectivity could increase the quality of supervision in the jails.
With many more applicants than spots, detention leadership could identify and
promote the people who have the most potential for supervising in a manner that
promotes/facilitates high quality, professional conduct. The lack of supervisor
candidates has been due in part to unsatisfactory rewards for promotion, most
significantly that new supervisors will have reduced seniority to bid on desirable
schedules. This means that, more often than not, new supervisors must work the
night shift for a considerable period before returning to the day shift, which is, for
many, the more desirable shift. The new pay plan for detention sergeants,
effective May 5, 2008, increases the pay differential between line deputies and
sergeants and has the potential to reduce the problem of insufficient applicants
for supervisory positions. This change, which is a very positive for advancement
to higher position, may help in the long run to reduce the size and scope of this
problem.
Additional actions are needed to increase the pool of applicants to supervisory
positions. In this context, staff in focus groups suggested that “years in rank”
should not be the only basis for one’s placement in the hierarchy used for
assignment bidding. A system could be developed that further considers the
number of years a person has been employed by the HCSO. The combined
factors---years of service and years in rank---would determine hierarchy
placement and might increase the likelihood that qualified, experienced jail staff
would apply for a supervisory position.
In many law enforcement agencies across the nation, insufficient attention is
given in the promotional process to a person’s ability to manage personnel to
promote professional, in-policy behavior. This can lead to the promotion of
individuals who have successfully memorized the standard operating procedures
(SOPs), but who cannot manage and lead the personnel under their command.
The current promotion test of the Sheriff’s Office emphasizes knowledge of
policies and procedures. The Sheriff’s Office new Employee Performance
Management System (EPMS), when fully implemented, should enhance the
opportunity for managerial skills to be considered for purposes of promotion.
Miscellaneous Accountability Mechanisms
The new Employee Performance Management System has the potential to
significantly promote personnel accountability and even the quality of
supervision. The adoption of this system by the Sheriff’s Office is commendable
and reflects significant foresight.
The fact that the Sheriff’s Office has had an Early Warning System (EWS) in
place since 2002 is also of significance. Such systems have great potential to
promote high quality work/behavior on the part of personnel. These systems
maintain information on individual employees and generate “alerts” to initiate
division commander review/intervention (three uses of force in a six-month period

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Report of the Independent Review Commission On Hillsborough County Jails

generate an “alert” calling for supervisory review). Currently, data elements in
the system used for both detention and law enforcement personnel are citizen
complaints, administrative investigations, use of force and vehicle pursuits. At
present, division commanders are expected to conduct the required review and
note their action on the Detention department log; there is no immediate
notification of or review of the commander’s actions by Professional Standards.
Instead, Professional Standards personnel verify this accomplishment during
their annual staff inspection. Supervisors are not currently trained in how to
maximize the accountability/management potential of the early warning system.
We acknowledge that the Sheriff’s Office will continue to develop this system by
incorporating other data elements.
We strongly support the continued
development of this important accountability/management system.
Blue Team, a web-based paperless reporting system utilized by detention and
law enforcement supervisors, complements this Early Warning System. Staff
interviewed indicated, however, that the system requires duplicative entry of
information and does not fully integrate the Department’s reporting systems.
When fully implemented in Detention, Professional Standards personnel will be
able to electronically monitor compliance with Early Warning System supervisory
reviews by Detention management.
During our review, the Commission noted several issues resulting from the
system in place prior to the advent of Blue Team in February 2008. The
Assailant Control Report template, for instance, did not include the name and/or
personal identification (PID) of the supervisor of the deputy submitting the
Report. Such information allows for monitoring of Use of Force activity under
individual supervisors and offers early notice of an unusual pattern of Use of
Force by deputies working for a particular supervisor. Additionally, data was not
kept in a manner to permit easy identification of the number of incidents,
regardless of the number of employees involved or Assailant Control Reports
filed. Both of these deficiencies, identified originally as areas of needed
improvement by the Use of Force Work Group, are corrected in the Blue Team
data system.
Sheriff’s Office policy includes Sheriff’s Order 0705.17, which establishes Rule
6.1.06 (Failure to Act) and requires employees to report inappropriate behavior
on the part of colleagues. One source indicated that recruits are trained to
intervene with peers who are acting inappropriately. Significantly, a number of
the charges against Detention personnel during the Sterner incident stemmed
from violations of this particular Order.
Community Involvement in the Jail System
During the Commission’s tenure, several citizens have recommended a formal
process of civilian oversight of Sheriff Office operations. While the efforts of this
Commission have centered on an examination of issues pertaining to the Jail,

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Report of the Independent Review Commission On Hillsborough County Jails

these citizens suggested civilian oversight over law enforcement operations as
well.
The Commission recognizes that the Sheriff is accountable to the citizens of
Hillsborough County through the electoral process and to the judicial system for
misconduct, misfeasance, or malfeasance in public office. The Hillsborough
County Sheriff’s Office has in place adequate policies, procedures, and
guidelines to define acceptable conduct by its personnel and to deal with citizen
complaints, grievances, and use of force issues. Our review finds that the
existing formal investigations of misconduct process for both administrative and
criminal violations is professional, responsive, and effective, and we have seen
no significant patterns of misconduct or abuse in our review of formal
investigations of misconduct, use of force, or grievance reports.
The current administration of this agency is equally concerned with assuring the
highest levels of professional conduct and has defined its expectations through
myriad policies, procedures, and approved practices. When leaders and
managers do their job, adequate internal oversight safeguards are in place to
ensure the protection of the citizens of Hillsborough County and the safety of its
law enforcement and detention personnel. This Commission, therefore, does not
support the establishment of a standing civilian oversight body.
Recommendations
The Commission recommends that:
o The Sheriff’s Office should consider, if feasible, incorporating
information on grievances filed by inmates against particular
Detention personnel in its Early Warning System. This inclusion
would be consistent with the current inclusion of citizen
complaints in the system.
o The Early Warning System should allow for more frequent
tracking of whether division commanders do, in fact, conduct the
required reviews following “flags/triggers” and monitor these
tracking data.
o The Department of Detention Services should explore a system
for developing the shift bidding hierarchy of supervisors that
considers both years of service and years in rank.
o The newly adopted Employee Performance Management
System (EPMS) should be used to consider more fully at
promotion the managerial skills of applicants and otherwise
attend more closely to managerial skills when screening
applicants for supervisory positions.

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Report of the Independent Review Commission On Hillsborough County Jails

o The periodic presence of command staff in all areas of the jail
and at all hours of operation should be maintained and, if
possible, increased to enhance oversight and ensure command
staff knowledge of the day-to-day activities of the jail.
Charge 4: Training and employee development
Commission Commentary
The Commission reviewed the Sheriff’s Office training activities through (1)
presentations by training staff, (2) review of curriculum outlines, (3)
demonstration of On-service training and review of On-service topics, (4)
attendance at several training sessions, and (5) discussions during focus groups
with staff regarding academy, on-service and in-service training.
Most of the employees participating in focus groups perceived that the training
they received was appropriate and has become increasingly effective. Indeed,
the Commission has documented a number of strengths associated with the
training provided to Sheriff’s Office employees:
�

�
�
�
�
�
�

�

The number of hours provided to academy trainees exceeds the
requirements of the Florida Criminal Justice Standards and Training
Commission (CJSTC), and trainees receive an additional 200 hours of
post-academy training prior to their assignment to a Field Training Officer.
Hours provided to in-service employees exceed CJSTC requirements for
mandatory retraining.
In recent years, the Sheriff’s Office has reduced in-service class sizes.
Additionally, employees can volunteer to take advanced, outside training
courses.
To set direction for the agency, the Sheriff required in-service training for
all captains, lieutenants, sergeants and corporals shortly after he took
office.
An emphasis in training is on the use of verbal skills to achieve inmate
cooperation and to defuse potentially tense or even violent situations.
The “On-service” (computerized) training is an innovative way to provide
training in a time of reduced resources.
Academy training and the five-week training provided to recruits before
their assignment to the Field Training Program include practical training
scenarios, in which the recruit trainee practices his/her skills and judgment
in role-play exercises. The scenario content is developed as a result of
actual incidents that have occurred in the jail.
Outside expert training resources are utilized to supplement Sheriff’s
Office resources.

Page 30 of 33

Report of the Independent Review Commission On Hillsborough County Jails

�

�
�

The Field Training Officer (FTO) program, which is eight weeks in length,
appears to be state of the art. Selection and training of FTOs appear to
be strong. It is important that the jail has twice as many applicants for
FTO positions as spots available; this allows for selectivity. While the
periodic meeting of FTOs as a group to discuss training issues is
commendable, these meetings may not occur frequently enough.
Sheriff’s Office support for employee education through tuition
reimbursement is positive.
The Sheriff’s Office uses a variety of mechanisms, including courses
presented by nationally recognized providers, to develop the skills and
abilities of current and future leaders. Over a number of years, personnel
have attended the FBI National Academy, the Senior Management
Institute for Police (provided by the Police Executive Research Forum),
the University of Louisville’s Southern Police Institute, and all three levels
of leadership courses presented by the Florida Criminal Justice Executive
Institute.

In our preliminary report, the Commission recommended that, “where practical,
in-service training be expanded to include the use of scenario based training.”
Training staff report that this has been implemented particularly in the training of
new personnel; current academy classes have more scenario-based training.
Several Commission members observed “practical training scenarios” as part of
the post-academy training that we judged to be very realistic and effective
learning experiences.
Scenarios are also being incorporated into new
supervisory training. As additional in-service training for detention deputies is
developed and implemented, it, too, should focus on the use of realistic scenariobased training dealing with contemporary issues, such as use of force and cell
entry and extraction techniques, experienced by Detention personnel.
During its research, the Commission learned that academy training on managing
the stress associated with detention responsibilities is limited to discussions of
stress in general and the need for exercise and other healthy habits. Again, the
development of an “applied” stress management curriculum can better prepare
new and experienced Detention personnel to deal with the psychological,
physiological, and emotional rigors of their job.
As a direct result of concerns arising out of the Sterner incident, staff of the
Sheriff’s Office Training Division and Department of Detention Services have
been working with personnel from the Florida Center for Inclusive Communities
and the Advocacy Center for Persons with Disabilities since February 20, 2008,
to develop training for detention staff on effectively interacting with persons with
mental and physical disabilities. Using a needs assessment survey completed
by 292 Detention deputies, the assigned staff have examined the techniques
used by other agencies in providing similar training and explored the best
avenues for delivery of training and informational materials within the
Hillsborough County Sheriff’s Office. As a result, the Sheriff’s Office will be

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Report of the Independent Review Commission On Hillsborough County Jails

implementing a three part training program in the immediate future: Phase 1 will
provide 8 hours of “Disability Awareness” training and 2 hours of control tactics
for dealing with the disabled during the academy for new personnel; Phase 2 will
provide 8 hours of web-based “Disability Awareness” in-service training for
existing personnel; and Phase 3 will provide 40 hours of Crisis Intervention
Training (CIT) for designated Detention personnel. Additionally, future training
efforts will increase the availability of in-house and contracted supervisory
training; will introduce scenario based training for supervisors; and, in conjunction
with the implementation of the Sheriff Office’s new Use of Force matrix for law
enforcement and detention, will ensure specialized training for all supervisors on
evaluation of the Use of Force.
Supervisor training is critically important to any law enforcement function.
Nationally, this training has been deficient; too frequently, attention to liability
issues and policy knowledge is at the expense of training on how to manage
supervisees in order to ensure quality performance and effectively deal with
personnel issues. According to testimony received by the Commission and
reinforced during the focus group sessions, there appear to have been similar
deficiencies in the training of Detention supervisors.
Even before the incident occurred that led to this Commission, the Sheriff’s Office
had planned new training for supervisors that does, in fact, highlight quality
management/oversight of employees. “Excelling as a First Line Supervisor” will
be given to newly appointed supervisors beginning in Fall 2008. According to the
provider, the Institute for Police Technology and Management, “This interactive
course will teach [supervisors] the fundamentals of coaching and how to
effectively coach employees to obtain maximum performance. [Supervisors] will
also learn how to tactfully counsel poor performers and set clear expectations for
improvement while maintaining their self-confidence.” This new training will
cover “stress awareness” to help supervisors deal with their own stress; it does
not, however, help supervisors detect and respond to the stress of those for
whom they are responsible. Effective training of first-line supervisors should help
them better recognize, respond to, and more effectively deal with personnel
stress prior to severe incidents of misconduct.
Following the Sterner incident, the Sheriff’s Office provided supervisors with
“review” training on how and when to document Use of Force and other incidents
and new training will provide enhanced coverage of how to evaluate Use of
Force incidents. As previously indicated, staff report inconsistencies in and
confusion regarding the definition of and documentation for such incidents;
additional training should be immediately forthcoming.
Upon promotion, supervisors are usually transitioning to both a new function and
a new location in the Jail system. The use of a structured mentor or Field
Training Officer program, such as that provided to new deputies, would be an
important supplement to classroom training. Existing Standard Operating

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Report of the Independent Review Commission On Hillsborough County Jails

Procedure 202.01, “Supervisor Field Training and Evaluation Program,”
establishes a field training program for new supervisors and should be fully and
completely implemented within the Department of Detention Services. An
additional “peer support” option could bring groups of same or similarly ranked
supervisors together periodically (e.g., quarterly) to discuss issues, successes,
and challenges.
Recommendations
The Commission recommends:
o Where practical, in-service training should be enhanced by the
use of scenario based training, and an increased emphasis
should be placed on detention specific in-service training.
o Training provided to detention deputies and medical personnel
assigned to intake/booking should be enhanced to include
required training unique to that environment; to provide a better
ability to anticipate and resolve problems, particularly relating to
substance abuse and mental health; and to include elements of
stress and anger management and crisis intervention training.
Personnel skilled in these unique areas of human behavior
should provide such training.
o More formalized training should be provided to medical staff on
the signs and symptoms of substance abuse and mental health,
as well as on co-occurring disorders; on appropriate intervention
strategies; on assessment techniques; and on enhanced clinical
skills.
o Supervisors should receive increased training in the
identification and management of stress among their
employees.
o The Department of Detention Services should offer enhanced
interpersonal skills training for detention deputies, including
“street survival Spanish” and techniques for de-escalation and
dealing with angry people
o The Hillsborough County Sheriff’s Office should utilize the Field
Training Officer concept in the development, training, and
evaluation of new Detention supervisors.
o Detention personnel should be encouraged to seek rotational
assignment to other areas of the agency as part of career
development efforts.

Page 33 of 33

Appendix A
Appendices

INDEPENDENT REVIEW COMMISSION ON JAILS
ORIENT ROAD JAIL
1201 ORIENT ROAD, TAMPA, FL 33619
MARCH 10, 2008 - 10:00 a.m. to 3:00 p.m.
AGENDA
Charge to the Commission

Sheriff David Gee

Introduction to Hillsborough County Jail System
� Organizational Chart
� Policies and Procedures

Colonel David Parrish

Jail Accreditation

Aimee Elliott, Accreditation Manager

Medical Accreditation

Joan Carver, Accreditation Manager

Training of Detention Personnel

Major James Previtera

Tour of Orient Road Jail

Colonel David Parrish & Staff

Development of Commission Work Plan

Dr. James Sewell

Schedule of Commission Meetings

Dr. James Sewell

Public Comments
Adjournment

A-1

INDEPENDENT REVIEW COMMISSION ON JAILS
4401 CYPRESS STREET, TAMPA FL
(JEFFERSON HIGH SCHOOL AUDITORIUM)
MARCH 21, 2008 - 10:00 a.m. to 3:00 p.m.
AGENDA
Beyond the Myths: the Jail in Your Community
(U.S. Department of Justice
National Institute of Corrections video)
Training
� Recruit/Cadet and In-service training
Human Diversity
Interpersonal Communication
�

Supervisory management development

Use of Force - Detention
� Use of Force Continuum
� Training
�

Major James Previtera
Colonel David Parrish/
Major James Previtera
Major James Previtera
Major James Previtera
Major James Previtera/
Colonel David Parrish
Colonel David Parrish

Documentation

Handling of Complaints of Employee Misconduct
and Inmate Grievances
� Early Warning System
� Complaints of Employee Misconduct
Procedure
Tracking and monitoring
Annual statistics (CY 2003 – CY 2007)
� Grievances
Procedure
Tracking and monitoring
Annual statistics (CY 2003 – CY 2007)
Filed / Sustained
Assaults
� Number of Inmate on Inmate per year
Assaults
Altercations (Fights)
� Number of Inmate on Deputy per year
Psychological Evaluations

Colonel David Parrish

(time certain 2:00 PM)

Sergeant Danny Tewmey
Sergeant Danny Tewmey

Colonel David Parrish

Colonel David Parrish
Colonel David Parrish
Dr. Vincent Skotko

Commission Work Plan

Dr. James Sewell

Schedule of Commission Meetings

Dr. James Sewell

Public Comments
Adjournment

A-2

INDEPENDENT REVIEW COMMISSION ON JAILS
April 4, 2008 - 10:00 a.m. to 3:00 p.m.
University Area Community Center
14013 N. 22nd Street
Tampa, FL 33613
AGENDA
Recruitment and Screening
of Detention (DTN) Deputy Applicants

Lt. Alan Hill
Training Division

Selection of Detention Deputy Candidates

Colonel David Parrish
Department of Detention Services

Training (DTN)
� Field Training Program
�

Lt. James Downie
Field Training Program Coordinator
Lt. James Downie

Selection of Field Training Officers

Stress Management
� Training
� Employee Assistance Program
� Critical Incident Stress Management
�

Peer Support Team

Personnel Evaluations

Captain Clyde Eisenberg
Child Protective Investigations Division

Promotion
� Process
� Candidate Selection

Captain Clyde Eisenberg
Colonel David Parrish

Fitness for Duty
�
�

Psychological
Medical

�

Drug Screening

Lt. Alan Hill
Michele Hamilton
John Garbreana
HCSO Chaplain
John Garbreana

Jim Livingston
Director, Support Services Division
Colonel David Parrish
Rick Swann
Director, Risk Management Bureau
Corporal Jeff Schiro
Professional Standards Section

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-3

INDEPENDENT REVIEW COMMISSION ON JAILS
April 15, 2008 - 6:00 p.m. to 9:00 p.m.
Hillsborough County Sheriff’s Office
Training Division - Pinebrooke Building
1409 Falkenburg Road
Tampa, FL 33619

AGENDA

Dealing with arrestees with physical disabilities
-

Policies*
Procedures*
Practices*

Dealing with arrestees under the influence
(of alcohol/illegal substance/medication)
-

Colonel David Parrish

Policies*
Procedures*
Practices*

Dealing with arrestees with mental health issues
-

Colonel David Parrish
Department of Detention Services

Colonel David Parrish

Policies*
Procedures*
Practices*

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment
*Policies, procedures and practices that were in effect on 01/29/08 and any revisions that
have occurred since that date.

A-4

INDEPENDENT REVIEW COMMISSION ON JAILS
April 25, 2008 - 10:00 a.m. to 3:00 p.m.
Tampa Port Authority Board Room
1101 Channelside Drive
Tampa, FL 33602

AGENDA

Administrative Confinement
-

Colonel David Parrish
Department of Detention Services

Disciplinary
Administrative
Psychological
Protective Custody

Commission Work - Drafting Preliminary Report

Dr. James Sewell

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-5

INDEPENDENT REVIEW COMMISSION ON JAILS
May 5, 2008 - 10:00 a.m. to 1:00 p.m.
Tampa Port Authority Board Room
1101 Channelside Drive
Tampa, FL 33602

AGENDA

Commission Work - Drafting Preliminary Report

Dr. James Sewell

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-6

INDEPENDENT REVIEW COMMISSION ON JAILS
June 2, 2008
10:00 a.m. to 12:00 p.m.
Hillsborough County Sheriff’s Office
Falkenburg Road Jail
520 Falkenburg Road
Tampa, FL 33619
12:00 p.m. to 3:00 p.m.
Training Division - Pinebrooke Building
1409 Falkenburg Road
Tampa, FL 33619
AGENDA
Tour of Falkenburg Road Jail

Falkenburg Road Jail Staff
Department of Detention Services

Inmate disciplinary due process

Sergeant Thomas Luckey
Department of Detention Services

Administrative Confinement
-Decision making process for assignments
-Periodic review of circumstances

Lieutenant Steven Wallace
Department of Detention Services

“On-service” training
-How knowledge of agency policy
is promoted
-Course review

Lieutenant James Downie
Department of Detention Services

Florida Center for Inclusive Communities
(Advocacy Center for Persons with Disabilities)
-Training development update

Major Jim Previtera
Training Division

Stress Management training (detailed review) for:
-All Detention personnel
-Supervisory/managerial personnel
- General stress management training
- Training in recognition and response to
job-related and personal stress

Major Jim Previtera
Training Division

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-7

INDEPENDENT REVIEW COMMISSION ON JAILS
June 20, 2008
10:00 a.m. to 3:00 p.m.
4211 N. Lois Avenue
Tampa FL 33614
AGENDA
Leadership and Management Training

Colonel Carl W. Hawkins, Jr.
Department of Administrative Services

“American Jail” video footage
Early Warning System
Statistics
Responses

Sergeant Danny Tewmey
Professional Standards Section

“American Jail” video footage
Inmate Programs

Joel Pietsch
Senior Treatment Counselor

“American Jail” video footage
Work Group Plans

Work Group members

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-8

INDEPENDENT REVIEW COMMISSION ON JAILS
July 11, 2008
10:00 a.m. to 3:00 p.m.
13th Judicial Circuit Main Courthouse
Judicial Conference Room – 6th Floor
800 E. Twigg St.
Tampa FL 33602
AGENDA
Hillsborough County Detention Facilities
�
�
�

Chief Judge Manuel Menendez, Jr.
Chief Judge - 13th Judicial Circuit
Judge James V. Dominguez
Judge - 13th Judicial Circuit
Chairperson – Public Safety
Coordinating Council
Mark A. Ober
State Attorney – 13th Judicial Circuit
Julianne M. Holt
Public Defender – 13th Judicial Circuit

Management
Control
Issues

Juveniles in the Criminal Justice System

Robin Rosenberg
Deputy Director, Children First
(Florida)
Marlene Sallo
Attorney Advocate, Florida Advocacy
Center for Persons with Disabilities

Work Group Status Reports

Work Group members

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-9

INDEPENDENT REVIEW COMMISSION ON JAILS
August 1, 2008
10:00 a.m. to 3:00 p.m.
Hillsborough County Center
Planning Commission Board Room 18th Floor
601 E. Kennedy Boulevard
Tampa FL 33602
AGENDA
Criminal Justice and Mental Health

Judge Steve Leifman
Special Advisor
Criminal Justice and Mental Health
Supreme Court of Florida

Equality Florida

Brian Winfield
Communications Director

American Civil Liberties Union (ACLU)

Michael E. Pheneger
ACLU Chairperson –
Greater Tampa Chapter

Vacancies in Detention (Sworn Positions)
2005-2007

Colonel David Parrish
Department of Detention Services

Work Group Plans

Work Group members

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-10

INDEPENDENT REVIEW COMMISSION ON JAILS
August 15, 2008
10:00 am to 3:00 pm
Hillsborough County Sheriff’s Office
Training Division - Pinebrooke Building
1409 Falkenburg Road
Tampa, FL 33619

AGENDA

Administrative Investigations
Related to Brian Sterner

Sgt. Danny Tewmey
Professional Standards

Florida Center for Inclusive Communities
(Advocacy Center for Persons with Disabilities)

Major Jim Previtera
Training Division

Review of Use of Force

Major Jim Previtera
Training Division

Work Group Reports

Work Group members

Commission Work Plan

Dr. James Sewell

Public Comments
Adjournment

A-11

INDEPENDENT REVIEW COMMISSION ON JAILS
August 22, 2008
10:00 a.m. to 3:00 p.m.
Hillsborough County Center
26th Floor
Conference Room A
601 E. Kennedy Boulevard
Tampa FL 33602
AGENDA

Presentation

Julianne M. Holt
Public Defender – 13th Judicial Circuit

Local Corrections:
A Historical Perspective

Commissioner Ned Hafner

Work Group Reports

Work Group members

Focus Group Reports

Focus Group members

Work on Final Report

Dr. James Sewell

Public Comments
Adjournment

A-12

Appendix B
Preliminar y
Repor t

Preliminary Report of the Independent Review Commission on Jails
Introduction
On February 28, 2008, Hillsborough County Sheriff David Gee announced the
creation of an Independent Review Commission to examine the policies,
practices and procedures in the Orient Road and Falkenburg Road jails. The
development of this Commission followed several publicized incidents in the jail,
including one involving Brian Sterner, an inmate in a wheelchair. As the news
release announcing this body indicated:
Recent reports about alleged abuse of inmates have cast a critical light on
the Detention Department. Sheriff Gee is keenly aware of the public
reaction and questions about what occurred in the jail, and understands
that public confidence in the county jail system is an essential element in
protecting the citizens. Internal investigations into the allegations are
currently under way; however Sheriff Gee believes an independent
commission needs to further examine the inmate booking and
incarceration procedures, and afford the public a legitimate, unbiased
report on the jails.
As established by Sheriff Gee, the Commission includes a diverse group of
professional and community leaders and lay citizens who have been given
unrestricted access to documents related to inmate booking and incarceration
procedures. In carrying out its duties, this Commission has been given the
freedom to interview Sheriff’s Office personnel to gather additional information
regarding these procedures and the policies and practices supporting them.
Commission Membership
The Commission is composed of eleven members:
� Dr. James D. Sewell, Assistant Commissioner (Retired), Florida
Department of Law Enforcement, Chair
� Dr. Lorie Fridell, Associate Professor, University of South Florida
� Ned Hafner, Director of Corrections (Retired), St. Johns County, FL,
Sheriff’s Office, and Director of Corrections and Jail Services, Florida
Sheriffs Association
� Honorable Al Higginbotham, Hillsborough County Commissioner
� Brian Kensel, Special Agent (Retired), Federal Bureau of Investigation
� Reverend Beverly Lane, Pastor, First Mount Carmel AME Church
� Clarence McKee, CEO, McKee Communications
� Linda McKinnon, Chief Executive Officer, Central Florida Behavioral
Health Network
� Dr. Delia Aguirre Palermo, Professor, St. Petersburg College

�
�

General Peter J. Schoomaker, U.S. Army (Retired)
Chief Raymond E. Velboom, Dade City Police Department

Personnel from the Hillsborough County Sheriff’s Office have provided staff
support for the Commission throughout its tenure.

Page 2 of 17

Commission Charge
As indicated, the Independent Review Commission on Jails was established by
Sheriff David Gee to examine the inmate booking and incarceration procedures
in Hillsborough County jails and to afford the public a legitimate, unbiased, and
public report. Specifically, the Commission has been charged with examining:
� Patterns, customs, and practices of conduct and discipline in the
jails;
� Policies and procedures that are or should be in place;
� Management and supervisory oversight;
� Training and employee development.
The Commission was further charged with conducting public workshops as
necessary and with providing two reports: a preliminary report by May 9, 2008,
and a final report by September 1, 2008.
Commission Meetings
During the course of its work in preparing this Preliminary Report, the
Commission held six public meetings, all of which provided time for public
comment:
�
�
�
�
�
�

On March 10, 2008, at Orient Road Jail
On March 21, 2008, at Jefferson High School
On April 4, 2008, at University Area Community Center
On April 15, 2008, at Hillsborough County Sheriff’s Office Training
Division, Pinebrooke Building Auditorium
On April 25, 2008, at Tampa Port Authority
On May 5, 2008, at Tampa Port Authority

The Commission heard presentations and testimony from 20 individuals who
were invited to speak, a number of whom, because of their responsibilities and
expertise, appeared at several meetings. Seven citizens offered comments
during the Public Comments section of the meeting agendas. Appendix A
reflects the formal agenda and invited speakers for each of the Commission
sessions. Additionally, transcriptions of each meeting and copies of all handout
material provided to the Commission are available on the Hillsborough County
Sheriff’s Office website (www.hcso.tampa.fl.us). All Commission meetings were
also videotaped, and copies of these are maintained by the Hillsborough County
Sheriff’s Office.
Individual members of the Commission have also conducted on-site visits of
booking and other functions at the Orient Road Jail and, for comparison
purposes, of the Pinellas and Polk County Jails. Commissioner members
conducted selected staff and inmate interviews during these on-site visits.

Page 3 of 17

Additionally, several members observed detention trainees participating in the
Final Practical Exercise for Class 198, conducted on March 24-26, 2006.
Commission members have reviewed numerous documents pertaining to jail and
prison practices and individually have interviewed a number of subject matter
experts, including personnel from the National Institute of Corrections, the
National Sheriffs Association, and the Los Angeles County Jail, to add to their
knowledge and understanding of jail operations.

Page 4 of 17

Commission Observations
The Commission has several observations and acknowledgements related to the
first segment of its work. First, the Commission acknowledges and commends
Sheriff David Gee for his decisive action in establishing this body. It is difficult to
open up one’s agency to an outside, independent group for the review of internal
actions and procedures. His leadership in aggressively responding to the
situation is outstanding.
Second, the Command Staff and a number of other personnel of the Hillsborough
County Sheriff’s Office have provided the Commission with a significant amount
of both testimony and written material to facilitate our efforts to become educated
about the jail system. The Commission appreciates their availability, openness,
and willingness to work with us.
Third, the Commission recognizes that the Hillsborough County jails are
accredited by three bodies: the Commission on Accreditation for Corrections, the
National Commission on Correctional Health Care, and the Florida Corrections
Accreditation Commission. These accreditations and their on-going compliance
reviews indicate that the formal policies, procedures, and basic operations meet
national and state standards, and the Hillsborough County Jail fully complies with
Florida Model Jail Standards. The staff of the Sheriff’s Office is to be
commended for its proactive efforts to attain and subsequently maintain these
professional recognitions.
Fourth, the Commission has focused its attention during these first 60 days on
gaining a better understanding of the organization, facilities, policies, procedures,
and training at the jail, particularly those implemented after the incidents reported
in mid-February. As a result, most of our meetings have consisted of
presentations by staff from the Sheriff’s Office. An adequate review of the actual
implementation of and compliance with such policies, procedures, and training,
however, will require interviews and discussion with jail personnel lower in the
chain-of-command and other individuals as discussed later in this report.
Fifth, several of the reported incidents of alleged misconduct, including the
incident involving Brian Sterner, are still undergoing Internal Affairs investigation
or disciplinary review. As a result, this Commission has not yet delved into these
allegations. However, upon the completion of these investigations and the
subsequent disciplinary review and prior to completing its Final Report, the
Commission fully intends to conduct a review of a number of critical issues,
especially relating to management and supervisory oversight and training,
identified during these incidents.

Page 5 of 17

Sixth, a number of issues relating to the Hillsborough County Sheriff’s Office and
the Hillsborough County Jail have been raised by concerned citizens. While
many of these will be addressed in the Preliminary and Final Reports of this
Commission, others are beyond the scope of this Commission’s work. These
latter issues include:
� Contract awarding procedures in the jail
� The need for future jail expansion
� Services for persons outside the jail system
Such issues are worth examination by appropriate staff of the Hillsborough
County Sheriff’s Office to assure the most effective use of taxpayer dollars and
the most appropriate and responsive treatment of individuals in custody.
Finally, it is significant that the survey of Sheriff’s Office employees conducted in
2005 indicates high employee satisfaction with their jobs. Retention rates have
improved significantly in recent years; this can have positive ramifications for
budgets and the retention of qualified personnel.

Page 6 of 17

Commission Preliminary Assessment
In this section of the report, the Commission provides a preliminary assessment
for each of our four charges. Within each section, we reflect a preliminary review
of the issue, outline the next steps for our inquiry, and set forth any preliminary
recommendations.
Charge 1: Patterns, customs, and practices of conduct in the jail
Preliminary Review
General
In any organization, it is the corporate culture—the patterns, customs, and
practices of accepted conduct—that defines the parameters of accepted
behavior. Especially in a law enforcement agency, it is imperative that such
patterns of behavior, customs, and accepted practices meet the highest
professional standards. The Commission’s preliminary work indicates that the
written policies and stated practices of the Hillsborough County Sheriff’s Office
set a high bar for professional conduct. Further work by the Commission is
necessary to assess the extent to which the behaviors of personnel at all levels
are consistent with these written policies and practices.
Several organizations have approached this Commission with a request to
provide additional information on the treatment of individuals in the jail system.
During its initial efforts at developing a baseline of knowledge about jail
operations and organization, the formal involvement of such groups has not yet
been possible. During its next stage of work, in preparation for our Final Report,
the Commission will formally solicit information from these groups.
Hiring Practices
It is significant that just one in 10 applicants for positions within the Hillsborough
County Jail is hired. The minimum requirements, background assessment and
psychological screening components appear to reflect industry standards and
would seem to facilitate and ensure the hiring of quality personnel. During his
testimony, Dr. Vincent Skotko recommended that the battery of pre-employment
psychological tests be expanded to include the Wonderlic Personnel Test, a
cognitive ability test with standardized norms for numerous occupations,
including correctional and law enforcement officers.
Inmate Services/Treatment
Direct Supervision appears to be a strong model for inmate supervision that
promotes the dignity of the inmate while ensuring the safety of staff and other
inmates. According to the philosophy underlying the model, the inmate is
expected to exhibit appropriate behavior and is treated based on that assumption
until inappropriate behavior is exhibited.

Page 7 of 17

Of the few inmates interviewed to date, a significant proportion was unaware of
the programs (e.g., drug treatment) available to them while in confinement.
It is commendable that the jail holds Cell Representative Meetings once per
month in each jail facility (Falkenburg and Orient). At these meetings, inmates
can report concerns/issues to jail staff. Certain staff members are required to
attend.
It is commendable that in 2001, following a year in which three suicides occurred
(after a ten year period with only one suicide), the Sheriff’s Office brought in an
expert to review its processes/facilities for dealing with suicidal inmates. The
Hillsborough County Jail has subsequently adopted new practices of suicide
prevention, including providing a suicide information/risk factors card to each
member of the Department of Detention Services staff.
Next Steps
In preparation for its Final Report, the Commission will:
o Invite the Circuit’s Chief Judge, State Attorney, Public Defender,
and Chair of the Public Safety Coordinating Council to address
jail operations at a future Commission meeting
o Conduct appropriate interviews with and/or surveys of line staff
of the jail
o Conduct a thorough review of grievances and completed
Internal Affairs investigations to determine any patterns of
inappropriate conduct on the part of personnel
o Develop and utilize appropriate mechanism(s) to receive
information from inmates regarding their experiences and
treatment
o Further explore the inclusion of the Wonderlic Personnel Test
during the agency’s psychological screening process
o Attend and observe Cell Representative Meetings
o Further review the programs available to inmates that might
promote their positive transition back to society
o Identify and invite to speak at Commission meetings individuals
(e.g., former inmates) or associations/groups in the community
(e.g., ACLU, NAACP, Human Rights Commission, CAIR,
defense attorneys) that have additional information to share
regarding inmate treatment and jail policies and practices
o Assess the on-going communication between medical and
detention staff.
Initial Recommendations
The Independent Review Commission has no recommendations regarding
patterns, customs, and practices of conduct at the jail at this time.

Page 8 of 17

Charge 2: Policies and procedures that are or should be in place
Preliminary Review
General
Especially in a detention setting, it is critical that policies, procedures, and
practices achieve their desired result. It is equally important that the reasons
behind a particular practice not be misconstrued or, particularly during this time
at the Hillsborough County Jail, generate an appearance of impropriety.
Consequently, all policies and procedures must be scrutinized to assure
compliance with these two goals. A particular example of a practice which can
be misunderstood is the use of well-being checklists in the booking area.
Detention deputies tape these checklists to the glass walls of the Orient Road
Jail holding cells to document the 15- and 30- minute checks of inmates. In one
instance, the paper was placed in such a manner that the view of the inmate by
the surveillance camera was impeded; the view by detention personnel, however,
was not obstructed. The inmate involved later claimed that he had been
mistreated and that the paper was intentionally placed to prevent surveillance
filming of the incident.
Use of Force
The use of force policy, including the response-to-resistance matrix, reflects
current professional standards. It is also positive that use of force reports are
required for all physical contact above escort and are reviewed up the chain of
command.
Detention’s current practice, implemented by an internal
memorandum, is for these reports to be reviewed up the chain through Colonel
David Parrish.
It is commendable that policy regarding the use of chemical spray designates its
use only as a defensive weapon and not to coerce behavior.
Confinement
The Commission learned that “confinement” (designating a more restrictive
environment with reduced contact with staff and other inmates) is used for death
row inmates, other “notorious or high profile” inmates, those in need of protective
custody, those who are a danger to self or others, and those receiving discipline.
Next Steps
In preparation for its Final Report, the Commission will:
o Complete a review of the policies and procedures of the jail
o Review specific post orders relating to booking and other key
areas
o Interview and/or survey appropriate personnel as a means of
assessing compliance with policies and procedures

Page 9 of 17

o Review selected/“random” use-of-force reports to assess
whether these reports are sufficiently descriptive, are given
meaningful review through the appropriate/designated chain of
command, and reflect policy
o Research industry standards regarding the administrative
confinement of “notorious or high profile inmates” and regarding
the care and treatment of inmates who are considered suicidal.
This research will help guide the Commission’s assessment of
these practices/policies at the Hillsborough County jails
o Conduct on-site visits to assess and observe the treatment of
inmates in administrative confinement, protective custody,
disciplinary detention and high security housing
o Review the decision-making process for assigning inmates to
confinement and periodically reviewing such assignments
o Request a presentation from jail staff on the due process
accorded inmates during the disciplinary process and review
selected closed inmate-disciplinary-action files to assess due
process, quality of review, and appropriateness of outcomes
o Observe disciplinary hearings
o Re-visit the Booking and Housing areas
o Conduct a tour of the Falkenburg Jail
Initial Recommendations
The Commission recommends that:
o Well-being checklists and any other items used in holding cells
be placed in such a manner that their location does not block
the view of the interior of the cell by either officers or cameras
o In its response-to-resistance matrix, the Sheriff’s Office reflect
that the use of Tasers in the Jail are allowed at Level 4

Page 10 of 17

Charge 3: Management and supervisory oversight
Preliminary Review
General
It must be observed that, even with the best prepared plans and policies and the
most comprehensive training programs, effective management and supervisory
oversight is necessary to ensure compliance and prevent misconduct. Jail
administration had already required the Central Command Lieutenant to review
videotapes of any incidents involving use of force, officer needs assistance,
fights, reported accidents, disturbances, or unusual situations. Since the incident
involving Mr. Sterner, the Hillsborough County Sheriff’s Office has taken a
number of steps to enhance such oversight at the Jail, particularly in the Booking
area, including:
o Requiring that the on-duty booking sergeant conduct his/her
work at a location nearer the first station at Booking.
o Requiring the Central Command Lieutenant to spend an hour
each shift reviewing videos taken from different vantages within
Booking.
Promotion to Supervisory Positions:
It is significant that line personnel do not seek promotions in numbers that would
allow for selectivity; such expanded selectivity could promote the
identification/promotion of people who could manage those they supervise in a
manner that would promote/facilitate high quality, professional conduct.
Preliminary information indicates that the lack of supervisor candidates is due in
part to unsatisfactory rewards that do not offset the fact that new supervisors will
have reduced seniority to bid on desirable schedules. The new pay plan for
detention sergeants, effective May 5, 2008, increases the pay differential
between line deputies and sergeants and has the potential to reduce the problem
of insufficient applicants for supervisory positions.
Information received by the Commission to date indicates that a person’s ability
to manage personnel to promote professional, in-policy behavior is not given
significant weight in the current promotion process. The Sheriff’s Office’s new
Employee Performance Management System (EPMS), when fully implemented,
should alleviate this problem.
Miscellaneous Accountability Mechanisms:
The new Employee Performance Management System has the potential to
significantly promote personnel accountability and even the quality of
supervision. The adoption of this system by the Sheriff’s Office is commendable.
The fact that the Sheriff’s Office has had in place an Early Warning System since
2002 is also of significance. Blue Team, a web-based paperless reporting
system utilized by detention and law enforcement supervisors, complements this

Page 11 of 17

system. Such systems have great potential to promote high quality work/behavior
on the part of personnel. Because of the unique nature of jail work, this system
should also reflect grievances filed against detention personnel.

Page 12 of 17

The manner in which policies and operating procedures are disseminated to
employees appears not to ensure knowledge of agency policy.
Importantly, Sheriff’s Office policy includes Sheriff’s Order 0705.17, which
establishes Rule 6.1.06 (Failure to Act) and requires employees to report
inappropriate behavior on the part of colleagues. One source indicated that
recruits are trained to intervene with peers who are acting inappropriately.
Longstanding policy has required lieutenants to review the video from on-site
cameras of incidents (e.g., use of force) at the end of their shifts. It is
commendable that the Sheriff’s Office has recently expanded this review, now
requiring lieutenants to spend one hour at the end of each shift reviewing
“random” segments of the video for that shift. Lieutenants are further required to
submit a report each shift indicating that they have conducted this review and
indicating what, if anything, was noteworthy.
A strong grievance receipt and review system is a critically important
accountability mechanism that can promote quality behavior in all detention
operations. In November, 2006, the Sheriff’s Office Department of Detention
Services changed the manner in which grievances are received and handled.
Prior to this change, all grievances, regardless of topic, were recorded; under the
new system, a supervisor has the discretion to intervene when a concern is
initially expressed and attempt to achieve informal resolution; if the concern is not
resolved during this process it becomes a formal grievance. The Sheriff’s Office
reported that this system facilitates the quality review of significant grievances
that were, under the prior policy, at risk of being given insufficient attention due to
the volume of grievances.
Next Steps
In preparation for its Final Report, the Commission will:
� Review Internal Affairs cases dealing with management and
supervisory oversight issues in the Jail
� Review disciplinary processes and procedures
� Conduct interviews and/or surveys with supervisors and
managers in the Jail
� Further explore the mechanisms that might ensure that
employees who would be quality supervisors apply and are
selected for promotions
� Explore how the promotion process might give more attention to
the candidate’s ability to promote high quality work on the part
of his/her subordinates
� Conduct a “random” review of grievances/complaints to assess
the quality of the investigation and the appropriateness of the
disposition

Page 13 of 17

�
�
�
�

�

Review selected reports submitted by lieutenants regarding their
“random” video review
Consider and provide recommendations concerning a more
effective mechanism for the dissemination of policies and
procedures
Assess the extent to which “on-service training” promotes
knowledge of agency policy
Give additional attention to the new grievances receipt system
to assure that sufficient safeguards are in place to ensure
appropriate use of supervisor discretion in their “informal”
resolution
Provide input to the Sheriff’s Office on how to maximize the
potential of the Early Warning System.

Initial Recommendations
The Commission recommends that:
� The Early Warning System include grievances filed against
individual detention personnel
� The Detention Department formalize its Department Order on
Booking Video Review into its Policy and Procedure Manual

Page 14 of 17

Charge 4: Training and employee development
Preliminary Review
There are a number of strengths associated with the training provided to Sheriff’s
Office employees. For instance:
� The number of hours provided to academy trainees exceeds the
requirements of the Florida Criminal Justice Standards and Training
Commission (CJSTC), and trainees receive an additional 200 hours of
post-academy training prior to their assignment to a Field Training Officer
� Hours provided to in-service employees exceed CJSTC requirements for
mandatory retraining
� In recent years, the Sheriff’s Office has reduced in-service class sizes.
Additionally, employees can volunteer to take advanced, outside training
courses.
� To set direction for the agency, the Sheriff required in-service training for
all sergeants and corporals shortly after he took office
� An emphasis in training is on the use of verbal skills to achieve inmate
cooperation and to defuse potentially tense or even violent situations
� The “on-service” (computerized) training is an innovative way to provide
training in a time of reduced resources
� Academy training and the five-week training provided to recruits before
their assignment to the Field Training Program include practical training
scenarios, in which the recruit trainee practices his/her skills and judgment
in role-play exercises. The scenario content is developed as a result of
actual incidents that have occurred in the jail
� Outside expert training resources are utilized to supplement Sheriff’s
Office resources
� The Field Training Officer (FTO) program, which is eight weeks in length,
appears to be state of the art. Selection and training of FTOs appear to
be strong. It is important that the jail has twice as many applicants for
FTO positions than spots available; this allows for selectivity. While FTOs
periodically meeting as a group to discuss training issues is
commendable, these meetings may not occur frequently enough
� Sheriff’s Office support for employee education through tuition
reimbursement is positive.

Page 15 of 17

According to testimony received by the Commission, staff of the Sheriff’s Office
Training Division met with personnel from the Florida Center for Inclusive
Communities on February 20, 2008, to begin discussions about improved training
for Sheriff’s Office staff who deal with persons with disabilities. It is the
understanding of the Commission that a needs assessment and focus groups are
currently underway. The implementation of this training should be a priority of
the Training Division and the staff of the Jail and the Commission is anticipating a
review of its results.
According to testimony received by the Commission, there appear to be several
deficiencies in the training of mid-level supervisors. They apparently receive little
training in recognizing or addressing personnel issues. This is particularly critical
in identifying warning signs of stress-related problems. Effective training of firstline supervisors on these topics allows the agency to better respond to and more
effectively deal with personnel stress prior to severe incidents of misconduct. It
should be noted that a supervisory class, “Excelling as a First Line Supervisor,”
will be given to newly appointed supervisors beginning in Fall 2008; its curriculum
meets many of these identified needs.
Next Steps
In preparation for its Final Report, the Commission will:
� Examine more closely the in-service training provided to Jail
personnel
� Review the curriculum and training developed in conjunction
with the Florida Center for Inclusive Communities
� Interview and/or survey jail personnel regarding training needs
� Review the list of “on-service” training courses and conduct
more in-depth review of selected courses
� Review in more depth the training provided to supervisors and
research comparable training provided by other sheriffs’
agencies and commercial providers. A key focus will be on
training to manage personnel to promote professional, in-policy
behavior
� Further review leadership development opportunities provided
by the Sheriff’s Office to in-service staff (e.g., courses available
from national associations or commercial providers)
� Further review the stress management training provided to all
jail employees and, in particular, the training provided to
managerial and supervisory personnel on the recognition of and
response to job-related and personal stress
� Further review training issues which may come to light following
the conclusion of pending internal affairs investigations.

Page 16 of 17

Initial Recommendations
The Commission recommends:
� Where practical, in-service training be expanded to include the
use of scenario based training
� Training provided to detention deputies assigned to
intake/booking be enhanced to include required training unique
to that environment, to provide a better ability to anticipate and
resolve problems, particularly relating to substance abuse and
mental health, and to include elements of stress and anger
management and crisis intervention training. Such training
should be provided by personnel skilled in these unique areas of
human behavior
� Ensure that more formalized training is provided to medical staff
on substance abuse and mental health issues, as well as
training on co-occurring disorders.

Page 17 of 17

Appendix C
Tasks to be
Completed
Following the
Preliminar y
Repor t

Tasks to be Completed Following the Preliminary Report
Charge 1: Patterns, customs, and practices of conduct in the jail
Follow-up on Action Steps Identified in the Preliminary Review
In its Preliminary Report, the Commission identified a number of action steps
necessary in preparing for its Final Report. The following reflect the
Commission’s efforts since its May 9 Report:
o Invite the Circuit’s Chief Judge, State Attorney, Public Defender,
and Chair of the Public Safety Coordinating Council to address
jail operations at a future Commission meeting
� Chief Judge Manuel Menendez, Jr., State Attorney Mark
Ober, Public Defender Julianne Holt, and Judge James
Dominguez, Chairperson of the Public Safety
Coordinating Council, appeared before the Commission
on July 11, 2008.
o Conduct appropriate interviews with and/or surveys of line staff
of the jail
� Members of the Commission conducted 12 focus group
interviews with Detention Department staff.
o Conduct a thorough review of grievances and completed
Internal Affairs investigations to determine any patterns of
inappropriate conduct on the part of personnel
� A working group of the Commission reviewed a random
sample of the grievances filed by inmates from 20052007 and completed Internal Affairs investigations.
o Develop and utilize appropriate mechanism(s) to receive
information from inmates regarding their experiences and
treatment
� Commission members received information during the
Cell Representative meetings, during contact with
individual inmates, and from former inmates and their
families.
o Further explore the inclusion of the Wonderlic Personnel Test
during the agency’s psychological screening process
� The Commission will provide recommendations later in
this Final Report.
o Attend and observe Cell Representative Meetings
� Members of the Commission have attended and
observed several Cell Representative meetings.
o Further review the programs available to inmates that might
promote their positive transition back to society
� At its session on June 2, 2008, the Commission reviewed
many of these programs available for inmates.
o Identify and invite to speak at Commission meetings individuals
(e.g., former inmates) or associations/groups in the community

C-1

(e.g., ACLU, NAACP, Human Rights Commission, CAIR,
defense attorneys) that have additional information to share
regarding inmate treatment and jail policies and practices
� The Commission invited representatives from a number
of groups, including the National Association for the
Advancement of Colored People, American Civil Liberties
Union, Equality Florida, Florida’s Children First,
Advocacy Center for Persons with Disabilities, and the
Hillsborough County Criminal Defense Lawyers
Association.
o Assess the on-going communication between medical and
detention staff.
� As part of its focus groups conducted, the Commission
assessed the communication between medical and
detention staff.
Charge 2: Policies and procedures that are or should be in place
Follow-up on Action Steps Identified in the Preliminary Review
In its Preliminary Report, the Commission identified a number of action steps
necessary in preparing for its Final Report. The following reflect the
Commission’s efforts since its May 9 Report:
o Complete a review of the policies and procedures of the jail
� The Commission has reviewed the policies and
procedures of the Jail.
o Review specific post orders relating to booking and other key
areas
� The Commission has reviewed a number of specific post
orders.
o Interview and/or survey appropriate personnel as a means of
assessing compliance with policies and procedures
� The Commission interviewed Detention personnel
concerning policy compliance as part of its focus group
sessions.
o Review selected/“random” use-of-force reports to assess
whether these reports are sufficiently descriptive, are given
meaningful review through the appropriate/designated chain of
command, and reflect policy
� A work group of the Commission conducted a random
review of Use of Force reports.
o Research industry standards regarding the administrative
confinement of “notorious or high profile inmates” and regarding
the care and treatment of inmates who are considered suicidal.
This research will help guide the Commission’s assessment of
these practices/policies at the Hillsborough County jails

C-2

The Commission will provide recommendations later in
this Final Report.
Conduct on-site visits to assess and observe the treatment of
inmates in administrative confinement, protective custody,
disciplinary detention and high security housing
� The Commission has conducted a number of on-site
visits to observe inmates in confinement, detention, and
high security.
Review the decision-making process for assigning inmates to
confinement and periodically reviewing such assignments
� The decision-making process for assignment to
administrative confinement was reviewed with the
Commission at its meeting on June 2, 2008.
Request a presentation from jail staff on the due process
accorded inmates during the disciplinary process and review
selected closed inmate-disciplinary-action files to assess due
process, quality of review, and appropriateness of outcomes
� Jail staff provided a presentation on due process during
the disciplinary process on June 2, 2008.
Observe disciplinary hearings
� Due to legal considerations, the Commission was unable
to observe any disciplinary hearings.
Re-visit the Booking and Housing areas
� Individual members of the Commission have re-visited
both the Booking and Housing areas.
Conduct a tour of the Falkenburg Jail.
� The Commission toured the Falkenburg Jail on June 2,
2008.
�

o

o

o

o
o
o

Charge 3: Management and supervisory oversight
Follow-up on Action Steps Identified in the Preliminary Review
In its Preliminary Report, the Commission identified a number of action steps to
take in preparing for its Final Report. The following reflect the Commission’s
efforts since its May 9 Report:
o Review Internal Affairs cases dealing with management and
supervisory oversight issues in the Jail
� A work group of the Commission conducted a random
review of Internal Affairs cases within the jail.
o Review disciplinary processes and procedures
� Disciplinary processes were discussed during several
Commission meetings, including during the presentation
of the Internal Affairs investigation resulting from the
Brian Sterner Case.

C-3

o Conduct interviews and/or surveys with supervisors and
o

o

o

o

o
o
o

o

managers in the Jail
� Supervisors and managers in the Jail were interviewed
as part of the focus group interview process.
Further explore the mechanisms that might ensure that
employees who would be quality supervisors apply and are
selected for promotions
� The Commission will provide recommendations later in
this Final Report.
Explore how the promotion process might give more attention to
the candidate’s ability to promote high quality work on the part
of his/her subordinates
� The Commission will provide recommendations later in
this Final Report.
Conduct a “random” review of grievances/complaints to assess
the quality of the investigation and the appropriateness of the
disposition
� A work group of the Commission conducted a random
review of inmate grievances and complaints.
Review selected reports submitted by lieutenants regarding their
“random” video review
� Commission members have reviewed the reports
submitted by Booking lieutenants as part of the Jail’s
random review process.
Consider and provide recommendations concerning a more
effective mechanism for the dissemination of policies and
procedures
� Commission input is provided later in this Final Report.
Assess the extent to which “on-service training” promotes
knowledge of agency policy
� Commission members discussed “on-service training”
with Detention personnel during the focus group process.
Give additional attention to the new grievances receipt system
to assure that sufficient safeguards are in place to ensure
appropriate use of supervisor discretion in their “informal”
resolution
� Commission members received input concerning the
grievance system during their focus group sessions.
Provide input to the Sheriff’s Office on how to maximize the
potential of the Early Warning System
� Commission input is provided later in this Final Report.

C-4

Charge 4: Training and employee development
Follow-up on Action Steps Identified in the Preliminary Review
In its Preliminary Report, the Commission identified a number of action steps to
take in preparing for its Final Report. The following reflect the Commission’s
efforts since its May 9 Report:
o Examine more closely the in-service training provided to Jail
personnel
� The Commission has received a number of briefings on
the in-service training provided to Detention personnel
and has discussed such training during the focus group
interviews.
o Review the curriculum and training developed in conjunction
with the Florida Center for Inclusive Communities
� The Commission was updated on the progress of this
training at its June 2, 2008 and August 15, 2008
meetings.
o Interview and/or survey jail personnel regarding training needs
� Commission members explored training needs of
Detention personnel during the focus group sessions.
o Review the list of “on-service” training courses and conduct
more in-depth review of selected courses
� Commission members were provided further review of
the “on-service” courses at their meeting on June 2, 2008
and discussed their effectiveness during the focus group
sessions.
o Review in more depth the training provided to supervisors and
research comparable training provided by other sheriffs’
agencies and commercial providers. A key focus will be on
training to manage personnel to promote professional, in-policy
behavior
� The Commission has been provided additional material
concerning training for supervisors.
o Further review leadership development opportunities provided
by the Sheriff’s Office to in-service staff (e.g., courses available
from national associations or commercial providers)
� The Commission heard testimony on leadership
development opportunities and efforts at its June 20,
2008 meeting.
o Further review the stress management training provided to all
jail employees and, in particular, the training provided to
managerial and supervisory personnel on the recognition of and
response to job-related and personal stress
� The Commission heard further testimony about stress
management training at its June 2, 2008 meeting.

C-5

o Further review training issues which may come to light following

the conclusion of pending internal affairs investigations.
� Further recommendations concerning training will be
provided in this Final Report.

C-6

Appendix D
Grievance
Wor k Group
Repor t

Independent Review Commission On Jails
Grievance Work Group Report
The Inmate Grievance process is a key method by which inmates can
communicate concerns to jail staff. It is a critical accountability mechanism and
management tool; its counterpart is the citizen complaint system associated with
the law enforcement (versus detention) side of the Sheriffs Office. Commission
members Lorie Fridell (Chair), Linda McKinnon, and Reverend Beverly Lane
comprised the work group to assess this system. The key objectives of the work
group were to assess the accessibility and integrity of the grievance process and
make any necessary recommendations to ensure/promote same. We assessed
the system as pertains to both non-medical and medical grievances. We
expanded our attention to medical issues by reviewing, not just the grievance
process, but also the contract with Armor Correctional Health Services.
The work group members completed a number of tasks as part of their
investigation. For purposes of assessing the process for handling non-medical
grievances, we:
1)
2)

3)
4)
5)
6)

7)
8)

Reviewed DTN 914.06, which is the HCSO policy on inmate
grievances.
Reviewed other documents and statistics provided by the HCSO in a
bound document disseminated at the 3/21 meeting of the Commission
entitled, “Procedures and Statistics for: Use of Force, Grievances,
Assaults and Altercations” (see 18 – 29).
Obtained copies of policies regarding grievances from other jails in the
region (e.g., those in Jacksonville, Polk, Pasco).
Reviewed coverage of grievances in the Inmate Handbook and
attempted, without success, to view the Orientation Video that
supposedly covers the same content.
Received information/commentary from speakers at Commission
meetings. See for instance Commission meeting transcript for 3/21,
pp. 95 through 101; and transcript for 7/11, p. 45).
Communicated by phone and email with Lt. Phillips of HCSO to
understand fully how the process is designed to work. Interviewed
Captain Herman to determine how concerns were conveyed by
inmates in booking.
Conducted interviews with inmates in the housing pods–asking about
their knowledge of and faith in the system, if they have used it, and
their experience with it.
Conducted interviews with staff regarding the strengths and
weaknesses of the current procedures. Included questions related to
grievances in the protocols used with the focus groups held with HCSO
staff.

D-1

9)
10)
11)
12)
13)

Reviewed all grievances filed/resolved during 2007 to assess
comprehensiveness of staff review and fairness/soundness of
disposition.
Received and reviewed statistics on inmate grievances filed during the
period 2003 through 2007, including a breakdown by type of grievance.
Requested and reviewed dispositions of grievances for 2006 and 2007.
Reviewed relevant accreditation standards.
Interviewed several national experts including Susan W. McCampbell,
President of the Center for Innovative Public Policies and Randy Berg
at the Florida Justice Institute.

To assess the process for handling medical grievances and the contract to
provide medical services, we:
1)
2)
3)
4)
5)
6)
7)

Reviewed the medical services contract and relevant HCSO policies.
Interviewed the Medical Services Contract Manager, Contract
Administrator, and Medical Grievance Coordinator.
Reviewed the period statistics produced by the contractor for the
Contract Manager.
Conferred with national experts on jails.
Interviewed inmates in medical and non-medical housing pods.
Conducted two focus groups with medical staff.
Reviewed relevant accreditation standards.
Observations: Non-Medical Grievances

In this section, we begin by describing how the (non-medical) inmate grievance
procedure is designed to work; we continue in this section with our observations
that inform our recommendations contained at the end of this report.
Description of Inmate Grievance Procedure per Policy
One expert with whom we conferred reported that many jails in this country have
no inmate grievance process whatsoever. The HCSO changed its methods for
processing grievances in November 21, 2006. Prior to that date, once an inmate
communicated a concern/grievance, s/he was given a Grievance Form by the
pod deputy and investigation/disposition commenced. This produced as many
as 4800 Grievance Forms per year. According to jail staff, the change was made
to the system because it was clear that many inmate concerns could, in fact, be
quickly and easily resolved and because, with the large numbers, there was a
risk that important concerns would be “lost” in the mass of minor ones. The
number of grievance forms filed in 2004 represented the peak of the five-year
summary provided to the Commission. This number plummeted to 212 in 2007,
the first full-year of the new system. This change of policy and the corresponding
reduced numbers led the Commission and this work group to look closely at
these new processes.

D-2

Pursuant to the new policy and consistent with the philosophy of direct
supervision, pod deputies are directed to try to resolve the issue immediately
without paperwork being filed. If the deputy cannot resolve the inmate’s concern,
the inmate can fill out an Inmate Request Form (IRF)1 to either (1) request to
meet with a supervisor, or (2) obtain a Grievance Form (GF).2 Either of these
requests are to result in a meeting between the inmate and a supervisor. The
supervisor will first determine if the concern is “grievable.” If it is not “grievable”
the supervisor will explain the procedure and why it is not “grievable” and
annotate his/her response on the IRF.3 If the concern is “grievable” the
supervisor can attempt to achieve resolution on the spot or furnish the inmate
with a GF. The inmate will fill out the GF and return it to a deputy who will enter it
into JAMS and record the computer generated number on it.
Per DTN 914.06, the GF goes to a supervisor/manager who will “determine if
s/he is responsible and/or able to respond to the grievance.”
If the
supervisor/manager is not able to handle the grievance, s/he is to assign the
grievance to the appropriate supervisor and update the Inmate Grievance Log. If
s/he is able to respond, s/he will investigate/review the inmate’s complaint,
“ensure that corrective action is taken” if the inmate’s complaint is founded, and
inform the inmate in writing within 10 days of any action that is to be taken. If the
grievance is unfounded or unsubstantiated, s/he is to similarly report this to the
inmate, with explanation, within 10 days.4
DTN 914.06 provides for shift commander and facility commander review of the
GFs including action/disposition. (See 914.06 IV D and E.) Each signs off on the
GF.5 The Facility Commander reviews all appeals to previously completed
grievances and provides the requisite response to the inmate who has appealed
within five days.
1

IRF’s are three part forms that are numbered at printing. The “Original” top copy is ultimately
placed in the inmate’s file after it has been completed. The second copy (Yellow) is returned to
the inmate after it, too, has been completed and is a carbon copy of the original. The third copy
(Pink) is retained by the inmate at the time s/he submits it so that s/he has proof of submission.
2
GF’s are four-part forms that are assigned numbers when entered into the Jail Administration
Management System (JAMS) using (INMGRV); this number is transposed to the “hard” copy of
the grievance. The number indicates where the grievance originated and keeps a tally of the total
number of grievances for that area (2008N0008 = Year: 2008, N = North Command, 0008 =
Number issued in that command for that year.) The “Original” top copy is ultimately placed in the
inmate’s file after it has been completed. The second copy (Canary) is forwarded to the Facility
Operations Manager for filing after completion. The third copy (Pink) is returned to the inmate
after completion. The bottom (Goldenrod) copy is kept by the inmate at the time s/he submits it
so that there is documentation of the submission.
3
The supervisor will give the inmate the yellow copy with his/her response and the white copy
will be forwarded to Inmate Records at the Orient Road Jail for placement in the inmate’s file.
4
The inmate receives the goldenrod copy showing resolution and all signatures. The disposition
is entered into the INMGRV program. “A copy of the JAMS report (is) printed and attached to the
original grievance.”
5
The white copy of the IGF goes to the inmate file.

D-3

Communication of Process to Inmates
Public Defender, Julianne Holt, in speaking to the Commission on 7/11 (see
transcript p. 18) highlighted the importance of inmates’ understanding of the
grievance process. According to Holt, “one of the things that we’ve talked about
in the past is to ensure that everyone really does know what the process is.” She
mentioned the Inmate Handbook in this context. The Inmate Handbook is to be
given to all inmates when they are transferred from intake to housing. This
document covers topics such as canteen, contraband/searches, initial per diem
fee, mail, library, meals, medical services, programs and services, to name a
few. The grievance process is addressed on page 6 of the English language
version and reads in full: “Inmates are afforded the opportunity to register
complaints about the conditions of confinement, policy, or incidents. Grievance
forms are available upon request from the pod deputy.” This very brief
description does not convey sufficient information and, relatedly, does not fully
reflect the new procedures that were adopted by the HCSO in 2006.
Ms. Holt also mentioned in this vein the importance of the inmate Orientation
Video, noting that “a significant (number) of our clientele cannot read past the
third-grade level.” At that same Commission Meeting, in response to these
comments, Colonel Parrish, too, highlighted the importance of the inmate
Orientation Video to supplement the written handbook. Commission Member
Fridell visited Orient Jail with notice, to view the Orientation Video, but was told it
was not available as it was currently undergoing revision.
Some inmates who were interviewed knew how to initiate a grievance, others did
not.
System Accessibility
Staff who were interviewed or participated in focus groups, for the most part,
reported that the grievance system is accessible to inmates; one commented that
it is “too accessible.” Other staff members and some inmates, however,
expressed concerns about the ability of inmates to utilize/access the grievance
system and, relatedly, concerns about whether all relevant parties understood
how the system was supposed to work. As conveyed above, the first step is for
the inmate to convey his/her concern to the pod deputy who can try to resolve it
immediately. Some inmates were reticent to approach a pod deputy with their
concerns, particularly if that deputy was the source/object of the concerns (e.g.,
the inmate’s concern was with force used by that deputy). Some inmates
anticipated non response or even retribution. When this issue raised by inmates
was shared with staff in interviews and focus groups, we were told that this issue
is “easily remedied.” If an inmate is reticent to initiate his/her concern with the
pod deputy on the job at the time the issue/concern manifested, s/he can raise
the issue with another pod deputy on another shift. However, other interviews

D-4

indicated that some inmates and deputies were not aware that inmates could
lodge the complaint on another shift. (Or said the inmate could only lodge a
complaint on another shift after s/he attempted to lodge it on the first one.)
Several inmates reported that when they approached a deputy “on another shift”
to initiate the grievance procedures, they were told that they could not do so.
Several inmates reported that, when they tried to lodge a concern, they were told
that their concern was “not grievable.” They did not understand what types of
concerns were officially “grievable” and “not grievable.” One inmate reported that
when he requested a Grievance Form he was told none were available.
Inmates were asked about their ability to request an interview with a supervisor if
the pod deputy could not resolve the issue they raised. Some reported success
with this step in the process; others did not. One inmate suggested that
“sometimes the deputies will pass the request on to the supervisor, sometimes
not.” One inmate reported during an interview that when he asked to see a
corporal the pod deputy told him, “No, you can talk to me when I’m a corporal.”
Some indicated a lack of faith that a request to speak to a supervisor would result
in a meeting at all or result in a meaningful meeting. Regarding the latter, they
assumed a supervisor would “side” with the pod deputy. Some of these inmates,
however, acknowledged that they had yet to test their assumptions. Some staff
denied that their supervisors would let them off the hook if they had done
something inappropriate. One commented to the effect, “I’m held accountable by
my supervisor and would not have it any other way.”
The inmates conveyed frustration that they did not understand fully how the
system was supposed to work and therefore did not know when it was or was not
serving them as designed. They suggested that the system might have more
integrity and credibility if the staff knew that the inmates knew what the process
was supposed to be.

D-5

Grievance Processing
Some interviewed inmates reported successful and fair processing of their
concerns and, in this context, reported that certain staff members were
particularly approachable and otherwise quite clearly dedicated to serving
inmates in a respectful manner. Some supervisors, they noted, went “above and
beyond” what was required to listen and respond to inmate concerns. Other pod
deputies and supervisors were not similarly regarded. One deputy whom the
inmates regarded very highly reported in an interview that the grievance process
needs some additional safeguards to ensure its accessibility and integrity. On
the other hand, asked if grievances were taken seriously once lodged, many staff
who were interviewed or participated in focus groups, indicated they thought they
were.
As noted above, all grievances filed in 2007 at all sites were reviewed. The
“depth” of information provided by the staff members investigating/resolving the
grievances varied considerably.
Some grievances required very little
investigation and documentation because of the simplicity of the concern raised
(e.g., not being allowed access to the law library). In others, it was difficult to
determine from the documentation whether a solid investigation had been
conducted and sufficient consideration given to the inmate’s concerns. DTN
914.06 merely says the supervisor/manager will “investigate/review” the inmate’s
complaint; it does not indicate what processes are expected, although we
acknowledge this might be covered in training.
We requested and received disposition information for grievances filed in 2006
and 2007. The results are reported below.
Founded
Non-Grievable
Open
Other
Unfounded
Unsubstantiated

2006
404
212
14
18
1427
167

2007
14
24
2
0
149
23

Total (%)
418 (17.0%)
236 (9.6%)
16 (0.7%)
18 (0.7%)
1576 (64.2%)
190 (7.7%)

Disposition information in any realm is not easy to interpret. In the law
enforcement realm, for instance, a low rate at which citizen complaints are
sustained could mean that the behavior of law enforcement is good or that the
investigation of complaints is not. It is similarly difficult to interpret the disposition
information above. We merely note with favor that the “founded” rate is not
questionably low, relative to industry standards. We are interpreting the
“founded” rate of 17.0% to mean there is at least some degree (maybe a high
degree, we cannot tell) of system integrity.

D-6

Following investigation and resolution, the Inmate Grievance Form is returned to
the inmate. On that form, the inmate can indicate by checking a box, “I would
like to request an appeal.” The form (that is returned to the inmate) indicates,
“Appeals must be submitted within 15 days and must include a copy of this
grievance.” In reviewing the files for 2007, we noted that not one inmate who
indicated an interest in an appeal ever filed it. For instance, we reviewed over 40
grievances filed at Orient Road Jail in 2007. In 18 of these, the inmate indicated
s/he “would like to request an appeal.” Stamped on every one of those forms
was the statement “No appeal has been filed, Fifteen days have expired.” While
we might expect a low level of inmate follow up on their desire to appeal, the
100% failure rate raises the question of whether the inmates understand what
they must do—beyond checking that box—to proceed. The Grievance Form
indicates that “Appeals must be submitted within 15 days and must include a
copy of this grievance.” It does not indicate how the appeal is initiated (using the
Inmate Request Form).
Documentation
In the context of discussing the relatively new procedures, Colonel Parrish told
the Commission that he wants to “get it automated so I can track it like we do all
the other things.” Subsequent interviews with command staff indicated that a
new tracking system is, in fact, forthcoming. This will include computerized
tracking of requests for and dispositions resulting from supervisor interviews with
inmates.
One national expert with whom the work group conferred expressed concern that
the grievance form, once the grievance is resolved, is placed into the inmate’s
file. This person indicated that this information in inmate files had the potential to
label the inmate as a “trouble maker.” We determined, however, that these “hard
copy” inmate files are not available to line staff, but are instead kept in a file room
at Orient Jail.
Concluding Comments on Observations
Much of the information about strengths and weaknesses of the system came
from interviews with inmates and staff. The work group members understand
fully that some individuals in either of these groups might be motivated to put the
system in the “best” or “worst” light. These interviews were important for
highlighting aspects of the system that one might expect would need
strengthening if it were implemented in any jail, if only because human beings
are being asked to implement it. Because we have come to believe that most of
the staff in the HCSO detention system are highly professional and well
intentioned, we do not recommend a return to the earlier system nor a switch to
some of the other systems we identified through our research on other jails.
Instead, we have produced some recommendations to strengthen the current
system.

D-7

Observations: Medical Grievances and Medical Services Contract
The contract for the outsourcing of medical services to Armor Correctional Health
Services (hereafter “Armor”) was reviewed. The contract specifies that the
medical provider is responsible for the following:
�
�
�
�
�

Providing or purchasing all medical, dental and behavioral health
(excluding psychiatric hospitalization) services, including comprehensive
health evaluations of each inmate following booking, and pharmacy.
Educating inmates and staff through e.g., an ongoing health education
program.
Maintaining medical records.
Completing all medical transfer forms for internal and external transfers.
Meeting the quality standards set forth by the National Commission on
Correctional Health Care (NCCHC), the American Correctional
Association (ACA), the Florida Model Jail Standards (FMJ), and the
Florida Corrections Accreditation Commission (FCAC).

Further the contract specifies that, “A quality assurance program will be ongoing
consisting of regularly scheduled audits of inmate health care services with
documentation of deficiencies and plans for correction of deficiencies.” A quality
plan must include an annual external peer review with results made available to
HCSO.
The HCSO provides one on-site FTE devoted to contract management and
oversight. The Contract Manager reviews the following monthly reports: staffing
(tied to payment), grievance by type, copies of grievance forms, and a myriad of
information available through data systems. The Contract Manager attends
quarterly Quality Improvement Committee (QI) meetings, but does not have
copies of QI documents as they contain Personal Health Information (PHI). The
manager receives the following daily reports from Armor for the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Transfers off site
Communicable disease
Suicide attempts, precautions
Number of inmates in local hospitals and infirmary
Staffing roster
Medical incident reports – copies
Medical grievance reports – copies
List of filing discrepancies
Status report of history and physicals

The Contract Manager also does an informal review of medical charts and
medical operations on a daily basis. Issues identified are conveyed verbally to
Armor management. If the issue is not resolved satisfactorily, the Contract
Manager notifies the appropriate Captain or Major; if necessary, Colonel Parrish

D-8

will become involved.
Written corrective actions are rare, and when
implemented, they require action plans. All other on-site and contract issues
related to review appear to be resolved on the verbal level and have not been
tracked.
The detention medical services are reviewed annually by Florida Model Jail
Standards and every three years by the National Commission on Correctional
Health Care (NCCHC), the American Correctional Association (ACA), and by the
Florida Corrections Accreditation Commission (FCAC). There is no formal
annual contract monitoring document or benchmarking of performance currently
in place.
The contract with the medical provider does not identify specific requirements
regarding the grievance process; these processes are set forth in the HCSO
grievance policy (DTN 914.06). Section H of this policy covers “Submission of
Inmate Medical Grievance,” and sections I, J, and K cover “Medical Grievance
Coordinator’s Responsibilities,” “Health Services Administrator Responsibilities,”
and “Medical Director Responsibilities,” respectively.
Armor provided Commission Member, McKinnon, with the following documents:
Grievance Policy, Inmate Grievance Medical Log, Request for Medical Review
Form, and Inmate Grievance Form – Medical Services. Armor has clear
processes by which inmates request medical services and file medical
grievances. Inmates may request medical services by completing a Sick Call
Request Form available in the pod. These requests are given directly to medical
staff. LPN’s circulate through all pods and make rounds three times daily.
Requests for sick call may receive the following responses depending on
urgency: urgent care (within 24 hours), clinic (within 36 hours), and general clinic
(within 5 to 7 day).
In addition, a Request for a Medical Interview Form may be completed by an
inmate at any time; it is given to the medical staff during rounds. Inmates may
request medical interviews for any reason, however the primary reason for
requesting a medical review is that the inmate is not satisfied that his/her medical
needs are being met. By contract, Armor has up to five days to respond to an
inmate request for review. Armor has a full time RN Grievance Coordinator to
address all inmate requests for medical reviews/interviews and maintains that
most are resolved quickly. The form identifies the issue, finding and identified
actions necessary. The form is signed by the Grievance Coordinator and the
inmate indicating either that the issue was resolved or that a formal grievance will
be initiated. A copy of the Medical Review Form is sent to the Health Services
Administrator.
Statistics as to number and type of medical requests are reported to and
reviewed by the HCSO Contract Manager and an internal committee monthly and
on a quarterly basis they are reported to and reviewed by QI Committee. While

D-9

the Contract Manager receives information regularly regarding requests for
interviews and grievances, there does not appear to be a mechanism whereby
jail administrators regularly receive/review this information.
If the inmate is not satisfied with the interview/review and decides to file a
grievance, s/he completes a Medical Grievance Form, and gives it to medical
staff. The Grievance Coordinator must investigate the complaint, ensure actions
are taken if the complaint is valid, and inform the inmate in writing of actions
taken. This information is entered into the JAMIS system. The information is
then forwarded, reviewed and signed off by both the Contract Administrator and
the Medical Director; the form must be returned to the inmate within 5 working
days. The inmate has 15 days to appeal.
For the month of June 2008 there were a total of 180 inmate requests for review
at Falkenburg Jail; 40 were unfounded, 140 founded. All issues, founded or
unfounded, were resolved. At Orient Jail there were a total of 51 requests for
medical interviews, 15 were unfounded, 36 founded. All were resolved. There
were zero grievances filed. The three categories that received the greatest
number of requests for interview were “dissatisfied with medical care” (n=52),
problems with medication (n= 69), and request to be seen (n=38). Armor states
that the issues are addressed by the Quality Improvement Committee, however
due to privacy considerations relevant to Personal Health Information, the
minutes or activities of the committee are not divulged. Due to HIPPA
regulations the Grievance Work Group of the Jail Commission was not able to
review any trending or corrective action reports and activities that have been
initiated as a result of the Quality Improvement Committee.
Grievance Work Group Initial Recommendations
We recommend that HCSO:
1)

2)

Ensure that inmates understand how to initiate a grievance and what to
expect from the system once it has been filed. This should include
accurate and expanded coverage in the Inmate Handbook that reflects the
procedures adopted in 2006 and corresponding coverage in the
Orientation Video. While the written and audio portions need not be
lengthy, the coverage should indicate what is grievable and not grievable
and reference all steps of the process. Importantly, the inmates should
learn from these sources that a concern does not need to be raised on the
shift during which it occurred/manifested, and that detention staff (per
recommendation below) can be disciplined for thwarting an inmate’s
legitimate attempts to use the system.
Make sure staff members understand the importance of the grievance
system and their own important role in it. Ensure a common understand
among staff regarding what concerns are grievable and not grievable.
Ensure that staff understand that they are to accept/process grievances

D-10

3)

4)
5)

6)

7)

8)

9)

10)

11)
12)

even if the concern arose on another shift. If necessary to ensure this
latter understanding, incorporate this into policy (DTN 914.06).
Incorporate into policy (e.g., DTN 914.06) a provision indicating that a jail
staff member is subject to discipline if s/he intentionally or due to
ignorance of policy thwarts an inmate’s efforts to use the procedures for
what appears to be a viable grievance. Communicate this changed policy
to staff.
Ensure through policy and/or training that supervisors who are charged
with investigating/resolving grievances conduct sufficiently comprehensive
reviews and document same in their reports.
Supplement procedures and forms, as necessary, to ensure that inmates
who check “I would like to request an appeal,” are uniformly provided with
information regarding the tasks they must complete. One option is to
include in the next iteration/printing of the Grievance Form, a sentence
indicating how the inmate initiates the appeal.
To ensure grievances are used by command staff as a monitoring and
management tool, produce reports on the number, nature and disposition
of grievances as frequently as Assailant Control Reports (ACRs) are
similarly reviewed. These reports should be reviewed by supervisory staff
up to and including, at regular intervals, Facility Commanders.
Compare grievance disposition statistics across similarly situated
supervisors who are conducting the investigations. A finding that a
particular supervisor has disposition statistics that are very different from
his/her peers would result in a further review of his/her processes.
Consider, if feasible, incorporating information on grievances filed against
particular deputies into the developing Early Intervention System (EIS).
This inclusion would be consistent with the current practice of including
complaints in that system. In evaluating the possible inclusion of
grievances into the EIS, policy makers should consider whether this
increased accountability might produce a corresponding unfortunate
increase in grievance “thwarting” behavior on the part of staff.
The Sheriff’s Office General Counsel Office should work with appropriate
staff from Armor Health Services to explore better information sharing
between Detention and medical personnel within the constraints of the
Health Insurance Portability and Accountability Act.
Detention Department management should ensure that medical
requirements not met through the various credentialing bodies are
regularly reviewed and documented according to a clearly defined process
understood by both the Sheriff’s Office and Armor Health Services.
Detention management should ensure that, per contract, an annual
external peer review of medical services is conducted and that the results
are made available to appropriate management within the Sheriff’s Office.
The Detention Department Medical Services Contract Manager should
ensure the creation of grievance trend reports for review by Detention
management.

D-11

13)

More formalized training should be provided to medical staff on
identification of signs and symptoms of substance abuse and mental
health, as well as on co-occurring disorders; on appropriate intervention
strategies; on assessment techniques; and on enhanced clinical skills.

D-12

Appendix E
Inter nal
Af fair s
Wor k Group
Repor t

Independent Review Commission On Jails
Internal Affairs Work Group Report
The Internal Affairs work group was formed to review the formal misconduct
investigations of Detention employees. The work group was comprised of Ray
Velboom, Delia Palermo and Al Higginbotham.
The work group met twice in conjunction with the Use of Force work group. The
Sheriff’s Office was requested to provide an analysis of formal investigations of
misconduct involving detention employees.
The members also reviewed
individual report investigations.
A list was provided of closed investigations from January 2005 through
December 2007. The list included administrative as well as criminal cases. The
information provided included the date, case number, employee name and ID
number, charge and finding.
Formal misconduct investigations findings are concluded in one of the following
categories as defined in the Hillsborough County Sheriff’s Office's Misconduct;
Suspension Standard Operating Procedure:
Sustained:

A finding or conclusion that an
allegation is supported by a preponderance
of evidence.

Unfounded:

A finding or conclusion that an allegation is
demonstrably false.

Unsubstantiated:

A finding or conclusion that sufficient
credible evidence was lacking to prove or
disprove the allegation.

Exonerated:

A finding or conclusion that the incident
occurred but the individual's actions were
lawful and proper.

Exonerated Due to Policy Failure:

A finding or conclusion that a present policy,
procedure, rule or regulation covering the
situation was non existent or inadequate. In
all cases involving a finding of Exonerated
Due to Policy Failure, the person making
the finding shall initiate a review of the
policy in question and draft a
recommendation to resolve the failure.

E-1

Other terms useful to analysis of this report:
UOF
ACR
ACIR
SOP

Use of force, here described as any force above that of
dialogue (Level 1) or simple escort (Level 2). (“UOFs” will
designate multiple Uses of Force).
Assailant Control Report, a document required of each deputy
who uses pain compliance, physical controls, or strikes with an
inmate.
Assailant Control Investigator Report, a document completed
by a supervisor on each UOF documented on an ACR
evaluating that UOF.
Standard Operating Procedure

Analysis
An analysis of the completed formal misconduct investigations conducted from
January 2005 to December 2007 that involved Detention personnel revealed the
following information:
Number
of
Incidents

Number
of
Charges

Number of
Involved
Detention
Personnel

2005

71

148

90

114 sustained
14 unfounded
20 unsubstantiated

2006

71

161

82

121 sustained
9 unfounded
23 unsubstantiated
8 exonerated

2007

56

150

62

132 sustained
9 unfounded
7 unsubstantiated
1 exonerated
1 exonerated due to policy failure

Year

Findings

Table: Analysis of Formal Misconduct Investigations – Detention Personnel 2005-2007

The Sheriff’s Office was requested to provide 25 formal investigations of
misconduct files that were randomly selected. These files included criminal
allegations as well as administrative cases.
The files were reviewed and discussed by work group members.
The
investigations were found to be substantive and quality investigations. One area
of concern was if formal investigations of misconduct occur when allegations of
excessive use of force are made. It was determined that this does occur and
several of the cases reviewed involved of use of force.

E-2

Initial Recommendations
The committee would recommend the following:
1. The use of force (UOF) definition should be clarified and disseminated to
ensure that all deputies understand what a use of force is and what must
be reported. The current atmosphere following the Sterner incident has
resulted in uncertainty and lack of consistency in definition and reporting
across shifts and personnel. Even the Sterner case itself presented some
confusion over “where to put it and whether to report it” within current use
of force parameters. Now supervisors are divided about what to report
and this uncertainty for deputies may lead to over or underreporting.
2. Once this consistency has been achieved through definition and
dissemination of the definition, the discipline for violations of failing to
document use of force through an Assailant Control Report could be
increased. We saw several cases involving the failure of filing Use of
Force reports. An increase of discipline would give more incentive for
filing of reports- once the term UOF was adequately defined.
3. Investigations rely on ACRs and ACIRs from deputies and supervisors at
the jails. Therefore, further training of supervisors on the Use of Force
reports would improve the basis on which investigations are begun.
Supervisor training would improve the usefulness and value of site
investigations before they reach the level of IA. Additionally, supervisor
training would improve the consistency across shifts and personnel of Use
of Force reporting.
4. Taser use is limited and rare. However, if the Taser were made more
accessible than is currently the case, that use may increase. HCSO
should employ any data recorded by the Taser itself to assess proper use
and to corroborate investigative reports.
5. One of most useful investigative tools is the review of images captured
from multiple cameras at the jails. However, use of sound with these
images would ensure greater accuracy and detail to reports.
6. Detention deputies should be assigned to Internal Affairs to ensure the
validity and reliability of investigations involving the unique circumstances
of detention personnel.

E-3

Appendix F
Use of Force
Wor k Group
Repor t

Independent Review Commission On Jails
Use of Force Work Group Report�
This work group examined the use of force in the Hillsborough County jail system
from January 2005 through the end of May 2008, the 41 month duration of the
administration of Sheriff David Gee. The numeric data were obtained from HCSO
computer systems; the subjective from numerous interviews, public hearing
testimony, focus group discussions, and the review of randomly selected written
narratives which are not captured or searchable by computer programs currently in
use. We reviewed pertinent policies, and conducted frame by frame analyses of 10
jail videos provided by HCSO, the American Civil Liberties Union, and the news
media. Only uses of force above Level 2 of the Use of Force matrix were examined
and reported below.
For clarity, following are explanations of terms used throughout this report:
UOF

Use of Force, here described as any force above that of dialogue
(Level 1) or simple escort (Level 2). (“UOFs” will designate multiple
Uses of Force).

ACR

Assailant Control Report, a document required of each deputy who
uses pain compliance, physical controls, or strikes with an inmate.

ACIR

Assailant Control Investigator Report, a document completed by a
supervisor on each UOF documented on an ACR evaluating that
UOF.

IR

Incident Report, a document required to record various events,
including use of the restraint chair, use of force, or any of
numerous other occurrences.

SOP

Standard Operating Procedure

Pain Compliance Level 3 on UOF Matrix, to include pressure points, joint
manipulations, pad subduing, redirection.
Physical Controls Level 4 including Oleoresin Capsicum (OC) foam, takedowns.
Strikes Level 5

punches, kicks, baton strikes, Tasers.

ORJ

Orient Road Jail

FRJ

Falkenburg Road Jail

F-1

CB

Central Booking, a location at ORJ

JAC

Juvenile Assessment Center

The record keeping systems primarily maintain statistics by the number of UOFs, by
the number of deputies involved, and less frequently, by the number of incidents.
Where statistics are used, their nature will be specified.
This report will follow the 10 areas designated by outline in the work group’s original
report to the Commission, and will describe the processes used, the findings and
then the work group’s recommendations. The Use of Force work group members are
Brian Kensel (Chair), Dr. Lorie Fridell, Dr. Delia Palermo and General Peter
Schoomaker.
The Use of Force work group’s outline listed the following items for examination:
1. The number of use of force incidents.
2. The number of times force was used by each deputy, to identify those using
force most frequently.
3. The types of incidents in which force is being used (assaults on staff, inmate
fights, etc.)
4. The frequency of use of the various levels/types of force used (chair, OC,
strikes, etc.)
5. The location(s) where force is most commonly used.
6. The frequency of injuries to inmates and staff.
7. Any correlations between the types of incidents (#3 above) and location(s)
(#5).
8. Any correlation between the type of force used (#4 above) and location(s)
(#5).
9. Prevalence of use of force by squad assignment.
10. The validity of the review system used to evaluate use of force events.

F-2

Each section of the report will be marked with ITEM 1-10 to indicate the issue it
addresses. They are not necessarily addressed in the order above.
ITEM 1
Any examination of the use of force must begin by quantifying its occurrence.
Examination of various HCSO data systems for the 41 month period previously
described revealed 3078 Uses of Force during 1720 incidents, an average of 42
incidents and 75 UOF per month. As most incidents involve multiple deputies (on
average, 1.8 deputies per incident), each of whom is required to independently report
his/her UOF via the completion of an ACR, the number of UOFs will always exceed
the number of incidents.
During this same period, a total of 247,999 people were booked into Hillsborough
County Jails. Force at a Level 2 or above was used 3078 times, for a rate of 1.2% of
the population if each UOF was directed at a separate person. However, as
determined above, an average of 1.8 UOFs are involved with each incident, thus the
actual percentage of people booked being involved in a UOF incident is .7 of 1%.
Further examination of the records revealed a small group of inmates was involved in
an inordinately high number of UOF incidents. Five inmates were involved with 92
UOF, or 3% of the total, a rate 1500 times higher than the statistical average. The
impact of a relatively small group of inmates will be explored in more detail below in
the section marked “ITEMS 3, 7”.
The annual rate of bookings and UOFs paralleled one another throughout the period,
showing a minor peak in 2006 with a slight downward trend since.
ITEM 2
The work group conducted an examination of the deputies involved in multiple UOFs.
Employment records indicate an average of 938 deputies of the rank sergeant and
below were employed in the jails each year of the period. Our examination chose
that group of employees to reflect those who have the most frequent contact with
inmates and excluded the higher ranks that are generally responsible for
administrative matters.
Using the previously described statistics, the “average” deputy used force as
described 3.28 times during the 41 months. A group of 20 deputies, representing
2.1% of all deputies in the study, were involved in 599 UOFs, or 19.5% of the total.
The top five were involved in 204 UOFs, representing 6.6% of all UOFs. In the group
of 20, the number of UOFs ranged from 48 to 19 for the 41 months, with an average
of 31.7 UOF per deputy, just under 10 times the department average. (Note:

F-3

Assailant Control Investigator Reports (ACIRs) were removed from the above
numbers for the two deputies in the group of 20 who became Corporals during the
period and thus became responsible for the review of some ACRS).
The length of service for the 20 deputies ranged from 39 months to 21.9 years, with
an average of 9.4 years.
Many of the ACRs for these incidents were reviewed for trends, to determine the
propriety of the UOF, and to examine the internal review process. Of the 599 UOFs
involving these 20 deputies, three resulted in Internal Affairs investigations. In one
instance, charges of excessive force and use of profanity were determined to be
unfounded and unsubstantiated, respectively. In another, a charge of excessive
force was unfounded, allegations of use of profanity were unsubstantiated, and a
charge of failure to follow Standard Operating Procedures/Directives was sustained
for deputies’ failure to complete an ACR. A third deputy resigned from service
following a separate incident. Overall, there were 17 investigations (including the
above) into allegations of the use of unnecessary or excessive force against
Detention personnel during the study period. Four of those allegations were
sustained; the others were unfounded.
A review of ACRs (and the resulting ACIRs) of the 20 deputies with the highest UOFs
revealed those other than those noted above were determined to be appropriate and
valid. Of the 3078 UOFs examined, the rate of those found to be inappropriate was
2/10ths of 1 percent.
ITEMS 3, 7
Also examined were the types of incidents that resulted in UOFs, and the locations
where they occurred. HCSO defines 19 types of incident by which it classifies UOFs,
the most commonly used of which are “Disruptive Inmate”, “Assaults on Staff”, and
“Inmate Altercations”. The following reflects their frequency at the two largest
facilities, by the number of deputies involved:
ORJ

FRJ

Total

1,129

562

1,691

Inmate Altercations

169

271

440

Assault on Staff

215

162

377

Disruptive Inmate

As previously mentioned, there is a relatively small group of inmates which is
involved in a disproportionate number of incidents involving UOF. The direct
supervision style of detention used by HCSO requires appropriate deportment by the

F-4

inmates, with sanctions for those who refuse to comply. The expected behavior
standards are provided to inmates as part of the booking process. This analysis of
UOF identified a number of inmates who, based on their multiple arrests/bookings,
would be expected to be aware of the behavior standards, but whose records
indicate they consistently refuse to behave according to those standards.
One inmate, for example, was involved in 11 UOFs between January 2005 and May
2008, requiring 31 deputies to control him. These 11 incidents took place during 7
separate arrests/bookings. (These numbers do not include this inmate’s multiple
confrontations with law enforcement prior to 2005.) Another inmate was also
involved in 11 incidents, requiring 21 deputies to use force during 3 jailings. This
pattern of behavior is not limited to male inmates; one female inmate was involved in
4 UOF incidents, requiring 11 deputies; she was arrested and booked nine times
during the 41-month period.
There were 230 inmates involved in multiple UOF incidents, ranging from 2 to 11
each, for a total of 560 incidents. Said differently, one tenth of 1% of the inmates
booked into Hillsborough County jails since January 2005 were involved in 18.2% of
the UOFs. Some of the deputies and supervisors interviewed in focus groups said
current classification practices make it difficult for them to place dangerous or
disruptive inmates in administrative confinement, which results in more
confrontations, and thus more UOFs. They attributed the problem to what they
described as inflexible classification clerks, and felt the ultimate classification
decision should rest with first line supervisors each shift.
ITEM 4
Discussion of the types of force used should note that there have been no instances
of Deadly Force (Level 6) used in HCSO detention facilities during our 41 month
period of study, nor were less than lethal munitions used. As previously described,
Levels 1 (presence and dialogue) and 2 (escort, touch, restraint devices) do not
require an ACR and are not considered UOFs for the purposes of this report.
Combining facility statistics for the period resulted in the following numbers of times
each level was used:
Level 3:

881 (684, or 78%, were “redirects”)

Level 4:

1,189 (930, or 78%, were “takedowns”. Additional 238, or 20%,
were use of OC, further described below)

Level 5:

92 (79, or 86%, were “defensive strikes”)

F-5

ITEM 5
The review also illustrated specific patterns regarding the location of these UOFs. Of
the 20 deputies responsible for the highest number of UOFs, 18 spent all or most of
the period assigned to Central Booking at ORJ, most of them working the 7p.m to
7a.m. shift. Examinations of all data confirm the greatest rate of UOFs occur as part
of the booking process, with 56% of them taking place during the night shift. Thus, it
is reasonable to expect those deputies assigned to work nights in CB to demonstrate
the highest incidence of UOF.
Since 2005, 28.6% of all incidents involving force, and 35% of all UOFs in all
Hillsborough County detention facilities took place in CB. Another 2.6% of the
incidents occurred in the booking area of the JAC, which performs the same duties
for juveniles as CB does for adult inmates. The remainder was spread throughout
the other parts of ORJ, FRJ, the JAC, the Work Release Center and Transportation.
UOFs each year were highest at ORJ (52-59%), followed by FRJ (36-42%).
The reasons for the preponderance of UOF in CB were addressed by Colonel David
Parrish at the Commission’s open meeting on March 10, 2008 when he described CB
as the “most overtaxed area in the jail system.” From deputies through middle
management, many of those interviewed described low staffing levels as the greatest
problem throughout the jails. They said staffing levels impact UOF statistics in
opposing ways: because they believe no backup deputies are readily available,
some deputies (primarily in housing units) ignore violations by inmates to avoid a
confrontation they would have to handle by themselves. Following recent events,
there now exists some confusion over what actions constitute a UOF; some deputies
are now instructed by supervisors to submit ACRs for even minor contacts with
inmates in order to avoid potential criticism.
ITEM 6
Our work group also examined the frequency and degree of injuries suffered by
inmates and by jail staff during UOFs:
UOF Injuries to Inmates ORJ FRJ JAC Totals
Hospitalized

1

0

0

1

Known Visible

5

3

0

8

Minor scrapes

12

17

2

31

Totals

18

20

2

40

F-6

�

UOF Injuries to Jail Deputies ORJ FRJ Totals
Hospitalized

1

0

1

Known Visible

4

3

7

Minor scrapes

7

15

22

Totals

12

19

30

These numbers reflect injury rates of 1 injury to every 6200 inmates, and 1 injury to
every 125 deputies. Deputies and supervisors advise that many minor injuries to
deputies are never reported, because doing so could further complicate what they
describe as dangerously low jail staffing levels. Some of those deputies said they
expect more deputies to be injured because of the understaffing if it continues.
ITEM 7
The results of our examination of the relationship between the types of incidents and
their locations were included in the response to ITEM 3, above.
ITEM 8
There were 238 incidents in which OC foam was used, involving 383 deputies. Most
OC incidents occurred at FRJ (68%), with 31% taking place at ORJ; the remaining
1% at the JAC, WRC, and Transportation. OC uses represent 14% of the total UOF
incidents.
There were 6 Taser uses during the study period; five at FRJ and one at ORJ,
representing 2/10ths of 1% of all UOFs by detention personnel. A study was
conducted of 23 OC uses in 2007 and 6 Taser uses in 2006 and 2007 by reviewing
IRs, ACRs and ACIRs.
OC Incidents
Most of the incidents involving OC spray in 2007 were precipitated by inmate
altercations. Deputies reported they ordered inmates to stop fighting and, when they
did not, used OC spray against one or more of the involved inmates. This use of OC
spray is consistent with the policy allowing for OC spray to defend against physical
force/resistance (against a jail employee or against other inmates).

F-7

Generally, the incident descriptions are satisfactory.
report has greater detail than the ACR.

In many cases the incident

The reports by the investigators present facts as well as conclusions. The
investigators usually indicated the specific individuals whom they interviewed as part
of the investigation. Generally, this included all involved inmates and deputies;
sometimes there were specific notations indicating why a particular inmate was not
interviewed or that the inmate was uncooperative. In one exception, a supervisor did
not explain why he did not interview an Inmate. Another investigator’s report did not
provide sufficient detail on the nature of his/her investigation but only reported, “I
conducted interviews regarding Deputy XXXX’s use of force.” This lack of detail
should have been questioned by supervisors who reviewed the paperwork for this
incident.
Only a few of the investigators reported interviewing inmates who had witnessed the
incident but were not involved in it, even though a number of the UOF incidents (e.g.,
precipitated by inmate altercations in housing) were likely in view of many. One
investigator is an exception; he reports that he interviewed ”the inmates in the pod
that witnessed the incident.” This report would have been further strengthened by
indicating the names of the people with whom he spoke.
In just one of the examined incidents did the investigator note that he reviewed the
video. Focus groups with supervisory personnel indicate they now routinely review
video on UOF investigations. That review was confirmed by examining recent
ACIRs.
Taser Incidents
It is notable and important that the Taser incident reports included detailed narratives.
Incident report narratives averaged a full single spaced page. Generally, these
narratives provided detail on the circumstances that led to the request to use a Taser,
the preparations for its use (e.g., bringing a video to the scene), the use of it and the
follow-up (e.g., probe removal and nurse check on subject). The reports appeared to
include all information required per SOP DTN 909.60.
In all but one incident, the jail staff reported a single 5-second activation of the Taser.
The other incident involved one activation using the probes, and two more with direct
contact. The reports of five of the six incidents mentioned that a video was brought
to the scene prior to weapon activation. Some reports mentioned that a nurse was
called to the scene prior to weapon activation; all reported that a nurse was present
at the scene after the activation to check on the subject. Deputies are trained to
apply handcuffs during the activation phase to take greatest advantage of the
inmate’s temporary incapacitation.

F-8

In several incidents the narrative did not indicate why immediate action was
necessary. All of these inmates appeared to be in single-person cells. All were
agitated and acting out, but only a few of the reports explained why immediate cell
entry was necessary. There may have been reasons that were not documented.
Taser devices have the ability to record various data whenever employed, which can
later be downloaded as part of an investigation. The presence of a video camera
and multiple witnesses in the jails makes collection of such data there less critical
than in Taser usage by deputies in street settings.
The Pro-Straint Chair was used 1195 times during the 41 months, with a peak of 400
in 2006 and a declining trend matching drops in booking and UOF rates in
subsequent years. It is noted that use of the restraint chair is generally not reported
on an ACR, unless Level 3 or higher force was used getting the inmate into the chair.
All chair use does require submission of an Incident Report.
ITEM 9
One of the fields on the computerized ACR is “Squad”, leading us to include in our
original outline of potential issues an examination of UOF by squad assignment.
However, our inquiry determined that detention deputies are not assigned by squad,
and that the 4 digit numbers appearing in the “Squad” field on ACRs in reality refer to
a telephone extension number in the area where the UOF took place. A list of those
telephone extension locations was used to assist in determining the location issues
addressed in item 5.
ITEM 10
HCSO has in place a review system and a program to monitor detention deputies’
uses of force. SOPs require each deputy who uses force above the level of “Escort”
to complete an ACR by the end of the work shift during which the UOF occurred.
The primary deputy also completes an Incident Report; deputies who assist in the
incident complete an ACR where appropriate, and a Supplement to the IR. In spite of
current record keeping requirements that assisting deputies in a UOF incident also
complete a supplement to the IR (DTN SOP 909.28), review of some files indicates
these supplements are not being prepared in all cases.
The immediate supervisor then conducts an investigation of the UOF, most
commonly consisting of interviews of the parties involved. He/she then completes an
Assailant Control Investigator Report (ACIR), and the package is forwarded up the
chain of command. Detention SOP 909.43 requires that oversight be conducted up
to the level of the facility commander. Since February, those reviews have been
extended to include the Colonel in charge of Detention. A substantial number of
supervisors interviewed advised that the incompatibility of ACRs/ACIRs and the Blue

F-9

Team program requires them to write UOF narratives twice, which they say wastes
time and creates potential trial problems.
Camera oversight of much of the jail, particularly CB, has been in place for about ten
years. Since February, shift Lieutenants are required to review one hour of randomly
selected camera footage during each shift.
The Sheriff’s Office also conducts quarterly command staff “Strategic Management”
reviews, including the use of force in the jail system. Examination of the 59 page
“Use of Force” graphic presentation created for the “Strategic Management” review of
December 2007 includes quarterly data for calendar years 2006 and 2007, with
graphs showing UOF by facility, the rates of UOF, locations of UOF, the frequency of
UOF by shift and location, the use of OC foam by shift and location, and the use of
the restraint chair and Taser, again by shift and location. The depth and detail of this
review appears to be adequate to alert the command staff to shifting trends in the
frequency, nature and/or location of the UOF.
The system historically used for most of the study period to monitor deputies’ UOF
was supplanted in February with the adoption of the Blue Team program, a topic
detailed by Sgt. Danny Tewmey in the Independent Review Commission on Jails
public meeting on March 21, 2008. The data base that has been in use since 1999
to track use of force and misconduct investigations, among other items, is IA Pro.
Blue Team is an adjunct program by the same software company that allows
standardized entry of events such as UOFs, and with IA Pro, generates early
intervention warnings of a deputy’s performance, including UOFs. The adoption of
Blue Team is to provide warnings of potential problems earlier than was possible
during the previous paper based system.
It appears that the monitoring system is functioning as intended. Of the 20 deputies
with the highest number of UOFs (described in ITEM 2, on page 3) identified by our
examination, a review of records found that 10 of them had been flagged by the
system, including the top six, and 10 of the top 12. These flags do not indicate
wrongdoing on a deputy’s part, but give supervisors an opportunity to examine the
patterns of behavior to determine if they are appropriate or not given an employee’s
specific assignment.
Conclusions/Recommendations
Our research uncovered no systemic problems regarding the use of force in
Hillsborough County Jails. Statistically, an arrestee entering the jail system faces
less than a one percent chance of being involved in a use of force incident at any
time during his/her time in jail. In 99.8% of those incidents in which force is used, an
investigation has deemed it necessary and appropriate to the circumstances.

F-10

Most of our recommendations address record keeping or other administrative matters
such as training, procedures and staffing.
1. Data down to the individual deputy level should be added to the quarterly
command staff reviews of the UOF, to include multiple UOFs as in ITEM 2.
This would permit a comprehensive overview of the individuals using force,
and thus would identify contributing (and mitigating) factors such as their
location of assignment, shift, etc. that may not be apparent from the broader
scope of the current reviews.
2. Consideration should be given to more frequent fixed rotations of employees
in high stress positions, particularly those in booking. With acknowledgement
of the bid process currently in use, and the preference of many deputies to
remain in those challenging jobs, the reality of leaving an employee with fewer
than four years of experience in a position where he/she has needed to use
force (albeit appropriately) almost 15 times as often as other deputies could
create liability, or the appearance of impropriety in future incidents. However,
basing assignments and transfers solely on legitimate UOFs may be perceived
by deputies as punitive, which could discourage the appropriate UOF, thus
exposing deputies to increased physical danger. These issues could be
overcome if high UOF assignments are rotated on a fixed & published
schedule, regardless of the number of UOFs amassed by any individual
deputy.
3. Additional categories should be created on the ACR template for the types of
force used. In the 3078 UOFs for the period examined, 436 listed “other” to
describe the nature of the force. Expanding the menu of options from those
currently offered would minimize the use of the catch-all “other” category and
thus provide a more clear and accurate portrait of the type of force being used.
Some types of force, such as OC, appear one place on some ACRs, and in
two places on others, permitting confusion and possibly inaccurate data being
recorded.
4. Relatedly, attempts should be made to integrate ACRs/ACIRs with Blue Team
to avoid having supervisors duplicate efforts. Supervisors say they are so
burdened with administrative responsibilities that they are often unable to
supervise. They recommended formation of dedicated UOF investigation
team(s) to review all UOF incidents, rather than the current system of
immediate supervisors doing so.
5. We recommend amending the ACR template to include the name and/or PID
of the supervisor of the deputy submitting the ACR. We further recommend

F-11

monitoring UOFs by supervisor, which would offer early notice of an unusual
pattern of UOF by deputies working for a particular supervisor.
6. Most UOF statistics appear to be kept by the number of deputies involved, and
the number of ACRs filed (which in theory would coincide). It is recommended
that data also be kept in a manner to permit easy identification of the number
of incidents, regardless of the number of employees involved. We were able
to eventually retrieve that number, but it does not appear to be a standard
means of data collection.
7. In view of the disproportionately high number of incidents involving a relatively
small number of repeat inmates (ITEM 1, pgs.3, 4), it is recommended that the
records of those inmates involved in multiple UOF incidents be flagged so
additional caution may be exercised during future bookings, and appropriate
housing is arranged during classification.
8. Similarly, in current practice, intake deputies are unaware of an inmate’s
identity/level of resistance until he or she arrives in the sally port.
Consideration should be given to requiring law enforcement officers from all
involved jurisdictions to contact booking via a designated radio channel or by
telephone when initiating transportation to ORJ to provide at least the
name/DOB of arrestee(s), and notification of any resistance, medical issues,
etc. which would permit booking to appropriately prepare for the inmate’s
arrival. Modifications to current classification procedures should allow at least
corporals and sergeants, if not deputies, to determine the appropriate type of
housing for historically dangerous inmates.
9. It is recommended that training be amended to broaden the understanding of
“Use of Force” and its parameters. It appears through review of files and
personnel interviews that some confusion exists over what out-of-the-ordinary
circumstances must be reported on an ACR. Some instances that fall outside
of the existing categories, including the Sterner incident, are not seen as UOF
by the involved deputy(ies), and thus never recorded via an ACR. Some
deputies said their supervisors now require ACRs for even escort force or
handcuffing, because of what they described as an environment where
“everyone is walking on egg shells.” Other supervisors apparently tell
deputies to avoid UOFs, so the supervisor will not have to “waste time entering
it in Blue Team.” Training should clarify the definition of force to ensure more
consistent reporting, and thus a more accurate record of jail activities. This
would avert a sudden spike in UOF statistics which is likely to occur if current
practices continue.

F-12

10. Training topics requested during interviews or focus groups were:
A.

training for all sworn jail staff in recognizing and dealing with
mental health issues (this training has since been announced
and scheduled).

B.

more cell entry/inmate extraction techniques and practice for
detention deputies.

C.

supervisors also requested specific training in investigating
UOFs. We concur that training in these areas should be
considered. Beyond these issues, many employees were highly
complimentary of the current training & FTO programs.

11. IRs and ACRs in Taser incidents should include the reason that immediate
use of the Taser was required. Consideration should be given to downloading
usage data from Tasers after each time a Taser is activated, and to mandating
review of both the jail camera videos and those shot specifically to document
the incident. Currently, Tasers are maintained by Lieutenants. Mid-level
supervisors support continuing the current practice; Corporals and Sergeants
urge increasing Taser availability by extending the authority and carriage of
Tasers to their level.
12. Some deputies said the currently available soft pads are rarely used for inmate
control because they are ineffective in protecting deputies. Consideration
should be given to obtaining hard shields for that purpose.
13. We reviewed two incidents in which UOF was not reported, apparently
because of confusion over those unusual events that fall outside of the
common definition of UOF. In both instances the deputy was sanctioned.
Such omissions generate the question, “How can the Sheriff’s Office ensure
that all uses of force are being reported by someone?”
A recent requirement was established that every employee must report
anything he/she sees that might be improper. The grievance process,
examined by another work group of the Commission, provides all inmates with
the means to report any deputy’s wrongdoing. Surveillance cameras, coupled
with random reviews of their images, are intended to serve as deterrents, and
are accomplishing that task according to deputies interviewed. The camera
system used in the jails, particularly ORJ, has been updated since its
installation. We recommend the addition of audio recording (as is utilized in
some other area jails) be explored as a means of further monitoring the
facilities. The existence of an audio record to enhance the existing video

F-13

would protect both inmates and deputies. Most supervisors interviewed are
confident that all uses of force are being reported, especially in the current
atmosphere; a few remain less convinced, but offer no recommendations.
14. Following are various recommendations made during focus groups by sworn
personnel that they feel would positively impact their safety, and reduce the
UOF:
A. Remove some privileges from inmates sent to disciplinary
confinement (DC), such as their access to canteen, visitation, daily
showers, etc. Perception of current system is that there is no
disincentive in DC, and that some inmates even provoke a
confrontation with housing deputies to be transferred to DC where
they have a “private” cell and few obligations. They recommended
the same limitations for juvenile DC inmates.
B. Some deputies perceive the greatest priority of the administration is
the cleanliness of the jails, rather than the deputies’ safety; some
say the effect has been lowered morale.
C. Several focus groups repeatedly described a staffing shortage that
negatively impacts their safety by reducing the number of deputies
available when a violent incident does occur. This was most
commonly voiced by FRJ personnel, because of the extended
distances between some units. They attributed some of the
shortage to recruiting standards. An opinion repeatedly expressed
suggests prohibitions against recruits with tattoos and tobacco
usage are responsible for the unfilled positions by excluding many
applicants with a military background. They noted that contract
medical personnel and CSOs are permitted to have tattoos.

F-14